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Li Z, Xu W, Wang L, Chai L, Ageno W, Romeiro FG, Li H, Qi X. Risk of Bleeding in Liver Cirrhosis Receiving Direct Oral Anticoagulants: A Systematic Review and Meta-analysis. Thromb Haemost 2023; 123:1072-1088. [PMID: 37336474 DOI: 10.1055/s-0043-1770100] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are effective for the management of thromboembolic disorders. However, bleeding remains a major concern in cirrhotic patients receiving DOACs. METHODS PubMed, EMBASE, and Cochrane Library databases were searched. The incidence of bleeding episodes in cirrhotic patients receiving DOACs was pooled. Odds ratios (ORs) were calculated to compare the incidence of bleeding episodes in cirrhotic patients who received DOACs versus those who received conventional anticoagulants and did not receive anticoagulants. RESULTS Twenty-nine studies were included. All bleeding, major bleeding, fatal bleeding, gastrointestinal bleeding, and intracranial hemorrhage episodes were observed in 310/2,469, 100/1,388, 2/611, 166/1,886, and 5/1,147 cirrhotic patients receiving DOACs, respectively. Their pooled incidences were 13, 6, 0, 8, and 0%, respectively. They became higher in subgroup analyses of studies with advanced age, a longer treatment duration, and Child-Turcotte-Pugh class C. Compared with conventional anticoagulants, DOACs were associated with lower incidences of all bleeding (OR = 0.71, 95% confidence interval [CI] = 0.52-0.98) and major bleeding (OR = 0.55, 95% CI = 0.37-0.83) in cirrhotic patients, but not those of fatal bleeding (OR = 0.21, 95% CI = 0.04-1.28), gastrointestinal bleeding (OR = 0.78, 95% CI = 0.52-1.17), or intracranial hemorrhage (OR = 0.36, 95% CI = 0.12-1.12). The incidences of all bleeding (OR = 1.04, 95% CI = 0.22-4.79) and major bleeding (OR = 0.96, 95% CI = 0.26-3.61) did not significantly differ between cirrhotic patients with portal vein thrombosis (PVT) who received DOACs and those who did not receive anticoagulants. CONCLUSION DOACs carry a low risk of bleeding in liver cirrhosis. Age, treatment duration, and Child-Turcotte-Pugh class may be associated with bleeding in cirrhotic patients receiving DOACs. The risk of bleeding is not increased by DOACs in cirrhotic patients with PVT.
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Affiliation(s)
- Zhe Li
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Wentao Xu
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Le Wang
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Lu Chai
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Fernando Gomes Romeiro
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University (UNESP), São Paulo, Brazil
| | - Hongyu Li
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
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Zhou H, Wu M, Yu S, Xia H, Yu W, Huang K, Chen Y. Comparison of the efficacy and safety between rivaroxaban and dabigatran in the treatment of acute portal vein thrombosis in cirrhosis. BMC Gastroenterol 2023; 23:329. [PMID: 37749527 PMCID: PMC10521568 DOI: 10.1186/s12876-023-02960-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 09/15/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND New oral anticoagulants (NOACs) have been becoming prevalent in recent years and are increasingly used in the treatment of port vein thrombosis. The difference of the efficacy and safety between rivaroxaban and dabigatran remains unclear in the treatment of cirrhotic patients with acute portal vein thrombosis (PVT). METHODS This retrospective study included all consecutive cirrhotic patients with acute portal vein thrombosis in our institute from January 2020 to December 2021. The patients received oral anticoagulation with rivaroxaban or dabigatran. The demographic, clinical, and imaging data of patients were collected. The diagnosis of acute PVT was confirmed by imaging examinations. The severity of liver cirrhosis was assessed using Child-Pugh score and Model for End-Stage Liver Disease (MELD) score. Outcomes included recanalization (complete, partial, and persistent occlusion), liver function, bleedings, and survival. The log-rank test was used to compare Kaplan-Meier distributions of time-to-event outcomes. The Cox proportional hazards model was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs). RESULTS A total of 94 patients were included, 52 patients (55%) received rivaroxaban and 42 (45%) with dabigatran. The complete and partial recanalization of PVT was observed in 41 patients. There was no significant difference in complete recanalization, partial recanalization, and persistent occlusion between the two groups. With multivariate analysis, D-dimer (HR 1.165, 95% CI 1.036-1.311, p = 0.011) was independent predictors of complete recanalization. The Child-Pugh score (p = 0.001) was significantly improved in both two groups after anticoagulation, respectively. However, there was no difference between the two groups. The probability of survival was 94%, 95% in the rivaroxaban and dabigatran groups (log-rank p = 0.830). Major bleedings were reported in 3 patients (6%) in rivaroxaban group and 1 patient (2%) in dabigatran group (p = 0.646). Six patients (12%) in rivaroxaban group experienced minor bleeding, and five (12%) from dabigatran group (p = 0.691). CONCLUSIONS The efficacy and safety were comparable between rivaroxaban and dabigatran in the treatment of cirrhotic patients with acute portal vein thrombosis. And D-dimer can contribute to the prediction of PVT recanalization in cirrhotic patients.
