Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
Thromb Res. 2018 Oct;170:102-108. doi: 10.1016/j.thromres.2018.08.011. Epub 2018 Aug 17.
Anticoagulant treatment in patients with liver cirrhosis is challenging. The aim of this systematic review was to evaluate clinical outcomes of direct oral anticoagulant (DOAC) therapy in cirrhosis patients.
A systematic search was performed in MEDLINE, Embase, and conference proceedings up to November 7th, 2017, for studies that evaluated the efficacy and safety of DOACs in cirrhosis patients with venous thromboembolism (VTE), splanchnic vein thrombosis (SVT), or atrial fibrillation (AF). Two authors independently screened titles, abstracts, and full-text articles, and assessed risk of bias. A meta-analysis could not be performed due to heterogeneity of the included studies.
Of the 2927 articles assessed, five retrospective cohort studies were included (n = 239, including 20 patients overlap). All studies had fair methodological quality. Two studies evaluated DOAC treatment only, and three also evaluated vitamin K antagonists (VKAs) or low-molecular-weight heparins (LMWHs). Recurrent VTE (DOAC n = 12, LMWH/VKA n = 8) or ischemic stroke (DOAC n = 37, LMWH/VKA n = 9) occurred in none of the patients. Progression of VTE was 8% with DOACs (n = 12) and 13% with VKAs and LWWH (n = 8). Recurrent SVT occurred in 0 to 4% with DOACs (n = 31). Progression of SVT was 0 to 5% with DOACs (n = 24) and 0 to 47% with VKAs and LMWH (n = 33). Major bleeding risk ranged from 4 to 15% with DOACs (n = 172) and from 7 to 28% with VKAs and LMWH (n = 67). All-cause mortality risk was 6% with DOACs (n = 36).
There is paucity of data on the efficacy and safety of DOACs in patients with cirrhosis. This analysis suggests that DOACs may be effective and safe for treatment of VTE, SVT, and AF in these patients.
在肝硬化患者中进行抗凝治疗具有挑战性。本系统评价旨在评估直接口服抗凝剂（DOAC）在肝硬化患者中的疗效和安全性。
我们在 MEDLINE、Embase 和会议论文集上进行了系统检索，检索时间截至 2017 年 11 月 7 日，以评估 DOAC 在伴有静脉血栓栓塞症（VTE）、内脏静脉血栓形成（SVT）或心房颤动（AF）的肝硬化患者中的疗效和安全性。两名作者独立筛选标题、摘要和全文文章，并评估偏倚风险。由于纳入研究的异质性，无法进行荟萃分析。
在评估的 2927 篇文章中，有 5 项回顾性队列研究被纳入（n=239，其中 20 例重叠）。所有研究的方法学质量均为中等。有两项研究仅评估了 DOAC 治疗，三项研究还评估了维生素 K 拮抗剂（VKA）或低分子肝素（LMWH）。DOAC 组（n=12）和 VKA/LMWH 组（n=8）均无复发性 VTE（DOAC n=12，LMWH/VKA n=8）或缺血性卒中（DOAC n=37，LMWH/VKA n=9）。DOAC 组 VTE 进展率为 8%（n=12），VKA 和 LWWH 组为 13%（n=8）。DOAC 组复发性 SVT 发生率为 0 至 4%（n=31）。DOAC 组 SVT 进展率为 0 至 5%（n=24），VKA 和 LMWH 组为 0 至 47%（n=33）。DOAC 组大出血风险为 4%至 15%（n=172），VKA 和 LMWH 组为 7%至 28%（n=67）。DOAC 组全因死亡率为 6%（n=36）。
目前关于 DOAC 在肝硬化患者中的疗效和安全性的数据有限。本分析表明，DOAC 可能对治疗这些患者的 VTE、SVT 和 AF 有效且安全。
