An imbalance of pro- vs anti-coagulation factors in plasma from patients with cirrhosis

Patients with cirrhosis have a disbalance between coagulation and fibrinolysis resulting in a prothrombotic phenotype

BACKGROUND

Patients with cirrhosis develop multiple hemostatic alterations. Although fibrinolysis is also affected by liver disease, studies have produced conflicting results, highlighting the need for a reliable fibrinolysis assay. Assessing the kinetics of plasmin generation (PG) is a new method to study the fibrinolytic state of cirrhosis patients.

OBJECTIVES

This study aimed to compare fibrinolysis between patients with cirrhosis and healthy subjects.

METHODS

This single-center cohort study included cirrhosis patients from the Padova University Hospital. Fibrinolysis and hemostasis were assessed with PG, thrombin generation (TG), and clot lysis time. To quantify malalignment between TG and PG, ratios were calculated.

RESULTS

In total, 101 patients with cirrhosis (Child-Pugh A/B/C: 36/24/41) and 20 healthy subjects were included. Compared with healthy subjects, patients showed a significantly lower endogenous plasmin potential and plasmin peak. The PG capacity decreased with liver disease severity. The lag time to PG was prolonged in patients. No differences in endogenous thrombin potential and lag time were found when comparing TG profiles. Patients had a shorter clot lysis time. Increased TG/PG ratios for the endogenous plasmin potential and plasmin peak were found in patients compared with that in controls. TG/PG ratios increased with liver disease severity.

CONCLUSION

Patients with cirrhosis have a complex fibrinolytic profile, with a delayed and decreased capacity to generate plasmin and a more rapid clot lysis. A disbalance was found between coagulation and fibrinolysis, with a normal-to-increased TG capacity and a decreased PG capacity. These results support the theory that cirrhosis patients are in a prothrombotic state.

Effect of direct oral anticoagulants in cirrhosis: an in vitro study

BACKGROUND

Cirrhosis is associated with a procoagulant state that may worsen disease evolution. Anticoagulation could be of particular interest in these patients. However, evidence on the use of direct oral anticoagulants (DOAC) in patients with cirrhosis is limited.

OBJECTIVES

Our aim was to explore the in vitro effect of DOAC on thrombin generation (TG) in plasma from patients with cirrhosis compared to plasma from healthy controls.

METHODS

Platelet-poor-plasma was obtained from patients with cirrhosis (n = 87; Child-Turcotte-Pugh class: A, n = 68; B, n = 14; C, n = 5) and controls (n = 17). TG was assessed with ST-Genesia analyzer. Plasma from patients with cirrhosis and thrombomodulin-mediated inhibition of endogenous thrombin potential <20% (ThromboScreen) were defined as "highly procoagulant" (n = 36), ≥20% to 50% as "procoagulant" (n = 31), and >50% as "nonprocoagulant" (n = 20). Plasma samples were spiked with apixaban, edoxaban, rivaroxaban, or dabigatran at final concentrations of 50 and 150 ng/mL. TG was measured (DrugScreen) in plasma samples without and with DOAC.

RESULTS

Apixaban, edoxaban, and rivaroxaban demonstrated significantly reduced inhibition of in vitro TG parameters in highly procoagulant plasma from patients with cirrhosis compared to plasma from controls, whereas possibly artifactual results were observed with dabigatran.

CONCLUSION

The anticoagulant potency of DOAC differs according to the individual procoagulant potential. Highly procoagulant plasma from patients with cirrhosis is less sensitive to the anticoagulant action of apixaban, edoxaban, and rivaroxaban than control plasma. These results, if confirmed in vivo, would support the concept of personalizing anticoagulant treatment in patients with a highly procoagulant state.

The efficacy and safety of venous thromboembolism prophylaxis among hospitalized cirrhotic patients: Systematic review and meta-analysis

BACKGROUND AND STUDY AIMS

This meta-analysis aims to evaluate the effect of prophylactic anticoagulation on incidence of venous thromboembolism (VTE), bleeding events, and mortality in hospitalized cirrhotic patients.

METHODS

We utilized the following databases (EMBASE, PubMed, MedRxiv and google-scholar) to search for studies that satisfied the reviewers pre-specified inclusion criteria. The incidence of VTE, bleeding risks, and mortality were assessed using a quality effect meta-analytic model.

RESULTS

From screening of 539 studies, a total of 9 studies (n = 6275 patients) satisfied inclusion criteria. Our results suggested no significant difference in the primary outcome of VTE events in both groups of cirrhotic patients who received and did not receive anticoagulation for VTE prophylaxis, (OR:0.9, 95 % CI:0.50-1.62). Similarly, there was a non-significant reduced risk of bleeding events in hospitalized cirrhotic amongst patient cohorts receiving VTE prophylaxis compared to those who did not (OR:0.51, 95 % CI:0.22-1.14). Analysis of three studies showed no significant difference in mortality in both groups (OR 1.02, 95 % CI:0.8-1.31).

CONCLUSION

In a pooled examination of studies evaluating outcomes in patients exposed to VTE prophylactic anticoagulation, we found no significant difference in the burden of VTE or mortality between treated and untreated patients with chronic liver disease (CLD). The retrospective design of a plurality of studies enrolled in the review meant further prospective studies are needed to objectively ascertain the efficacy and safety of VTE prophylaxis amongst patient cohorts with CLD.

Impact of portal vein thrombosis grade and donor characteristics on biliary complications after liver transplantation: A risk stratification framework

BACKGROUND

Portal vein thrombosis in liver transplant recipients presents a significant challenge, with potential implications for posttransplant biliary complications. This study investigated the relationship between portal vein thrombosis and posttransplant biliary complications, aiming to identify risk factors and establish a stratification framework.

METHODS

We conducted a single-center retrospective study of 914 adult liver transplant recipients from 2016 to 2023. Portal vein thrombosis was classified using the Yerdel system, and multivariate logistic regression analysis was conducted to identify the predictors for posttransplant biliary complications.

RESULTS

Portal vein thrombosis was present in 109 (11.9%) recipients, with grade I in 78 (71.6%), grade II in 25 (22.9%), and grade III in 6 (5.6%) cases. Posttransplant biliary complication rates increased with portal vein thrombosis severity (grade I: 15.4%, grade II: 52.0%, grade III: 100%). Multivariate analysis identified portal vein thrombosis (odds ratio, 2.68; P < .001), donation after circulatory death (odds ratio, 1.50; P = .04), and advanced donor age (odds ratio, 1.01; P = .04) as independent risk factors for posttransplant biliary complications. Donation after circulatory death donors showed consistently greater posttransplant biliary complication rates across all age groups, whereas donation after brain death donors demonstrated increased risk with age >40 years. Although graft survival was comparable between groups, portal vein thrombosis recipients required more frequent endoscopic retrograde cholangiopancreatography interventions within the first post-transplant year (38.5% vs 28.2%, P = .03).

CONCLUSION

Portal vein thrombosis significantly increases posttransplant biliary complication risk, particularly with greater Yerdel grades and when combined with donation after circulatory death grafts or advanced donor age. Although long-term outcomes remain similar, portal vein thrombosis recipients require more frequent interventions. Preoperative risk stratification on the basis of these factors may guide intraoperative management and post-transplant surveillance, potentially improving outcomes in this challenging population.

Effectiveness and safety of antithrombin for treatment of portal vein thrombosis: Nationwide prospective surveillance of 4 years of clinical experience in Japan

AIM

Antithrombin (AT), a plasma protein with anticoagulant properties, has a long-standing medical history, primarily for treatment of congenital AT deficiency. Accumulated clinical experiences suggest AT is a potential anticoagulant for thrombotic diseases. This study aimed to clarify the effectiveness, safety, and clinical significance of AT in portal vein thrombosis (PVT) treatment in clinical practice in Japan, particularly in liver cirrhosis, where bleeding tendencies are increased.

METHODS

This prospective, observational post-marketing surveillance study assessed effectiveness and safety of AT in patients with PVT. Data were collected through electronic case report forms at medical institutions across Japan (from February 2018 to January 2021).

RESULTS

Of 680 patients, cirrhosis was the most prevalent underlying disease (79.7%), and the use of concomitant anticoagulants was common (62.8%). In the effectiveness analysis set (N = 477), overall improvement rate after AT administration was 51.2%, reaching 54.1% in patients with class C (severe) cirrhosis. Factors influencing clinical response included AT activity, Child-Pugh score, number of treatment courses, cause of thrombus, and thrombus obstruction. Responders showed a lower cumulative mortality rate versus nonresponders (18.3% vs. 27.6%; p = 0.013); 1-year recurrence rate among responders was 19.3%. In the safety analysis set (N = 680), bleeding events occurred in 5.15% of patients, with 1.32% having major bleeding events.

CONCLUSIONS

AT showed promise as an anticoagulant for high-risk PVT cases, especially in liver cirrhosis. Further well-designed comparative studies are needed to verify its efficacy in terms of true endpoints, such as long-term prognosis or improvement in cirrhosis.

