Objectives. We compared venous thromboembolism (VTE) prophylaxis practices and incidence in critically ill cirrhotic versus noncirrhotic patients and evaluated cirrhosis as a VTE risk factor. Methods. A cohort of 798 critically ill patients followed for the development of clinically detected VTE were categorized according to the diagnosis of cirrhosis. VTE prophylaxis practices and incidence were compared. Results. Seventy-five (9.4%) patients had cirrhosis with significantly higher INR (2.2 ± 0.9 versus 1.3 ± 0.6, ), lower platelet counts (115,000 ± 90,000 versus 258,000 ± 155,000/μL, ), and higher creatinine compared to noncirrhotic patients. Among cirrhotics, 31 patients received only mechanical prophylaxis, 24 received pharmacologic prophylaxis, and 20 did not have any prophylaxis. Cirrhotic patients were less likely to receive pharmacologic prophylaxis (odds ratio, 0.08; 95% confidence interval (CI), 0.04–0.14). VTE occurred in only two (2.7%) cirrhotic patients compared to 7.6% in noncirrhotic patients ( ). The incidence rate was 2.2 events per 1000 patient-ICU days for cirrhotic patients and 3.6 events per 1000 patient-ICU days for noncirrhotics (incidence rate ratio, 0.61; 95% CI, 0.15–2.52). On multivariate Cox regression analysis, cirrhosis was not associated with VTE risk (hazard ratio, 0.40; 95% CI, 0.10–1.67). Conclusions. In critically ill cirrhotic patients, VTE incidence did not statistically differ from that in noncirrhotic patients. 1. Background Chronic liver disease leads to decreased synthesis of coagulation proteins, such as factors II, VII, IX, and X, and is frequently associated with thrombocytopenia [1–3]. Whether these abnormalities make cirrhotic patients less prone to venous thromboembolism (VTE) than the general population is unclear, especially given that cirrhosis is also associated with decreased production of anticoagulation factors, such as protein C, protein S, and antithrombin III [2, 3]. A population-based, case-control study found that liver disease was associated with reduced VTE risk (odds ratio (OR), 0.1; 95% CI, 0.0–0.7) . One retrospective case-control study in hospitalized cirrhotic patients found that VTE occurred in only 0.5% of patients , a rate that was lower than that reported in general medical patients . However, more recent studies found higher VTE rates in hospitalized cirrhotic patients (2.7–6.3%) [6, 7]. Additionally, a study of 963 cirrhotic patients and 12,405 controls admitted to a tertiary care hospital found that cirrhotics had higher (1.8%) VTE incidence than controls in general
F. N. Bashour, J. C. Teran, and K. D. Mullen, “Prevalence of peripheral blood cytopenias (hypersplenism) in patients with nonalcoholic chronic liver disease,” The American Journal of Gastroenterology, vol. 95, no. 10, pp. 2936–2939, 2000.
M. Senzolo, P. Burra, E. Cholongitas, and A. K. Burroughs, “New insights into the coagulopathy of liver disease and liver transplantation,” World Journal of Gastroenterology, vol. 12, no. 48, pp. 7725–7736, 2006.
J. A. Heit, M. D. Silverstein, D. N. Mohr, T. M. Petterson, W. M. O'Fallon, and L. J. Melton III, “Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study,” Archives of Internal Medicine, vol. 160, no. 6, pp. 809–815, 2000.
P. G. Northup, M. M. McMahon, A. P. Ruhl et al., “Coagulopathy does not fully protect hospitalized cirrhosis patients from peripheral venous thromboembolism,” The American Journal of Gastroenterology, vol. 101, no. 7, pp. 1524–1528, 2006.
A. Aldawood, Y. Arabi, A. Aljumah et al., “The incidence of venous thromboembolism and practice of deep venous thrombosis prophylaxis in hospitalized cirrhotic patients,” Thrombosis Journal, vol. 9, article 1, 2011.
O. Dabbagh, A. Oza, S. Prakash, R. Sunna, and T. M. Saettele, “Coagulopathy does not protect against venous thromboembolism in hospitalized patients with chronic liver disease,” Chest, vol. 137, no. 5, pp. 1145–1149, 2010.
D. Gulley, E. Teal, A. Suvannasankha, N. Chalasani, and S. Liangpunsakul, “Deep vein thrombosis and pulmonary embolism in cirrhosis patients,” Digestive Diseases and Sciences, vol. 53, no. 11, pp. 3012–3017, 2008.
W. H. Geerts, D. Bergqvist, G. F. Pineo et al., “Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition),” Chest, vol. 133, no. 6, pp. 381S–453S, 2008.
A. Qaseem, R. Chou, L. L. Humphrey, M. Starkey, and P. Shekelle, “Venous thromboembolism prophylaxis in hospitalized patients: a clinical practice guideline from the American College of Physicians,” Annals of Internal Medicine, vol. 155, no. 9, pp. 625–632, 2011.
S. R. Kahn, W. Lim, A. S. Dunn et al., “Prevention of VTE in nonsurgical patients. Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines,” Chest, vol. 141, no. 2, pp. e195S–e226S, 2012.
Y. Arabi, A. Alshimemeri, and S. Taher, “Weekend and weeknight admissions have the same outcome of weekday admissions to an intensive care unit with onsite intensivist coverage,” Critical Care Medicine, vol. 34, no. 3, pp. 605–611, 2006.
H. Riess, S. Haas, U. Tebbe et al., “A randomized, double-blind study of certoparin vs. unfractionated heparin to prevent venous thromboembolic events in acutely ill, non-surgical patients: CERTIFY Study,” Journal of Thrombosis and Haemostasis, vol. 8, no. 6, pp. 1209–1215, 2010.
F. Fraisse, L. Holzapfel, J.-M. Coulaud et al., “Nadroparin in the prevention of deep vein thrombosis in acute decompensated COPD. The Association of Non-University Affiliated Intensive Care Specialist Physicians of France,” American Journal of Respiratory and Critical Care Medicine, vol. 161, no. 4, part 1, pp. 1109–1114, 2000.
C. R. A. Lesmana, S. Inggriani, L. Cahyadinata, and L. A. Lesmana, “Deep vein thrombosis in patients with advanced liver cirrhosis: a rare condition?” Hepatology International, vol. 4, no. 1, pp. 433–438, 2010.
R. S. Boersma, K.-S. G. Jie, A. Verbon, E. C. M. van Pampus, and H. C. Schouten, “Thrombotic and infectious complications of central venous catheters in patients with hematological malignancies,” Annals of Oncology, vol. 19, no. 3, pp. 433–442, 2008.
G. M. Joynt, J. Kew, C. D. Gomersall, V. Y. F. Leung, and E. K. H. Liu, “Deep venous thrombosis caused by femoral venous catheters in critically III adult patients,” Chest, vol. 117, no. 1, pp. 178–183, 2000.
D. Cook, M. Crowther, M. Meade et al., “Deep venous thrombosis in medical-surgical critically ill patients: prevalence, incidence, and risk factors,” Critical Care Medicine, vol. 33, no. 7, pp. 1565–1571, 2005.
D. R. Hirsch, E. P. Ingenito, and S. Z. Goldhaber, “Prevalence of deep venous thrombosis among patients in medical intensive care,” Journal of the American Medical Association, vol. 274, no. 4, pp. 335–337, 1995.
E. H. Ibrahim, M. Iregui, D. Prentice, G. Sherman, M. H. Kollef, and W. Shannon, “Deep vein thrombosis during prolonged mechanical ventilation despite prophylaxis,” Critical Care Medicine, vol. 30, no. 4, pp. 771–774, 2002.