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Published on: August 4, 2018
Percutaneous liver biopsy and revised coagulation guidelines: a 9-year experience
Douglas R Kitchin1, Alejandro Munoz Del Rio2, Michael Woods2
1Madison Radiologists, SC. PO Box 44428, Madison, WI, 53744-4428, USA. dougkitchin@gmail.com.
Insights
Revised coagulation guidelines for liver biopsy did not increase bleeding complications. Less stringent parameters (INR ≤ 2.0, platelets ≥ 25,000) reduced blood product use without raising hemorrhagic risks.
Area of Science:
- Hepatology
- Interventional Radiology
- Coagulation Medicine
Background:
- Percutaneous liver biopsy requires careful coagulation assessment to minimize bleeding.
- Previous guidelines (SIR) mandated stricter parameters (INR ≤ 1.5, platelets ≥ 50,000).
- The impact of revised, less stringent guidelines on complication rates and resource utilization was unclear.
Purpose of the Study:
- To evaluate if revised, less stringent pre-procedural coagulation guidelines for percutaneous liver biopsy increase hemorrhagic complications.
- To assess the effect of guideline changes on fresh frozen plasma (FFP) and platelet utilization.
- To determine the relationship between INR, platelet levels, blood product administration, and bleeding complications.
Main Methods:
- Retrospective review of 1846 percutaneous liver biopsies in 1740 patients.
- Comparison of outcomes under strict SIR guidelines versus revised departmental guidelines (INR ≤ 2.0, platelets ≥ 25,000).
- Analysis of departmental complication rates, blood product usage, and individual patient risk factors (INR, platelets).
Main Results:
- Fewer hemorrhagic complications occurred department-wide after adopting less stringent guidelines (1.6% vs. 3.4%, p=0.0192).
- Significant decreases in pre-procedural FFP (0.8% vs. 3.9%) and platelet transfusions (0.3% vs. 1.2%) were observed.
- Increased INR and decreased platelet counts correlated with higher individual bleeding risk, but transfusions did not mitigate this risk.
Conclusions:
- Less stringent coagulation guidelines (INR ≤ 2.0, platelets ≥ 25,000) for liver biopsy are safe and do not increase departmental hemorrhagic complications.
- These revised guidelines significantly reduce the need for pre-procedural blood product administration.
- While individual bleeding risk is linked to INR and platelet levels, prophylactic transfusions did not prove effective in preventing complications.
Purpose:
To retrospectively review revised pre-procedural coagulation guidelines for percutaneous liver biopsy to determine whether their implementation is associated with increased hemorrhagic complications on a departmental scale. Secondary endpoints were to determine the effect of this change on pre-procedural blood product (FFP and platelet) utilization, to evaluate the impact of administered blood products on hemorrhagic complications, and to determine whether bleeding complications were related to INR and platelet levels.
Materials And Methods:
This IRB-approved, HIPAA-compliant, retrospective study reviewed 1846 percutaneous liver biopsies in 1740 patients, comparing biopsies performed, while SIR consensus pre-procedural coagulation guidelines were in place (INR ≤ 1.5, platelets ≥50,000 µL) to those performed after departmental implementation of revised, less stringent guidelines (INR ≤ 2.0, platelets ≥25,000 µL).
Results:
On a departmental scale, there were significantly fewer hemorrhagic complications in the population of patients treated after adoption of less stringent guidelines as compared to those treated under the SIR guidelines (1.6% vs. 3.4%, p = 0.0192) despite a significant decrease in pre-procedural FFP (0.8% vs. 3.9%, p < 0.001) and platelet transfusions (0.3% vs. 1.2%, p = 0.021). Individual patient hemorrhagic complication rates significantly increased as INR increased (p = 0.006) and platelet counts decreased (p = 0.004), but pre-procedural FFP (p = 0.64) and/or platelet transfusion (p = 0.5) did not have a significant impact on hemorrhagic complication rates.
Conclusion:
Implementation of less stringent pre-procedural coagulation parameter guidelines for percutaneous liver biopsy (INR ≤ 2.0, platelets ≥25,000 µL) did not result in an increase in departmental hemorrhagic complication rates but did significantly decrease pre-procedural FFP/platelet administration. An individual patient's bleeding risk does increase as INR increases and platelets decrease, but pre-procedural FFP and/or platelet transfusion did not mitigate that increased risk.
