1
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Balaceanu LA, Dina I. D-dimers in advanced liver cirrhosis: Useful biomarker or not? Am J Med Sci 2024:S0002-9629(24)01264-3. [PMID: 38788925 DOI: 10.1016/j.amjms.2024.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 02/03/2024] [Accepted: 05/20/2024] [Indexed: 05/26/2024]
Abstract
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.
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Affiliation(s)
- Lavinia Alice Balaceanu
- Internal Medicine Department, "Carol Davila" University of Medicine and Pharmacy, Emergency Clinical Hospital "Sf. Ioan," Bucharest, Romania.
| | - Ion Dina
- Gastroenterology Department, "Carol Davila" University of Medicine and Pharmacy, Emergency Clinical Hospital "Sf. Ioan," Bucharest, Romania
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2
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Kampelos G, Alexopoulos T, Vasilieva L, Mani I, Hadziyannis E, Giannouli S, Manioudaki S, Nomikou E, Alexopoulou A. A combination of clot formation abnormalities in thromboelastometry has a high prognostic value in patients with acute-on-chronic liver failure. Eur J Gastroenterol Hepatol 2024; 36:76-82. [PMID: 37823404 DOI: 10.1097/meg.0000000000002630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
BACKGROUND Global coagulation tests offer a better tool to assess procoagulant and anticoagulant pathways, fibrinolysis and clot firmness and evaluate more accurately coagulation defects compared to conventional coagulation tests. Their prognostic role in acute-on-chronic liver disease (ACLF) or acute decompensation (AD) has not been well established. AIMS To assess the properties and prognostic value of the coagulation profile measured by rotational thromboelastometry (ROTEM) in ACLF and AD. METHODS 84 consecutive patients (35 ACLF and 49 AD) were prospectively studied. Twenty healthy persons matched for age and gender were used as controls. 'Hypocoagulable' or 'hypercoagulable' profiles on admission were assessed based on nine ROTEM parameters and mortality was recorded at 30 and 90 days. RESULTS Individual ROTEM parameters denoted significantly more hypocoagulability in patients compared to controls. 'Hypocoagulable' profile (defined as a composite of 4 or more ROTEM parameters outside the range) was associated with more severe liver disease assessed either as MELD or Child-Pugh scores ( P < 0.001 for both) and higher 30-day mortality (Log-rank P = 0.012). 'Hypocoagulable' profile (HR 3.160, 95% CI 1.003-9.957, P = 0.049) and ACLF status (HR 23.786, 95% CI 3.115-181.614, P = 0.002) were independent predictors of 30-day mortality, in multivariate model. A higher early mortality rate was shown in ACLF patients with 'hypocoagulable' phenotype compared to those without (Log-rank P = 0.017). 'Hypocoagulable' profile was not associated with mortality in AD. CONCLUSION 'Hypocoagulable' profile was associated with more advanced liver disease and higher short-term mortality in patients with ACLF.