Thrombin Generation Assays: What are the Current Clinical Applications?

The thrombin generation assay (TGA), originally developed by McFarlane and Biggs in 1956, was modified in the 2000s by Hemker and coworkers. TGA aims to monitor the continuous generation of thrombin upon activation of coagulation in plasma by the addition of such triggers as small amounts of tissue factor, synthetic phospholipids, and calcium chloride. TGA is sensitive to hypo- and hypercoagulability and is affected by prohemostatic as well as antithrombotic drugs. The review of the current literature shows that TGA is mainly used to investigate conditions characterized by hypo- as well as hypercoagulability and as a laboratory tool to elucidate coagulation mechanisms that are not yet completely understood. This article aims to overview the value and limits of current procedures for TGA for the investigation of hemostasis.

Extensive Portal Vein Thrombosis Following Laparoscopic Cholecystectomy: Interplay of Liver Cirrhosis, Psoriasis, and Anticoagulation Oversight

Portal vein thrombosis (PVT) is a rare but serious condition often associated with liver cirrhosis, malignancy, and hypercoagulable states. While PVT following laparoscopic surgery is uncommon, certain risk factors can predispose patients to this complication. A 65-year-old male with a history of untreated plaque psoriasis and alcoholic liver cirrhosis with portal hypertension developed PVT after a robot-assisted laparoscopic cholecystectomy. The patient presented with abdominal swelling and mild epigastric pain two months postoperatively. Imaging revealed an occlusive thrombus in the portal vein extending into the splenic and superior mesenteric veins, accompanied by bowel congestion, edema, and early signs of ischemia. The patient had been on warfarin prior to surgery for an unclear reason but had failed to resume warfarin use postoperatively due to a lack of follow-up with his primary care physician. After managing the patient's PVT with a heparin drip followed by apixaban, his symptoms improved. A thrombophilia panel revealed decreased activity of antithrombin III, factor II, and protein C. Thorough preoperative history-taking and postoperative primary care follow-up are essential, particularly in patients with multiple thromboembolic risk factors. The unexpected role of untreated psoriasis as a potential contributor to PVT highlights the need for further research into the systemic effects of chronic inflammatory conditions.

Management of the acute on chronic liver failure in the intensive care unit

Acute on chronic liver failure (ACLF) reflects the development of organ failure(s) in a patient with cirrhosis and is associated with high short-term mortality. Given that ACLF has many different 'phenotypes', medical management needs to take into account the relationship between precipitating insult, organ systems involved and underlying physiology of chronic liver disease/cirrhosis. The goals of intensive care management of patients suffering ACLF are to rapidly recognize and treat inciting events (e.g. infection, severe alcoholic hepatitis and bleeding) and to aggressively support failing organ systems to ensure that patients may successfully undergo liver transplantation or recovery. Management of these patients is complex since they are prone to develop new organ failures and infectious or bleeding complications. ICU therapy parallels that applied in the general ICU population in some complications but differs in others. Given that liver transplantation in ACLF is an emerging and evolving field, multidisciplinary teams with expertise in critical care and transplant medicine best accomplish management of the critically ill ACLF patient. The focus of this review is to identify the common complications of ACLF and to describe the proper management in critically ill patients awaiting liver transplantation in our centres, including organ support, prognostic assessment and how to assess when recovery is unlikely.

[Acute management of bleeding complications and coagulation disorders in critically ill patients with liver cirrhosis]

Critically ill patients with liver cirrhosis exhibit complex alterations in coagulation that should be considered in clinical acute management. As routine laboratory tests (e.g., INR, aPTT, platelet count) cannot always adequately reflect the coagulation status of critically ill patients with liver cirrhosis, functional hemostatic tests, such as viscoelastic tests, should also be used to assess coagulation disorders in these patients. If invasive procedures are planned, hemostatic interventions to prevent bleeding and measures to stabilize coagulation disorders should be considered depending on the risk of procedure-associated bleeding, while a prophylactic routine correction of abnormal laboratory coagulation parameters should be avoided. If an acute bleeding complication manifests in critically ill patients with liver cirrhosis, an individualized correction of hemostatic changes is indicated in addition to prompt identification of the source of bleeding. This review article describes the pathophysiological changes underlying the altered hemostatic system in critically ill patients with liver cirrhosis and provides an overview of diagnostic and therapeutic options for hemostatic complications.

Association between Clot Waveform Analysis Parameters and the Severity of Liver Cirrhosis

BACKGROUND

 Clot waveform analysis (CWA) provides a global assessment of hemostasis and may be useful for patients with cirrhosis with complex hemostatic abnormalities. This study aimed to assess the association between prothrombin time (PT-) and activated partial thromboplastin time (aPTT-) based CWA parameters and cirrhosis severity and prospectively evaluate the role of CWA in predicting mortality and acute decompensation (AD) over 1 year.

METHODS

 This prospective study included adult patients with cirrhosis between June 2021 and December 2023 at Chulalongkorn University Hospital. The PT- and aPTT-based CWA parameters were obtained using an automated coagulation analyzer.

RESULTS

 A total of 560 patients with cirrhosis were included; 165 (29.5%) and 47 (11.5%) had Child-Turcotte-Pugh (CTP) B and C cirrhosis, respectively. The PT- and aPTT-based CWA parameters, including maximum velocity (min1), maximum acceleration (min2), and maximum deceleration (max2), were significantly lower (p ≤ 0.05) in patients with decompensated cirrhosis than in those with compensated cirrhosis. Additionally, CWA values were significantly higher in patients with higher CTP and Model for End-Stage Liver Disease (MELD) scores. Multivariable analysis revealed that liver stiffness (LS) and max2 of PT-based CWA assay were independently associated with CTP B/C. In addition, min2 and max2 of PT-based CWA assay were independently associated with 1-year mortality. No significant differences in CWA parameters were observed between patients with and without portal vein thrombosis. CWA parameters were not related to AD during the 1-year follow-up.

CONCLUSION

 A hypocoagulable profile based on CWA parameters is associated with advanced-stage cirrhosis. CWA may be a useful objective marker for assessing cirrhosis severity and predicting 1-year mortality.

Assessment of Hypercoagulability in Splanchnic Vein Thrombosis by Measurement of the Hemostasis Enzymes Thrombin and Activated Protein C

Splanchnic vein thrombosis (SVT), which is particularly prevalent in myeloproliferative neoplasms (MPNs), has a multifactorial pathomechanism involving the anticoagulant protein C (PC) pathway. To better characterize the hypercoagulable state in SVT we assessed its key enzymes thrombin and activated PC (APC). The study population included 73 patients with SVT, thereof 36 MPN+, confirmed by bone marrow biopsy, 37 MPN-, and 30 healthy controls. Direct measurement of the active enzyme forms of thrombin and APC in the circulation was achieved by using oligonucleotide-based enzyme capture assays (OECA). Additionally, activation markers of coagulation and fibrinolysis were measured. Plasma levels of free thrombin and APC were higher in the MPN+ than in the MPN- cohort, with 0.49 vs. <0.46 pmol/L (p = 0.0057), respectively, 1.23 vs. 0.58 pmol/L (p = 0.0122), and in healthy controls (vs. <0.46 pmol/L, p = 0.0012; vs. 0.54 pmol/L, p = 0.0035). The indirect activation markers prothrombin fragment 1+2, thrombin-antithrombin complex, and D-dimer did not differ between groups. Receiver operating characteristic analysis suggested that SVT patients with MPN can be better distinguished by APC than by conventional indirect thrombin markers. A potential application of these biomarkers to guide anticoagulant therapy and to investigate the role of the PC pathway in MPN-associated hypercoagulability should be further studied.

Relevance of perioperative fluid dynamics in liver transplantation to acute kidney injury and patient outcomes: a cross-sectional survey

Background

Fluid administration is a critical component of perioperative management for liver transplant recipients, and excessive fluid infusion can lead to acute kidney injury (AKI) and poor patient outcomes.

Method

We conducted a cross-sectional survey on the fluid intake and output of adult liver transplant recipients over a 7-day period. The patients were divided into AKI and non-AKI groups. Multivariate logistic regression analyses were used to evaluate the association between fluid balance (FB) and AKI. A Kaplan-Meier survival analysis was performed to determine the survival of the recipient survival at 180 days.

Results

A total of 210 liver transplant recipients were included. The peak FB occurred on the second day after transplantation, which was higher than on the seventh day (0.3 [IQR, -0.2 to 0.8] L vs. -0.4 [IQR, -1.0 to 0.3] L, p < 0.001). The highest incidence of AKI was observed on the second day after transplantation and the lowest on the seventh day (52.4% vs. 15.4%, p < 0.001). Multivariate analysis showed that a cumulative FB > 1 L within the first 2 days postoperatively was an independent risk factor for AKI on the second day after liver transplantation (LT) (OR = 2.66, 95% CI, 1.31-5.41, p = 0.007). Survival analysis indicated significant differences in 180-day survival rates among patients with different grades of AKI [94.0% (grade 1) vs. 91.4% (grade 2) vs. 77.8% (grade 3), χ 2  = 12.93, p < 0.001].

