Risks of venous thromboembolism in patients with liver cirrhosis: a nationwide cohort study in Taiwan

Impact of Cirrhosis Etiology on the Risk for Venous Thromboembolism

BACKGROUND

Cirrhosis is associated with an increased risk for both bleeding and venous thromboembolic (VTE) complications. The data regarding the impact of etiology of cirrhosis on VTE risk is poorly understood.

METHODS

In this retrospective observational analysis of the US Nationwide readmissions database 2019, we identified hospitalized patients who had cirrhosis from alcohol, viral, or nonalcoholic steatohepatitis (NASH) etiologies. We identified patients who had acute VTE, chronic/history of VTE, and portal venous thrombosis (PVT). Overall VTE risk was defined as the composite of acute and chronic VTE or PVT. The impact of etiology of cirrhosis on the crude and risk adjusted rates of VTE and PVT was studied.

RESULTS

Of 432,383 patients with cirrhosis, 41.4% patients had NASH-cirrhosis, 39.7% had alcohol-related cirrhosis, and 18.9% had viral cirrhosis. The overall VTE rate was highest in patients with NASH cirrhosis (10.8%) followed by viral cirrhosis (9.7%) and alcohol-related cirrhosis (7.5%; P < 0.001). Similar results were observed for acute and chronic VTE. After risk adjustment, patients with NASH (OR 1.48 95% CI 1.42-1.54) and viral cirrhosis (OR 1.22 95% CI 1.17-1.29) had significantly higher overall VTE risk compared with alcohol-related cirrhosis. When separately evaluated, the adjusted risk for acute and chronic VTE was similar between patients with alcohol-related and viral cirrhosis but higher with NASH cirrhosis. PVT rate was highest with viral cirrhosis (4.3%) followed by NASH (2.8%) and alcohol-related cirrhosis (2.4%; P < 0.001). The adjusted risk of PVT was higher with viral (OR 1.61 95% CI 1.50-1.72) and NASH cirrhosis (OR 1.41 95% CI 1.31-1.52).

CONCLUSION

NASH cirrhosis was associated with a higher VTE risk compared with alcohol-related and viral etiologies. As NASH cirrhosis increases in prevalence as the major etiology of cirrhosis, it is important to understand the increased VTE risk associated with this condition to improve management strategies and patient outcomes.

D-dimers in advanced liver cirrhosis: Useful biomarker or not?

In clinical practice, the d-dimer levels rule out venous thromboembolism and diagnose disseminated intravascular coagulation. d-dimers increase in both physiological and pathological conditions. Liver cirrhosis, especially in the final stages, is characterized by complex coagulation and fibrinolysis factor disorders. Multiple mechanisms tried to explain the increased d-dimer levels in patients with liver cirrhosis and ascites. The d-dimer cut-off level used to rule out venous thromboembolism in cirrhosis is higher than that used to confirm the diagnosis of VTE or DIC in noncirrhotic patients. The cut-off d-dimer level used for the prognosis of thrombotic events is not standardized in advanced liver cirrhosis. Thus, it is necessary to update the clinical guidelines regarding the usefulness of d-dimer testing in advanced liver cirrhosis and the cut-off d-dimer levels, which should vary based on the detection method.

Long-term risk of venous thromboembolism among patients with gastrointestinal non-neoplastic and neoplastic diseases: A prospective cohort study of 484 211 individuals

We conducted a prospective cohort study to examine the associations of 21 gastrointestinal diseases with the risk of incident venous thromboembolism (VTE). The study included 485 936 UK Biobank participants free of baseline VTE. The gastrointestinal diseases were defined by the International Classification of Disease (ICD)-9 and 10 codes with data from the nationwide inpatient data set, the primary care data set, and the cancer registries. Incident VTE cases were defined by ICD-9 and 10 codes with data from the nationwide inpatient data set. Cox proportional hazards regression was used to estimate the associations of baseline gastrointestinal diseases with incident VTE risk. During a median follow-up of 12.0 years, 13 646 incident VTE cases were diagnosed. Eleven gastrointestinal diseases (nine non-neoplastic and two neoplastic) were associated with an increased risk of incident VTE after Bonferroni corrections. The risk of VTE was >50% higher among patients with gallbladder and biliary tract cancer (hazard ratio [HR] 3.15, 95% confidence interval [CI] 95% CI 1.74-5.70), pancreatic cancer (HR 2.84, 95% CI 1.65-4.91), cirrhosis (HR 2.34, 95% CI 1.96-2.79), Crohn's disease (HR 1.61, 95% CI 1.33-1.95), or pancreatitis (HR 1.57, 95% CI 1.31-1.88) compared with individuals without each of these diseases. We observed multiplicative interactions of age, sex, and body mass index with some gastrointestinal diseases (p < .05). A more pronounced, increased risk of VTE was found among younger, female, or obese patients. The study suggests a 50% higher risk of developing VTE among patients with gallbladder and biliary tract cancer, pancreatic cancer, cirrhosis, Crohn's disease, or pancreatitis.

