traditionally , patients with liver cirrhosis have an auto - anticoagulation status because they often have an elevated prothrombin time ( pt ) or international normalized ratio ( inr ) [ 14 ] . however , the accumulated evidence suggests that cirrhotic patients have an increased risk of venous thromboembolism ( vte ) , which is defined as deep vein thrombosis ( dvt ) and pulmonary embolism ( pe ) [ 525 ] . case - control studies have also confirmed that cirrhotic patients are more likely to develop vte than the general population . our recent systematic review and meta - analysis found that about 1% of patients with chronic liver diseases had and developed vte during their hospitalizations . however , the relevant data are almost all from western countries ; by comparison , few studies have been conducted in chinese populations . the most common etiology of liver cirrhosis was hepatitis b virus in china . on the other hand , there was no consensus about the risk factors of vte in liver cirrhosis . herein , we conducted a retrospective observational study to evaluate the epidemiology and risk factors of vte in chinese hospitalized patients with liver cirrhosis and to explore whether vte might influence the in - hospital mortality of liver cirrhosis . in this retrospective observational study , all patients with a diagnosis of liver cirrhosis who were consecutively admitted to the general hospital of shenyang military area between january 2011 and december 2013 were identified by searching the international classification codes ( icd)-9 , icd-10 , and discharge diagnoses in the department of information . diagnosis of liver cirrhosis was primarily established according to the history of liver disease , clinical presentations , laboratory tests , and abdominal imaging . the study protocol was approved by the ethics committee of our hospital the number was k(2015)30 . informed written consents were waived . considering that the potential pathogenesis and prognosis might be different between vte and portal venous system thrombosis , portal venous system thrombosis was not considered in the present study . the medical records were thoroughly searched by an investigator to identify the history and new onset of vte ( xz ) . additional data were collected by our study group , including the age , sex , blood pressure at admission , history of liver cirrhosis , etiology of liver disease , acute gastrointestinal bleeding ( augib ) , ascites , hepatic encephalopathy , and laboratory tests ( red blood cell count , hemoglobin , white blood cell count , platelets , total bilirubin , albumin , alanine aminotransferase , aspartate aminotransferase , alkaline phosphatase , glutamyl transpeptidase , blood urea nitrogen , creatinine , potassium , sodium , pt / inr , activated partial thromboplastin time , and d - dimer ) . arterial hypertension was classified into grade i , ii , and iii according to the guideline . child - pugh and model for end - stage liver diseases ( meld ) scores were calculated according to the previous criteria . in - hospital death continuous data are expressed as mean  standard deviation and median with range and were compared by the independent sample t test . categorical data were expressed as frequency ( percentage ) and were compared by the chi - square test or fisher exact test . a bar chart was also drawn to compare the in - hospital mortality between patients with and without vte . continuous data are expressed as mean  standard deviation and median with range and were compared by the independent sample t test . categorical data were expressed as frequency ( percentage ) and were compared by the chi - square test or fisher exact test . a bar chart was also drawn to compare the in - hospital mortality between patients with and without vte . a majority of patients were male , had hepatitis b virus and alcohol abuse , and had child - pugh class a and b ( table 1 ) . among them , 5 patients had a previous history of lower extremity dvt , 1 patient had a previous history of lower extremity dvt and developed new onset of pe during hospitalization , 1 patient developed new onset of pe during hospitalization , and 2 patients developed new onset of dvt during hospitalization . thus , the prevalence of vte in liver cirrhosis during hospitalization was 0.4% ( 9/2006 ) and the incidence of vte was 0.2% ( 4/2006 ) . compared with those without vte , patients with vte had a significantly higher proportion of hypertension and significantly higher red blood cells , hemoglobin , alanine aminotransferase , aspartate aminotransferase , pt , inr , d - dimer , and child - pugh scores ( table 1 ) . the in - hospital mortality was significantly higher in patients with vte than in those without vte ( 33.3% [ 3/9 ] versus 3.4% [ 67/1997 ] , p<0.001 ) ( figure 1 ) . the overall mortality due to vte was 0.09% ( 2/2006 ) and vte accounted for 2.8% of all causes of death ( 2/70 ) . a majority of patients were male , had hepatitis b virus and alcohol abuse , and had child - pugh class a and b ( table 1 ) . among them , 5 patients had a previous history of lower extremity dvt , 1 patient had a previous history of lower extremity dvt and developed new onset of pe during hospitalization , 1 patient developed new onset of pe during hospitalization , and 2 patients developed new onset of dvt during hospitalization . thus , the prevalence of vte in liver cirrhosis during hospitalization was 0.4% ( 9/2006 ) and the incidence of vte was 0.2% ( 4/2006 ) . compared with those without vte , patients with vte had a significantly higher proportion of hypertension and significantly higher red blood cells , hemoglobin , alanine aminotransferase , aspartate aminotransferase , pt , inr , d - dimer , and child - pugh scores ( table 1 ) . causes of death are shown in table 2 . the in - hospital mortality was significantly higher in patients with vte than in those without vte ( 33.3% [ 3/9 ] versus 3.4% [ 67/1997 ] , p<0.001 ) ( figure 1 ) . the overall mortality due to vte was 0.09% ( 2/2006 ) and vte accounted for 2.8% of all causes of death ( 2/70 ) . our study demonstrated that the prevalence and incidence of vte during hospitalization was 0.4% and 0.2% in chinese patients with liver cirrhosis , respectively . this finding was relatively lower than our recent systematic review that the incidence of vte in patients with chronic liver diseases was 1% ( 95% confidence interval : 0.71.3% ) , and the prevalence of vte was 1% ( 95% confidence interval : 0.71.2% ) . this discrepancy might be explained by the heterogeneous sample size and etiology of liver cirrhosis among studies ; despite this , we preferred to emphasize another major finding  that patients with vte