抗凝血剂对肝硬化和门静脉血栓形成患者的影响是什么？

StephenW

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What are the Effects of Anticoagulants in Patients With Cirrhosis and Portal Vein Thrombosis?
by Kristine Novak

Vitamin K antagonists (VKAs) increase risk of minor bleeding in patients with cirrhosis given anticoagulants for portal vein thrombosis (PVT), compared to patients without cirrhosis given VKAs, researchers report in the July issue of Clinical Gastroenterology and Hepatology. However, this risk is offset by the ability of VKA to increase portal hypertension-related, event-free, and transplantation-free survival of patients with PVT recanalization. Portal hypertension (PHT), rather than anticoagulant use, appears to account for the difference in risk of bleeding between patients with PVT vs patients with venous thromboembolism.

Risk of bleeding in the comparative cohort analysis. (A) Cumulative incidence function for any hemorrhage.

Cirrhosis is associated with increased risks of bleeding and thrombosis. Although PHT is the main determinant of gastrointestinal bleeding, the risk of thrombosis depends on combined effects of reduced blood flow in the portal venous system, endothelial dysfunction, and procoagulant imbalance.

Anticoagulant treatment is recommended for patients with cirrhosis and PVT who have been placed on the waitlist for liver transplantation or symptomatic or progressive PVT, and does not appear to increase the risk of gastrointestinal bleeding subsequent to PHT, provided that patients receive adequate prophylaxis of variceal hemorrhage. VKAs promote recanalization of PVT in patients with cirrhosis. However, the benefit of PVT recanalization might be offset by major and minor bleeding associated with use of anticoagulants.

Vincenzo La Mura et al performed a retrospective analysis of 63 patients with cirrhosis and PVT (PVT cohort) vs 160 patients without cirrhosis but with venous thromboembolism (VTE cohort) to determine the risk of bleeding associated with VKA treatment. The bleeding risk during anticoagulation in the PVT cohort was adjusted for the bleeding risk due to PHT by comparing the PVT cohort with 139 patients with cirrhosis without PVT who were not exposed to VKAs (controls).

The authors found the incidence of major bleeding to be significantly higher in the PVT cohort (24%) than the VTE cohort (7%), as well as minor bleeding (29% vs 19%) (see figure). The PVT had a higher incidence of major bleeding from the upper-gastrointestinal tract than the VTE cohort, but there were no significant differences in other types of major bleeding.

Patients with PVT and controls had the same rate of upper-gastrointestinal bleeding. Complete recanalization in patients with PVT receiving VKA (n = 31) was independently associated with increased portal hypertension-related event-free and transplantation-free survival times.

La Mura et al conclude that, as for all patients, the benefits of anticoagulation must be weighed against the risk of bleeding in patients with cirrhosis.  In comparing patients receiving VKAs for thromboembolic risk vs patients with cirrhosis and portal vein thrombosis, cirrhosis was a risk factor for major upper gastrointestinal bleeding and minor bleeding. Importantly, the rate of upper-gastrointestinal bleeding in the PVT cohort was comparable with that of patients with cirrhosis without PVT, not exposed to anticoagulation (controls), supporting the conclusion that portal hypertension, rather than anticoagulation, mediates this risk.

Furthermore, patients with PVT and complete recanalization after VKA treatment were most likely to survive free of portal hypertension-related events and transplantation. This means that the hemorrhagic risk posed by anticoagulation with VKAs could be counterbalanced by a beneficial effect on the progression of cirrhosis in patients with PVT.
Kristine Novak | July 17, 2018 at 7:44 am | Tags: event, PHT, PVT, recanalization, vitamin K antagonist, VKA | URL: https://wp.me/p4B9rV-23l   

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抗凝血剂对肝硬化和门静脉血栓形成患者的影响是什么？
作者：Kristine Novak

研究人员在7月出版的“临床胃肠病学和肝病学”杂志上报告说，维生素K拮抗剂（VKAs）与给予VKA的无肝硬化患者相比，增加了门静脉血栓形成（PVT）抗凝剂治疗肝硬化患者的轻微出血风险。然而，这种风险被VKA增加PVT再通患者的门脉高压相关，无事件和无移植存活的能力所抵消。门静脉高压症（PHT）而不是抗凝血剂似乎可以解释PVT患者与静脉血栓栓塞患者出血风险的差异。

比较队列分析中出血风险。 （A）任何出血的累积发病率。

肝硬化与出血和血栓形成的风险增加有关。尽管PHT是胃肠道出血的主要决定因素，但血栓形成的风险取决于门静脉系统血流量减少，内皮功能障碍和促凝血失衡的综合影响。

对于已经被列入肝移植等候名单或有症状或进行性PVT的肝硬化和PVT患者，建议进行抗凝治疗，并且如果患者接受充分预防静脉曲张出血，则不会增加PHT后胃肠道出血的风险。 。 VKAs促进肝硬化患者PVT的再通。然而，PVT再通的益处可能被使用抗凝血剂引起的主要和轻微出血所抵消。

Vincenzo La Mura等人对63例肝硬化和PVT（PVT队列）患者和160例无肝硬化但静脉血栓栓塞（VTE队列）的患者进行了回顾性分析，以确定与VKA治疗相关的出血风险。通过比较PVT队列与139例未接受VKA治疗的没有PVT的肝硬化患者（对照组），调整PVT组抗凝期间出血风险的PHT引起的出血风险。

作者发现，PVT队列中大出血的发生率（24％）显着高于VTE队列（7％），以及轻微出血（29％对19％）（见图）。 PVT的上消化道大出血发生率高于VTE队列，但其他类型的大出血没有显着差异。

PVT和对照组患者的上消化道出血率相同。接受VKA（n = 31）的PVT患者完全再通与门静脉高压相关的无事件和无移植存活时间增加独立相关。

La Mura等总结说，对于所有患者，必须权衡抗凝治疗对肝硬化患者出血风险的影响。在比较接受VKA治疗血栓栓塞风险的患者与肝硬化和门静脉血栓形成患者的比较中，肝硬化是主要上消化道出血和轻微出血的危险因素。重要的是，PVT队列中上消化道出血的发生率与没有PVT的肝硬化患者相当，未接受抗凝治疗（对照组），支持门静脉高压而不是抗凝治疗这一风险的结论。

此外，VKA治疗后PVT和完全再通的患者最有可能在没有门静脉高压相关事件和移植的情况下存活。这意味着VK抗凝治疗引起的出血风险可以通过对PVT患者肝硬化进展的有益影响来抵消。
Kristine Novak | 2018年7月17日上午7:44 |标签：事件，PHT，PVT，再通，维生素K拮抗剂，VKA |网址：https：//wp.me/p4B9rV-23l