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Affiliation(s)
- George Kampelos
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, National & Kapodistrian University of Athens, Hippokration General Hospital
| | - Theodoros Alexopoulos
- Gastroenterology Department, National & Kapodistrian University of Athens, Medical School, Laiko General Hospital
| | | | - Iliana Mani
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, National & Kapodistrian University of Athens, Hippokration General Hospital
| | - Emilia Hadziyannis
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, National & Kapodistrian University of Athens, Hippokration General Hospital
| | - Stavroula Giannouli
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, National & Kapodistrian University of Athens, Hippokration General Hospital
| | | | - Efrosyni Nomikou
- Blood Bank and Haemophilia Unit, Hippokratio General Hospital of Athens, Athens, Greece
| | - Alexandra Alexopoulou
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, National & Kapodistrian University of Athens, Hippokration General Hospital
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3
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Tomić Mahečić T, Baronica R, Mrzljak A, Boban A, Hanžek I, Karmelić D, Babić A, Mihaljević S, Meier J. Individualized Management of Coagulopathy in Patients with End-Stage Liver Disease. Diagnostics (Basel) 2022; 12:diagnostics12123172. [PMID: 36553179 PMCID: PMC9777026 DOI: 10.3390/diagnostics12123172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/02/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Over the last decades, individualized approaches and a better understanding of coagulopathy complexity in end-stage liver disease (ESLD) patients has evolved. The risk of both thrombosis and bleeding during minimally invasive interventions or surgery is associated with a worse outcome in this patient population. Despite deranged quantitative and qualitative coagulation laboratory parameters, prophylactic coagulation management is unnecessary for patients who do not bleed. Transfusion of red blood cells (RBCs) and blood products carries independent risks for morbidity and mortality, including modulation of the immune system with increased risk for nosocomial infections. Optimal coagulation management in these complex patients should be based on the analysis of standard coagulation tests (SCTs) and viscoelastic tests (VETs). VETs represent an individualized approach to patients and can provide information about coagulation dynamics in a concise period of time. This narrative review will deliver the pathophysiology of deranged hemostasis in ESLD, explore the difficulties of evaluating the coagulopathies in liver disease patients, and examine the use of VET assays and management of coagulopathy using coagulation factors. Methods: A selective literature search with PubMed as the central database was performed with the following.
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Affiliation(s)
- Tina Tomić Mahečić
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, and Pain Treatment, University Hospital Center Zagreb, 10000 Zagreb, Croatia
- Correspondence: ; Tel.: +385-98-457-189
| | - Robert Baronica
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, and Pain Treatment, University Hospital Center Zagreb, 10000 Zagreb, Croatia
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Anna Mrzljak
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
- Liver Transplant Center, Department of Gastroenterology and Hepatology, University Hospital Center Zagreb, 10000 Zagreb, Croatia
| | - Ana Boban
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
- Department of Hematology, University Hospital Center Zagreb, 10000 Zagreb, Croatia
| | - Ivona Hanžek
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, and Pain Treatment, University Hospital Center Zagreb, 10000 Zagreb, Croatia
| | - Dora Karmelić
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, and Pain Treatment, University Hospital Center Zagreb, 10000 Zagreb, Croatia
| | - Anđela Babić
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, and Pain Treatment, University Hospital Center Zagreb, 10000 Zagreb, Croatia
| | - Slobodan Mihaljević
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, and Pain Treatment, University Hospital Center Zagreb, 10000 Zagreb, Croatia
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Jens Meier
- Clinic of Anesthesiology and Intensive Care Medicine, Kepler University Clinic, Johannes Kepler University, 4040 Linz, Austria
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4
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Aimagambetov MZ, Orazgalieva MT, Omarov NB, Zhanybekov SD, Orazalina AS. Blood Disorders in Patients with Obstructive Jaundice: A Literature Review. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.10470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND: Mechanical jaundice is a pathological syndrome consisting in a violation of the outflow of hepatic bile through the bile ducts into the duodenum due to mechanical obstacles. The most common causes of mechanical jaundice are gallstone disease, malignant tumors, as well as cicatricial stricture of the bile duct or the large duodenal papilla of the duodenum. All this leads to the development of renal-hepatic insufficiency. Thrombohemorrhagic changes develop in the vascular bed, leading to the development of disseminated intravascular coagulation syndrome. Prevention and treatment of cholemic bleeding in case of mechanical jaundice remains one of the complex problems of hepatobiliary surgery. This article is an overview of the causes and pathophysiological changes affecting hemostasis in mechanical jaundice, as well as the main points of treatment of hemostasis disorders in patients with mechanical jaundice.
AIM: This study aims to study the literature on homeostasis in patients with mechanical jaundice.
SEARCH STRATEGY: To conduct a systematic search for scientific information and to achieve this goal, an analysis of scientific publications in evidence-based medicine databases (PubMed), using specialized search engines (Google Scholar) and in electronic scientific libraries (CyberLeninka, e-library) was carried out from 2005 to 2020.
