TY - JOUR
T1 - Expert opinion on bleeding risk from invasive procedures in cirrhosis
AU - the Bleeding in liver diseases investigators
AU - Riescher-Tuczkiewicz, Alix
AU - Caldwell, Stephen H.
AU - Kamath, Patrick S.
AU - Villa, Erica
AU - Rautou, Pierre Emmanuel
AU - Nezam H, Afdhal
AU - Walter, Ageno
AU - Marcello, Bianchini
AU - Annabel, Blasi
AU - Stephen H, Caldwell
AU - Mark, Callaway
AU - Andres, Cardenas
AU - Sarwa, Darwish Murad
AU - Andrea, De Gottardi
AU - Lesley, De Pietri
AU - Emmanuelle, De Raucourt
AU - Alessandra, Dell'Era E.
AU - Alban, Denys
AU - Laure, Elkrief
AU - Juan-Carlos, Garcia Pagan
AU - Guadalupe, Garcia Tsao
AU - Alexander, Gatt
AU - Edoardo G, Giannini
AU - Rita, Golfieri
AU - Charles S, Greenberg
AU - Virginia, Hernández Gea
AU - Mathis, Heydtmann
AU - Nicolas M, Intagliata
AU - Patrick S, Kamath
AU - Will, Lester
AU - Maria, Magnusson
AU - James, Neuberger
AU - Patrick G, Northup
AU - G, O'Leary Jacqueline
AU - Heather, Patton
AU - Markus, Peck Radosavljevic
AU - Anjana, Pillai
AU - Aurélie, Plessier
AU - Pierre-Emmanuel, Rautou
AU - Cristina, Ripoll
AU - Lara N, Roberts
AU - Ammar, Sarwar
AU - Marco, Senzolo
AU - Akash, Shukla
AU - Paolo, Simioni
AU - Douglas A, Simonetto
AU - Ashwani K, Singal
AU - Robin, Soto
AU - Jonathan G, Stine
AU - Elliot B, Tapper
N1 - Publisher Copyright:
© 2023 The Authors
PY - 2024/3
Y1 - 2024/3
N2 - 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.
AB - 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.
KW - anticoagulant
KW - aPTT
KW - biopsy
KW - coagulation
KW - fibrinogen
KW - haemorrhage
KW - haemostasis
KW - INR
KW - platelet
KW - procedural related bleeding
UR - http://www.scopus.com/inward/record.url?scp=85185552371&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85185552371&partnerID=8YFLogxK
U2 - 10.1016/j.jhepr.2023.100986
DO - 10.1016/j.jhepr.2023.100986
M3 - Article
AN - SCOPUS:85185552371
SN - 2589-5559
VL - 6
JO - JHEP Reports
JF - JHEP Reports
IS - 3
M1 - 100986
ER -