Incidence, predictive factors and clinical significance of development of portal vein thrombosis in cirrhosis: A prospective study

Abstract

Background and aims: The role of portal vein thrombosis (PVT) in the natural history of cirrhosis is controversial. There are few prospective studies validating risk factors for development of PVT. We analysed the incidence, factors associated with PVT development and its influence on cirrhosis decompensations and orthotopic liver transplant (OLT)-free survival. Methods: In this prospective observational study between January 2014 and March 2019, 445 consecutive patients with chronic liver disease were screened and finally 241 with cirrhosis included. Factors associated with PVT development and its influence on cirrhosis decompensations and OLT-free survival by time dependent covariate coding were analysed. Results: Majority of patients belonged to Child-Pugh class A 184 (76.3%) and the average MELD score was 10 ± 5. Previous cirrhosis decompensations occurred in 125 (52.1%), 63 (26.1%) were on NSBB and 59 (27.2%) had undergone banding for bleeding prophylaxis. Median follow-up was 29 (1-58) months. Cumulative incidence of PVT was 3.7% and 7.6% at 1 and 3 years. Previous decompensation of cirrhosis and low platelet counts but not NSBB independently predicted the development of PVT. During follow-up, 82/236 (34.7%) patients developed cirrhosis decompensations.OLT-free survival was 100% and 82.8% at 3 years, with and without PVT respectively. MELD score, but not PVT, independently predicted cirrhosis decompensations (HR 1.14; 95%CI:1.09-1.19) and OLT-free survival (HR 1.16;95%CI:1.11-1.21).

Vascular Liver Disorders, Portal Vein Thrombosis, and Procedural Bleeding in Patients With Liver Disease: 2020 Practice Guidance by the American Association for the Study of Liver Diseases

“…Severity of portal hypertension and liver disease are major predictive factors for PVT in patients with cirrhosis. ( 113‐118 ) Decreased velocity of PV flow at baseline has been recognized as a risk factor for PVT in patients with cirrhosis in several studies, albeit with varied predictive value. ( 117‐120 ) Some studies have identified specific thresholds of portal flow associated with increased risk of PVT, ranging from 10 to 15 cm/s, as determined by Doppler ultrasonography.…”

“…Other prospective studies have arrived at similar conclusions. ( 114,137 ) In contrast, a small, prospective, randomized controlled trial of enoxaparin compared to no anticoagulation therapy in prevention of PVT in high‐risk patients with cirrhosis ( 125 ) showed not only efficacy in prevention of PVT in the enoxaparin group, but also a survival and decompensation benefit. Although this study has not been replicated, the implication of prolonging decompensation‐free survival with prevention of PVT implies etiological potential.…”

“…( 122 ) However, analysis of confounding variables in this study attributable to the presence of esophageal varices, extent of portal hypertension, and nonselective beta‐blocker use as secondary variceal bleeding prophylaxis has raised questions about the independent effect of the nonselective beta‐blockers in development of PVT. ( 114,115,123 ) The potential role of an altered endothelium has been underinvestigated ( 124 ) and data on the role of inflammation/bacterial translocation are still limited. ( 107,125 ) Obesity, metabolic syndrome, and NASH cirrhosis are also recognized as independent risk factors for PVT.…”

<p>Clinical Implications of Thrombocytopenia for the Cirrhotic Patient</p>

“…50,51 Rather, the presence of thrombocytopenia is strongly associated with the development of portal vein thrombosis. 52 Given the underlying perception that patients with decompensated cirrhosis are coagulopathic, there is often suboptimal use of pharmacologic VTE prophylaxis, likely due to misconceptions about bleeding risk. 53…”

Controversies in the Management of Portal Vein Thrombosis in Liver Cirrhosis

“…However, this meta-analysis should be evaluated with caution, as it included studies with heterogeneous populations (partial and branch PVT cases were excluded in one study, and partial and total PVT cases were mixed in another). Moreover, the results of the meta-analysis [8] contradict those of many other (primarily retrospective) studies, which have predominantly reported that PVT had no impact on the mortality of patients on waiting lists for liver transplant (LT) [12][13][14][15][16][17][18].…”