Regular ArticleRisk-assessment and pharmacological prophylaxis of venous thromboembolism in hospitalized patients with chronic liver disease
Introduction
Anticoagulant prophylaxis is recommended for most acutely ill patients who are at increased risk of venous thromboembolism (VTE) [1]. However, in patients with chronic liver disease (CLD), the utility of thromboprophylaxis continues to be debated [2]. Previously, it was accepted that elevated international normalization ratio in patients with CLD conferred protection from VTE because of an acquired coagulopathy, resulting from a decreased production of coagulation factors. However, it is now believed that these patients are conversely at an increased risk of VTE because of a decreased production of endogenous anticoagulants such as protein C [2] as well as elevated levels of von Willebrand factor, which can promote platelet adhesion [3]. Thus there is a delicate balance between prothrombotic and antithrombotic factors, which contribute to the risk for VTE. This balance may be affected by various factors including acute illness, inflammation, or comorbidities. At this time, it is common that VTE prophylaxis is avoided in these patients, even though they may be at high-risk based on traditional scoring systems. Thus there is a need to determine if traditional risk-assessment methods apply to patients with CLD and to determine if pharmacological prophylaxis for VTE is indicated in these patients.
Current guidelines do not specifically address the use of thromboprophylaxis or risk-assessment in patients with CLD [1]. This is because of the perceived risk of bleeding complications, laboratory evidence of potential coagulopathy, and lack of large clinical trials to assess the safety and efficacy of thromboprophylaxis in these patients. The Padua Predictor Score (PPS) is considered to be the best method for risk-assessment of hospitalized patients and guideline recommendations are based on risk-stratification using this system. A few studies have evaluated potential risk factors for VTE in patients with CLD, however none have assessed the utility of the PPS in this population [3], [4], [5], [6], [7], [8].
The primary objective of this study was to evaluate the PPS as a risk-stratification tool for the development of VTE in hospitalized patients with CLD. The secondary objective was to compare the occurrence of VTE in CLD patients with and without pharmacological prophylaxis stratified by PPS. We hypothesized that patients with a high-risk assessment on PPS would have a greater risk for VTE and would benefit from pharmacological prophylaxis.
Section snippets
Study Design, Setting and Patient Selection
This was a retrospective cohort study conducted in an academic medical center in the United States. The Institutional Review Board of the university approved the study prior to data collection. All consecutive patients with a discharge diagnosis of CLD were identified from the electronic medical record between May 1, 2010 and May 1, 2013 based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. These included alcoholic fatty liver (571.0),
Study Cohort
A total of 163 patients were included in the study cohort. Of these, 18 (11%) developed VTE. VTE included deep venous thrombosis (n = 12), portal vein thrombosis (n = 4) and pulmonary embolism (n = 2). The mean age was 54 ± 11 years, 106 (65%) were male, and 83 (51%) were of White race. Patients were admitted to the medicine service (n = 125, 77%), surgery service (n = 20, 12%), or other (n = 18, 11%). The most common cause of CLD was hepatitis C (n = 85, 52%), followed by alcoholic liver disease (n = 37, 23%),
Discussion
An important finding in this study is that the PPS was significantly associated with risk of VTE. Thus it appeared to be an effective assessment tool even in patients with CLD. The PPS was a risk assessment model created by the University of Padua in Italy and was based on the work originally conducted by Kucher et al. [10] The model primarily includes demographics and comorbidities, and does not include laboratory parameters. The value of the refined model was tested in a prospective cohort of
Financial support and conflicts of interest
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Acknowledgments
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Cited by (0)
- 1
Present address: Clinical Pharmacy Faculty of Pharmacy, King Abdulaziz University, Aljamaah District, PO Box 80200, Jeddah, 21589, Saudi Arabia.
- 2
(Institution where work was performed).