Case Presentation: A 45 yo woman with alcohol use, liver cirrhosis, hepatic encephalopathy and recurrent abdominal ascites, presented to hospital with decreased urine output and abdominal swelling. She was found to have severe acute renal failure and was treated for suspected hepatorenal syndrome with intravenous albumin infusion. She did not recover renal function and required dialysis treatment initiation. A dialysis catheter was placed and the patient was discharged in stable condition. She was readmitted 1 week later with acute gastrointestinal bleeding related to esophageal varices, which was controlled during endoscopy. During this time her renal function and urine output had improved. It was decided she no longer required dialysis treatment and her dialysis catheter would be removed by Interventional Radiology.
After review of the patient’s INR (2.5), the radiology consultant requested administration of IV phytonadione (vitamin K) with the aim of decreasing the patient’s risk of bleeding during the procedure. The patient was not on oral anticoagulants and her coagulopathy was chronic, attributed to poor synthetic liver function by the medical team. During IV vitamin K administration the patient developed itchiness, hives, flushing and complained of severe dyspnea. Vital signs included blood pressure 90/50 mmHg, pulse 130 bpm, respiratory rate 28 per minute, and pulse oximetry of 65% on non-rebreather oxygen mask. On physical exam the patient was in respiratory distress and exhibited labored breathing. Hives and flushing were noted on her skin exam. Wheezing was absent on pulmonary exam but air flow was severely diminished. IV epinephrine, diphenhydramine, ranitidine, and methylprednisolone were administered with slow but gradual improvement of respiratory symptoms. The patient was transferred to the intensive care unit and 24 hours later had recovered to baseline. Her dialysis catheter was removed several days later with an unchanged INR (2.5) and without bleeding complications.
Discussion: International normalized ratio (INR) in patients with liver cirrhosis, although useful as a marker of prognosis, is a poor indicator of bleeding risk. Recent data indicates low likelihood of bleeding risk for low-risk procedures such as endoscopy, paracentesis and central line placement in patients with stable cirrhosis (1). Clinical evidence does not exist to support the practice of administration of phytonadione (Vitamin K) as a “reversal” agent in cirrhotic patients. Hypersensitivity to Vitamin K may manifest as an anaphylactoid reaction, leading to histamine release and diffuse vasodilatation. Clinical signs include rash, hives, flushing, wheezing, respiratory distress and hypotension. Although most patient recover with supportive measures and discontinuation of vitamin K infusion, a small number of fatalities have been reported (2).
Conclusions: Patients with an elevated INR due to cirrhosis of the liver are frequently encountered on hospital wards. Although consultants may request vitamin K administration prior to low-risk procedures in cirrhotic patients, hospitalist physicians need to be aware of the limited benefits and potential catastrophic effects of this management strategy.
References:
1. Zakeri, N., Tsochatzis, E.A. Bleeding Risk with Invasive Procedures in Patients with Cirrhosis and Coagulopathy. Curr Gastroenterol Rep. (2017) 19: 45.
2. Britt RB, Brown JN. Characterizing the Severe Reactions of Parenteral Vitamin K1. Clin Appl Thromb Hemost. 2016 Jan 1:[Epub ahead of print].