Conclusion

There is a significant correlation between post-LT AKI and perioperative FB. Cumulative FB > 1 L in the first 2 days postoperatively is an independent risk factor for AKI on the second day after LT. AKI after LT is associated with a lower 180-day survival rate in patients.

Unravelling the coagulation paradox in liver cirrhosis: challenges and insights

Patients with liver disease experience complex haemostatic changes leading to a state of 'rebalanced haemostasis' that may shift towards bleeding or thrombosis due to complications like kidney dysfunction, bacterial infection, or acute-on-chronic liver failure. Traditional coagulation tests inadequately capture haemostasis in cirrhosis, whereas advanced assays like thrombin generation assay and viscoelastic testing offer better insights but remain limited in clinical outcome prediction or guiding pre-procedural prophylaxis.Contrary to the traditional view of cirrhosis as a bleeding disorder, recent evidence highlights a paradox of higher venous thromboembolism incidence in hospitalised cirrhotic patients. Misconceptions about 'auto-anticoagulation' and concerns about anticoagulation safety hinder consistent thromboprophylaxis. Emerging data suggest that low molecular weight heparin is safe and effective in cirrhotic patients, supporting more evidence-based thromboprophylaxis. For thrombotic events or conditions like atrial fibrillation, therapeutic anticoagulation is recommended, and may offer additional benefits, such as attenuating liver fibrosis and portal hypertension. However, anticoagulation is not established as a core therapy in cirrhosis, given safety concerns in advanced disease.Bleeding remains a significant challenge in cirrhosis, with management focusing on specific aetiologies, including portal hypertension or procedural injuries. In pre-procedural planning, there is a trend of unnecessary blood product use, often based on an assumed bleeding risk. Rational pre-procedural planning should minimize unnecessary transfusions, optimise modifiable risks, and include a plan for managing potential bleeding.This review aims to clarify the 'coagulation paradox' in cirrhosis, promoting a nuanced, individualized approach to managing bleeding and thrombosis in chronic liver disease.

Testosterone Therapy Does Not Affect Coagulation in Male Hypogonadism: A Longitudinal Study Based on Thrombin Generation

CONTEXT

Testosterone therapy has been variably associated with increased thrombotic risk but investigations of global coagulation in this setting are lacking.

OBJECTIVE

This work aimed to compare global coagulation of hypogonadal men before (T0) and 6 months after (T1) starting testosterone replacement therapy (TRT), and healthy controls (HCs).

METHODS

An observational prospective cohort study was conducted at 2 tertiary endocrinological ambulatory care centers. Patients included 38 men with hypogonadism (mean age 55 years, SD 13) and 38 age-matched HCs. Thrombin generation assay (TGA) was performed at T0 and T1 in hypogonadal men and in HCs. TGA is an in vitro procedure based on the continuous registration of thrombin generation and decay under conditions mimicking the process that occurs in vivo. The following TGA parameters were recorded: lag time; thrombin-peak concentration; time-to-reach peak, velocity index, and endogenous thrombin potential (ETP), the latter representing the total amount of thrombin generated under the driving forces of procoagulants opposed by the anticoagulants. Protein C, antithrombin, factor (F) VIII, and fibrinogen were assessed.

RESULTS

No changes in TGA parameters were observed between T0 and T1. Hypogonadal men displayed significantly higher ETP, fibrinogen, and significantly lower antithrombin levels both at T0 and T1 compared to HCs. Thrombin peak of hypogonadal men was significantly higher than HCs at T0 but not at T1. ETP and antithrombin were correlated with testosterone levels.

CONCLUSION

Hypogonadal men display a procoagulant imbalance detected by increased thrombin generation. Short-term TRT does not worsen global coagulation, suggesting that the treatment can be safely prescribed to men diagnosed with hypogonadism.

Hematological abnormalities in liver cirrhosis

Hematological abnormalities are common in cirrhosis and are associated with various pathophysiological mechanisms. Studies have documented a prevalence of thrombocytopenia, leukopenia, and anemia in patients with compensated cirrhosis of 77.9%, 23.5%, and 21.1%, respectively. These abnormalities carry significant clinical implications, including considerations for invasive procedures, infection risk, bleeding risk, and prognosis. Previously, cirrhosis was believed to predispose patients to bleeding due to alterations observed in classical coagulation tests such as prothrombin time, partial thromboplastin time, international normalized ratio, and thrombocytopenia. However, this understanding has evolved, and cirrhosis patients are now also acknowledged as being at a high risk for thrombotic events. Hemostasis in cirrhosis patients presents a complex phenotype, with procoagulant and anticoagulant abnormalities offsetting each other. This multifactorial phenomenon is inadequately reflected by routine laboratory tests. Thrombotic complications are more prevalent in decompensated cirrhosis and may correlate with disease severity. Bleeding is primarily associated with portal hypertension, endothelial dysfunction, mechanical vessel injury, disseminated intravascular coagulation, endotoxemia, and renal injury. This review comprehensively outlines hematologic index abnormalities, mechanisms of hemostasis, coagulation, and fibrinolysis abnormalities, limitations of laboratory testing, and clinical manifestations of bleeding and thrombosis in patients with liver cirrhosis.

Anticoagulation for stroke prevention in atrial fibrillation and treatment of venous thromboembolism and portal vein thrombosis in cirrhosis: guidance from the SSC of the ISTH

While advanced liver disease was previously considered to be an acquired bleeding disorder, there is increasing recognition of an associated prothrombotic state with patients being at higher risk of atrial fibrillation (AF) and stroke and venous thromboembolism (VTE) including portal vein thrombosis (PVT). We review the available literature on epidemiology, pathophysiology, and risk factors and provide guidance on anticoagulant management of these conditions in adults with cirrhosis. In patients with Child-Pugh A or B cirrhosis and AF, we recommend anticoagulation with standard-dose direct oral anticoagulants (DOACs) in accordance with cardiology guideline recommendations for patients without liver disease. In those with Child-Pugh C cirrhosis, there is inadequate evidence with respect to the benefit and risk of anticoagulation for stroke prevention in AF. In patients with cirrhosis and acute deep vein thrombosis or pulmonary embolism, we recommend anticoagulation and suggest use of either a DOAC or low-molecular-weight heparin (LMWH)/vitamin K antagonist (VKA) in Child-Pugh A or B cirrhosis and LMWH alone (or as a bridge to VKA in patients with a normal baseline international normalized ratio) in Child-Pugh C cirrhosis. We recommend anticoagulation for patients with cirrhosis and symptomatic PVT. We suggest anticoagulation for those with asymptomatic, progressing PVT and recommend continuing extended anticoagulation for liver transplant candidates with PVT.

Direct oral anticoagulants in cirrhosis: Rationale and current evidence

Cirrhosis is a major health concern worldwide with a complex pathophysiology affecting various biological systems, including all aspects of haemostasis. Bleeding risk is mainly driven by portal hypertension, but in end-stage liver disease it is further increased by alterations in haemostatic components, including platelet function, coagulation, and fibrinolysis. Concurrently, patients with cirrhosis are prone to venous thromboembolic events (VTE) because of the altered haemostatic balance, in particular an increase in thrombin generation. In patients with cirrhosis, vitamin K antagonists (VKA) and low molecular weight heparins (LMWH) are currently the standard of care for VTE prevention, with VKA also being standard of care for stroke prevention in those with atrial fibrillation. However, direct oral anticoagulants (DOAC) could have specific advantages in this patient population. Clinical experience suggests that DOAC are a safe and possibly more effective alternative to traditional anticoagulants for the treatment of VTE in patients with compensated cirrhosis. In addition, emerging data suggest that primary prophylactic treatment with anticoagulants may improve clinical outcomes in patients with cirrhosis by reducing the risk of hepatic decompensation. The selection of the most appropriate DOAC remains to be clarified. This review focuses on the rationale for the use of DOAC in patients with cirrhosis, the specific effects of the different DOAC (as assessed by in vitro and in vivo pharmacokinetic and pharmacodynamic studies), as well as clinical outcomes in patients with cirrhosis on DOAC.

Metabolic dysfunction-associated steatotic liver disease related cirrhosis and incidence of portal vein thrombosis

BACKGROUND

There is heterogeneous data on whether metabolic-associated steatohepatitis is an independent risk factor for portal vein thrombosis (PVT). We aim to compare the incidence of PVT in patients with cirrhosis with and without metabolic dysfunction-associated steatotic liver disease (MASLD).

METHODS

This is a single-center retrospective study of patients with cirrhosis seen between 1 January 2016 and 31 January 2021. Patients with a history of hepatocellular cancer, liver transplant, Budd-Chiari syndrome, and intra-abdominal malignancies were excluded. Patients with cirrhosis were followed from their first hepatology visit for 180 days to determine the incidence of PVT. Cox proportional hazard regression was used to determine the relationship between MASLD with PVT.

