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Invasive Hemodynamic Characterization of the Portal-hypertensive Syndrome in Cirrhotic Rats
Published on: August 1, 2018
Expert opinion on bleeding risk from invasive procedures in cirrhosis
Alix Riescher-Tuczkiewicz1, Stephen H Caldwell2, Patrick S Kamath3
1Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France.
Insights
Experts established consensus on bleeding risk for invasive procedures in cirrhosis patients. Platelet count thresholds were defined, with low-risk procedures acceptable at 30×10^9/L and high-risk at 50×10^9/L.
Area of Science:
- Hepatology
- Gastroenterology
- Interventional Medicine
Background:
- Lack of consensus on bleeding risk and safety thresholds for invasive procedures in cirrhosis patients.
- Existing international guidelines offer conflicting recommendations for managing these patients.
Purpose of the Study:
- To establish a position paper on bleeding risk for invasive procedures in patients with cirrhosis.
- To define expert consensus on safety thresholds for laboratory parameters before procedures.
Main Methods:
- Surveyed 52 experts involved in international guidelines for cirrhosis patient procedures.
- Experts classified 80 procedures as high or low bleeding risk (≥1.5% major bleeding risk).
- Determined consensus (≥75% agreement) on acceptable laboratory test thresholds for safe procedure performance.
Main Results:
- Consensus reached on 52 (65%) of 80 procedures: 17 high-risk and 35 low-risk.
- Lowest acceptable platelet counts: 30×10^9/L (low-risk) and 50×10^9/L (high-risk/surgery).
- Experts generally agreed that international normalized ratio (INR) is not critical for low-risk procedures and largely for high-risk procedures.
Conclusions:
- The expert-based classification provides a framework for refining future study designs.
- Findings guide clinical decision-making for invasive procedures in patients with cirrhosis.
- Consensus on platelet count and INR thresholds informs physicians on acceptable laboratory values prior to procedures.
Background & Aims:
Despite several recent international guidelines, no consensus exists on the bleeding risk nor haemostatic parameter thresholds that define the safety of invasive procedures in patients with cirrhosis. The aim of this study was to establish a position paper on the bleeding risk associated with invasive procedures in patients with cirrhosis among the experts involved in various guidelines.
Methods:
All experts involved in recent guidelines on the management of invasive procedures in patients with cirrhosis were invited to classify 80 procedures as "high risk" or "low risk" with respect to bleeding. Procedures were considered high risk when the estimated risk of major bleeding was 1.5% or more, or when even minor bleeding might lead to significant morbidity or death. The experts were also asked to choose safety thresholds for laboratory test values at which elective invasive procedures could be safely performed. The predetermined threshold considered as "consensus" was ≥75% agreement.
Results:
Fifty-two experts participated in the study. Out of 80 procedures, a consensus opinion was reached for 52 procedures (65%): 17 procedures were classified as "high risk", primarily interventional endoscopic procedures, percutaneous organ biopsies, or procedures involving the central nervous system; and 35 as "low risk", primarily "diagnostic" procedures. The lowest platelet counts at which performance of a low-risk procedure or a high-risk procedure/surgery were deemed acceptable were 30 × 109/L and 50 × 109/L, respectively. Experts did not believe that international normalised ratio should be considered before performing low-risk procedures; 71% also indicated that it should not be considered before performing high-risk procedures.
Conclusions:
This experience-based classification may be helpful to refine future study designs and to guide clinical decision making regarding invasive procedures in patients with cirrhosis.
Impact And Implications:
Several risk classifications and management guidelines for invasive procedures in patients with cirrhosis have been proposed, but with conflicting recommendations. By providing a position paper, based on the opinion of a broad panel of experts, on the bleeding risk associated with 52 invasive procedures in patients with cirrhosis, this survey will help to provide a framework for future study design. The consensus on platelet count, international normalised ratio, fibrinogen and activated partial thromboplastin time identified in this survey will inform physicians regarding the laboratory test values considered acceptable by the experts prior to the performance of an elective invasive procedure in patients with cirrhosis.
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