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Liu Y, Zhuang Y, Xu G, Wang X, Lin L, Ding Q. Fibrinogen dysfunction and fibrinolysis state in patients with hepatitis B-related cirrhosis. Hematology 2024; 29:2392028. [PMID: 39222052 DOI: 10.1080/16078454.2024.2392028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 08/07/2024] [Indexed: 09/04/2024] Open
Abstract
OBJECTIVE To assess the fibrinogen function in patients with hepatitis B-related cirrhosis and explore the relationship between dysfibrinogenemia and bleeding and thrombotic events. METHODS Medical records and laboratory data of the patients with hepatitis B-related cirrhosis were collected. Patients were categorized into three groups based on the Child-Pugh score. Fibrinogen activity and antigen, fibrinogen-bound sialic acid (FSA), fibrinogen polymerization and fibrinolysis kinetic analysis, thrombin-antithrombin complex (TAT) and plasmin-α2-antiplasmin complex (PAP) were detected. RESULTS Eighty patients with seventeen, thirty-eight and twenty-five in Child-Pugh A, B and C, respectively, were included. Seventeen patients experienced bleeding events and eight patients had thrombotic events. Fibrinogen activity and antigen levels were reduced with the severity of cirrhosis. Twenty-two patients exhibited dysfibrinogenemia. The FSA levels in patients with non-dysfibrinogenemia and those with dysfibrinogenemia were increased to 1.25 and 1.37 times of healthy controls, negatively correlated with fibrinogen activity (ρ = -0.393, p = 0.006). Compared to healthy controls, the amount of clot formation was reduced (p < 0.001), the polymerization was delayed (p < 0.001) and the rate of fibrinolysis was reduced (p < 0.001). The TAT levels were significantly increased in the Child-Pugh C patients compared to the Child-Pugh B patients (p = 0.032) while the PAP levels were comparable among 3 groups (p = 0.361). CONCLUSION Sialylation of fibrinogen is one of the main causes of modifications of fibrinogen in patients with hepatitis B-related cirrhosis. The polymerization and fibrinolysis functions of fibrinogen are impaired. The degree of impaired fibrinolysis function is more severe than that of polymerization function, and may be partly related to the occurrence of thrombotic events.
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Affiliation(s)
- Yu Liu
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Yan Zhuang
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Guanqun Xu
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Xuefeng Wang
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Lanyi Lin
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Qiulan Ding
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
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Deng F, Cao Y, Wang H, Zhao S. Prognosis of major bleeding based on residual variables and machine learning for critical patients with upper gastrointestinal bleeding: A multicenter study. J Crit Care 2024; 85:154923. [PMID: 39357434 DOI: 10.1016/j.jcrc.2024.154923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Revised: 09/11/2024] [Accepted: 09/19/2024] [Indexed: 10/04/2024]
Abstract
BACKGROUND Upper gastrointestinal bleeding (UGIB) is a significant cause of morbidity and mortality worldwide. This study investigates the use of residual variables and machine learning (ML) models for predicting major bleeding in patients with severe UGIB after their first intensive care unit (ICU) admission. METHODS The Medical Information Mart for Intensive Care IV and eICU databases were used. Conventional ML and long short-term memory models were constructed using pre-ICU and ICU admission day data to predict the recurrence of major gastrointestinal bleeding. In the models, residual data were utilized by subtracting the normal range from the test result. The models included eight algorithms. Shapley additive explanations and saliency maps were used for feature interpretability. RESULTS Twenty-five ML models were developed using data from 2604 patients. The light gradient-boosting machine algorithm model using pre-ICU admission residual data outperformed other models that used test results directly, with an AUC of 0.96. The key factors included aspartate aminotransferase, blood urea nitrogen, albumin, length of ICU admission, and respiratory rate. CONCLUSIONS ML models using residuals improved the accuracy and interpretability in predicting major bleeding during ICU admission in patients with UGIB. These interpretable features may facilitate the early identification and management of high-risk patients, thereby improving hemodynamic stability and outcomes.
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Affiliation(s)
- Fuxing Deng
- Department of Oncology, Xiangya Hospital, Central South University, 410008 Changsha, China.
| | - Yaoyuan Cao
- Department of Forensic Medicine, School of Basic Medical Sciences, Central South University, No 172. Tongzipo Road, 410013 Changsha, Hunan, China
| | - Hui Wang
- School of Automation, Central South University, 410083 Changsha, China
| | - Shuangping Zhao
- Department of Intensive Critical Unit, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, 410008 Changsha, China.