RESULTS

We analyzed data from 2785 patients with cirrhosis who met inclusion and exclusion criteria [mean age: 61.0 ± 12.3 years, 44.3% female, 63.8% Whites and mean model for end-stage liver disease-sodium (MELD-Na) score: 11.7 ± 6.1]. MASLD was present in 21.7% of patients. A total of 89 patients developed PVT during the follow-up, which was fewer in patients with MASLD [2.0% vs. 3.5%, P  = 0.04, unadjusted heart rate (HR): 0.60, 95% confidence interval (CI): 0.27-0.96, P  = 0.04]. After adjusting for the demographics, MASLD-related comorbid conditions and MELD-Na score, MASLD was associated with a lower incidence of PVT as compared to non-MASLD cirrhosis (HR: 0.44, 95% CI: 0.21-0.92, P  = 0.03). After adjusting for the indicators of Child-Pugh Turcotte score, the risk of PVT in patients with MASLD compared to non-MASLD was not statistically significant (HR: 0.50, 95% CI: 0.22-1.13, P  = 0.096).

CONCLUSION

PVT incidence was lower in patients with MASLD cirrhosis as compared to non-MASLD cirrhosis. However, the difference was not significantly different after adjusting for liver decompensation.

Limb Ischemic Necrosis Secondary to Microvascular Thrombosis: A Brief Historical Review

Ischemic limb injury can be broadly classified into arterial (absent pulses) and venous/microvascular (detectable pulses); the latter can be divided into two overlapping disorders-venous limb gangrene (VLG) and symmetrical peripheral gangrene (SPG). Both VLG and SPG feature predominant acral (distal) extremity ischemic necrosis, although in some instances, concomitant nonacral ischemia/skin necrosis occurs. Historically, for coagulopathic disorders with prominent nonacral ischemic necrosis, clinician-scientists implicated depletion of natural anticoagulants, especially involving the protein C (PC) system. This historical review traces the recognition of natural anticoagulant depletion as a key feature of nonacral ischemic syndromes, such as classic warfarin-induced skin necrosis, neonatal purpura fulminans (PF), and meningococcemia-associated PF. However, only after several decades was it recognized that natural anticoagulant depletion is also a key feature of predominantly acral ischemic microthrombosis syndromes-VLG and SPG-even when accompanying nonacral thrombosis is not present. These acquired acral limb ischemic syndromes typically involve the triad of (a) disseminated intravascular coagulation, (b) natural anticoagulant depletion, and (c) a localizing explanation for microthrombosis occurring in one or more limbs, either deep vein thrombosis (helping to explain VLG) or circulatory shock (helping to explain SPG). In most cases of VLG or SPG there are one or more events that exacerbate natural anticoagulant depletion, such as warfarin therapy (e.g., warfarin-associated VLG complicating heparin-induced thrombocytopenia or cancer hypercoagulability) or acute ischemic hepatitis ("shock liver") as a proximate factor predisposing to severe depletion of hepatically synthesized natural anticoagulants (PC, antithrombin) in the setting of circulatory shock.

Predictors of Non-Variceal Hemorrhage in a National Cohort of Patients With Chronic Liver Disease

Background

Non-variceal hemorrhage in patients with chronic liver disease (CLD) increases morbidity, mortality, and healthcare costs. There are limited data on risk factors for non-variceal hemorrhage in the CLD population. The aim of this study was to assess the predictive value of various clinical and laboratory parameters for non-variceal hemorrhage in CLD patients.

Methods

We conducted a retrospective cohort study of US veterans diagnosed with CLD between 2002 and 2018 within the Veterans Health Administration database. We derived candidate variables from existing risk prediction models for hemorrhage, risk calculators for severity of liver disease, Charlson index of prognostic comorbidities, and prior literature. We used a competing risk analysis to study the relationship between putative risk factors and incidence of non-variceal hemorrhage in patients with CLD.

Results

Of 15,183 CLD patients with no history of cancer or anticoagulation use, 674 experienced non-variceal hemorrhage within 1 year of CLD diagnosis. In multivariable analysis, 11 of the 26 candidate variables independently predicted non-variceal hemorrhage: race, international normalized ratio (INR) > 1.5, bilirubin ≥ 2 mg/dL, albumin ≤ 3.5 g/dL, anemia, alcohol abuse, antiplatelet therapy, chronic kidney disease, dementia, proton pump inhibitor prescription, and recent infection.

Conclusions

In this study of almost 15,000 veterans, risk factors for non-variceal bleeding within the first year after diagnosis of CLD included non-Caucasian race, laboratory parameters indicating severe liver disease and recent infection in addition to the risk factors for bleeding observed in a general non-CLD population.

Hypoalbuminemia and Risk of Portal Vein Thrombosis in Cirrhosis

BACKGROUND AND AIMS

Hypoalbuminemia, as defined by serum albumin (SA) levels ≤35 g/L, is associated to venous and arterial thrombosis in general population and in patients at risk of cardiovascular disease. It is unknown if SA ≤35 g/L is also associated to portal vein thrombosis (PVT) in cirrhosis.

METHODS

Cirrhotic patients enrolled in the Portal vein thrombosis Relevance On Liver cirrhosis: Italian Venous thrombotic Events Registry (PRO-LIVER) study (n = 753), were followed-up for 2 years to assess the risk of PVT, that was diagnosed by Doppler ultrasonography. Child-Pugh classes, Model for End-Stage Liver Disease score, presence of hepatocellular carcinoma and laboratory variables including SA, D-dimer, and high-sensitivity C-reactive protein (hs-CRP) were measured at baseline.

RESULTS

SA ≤35 g/L was detected in 52% of patients. A logistic multivariate regression analysis showed that higher Child-Pugh class, hepatocellular carcinoma and thrombocytopenia were significantly associated to SA ≤35 g/L. In a subgroup of patients where data regarding hs-CRP and D-dimer were available, SA ≤35 g/L was inversely associated with hs-CRP and D-dimer. During the follow-up, a total of 61 patients experienced PVT. A Kaplan Meier survival analysis showed SA ≤35 g/L was associated to increased risk of PVT compared to SA >35 g/L (P = .005). A multivariate Cox proportional hazards regression analysis showed that male sex, lower platelet count, and SA ≤35 g/L remained associated to PVT after adjusting for confounding factors.

CONCLUSION

Cirrhotic patients with SA ≤35 g/L are at higher risk of experiencing PVT compared to those with SA >35 g/L and could be considered as potential candidates to anticoagulant prophylaxis for PVT prevention.

Portal vein velocity predicts portal vein system thrombosis after splenectomy with esophagogastric devascularization

BACKGROUND

Portal vein system thrombosis (PVST) is a potentially fatal complication after splenectomy with esophagogastric devascularization (SED) in cirrhotic patients with portal hypertension. However, the impact of portal vein velocity (PVV) on PVST after SED remains unclear. Therefore, this study aims to explore this issue.

METHODS

Consecutive cirrhotic patients with portal hypertension who underwent SED at Tongji Hospital between January 2010 and June 2022 were enrolled. The patients were divided into two groups based on the presence or absence of PVST, which was assessed using ultrasound or computed tomography after the operation. PVV was measured by duplex Doppler ultrasound within one week before surgery. The independent risk factors for PVST were analyzed using univariate and multivariate logistic regression analysis. A nomogram based on these variables was developed and internally validated using 1000 bootstrap resamples.

RESULTS

A total of 562 cirrhotic patients with portal hypertension who underwent SED were included, and PVST occurred in 185 patients (32.9%). Multivariate logistic regression analysis showed that PVV was the strongest independent risk factor for PVST. The incidence of PVST was significantly higher in patients with PVV ≤ 16.5 cm/s than in those with PVV > 16.5 cm/s (76.2% vs. 8.5%, p < 0.0001). The PVV-based nomogram was internally validated and showed good performance (optimism-corrected c-statistic = 0.907). Decision curve and clinical impact curve analyses indicated that the nomogram provided a high clinical benefit.

CONCLUSION

A nomogram based on PVV provided an excellent preoperative prediction of PVST after splenectomy with esophagogastric devascularization.

Regional Citrate Anticoagulation versus No Anticoagulation for CKRT in Patients with Liver Failure with Increased Bleeding Risk

BACKGROUND

The opinions on the efficacy and safety of no anticoagulation versus regional citrate anticoagulation for continuous KRT (CKRT) were controversial in patients with severe liver failure with a higher bleeding risk. We performed a randomized controlled trial to assess no anticoagulation versus regional citrate anticoagulation for CKRT in these patients.

METHODS

Adult patients with liver failure with a higher bleeding risk who required CKRT were considered candidates. The included participants were randomized to receive regional citrate anticoagulation or no-anticoagulation CKRT. The primary end point was filter failure.

