Should we give thromboprophylaxis to patients with liver cirrhosis and coagulopathy?

Authors

  • Marco Senzolo,

    Corresponding author
    1. Gastroenterology, Department of Surgical and Gastroenterological Sciences, University Hospital of Padua, Padua
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  • Maria Teresa Sartori,

    1. 2nd Chair Internal Medicine, Department of Cardiac, Thoracic and Vascular Sciences, University Hospital of Padua, Padua, Italy, and
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  • Ton Lisman

    1. Department of Surgery, Section Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, the Netherlands
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Marco Senzolo, Gastroenterology, Department of Surgical and Gastroenterological Sciences, University Hospital of Padua, Via Giustiniani 2, 35136, Padua, Italy. Tel: +39 498218726; Fax: +39 4982182727; E-mail: marcosenzolo@hotmail.com

Abstract

Patients with liver cirrhosis are characterized by decreased synthesis of both pro- and anticoagulant factors, and recently there has been evidence of normal generation of thrombin resulting in a near normal haemostatic balance. Although it is generally recognized that bleeding is the most common clinical manifestation as a result of decreased platelet function and number, diminished clotting factors and excessive fibrinolysis, hypercoagulability may play an under recognized but important role in many aspects of chronic liver disease. In fact, they can encounter thrombotic complications such as portal vein thrombosis, occlusion of small intrahepatic vein branches and deep vein thrombosis (DVT). In particular, patients with cirrhosis appear to have a higher incidence of unprovoked DVT and pulmonary embolism (PE) compared with the general population. In dedicated studies, the incidence of DVT/PE ranges from 0.5% to 1.9%, similar to patients without comorbidities, but lower than patients with other chronic diseases (i.e, renal or heart disease). Surprisingly, standard coagulation laboratory parameters are not associated with a risk of developing DVT/PE; however, with multivariate analysis, serum albumin level was independently associated with the occurrence of thrombosis. Moreover, patients with chronic liver disease share the same risk factors as the general population for DVT/PE, and specifically, liver resection can unbalance the haemostatic equilibrium towards a hypercoagulable state. Current guidelines on antithrombotic prophylaxis do not specifically comment on the cirrhotic population as a result of the perceived risk of bleeding complications but the cirrhotic patient should not be considered as an auto-anticoagulated patient. Therefore, thromboprophylaxis should be recommended in patients with liver cirrhosis at least when exposed to high-risk conditions for thrombotic complications. Low molecular weight heparins (LWMHs) seem to be relatively safe in this group of patients; however, when important risk factors for bleeding are present, graduated compression stockings or intermittent pneumatic compression should be considered.

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