INCLUSION CRITERIA: Research of high methodological quality: Meta-analysis, systematic review and cohort studies, as well as publications with clearly formulated and statistically proven conclusions in English, Russian, and Kazakh.
EXCLUSION CRITERIA: Summaries of reports, reports in the form of abstracts, and advertising articles.
RESULTS: The mechanisms that affect hemostasis in obstructive jaundice can be considered from four perspectives: The first relates to Vitamin K deficiency in obstructive jaundice, the second describes the effect of ongoing fibrosis and cirrhosis of the liver on hemostasis, the third analyzes the relationship between infectious-septic mechanisms and the hemostasis system, their clinical significance in patients with obstructive jaundice, and the latter involves the analysis of specific factors that manifest obstructive jaundice and may themselves affect the blood coagulation system.
CONCLUSION: Understanding the pathophysiology of hemostatic changes in patients with cholestasis and, more generally, liver disease is a clear way to accurate diagnosis and treatment. The combination of good knowledge with careful examination of each patient can lead to the most promising result.
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5
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[Clinical presentation of bleeding in critically ill patients in the intensive care unit : Organ systems and clinical implications]. Med Klin Intensivmed Notfmed 2021; 116:482-490. [PMID: 34427697 DOI: 10.1007/s00063-021-00845-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 07/09/2021] [Indexed: 10/20/2022]
Abstract
Bleedings are frequent and clinically important complications in critically ill patients in the intensive care unit, and-depending on location and intensity-are associated with high morbidity and mortality. The clinical impact of different bleeding entities is affected by the location (e.g. intracerebral bleedings), the severity (e.g. fulminant variceal bleeding) and the incidence (e.g. gastrointestinal bleeding) of the respective bleeding type. Therapy varies among bleeding entities, but consists of stabilization of the patient, control of the bleeding, and prevention of complications. This review describes relevant therapeutic aspects of selected bleeding complications in critically ill patients.
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6
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Pradhan-Sundd T, Gudapati S, Kaminski TW, Ragni MV. Exploring the Complex Role of Coagulation Factor VIII in Chronic Liver Disease. Cell Mol Gastroenterol Hepatol 2021; 12:1061-1072. [PMID: 33705963 PMCID: PMC8342958 DOI: 10.1016/j.jcmgh.2021.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/25/2021] [Accepted: 02/25/2021] [Indexed: 12/22/2022]
Abstract
Chronic liver disease is one of the leading causes of death in the United States. Coagulopathy is often a sequela of chronic liver disease, however, the role and regulation of coagulation components in chronic liver injury remain poorly understood. Clinical and experimental evidence indicate that misexpression of the procoagulant factor VIII (FVIII) is associated with chronic liver disease. Nevertheless, the molecular mechanism of FVIII-induced chronic liver injury progression remains unknown. This review provides evidence supporting a pathologic role for FVIII in the development of chronic liver disease using both experimental and clinical models.
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Affiliation(s)
- Tirthadipa Pradhan-Sundd
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, Pittsburgh, Pennsylvania; Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Shweta Gudapati
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, Pittsburgh, Pennsylvania
| | - Tomasz W Kaminski
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, Pittsburgh, Pennsylvania
| | - Margaret V Ragni
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, Pittsburgh, Pennsylvania; Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Hemophilia Center of Western Pennsylvania, Pittsburgh, Pennsylvania
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7
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Hayashi M, Sugaya T, Fujita M, Nakamura J, Imaizumi H, Abe K, Takahashi A, Takagi T, Hikichi T, Ohira H. Sigmoid Colon Varices due to Massive Thrombosis of a Noncirrhotic Extrahepatic Portosystemic Shunt. Intern Med 2020; 59:2705-2710. [PMID: 32669497 PMCID: PMC7691034 DOI: 10.2169/internalmedicine.4925-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
A 33-year-old man presented with hepatic encephalopathy and was diagnosed to have a noncirrhotic extrahepatic portosystemic shunt (NCPSS). He presented with abdominal pain 16 months after the NCPSS diagnosis. Computed tomography revealed thrombosis between the intrahepatic portal vein and the left internal iliac vein, including the NCPSS, and varices of the sigmoid colon. Thrombosis was treated with danaparoid sodium and antithrombin III followed by edoxaban. After treatment, the thrombosis disappeared from the intrahepatic portal vein, but it remained in the NCPSS. The sigmoid colon varices were followed up without any treatment. Follow-up is needed in NCPSS patients in order to make an early detection of complications.