RESULTS

Of the included participants, 44 and 45 were randomized to receive regional citrate anticoagulation and no-anticoagulation CKRT, respectively. The no-anticoagulation group had a significantly higher filter failure rate (25 [56%] versus 12 [27%], P = 0.003), which was confirmed by cumulative incidence function analysis and sensitive analysis including only the first CKRT sessions. In the cumulative incidence function analysis, the cumulative filter failure rates at 24, 48, and 72 hours of the no-anticoagulation and regional citrate anticoagulation groups were 31%, 58%, and 76% and 11%, 23%, and 35%, respectively. Participants in the regional citrate anticoagulation group had significantly higher incidences of Ca 2+tot /Ca 2+ion >2.5 (7% versus 57%, P < 0.001), hypocalcemia (51% versus 82%, P = 0.002), and severe hypocalcemia (13% versus 77%, P < 0.001). However, most (73%) of the increased Ca 2+tot /Ca 2+ion ratios were normalized after the upregulation of the calcium substitution rate. In the regional citrate anticoagulation group, there was no significant additional increase in the systemic citrate concentration after 6 hours.

CONCLUSIONS

For patients with liver failure with a higher bleeding risk who required CKRT, regional citrate anticoagulation resulted in significantly longer filter lifespan than no anticoagulation. However, regional citrate anticoagulation in patients with liver failure was associated with a significantly higher risk of hypocalcemia, severe hypocalcemia, and Ca 2+tot /Ca 2+ion >2.5.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

RCA for CRRT in Liver Failure and High Risk Bleeding Patients, NCT03791190 .

Intestinal Obstruction as Initial Presentation of Idiopathic Portal and Mesenteric Venous Thrombosis: Diagnosis, Management, and Literature Review

It is quite common for portal vein thrombosis to occur in subjects who present predisposing conditions such as cirrhosis, hepatobiliary malignancies, infectious or inflammatory abdominal diseases, or hematologic disorders. The incidence of idiopathic portal vein thrombosis in non-cirrhotic patients remains low, and despite the intensive workup that is performed in these cases, in up to 25% of cases, there is no identifiable cause. If portal vein thrombosis is untreated, complications arise and include portal hypertension, cavernous transformation of the portal vein, gastroesophageal and even small intestinal varices, septic thrombosis, or intestinal ischemia. However, intestinal ischemia develops as a consequence of arterial thrombosis or embolism, and the thrombosis of the mesenteric vein accounts for about 10% of cases of intestinal ischemia. Although acute superior mesenteric vein thrombosis can cause acute intestinal ischemia, its chronic form is less likely to cause acute intestinal ischemia, considering the possibility of developing collateral drainage. Ileus due to mesenteric venous thrombosis is rare, and only a small number of cases have been reported to date. Most patients experience a distinct episode of acute abdominal pain due to ischemia, and in the second phase, they develop an obstruction/ileus. Acute superior mesenteric venous thrombosis is a rare condition that is still associated with a high mortality rate. The management of such cases of superior mesenteric venous thrombosis is clinically challenging due to their insidious onset and rapid development. A prompt and accurate diagnosis followed by a timely surgical treatment is important to save patient lives, improve the patient survival rate, and conserve as much of the patient's bowel as possible, thus leading to fewer sequelae.

Liver cirrhosis and complications from the perspective of dysbiosis

The gut-liver axis refers to the intimate relationship and rigorous interaction between the gut and the liver. The intestinal barrier's integrity is critical for maintaining liver homeostasis. The liver operates as a second firewall in this interaction, limiting the movement of potentially dangerous compounds from the gut and, as a result, contributing in barrier management. An increasing amount of evidence shows that increased intestinal permeability and subsequent bacterial translocation play a role in liver damage development. The major pathogenic causes in cirrhotic individuals include poor intestinal permeability, nutrition, and intestinal flora dysbiosis. Portal hypertension promotes intestinal permeability and bacterial translocation in advanced liver disease, increasing liver damage. Bacterial dysbiosis is closely related to the development of cirrhosis and its related complications. This article describes the potential mechanisms of dysbiosis in liver cirrhosis and related complications, such as spontaneous bacterial peritonitis, hepatorenal syndrome, portal vein thrombosis, hepatic encephalopathy, and hepatocellular carcinoma, using dysbiosis of the intestinal flora as an entry point.

Reappraisal of the conventional hemostasis tests as predictors of perioperative bleeding in the era of rebalanced hemostasis in cirrhosis

New global laboratory procedures mimicking the in vivo hemostasis process led to the changing paradigm of cirrhosis from the prototype of hemorrhagic diseases to a condition in which hemostasis is normal but fragile, thus justifying the hemorrhagic/thrombotic tendencies that affect these patients. The new paradigm was instrumental to change the management of cirrhosis. For example, international guidelines warn against the entrenched practice of testing patients with conventional hemostasis tests and infusing those with abnormalities with fresh-frozen plasma, coagulation factor concentrates, or platelets, prior to surgery/invasive procedures. These recommendations are, however, largely disattended. The practice of testing patients with the prothrombin time or viscoelastometry and using arbitrary cutoffs to make decisions on perioperative prophylaxis is still common and probably driven by medicolegal issues. There is no doubt that prothrombin time and congeners tests are unable to predict bleeding in cirrhosis. However, it cannot be excluded that some tests may be useful in patients who are severely decompensated. Large prospective collaborative studies are warranted. Enrolled patients should be randomized to receive perioperative prophylaxis based on laboratory testing (eg, viscoelastometry, thrombomodulin-modified thrombin generation) or to usual care. However, for these trials to be useful, a third group of patients who do not receive prophylaxis should be included. In conclusion, until results from these studies are available, physicians attending cirrhosis should refrain from using laboratory tests with arbitrary cutoffs to make decision on perioperative prophylaxis. Decision should be made by considering the clinical history of individual patients and the risk of hemorrhage of specific procedures.

Comparison of the Efficacy and Safety of Direct Oral Anticoagulants and Warfarin in Cirrhotic Patients: A Systematic Review and Meta-Analysis

OBJECTIVE

Currently, there is limited evidence regarding the use of direct oral anticoagulants (DOACs) for patients with liver cirrhosis (LC). We performed a meta-analysis to compare the efficacy and safety of DOACs versus warfarin in this population.

METHODS

We searched PubMed, Cochrane Library, Web of Science, Embase and Scopus databases from inception to August 2024. Clinical studies comparing the use of DOACs with warfarin in cirrhotic patients were included. Hazard ratios (HRs) with 95% CIs were estimated by either fixed or random effects models. Primary efficacy outcomes were ischemic stroke/thromboembolism (IS/TE) and all-cause death, the primary safety outcomes were the bleeding risks.

RESULTS

Sixteen studies were included (16 829 individuals). DOACs had similar benefits in preventing IS/TE (HR = 0.87, 95% CI: 0.69-1.10), but DOACs were significantly associated with reduced risk of all-cause death (HR = 0.87, 95% CI: 0.79-0.97). On the other hand, we observed significantly reduced risks of any bleeding (HR = 0.60; 95%CI: 0.37-0.95), major bleeding (HR = 0.72; 95%CI: 0.63-0.82), intracranial hemorrhage (ICH) (HR = 0.47; 95%CI: 0.30-0.73), and gastrointestinal bleeding (GIB) (HR = 0.72, 95% CI: 0.60-0.87) in patients receiving DOACs. Results were consistent in cirrhotic patients with AF. Furthermore, DOACs reduced the incidence of major bleeding (HR = 0.65, 95%CI: 0.55-0.78) and ICH (HR = 0.17, 95%CI: 0.04-0.76) in patients with moderate to severe cirrhosis.

CONCLUSION

Our study demonstrates that DOACs, compared with warfarin, exerted comparable efficacy and better safety and may represent a safer alternative to warfarin in cirrhotic patients.

Spontaneous muscle haematoma in a patient with cirrhosis

Decompensated liver disease is associated with alterated haemostasis that can either lead to spontaneous bleeding or development of thrombosis. Alcohol consumption coupled with advanced liver disease favours spontaneous bleeding. There have been only few documented cases of spontaneous muscle haematoma (SMH) in patients with cirrhosis. The pathogenesis of SMH is hypothesised to be multifactorial and it has been seen in patients on anticoagulation or with haemostatic disorders. We report a case of alcohol-related cirrhosis presenting with an expanding, voluminous haematoma in the intermuscular plane between the trapezius and the teres major muscles. This patient also had a retroperitoneal haemorrhage, clinically evidenced by the Grey Turner's and Cullen's signs. Haemorrhage was confirmed radiologically by CT. The patient was managed in an intensive care facility and treated with multiple blood products, including packed red blood cells, fresh frozen plasma and cryoprecipitates. However, as his clinical condition deteriorated, he required surgical intervention by incision and drainage, followed by evacuation. Early identification of coagulopathy and aggressive treatment are essential in these cases of cirrhosis to avoid unfavourable outcomes.