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Affiliation(s)
- Haonan Zhou
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, #76 Linjiang Road, Yuzhong District, Chongqing, 400010 People’s Republic of China
| | - Mingdong Wu
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, #76 Linjiang Road, Yuzhong District, Chongqing, 400010 People’s Republic of China
| | - Shixiong Yu
- Department of General Surgery, The First Affiliated Hospital of Chongqing Medical and Pharmaceutical College, Chongqing, 400060 People’s Republic of China
| | - Han Xia
- Department of Cardiothoracic Surgery, Second Clinical Hospital, Army Medical University, Chongqing, 400000 People’s Republic of China
| | - Wu Yu
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, #76 Linjiang Road, Yuzhong District, Chongqing, 400010 People’s Republic of China
| | - Kai Huang
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, #76 Linjiang Road, Yuzhong District, Chongqing, 400010 People’s Republic of China
| | - Yikuan Chen
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, #76 Linjiang Road, Yuzhong District, Chongqing, 400010 People’s Republic of China
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Wang SM, Wen J, Hu L, Wu LP, Yuan DQ. Rivaroxaban combined with repeat hepatectomy for treatment of cirrhosis-related acute portal vein thrombosis with hepatocellular carcinoma: A case report. Shijie Huaren Xiaohua Zazhi 2023; 31:201-206. [DOI: 10.11569/wcjd.v31.i5.201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND Acute portal vein thrombosis (PVT) with hepatocellular carcinoma (HCC) is a severe complication of liver cirrhosis and its prognosis is affected by clinical decision to a large extent, while the order of management, the approaches of treatment, and the adjustment of the plan are all the key and difficult points.
CASE SUMMARY This case was treated with low molecular weight heparin (4000 U/12 h) for 14 d, followed by rivaroxaban (10 mg/12 h) and then partial hepatectomy twice, of which the first was performed 1 mo after anticoagulation, and the second was performed 4 mo later, by which the primary lesion and postoperative new lesion were resected, respectively. Rivaroxaban was taken constantly except the perioperative period, while gingival bleeding occurred after 8 mo of anticoagulation, so suspension of rivaroxaban was carried out for 1 wk, after which the bleeding was relieved, and a half dose of rivaroxaban (10 mg/d) was used to continue anticoagulation from then on. The thrombus remained recanalized and there was no tumor recurrence during the following 2 years.
CONCLUSION When there are indications for anticoagulation and partial hepatectomy in patients with cirrhosis-related acute PVT with HCC, anticoagulation followed by surgery is recommended, as anticoagulation may reduce thrombosis in a short time, which could not only decrease the risk of surgery, but also have little influence on the opportunity of tumor treatment. And when recurrence of HCC occurs, if possible, repeat hepatectomy should be considered to improve the prognosis. Anticoagulant strategy should be adjusted accordingly if rivaroxaban causes bleeding, and it should be stopped or reduced after the bleeding is stable.
