The risk of venous thromboembolism in patients with cirrhosis

Abstract

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

Platelet‐leucocyte aggregation is augmented in cirrhosis and further increased by platelet transfusion

“…Platelet‐leucocyte aggregates are regarded as pro‐thrombogenic, which mechanistically is explained by increased tissue factor production by the involved leucocytes accompanied by enhanced fibrin deposition . This may add to the already increased risk of venous thrombosis in these patients . Indeed, the increase in thrombin‐antithrombin complexes following platelet transfusion suggests a prohaemostatic effect of donor platelets.…”

Pathogenesis, prevention, and management of bleeding and thrombosis in patients with liver diseases

“…In acute liver failure, clinically significant bleeding is rare, and in contrast to patients with cirrhosis bleeding from esophageal varices is virtually absent, which is explained largely by the usual absence of portal hypertension. Third, patients with liver disease are not protected from thrombotic events, and increasing clinical data refute the twentieth‐century concept of patients with liver diseases being “auto‐anticoagulated.” Cirrhosis has been identified as a risk factor for venous thrombosis, and in patients with acute liver failure, thrombotic complications are even more common than bleeding in patients with acute liver failure in recent series …”

In vitro efficacy of pro‐ and anticoagulant strategies in compensated and acutely ill patients with cirrhosis

“…It is, however, unknown whether there is a causal link between bleeding risk and these laboratory abnormalities, and studies assessing whether reversal of thrombocytopenia and/or hypofibrinogenemia decrease the bleeding risk in these patients will be required to ascertain this. It is unknown whether acutely ill patients with cirrhosis are at risk for development of venous thrombosis similar to the increased risk in well compensated patients . Nevertheless, prophylactic or therapeutic antithrombotic strategies may be required in acutely ill patients with cirrhosis, in the context of venous thrombosis, portal vein thrombosis, and thrombosis of extracorporeal assist devices …”