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Affiliation(s)
- Manabu Hayashi
- Department of Gastroenterology, Fukushima Medical University, Japan
| | - Tatsuro Sugaya
- Department of Gastroenterology, Fukushima Medical University, Japan
| | - Masashi Fujita
- Department of Gastroenterology, Fukushima Medical University, Japan
| | - Jun Nakamura
- Department of Gastroenterology, Fukushima Medical University, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Japan
| | - Hiromichi Imaizumi
- Department of Gastroenterology, Fukushima Medical University, Japan
- Department of Internal Medicine, Iwase General Hospital, Japan
| | - Kazumichi Abe
- Department of Gastroenterology, Fukushima Medical University, Japan
| | | | - Tadayuki Takagi
- Department of Gastroenterology, Fukushima Medical University, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University, Japan
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8
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Noronha Ferreira C, Marinho RT, Cortez-Pinto H, Ferreira P, Dias MS, Vasconcelos M, Alexandrino P, Serejo F, Pedro AJ, Gonçalves A, Palma S, Leite I, Reis D, Damião F, Valente A, Xavier Brito L, Baldaia C, Fatela N, Ramalho F, Velosa J. Incidence, predictive factors and clinical significance of development of portal vein thrombosis in cirrhosis: A prospective study. Liver Int 2019; 39:1459-1467. [PMID: 31021512 DOI: 10.1111/liv.14121] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 04/01/2019] [Accepted: 04/14/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS The role of portal vein thrombosis (PVT) in the natural history of cirrhosis is controversial. There are few prospective studies validating risk factors for development of PVT. We analysed the incidence, factors associated with PVT development and its influence on cirrhosis decompensations and orthotopic liver transplant (OLT)-free survival. METHODS In this prospective observational study between January 2014 and March 2019, 445 consecutive patients with chronic liver disease were screened and finally 241 with cirrhosis included. Factors associated with PVT development and its influence on cirrhosis decompensations and OLT-free survival by time dependent covariate coding were analysed. RESULTS Majority of patients belonged to Child-Pugh class A 184 (76.3%) and the average MELD score was 10 ± 5. Previous cirrhosis decompensations occurred in 125 (52.1%), 63 (26.1%) were on NSBB and 59 (27.2%) had undergone banding for bleeding prophylaxis. Median follow-up was 29 (1-58) months. Cumulative incidence of PVT was 3.7% and 7.6% at 1 and 3 years. Previous decompensation of cirrhosis and low platelet counts but not NSBB independently predicted the development of PVT. During follow-up, 82/236 (34.7%) patients developed cirrhosis decompensations. OLT-free survival was 100% and 82.8% at 3 years, with and without PVT respectively. MELD score, but not PVT, independently predicted cirrhosis decompensations (HR 1.14; 95%CI:1.09-1.19) and OLT-free survival (HR 1.16;95%CI:1.11-1.21). CONCLUSION Previous decompensations of cirrhosis and thrombocytopenia predict PVT development in cirrhosis suggesting a pathophysiologic role for severity of portal hypertension. PVT development did not independently predict cirrhosis decompensations or lower OLT-free survival.
