Different risks of hemorrhage in patients with elevated international normalized ratio from chronic liver disease versus warfarin therapy, a population-based retrospective cohort study.
Different risks of hemorrhage in patients with elevated international normalized ratio from chronic liver disease versus warfarin therapy, a population-based retrospective cohort study.
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DOI：
10.1111/jth.15743
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发表时间：
2022-07
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慢性肝病（CLD）患者通常会出现国际标准化比值（INR）升高。尽管INR升高反映华法林使用者出血风险较高，但其在CLD患者中的临床意义尚不清楚。我们使用退伍军人健康管理局的数据来量化CLD患者与华法林使用者相比INR和（非静脉曲张）出血之间的相关性。我们进行了一项多变量竞争风险分析，以研究两个队列中INR与出血之间的相关性。我们使用INR和队列（CLD/华法林使用者）之间的相互作用项来测试INR对两个队列中出血的影响是否不同。分析了80，134例患者的数据（14，412例CLD患者和65，722例服用华法林患者）。INR对CLD患者和华法林使用者出血风险的影响不同（相互作用p<0.001）。随着INR升高至1.5以上，CLD患者出血的校正风险比（aHR）升高至2.25，但随着INR值的进一步升高，aHR保持相当稳定。相比之下，服用华法林的患者出血风险在INR处于亚治疗范围（INR < 2.0）和治疗范围（INR 2.0-3.0）时保持较低，在INR处于超治疗范围时呈指数增加（INR >3.0-3.5时aHR 1.64，INR > 3.5时aHR 4.70）。CLD患者INR与出血风险的关系不同于华法林使用者。在CLD患者中，应谨慎外推华法林使用者的数据以做出临床决策。
Patients with chronic liver disease (CLD) often present with an elevated International Normalized Ratio (INR). Although elevated INR reflects a higher risk of hemorrhage among warfarin users, its clinical significance in CLD patients is less clear. We used Veterans Health Administration data to quantify the association between INR and (non-variceal) hemorrhage in patients with CLD as compared to warfarin users. We performed a multivariate competing risk analysis to study the association between INR and hemorrhage in the two cohorts. We used an interaction term between INR and cohort (CLD/warfarin users) to test if INR had different effects on hemorrhage in the two cohorts. Data from 80,134 patients (14,412 with CLD and 65,722 taking warfarin) were analyzed. The effect of INR on the risk of hemorrhage differed between CLD patients and warfarin users (interaction p<0.001). As INR increased above 1.5, the adjusted hazards ratio (aHR) for hemorrhage in CLD patients increased to 2.25 but remained fairly constant with further elevation in INR values. In contrast, the risk of hemorrhage in patients taking warfarin remained low with INR in the sub-therapeutic (INR < 2.0) and therapeutic ranges (INR 2.0–3.0), and increased exponentially with INR in the supra-therapeutic range (aHR 1.64 with INR >3.0–3.5, and 4.70 with INR > 3.5). The relationship between INR and risk of hemorrhage in CLD patients is different from that in warfarin users. Caution should be exercised extrapolating data from warfarin users to make clinical decisions in CLD patients.
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影响因子：
168.9
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