Sodium-glucose co-transporter-2 inhibitors and the risk of venous thromboembolism: A nationwide population-based study and meta-analysis

AIMS

Sodium-glucose cotransporter-2 inhibitors (SGLT-2i) have off-target effects on haemoconcentration and anti-inflammation. The impact of SGLT-2i on the risk of venous thromboembolism (VTE) in patients with diabetes mellitus (DM) remains unclear. This study aimed to evaluate the risk of newly diagnosed VTE in patients with DM using SGLT-2i in comparison to dipeptidyl peptidase-4 inhibitors (DPP-4i) or glucagon-like peptide-1 receptor agonists (GLP-1RA).

MATERIALS AND METHODS

In this nationwide retrospective cohort study, we used data from Taiwan's National Health Insurance Research Database. Patients with diabetes aged 20 years or older who received SGLT-2i, DPP-4i, or GLP-1RA between 1 May 2016, and 31 December 2020, were included. The risks of VTE in SGLT-2i users were compared with those of DPP-4i and GLP-1RA users. A Cox regression model with stabilised inverse probability of treatment weighting was used to calculate hazard ratio (HR) for VTE risk. Additionally, a meta-analysis of relevant articles published before 23 May 2023, was conducted.

RESULTS

Data from 136,530 SGLT-2i, 598,280 DPP-4i, and 5760 GLP-1RA users were analysed. SGLT-2i use was associated with a lower risk of VTE than DPP-4i (HR, 0.70; 95% CI, 0.59-0.84; p < 0·001), but not with GLP-1RA (HR, 1.39; 95% CI, 0.32-5.94; p = 0.66). Our meta-analysis further supported these findings (SGLT-2i vs. DPP-4i: HR, 0.71; 95% CI, 0.62-0.82; p < 0·001; SGLT-2i vs. GLP-1RA: HR, 0.91; 95% CI, 0.73-1.15; p = 0.43), suggesting the robustness of our retrospective analysis.

CONCLUSIONS

In patients with DM, SGLT-2i was associated with a lower risk of VTE compared to DPP-4i, but not GLP-1RA.

Risk of Incident Venous Thromboembolism Among Patients With Bullous Pemphigoid or Pemphigus Vulgaris: A Nationwide Cohort Study With Meta-Analysis

Background Bullous pemphigoid (BP) and pemphigus vulgaris (PV) share similar pathophysiology with venous thromboembolism (VTE) involving platelet activation, immune dysregulation, and systemic inflammation. Nevertheless, their associations have not been well established. Methods and Results To examine the risk of incident VTE among patients with BP or PV, we performed a nationwide cohort study using Taiwan's National Health Insurance Research Database and enrolled 12 162 adults with BP or PV and 12 162 controls. A Cox regression model considering stabilized inverse probability weighting was used to calculate the hazard ratios (HRs) for incident VTE associated with BP or PV. To consolidate the findings, a meta-analysis that incorporated results from the present cohort study with previous literature was also conducted. Compared with controls, patients with BP or PV had an increased risk for incident VTE (HR, 1.87 [95% CI, 1.55-2.26]; P<0.001). The incidence of VTE was 6.47 and 2.20 per 1000 person-years in the BP and PV cohorts, respectively. The risk for incident VTE significantly increased among patients with BP (HR, 1.85 [95% CI, 1.52-2.24]; P<0.001) and PV (HR, 1.99 [95% CI, 1.02-3.91]; P=0.04). In the meta-analysis of 8 studies including ours, BP and PV were associated with an increased risk for incident VTE (pooled relative risk, 2.17 [95% CI, 1.82-2.62]; P<0.001). Conclusions BP and PV are associated with an increased risk for VTE. Preventive approaches and cardiovascular evaluation should be considered particularly for patients with BP or PV with concomitant risk factors such as hospitalization or immobilization.

Risk of Venous Thromboembolism Among Adults With Atopic Dermatitis

Importance

The associations of atopic dermatitis (AD) with multiple cardiovascular comorbidities have been investigated because of its pathomechanisms regarding chronic systemic inflammation and potential vascular effects. Nevertheless, the association between AD and incident venous thromboembolism (VTE) in adulthood is largely unknown. This study aimed to investigate the association of AD with incident VTE.

Objective

To examine the risk of incident VTE among patients with AD.

Design, Setting, and Participants

This population-based nationwide cohort study included adults 20 years or older (adults with AD newly diagnosed between 2003 and 2017 and matched controls) from the National Health Insurance Research Database. Patients with AD were subgrouped according to the severity of the disease. A Cox regression model was used to estimate hazard ratios (HRs) for VTE. Stratified analyses according to age and sex, and a sensitivity analysis excluding systemic steroid users were performed.

Main Outcomes and Measures

Hazard ratios (HRs) for incident VTE associated with AD.

Results

This analysis included a total of 284 858 participants, with 142 429 participants each in the AD (mean [SD] age, 44.9 [18.3] years; 78 213 women) and non-AD cohorts (mean [SD] age, 44.1 [18.1] years; 79 636 women). During the follow-up, 1066 patients (0.7%) in the AD cohort and 829 patients (0.6%) in the non-AD cohort developed VTE, with incidence rates of 1.05 and 0.82 per 1000 person-years, respectively. Adults with AD had a significantly increased risk of incident VTE (HR, 1.28; 95% CI, 1.17-1.40) compared with adults without AD. Individual outcome analyses suggested that AD was associated with higher risks of deep vein thrombosis (HR, 1.26; 95% CI, 1.14-1.40) and pulmonary embolism (HR, 1.30; 95% CI, 1.08-1.57).