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Affiliation(s)
- Carlos Noronha Ferreira
- Serviço De Gastrenterologia e Hepatologia, Hospital De Santa Maria - Centro Hospitalar Lisboa Norte, Lisboa, Portugal.,Faculdade de Medicina, Clínica Universitária de Gastrenterologia, Universidade de Lisboa, Lisboa, Portugal
| | - Rui T Marinho
- Serviço De Gastrenterologia e Hepatologia, Hospital De Santa Maria - Centro Hospitalar Lisboa Norte, Lisboa, Portugal.,Faculdade de Medicina, Clínica Universitária de Gastrenterologia, Universidade de Lisboa, Lisboa, Portugal
| | - Helena Cortez-Pinto
- Serviço De Gastrenterologia e Hepatologia, Hospital De Santa Maria - Centro Hospitalar Lisboa Norte, Lisboa, Portugal.,Faculdade de Medicina, Clínica Universitária de Gastrenterologia, Universidade de Lisboa, Lisboa, Portugal
| | - Paula Ferreira
- Serviço De Gastrenterologia e Hepatologia, Hospital De Santa Maria - Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Margarida S Dias
- Serviço De Gastrenterologia e Hepatologia, Hospital De Santa Maria - Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Mariana Vasconcelos
- Serviço De Gastrenterologia e Hepatologia, Hospital De Santa Maria - Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Paula Alexandrino
- Serviço De Gastrenterologia e Hepatologia, Hospital De Santa Maria - Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Fátima Serejo
- Serviço De Gastrenterologia e Hepatologia, Hospital De Santa Maria - Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Ana Júlia Pedro
- Serviço De Medicina II, Hospital De Santa Maria - Centro Hospitalar Lisboa, Lisboa, Portugal
| | - Afonso Gonçalves
- Serviço De Imagiologia, Hospital De Santa Maria - Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Sónia Palma
- Serviço De Imagiologia, Hospital De Santa Maria - Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Inês Leite
- Serviço De Imagiologia, Hospital De Santa Maria - Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Daniela Reis
- Serviço De Gastrenterologia e Hepatologia, Hospital De Santa Maria - Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Filipe Damião
- Serviço De Gastrenterologia e Hepatologia, Hospital De Santa Maria - Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Ana Valente
- Serviço De Gastrenterologia e Hepatologia, Hospital De Santa Maria - Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Leonor Xavier Brito
- Serviço De Gastrenterologia e Hepatologia, Hospital De Santa Maria - Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Cilenia Baldaia
- Serviço De Gastrenterologia e Hepatologia, Hospital De Santa Maria - Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Narcisa Fatela
- Serviço De Gastrenterologia e Hepatologia, Hospital De Santa Maria - Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Fernando Ramalho
- Serviço De Gastrenterologia e Hepatologia, Hospital De Santa Maria - Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - José Velosa
- Serviço De Gastrenterologia e Hepatologia, Hospital De Santa Maria - Centro Hospitalar Lisboa Norte, Lisboa, Portugal
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9
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Ning Q. Main Complications of AECHB and Severe Hepatitis B (Liver Failure). ACUTE EXACERBATION OF CHRONIC HEPATITIS B 2019. [PMCID: PMC7498917 DOI: 10.1007/978-94-024-1603-9_2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Qin Ning
- Department of Infectious Disease, Tongji Hospital, Wuhan, China
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10
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Cancer-Associated Thrombosis in Cirrhotic Patients with Hepatocellular Carcinoma. Cancers (Basel) 2018; 10:cancers10110450. [PMID: 30453547 PMCID: PMC6266984 DOI: 10.3390/cancers10110450] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 11/02/2018] [Accepted: 11/13/2018] [Indexed: 12/24/2022] Open
Abstract
It is common knowledge that cancer patients are more prone to develop venous thromboembolic complications (VTE). It is therefore not surprising that patients with hepatocellular carcinoma (HCC) present with a significant risk of VTE, with the portal vein being the most frequent site (PVT). However, patients with HCC are peculiar as both cancer and liver cirrhosis are conditions that can perturb the hemostatic balance towards a prothrombotic state. Because HCC-related hypercoagulability is not clarified at all, the aim of the present review is to summarize the currently available knowledge on epidemiology and pathogenesis of non-malignant thrombotic complications in patients with liver cirrhosis and HCC. They are at increased risk to develop both PVT and non-splanchnic VTE, indicating that both local and systemic factors can foster the development of site-specific thrombosis. Recent studies have suggested multiple and often interrelated mechanisms through which HCC can tip the hemostatic balance of liver cirrhosis towards hypercoagulability. Described mechanisms include increased fibrinogen concentration/polymerization, thrombocytosis, and release of tissue factor-expressing extracellular vesicles. Currently, there are no specific guidelines on the use of thromboprophylaxis in this unique population. There is the urgent need of prospective studies assessing which patients have the highest prothrombotic profile and would therefore benefit from early thromboprophylaxis.