had an approximately 10-fold higher risk of in - hospital death than those without vte . certainly , a small number of patients with vte might restrict the interpretation of comparative analysis . considering a statistically significant difference of in - hospital mortality between the 2 groups , we had to acknowledge the importance of early diagnosis and treatment of vte in liver cirrhosis . d - dimer , red blood cells , hemoglobin , alanine aminotransferase , aspartate aminotransferase , pt , inr , and child - pugh scores were significantly associated with the presence of vte . except for d - dimer , which has been a routine diagnostic test for vte , and arterial hypertension , which is an important determinant of vte in the general population , the risk factors for vte should be interpreted carefully . first , patients with vte had significantly higher red blood cell and hemoglobin than those without vte , possibly because none of patients with vte had augib , but 28.3% of patients without vte had augib . second , patients with vte had significantly higher alanine aminotransferase and aspartate aminotransferase than those without vte . similarly , patients with vte also had significantly higher child - pugh scores than those without vte . additionally , higher total bilirubin and lower albumin were observed in patients with vte , but the difference was not statistically significant . thus , the relationship between severity of liver dysfunction and probability of vte is suggested . third , patients with vte had significantly higher pt and inr than those without vte . this finding is seemingly counterintuitive , but was largely consistent with the modern concept that pt and inr do not reflect the global coagulation status , and that elevated pt and inr does not protect cirrhotic patients from the development of vte . this has been repeatedly reported in previous studies and was recently reviewed [ 4244 ] . this finding can be explained by the fact that pt and inr mirror the liver synthesis of the procoagulants only , whereas other parameters associated with an overall decrease of liver function can be more accurate surrogates for impaired production of procoagulants as well as natural anticoagulants . except for our findings , previous studies should be deeply and systematically discussed . we described a detailed search strategy in our recent systematic review of the epidemiology of vte in liver diseases . studies were eligible if they compared the characteristics between liver disease patients with and without vte . notably , we just summarized the risk factors of vte in the patients with liver diseases , but not in the general population . indeed , in the latter condition , the presence of liver disease might be one of the variables included . thus , the following items about the risk factors of vte were collected : variables included in the univariable analyses , significant factors calculated in the univariate analyses , the variables included in the multivariate analyses , and the independent predictors calculated in the multivariate analyses . the odds or risk ratio for each factor was also recorded to clarify whether the independent factors increased or decreased the risk of vte in liver diseases . overall , 7 individual studies evaluated the risk factors of predicting the development of vte in patients with liver diseases in univariate analyses , and 5 of them also conducted multivariate analyses   ( table 3 ) . they included age , race , charlson co - morbidity index , insurance , encephalopathy , variceal bleeding , ascites , coagulopathy , hypo - osmolality , malnutrition , total parenteral nutrition , mechanical ventilation , central venous line placement , diabetes mellitus , albumin , creatinine , aspartate aminotransferase , alanine aminotransferase , and hematocrit . the race with the highest risk of vte was black , followed by white and hispanics . a higher charlson co - morbidity index , malnutrition , central venous line placement , active malignancy , trauma or surgery during hospitalization , history of vte , and diabetes mellitus the presence of encephalopathy , variceal bleeding , ascites , coagulopathy , and hypo - osmolality , medicaid insurance , and use of vte prophylaxis were associated with a decreased risk of vte . a lower albumin level was identified as an independent predictor of vte in 2 studies by northup   and walsh . in the study by northup , the albumin level was significantly lower in cirrhotic patients with vte than in those without vte ( mean : 2.85 g / dl , 95%ci : 2.703.01 versus mean : 3.10 g / dl , 95%ci : 2.963.23 , p=0.01 ) ; in the study by walsh , the albumin level was significantly lower in patients with vte than in those without vte ( median : 2.1 g / dl , interquartile range : 1.72.6 versus median : 2.4 g / dl , interquartile range : 22.8 , p=0.02 ) . by contrast , another two studies did not identify the albumin level as a significant predictor of vte in the multivariate analyses . in the study by lesmana , the proportion of an albumin level <3 mg / dl was lower in patients with dvt than in those without dvt ( 75% [ 9/12 ] versus 49.2% [ 120/244 ] , p=0.081 ) , but the difference was not statistically significant . although a firm conclusion was not achieved , these preliminary findings from our team and others are helpful for the identification of high - risk patients . however , these data were scattered and needed to be integrated into a score system or predictive index . ideally , a prospective study should include a training cohort to produce a predictive model to stratify the risk of the development of vte and a validation cohort to confirm its accuracy . although we selected all patients consecutively admitted to our hospital and had very few exclusion criteria , the patient selection bias should not be neglected in a retrospective study . second , laboratory and radiological examinations for the diagnosis of vte were not routinely performed . prospective studies might be warranted to establish the accurate epidemiology of vte , especially asymptomatic vte . third , the regional and ethnic difference in the epidemiology of vte could not be evaluated in this single - center study . vte was observed in 0.4% of patients with liver cirrhosis during hospitalization and it significantly increased the in - hospital mortality . degree of liver dysfunction might be significantly associated with the presence of vte in liver cirrhosis . more importantly , elevated pt / inr did not protect from the development of vte , but increased the risk of vte in liver cirrhosis . due to potential study limitations , these findings should be cautiously interpreted and further validated .