Conclusions and Relevance

The results of this cohort study suggest that AD in adulthood is associated with an increased risk of VTE; however, the absolute risk difference of VTE between adults with and without AD appears small. Nevertheless, cardiovascular examination and imperative management may be considered for adults with AD who present with symptoms suggestive of VTE. Future research is warranted to elucidate the pathophysiology underlying the association between AD and VTE.

Venous thromboembolism in in-hospital cirrhotic patients: A systematic review

INTRODUCTION

Patients with liver cirrhosis are at a higher risk of hospitalization. The present review aimed to assess the risk of thromboembolism and its burden on hospitalized cirrhotic patients.

MATERIALS AND METHODS

A systematic review (PROSPERO: CRD42021256869) was conducted in PubMed, Embase, Cochrane, Lilacs, and a manual search of references. It evaluated studies that compare cirrhotic patients with venous thromboembolism (VTE) with cirrhotic patients without VTE or studies that compare cirrhotic patients with non-cirrhotic patients. No restrictions were set for the date of publication or language. The last search was conducted in June 2021.

RESULTS

After selection, 17 studies were included from an initial search of 5,323 articles. The chronic liver disease etiologies comprise viral, alcohol, autoimmune, NASH (non-alcoholic steatohepatitis), cryptogenic, hemochromatosis, cholestasis, and drug-related. The included studies were conflicted regarding the outcomes of VTE, pulmonary embolism, or bleeding. Patients with cirrhosis associated with VTE had prolonged length of hospital stay, and patients with cirrhosis were at higher risk of portal thrombosis.

CONCLUSION

In-hospital cirrhotic patients are a heterogeneous group of patients that may present both thrombosis and bleeding risk. Clinicians should take extra caution to apply both prophylactic and therapeutic anticoagulation strategies.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/PROSPERO/], identifier [CRD42021256869].

Clinical predictors for thrombus progression in cirrhotic patients with untreated splanchnic vein thrombosis

INTRODUCTION

Splanchnic vein thrombosis (SVT) occurs in a heterogenous group of patients secondary to a variety of risk factors including liver disease. Minimal data regarding natural history and outcomes of SVT exists to inform management decisions. As such, there is equipoise regarding the utility of anticoagulation in cirrhotic patients with SVT. We sought to identify clinical factors predictive of new or progressive thrombosis in a cohort of patients with untreated SVT.

METHODS

We conducted a retrospective cohort study of cirrhotic patients over 18 years of age diagnosed with SVT at the Oregon Health & Science University from 2015 to 2020, excluding those initially treated with anticoagulation. The primary study endpoint was a composite of the following: imaging-confirmed progression of SVT, development of cavernous transformation, intestinal ischemia, portal cholangiopathy or new venous or arterial thrombosis.

RESULTS

261 patients were included in the analysis (median age 61 years, 68% male, 32% female). Forty percent of all patients experienced the primary composite endpoint. Multivariable logistic regression found that only the presence of pancreatitis or abdominal infection at diagnosis was associated with an increased likelihood of experiencing thrombus progression in patients with untreated SVT (OR 3.61, P = 0.02). There was a statistically significant overall survival difference between patients that did and did not experience the primary composite endpoint after controlling for confounding variables. (p = 0.0068).

CONCLUSIONS

Overall, only the presence of pancreatitis or intrabdominal infection were found to be significantly associated with thrombotic progression, with varices identified as marginally non-significant risk factor. Notably, thrombotic progression was associated with a significant reduction in overall survival.

Anticoagulation in Cirrhosis: Evidence for the Treatment of Portal Vein Thrombosis and Applications for Prophylactic Therapy

The clinical utility of anticoagulation for patients with cirrhosis and asymptomatic portal vein thrombosis (PVT) is widely debated. Complex hemostatic derangements in cirrhosis that increase risk of both bleeding and thrombosis, as well as a lack of randomized controlled data, limit conclusive assessments regarding optimal management of anticoagulation in this setting. In this review, we summarize the relevant literature pertaining to PVT in cirrhosis, including the effect of untreated PVT on the natural progression of liver disease and the overall impact of anticoagulation on clot burden and other relevant clinical outcomes. Apart from patients who are symptomatic or listed for liver transplantation, data supporting anticoagulation for the treatment of PVT is limited and without clear consensus guidelines. In patients with cirrhosis without PVT, emerging evidence for the role of prophylactic anticoagulation to mitigate the progression of fibrosis suggests an optimal risk-benefit tradeoff with decreased rates of liver decompensation and mortality, without a heightened risk of bleeding. In summation, as our understanding of the role of both prophylactic and therapeutic anticoagulation in cirrhosis continues to evolve, ongoing risk stratification of patients with asymptomatic PVT demands further attention.