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11
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Stravitz RT. Algorithms for managing coagulation disorders in liver disease. Hepatol Int 2018; 12:390-401. [PMID: 30066204 DOI: 10.1007/s12072-018-9886-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 07/10/2018] [Indexed: 12/21/2022]
Abstract
Patients with advanced liver disease have traditionally been considered at risk for bleeding complications. However, although bleeding in patients with cirrhosis frequently occurs due to complications of portal hypertension, research performed within the last 15 years has increasingly shown that hemostasis in patients with liver failure generally achieves a state of "rebalance", whereby compensatory systems restore a relatively neutral or even slightly pro-thrombotic state. Much recent clinical and in vitro research has, in fact, shown over-compensation, such that patients with acute and stable chronic liver failure may have a thrombotic tendency, which may participate in the progression of liver disease and cause systemic and portal thrombosis. Investigators have started to identify differences in hemostasis in patients with unstable cirrhosis, the newly defined syndrome of acute-on-chronic liver failure (ACLF), compared to those with stable cirrhosis. The following discussion will summarize much of the background of rebalanced hemostasis in patients with cirrhosis and acute liver failure (ALF), and suggest management algorithms for coagulation abnormalities before invasive procedures, during active bleeding, and for prophylaxis and treatment of thrombotic complications.
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Affiliation(s)
- R Todd Stravitz
- Section of Hepatology, Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, VA, USA.
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12
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Drolz A, Ferlitsch A, Fuhrmann V. Management of Coagulopathy during Bleeding and Invasive Procedures in Patients with Liver Failure. Visc Med 2018; 34:254-258. [PMID: 30345282 DOI: 10.1159/000491106] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Alterations in hemostasis are a characteristic feature of advanced liver disease. Patients with coagulopathy of advanced liver disease are prone to bleedings and also thromboembolic events. Under stable conditions, cirrhosis patients show alterations in both pro- and anticoagulatory pathways, frequently resulting in a rebalanced hemostasis. This review summarizes current recommendations of management during bleeding and prior to invasive procedures in patients with cirrhosis.
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Affiliation(s)
- Andreas Drolz
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Arnulf Ferlitsch
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Internal Medicine I, St. John of God Hospital Vienna, Vienna, Austria
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Medicine B, University of Münster, Münster, Germany
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13
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Song JC. Monitoring and treatment of liver dysfunction-associated coagulopathy. Shijie Huaren Xiaohua Zazhi 2018; 26:1156-1160. [DOI: 10.11569/wcjd.v26.i19.1156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Liver dysfunction-associated coagulopathy may manifest as hypercoagulation, hypocoagulation or normal coagulation, resulting in reduced synthesis of most coagulation factors, protein C and protein S, drop of platelet count, and increase of coagulation factor Ⅷ, Von Willebrand factor and tissue plasminogen activator. The use of viscoelastic coagulation monitoring equipment can accurately determine the coagulation state of patients with liver failure and guide accurate replacement therapy or anticoagulant therapy.
