Liver and Bile
J Hepatol. 2023;79(1):69–78
Anticoagulation improves survival in patients with cirrhosis and portal vein thrombosis: The IMPORTAL competing-risk meta-analysis
Background and aims: Previous meta-analyses demonstrated the safety and efficacy of anticoagulation in the recanalization of portal vein thrombosis (PVT) in patients with cirrhosis. Whether this benefit translates into improved survival is unknown. The authors conducted an individual patient data (IPD) meta-analysis to assess the effect of anticoagulation on all-cause mortality in patients with cirrhosis and PVT.
Methods: In this IPD meta-analysis, they selected studies comparing anticoagulation versus no treatment in patients with cirrhosis and PVT from PubMed, Embase, and Cochrane databases (until June 2020). IPD were subsequently requested from authors. The primary outcome – the effect of anticoagulation on all-cause mortality – was assessed by a 1-step meta-analysis based on a competing-risk model with liver transplantation as the competing event. The model was adjusted for clinically relevant confounders. A multilevel mixed-effects logistic regression model was used to determine the effect of anticoagulation on recanalization.
Results: Individual data on 500 patients from 5 studies were included; 205 (41%) received anticoagulation and 295 did not. Anticoagulation reduced all-cause mortality (adjusted subdistribution hazard ratio = 0.59; 95% confidence interval [CI]: 0.49–0.70), independently of thrombosis severity and recanalization. The effect of anticoagulation on all-cause mortality was consistent with a reduction in liver-related mortality. The recanalization rate was higher in the anticoagulation arm (adjusted odds ratio = 3.45; 95% CI: 2.22–5.36). The non-portal-hypertension-related bleeding rate was significantly greater in the anticoagulation group.
Conclusions: Anticoagulation reduces all-cause mortality in patients with cirrhosis and portal vein thrombosis independently of recanalization, but at the ex pense of increasing non-portal hypertension-related bleeding.