Pharmacologic prophylaxis against venous thromboembolism in hospitalized patients with cirrhosis and associated coagulopathies

Abstract

Purpose: Published evidence on the incidence and predictors of venous thromboembolism (VTE) in patients with cirrhosis of the liver is reviewed.

Summary: The frequently observed phenomenon of elevated International Normalized Ratio (INR) values in patients with cirrhosis has led to a theory of "autoanticoagulation" and the assertion that such patients may not benefit from the VTE risk-reduction therapies routinely used in other groups of hospitalized patients. A literature search identified six reports specifically addressing the issue of VTE risk in patients with cirrhosis. Reported rates of VTE development in such patients vary widely (0.5-8.2%) as a result of investigators' use of varying study methods and endpoints. The results of three studies (including two studies of longitudinal data on about 100,000 and nearly 450,000 patients) found no significant correlation of INR values and VTE risk. With regard to potential clinical markers of VTE risk in the context of cirrhosis, data from two studies suggested that serum albumin might serve as a reliable marker of coagulation status and, therefore, VTE risk. The results of other studies indicated that independent predictors of VTE in patients with cirrhosis include malnutrition and significant comorbidities such as chronic kidney disease and congestive heart failure. In aggregate, the available evidence does not support the autoanticoagulation theory.

Conclusion: In hospitalized patients with cirrhosis who have elevated INR values, pharmacologic VTE prophylaxis should be strongly considered if there is no active or recent bleeding and if more than one risk factor for VTE is present.