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Affiliation(s)
- Shi-Mei Wang
- Department of Gastroenterology, The Third People's Hospital of Chengdu and Affiliated Hospital of Southwest Jiaotong University, Chengdu 610031, Sichuan Province, China
| | - Jun Wen
- Department of General Surgery, The Third People's Hospital of Chengdu and Affiliated Hospital of Southwest Jiaotong University, Chengdu 610031, Sichuan Province, China
| | - Ling Hu
- Department of Gastroenterology, The Third People's Hospital of Chengdu and Affiliated Hospital of Southwest Jiaotong University, Chengdu 610031, Sichuan Province, China
| | - Li-Ping Wu
- Department of Gastroenterology, The Third People's Hospital of Chengdu and Affiliated Hospital of Southwest Jiaotong University, Chengdu 610031, Sichuan Province, China
| | - De-Qiang Yuan
- Department of Gastroenterology, The Third People's Hospital of Chengdu and Affiliated Hospital of Southwest Jiaotong University, Chengdu 610031, Sichuan Province, China
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Pan J, Wang L, Gao F, An Y, Yin Y, Guo X, Nery FG, Yoshida EM, Qi X. Epidemiology of portal vein thrombosis in liver cirrhosis: A systematic review and meta-analysis. Eur J Intern Med 2022; 104:21-32. [PMID: 35688747 DOI: 10.1016/j.ejim.2022.05.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/23/2022] [Accepted: 05/30/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Portal vein thrombosis (PVT) may be associated with negative outcomes in patients with liver cirrhosis. However, the prevalence and incidence of PVT in liver cirrhosis are heterogeneous among studies and have not been sufficiently determined yet. METHODS The PubMed, EMBASE, and Cochrane Library databases were searched. Eligible studies would explore the prevalence and/or incidence of PVT in liver cirrhosis without hepatocellular carcinoma or abdominal surgery. Pooled proportion with 95% confidence interval (CI) was calculated using a random-effect model. Factors associated with the presence/occurrence of PVT were also extracted. RESULTS Among the 8549 papers initially identified, 74 were included. Fifty-four studies explored the prevalence of PVT in liver cirrhosis with a pooled prevalence of 13.92% (95%CI=11.18-16.91%). Based on cross-sectional data, Child-Pugh class B/C, higher D-dimer, ascites, and use of non-selective beta-blockers (NSBBs) were associated with the presence of PVT in liver cirrhosis. Twenty-three studies explored the incidence of PVT in liver cirrhosis with a pooled incidence of 10.42% (95%CI=8.16-12.92%). Based on cohort data, Child-Pugh class B/C, higher model of end-stage liver disease score, higher D-dimer, lower platelets count, decreased portal flow velocity, ascites, use of NSBBs, and moderate or high-risk esophageal varices could predict the occurrence of PVT in liver cirrhosis. CONCLUSION Approximately one seventh of cirrhotic patients have PVT, and one tenth will develop PVT. Progression of liver cirrhosis and portal hypertension seems to be in parallel with the risk of PVT. Prospective studies with detailed information about classification and extension of PVT in liver cirrhosis are needed.
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Affiliation(s)
- Jiahui Pan
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, PR China; Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, PR China
| | - Le Wang
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, PR China; Postgraduate College, China Medical University, Shenyang 110122, PR China
| | - Fangbo Gao
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, PR China; Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, PR China
| | - Yang An
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, PR China; Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, PR China
| | - Yue Yin
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, PR China
| | - Xiaozhong Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, PR China
| | - Filipe Gaio Nery
- Centro Hospitalar Universitário do Porto, Porto, Portugal; EpiUnit, Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal
| | - Eric M Yoshida
- Division of Gastroenterology, Vancouver General Hospital, Vancouver, BC, Canada
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, PR China; Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, PR China; Postgraduate College, China Medical University, Shenyang 110122, PR China.
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Efficacy and safety of direct oral anticoagulants versus vitamin K antagonist for portal vein thrombosis in cirrhosis: A systematic review and meta-analysis. Dig Liver Dis 2022; 54:56-62. [PMID: 34393072 DOI: 10.1016/j.dld.2021.07.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/19/2021] [Accepted: 07/24/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION AND AIM Portal vein thrombosis (PVT) is associated with a higher risk of liver-related complications. Recent guidelines recommend direct-acting anticoagulants (DOAC) in patients with cirrhosis and non-tumoral PVT. However, data on the efficacy and safety of DOAC in these patients remain limited. We aim to investigate the efficacy and safety of DOAC compared to vitamin K antagonists (VKA) to treat non-tumoral PVT in patients with cirrhosis. METHODS We performed a systematic search of six electronic databases using MeSH term and free text. We selected all studies comparing the use of DOACs with vitamin K antagonist to treat PVT in cirrhosis. The primary outcome was PVT recanalization. Secondary outcomes were and PVT progression, major bleeding, variceal bleeding and death. RESULTS From 944 citations, we included 552 subjects from a total of 11 studies (10 observational and 1 randomized trial) that fulfilled the inclusion criteria. We found that DOAC were associated with a higher pooled rate of PVT recanalization (RR = 1.67, 95%CI: 1.02, 2.74, I2 = 79%) and lower pooled risk of PVT progression (RR = 0.14, 95%CI: 0.03-0.57, I2 = 0%). The pooled risk of major bleeding (RR = 0.29, 95%CI: 0.08-1.01, I2 = 0%), variceal bleeding (RR = 1.29, 95%CI: 0.64-2.59, I2 = 0%) and death (RR = 0.31, 95%CI: 0.01-9.578, I2 = 80%) was similar between DOAC and VKA. CONCLUSION For the treatment of PVT in patients with cirrhosis, the bleeding risk was comparable between DOAC and VKA. However, DOAC were associated with a higher pooled rate of PVT recanalization. Dedicated randomized studies are needed to confirm these findings.
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Zhang Z, Zhao Y, Han B, Zhu Z, Sun L, Cui X. The Efficacy and Safety of Anticoagulants in the Treatment of Cirrhotic Portal Vein Thrombosis: A Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost 2022; 28:10760296221104797. [PMID: 35656719 PMCID: PMC9168872 DOI: 10.1177/10760296221104797] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective To evaluate the efficacy and safety of anticoagulant therapy in patients with
cirrhotic PVT, and compare differences in efficacy and safety among
different anticoagulants. Methods We comprehensively searched Pubmed, Cochrane Library, EMBASE, and
ClinicalTrials.gov from inception to April 2022 for studies using
anticoagulants for cirrhotic PVT. Meta-analysis was performed to calculate
odds ratios (ORs) with 95% confidence intervals (CIs). Results 3 RCTs and 14 cohort studies involving 1270 patients were included.
Anticoagulant therapy can increase the recanalization rate compared with
non-anticoagulation therapy (OR 4.44, 95% CI 3.11-6.32,
I2 = 2.5%) and can decrease the extension rate of cirrhotic PVT
(OR 0.33, 95% CI 0.18-0.62, I2 = 41.0%), without increasing the
incidence of total bleeding (OR 1.21, 95% CI 0.75-1.97,
I2 = 9.8%), major bleeding (OR 0.98, 95% CI 0.49-1.95,
I2 = 19.7%), and variceal bleeding (OR 0.35, 95% CI
0.12-1.01, I2 = 39.9%). Subgroup analysis showed that VKA, LMWH,
and DOACs could increase the recanalization rate of PVT and were not
associated with the risk of bleeding. Studies that compared direct oral
anticoagulants (DOACs) with warfarin directly showed that the recanalization
rate of PVT in the DOACs group might be higher than that in the warfarin
group (OR 30.99, 95% CI 7.39-129.87, I2 = 0.0%), and there was no
difference in the rate of total bleeding (OR 0.30, 95% CI 0.01-8.65,
I2 = 79.6%). Conclusions Anticoagulants are safe and effective in patients with cirrhotic PVT. The
rate of PVT recanalization associated with DOACs may be higher than
warfarin.
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Affiliation(s)
- Zhiqi Zhang
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,College of Pharmacy, 26455Capital Medical University, Beijing, China
| | - Ying Zhao
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Baofeng Han
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,College of Pharmacy, 26455Capital Medical University, Beijing, China
| | - Zhijun Zhu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Liying Sun
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xiangli Cui
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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