Incidence and prevalence of venous thromboembolism in chronic liver disease: A systematic review and meta-analysis

BACKGROUND AND AIMS

Historically, bleeding was thought to be a frequent and fatal complication of liver disease. However, thrombosis due to coagulation disorders in cirrhosis remains a real risk. We aim to systematically analyse published articles to evaluate epidemiology of venous thromboembolism (VTE) in chronic liver disease (CLD).

METHOD

Electronic search was conducted on Ovid Medline, EMBASE and Scopus from inception to November 2021 to identify studies presenting epidemiology VTE (deep vein thrombosis and pulmonary embolism) in CLD in inpatients and/or community settings. Random-effects meta-analysis was performed to determine pooled per-year cumulative incidence, incidence rate and prevalence. Heterogeneity was measured by I² test, and, potential sources of heterogeneity by meta-regression and sensitivity analysis. PROSPERO registration-CRD42021239117.

RESULTS

Twenty-nine studies comprising 19,157,018 participants were included, of which 15,2049 (0.79%) had VTE. None of the included studies were done in the community. In hospitalised patients with CLD: pooled cumulative incidence of VTE was 1.07% (95% CI 0.80,1.38) per-year, incidence rate was 157.15 (95% CI 14.74,445.29) per 10,000 person-years, and period prevalence was 1.10% (95% CI 0.85,1.38) per year. There was significant heterogeneity and publication bias. Pooled relative risk (RR) of studies reporting incidence rate was 2.11 (95% CI 1.35,3.31). CLD patients (n = 1644), who did not receive pharmacological prophylaxis were at 2.78 times (95% CI 1.11, 6.98) increased risk of VTE compared to those receiving prophylaxis.

CONCLUSION

Hospitalised patients with CLD may be at an increased risk of VTE. For every 1000 hospitalised patients with CLD ten have new, and eleven have pre-existing diagnoses of VTE per-year.

EASL Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis

The prevention and management of bleeding and thrombosis in patients with cirrhosis poses several difficult clinical questions. These Clinical Practice Guidelines have been developed to provide practical guidance on debated topics, including current views on haemostasis in liver disease, controversy regarding the need to correct thrombocytopenia and abnormalities in the coagulation system in patients undergoing invasive procedures, and the need for thromboprophylaxis in hospitalised patients with haemostatic abnormalities. Multiple recommendations in this document are based on interventions that the panel feels are not useful, even though widely applied in clinical practice.

Clinical Characteristics and Outcomes of Decompensated Cirrhosis Patients Admitted to Hospitals With Acute Pulmonary Embolisms: A Nationwide Analysis

Introduction: Cirrhosis is a significant cause of mortality and morbidity worldwide. Recent studies suggested that cirrhosis is associated with an increased risk of venous thromboembolism (VTE), which disproves the old belief that chronic liver disease coagulopathy is considered protective against VTE. We conducted a retrospective study which is to our knowledge the first of its kind to assess clinical characteristics and outcomes of decompensated cirrhosis (DC) patients admitted with acute pulmonary embolism (APE).

Methodology: We used the National Inpatient Sample database for the years 2016-2019. All adults admitted to the hospitals with a primary diagnosis of APE were included. Patients less than 18 years old, missing race, gender, or age were excluded. Patients were divided into two groups, either having DC or not. A multivariate logistic regression model was built by using only variables associated with the outcome of interest on univariable regression analysis at P < 0.05.

Results: 142 million discharges were included in the NIS database between the years 2016 and 2019, of which 1,294,039 met the study inclusion criteria, 6,200 patients (0.5%) had DC. For adult patients admitted to the hospitals with APE, odds of inpatient all-cause mortality were higher in the DC group than in patients without DC; OR of 1.996 (95% CI, 1.691-2.356, P-value < 0.000). Also, vasopressor use, mechanical ventilation, and cardiac arrest were more likely to occur in the DC group, OR of 1.506 (95% CI, 1.254-1.809, P-value < 0.000), OR of 1.479 (95% CI, 1.026-2.132, P-value 0.036), OR of 1.362 (95% CI, 1.050-1.767, P-value 0.020), respectively. In addition, DC patients tend to have higher total hospital charges and longer hospital length of stay, coefficient of 14521 (95% CI, 6752-22289, P-value < 0.000), and a coefficient of 1.399 (95% CI, 0.848-1.950, P-value < 0.000), respectively.

Conclusion: This study demonstrates that DC is a powerful predictor of worse hospital outcomes in patients admitted with APE. An imbalance between clotting factors and natural anticoagulants produced by the liver is believed to be the primary etiology of thrombosis in patients with DC. The burden of APE can be much more catastrophic in cirrhotic than in non-cirrhotic patients; therefore, those patients require closer monitoring and more aggressive treatment.

