Venous Thromboembolism in Patients with Cirrhosis

Abstract

Purpose: It is the general notion that cirrhotic patients do not suffer from DVT/PE as they are naturally anticoagulated. However, there are no studies that objectively addressed if patients with cirrhosis have lower frequency of venous thromboembolism (VTE). Therefore, we conducted a case-control study to examine the relationship between cirrhosis and VTE. Methods: A case-control study of patients seen at Wishard Hospital between 1995–2005 was performed using the Regenstrief Medical Record System. Cases were defined as hospitalized patients with biopsy and/or imaging plus clinical evidence of cirrhosis. Age, gender, and race-matched patients with no known evidence of cirrhosis seen during the same time period served as controls. The development of VTE was identified by the ICD-9 codes followed by cross referencing studies with Doppler ultrasound, V/Q scan, and CT chest. Subjects previously hospitalized with VTE were excluded. Charlson Index was calculated to determine the comorbidity. Patients with cirrhosis were also compared to age, gender, race, and Charlson Index matched non-cirrhotic patients with other chronic illnesses including chronic kidney disease (CKD), congestive heart failure (CHF), and five most common cancers in the US. Logistic regressions were performed to identify variables with predictive value. Results: This study consisted of 963 cirrhotics (51 ± 11 yrs, females 34%, and Caucasians 60%) and 12,405 controls (51 ± 11 yrs, females 36%, and Caucasians 60%). Patients with cirrhosis had VTE (1.8%) and this is significantly higher than the controls (0.9%, OR: 1.78, P= 0.007). The Charlson Index in cirrhotic patients was higher than that in controls (3.2 ± 1.8 vs. 0.9 ± 1.5, P < 0.001). However, in the combined cohort, cirrhosis (OR 0.87, 95% CI 0.2–2.6) and Charlson index (OR 0.93, 95% CI 0.74–1.16) were not independently associated with VTE. PTT (OR 0.88: 95% CI 0.84–0.94) and serum albumin (OR 0.47, 95% CI 0.23–0.93) were the independent predictors of VTE in the entire cohort. The risk of VTE in cirrhotics was much lower than those with other medical illnesses: 7.1% in CKD (OR 0.25; 95% CI 0.15–0.41), 7.8% in CHF (OR 0.23, 95% CI 0.14–0.37), and 6.1% in cancers (OR 0.29, 95% CI 0.17–0.52). Conclusion: Underlying cirrhosis seems to be protective against VTE when compared to other chronic illnesses. However, patients with cirrhosis do not have lower risk of VTE compared to non-cirrhotic controls. PTT and serum albumin were independent predictors of VTE in cirrhotic patients.