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Affiliation(s)
- Jing-Chun Song
- Department of Intensive Medicine, The 94th Hospital of The Chinese People's Liberation Army, Nanchang 330002, Jiangxi Province, China
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14
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Stravitz RT. Thrombosis and coagulopathy in the liver transplant candidate and recipient. Clin Liver Dis (Hoboken) 2017; 9:11-17. [PMID: 30992949 PMCID: PMC6467126 DOI: 10.1002/cld.606] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 10/10/2016] [Accepted: 11/02/2016] [Indexed: 02/04/2023] Open
Affiliation(s)
- R. Todd Stravitz
- Department of Medicine, Medical Director of Liver TransplantationHume‐Lee Transplant Center of Virginia Commonwealth UniversityRichmondVA
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Zhang JY, Wang YB, Gong JP, Zhang F, Zhao Y. Postoperative Anticoagulants in Preventing Portal Vein Thrombosis in Patients Undergoing Splenectomy Because of Liver Cirrhosis: A Meta-Analysis. Am Surg 2016. [DOI: 10.1177/000313481608201222] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Portal vein thrombosis (PVT) frequently occurs in patients undergoing splenectomy because of liver cirrhosis. Whether the use of postoperative anticoagulants can decrease the incidence of PVT in these subjects is inconclusive. Moreover, the safety of the use of postoperative anticoagulants in the aforementioned patients is a concern. This meta-analysis aims to explore the effectiveness and safety of the preventive anticoagulants to prevent PVT in patients undergoing splenectomy because of liver cirrhosis. Four English language databases (i.e., PubMed, Embase, Cochrane Library, and Web of Science) and four Chinese language databases (i.e., Wanfang, CNKI, Cqvip, and CBM) were searched for randomized controlled trials, cohort studies, and case-control studies on the use of preventive anticoagulants to prevent PVT in patients undergoing splenectomy because of liver cirrhosis from their inception to September 15, 2015. The primary outcome was postoperative PVT incidence. The secondary outcomes included postoperative complications and adverse reaction. Study-specific odds ratios were combined to calculate pooled value through a fixed effects model. A total of 17 original studies were included, involving 1,497 patients. This meta-analysis showed that the preventive anticoagulant group had a lower incidence of PVT than the no anticoagulant group (odds ratio, 0.31; 95% confidence interval, 0.23–0.40; P < 0.05). According to the description of limited studies, the upper gastrointestinal hemorrhage mainly occurred in the no anticoagulant group. Meanwhile, the adverse reaction was trivial in the group using anticoagulants, which could easily be released with no special management. Postoperative anticoagulants can effectively decrease PVT incidence in subjects undergoing splenectomy because of liver cirrhosis. These published studies are more prone to show that no serious negative influence of anticoagulants exists in the aspect of safety. However, further studies are still needed.
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Affiliation(s)
- Jian-Ying Zhang
- Graduate School, Chongqing Medical University
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University
| | - Yun-Bing Wang
- Graduate School, Chongqing Medical University
- Department of Hepatobiliary, The Second Affiliated Hospital of Chongqing Medical University; and
| | - Jian-Ping Gong
- Department of Hepatobiliary, The Second Affiliated Hospital of Chongqing Medical University; and
| | - Fan Zhang
- School of Public Health and Management, Chongqing Medical University, Chongqing, China
| | - Yong Zhao
- School of Public Health and Management, Chongqing Medical University, Chongqing, China
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16
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Drolz A, Horvatits T, Roedl K, Rutter K, Staufer K, Kneidinger N, Holzinger U, Zauner C, Schellongowski P, Heinz G, Perkmann T, Kluge S, Trauner M, Fuhrmann V. Coagulation parameters and major bleeding in critically ill patients with cirrhosis. Hepatology 2016; 64:556-68. [PMID: 27124745 DOI: 10.1002/hep.28628] [Citation(s) in RCA: 123] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 03/22/2016] [Accepted: 04/27/2016] [Indexed: 12/15/2022]
Abstract
UNLABELLED Disturbances of coagulation and hemostasis are common in patients with liver cirrhosis. The typical laboratory pattern mimics disseminated intravascular coagulation (DIC). The aim of this study was to assess the impact of routine coagulation parameters in critically ill cirrhosis patients with regard to new onset of major bleeding and outcome. A total of 1,493 critically ill patients were studied prospectively. Routine coagulation parameters were assessed, and the DIC score was calculated based on platelets, fibrinogen, d-dimer, and prothrombin index. New onset of major bleeding during the stay at the intensive care unit and mortality were assessed. Patients were followed for 1 year. Two hundred eleven patients of the cohort had liver cirrhosis. Platelets, fibrinogen, prothrombin index, activated partial