Von Willebrand factor indicates bacterial translocation, inflammation, and procoagulant imbalance and predicts complications independently of portal hypertension severity.

Background: Elevated plasma von Willebrand factor antigen (vWF) has been shown to indicate the presence of clinically significant portal hypertension, and thus, predicts the development of clinical events in patients with cirrhosis. Aim: To investigate the impact of bacterial translocation and inflammation on vWF, as well as the association between vWF and procoagulant imbalance. Moreover, we assessed whether vWF predicts complications of cirrhosis, independent of the severity of portal hypertension. Methods: Our study population comprised 225 patients with hepatic venous pressure gradient (HVPG) >= 10mm Hg without active bacterial infections or hepatocellular carcinoma. Results: vWF correlated with markers of bacterial translocation (lipopolysaccharide-binding protein [LBP; =0.201; P=0.021]), inflammation (interleukin 6 [IL-6; =0.426; P<0.001] and C-reactive protein [CRP; =0.249; P<0.001]), and procoagulant imbalance (factor VIII/protein C ratio; =0.507; P<0.001). Importantly, the associations between vWF and these parameters were independent of HVPG. Moreover, vWF (per 10%) independently predicted variceal bleeding (hazard ratio [HR]: 1.08 [95% confidence interval (95% CI): 1.01-1.16]; P=0.023), requirement of paracentesis (HR: 1.05 [95% CI: 1.01-1.1]; P=0.023) and bacterial infections (HR: 1.04 [95% CI: 1-1.09]; P=0.04) including spontaneous bacterial peritonitis (HR: 1.09 [95% CI: 0.999-1.18]; P=0.053) on a trend-wise level. After backward elimination, vWF (HR: 1.05 [95% CI: 1.02-1.08]; P=0.003) and CRP (per 10mg/L; HR: 1.53 [95% CI: 1.14-2.05]; P=0.005) remained in the final model for transplant-free mortality. Finally, the independent prognostic value of vWF/CRP groups for mortality was confirmed by competing risk analysis. Conclusion: Our results demonstrate that vWF is not only a marker of portal hypertension but also independently linked to bacterial translocation, inflammation and procoagulant imbalance, which might explain its HVPG-independent association with most clinical events. Prognostic groups based on vWF/CRP efficiently discriminate between patients with a poor 5-year survival and patients with a favourable prognosis.