The prothrombotic tendency of metabolic-associated fatty liver disease

Our understanding of the function of the liver has evolved over the centuries. Early theories proposing that the liver could be used to divine the future have been superseded by our current knowledge of the importance of the liver in processes such as digestion and detoxification. Similarly, although liver disease was previously associated with only an increased risk of bleeding, there is now a substantial body of evidence demonstrating an increased thrombotic potential in patients with this disease. Metabolic-associated fatty liver disease (MAFLD) is increasing in frequency and is likely to overtake alcoholic liver disease as the primary indication for liver transplant in the future. In this review, we discuss the evidence linking liver disease, and MAFLD in particular, with arterial and venous thromboembolic disease. We review the safety and efficacy of anticoagulation in advanced liver disease and consider whether antithrombotic agents could slow or halt the progression of fibrosis in MAFLD.

Interpretable machine learning models for predicting venous thromboembolism in the intensive care unit: an analysis based on data from 207 centers

BACKGROUND

Venous thromboembolism (VTE) is a severe complication in critically ill patients, often resulting in death and long-term disability and is one of the major contributors to the global burden of disease. This study aimed to construct an interpretable machine learning (ML) model for predicting VTE in critically ill patients based on clinical features and laboratory indicators.

METHODS

Data for this study were extracted from the eICU Collaborative Research Database (version 2.0). A stepwise logistic regression model was used to select the predictors that were eventually included in the model. The random forest, extreme gradient boosting (XGBoost) and support vector machine algorithms were used to construct the model using fivefold cross-validation. The area under curve (AUC), accuracy, no information rate, balanced accuracy, kappa, sensitivity, specificity, precision, and F1 score were used to assess the model's performance. In addition, the DALEX package was used to improve the interpretability of the final model.

RESULTS

This study ultimately included 109,044 patients, of which 1647 (1.5%) had VTE during ICU hospitalization. Among the three models, the Random Forest model (AUC: 0.9378; Accuracy: 0.9958; Kappa: 0.8371; Precision: 0.9095; F1 score: 0.8393; Sensitivity: 0.7791; Specificity: 0.9989) performed the best.

CONCLUSION

ML models can be a reliable tool for predicting VTE in critically ill patients. Among all the models we had constructed, the random forest model was the most effective model that helps the user identify patients at high risk of VTE early so that early intervention can be implemented to reduce the burden of VTE on the patients.

The Yin and the Yang of Hemostasis in End-Stage Liver Disease

Patients with end-stage liver disease (ESLD) undergoing liver transplantation (LT) are prone to thromboses both while on the waiting list and in the perioperative period. This hypercoagulability is associated with significant endothelial dysfunction (ED) due to nitric oxide dysregulation. ED and increased thrombin generation are the main factors responsible for this hypercoagulability. Sepsis alone can significantly alter a patient's coagulation profile. In combination with ESLD, however, sepsis or septic shock are responsible for very complex changes. This makes both the assessment and management of coagulation in septic patients with ESLD very challenging. Viscoelastic testing (VET) is the preferred method of coagulation management in patients with cirrhosis because, as with standard laboratory testing, VET can assess the entire coagulation system including the interaction between both pro- and anticoagulants and platelets.

Long term prophylactic anticoagulation for portal vein thrombosis after splenectomy: A systematic review and meta-analysis

AIM

The aim of this study was to evaluate the efficacy and safety of the anticoagulants for the prevention of portal vein system thrombosis (PVST) in patients with cirrhosis after splenectomy and explore the optimal time of anticoagulant administration.

METHODS

A systematic literature search was performed using PubMed, Embase and China Biology Medicine disc (CBM)databases, so as to screen out studies comparing the prognoses between cirrhotic post-splenectomy patients treated with and without anticoagulants. The parameters that were analyzed included the incidence of PVST and postoperative bleeding.

RESULTS

With a total of 592 subjects, we included 8 studies (6 observational and 2 randomized trials) that fulfilled the inclusion criteria. We found that the incidence of PVST was significantly lower in the anticoagulation group during the first 6 months of anticoagulant administration. And the largest difference in the incidence of PVST between the anticoagulation and control groups was observed at 3 months (odds ratio 0.17(0.11~0.27); P = 0.767; I2 = 0.0%) and 6 months (OR = 0.21(0.11~0.40); P = 0.714; I2 = 0.0%) postoperatively. The incidence of bleeding was not significantly higher in the anticoagulation group (odds ratio 0.71 (0.30~1.71); P = 0.580; I2 = 0.0%).

CONCLUSION

Low-molecular weight heparin (LMWH) and warfarin can decrease the incidence of PVST in post-splenectomy cirrhotic patients without an increased risk of bleeding. And the optimal use time of warfarin is 6 months after splenectomy.

Molecular Mechanisms Underlying Vascular Liver Diseases: Focus on Thrombosis

Vascular liver disorders (VLDs) comprise a wide spectrum of clinical-pathological entities that primarily affect the hepatic vascular system of both cirrhotic and non-cirrhotic patients. VLDs more frequently involve the portal and the hepatic veins, as well as liver sinusoids, resulting in an imbalance of liver homeostasis with serious consequences, such as the development of portal hypertension and liver fibrosis. Surprisingly, many VLDs are characterized by a prothrombotic phenotype. The molecular mechanisms that cause thrombosis in VLD are only partially explained by the alteration in the Virchow's triad (hypercoagulability, blood stasis, and endothelial damage) and nowadays their pathogenesis is incompletely described and understood. Studies about this topic have been hampered by the low incidence of VLDs in the general population and by the absence of suitable animal models. Recently, the role of coagulation imbalance in liver disease has been postulated as one of the main mechanisms linked to fibrogenesis, so a novel interest in vascular alterations of the liver has been renewed. This review provides a detailed analysis of the current knowledge of molecular mechanisms of VLD. We also focus on the promising role of anticoagulation as a strategy to prevent liver complications and to improve the outcome of these patients.

Viscoelastometry to Manage Bleeding in Liver Disease

A state of "re-balanced haemostasis" describes complex coagulation changes that arise in patients with liver disease. Changes include alterations in procoagulant and anticoagulant proteins, platelets and von Willebrand factor, as well as the fibrinolytic system. Various circumstances including infection, trauma, or surgery may disrupt this balance and predispose an individual to bleeding or thrombosis. The prothrombin time, international normalised ratio, and activated partial thromboplastin time are conventional coagulation screening tests that are routinely employed by clinicians to investigate unexplained bleeding, monitor anticoagulation, and inform preoperative assessments of bleeding risk. These standard coagulation tests assess quantitative defects in procoagulant clotting factors and are insensitive to levels of natural anticoagulants, which together with procoagulant factors, are often perturbed in liver disease. Therefore, the prolongation of clotting times measured by these tests often does not reflect the multifaceted alterations of haemostasis in these patients. Viscoelastic testing (VET) provides a more encompassing assessment of clotting function by recording real-time viscoelastic changes in whole blood and includes parameters that provide information on coagulation factor function, platelet contribution to clot formation, as well as fibrinolysis. To date, VET has been employed to predict and inform transfusion support in obstetric, trauma, and cardiac surgical fields, and its use in patients undergoing liver transplantation is well established. The ability of VET to accurately predict bleeding risk and precisely guide transfusion algorithms for patients with liver disease undergoing other invasive procedures or experiencing bleeding complications has been the topic of research over the last decade. This review is a critical summary of this data and provides a detailed snapshot of the position of VET as a clinical tool in patients with liver disease.

Safety and efficacy of venous thromboembolism prophylaxis in patients with cirrhosis: A systematic review and meta-analysis

BACKGROUND & AIMS

Patients with cirrhosis are considered in a haemostatic balance, though weaker than in normal subjects. In these patients, however, the use of pharmacological prophylaxis for venous thromboembolism (VTE) remains controversial. Therefore, in this study, we aimed to assess the safety and efficacy of VTE prophylaxis in patients with cirrhosis.

METHODS

We conducted a systematic review of studies reporting the occurrence of bleeding and VTE events in patients with cirrhosis, and controls, undergoing VTE prophylaxis. Meta-regression analysis was conducted to further explore the determinants of heterogeneity in the study of the occurrence of either bleeding or VTE events.

RESULTS

In a total of 10 studies, including 5712 patients, of which 2330 undergoing VTE prophylaxis, bleeding (n = 5513) and VTE events occurred in 8.2% and 2.8% patients respectively. A total of 2963 and 3162 patients were included from low-risk of bias studies in bleeding and VTE analysis respectively: while administration of VTE prophylaxis did not seem to reduce VTE (OR = 1.07, CI 0.39-2.96, p = .89), importantly prophylaxis was not associated with increased bleeding risk (OR = 0.56, CI 0.20-1.59, p = .27). Meta-regression analysis showed that no parameter significantly influenced the heterogeneity of data regarding bleeding or VTE events.

CONCLUSIONS

In patients with cirrhosis, current evidence is insufficient to advise for or against the use of VTE prophylaxis, mainly due to lack of quality and homogeneity of available data. However, its use does not appear to be associated with a significant bleeding risk. Adequately designed studies are required to provide a measure of its overall utility.

