Abnormal hemostasis tests and bleeding in chronic liver disease: are they related? No, but they need a careful look

Risks and predicting factors of bleeding complications in hepatitis B virus-related acute-on-chronic liver failure

BACKGROUND/AIMS

This study aimed to provide supporting evidence for prevention and prognostic evaluation of bleeding complications in the early stage by exploring the risk and predicting factors in patients with acute-on-chronic liver failure (ACLF).

MATERIALS AND METHODS

A total of 101 hospitalized patients with ACLF were retrospectively included from January 1, 2014 to December 31, 2015. The patients were divided into bleeding (n=38) and nonbleeding groups (n=63). Demographic data and laboratory tests were recorded and compared between the two groups. The incidence, risk factors, and prognosis of bleeding complications among patients with ACLF were investigated.

RESULTS

A total of 38 cases (37.62%) had bleeding complications: 26 (25.74%) were spontaneous and 12 (11.88%) were postprocedural. Patients with bleeding complications had lower platelet (p=0.008), fibrinogen (p<0.001), factor V (p=0.001), and factor VII (p=0.026) levels; higher serum creatinine levels (p=0.004); and a higher proportion of cirrhosis (p=0.013). Logistic regression analysis showed that cirrhosis (odds ratio=3.251, p=0.046), fibrinogen level (odds ratio=0.352, p=0.007), and factor VII level (odds ratio=0.951, p=0.011) contributed to the development of bleeding complications. A subgroup analysis of invasive manipulation-induced bleeding complications showed lower levels of factors V (p=0.018) and VII (p=0.021) in the postprocedural bleeding group. Follow-up studies showed that the nonbleeding group had a higher survival rate than the bleeding group at day 90 (73.33% versus 51.85%, p=0.040).

CONCLUSION

Liver cirrhosis, lower levels of fibrinogen, and major coagulation factor activity in patients with ACLF were associated with an elevated risk of bleeding events during hospitalization, which further impaired the 90-day survival rate.

Portal vein thrombosis in liver cirrhosis: incidence, management, and outcome

Background

Portal vein thrombosis (PVT) is a serious complication in liver cirrhosis with portal hypertension. We examined the treatment, recurrence and prognosis of PVT in cirrhotic patients.

Methods

The study subjects were all 90 cirrhotic patients with PVT treated with danaparoid sodium (DS) at our department between July 2007 and September 2016. The mean age was 68 years and mean Child-Pugh score was 7. All patients received 2500 U/day of DS for 2 weeks, and repeated in those who developed PVT recurrence after the initial therapy.

Results

Complete response was noted in 49% (n = 44), partial response (shrinkage ≥70%) in 33% (n = 30), and no change (shrinkage <70%) in 18% (n = 16) of the patients after the initial course of treatment. DS treatment neither caused adverse events, particularly bleeding or thrombocytopenia, nor induced significant changes in serum albumin, total bilirubin, prothrombin time, and residual liver function. Re-treatment was required in 44 patients who showed PVT recurrence and 61% of these responded to the treatment. The cumulative recurrence rates at 1 and 2 posttreatment years were 26 and 30%, respectively. The recurrence rates were significantly lower in patients with acute type, compared to the chronic type (p = 0.0141). The cumulative survival rates at 1 and 3 years after treatment (including maintenance therapy with warfarin) were 83 and 60%, respectively, and were significantly higher in patients with acute type than chronic type (p = 0.0053).

Conclusion

We can expect prognostic improvement of liver cirrhosis by warfarin following two-week DS therapy for the treatment of PVT in patients with liver cirrhosis safety and effectiveness. An early diagnosis of PVT along with the evaluation of the volume of PVT on CT and an early intervention would contribute to the higher efficacy of the treatment.

Anticoagulation for the treatment of portal vein thrombosis in liver cirrhosis: a systematic review and meta-analysis of observational studies

BACKGROUND & AIMS

Systematic review and meta-analysis were performed to evaluate the safety and efficacy of anticoagulation for the treatment of portal vein thrombosis (PVT) in cirrhotic patients.

METHODS

The PubMed, EMBASE, Cochrane Library, and ScienceDirect databases were searched. The rates of bleeding complications and portal vein recanalization in patients who received anticoagulant therapy were pooled. The odds ratio (OR) with 95% confidence interval (CI) was calculated to express the difference in the rate of portal vein recanalization between anticoagulation and non-anticoagulation groups. All meta-analyses were conducted by using a random-effects model.

RESULTS

Sixteen of 960 initially identified papers were included. Two studies reported a low incidence of major anticoagulation-related complications (4% [2/55] and 3% [1/33]), but no lethal complications occurred. The rate of anticoagulation-related bleeding ranged from 0% to 18% with a pooled rate of 3.3% (95% CI=1.1%-6.7%). The heterogeneity was not significant in the meta-analysis. The total rate of portal vein recanalization ranged from 37% to 93% with a pooled rate of 66.6% (95% CI=54.7%-77.6%). The rate of complete portal vein recanalization ranged from 0% to 75% with a pooled rate of 41.5% (95% CI=29.2%-54.5%). However, the heterogeneity was significant in the 2 meta-analyses. The rate of complete portal vein recanalization was significantly higher in anticoagulation group than in non-anticoagulation group (OR=4.16, 95% CI=1.88-9.20, P=0.0004). The heterogeneity was not significant in the meta-analysis.

CONCLUSION

Anticoagulation could achieve a relatively high rate of portal vein recanalization in cirrhotic patients with PVT. Given that only a small number of non-randomized comparative studies are reported, randomized controlled trials are warranted to confirm the risk-to-benefit of anticoagulation in such patients, especially anticoagulation-related bleeding.