Thromboprophylaxis for venous thromboembolism prevention in hospitalized patients with cirrhosis: Guidance from the SSC of the ISTH
Thromboprophylaxis for venous thromboembolism prevention in hospitalized patients with cirrhosis: Guidance from the SSC of the ISTH
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DOI：
10.1111/jth.15829
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发表时间：
2022-08-10
影响因子：
10.4
通讯作者：
Lisman, Ton
中科院分区：
文献类型：
--
作者：
Roberts, Lara N.;Hernandez-Gea, Virginia;Lisman, Ton
医院相关性静脉血栓栓塞（HA-VTE）是发病率和死亡率的主要原因，是国际公认的重要患者安全问题。虽然传统上认为肝硬化容易出血，但这些患者发生静脉血栓栓塞的风险也会增加，死亡率也会相应增加。肝硬化患者的住院率正在增加，由于血栓形成和出血风险之间的不确定平衡，有关血栓预防的决定很复杂。肝硬化患者的止血紊乱（通常被认为是药物血栓预防的禁忌症）进一步加剧了这一点。由于VTE风险评估和血栓预防的开创性研究的入选和排除标准严格，因此指导该患者组决策的数据有限。本指南文件回顾了肝硬化患者HA-VTE的发生率和风险因素，概述了血栓预防使用的证据，并为肝硬化住院患者预防VTE提供了实用的建议。简言之，在肝硬化住院患者中：我们建议将门静脉血栓形成作为未来研究的一个独特的临床重要终点。我们建议不要将血小板减少症和/或凝血酶原时间/国际标准化比值延长作为抗凝血栓预防的绝对禁忌症。我们建议按照当地方案进行抗凝血栓预防，并建议使用低分子量肝素（LMWH）或磺达肝癸钠而非普通肝素（UFH）。在肾损害中，我们建议LMWH优于UFH。对于重症患者，我们建议根据具体情况考虑血栓预防。我们建议进行研究，以完善静脉血栓栓塞的危险分层，并建立血栓预防的最佳剂量和持续时间。
Hospital-associated venous thromboembolism (HA-VTE) is a major cause of morbidity and mortality and is internationally recognized as a significant patient safety issue. While cirrhosis was traditionally considered to predispose to bleeding, these patients are also at an increased risk of VTE, with an associated increase in mortality. Hospitalization rates of patients with cirrhosis are increasing, and decisions regarding thromboprophylaxis are complex due to the uncertain balance between thrombosis and bleeding risk. This is further accentuated by derangements of hemostasis in patients with cirrhosis that are often considered contraindications to pharmacological thromboprophylaxis. Due to the strict inclusion and exclusion criteria of seminal studies of VTE risk assessment and thromboprophylaxis, there is limited data to guide decision making in this patient group. This guidance document reviews the incidence and risk factors for HA-VTE in patients with cirrhosis, outlines evidence to inform the use of thromboprophylaxis, and provides pragmatic recommendations on VTE prevention for hospitalized patients with cirrhosis. In brief, in hospitalized patients with cirrhosis: We suggest inclusion of portal vein thrombosis as a distinct clinically important endpoint for future studies. We recommend against the use of thrombocytopenia and/or prolongation of prothrombin time/international normalized ratio as absolute contraindications to anticoagulant thromboprophylaxis. We suggest anticoagulant thromboprophylaxis in line with local protocols and suggest low molecular weight heparin (LMWH) or fondaparinux over unfractionated heparin (UFH). In renal impairment, we suggest LMWH over UFH. For critically ill patients, we suggest case-by-case consideration of thromboprophylaxis. We recommend research to refine VTE risk stratification, and to establish the optimal dosing and duration of thromboprophylaxis.