Digestive Diseases Section, Department of Medicine, Yale University, New Haven, CT, USA.
Digestive Diseases Section, Department of Internal medicine, VA-CT Healthcare System, West Haven, CT, USA.
Liver Int. 2018 Aug;38(8):1437-1441. doi: 10.1111/liv.13712. Epub 2018 Feb 24.
Bleeding after low-risk invasive procedures can be life-threatening or can lead to further complications in decompensated cirrhosis patients. In unstratified cohorts of hospitalized patients with cirrhosis, the rate of procedure-related bleeding is low despite abnormal coagulation parameters. Our objective was to identify patients with decompensated cirrhosis at a high risk of developing procedure-related bleeding in whom the value of pre-procedure transfusions could be assessed.
Hospitalized patients with cirrhosis who developed post-paracentesis hemoperitoneum confirmed by CT scan, from the period of January 2012 to August 2016, constituted the study group. They were compared to patients hospitalized in the same period in whom post-paracentesis hemoperitoneum was suspected but ruled out by CT scan. A retrospective chart review was conducted to determine specifics of the adverse event, patient characteristics and risk factors for bleeding.
On multivariate analysis, acute kidney injury prior to paracentesis was the only independent predictor of post-paracentesis hemoperitoneum (OR 4.3, 95% CI 1.3-13.5, P = .01), independent of MELD score, large volume paracentesis, sepsis, platelets, INR and haemoglobin levels.
Infection/sepsis is generally considered predictive of bleeding in cirrhosis. Our study suggests that acute kidney injury, and not sepsis, is the most important predictor of post-procedure bleeding in patients with decompensated cirrhosis. Although end-stage renal disease is a known cause of bleeding in non-cirrhotic patients, there are no studies establishing acute kidney injury as a risk factor for post-procedure bleeding in cirrhosis. Future studies investigating blood product transfusion needs in cirrhosis prior to procedures should carefully look at patients with acute kidney injury.
低危侵入性操作后出血可能危及生命，或导致失代偿期肝硬化患者出现进一步并发症。尽管凝血参数异常，但在肝硬化住院患者的未分层队列中，操作相关出血的发生率较低。我们的目的是确定失代偿期肝硬化患者，这些患者发生操作相关出血的风险较高，需要评估术前输血的价值。
2012 年 1 月至 2016 年 8 月期间，因 CT 扫描证实经皮穿刺引流术后发生血腹而住院的肝硬化患者构成研究组。将他们与同期因 CT 扫描怀疑但排除经皮穿刺引流术后血腹的住院患者进行比较。进行回顾性病历审查，以确定不良事件的具体情况、患者特征和出血的危险因素。
多变量分析显示，经皮穿刺引流术前急性肾损伤是经皮穿刺引流术后血腹的唯一独立预测因素（OR 4.3，95%CI 1.3-13.5，P=0.01），独立于 MELD 评分、大量经皮穿刺引流术、脓毒症、血小板、INR 和血红蛋白水平。
感染/脓毒症通常被认为是肝硬化出血的预测因素。我们的研究表明，急性肾损伤而不是脓毒症，是失代偿期肝硬化患者术后出血的最重要预测因素。尽管终末期肾病是非肝硬化患者出血的已知原因，但尚无研究确定急性肾损伤是肝硬化患者术后出血的危险因素。未来研究在进行手术前应仔细研究急性肾损伤患者，以调查肝硬化患者的血液制品输血需求。