Association between Hyperosmolar Hyperglycemic State and Venous Thromboembolism in Diabetes Patients: A Nationwide Analysis in Taiwan

Background: Previous studies in Western countries have shown that a hyperosmolar hyperglycemic state (HHS) is associated with an increased risk of venous thromboembolism (VTE); in these cases, prophylactic anticoagulant treatment is suggested. However, the association between HHS and VTE in Asian populations remains undetermined. Therefore, we aimed to evaluate whether HHS is associated with an increased risk of VTE in diabetic Taiwanese patients. Methods: This nationwide, population-based, retrospective cohort study was conducted using the Taiwan National Health Insurance Research Database. We enrolled a total of 4,723,607 admission records of patients with diabetes diagnosed with one or more of seven common diseases (pneumonia, urinary tract infection, sepsis, heart disease, stroke, malignancy, and respiratory tract disease) between 2001 and 2018 in Taiwan. The patients were divided into two groups based on the presence (n = 46,000) or absence (n = 4,677,607) of HHS. We estimated the adjusted odds ratio (aOR) for developing VTE within 90 days after the index hospitalization using multivariable logistic regression with generalized estimating equations accounting for repeated measures. Results: Overall, patients admitted with HHS had a similar risk of VTE compared with those admitted without HHS (408/46,000 vs. 39,345/4,677,607; aOR = 1.06, 95% CI: 0.97–1.17, p = 0.190). A similar non-significant association between HHS and VTE was found regardless of age and sex subgroups. Conclusions: There was no significant association between HHS and overall VTE risk in patients with diabetes in Taiwan. The results of our study may not support the use of prophylactic anticoagulant therapy in diabetic Taiwanese patients with HHS.

A Review on Clinical, Pathophysiological, and Diagnostic Hematological Features in Children With Liver Cirrhosis

Appropriate diagnostic and therapeutic measures for liver cirrhosis is critical, particularly in children. In the present review, a comprehensive approach was provided toward hematological parameters in pediatric liver cirrhosis. The literature search included MeSH terms "liver cirrhosis" and "hepatic cirrhosis" and databases such as PubMed, Web of Science, Scopus, and Google Scholar were searched up until December 2017. Hematologic changes in the liver cirrhosis mainly encompassed anemia and coagulopathies. In addition, bleeding diathesis was considered as the most clinical complication in these patients. In addition to reduced coagulation factors, hyperfibrinolysis is a common feature in childhood cirrhosis and may be an important contributor to the risk of bleeding. Based on the results, children with liver cirrhosis also demonstrated a procoagulant state at laboratory and clinical levels. This may be partly due to a reduction in coagulation inhibitors such as anti-thrombin, C1 inhibitor, and α1-antitrypsin in children with cirrhosis. The portal vein thrombosis and portal hypertension are considered as the most clinical presentations of the hypercoagulable state. Further, children with liver cirrhosis complicated with portal hypertension usually show leukopenia, anemia, and thrombocytopenia due to hypersplenism. Although the etiology of childhood and adult cirrhosis may be different, their hematological compilations and clinicopathological features are somehow similar.

Who Orders a Head CT?: Perceptions of the Cirrhotic Bleeding Risk in an International, Multispecialty Survey Study

OBJECTIVE

Traditional coagulopathic indices, including elevated international normalized ratio, do not correlate with bleeding risk in patients with cirrhosis. For this reason, head computed tomography (CT) has a low yield in cirrhotic patients with altered mental status and no trauma history. The initial diagnostic evaluation, however, is often made by nongastroenterologists influenced by the so-called "coagulopathy of cirrhosis." We sought to examine the prevalence, impact, and malleability of this perception in an international, multispecialty cohort.

DESIGN

An electronic survey was distributed to internal medicine, surgery, emergency medicine, and gastroenterology physicians. Respondents were presented with a cirrhotic patient with hepatic encephalopathy, no history of trauma, and a nonfocal neurological examination. Respondents rated likelihood to order head CT at presentation, after obtaining labs [international normalized ratio (INR) 2.4 and platelets 59×10/μL], and finally after reading the results of a study demonstrating the low yield of head CT in this setting.

RESULTS

In total, 1286 physicians from 6 countries, 84% from the United States. Of these, 62% were from internal medicine, 25% from emergency medicine, 8% from gastroenterology, and 5% from surgery. Totally, 47% of respondents were attending physicians. At each timepoint, emergency physicians were more likely, and gastroenterologists less likely, to scan than all other specialties (P<0.0001). Evidence on the low yield of head CT reduced likelihood to scan for all specialties. Qualitative analysis of open-ended comments confirmed that concern for "coagulopathy of cirrhosis" motivated CT orders.

CONCLUSIONS

Perceptions regarding the coagulopathy of cirrhosis, which vary across specialties, impact clinical decision-making. Exposure to clinical evidence has the potential to change practice patterns.

Association between Chronic Kidney Disease and Risk of Cataract: A Nationwide Retrospective Cohort Study

BACKGROUND

Previous studies have established a relationship between chronic kidney disease (CKD) and cataract, but the relationship between the severity of renal impairment and risk of cataract is uncertain. This study investigates the relationship between the severity of renal disease and cataract in a nationwide sample from Taiwan.

METHODS

The cohort from 1-million National Health Insurance beneficiaries from Taiwan was retrospectively analyzed. All adult beneficiaries were followed from January 1, 2005 until December 31, 2013, to identify patients who underwent cataract surgeries. On the basis of the ambulatory care records, those diagnosed with CKD (ICD-9-CM code: 585) during the follow-up period were enrolled as CKD patients after careful evaluation. Each patient with CKD was age- and gender-matched with 4 individuals who did not have CKD. Cox regression models were applied to compare the hazard of cataract surgery in individuals with and without CKD. Subgroup analysis was used to compare patients with end-stage renal disease (ESRD) with age- and gender-matched non-CKD individuals. ESRD was defined by CKD patients who need regular renal replacement therapy. The same method was applied to evaluate hazard ratios (HRs).

