Efird Lydia M, Mishkin Daniel S, Berlowitz Dan R, Ash Arlene S, Hylek Elaine M, Ozonoff Al, Reisman Joel I, Zhao Shibei, Jasuja Guneet K, Rose Adam J
From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University School of Public Health, MA (D.R.B., G.K.J.); Division of Biostatistics and Health Services Research, Department of Quantitative Health Sciences, University of Massachusetts School of Medicine, Worcester (A.S.A.); and Biostatistics Section, Boston Children's Hospital, MA (A.O.).
Circ Cardiovasc Qual Outcomes. 2014 May;7(3):461-7. doi: 10.1161/CIRCOUTCOMES.113.000817. Epub 2014 May 13.
Chronic liver disease presents a relative contraindication to warfarin therapy, but some patients with liver disease nevertheless require long-term anticoagulation. The goal is to identify which patients with liver disease might safely receive warfarin.
Among 102 134 patients who received warfarin from the Veterans Affairs from 2007 to 2008, International Classification of Diseases-Ninth Revision codes identified 1763 patients with chronic liver disease. Specific diagnoses and laboratory values (albumin, aspartate aminotransferase, alanine aminotransferase, creatinine, and cholesterol) were examined to identify risk of adverse outcomes, while controlling for available bleeding risk factors. Outcomes included percent time in therapeutic range, a measure of anticoagulation control, and major hemorrhagic events, by International Classification of Diseases-Ninth Revision codes. Patients with liver disease had lower mean time in therapeutic range (53.5%) when compared with patients without (61.7%; P<0.001) and more hemorrhages (hazard ratio, 2.02; P<0.001). Among patients with liver disease, serum albumin and creatinine levels were the strongest predictors of both outcomes. We created a 4-point score system: patients received 1 point each for albumin (2.5-3.49 g/dL) or creatinine (1.01-1.99 mg/dL), and 2 points each for albumin (<2.5 g/dL) or creatinine (≥2 mg/dL). This score predicted both anticoagulation control and hemorrhage. When compared with patients without liver disease, those with a score of zero had modestly lower time in therapeutic range (56.7%) and no increase in hemorrhages (hazard ratio, 1.16; P=0.59), whereas those with the worst score (4) had poor control (29.4%) and high hazard of hemorrhage (hazard ratio, 8.53; P<0.001).
Patients with liver disease receiving warfarin have poorer anticoagulation control and more hemorrhages. A simple 4-point scoring system using albumin and creatinine identifies those at risk for poor outcomes.
慢性肝病是华法林治疗的相对禁忌证，但一些肝病患者仍需要长期抗凝治疗。目标是确定哪些肝病患者可以安全地接受华法林治疗。
在2007年至2008年从退伍军人事务部接受华法林治疗的102134例患者中，根据国际疾病分类第九版编码确定了1763例慢性肝病患者。检查特定诊断和实验室值（白蛋白、天冬氨酸转氨酶、丙氨酸转氨酶、肌酐和胆固醇）以确定不良结局风险，同时控制可用的出血风险因素。结局包括治疗范围内的时间百分比（一种抗凝控制指标）以及根据国际疾病分类第九版编码确定的重大出血事件。与无肝病患者相比，肝病患者的治疗范围内平均时间较低（53.5%对61.7%；P<0.001），出血更多（风险比为2.02；P<0.001）。在肝病患者中，血清白蛋白和肌酐水平是这两种结局的最强预测因素。我们创建了一个4分评分系统：白蛋白（2.5 - 3.49 g/dL）或肌酐（1.01 - 1.99 mg/dL）各得1分，白蛋白（<2.5 g/dL）或肌酐（≥2 mg/dL）各得2分。该评分可预测抗凝控制和出血情况。与无肝病患者相比，评分为零的患者治疗范围内时间略低（56.7%），出血无增加（风险比为1.16；P = 0.59），而评分最差（4分）的患者控制不佳（29.4%）且出血风险高（风险比为8.53；P<0.001）。
接受华法林治疗的肝病患者抗凝控制较差且出血较多。使用白蛋白和肌酐的简单4分评分系统可识别出结局不良风险较高的患者。
