Yang Linda S, Alukaidey Sumaya, Croucher Katherine, Dowling Damian
Department of Gastroenterology, University Hospital Geelong, Geelong, Victoria, Australia.
Intern Med J. 2018 Sep;48(9):1056-1063. doi: 10.1111/imj.13766.
Cirrhosis was previously perceived as a haemorrhagic disease state due to frequent associations with coagulopathy and bleeding. However, the coagulopathy of cirrhosis is complex with defects in both procoagulant and anticoagulant factors. Derangements in common laboratory indices of coagulation do not accurately reflect bleeding risk or protection from thrombotic events.
To assess the rate of pharmacological prophylaxis for venous thromboembolism (VTE) among hospital inpatients with cirrhosis and analyse factors associated with prophylaxis being inappropriately withheld.
A retrospective cohort study was performed in a tertiary teaching hospital. Patients included were admitted for greater than 48 h with discharge diagnosis codes corresponding to chronic liver disease and/or cirrhosis. The use of VTE chemoprophylaxis with enoxaparin was assessed in cirrhotic patients and non-cirrhotic controls. Patient data collected included contraindications to prophylaxis, known high-risk varices, international normalised ratio (INR), creatinine, bilirubin, haemoglobin and platelet count.
Of 108 patients with cirrhosis eligible for VTE prophylaxis, 61 (56.5%) received prophylaxis compared to 104 (96.3%) non-cirrhotic patients. Platelets and INR were significantly different between those who did and did not receive VTE prophylaxis. On multivariate analysis, platelet count and INR were independent predictors for VTE not being administered.
The administration of chemoprophylaxis in accordance with the hospital guidelines was suboptimal in patients with cirrhosis. Platelet count and INR were independent predictors of prophylaxis use. Our results suggest persistent misperceptions that prolonged INR and thrombocytopenia predict bleeding risk in cirrhosis.
由于肝硬化常与凝血病和出血相关，以往被视为一种出血性疾病状态。然而，肝硬化的凝血病较为复杂，促凝和抗凝因子均存在缺陷。常见凝血实验室指标的紊乱并不能准确反映出血风险或预防血栓形成事件的情况。
评估肝硬化住院患者中静脉血栓栓塞（VTE）药物预防的比例，并分析与预防措施未适当应用相关的因素。
在一家三级教学医院进行了一项回顾性队列研究。纳入的患者住院时间超过48小时，出院诊断编码对应慢性肝病和/或肝硬化。对肝硬化患者和非肝硬化对照者使用依诺肝素进行VTE化学预防的情况进行评估。收集的患者数据包括预防的禁忌证、已知的高危静脉曲张、国际标准化比值（INR）、肌酐、胆红素、血红蛋白和血小板计数。
在108例符合VTE预防条件的肝硬化患者中，61例（56.5%）接受了预防，而非肝硬化患者为104例（96.3%）。接受和未接受VTE预防的患者之间血小板和INR存在显著差异。多因素分析显示，血小板计数和INR是未进行VTE预防的独立预测因素。
肝硬化患者按照医院指南进行化学预防的情况并不理想。血小板计数和INR是预防措施使用的独立预测因素。我们的结果表明，人们持续存在误解，认为INR延长和血小板减少可预测肝硬化患者的出血风险。