RESULTS

After age and gender matching, there were 11,881 patients in the CKD group and 47,524 in the non-CKD group. After control for possible confounding, the adjusted HR (aHR) of cataract was 1.84 (95% CI 1.73-1.95) for the CKD group. Subgroup analysis of patients with ESRD (n = 3,209) and non-CKD individuals (n = 12,836), with matching done on the basis of age and gender, indicated an aHR of cataract was 2.33 (95% CI 2.10-2.59) for the ESRD group.

CONCLUSIONS

This study indicates a relationship between CKD and cataract, and suggests that the risk for cataract increases with the severity of renal impairment.

The risk of venous thromboembolism in patients with cirrhosis. A systematic review and meta-analysis

Some studies suggest that patients with cirrhosis have an increased risk of deep venous thrombosis (DVT) and pulmonary embolism (PE). Unfortunately, available data on this association are contrasting. It was the objective of this study to perform a systematic review and meta-analysis of literature to evaluate the risk of venous thromboembolism (VTE) associated with cirrhosis. Studies reporting on VTE risk associated with cirrhosis were systematically searched in the PubMed, Web of Science, Scopus and EMBASE databases. Eleven studies (15 data-sets) showed a significantly increased VTE risk in 695,012 cirrhotic patients as compared with 1,494,660 non-cirrhotic controls (OR: 1.703; 95 %CI: 1.333, 2.175; P<0.0001). These results were confirmed when specifically considering the risk of DVT (7 studies, OR: 2.038; 95 %CI: 1.817, 2.285; P<0.0001) and the risk of PE (5 studies, OR: 1.655; 95 %CI: 1.042, 2.630; p=0.033). The increased VTE risk associated with cirrhosis was consistently confirmed when analysing nine studies reporting adjusted risk estimates (OR: 1.493; 95 %CI: 1.266, 1.762; p<0.0001), and after excluding studies specifically enrolling populations exposed to transient risk factors for VTE (OR: 1.689; 95 %CI: 1.321, 2.160; p<0.0001). Meta-regression models suggested that male gender may significantly impact on the risk of VTE associated with cirrhosis. Results of our meta-analysis suggest that cirrhotic subjects may exhibit an increased risk of VTE. This should be considered to plan specific prevention strategies in this clinical setting.

Effect of glycemic control on the risk of pancreatic cancer: A nationwide cohort study

Although the relationship between diabetes and pancreatic cancer has been studied, the effects of glycemic control on pancreatic cancer have never been evaluated. This study investigates the relationship between glycemic control and pancreatic cancer.Data from 1 million National Health Insurance beneficiaries were screened. The study cohort consisted of 46,973 diabetic patients and 652,142 nondiabetic subjects. Of the patients with diabetes, 1114 who had been admitted for hyperglycemic crisis episodes were defined as having poorly controlled diabetes. All adult beneficiaries were followed from January 1, 2005 to December 31, 2013, to determine whether pancreatic cancer was diagnosed. The Cox regression model was applied to compare the adjusted hazards for potential confounders.After controlling for age, sex, urbanization level, socioeconomic status, chronic liver disease, hypertension, coronary artery disease, hyperlipidemia, malignancies, smoking, chronic obstructive pulmonary disease, obesity, history of alcohol intoxication, chronic renal insufficiency, biliary tract disease, chronic pancreatitis, Charlson Comorbidity Index score, and high-dimensional propensity score, the adjusted hazard ratio of pancreatic cancer was 2.53 (95% confidence interval 1.96-3.26) in patients with diabetes. In diabetic patients with poor glycemic control, the hazard ratio of pancreatic cancer was significantly higher (hazard ratio 3.61, 95% confidence interval 1.34-9.78).This cohort study reveals a possible relationship between diabetes and pancreatic cancer. Moreover, poorly controlled diabetes may be associated with a higher possibility of pancreatic cancer.

Direct Oral Anticoagulants in Cirrhosis Patients Pose Similar Risks of Bleeding When Compared to Traditional Anticoagulation

BACKGROUND AND AIMS

Direct oral anticoagulants (DOAC) are important new anticoagulant therapies that are not well studied in patients with chronic liver disease. The aim of this study was to compare rates of bleeding in cirrhosis patients treated with DOAC (factor Xa inhibitors: rivaroxaban and apixaban) to those in cirrhosis patients treated with traditional anticoagulation (warfarin and low molecular weight heparin).

METHODS

We identified a total of 39 patients with cirrhosis who received anticoagulation therapy over a 3-year period (20 DOAC and 19 traditional anticoagulation) from a research database. Medical records were reviewed to obtain clinical data to compare between the groups.

RESULTS

Clinical characteristics between the two groups were similar. There were three documented bleeding events in the traditional anticoagulation group and four bleeding events in the DOAC group (p = 0.9). There were two major bleeding events in the traditional anticoagulation group and one major bleeding event in the DOAC group. There were no documented reports of drug-induced liver injury during this study period. Among all patients, no significant predictors of bleeding were identified using univariate regression and Cox proportional hazard modeling.

