Incidence and Risk Factors of Deep Vein Thrombosis After Liver Transplantation A. Annamalai*, I. Kim, V. Sundaram, and A. Klein Cedars Sinai Medical Center, Los Angeles, California
ABSTRACT Background. Deep venous thrombosis (DVT) occurs in 0.1% of persons per year, affecting 15%e40% of general surgical procedures without prophylaxis. Thromboembolic prophylaxis is not commonly used after orthotopic liver transplantation (LT) owing to the risks of bleeding and coagulopathy. Cirrhosis and the association with the coagulation cascade, before and after transplantation, are not well understood. The purpose of this study was to determine the incidence of DVT and its risk factors after LT. Methods. We retrospectively reviewed LTs performed at our center from 2005 to 2012. We identified patients with Doppler examinations showing DVT after LT, platelet count, and international normalized ratio (INR) at time of DVT, associated symptoms, DVT prophylaxis, and perioperative risk factors. We determined the incidence of DVT, the odds ratio of each preoperative risk factor, the difference in platelet count and INR between those with and without a DVT, and the weighted risk of each factor in the development of DVT with the use of logistic regression modeling. Results. Of 314 patients, the incidence of DVT was 8.6% (27/314). Between those with and without DVT there was no significant difference in age, sex, platelet count, INR, infection, hepatocellular cancer, use of venous bypass, and prior surgery. There was a significant difference in mobility, 67% vs 20% (P < .0001), and the use of factor VII, 11% vs 2% (P < .05). The estimated risk for of developing DVT for patients with neither of these factors was 4%; with factor VII the risk rose to 17%; with mobility difficulty the risk rose to 23%; and with both the risk was 62%. In our entire population, there were no cases of pulmonary embolism. Conclusions. The risk of developing a DVT after LT is 9% even with mechanical DVT prophylaxis. Consideration should be given to using both mechanical and chemical prophylaxis after LT.
V
ENOUS THROMBOEMBOLISM (VTE) is the most common cause of preventable hospital-related death [1]. Annually, there are >900,000 people in the United States afflicted with deep venous thrombosis (DVT) or pulmonary embolism (PE) and w300,000 related deaths [2]. Thus VTE is a major disorder, with the adoption of guidelines and risk assessment tools for implementing proper prophylaxis. These guidelines have been derived primarily from observations made in hospitalized general medicine or surgical populations. Some more recent studies, however, have focused on DVT occurring in subgroups of patients, such as those with trauma or cancer or the elderly. These studies have elucidated the many risk factors now found in our DVT assessment
calculators: increasing age, respiratory disease, congestive heart disease, cancer, infection, dehydration, rheumatologic disorders, etc [3]. Importantly, based on these studies, most patients with end-stage liver disease requiring transplantation would also have high DVT risk scores. Despite a widespread appreciation of the potentially devastating consequence of VTE in a high-risk patient cohort such as those with advanced cirrhosis, the 2012 American College of Chest Physicians *Address correspondence to Alagappan Annamalai, MD, FACS, Cedars Sinai Medical Center 8635 West 3rd St., West Tower 590, Los Angeles, CA 90048. E-mail: alagappan. [email protected]
0041-1345/14 http://dx.doi.org/10.1016/j.transproceed.2014.09.113
ª 2014 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
3564
Transplantation Proceedings, 46, 3564e3569 (2014)
DEEP VEIN THROMBOSIS AFTER LT
guidelines [4] do not specifically address prophylaxis in patients with coagulopathy and cirrhosis [5]. There are currently no standardized or accepted practice guidelines for VTE prophylaxis in patients with end-stage liver disease. The VTE risk has been reported in a few studies and ranges from
ABSTRACT Background. Deep venous thrombosis (DVT) occurs in 0.1% of persons per year, affecting 15%e40% of general surgical procedures without prophylaxis. Thromboembolic prophylaxis is not commonly used after orthotopic liver transplantation (LT) owing to the risks of bleeding and coagulopathy. Cirrhosis and the association with the coagulation cascade, before and after transplantation, are not well understood. The purpose of this study was to determine the incidence of DVT and its risk factors after LT. Methods. We retrospectively reviewed LTs performed at our center from 2005 to 2012. We identified patients with Doppler examinations showing DVT after LT, platelet count, and international normalized ratio (INR) at time of DVT, associated symptoms, DVT prophylaxis, and perioperative risk factors. We determined the incidence of DVT, the odds ratio of each preoperative risk factor, the difference in platelet count and INR between those with and without a DVT, and the weighted risk of each factor in the development of DVT with the use of logistic regression modeling. Results. Of 314 patients, the incidence of DVT was 8.6% (27/314). Between those with and without DVT there was no significant difference in age, sex, platelet count, INR, infection, hepatocellular cancer, use of venous bypass, and prior surgery. There was a significant difference in mobility, 67% vs 20% (P < .0001), and the use of factor VII, 11% vs 2% (P < .05). The estimated risk for of developing DVT for patients with neither of these factors was 4%; with factor VII the risk rose to 17%; with mobility difficulty the risk rose to 23%; and with both the risk was 62%. In our entire population, there were no cases of pulmonary embolism. Conclusions. The risk of developing a DVT after LT is 9% even with mechanical DVT prophylaxis. Consideration should be given to using both mechanical and chemical prophylaxis after LT.
V
ENOUS THROMBOEMBOLISM (VTE) is the most common cause of preventable hospital-related death [1]. Annually, there are >900,000 people in the United States afflicted with deep venous thrombosis (DVT) or pulmonary embolism (PE) and w300,000 related deaths [2]. Thus VTE is a major disorder, with the adoption of guidelines and risk assessment tools for implementing proper prophylaxis. These guidelines have been derived primarily from observations made in hospitalized general medicine or surgical populations. Some more recent studies, however, have focused on DVT occurring in subgroups of patients, such as those with trauma or cancer or the elderly. These studies have elucidated the many risk factors now found in our DVT assessment
calculators: increasing age, respiratory disease, congestive heart disease, cancer, infection, dehydration, rheumatologic disorders, etc [3]. Importantly, based on these studies, most patients with end-stage liver disease requiring transplantation would also have high DVT risk scores. Despite a widespread appreciation of the potentially devastating consequence of VTE in a high-risk patient cohort such as those with advanced cirrhosis, the 2012 American College of Chest Physicians *Address correspondence to Alagappan Annamalai, MD, FACS, Cedars Sinai Medical Center 8635 West 3rd St., West Tower 590, Los Angeles, CA 90048. E-mail: alagappan. [email protected]
0041-1345/14 http://dx.doi.org/10.1016/j.transproceed.2014.09.113
ª 2014 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
3564
Transplantation Proceedings, 46, 3564e3569 (2014)
DEEP VEIN THROMBOSIS AFTER LT
guidelines [4] do not specifically address prophylaxis in patients with coagulopathy and cirrhosis [5]. There are currently no standardized or accepted practice guidelines for VTE prophylaxis in patients with end-stage liver disease. The VTE risk has been reported in a few studies and ranges from