Microvascular Thrombosis and Liver Fibrosis Progression: Mechanisms and Clinical Applications

Fibrosis is an unavoidable consequence of chronic inflammation. Extracellular matrix deposition by fibroblasts, stimulated by multiple pathways, is the first step in the onset of chronic liver disease, and its propagation promotes liver dysfunction. At the same time, chronic liver disease is characterized by alterations in primary and secondary hemostasis but unlike previously thought, these changes are not associated with an increased risk of bleeding complications. In recent years, the role of coagulation imbalance has been postulated as one of the main mechanisms promoting hepatic fibrogenesis. In this review, we aim to investigate the function of microvascular thrombosis in the progression of liver disease and highlight the molecular and cellular networks linking hemostasis to fibrosis in this context. We analyze the predictive and prognostic role of coagulation products as biomarkers of liver decompensation (ascites, variceal hemorrhage, and hepatic encephalopathy) and liver-related mortality. Finally, we evaluate the current evidence on the application of antiplatelet and anticoagulant therapies for prophylaxis of hepatic decompensation or prevention of the progression of liver fibrosis.

Interventional Approach to Portal Vein Thrombosis and Liver Transplantation: State of the Art

Porto-mesenteric vein thrombosis (PVT) is a well-recognized but uncommon disease entity in patients with and without cirrhosis. Given the complexity of these patients, there are many differing treatment algorithms depending on the individual circumstances of a given patient. The focus of this review is primarily patients with cirrhosis, with an emphasis on liver transplantation considerations. The presence of cirrhosis substantially affects work-up, prognosis, and management of these patients and will substantially affect the patient treatment and have additional implications for prognosis and long-term outcomes. Here, we review the incidence of portal vein thrombosis in known cirrhotic patients, medical and interventional treatment options that are currently used, and, in particular, how to approach cirrhotic patients with PVT who are awaiting liver transplantation.

Plasma Antithrombin III Levels Can Be a Prognostic Factor in Liver Cirrhosis Patients with Portal Vein Thrombosis

Liver function influences the plasma antithrombin (AT)-III levels. AT-III is beneficial for patients with portal vein thrombosis (PVT) and low plasma AT-III levels. However, whether these levels affect prognosis in patients with cirrhosis-associated PVT remains unknown. This retrospective study involved 75 patients with cirrhosis and PVT treated with danaparoid sodium with or without AT-III. The plasma AT-III level was significantly lower in patients with liver failure-related death than in those with hepatocellular carcinoma (HCC)-related death (p = 0.005), although the Child-Pugh and albumin-bilirubin (ALBI) scores were not significantly different between these two groups. Receiver operating characteristic curve analysis of the plasma AT-III levels showed cutoff values of 54.0% at 5-year survival. Low plasma AT-III levels (<54.0%) were associated with significantly worse prognosis than high levels in both overall survival (p = 0.0013) and survival excluding HCC-related death (p < 0.0001). Low plasma AT-III (<54.0%) was also associated with a significantly worse prognosis among patients with Child-Pugh A/B or ALBI grade 1/2 (p < 0.0001). Multivariate analyses indicated that low plasma AT-III levels (<54.0%) were an independent prognostic factor for poor survival outcome. Low plasma AT-III levels may be associated with mortality, particularly liver failure-related death, independent of liver function.

Sulodexide attenuates liver fibrosis in mice by restoration of differentiated liver sinusoidal endothelial cell

Sulodexide is a heparinoid compound with wide-ranging pharmacological activities. However, the effect of sulodexide on liver fibrogenesis has not been reported. In this study, we aim to evaluate the therapeutic potential of sulodexide in mouse model of liver fibrosis and explore the underlying antifibrotic mechanisms. We found that sulodexide treatment significantly attenuated thioacetamide (TAA) and 3,5-diethoxycarbonyl-1,4-dihydrocollidine (DDC)-induced liver fibrosis in mice. Transcriptome analysis revealed that sulodexide treatment downregulated fibrosis-related genes and liver sinusoidal endothelial cells (LSECs) capillarization-associated genes in fibrotic livers. Immunohistochemistry confirmed that the increased expression of LSEC capillarization-related genes (CD34, CD31 and Laminin) in liver fibrotic tissues was reduced by sulodexide treatment. Scanning electron microscopy showed that LSECs fenestrations were preserved upon sulodexide treatment. Quantitative real-time PCR and immunofluorescence demonstrated that the expression of mesenchymal markers was downregulated by sulodexide administration, suggesting sulodexide inhibited endothelial-mesenchymal transition of LSECs during liver fibrosis. Furthermore, sulodexide administration protected primary LSECs from endothelial dysfunction in vitro. In conclusion, sulodexide attenuated liver fibrosis in mice by restoration of differentiated LSECs, indicating that sulodexide treatment may present as a potential therapy for patients with liver fibrosis.

The use of prothrombin complex concentrate in chronic liver disease: A review of the literature

Patients with chronic liver disease (CLD) and cirrhosis present a rebalanced hemostatic system in the three phases of haemostasis. This balance is however unstable and can easily tip towards bleeding or thrombosis. Management of both spontaneous bleeding and bleeding during invasive procedures remains a challenge in this patient population. Transfusion of blood products can result in circulatory overload and thereby worsen portal hypertension. As an alternative to fresh frozen plasma (FFP), prothrombin complex concentrates (PCC) may have merit in patients with liver disease because of their low volume. The impact of PCC in in-vitro spiking experiments of cirrhotic plasma is promising, but also warrants cautious use in light of thromboembolic risk. The majority of existing studies carried-out in CLD patients are retrospective or do not have an adequate control arm. A prospective study (the PROTON trial) was set up in 2013 to investigate the utility of PCC in patients undergoing liver transplantation. However, the study has never recruited the planned number of patients. Robust data on PCC safety in CLD is also required. The limited existing evidence does not seem to indicate an excessive thromboembolic risk. Currently, the utilisation of PCC in CLD cannot be routinely recommended but can provide an option for carefully selected cases in which other measures were not sufficient to control bleeding and after delicately weighing risks and benefits.

Anticoagulation for Atrial Fibrillation in Patients with Decompensated Liver Cirrhosis: Bold and Brave?

Atrial fibrillation is frequently diagnosed in patients with liver cirrhosis, especially in those with non-alcoholic steatohepatitis or alcoholic etiology. Anticoagulant treatment is recommended for thromboembolic protection in patients with atrial fibrillation. Considering the impaired coagulation balance in liver cirrhosis, predisposing patients to bleed or thrombotic events, the anticoagulant treatment is still a matter of debate. Although patients with liver cirrhosis were excluded from the pivotal studies that confirmed the efficacy and safety of the anticoagulant treatment in patients with atrial fibrillation, data from real-life cohorts demonstrated that the anticoagulant treatment in patients with liver cirrhosis could be safe. This review aimed to evaluate the recent data regarding the safety and efficacy of anticoagulant treatment in patients with decompensated liver cirrhosis. Direct oral anticoagulants are safer than warfarin in patients with compensated liver cirrhosis. In Child-Pugh class C liver cirrhosis, direct oral anticoagulants are contraindicated. New bleeding and ischemic risk scores should be developed especially for patients with liver cirrhosis, and biomarkers for bleeding complications should be implemented in clinical practice to personalize this treatment in a very difficult population represented by decompensated liver cirrhosis patients.

Cirrhosis is independently associated with complications and mortality following operative treatment of acetabular fractures

INTRODUCTION

Patients with cirrhosis are at higher risk for morbidity after injury. Acetabular fractures represent a highly morbid injury pattern. Few studies have specifically examined an effect of cirrhosis on risk of complications after acetabular fracture. We hypothesized that cirrhosis is independently associated with increased risk of inpatient complications following operative treatment of acetabular fractures.

METHODS

Adults patients with acetabular fracture who underwent operative treatment were identified from Trauma Quality Improvement Program data from 2015 to 2019. Patients with and without cirrhosis were matched on a propensity score predicting cirrhotic status and inpatient complications based on patient, injury, and treatment characteristics. The primary outcome was overall complication rate. Secondary outcomes included serious adverse event rate, overall infection rate, and mortality.

RESULTS

After propensity score matching, 137 cirrhosis+ and 274 cirrhosis- remained. No significant differences existed in observed characteristics after matching. Compared to cirrhosis- patients, cirrhosis+ patients experienced 43.4% (83.9 vs 40.5%, p < 0.001) greater absolute risk difference of any inpatient complication, 29.9% (51.8 vs 21.9%, p < 0.001) greater absolute risk difference of serious adverse events, 28.5% (41.6 vs 13.1%, p < 0.001) greater absolute risk difference of any infection, and 2.9% (2.9% vs 0.0%, p = 0.02) greater absolute risk difference of inpatient mortality.

CONCLUSION

Cirrhosis is associated with higher rates of inpatient complications, serious adverse events, infection, and mortality among patients undergoing operative repair of acetabular fracture.

LEVEL OF EVIDENCE

Prognostic Level III.

Elevated levels of soluble glycoprotein V - The plasma marker of platelet activation by thrombin in patients with early stage primary biliary cholangitis (PBC)

PURPOSE

There is a growing body of evidence for a prothrombotic tendency in patients with primary biliary cholangitis (PBC). The aim of the study was to evaluate coagulation disorders in patients with early stage PBC compared to healthy controls and evaluation of their relationship with clinical data, with particular emphasis on minimal hepatic encephalopathy (MHE).