CONCLUSIONS

This is the first clinical study evaluating the use of DOAC in patients with cirrhosis. DOAC display similar safety characteristics when compared to traditional anticoagulation in patients with cirrhosis and are potentially attractive agents for anticoagulation therapy. Larger studies are now needed to better understand the safety and efficacy of these agents in cirrhosis.

Autoimmune conditions are associated with perioperative thrombotic complications in liver transplant recipients: A UNOS database analysis

BACKGROUND

End stage liver disease (ESLD) is associated with significant thrombotic complications. In this study, we attempted to determine if patients with ESLD, due to oncologic or autoimmune diseases, are susceptible to thrombosis to a greater extent than patients with ESLD due to other causes.

METHODS

In this retrospective study, we analyzed the UNOS database to determine the incidence of thrombotic complications in orthotopic liver transplant (OLT) recipients with autoimmune and oncologic conditions. Between 2000 and 2012, 65,646 OLTs were performed. We found 4,247 cases of preoperative portal vein thrombosis (PVT) and 1,233 cases of postoperative vascular thrombosis (VT) leading to graft failure.

RESULTS

Statistical evaluation demonstrated that patients with either hepatocellular carcinoma (HCC) or autoimmune hepatitis (AIC) had a higher incidence of PVT (p = 0.05 and 0.03 respectively). Patients with primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC) and AIC had a higher incidence of postoperative VT associated with graft failure (p < 0.0001, p < 0.0001, p = 0.05 respectively). Patients with preoperative PVT had a higher incidence of postoperative VT (p < 0.0001). Multivariable logistic regression demonstrated that patients with AIC, and BMI ≥40, having had a transjugular intrahepatic portosystemic shunt, and those with diabetes mellitus were more likely to have preoperative PVT: odds ratio (OR)(1.36, 1.19, 1.78, 1.22 respectively). Patients with PSC, PBC, AIC, BMI ≤18, or with a preoperative PVT were more likely to have a postoperative VT: OR (1.93, 2.09, 1.64, 1.60, and 2.01, respectively).

CONCLUSION

Despite the limited number of variables available in the UNOS database potentially related to thrombotic complications, this analysis demonstrates a clear association between autoimmune causes of ESLD and perioperative thrombotic complications. Perioperative management of patients at risk should include strategies to reduce the potential for these complications.

Increased risk of ischemic stroke in patients with burn injury: a nationwide cohort study in Taiwan

Background

Conflicting results have been obtained by studies attempting to assess the risks of ischemic stroke in patients with burn injury, while the long-term risk of stroke in survivors of burn injury remains unexplored. We evaluated whether the risk of ischemic stroke in patients hospitalized with burn injury in Taiwan is higher when compared to the general population.

Methods

The data from one million National Health Insurance (NHI) adult beneficiaries were evaluated from January 1, 2005 until December 31, 2012 to identify those who developed ischemic stroke. Each identified patient with burn injury was matched with one hundred unexposed patients based on a high-dimensional propensity score. Cox regression models were applied to compare the risks of the development of ischemic stroke in the matched cohorts.

Results

A total of 743,237 patients were enrolled. After matching, 1,763 burn injury patients and 176,300 unexposed patients were selected and compared. The adjusted hazard ratio of ischemic stroke was significantly increased in burn injury patients (1.84; 95 % CI, 1.43–2.36). A subgroup analysis based on patients who survived longer than 12 months in the matched cohort also revealed higher hazard ratio in the burn injury patients (1.54; 95 % CI, 1.11–2.13).

Conclusion

The risk of ischemic stroke is significantly higher in patients hospitalized with burn injury than in the general population, and these risks may extend longer than expected.

Bidirectional Relationship Between Diabetes and Acute Pancreatitis: A Population-Based Cohort Study in Taiwan

The proposed bidirectional relationship between acute pancreatitis (AP) and diabetes has never been examined with the same source of data. Furthermore, the effects of disease severity on this relationship have not been fully evaluated. The present study employed the findings from a single database to measure the strength of the association between AP and diabetes.Findings from 1 million National Health Insurance beneficiaries were utilized. Two cohort studies with this database were selected to evaluate the linkage between diabetes and AP. The first cohort analysis addressed the risk of AP among diabetic patients and was comprised of 42,080 diabetic patients and 672,146 unexposed subjects. The second cohort analysis considered the risk of diabetes among patients with AP and enrolled 3187 patients with AP and 709259 unexposed subjects. All adult beneficiaries were followed from January 1, 2005 to December 31, 2012 to identify outcomes of interest. Cox regression models were applied to compare hazards adjusted for potential confounders.For the first cohort, the adjusted hazard ratio (HR) of AP was significantly increased by the presence of diabetes (1.72; 95% confidence interval [CI], 1.52-1.96). In diabetic patients with a history of hyperglycemic crisis episodes (HCEs), the HR was even higher (6.32; 95% CI, 4.54-8.81). For the second cohort, the adjusted HR of diabetes in patients with AP was increased compared to the general population (2.15; 95% CI, 1.92-2.41). For patients with severe AP, the HR was also higher (2.22; 95% CI, 1.50-3.29) but did not differ significantly from that for patients with nonsevere AP.The 2 cohort studies provided evidence for the bidirectional relationship between diabetes and AP. Moreover, diabetic patients with history of HCEs may be associated with higher risk of AP.

