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Clinical Cirrhosis Dilemmas: Survey of Practice from the 7th International Coagulation in Liver Disease Conference

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Abstract

Introduction and Aim

Hemostatic disorders in chronic liver disease and cirrhosis show continued expansion of research efforts. However, clinical decision making is often practiced on an individual patient level as consensus guidelines are lacking. We aimed to better assess individual day-to-day clinical practice through gauging clinicians’ responses to common clinical scenarios.

Materials and Methods

A series of ten clinical scenarios (seven procedural coagulation and three thrombosis management) were posed to conference attendees utilizing real-time polling software (Poll Everywhere). Responses were binomial and were submitted as “Agree” or “Disagree.” Results were displayed real time following a standardized response period and an open-forum discussion ensued between conference faculty and attendees following response submission.

Results

Twenty conference attendees participated in the clinical scenario plenary session. In general, agreement rates were high. All but one of the ten clinical scenarios had ≥ 70% agreement. Agreement was based both on procedural risk, with greatest agreement seen for low-risk procedures (80–93%), and on peri-procedural coagulation parameters of platelet count and fibrinogen level where > 50,000μ/L and 120 mg/dL were the most agreed upon thresholds, respectively. 75–95% agreement was reached when surveying the need for anticoagulation for mesenteric vein thrombosis in liver transplant candidates; slightly less (71%) agreement was found when deciding to proceed with anticoagulation in non-liver transplant candidates with mesenteric vein thrombosis.

Conclusions

While large-scale, methodologically rigorous randomized controlled trials are lacking to guide clinical decision making in patients with coagulation disorders and chronic liver disease, consensus expert opinion regarding mitigating peri-procedural bleeding risk and treatment of thrombosis appears consistent and strong.

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References

  1. Northup PG, McMahon MM, Ruhl AP, et al. Coagulopathy does not fully protect hospitalized cirrhosis patients from peripheral venous thromboembolism. Am J Gastroenterol. 2006;101:1524–1528. https://doi.org/10.1111/j.1572-0241.2006.00588.x.

    Article  PubMed  Google Scholar 

  2. Caldwell SH, Hoffman M, Lisman T, et al. Coagulation disorders and hemostasis in liver disease: pathophysiology and critical assessment of current management. Hepatology (Baltimore, Md.). 2006;44:1039–1046. https://doi.org/10.1002/hep.21303.

    Article  CAS  Google Scholar 

  3. Violi F, Ferro D, Basili S, et al. Ongoing prothrombotic state in the portal circulation of cirrhotic patients. Thromb Haemost. 1997;77:44–47.

    Article  CAS  Google Scholar 

  4. Zocco MA, Di Stasio E, De Cristofaro R, et al. Thrombotic risk factors in patients with liver cirrhosis: correlation with MELD scoring system and portal vein thrombosis development. J Hepatol. 2009;51:682–689. https://doi.org/10.1016/j.jhep.2009.03.013.

    Article  PubMed  Google Scholar 

  5. Lisman T, Bongers TN, Adelmeijer J, et al. Elevated levels of von Willebrand factor in cirrhosis support platelet adhesion despite reduced functional capacity. Hepatology. 2006;44:53–61. https://doi.org/10.1002/hep.21231.

    Article  PubMed  CAS  Google Scholar 

  6. Arshad F, Lisman T, Porte RJ. Hypercoagulability as a contributor to thrombotic complications in the liver transplant recipient. Liver Int. 2013;33:820–827. https://doi.org/10.1111/liv.12140.

    Article  PubMed  CAS  Google Scholar 

  7. Qi X, Chen H, Han G. Effect of antithrombin, protein C and protein S on portal vein thrombosis in liver cirrhosis: a meta-analysis. Am J Med Sci. 2013;346:38–44. https://doi.org/10.1097/MAJ.0b013e31826485fc.

    Article  PubMed  Google Scholar 

  8. Tripodi A, Mannucci PM. The coagulopathy of chronic liver disease. N Engl J Med. 2011;365:147–156. https://doi.org/10.1056/NEJMra1011170.

    Article  PubMed  CAS  Google Scholar 

  9. Stein SF, Harker LA. Kinetic and functional studies of platelets, fibrinogen, and plasminogen in patients with hepatic cirrhosis. J Lab Clin Med. 1982;99:217–230.

    PubMed  CAS  Google Scholar 

  10. Intagliata NM, Argo CK, Stine JG, Lisman T, Caldwell SH, Violi F. Concepts and controversies in haemostasis and thrombosis associated with liver disease: proceedings of the 7th international coagulation in liver disease conference. Thromb Haemost. 2018;118:1491–1506. https://doi.org/10.1055/s-0038-1666861.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  11. Gubbiyappa KS, Barua A, Das B, Vasudeva Murthy CR, Baloch HZ. Effectiveness of flipped classroom with poll everywhere as a teaching-learning method for pharmacy students. Indian J Pharmacol. 2016;48:S41–s46. https://doi.org/10.4103/0253-7613.193313.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Yerdel MA, Gunson B, Mirza D, et al. Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome. Transplantation. 2000;69:1873–1881.

    Article  CAS  Google Scholar 

  13. McHugh ML. Interrater reliability: the kappa statistic. Biochem Med (Zagreb). 2012;22:276–282.

    Article  Google Scholar 

  14. Tripodi A, Primignani M, Chantarangkul V, et al. Thrombin generation in patients with cirrhosis: the role of platelets. Hepatology. 2006;44:440–445. https://doi.org/10.1002/hep.21266.

    Article  PubMed  CAS  Google Scholar 

  15. Lisman T. Re: bleeding risk and management in interventional procedures in chronic liver disease. J Vasc Interv Radiol. 2017;28:1336–1337. https://doi.org/10.1016/j.jvir.2017.06.005.

    Article  PubMed  Google Scholar 

  16. Napolitano G, Iacobellis A, Merla A, 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. https://doi.org/10.1016/j.ejim.2016.11.007.

    Article  PubMed  Google Scholar 

  17. 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. https://doi.org/10.1016/j.cgh.2010.06.018.

    Article  PubMed  Google Scholar 

  18. 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. https://doi.org/10.1016/j.joms.2016.08.033.

    Article  PubMed  Google Scholar 

  19. Drolz A, Horvatits T, Roedl K, et al. Coagulation parameters and major bleeding in critically ill patients with cirrhosis. Hepatology. 2016;64:556–568. https://doi.org/10.1002/hep.28628.

    Article  PubMed  CAS  Google Scholar 

  20. Bolliger D, Szlam F, Molinaro RJ, Rahe-Meyer N, Levy JH, Tanaka KA. Finding the optimal concentration range for fibrinogen replacement after severe haemodilution: an in vitro model. Br J Anaesth. 2009;102:793–799. https://doi.org/10.1093/bja/aep098.

    Article  PubMed  CAS  Google Scholar 

  21. Stine JG, Northup PG. Coagulopathy before and after liver transplantation: from the hepatic to the systemic circulatory systems. Clin Liver Dis. 2017;21:253–274. https://doi.org/10.1016/j.cld.2016.12.003.

    Article  PubMed  Google Scholar 

  22. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med. 2002;346:1128–1137. https://doi.org/10.1056/NEJMsa012337.

    Article  PubMed  Google Scholar 

  23. Frati P, Busardo FP, Sirignano P, Gulino M, Zaami S, Fineschi V. Does defensive medicine change the behaviors of vascular surgeons? A qualitative review. Biomed Res Int. 2015;2015:170692. https://doi.org/10.1155/2015/170692.

    Article  PubMed  PubMed Central  Google Scholar 

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Funding

Meeting Sponsors: Dova Pharmaceuticals; Diagnostica Stago; Bayer; AlfaSigma; Boehringer Ingelheim; BristolMyers-Squibb.

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Authors and Affiliations

  1. Division of Gastroenterology and Hepatology, Department of Medicine, The Pennsylvania State University, Milton S. Hershey Medical Center, Hershey, PA, USA

    Jonathan G. Stine

  2. Department of Public Health Sciences, The Pennsylvania State University, Milton S. Hershey Medical Center, Hershey, PA, USA

    Jonathan G. Stine

  3. Division of Gastroenterology and Hepatology, Department of Medicine, University of Virginia, Charlottesville, VA, USA

    Nicolas M. Intagliata, Neeral L. Shah, Stephen H. Caldwell & Curtis K. Argo

  4. Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

    Ton Lisman

  5. Department of Internal and Specialized Medicine, Sapienza University of Rome, Rome, Italy

    Francesco Violi

  6. Pennsylvania State University Milton S. Hershey Medical Center Liver Center, Hershey, PA, USA

    Jonathan G. Stine

Authors
  1. Jonathan G. Stine
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  2. Nicolas M. Intagliata
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  4. Ton Lisman
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  5. Francesco Violi
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  6. Stephen H. Caldwell
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  7. Curtis K. Argo
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Corresponding author

Correspondence to Jonathan G. Stine.

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Conflict of interest

Curtis K. Argo, Ton Lisman, and Francesco Violi declare no conflict of interest. Jonathan G. Stine received research support from Target Pharma, Inc. Nicolas M. Intagliata received research support from Eisai. Stephen H. Caldwell received research support from Gilead, GenFit, Galmed, NGM, Immuron, Mallinckrodt, Conatus, Vital Therapy, TaiwanJ, and Intercept. Stephen H. Caldwell received royalty support from Halyary. Stephen H. Caldwell also serves as a consultant for Gencia and Shionogi. Jonathan G. Stine also serves as a consultant for Bayer.

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Stine, J.G., Intagliata, N.M., Shah, N.L. et al. Clinical Cirrhosis Dilemmas: Survey of Practice from the 7th International Coagulation in Liver Disease Conference. Dig Dis Sci 65, 1334–1339 (2020). https://doi.org/10.1007/s10620-019-05884-0

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  • DOI: https://doi.org/10.1007/s10620-019-05884-0

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