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Stratifying the Risks of Oral Anticoagulation

in Patients
With Liver Disease
M. Bagus Rizkiyanto
Iswanto Pratanu
Advanced liver disease has been described as an
imbalanced state of both pro and anticoagulants
and is characterized by hematologic abnormalities
Warfarin effective for preventing
thromboembolic events but may not be safe in
patients with chronic liver disease

The goal is to identify which patients with liver

disease might safely receive warfarin
103 897 patients receiving oral anticoagulation with
warfarin from 100 sites of care in the Veterans
Health Administration (VA) between October 1,
2006 - September 30, 2008
Patients were excluded :
During their first 6 months on warfarin
Patients undergoing anticoagulation for
mechanical heart valves
Definition of Liver Disease

1 of the International
Classification of Diseases-Ninth
Revision (ICD-9) codes for chronic
liver disease

Portal vein thrombosis (452.x) was

not among the conditions used to
establish a diagnosis of liver
Poorer TTR

Albumin general marker of health and nutritional
status, Specifically for liver disease marker of
synthetic function of the liver and part of Child-
Pugh model to predict mortality
The elevation of creatinine above the normal range
may suggest advanced liver disease
Patients with hepatic disease and a normal albumin
(3.5) and normal renal function (creatinine, <1.0)
have similar anticoagulation control and a similar
risk of hemorrhagic events when compared with
those without liver disease
Clinicians categorize patients at highest risk
prospectively and guidance for clinical decision
making for patients with chronic liver disease with
indication for anticoagulation
Limitation patients undergoing anticoagulation
for nonliver-related reasons, and may not fully
reflect a general population of patients with liver
Limitation does not consider patients with
valvular heart disease
Patients with liver disease and receiving
anticoagulation with warfarin for varied
poor anticoagulation control and an elevated risk
for major hemorrhage
However, these effects were not uniform, and a
simple 4-point risk score based on serum albumin
and creatinine was able to meaningfully risk-
stratify these patients with regard to the major
hemorrhage and may inform better decisions