Search

The concept of rebalanced hemostasis in cirrhosis challenges the policy of transfusing plasma or platelets before invasive procedures in patients with prolonged PT or severe thrombocytopenia. Recent guidelines recommend against plasma transfusion and suggest avoiding/minimizing platelet transfusions. We assessed how hepato-gastroenterologists manage prolonged PT/INR or severe thrombocytopenia before invasive procedures. On May 2021, AISF members were sent a questionnaire addressing the PT/INR and platelet thresholds required before invasive procedures, the use of other markers of bleeding risk or other hemostatic treatments and the burden of pre-emptive plasma and platelet transfusions. Of 62 respondents, 94% and 100% use PT/INR and platelet count to assess bleeding risk, respectively. Only 37% and 32% require less conservative PT/INR or platelet counts thresholds for low-risk procedures, respectively. As for those applying single thresholds, 68% require PT/INR <1,5 and 86% require platelet counts ≥50 × 109/L. Half respondents use additional indicators of bleeding risk and 63% other hemostatic treatments. Low-risk procedures account for 70% of procedures, and for 50% and 59% of plasma and platelets units transfused, respectively. the survey indicates lack of compliance with guidelines that advise against plasma and platelet transfusions before invasive procedures and the need for prospective studies and inter-society consensus workshops. [ABSTRACT FROM AUTHOR]

Liver stiffness measurement (LSM) <20 kPa and platelet count >150,000/mm3 exclude varices needing treatment (VNT) in viral compensated advanced chronic liver disease (cACLD), saving-up to 20–25% endoscopies (Baveno VI criteria). Refinements of such criteria to further reduce endoscopies and an approach without LSM (Platelet 150/MELD 6) were later proposed. To assess LSM 25/platelet 125, LSM 25/platelet 110 (Expanded-Baveno VI) and Platelet 150/MELD 6 accuracy versus Baveno VI criteria, and the impact of platelet count variability on criteria accuracy in all-etiologies cACLD. cACLD patients undergoing screening endoscopy with laboratory data within 6 months and LSM within one year. Of 442 patients, 31% had varices (7% with VNT). Baveno VI criteria had 100% sensitivity (Se) and negative predictive value (NPV) and spared 19.5% endoscopies. "LSM 25/platelet 125" and "Expanded-Baveno VI" criteria maintained such accuracy, sparing 15% and 24% more endoscopies, respectively (p < 0.001). Platelet 150/MELD 6 was less accurate, misclassifying 10% VNT. Platelet count variability exceeded 8% and one VNT patient was misclassified with both "Expanded-Baveno VI" and "LSM 25/platelet 125" criteria considering the previous platelet count. Both "Expanded-Baveno VI" and "LSM 25/platelet 125" criteria are accurate in cACLD, but the former are more advantageous. Platelet 150/MELD 6 proved inadequate. [ABSTRACT FROM AUTHOR]

Background/aims Information on coagulation for cirrhotics on anticoagulants is scanty. We investigated plasma from 23 cirrhotics treated with low-molecular-weight-heparin (LMWH) followed by vitamin K antagonists (VKA). Methods On days 1–4 patients received full-dose LMWH. On day-5 VKA was started and LMWH was terminated when INR therapeutic-interval was reached. Blood was collected at peak and trough during LMWH, LMWH + VKA and VKA. Non-cirrhotics on VKA were included as controls. Results Anti-factor Xa increased from baseline-to-peak during LMWH. During LMWH + VKA was high and reverted to zero during VKA. INR was slightly high at baseline, trough or peak during LMWH and increased to 2.2 during LMWH + VKA or VKA. Mean VKA weekly-doses for cirrhotics and controls were 28.5 mg and 28.6 mg. Protein C decreased upon VKA, but not to the expected extent. Endogenous-thrombin-potential (ETP) decreased from baseline (1436 nM min) to trough (1258 nM min) and peak (700 nM min) during LMWH and was further reduced during LMWH + VKA (395 nM min). Conclusions Target-INR for cirrhotics can be reached by VKA dosages similar to those for non-cirrhotics. ETP reduction parallels the effect of LMWH and/or VKA. Whether these parameters represent the antithrombotic action elicited by these drugs remains to be determined by clinical-trials and laboratory-measurements. ETP, being a global-test reflecting both pro- and anti-coagulants targeted by antithrombotic drugs, seems the candidate for these trials. [ABSTRACT FROM AUTHOR]

Abstract: Background: Influence of portal vein thrombosis on efficacy of endoscopic variceal banding in patients with cirrhosis or extrahepatic portal vein obstruction has never been evaluated. Aim of the study was to assess influence of thrombosis on rate and time to eradication in cirrhosis and extrahepatic portal vein obstruction undergoing banding, compared to cirrhotic patients without thrombosis. Methods: Retrospective analysis of 235 consecutive patients (192 with cirrhosis without thrombosis, 22 cirrhosis and thrombosis and 21 extrahepatic portal vein obstruction) who underwent banding. Banding was performed every 2–3 weeks until eradication; endoscopic follow-up was performed at 1, 3, 6 months, then annually. Results: Eradication was achieved in 233 patients. Median time to eradication in cirrhotic patients with portal vein thrombosis vs. cirrhotic patients without thrombosis was 50.9 days (12–440) vs. 43.4 days (13–489.4); log-rank: 0.04; patients with extrahepatic portal vein obstruction vs. cirrhotic patients without thrombosis 63.9 days (31–321.6) vs. 43.4 days (13.0–489.4); log-rank: 0.008. Thrombosis was shown to be the only risk factor for longer time to eradication. Conclusions: Portal vein thrombosis per se appears to be the cause of a longer time to achieve eradication of varices but, once eradication is achieved, it does not influence their recurrence. [Copyright &y& Elsevier]