title: The international normalized ratio does not reflect bleeding risk in esophageal variceal hemorrhage.
abstract: OBJECTIVE
  The international normalized ratio (INR) has not been validated as a predictor of bleeding risk in cirrhotics. The aim of this study was to determine whether elevation in the INR correlated with risk of esophageal variceal hemorrhage and whether correction of the INR prior to endoscopic therapy affects failure to control bleeding.
  
  
  METHODS
  Patient records were retrospectively reviewed from January 1, 2000 to December 31, 2010. Cases were cirrhotics admitted to the hospital due to bleeding esophageal varices. Controls were cirrhotics with a history of non-bleeding esophageal varices admitted with ascites or encephalopathy. All variceal bleeders were treated with octreotide, antibiotics, and band ligation. Failure to control bleeding was defined according to the Baveno V criteria.
  
  
  RESULTS
  We analyzed 74 cases and 74 controls. The mean INR at presentation was lower in those with bleeding varices compared to non-bleeders (1.61 vs 1.74, P = 0.03). Those with bleeding varices had higher serum sodium (136.1 vs 133.8, P = 0.02), lower hemoglobin (9.59 vs 11.0, P < 0.001), and lower total bilirubin (2.47 vs 5.50, P < 0.001). Multivariable logistic regression showed total bilirubin to inversely correlate with bleeding (OR = 0.74). Bleeders received a mean of 1.14 units of fresh frozen plasma (FFP) prior to endoscopy (range 0-11 units). Of the 14 patients (20%) with failure to control bleeding, median INR (1.8 vs 1.5, P = 0.02) and median units of FFP transfused (2 vs 0, P = 0.01) were higher than those with hemostasis after the initial endoscopy.
  
  
  CONCLUSIONS
  The INR reflects liver dysfunction, not bleeding risk. Correction of INR with FFP has little effect on hemostasis.
authors.forename: Tammy T
authors.initials: TT
authors.lastname: Hshieh
authors.forename: Aung
authors.initials: A
authors.lastname: Kaung
authors.forename: Syed
authors.initials: S
authors.lastname: Hussain
authors.forename: Michael P
authors.initials: MP
authors.lastname: Curry
authors.affiliation: Department of Medicine and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, US.
authors.forename: Vinay
authors.initials: V
authors.lastname: Sundaram
mesh_terms: D000328:Adult; D000368:Aged; D004724:Endoscopy; D004932:Esophageal and Gastric Varices / Q000097:blood* / Q000175:diagnosis / Q000209:etiology*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000097:blood* / Q000175:diagnosis / Q000209:etiology*; D006801:Humans; D019934:International Normalized Ratio; D008103:Liver Cirrhosis / Q000097:blood / Q000150:complications*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors