King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital, London, UK.
Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, IDIBAPS, University of Barcelona, Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain.
J Thromb Haemost. 2022 Oct;20(10):2237-2245. doi: 10.1111/jth.15829. Epub 2022 Aug 10.
Hospital-associated venous thromboembolism (HA-VTE) is a major cause of morbidity and mortality and is internationally recognized as a significant patient safety issue. While cirrhosis was traditionally considered to predispose to bleeding, these patients are also at an increased risk of VTE, with an associated increase in mortality. Hospitalization rates of patients with cirrhosis are increasing, and decisions regarding thromboprophylaxis are complex due to the uncertain balance between thrombosis and bleeding risk. This is further accentuated by derangements of hemostasis in patients with cirrhosis that are often considered contraindications to pharmacological thromboprophylaxis. Due to the strict inclusion and exclusion criteria of seminal studies of VTE risk assessment and thromboprophylaxis, there is limited data to guide decision making in this patient group. This guidance document reviews the incidence and risk factors for HA-VTE in patients with cirrhosis, outlines evidence to inform the use of thromboprophylaxis, and provides pragmatic recommendations on VTE prevention for hospitalized patients with cirrhosis. In brief, in hospitalized patients with cirrhosis: We suggest inclusion of portal vein thrombosis as a distinct clinically important endpoint for future studies. We recommend against the use of thrombocytopenia and/or prolongation of prothrombin time/international normalized ratio as absolute contraindications to anticoagulant thromboprophylaxis. We suggest anticoagulant thromboprophylaxis in line with local protocols and suggest low molecular weight heparin (LMWH) or fondaparinux over unfractionated heparin (UFH). In renal impairment, we suggest LMWH over UFH. For critically ill patients, we suggest case-by-case consideration of thromboprophylaxis. We recommend research to refine VTE risk stratification, and to establish the optimal dosing and duration of thromboprophylaxis.
医院相关性静脉血栓栓塞症（HA-VTE）是发病率和死亡率的主要原因，被国际公认为是一个重大的患者安全问题。虽然肝硬化传统上被认为易导致出血，但这些患者也有更高的 VTE 风险，死亡率也随之增加。肝硬化患者的住院率正在增加，由于血栓形成和出血风险之间的平衡不确定，关于血栓预防的决策变得复杂。肝硬化患者止血功能紊乱进一步加剧了这种情况，这些紊乱通常被认为是药物性血栓预防的禁忌症。由于评估 VTE 风险和血栓预防的重要研究的严格纳入和排除标准，因此，针对该患者群体的决策缺乏指导数据。本指南文件回顾了肝硬化患者发生 HA-VTE 的发生率和危险因素，概述了用于指导血栓预防的证据，并为肝硬化住院患者的 VTE 预防提供了实用建议。简而言之，对于肝硬化住院患者：我们建议将门静脉血栓形成作为未来研究的一个独特的重要临床终点。我们不建议将血小板减少症和/或延长凝血酶原时间/国际标准化比值作为抗凝血栓预防的绝对禁忌症。我们建议根据当地方案进行抗凝血栓预防，并建议使用低分子肝素（LMWH）或磺达肝癸钠优于普通肝素（UFH）。在肾功能不全的情况下，我们建议使用 LMWH 优于 UFH。对于重症患者，建议根据具体情况考虑血栓预防。我们建议开展研究以完善 VTE 风险分层，并确定血栓预防的最佳剂量和持续时间。
