Association of coagulopathy with the risk of bleeding after invasive procedures in liver cirrhosis

Jing Li, Bing Han, Hongyu Li, Han Deng, Nahum Méndez-Sánchez, Xiaozhong Guo, Xingshun Qi, Jing Li, Bing Han, Hongyu Li, Han Deng, Nahum Méndez-Sánchez, Xiaozhong Guo, Xingshun Qi

Abstract

Background/aim: Bleeding risk among patients with acute or chronic liver disease after invasive procedures is a common concern in clinical practice. This retrospective study aimed to explore whether the presence of coagulopathy increased the risk of major bleeding after invasive procedures in cirrhosis.

Patients and methods: A total of 874 cirrhotic patients underwent invasive procedures. Coagulopathy was defined as international normalized ratio (INR) ≥1.5 and/or platelets (PLTs) ≤50 × 109/L. Severe thrombocytopenia was defined as PLTs ≤ 50 × 109/L. Invasive procedures, major bleeding after invasive procedures, and in-hospital deaths were recorded.

Results: In all, 296 patients (33.9%) had coagulopathy. Major bleeding after invasive procedures occurred in 21 patients (2.4%). Major bleeding after invasive procedures was more frequent in patients with coagulopathy than those without coagulopathy (4.1% vs 1.6%, P = 0.023). Major bleeding after invasive procedures was more frequent in patients with severe thrombocytopenia than those without severe thrombocytopenia (4.9% vs 1.6%, P = 0.008). Incidence of major bleeding after invasive procedures was not significantly different between patients with INR ≥ 1.5 and INR < 1.5 (4.5% vs 2.0%, P = 0.065). Patients with INR ≥1.5 had a significantly higher in-hospital mortality than those with INR < 1.5 (6.4% vs 1.3%, P < 0.001).

Conclusion: Severe thrombocytopenia significantly increased the risk of major bleeding after invasive procedures in cirrhosis. INR ≥ 1.5 significantly increased in-hospital mortality.

Keywords: In-hospital mortality; international normalized ratio; platelets; prothrombin time; thrombocytopenia.

Conflict of interest statement

There are no conflicts of interest

References

    1. Muciño-Bermejo J, Carrillo-Esper R, Uribe M, Méndez-Sánchez N. Coagulation abnormalities in the cirrhotic patient. Ann Hepatol. 2013;12:713–24.
    1. Northup PG, Caldwell SH. Coagulation in liver disease: A guide for the clinician. Clin Gastroenterol Hepatol. 2013;11:1064–74.
    1. Tripodi A, Primignani M, Mannucci PM. Abnormalities of hemostasis and bleeding in chronic liver disease: The paradigm is challenged. Intern Emerg Med. 2010;5:7–12.
    1. De Franchis R. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015;63:743–52.
    1. Tripodi A. The coagulopathy of chronic liver disease: Is there a causal relationship withbleeding? No. Eur J Intern Med. 2010;21:65–9.
    1. Tripodi A, Caldwell SH, Hoffman M, Trotter JF, Sanyal AJ. Review article: The prothrombintime test as a measure of bleeding risk and prognosis in liver disease. Aliment Pharmacol Ther. 2007;26:141–8.
    1. Caldwell SH, Hoffman M, Lisman T, Macik BG, Northup PG, Redy KR, et al. Coagulation disorders and hemostasis in liver disease: Pathophysiology and critical assessment of current management. Hepatology. 2006;44:1039–46.
    1. Mannucci PM. Abnormal hemostasis tests and bleeding in chronic liver disease: Are they related? No. J Thromb Haemost. 2006;4:721–3.
    1. Reverter JC. Abnormal hemostasis tests and bleeding in chronic liver disease: Are they related? Yes. J Thromb Haemost. 2006;4:717–20.
    1. Napolitano G, Iacobellis A, Merla A, Niro G, Valvano MR, Terracciano F, et al. Bleeding after invasive procedures is rare and unpredicted by platelet counts in cirrhotic patients with thrombocytopenia. Eur J Intern Med. 2017;38:79–82.
    1. Shah A, Amarapurkar D, Dharod M, Chandnani M, Baijal R, Kumar P, et al. Coagulopathy in cirrhosis: A prospective study to correlate conventional tests of coagulation and bleeding following invasive procedures in cirrhotics. Indian J Gastroenterol. 2015;34:359–64.
    1. Cocero N, Bezzi M, Martini S, Carossa S. Oral surgical treatment of patients with chronic liver disease: Assessments of bleeding and its relationship with thrombocytopenia and blood coagulation parameters. J Oral Maxillofac Surg. 2017;75:28–34.
    1. Giannini EG, Greco A, Marenco S, Andorno E, Valente U, Savarino V. Incidence of bleeding following invasive procedures in patients with thrombocytopenia and advanced liver disease. Clin Gastroenterol Hepatol. 2010;8:899–902.
    1. Deng H, Qi X, Zhang Y, Peng Y, Li J, Guo X. Diagnostic accuracy of contrast-enhanced computed tomography for esophageal varices in liver cirrhosis: A retrospective observational study. J Evid Based Med. 2017;10:46–52.
    1. Li J, Qi X, Deng H, Peng Y, Shao L, Ma J, et al. Coagulation tests with the risk of acute upper gastrointestinal bleeding in liver cirrhosis: A retrospective study. Gastroenterol Rep (Oxf) 2016;4:315–9.
    1. Wang R, Qi X, Peng Y, Deng H, Li J, Ning Z, et al. Association of umbilical hernia with volume of ascites in liver cirrhosis: A retrospective observational study. J Evid Based Med. 2016;9:170–80.
    1. Zhang X, Qi X, De Stefano V, Hou F, Ning Z, Zhao J, et al. Epidemiology, risk Factors, and in-hospital mortality of venous thromboembolism in liver cirrhosis: A single-center retrospective observational study. Med Sci Monit. 2016;22:969–76.
    1. Child CG, Turcotte JG. Surgery and portal hypertension. Major Probl Clin Surg. 1964;1:1–85.
    1. Kamath PS, Kim WR. The model for end-stage liver disease (MELD) Hepatology. 2007;45:797–805.
    1. Malloy PC, Grassi CJ, Kundu S, Gervais DA, Miller DL, Osnis RB, et al. Consensus guidelines for periprocedural management of coagulation status and hemostasis risk in percutaneous image-guided interventions. J Vasc Interv Radiol. 2009;20:240–9.
    1. De Pietri L, Bianchini M, Montalti R, De Maria N, Di Maira T, Begliomini B, et al. Thrombelastography-guided blood product use before invasive procedures in cirrhosis with severe coagulopathy: A randomized, controlled trial. Hepatology. 2016;63:566–73.
    1. Townsend JC, Heard R, Powers ER, Reuben A. Usefulness of international normalized ratio to predict bleeding complications in patients with end-stage liver disease who undergo cardiac catheterization. Am J Cardiol. 2012;110:1062–5.
    1. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46:922–38.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera