- Introduction
“The Hepatology Digest -Liver Vascular Disease Column” is an academic section jointly initiated by Dr. Xingshun Qi of the Department of Gastroenterology, Northern Theater General Hospital, at the invitation of the Hepatology Digest editorial team. It regularly collects and discusses the latest research in the field of liver vascular diseases. Every two weeks, on Wednesdays, it features an in-depth discussion of a significant publication, aiming to enlighten readers about the rationale behind these findings and inspire clinical research and practical application.
- Article Brief
Portal vein thrombosis (PVT) is a rare condition. Patients with advanced liver cirrhosis experience hemodynamic changes, leading to risks of bleeding and thrombosis formation (Senzolo M, et al. J Hepatol. 2021; 75(2):442 – 453). As liver disease worsens, the risk of PVT gradually increases (Ponziani FR, et al. Transplant Rev (Orlando). 2014; 28(2):92 – 101). In the general population, the incidence of PVT is 0.05% to 0.5%, but it can be as high as 5% to 18% in patients with decompensated cirrhosis (Costache RS, et al. Exp Ther Med. 2021; 22(1):759). Treatments for PVT include anticoagulation, thrombectomy, thrombolysis, and transjugular intrahepatic portosystemic shunt procedures. Clinicians should consider the underlying causes of PVT, patient preferences, and a benefit-risk assessment when choosing a treatment plan (Wu M, et al. J Clin Transl Hepatol. 2019; 7(2):154 – 164). The safety of anticoagulation therapy in liver cirrhosis PVT remains controversial, with a particular focus on the risk of bleeding (Amitrano L, et al. J Clin Gastroenterol. 2010; 44(6):448 – 451).
In August 2022, the Postgraduate Medical Journal published an article titled ” Safety of anticoagulation use for treatment of portal vein thrombosis in liver cirrhosis and its effect on hospital-based outcomes: an insight from a US nationwide database “. This article aimed to explore the effects of anticoagulation therapy on hospital outcomes in patients with liver cirrhosis PVT.
Tarar and colleagues reviewed hospital records from 2016 to 2018, including 60,505 patients with liver cirrhosis PVT, and divided them into anticoagulation and non-anticoagulation groups. The primary outcomes studied were mortality rates and the incidence of variceal bleeding, hepatic encephalopathy, acute kidney injury (AKI), hepatic renal syndrome (HRS), spontaneous bacterial peritonitis (SBP), and sepsis. The study also examined independent predictors of mortality, reasons for hospitalization, average total hospital costs, and average length of stay (LOS). The findings showed that compared to the non-anticoagulation group, patients in the anticoagulation group had lower mortality rates, lower incidence of variceal bleeding, HRS, AKI, SBP, and sepsis, and shorter average LOS. The average total hospital cost for the anticoagulation group was $20,034 less than that for the non-anticoagulation group.
In summary, anticoagulation therapy for patients with liver cirrhosis PVT is safe and associated with better hospital outcomes.
- Analysis of Key Research Results and their Clinical Significance
- Patient Selection Flow Chart
Source: From the Literature
Between 2016 and 2018, a total of 21 million patients were discharged nationwide, among which 144,190 had PVT. After excluding 83,685 PVT patients without liver cirrhosis, a final sample of 60,505 patients with liver cirrhosis PVT was included. Of these, 4,015 patients received anticoagulation therapy, while 56,490 did not.
2. Baseline Characteristics of Patients
Source: From the Literature
Compared to the non-anticoagulation group, the anticoagulation group had a higher proportion of Caucasian patients (67.6% vs. 61.1%, P<0.004), a higher percentage of females (39.65% vs. 35.76%, P=0.03), and a lower Charlson Comorbidity Index (85.06% vs. 89.16%, P=0.004). Most patients in both groups had medical insurance and received treatment in large urban teaching hospitals.
3. Reasons for Hospitalization of Patients with Liver Cirrhosis PVT
Source: From the Literature
The reasons for hospitalization in patients with liver cirrhosis PVT were AKI (30.72%), sepsis (13.55%), non-variceal bleeding (11.66%), variceal bleeding (8.82%), SBP (6.44%), and hepatic encephalopathy (0.27%).
4. Hospital Outcomes of Patients with Liver Cirrhosis PVT
Source: From the Literature
Compared to the non-anticoagulation group, the anticoagulation group had a significantly lower mortality rate (2.12% vs. 9.72%, P<0.001). The incidence of variceal bleeding, HRS, AKI, SBP, and sepsis was significantly lower in the anticoagulation group. The incidence of hepatic encephalopathy was low in both groups, and the rates of non-variceal bleeding and mesenteric ischemia were similar. The average length of stay (LOS) for the anticoagulation group was 5.23 days, compared to 7.60 days for the non-anticoagulation group. The average total hospital cost for the anticoagulation group was $58,491, compared to $100,658 for the non-anticoagulation group.
5. Univariate and Multivariate Regression Analysis of Hospital Outcomes for Patients with Liver Cirrhosis PVT
Source: From the Literature
Univariate regression analysis showed that, compared to the non-anticoagulation group, the anticoagulation group had a significantly lower mortality rate (OR=0.20, 95%CI: 0.12–0.33, P<0.001), and lower incidence of variceal bleeding (OR=0.66, 95%CI: 0.49–0.89, P<0.001), hepatic encephalopathy (OR=0.56, 95%CI: 0.76–4.75, P=0.57), HRS (OR=0.46, 95%CI: 0.31–0.68, P<0.001), AKI (OR=0.55, 95%CI: 0.46–0.65, P<0.001), SBP (OR=0.60, 95%CI: 0.43–0.85, P=0.004), and sepsis (OR=0.42, 95%CI: 0.26–0.67, P<0.001). The anticoagulation group also had a shorter average LOS (unadjusted mean LOS=-2.37, 95%CI: -2.72 to -2.02, P<0.001) and lower average total hospital costs (-$42,167, 95%CI: -$49,489 to -$34,845, P<0.001). The incidence of non-variceal bleeding (AOR=1.01, 95%CI: 0.81–1.26, P=0.92) was similar between the groups.
Multivariate regression analysis revealed that, compared to the non-anticoagulation group, the anticoagulation group had a significantly reduced mortality rate (AOR=0.27, 95%CI: 0.15–0.46, P<0.001), and lower incidence of variceal bleeding (AOR=0.71, 95%CI: 0.53–0.96, P=0.03), HRS (AOR=0.56, 95%CI: 0.37–0.85, P=0.01), AKI (AOR=0.57, 95%CI: 0.48–0.69, P<0.001), SBP (AOR=0.62, 95%CI: 0.43–0.89, P=0.01), and sepsis (AOR=0.57, 95%CI: 0.35–0.93, P=0.03). The average LOS was shorter (adjusted mean LOS=-1.15, 95%CI: -1.51 to -0.79, P<0.001), and the average total hospital cost was $20,034 less (95%CI: -$27,077 to -$12,991, P<0.001) in the anticoagulation group. The rates of non-variceal bleeding (AOR=1.08, 95%CI: 0.86–1.36, P=0.49) and hepatic encephalopathy (AOR=1.00, 95%CI: 0.14–7.19, P=0.99) were similar between the groups.
6. Independent Predictive Factors for Mortality in Patients with Liver Cirrhosis PVT
Source: From the Literature
The independent predictive factors for mortality in patients with liver cirrhosis PVT include age, Charlson Comorbidity Index, acute renal failure, spontaneous bacterial peritonitis (SBP), alcohol abuse, and sepsis.
7. The Impact of Treatment in Teaching Hospitals on Hospital Outcomes for Patients with Liver Cirrhosis PVT
Source: From the Literature
Compared to patients treated in non-teaching hospitals, those treated in teaching hospitals had higher rates of SBP (AOR=1.20, 95%CI: 1.01–1.43, P=0.04), acute kidney injury (AKI) (AOR=1.35, 95%CI: 1.23–1.48, P<0.001), and hepatic renal syndrome (HRS) (AOR=1.50, 95%CI: 1.23–1.83, P<0.001), but a lower incidence of variceal bleeding (AOR=0.83, 95%CI: 0.75–0.95, P=0.004).
- Summary and Outlook
Compared to the non-anticoagulation group, patients in the anticoagulation group had a lower mortality rate and lower incidence of variceal bleeding, HRS, AKI, SBP, and sepsis. However, the incidence of hepatic encephalopathy and non-variceal bleeding was similar between the groups. Anticoagulation therapy for liver cirrhosis PVT patients is safe and can reduce the economic burden on patients.
Recruitment for Multicenter Studies on Liver Cirrhosis Portal Vein Thrombosis Prevalence
Portal vein thrombosis (PVT), especially complete occlusive PVT, can increase portal vein pressure in patients with liver cirrhosis, thereby increasing the risk of ascites and esophagogastric variceal bleeding. Proper management of liver cirrhosis PVT remains a clinical challenge. Additionally, the prevalence of liver cirrhosis PVT is not yet clear, and there is a lack of large-scale epidemiological studies in China to clarify this issue. To this end, Dr. Xingshun Qi from the Department of Gastroenterology, Northern Theater General Hospital, is preparing to initiate a national multicenter study based on enhanced CT scan results to determine the prevalence of PVT in patients with liver cirrhosis and to further retrospectively analyze related risk factors. We sincerely invite doctors in gastroenterology, hepatology, infectious diseases, and radiology to participate. If you are interested in this study, please contact us for more detailed research information.
Contact: Dr. Wang
Email: 923824852@qq.com
WeChat: lucky_lucky_le
Founder and Reviewer of the ‘ Hepatology Degist -Liver Vascular Disease’ Column
Xingshun Qi, Chief of the Department of Gastroenterology, Northern Theater General Hospital, part-time master’s supervisor at China Medical University, Shenyang Pharmaceutical University, Dalian Medical University, and Jinzhou Medical University, and part-time doctoral supervisor at Northeastern University and China Medical University.