PATIENTS AND METHODS

Fifty-one participants (PBC group - 38 patients, all patients but one Child-Pugh A; control group - 13 healthy controls) were included in our prospective, single center study. We assessed the plasma levels of sGPV, plasma procoagulant phospholipids (PPL) and rotational thromboelastometry (ROTEM) profiles in all study participants. Porto-systemic encephalopathy syndrome test was used to assess MHE.

RESULTS

The sGPV levels were higher in the PBC group compared to the controls: 36.07 ​± ​11.32 ​ng/mL vs 27.04 ​± ​11.72 ​ng/mL, p ​= ​0.031. The PPL level was lower in the PBC group compared to controls resulting in increased clotting time in a factor Xa-based coagulation assay: 54.65 (47.83-58.83) sec. vs 45.90 (43.3-50.5) sec., p ​= ​0.0065. PPL levels were correlated with platelet count (rho ​= ​-0.46, p ​= ​0.001). ROTEM parameters did not differ significantly between groups. Coagulation parameters did not differ significantly between patients with and without MHE.

CONCLUSIONS

We have showed increased levels of sGPV - a plasma marker of platelet activation by thrombin in patients with early stage PBC compared to healthy controls. We found no relationship between the coagulation disorders and the occurrence of MHE. The PPL level was lower in the PBC group.

Portal Vein Recanalization-Transjugular Intrahepatic Portosystemic Shunt (PVR-TIPS) Facilitates Liver Transplantation in Cirrhotic Patients with Occlusive Portal Vein Thrombosis

Portal vein thrombosis (PVT) is a heterogeneous condition with multiple possible etiologies and to varying degrees has historically limited candidacy for liver transplant (LT) in the cirrhotic patient population due to resultant difficulties in constructing a robust portal vein anastomosis. While intraoperative approaches to managing PVT are well-described, methods which approximate normal portal physiology are not always feasible depending on the extent of PVT, and other nonphysiologic techniques are linked with substantial morbidity and poor long-term outcomes. Portal vein recanalization-transjugular intrahepatic portosystemic shunt (PVR-TIPS) creation is an efficacious method of restoring physiologic portal flow in cirrhotic patients prior to LT allowing for end-to-end PV anastomosis, and is the product of decades-long institutional expertise in TIPS/LT and the support of a multidisciplinary liver tumor board. To follow is a review of the pertinent pathophysiology of PVT in cirrhosis, the rationale leading to the development and subsequent evolution of the PVR-TIPS procedure, technical lessons learned, and a summary of outcomes to date.

Impact of cardiac and noncardiac cirrhosis on coronary revascularization outcomes from the National Inpatient Sample, 2016 to 2018

Data on coronary revascularization in patients with cirrhosis are scarce because it is often deferred in the setting of significant comorbidities and coagulopathies. It is unknown whether patients with cardiac cirrhosis have a worse prognosis. The National Inpatient Sample was surveyed to identify patients who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for acute coronary syndrome (ACS) from 2016 to 2018. Those with and without liver cirrhosis were propensity score-matched and compared within the PCI and CABG cohorts. Primary outcome was in-hospital mortality. Patients with cirrhosis were further classified into cardiac and noncardiac cirrhosis and their in-hospital mortalities were compared. A total of 1,069,730 PCIs and 273,715 CABGs were performed for ACS, of which 0.6% and 0.7%, respectively, were performed in patients with cirrhosis. In both the PCI cohort (odds ratio = 1.56; 95% confidence interval, 1.10-2.25; P = 0.01) and the CABG cohort (odds ratio = 2.34; 95% confidence interval, 1.19-4.62; P = 0.01), cirrhosis was associated with higher in-hospital mortality. In-hospital mortality was greatest in cardiac cirrhosis (8.4% and 7.1%), followed by noncardiac cirrhosis (5.5% and 5.0%) and no cirrhosis (2.6% and 2.3%) in PCI and CABG cohorts, respectively. Higher in-hospital mortality and periprocedural morbidities should be considered when performing coronary revascularization in patients with cirrhosis.

Gut dysbiosis, endotoxemia and clotting activation: A dangerous trio for portal vein thrombosis in cirrhosis

Liver cirrhosis (LC) is associated with portal venous thrombosis (PVT) in roughly 20% of cirrhotic patients but the underlying mechanism is still unclear. Low-grade endotoxemia by lipopolysaccharides (LPS), a component of outer gut microbiota membrane, is detectable in the portal circulation of LC and could predispose to PVT. LPS may translocate into systemic circulation upon microbiota dysbiosis-induced gut barrier dysfunction, that is a prerequisite for enhanced gut permeability and ensuing endotoxemia. Experimental and clinical studies provided evidence that LPS behaves a pro-thrombotic molecule so promoting clotting and platelet activation. Experiments conducted in the portal circulation of cirrhotic patients showed the existence of LPS-related enhanced thrombin generation as well as endothelial dysfunction, venous stasis, and platelet activation. The review will analyze 1) the pro-thrombotic role of endotoxemia in the context of LC 2) the biological plausibility linking endotoxemia with PVT and 3) the potentially interventional tools to lower endotoxemia and eventually hypercoagulation.

Liver fibrosis-4 score predicts outcome of patients with ischemic stroke undergoing intravenous thrombolysis

Some evidence suggests a possible influence of liver disease on stroke prognosis. We investigated the association between fibrosis-4 (FIB-4) score, a marker of liver disease, and the 3-month outcome in patients with ischemic stroke undergoing intravenous thrombolysis. We also evaluated the rate of symptomatic intracranial hemorrhage after thrombolysis. In this prospective cohort study, we enrolled consecutive patients with ischemic stroke treated with thrombolysis who had a 3-month follow-up. The FIB-4 score was calculated and the validated cut-off values were used to indicate high/low risk of advanced liver fibrosis. The primary outcome was 3-month poor prognosis estimated as a modified Rankin scale score ≥3. Of the 264 included patients, 131 (49.62%) had a 3-month mRS ≥3, with a significantly higher FIB-4 score, compared to those with a mRS <3 score (_adjp <0.001). When adjusted for possible confounders by multivariate logistic regression, FIB-4 score remained a significant predictor of poor outcome (OR 1.894, p = 0.011), along with history of atrial fibrillation (OR 3.488, p = 0.017), admission NIHSS score (OR 1.305, p < 0.001), and low values of hemoglobin (OR 0.730, p < 0.001). Mechanical thrombectomy had a favorable effect on patients' outcome (OR 0.201, p = 0.005). The risk of poor 3-month outcome was significantly higher among the 32 patients (12.1%) with high risk of severe fibrosis (p = 0.007). FIB-4 score values were also related to symptomatic intracranial hemorrhage (p = 0.004), specifically among patients with high probability of advanced hepatic fibrosis (p = 0.037). FIB-4 score can be considered as a promising independent predictor of poor prognosis in patients with acute ischemic stroke undergoing intravenous thrombolysis.

Haemostasis patterns in patients with acute-on-chronic liver failure and acute decompensation of cirrhosis including thromboelastometric tests with and without the addition of Protac: a pilot study

BACKGROUND

Thromboelastometry is considered the best method to assesses hemostasis in liver disease. Diagnostic performance could be improved by adding protein C activators such as thrombomodulin or Protac®. We assessed changes in ROTEM parameters after the addition of Protac® in patients with acute-on-chronic liver failure (ACLF), acute decompensation (AD), and healthy individuals (HI) to define different hemostasis patterns, considering standard and velocity ROTEM parameters, and assess whether Protac® can improve the definition of the pattern.

METHODS

Pre-test, we investigated whether diluted EXTEM reagent improved the effect of Protac® on the clotting time (CT)-ratio with and without Protac®. Ten ACLF and 20 AD patients and 21 HI were included in the main study.

RESULTS

Standard EXTEM was used in the main study. INTEM CFT, INTEM A5 (inverse), and INTEM TPI (inverse) were the parameters that best differentiated liver disease from HI (ROC AUC, 0.921, 0.906, and 0.928, respectively; all P-values < 0.001). Combining INTEM CFT with EXTEM LI60-ratio only slightly improved the diagnostic performance (ROC AUC, 0.948; P < 0.001). EXTEM LI60 and INTEM maxV-t were the parameters that best differentiated between ACLF and AD patients (ROC AUC, 0.743, P = 0.033; and 0.723, P = 0.050; respectively). Combining EXTEM LI60 + INTEM maxV-t moderately improved the diagnostic performance (ROC AUC, 0.81, P < 0.001).

CONCLUSIONS

ROTEM velocity, fibrinolysis parameters and the indices calculated improve the diagnosis in combination with standard parameters (e.g., CFT and A5). Ratios calculated with and without Protac® (e.g., EXTEM LI60-ratio) only slightly increased the diagnostic performance in discriminating hemostasis patterns.