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Outcome of patients with primary hepatic venous obstruction treated with anticoagulants alone
Akash Shukla1, Shobna J Bhatia
1Department of Gastroenterology, Seth G S Medical College and KEM Hospital, Mumbai, 400 012, India.
Insights
Anticoagulation alone can improve outcomes for hepatic venous outflow tract obstruction (HVOTO) patients. Over half of patients showed response, particularly those with lower Child-Pugh scores, indicating a viable treatment option.
Area of Science:
- Hepatology
- Vascular Medicine
- Internal Medicine
Background:
- Hepatic venous outflow tract obstruction (HVOTO) management has advanced with anticoagulants, radiological interventions, and liver transplantation.
- In India, limited availability and high cost of advanced treatments lead many patients to rely solely on anticoagulation.
- This study evaluates the clinical outcomes of HVOTO patients treated with anticoagulation alone.
Purpose of the Study:
- To assess the effectiveness of anticoagulation and supportive medical therapy as a standalone treatment for hepatic venous outflow tract obstruction (HVOTO).
- To identify factors predicting response and mortality in HVOTO patients managed conservatively.
Main Methods:
- Prospective follow-up of 43 HVOTO patients receiving oral anticoagulation and supportive care, excluding radiological or surgical interventions.
- Diagnosis confirmed by color Doppler, angiography, or magnetic resonance venography; warfarin adjusted for an international normalized ratio (INR) of 2.0-3.0.
- Response defined by absence of ascites/encephalopathy, normal liver enzymes, bilirubin <1.5 mg/dL, and no portal hypertension-related bleeding.
Main Results:
- 61% of patients (26/43) achieved a response, with response onset varying from within 2 to 5 months.
- Seven patients died from liver failure or gastrointestinal bleeding; nine experienced anticoagulation-related complications.
- Univariate analysis indicated low Child-Pugh (CP) or Clichy scores predicted response, while multivariate analysis confirmed low CP score as the sole predictor of response.
Conclusions:
- Supportive medical therapy and anticoagulation alone can lead to positive outcomes in over half of HVOTO patients.
- Patients with lower Child-Pugh scores demonstrate a higher likelihood of response to conservative management.
- Delayed response to anticoagulation therapy is possible in some HVOTO patients.
Background:
Outcome of patients with hepatic venous outflow tract obstruction (HVOTO) has improved with newer treatments, including anticoagulants, radiological interventions and liver transplant. In India, however, liver transplant and radiological interventions are costly and have limited availability. Hence, patients often opt for anticoagulation alone. We followed up a group of such patients to determine the clinical outcome with such treatment.
Methods:
Consecutive patients with HVOTO, treated with oral anticoagulation and supportive medical therapy but no radiological or surgical intervention, were followed up for at least 12 months. Diagnosis of HVOTO was based on color Doppler, and either angiography or magnetic resonance venography. Warfarin dose was adjusted to maintain international normalized ratio (INR) between 2.0 and 3.0. Patients with secondary HVOTO and those with baseline INR > or = 2.0 were excluded. Response was defined as absence of ascites and/or encephalopathy, normal AST/ALT, bilirubin <1.5 mg/dL, and no portal hypertension related bleed after starting therapy.
Results:
Of 43 patients (mean [SD] age=28.7 [8.4] years; 20 men), 26 (61%) had a response during a median follow up of 23 (range 15-33) months. The response first appeared within 2 months of the start of treatment in 18 patients and between 2 and 5 months from the start of treatment in eight patients. Seven patients died of progressive liver failure (6 patients) or GI bleed (1 patient). Nine patients had anticoagulation-related complications. On univariate analysis, short duration of symptoms, high serum albumin, low baseline INR, and low baseline Child-Pugh's (CP) or Clichy scores predicted response. Presence of hepatic encephalopathy, portal vein thrombosis, obstruction of all hepatic veins, low albumin, high INR, high serum bilirubin, high baseline CP score, Murad score and adverse Clichy index were associated with higher mortality rate. However, on multivariate analysis, only low CP score was associated with response, and no factor was found to predict death.
Conclusions:
More than half of patients with HVOTO show response with only supportive medical therapy and anticoagulants. This occurs more often in patients with low CP score. Some patients may have delayed response.
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