thromboplastin time, and d-dimer as well as the DIC score differed significantly between patients with and without cirrhosis (P < 0.001 for all). Moreover, fibrinogen, platelets, and activated partial thromboplastin time (but not prothrombin index) differed significantly between cirrhosis patients with and without major bleeding (P < 0.01 for all). Bleeding on admission, platelet count <30 < 10(9) /L, fibrinogen level <60 mg/dL, and activated partial thromboplastin time values >100 seconds were the strongest independent predictors for new onset of major bleeding in multivariate regression analysis. One-year mortality in cirrhosis patients with and without major bleeding was 89% and 68%, respectively (P < 0.05 between groups). CONCLUSION Abnormal coagulation parameters and high DIC scores (primarily due to fibrinogen and platelets) correspond to increased bleeding risk in patients with liver cirrhosis in the intensive care unit, and fibrinogen and platelet count were identified as the best routine coagulation parameters for prediction of new onset of major bleeding; however, further studies are required to evaluate the potential therapeutic implications of these findings. (Hepatology 2016;64:556-568).
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Affiliation(s)
- Andreas Drolz
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Horvatits
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kevin Roedl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karoline Rutter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Katharina Staufer
- Division of Transplantation, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Nikolaus Kneidinger
- Department of Internal Medicine V, Comprehensive Pneumology Center, Member of the German Center for Lung Research, University of Munich, Munich, Germany
| | - Ulrike Holzinger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Christian Zauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Peter Schellongowski
- Division of Oncology and Infectious Diseases, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Gottfried Heinz
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Thomas Perkmann
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Valentin Fuhrmann
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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17
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Flanagan E, Ghaderi I, Overby DW, Farrell TM. Reduced Survival in Bariatric Surgery Candidates Delayed or Denied by Lack of Insurance Approval. Am Surg 2016. [DOI: 10.1177/000313481608200222] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Bariatric surgery reduces mortality for Americans who meet candidacy criteria and have insurance coverage. Unfortunately, some medically suitable candidates are denied or delayed during insurance approval processes. The long-term impact of such care delays on survival is unknown. Using a prospectively maintained bariatric intake database, we identified consecutive applicants who were evaluated and medically cleared by our multidisciplinary care team and for whom insurance approval was requested. We compared survival in those who were initially approved by their insurance carriers (controls) and those who were initially denied coverage (subjects). Mortality was determined using the Social Security Death Index. Kaplan–Meier survival curves were plotted and the log-rank test for significance was applied. From August 2003 to December 2008, 463 patients (391 females, mean age 45 ± 10 years, mean body mass index 52.5 ± 9.4 kg/m2) were medically cleared for a bariatric procedure. Of these, 363 were approved by insurance on initial request, whereas 100 were denied. Given the study's intention to measure the aggregate impact of delays and denials, nine patients who later came to operation after appeal or coverage change were maintained in the subject cohort. During 0- to 113-month follow-up, six subjects (6%) died compared with seven controls (1.9%), corresponding to a statistically significant survival benefit for patients initially approved for bariatric surgery without delay or denial ( P < 0.001). In conclusion, access to bariatric surgical care was impeded by insurance certification processes in 22 per cent of medically acceptable candidates. Processes that delay or restrict efficient access to bariatric surgery are associated with a 3-fold mortality increase.
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Affiliation(s)
- Eleisha Flanagan
- From the Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Iman Ghaderi
- From the Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - D. Wayne Overby
- From the Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Timothy M. Farrell
- From the Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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18
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De Stefano V, Rossi E. Venous thromboembolism in patients with liver diseases. Intern Emerg Med 2015; 10:489-91. [PMID: 25764052 DOI: 10.1007/s11739-015-1215-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 02/12/2015] [Indexed: 02/07/2023]
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