End-tidal carbon dioxide monitoring may be associated with a higher possibility of return of spontaneous circulation during out-of-hospital cardiac arrest: a population-based study

Background

During cardiac arrest, end-tidal carbon dioxide (ETCO₂) monitoring is recommended as a chest compression performance indicator. However, its frequency of use during out-of-hospital cardiac arrest (OHCA) and its benefits have never been evaluated in real clinical situations.

Objective

We investigated OHCA patients in Taiwan to evaluate the frequency of ETCO₂ monitoring and its effects on sustained return of spontaneous circulation (ROSC).

Methods

We sampled the Taiwan National Health Insurance claims database, which contains 1 million beneficiaries. All adult beneficiaries older than 18 years who presented with OHCA and received chest compression between 1 January 2005 and 31 December 2012 were enrolled. We further identified patients with ETCO₂ monitoring and matched each 1 with 20 patients who did not receive ETCO₂ monitoring based on their propensity scores. A simple conditional logistic regression model was applied to compare the odds ratio (OR) for sustained ROSC in the matched cohorts.

Results

A total of 5041 OHCA patients were enrolled. The frequency of ETCO₂ monitoring has increased since 2010 but still is low. After matching, 53 patients with ETCO₂ monitoring and 1060 without ETCO₂ monitoring were selected. The OR of sustained ROSC in the ETCO₂ group was significantly increased (2.38, 95 % CI 1.28–4.42).

Conclusion

Patients who received ETCO₂ monitoring during OHCA had a higher possibility of sustained ROSC, but the overall use of ETCO₂ monitoring is still low despite strong recommendations for its use.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-015-0187-y) contains supplementary material, which is available to authorized users.

Hepatitis C Virus Infection Associated With an Increased Risk of Deep Vein Thrombosis: A Population-Based Cohort Study

The association between the hepatitis C virus (HCV) infection and the risk of myocardial infarction (MI) and stroke has been previously investigated. However, the association between the HCV infection and the risk of venous thromboembolism (VTE) has not been extensively discussed. Using the Longitudinal Health Insurance Database 2000 (LHID2000), we selected 3686 patients with newly diagnosed HCV infection. We randomly selected 14,744 people with no HCV or hepatitis B virus (HBV) infection as comparison group and frequency matched them with patients with HCV infection according to their age, sex, and index year. The incidence density rates and hazard ratios (HRs) of deep vein thrombosis (DVT) and pulmonary embolism (PE) were calculated until the end of 2011. The mean follow-up duration of 5.14 years for the HCV cohort and 5.61 years for the non-HCV cohort, the overall incidence density rates of DVT were 7.92 and 3.51 per 10,000 person-years in the non-HCV group, and the HCV groups, respectively (crude HR = 2.25; 95% confidence interval [CI] = 1.21-4.21). After adjusted for age, sex, and comorbidities, the risk of DVT remained significantly higher in the HCV group than in the non-HCV group (adjusted HR = 1.96; 95% CI = 1.03-3.73). The overall incidence density rates of PE in the HCV and non-HCV groups were not significantly different (crude HR = 2.20; 95% CI = 0.94-5.14). HCV infection is associated with the risk of DVT in a long-term follow-up period.

The effect of chronic liver disease on venous thromboembolism among medically managed patients in Singapore General Hospital

BACKGROUND

Chronic liver disease (CLD) has been suggested to be associated with venous thromboembolism (VTE) in western populations. However, little is known about the risk effects of CLD on VTE among Asians.

OBJECTIVE

To compute the prevalence of VTE among hospitalised Asian patients, and to evaluate the pattern and scale of risk effects of CLD on VTE occurrence.

METHOD

Retrospective study of hospital discharge database from 2004 to 2011 to identify patients with VTE and CLD using International Statistical Classification of Diseases and Related Health Problems, 9th Revision, Australian Modification (ICD-9-AM) codes.

RESULTS

Of 199904 medically managed inpatients during the 8years, 1744 (0.9%) patients had VTE. Patients with CLD had significant higher prevalence of VTE (non-cirrhosis CLD 1.5%, cirrhosis 2.0%) than patients without CLD (0.8%, p<0.001). In the logistic regression analyses, non-cirrhosis CLD (odds ratio, OR 1.4, 95% CI 1.2-1.7, p<0.001) and cirrhosis (OR 1.5, 95% CI 1.2-2.0, p=0.002) were significant predictors of VTE after adjustment for age, gender, ethnicity, hospital long stayer, cancer, infectious disease, and other comorbid conditions such as diabetic mellitus, anaemia, and cardiovascular, cerebrovascular, renal and pulmonary diseases.

CONCLUSION

CLD, particular liver cirrhosis, increases the risks of VTE in hospitalised Asian patients. As CLD patients are perceived to be at risks of bleeding due to the prolonged clotting times and thrombocytopenia, the results of this study brings attention to opposite end of the haemostatic pendulum in patients with chronic liver disease.