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Fierro-Angulo OM, González-Regueiro JA, Pereira-García A, Ruiz-Margáin A, Solis-Huerta F, Macías-Rodríguez RU. Hematological abnormalities in liver cirrhosis. World J Hepatol 2024; 16:1229-1244. [PMID: 39351511 PMCID: PMC11438588 DOI: 10.4254/wjh.v16.i9.1229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 08/09/2024] [Accepted: 08/22/2024] [Indexed: 09/23/2024] Open
Abstract
Hematological abnormalities are common in cirrhosis and are associated with various pathophysiological mechanisms. Studies have documented a prevalence of thrombocytopenia, leukopenia, and anemia in patients with compensated cirrhosis of 77.9%, 23.5%, and 21.1%, respectively. These abnormalities carry significant clinical implications, including considerations for invasive procedures, infection risk, bleeding risk, and prognosis. Previously, cirrhosis was believed to predispose patients to bleeding due to alterations observed in classical coagulation tests such as prothrombin time, partial thromboplastin time, international normalized ratio, and thrombocytopenia. However, this understanding has evolved, and cirrhosis patients are now also acknowledged as being at a high risk for thrombotic events. Hemostasis in cirrhosis patients presents a complex phenotype, with procoagulant and anticoagulant abnormalities offsetting each other. This multifactorial phenomenon is inadequately reflected by routine laboratory tests. Thrombotic complications are more prevalent in decompensated cirrhosis and may correlate with disease severity. Bleeding is primarily associated with portal hypertension, endothelial dysfunction, mechanical vessel injury, disseminated intravascular coagulation, endotoxemia, and renal injury. This review comprehensively outlines hematologic index abnormalities, mechanisms of hemostasis, coagulation, and fibrinolysis abnormalities, limitations of laboratory testing, and clinical manifestations of bleeding and thrombosis in patients with liver cirrhosis.
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Affiliation(s)
- Oscar Manuel Fierro-Angulo
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico 14080, Mexico
| | - José Alberto González-Regueiro
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico 14080, Mexico
| | - Ariana Pereira-García
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico 14080, Mexico
| | - Astrid Ruiz-Margáin
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico 14080, Mexico
| | - Fernando Solis-Huerta
- Department of Hematology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico 14080, Mexico
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Janko N, Majeed A, Commins I, Gow P, Kemp W, Roberts SK. Rotational thromboelastometry predicts future bleeding events in patients with cirrhosis. Scand J Gastroenterol 2024; 59:1062-1068. [PMID: 39010734 DOI: 10.1080/00365521.2024.2375591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 06/17/2024] [Accepted: 06/27/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND AND AIMS Patients with cirrhosis of the liver are in a delicate state of rebalanced haemostasis and are at risk of developing both bleeding and thrombotic complications. Conventional haemostatic tests are unable to predict bleeding and thrombosis in these patients. We aimed to explore the role of Rotational Thromboelastometry (ROTEM) in predicting bleeding and thrombotic events in patients with cirrhosis. METHODS We conducted a prospective cohort study of patients with cirrhosis at two metropolitan hospitals. All patients underwent ROTEM analysis and were then followed to record any bleeding and thrombotic events. Univariate and multivariate logistic regression analyses were performed to explore associations with bleeding and thrombotic events. RESULTS Nineteen of the 162 patients recruited experienced a bleeding event within one year of ROTEM analysis. On univariate analysis, maximum clot firmness (MCF) using both EXTEM and INTEM tests was significantly reduced in patients who had a bleeding event, compared to those who did not (50 mm vs. 57 mm, p < 0.01 and 48 mm vs. 54 mm, p < 0.01, respectively). In addition, on univariate analysis, clotting time (CT) in the INTEM test was prolonged in the bleeding group (214 s vs. 198 s, p = 0.01). On multivariate analysis, only MCFEX was a significant predictor of bleeding events. In contrast, there was no association found between ROTEM parameters and development of thrombosis within a one-year period. CONCLUSIONS ROTEM may provide a useful tool in predicting future bleeding events in patients with cirrhosis. Larger studies are required to further validate this finding and explore its application in clinical practice.
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Affiliation(s)
- Natasha Janko
- Department of Gastroenterology, Alfred Health, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - Ammar Majeed
- Department of Gastroenterology, Alfred Health, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - Isabella Commins
- Department of Gastroenterology, Alfred Health, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - Paul Gow
- Victorian Liver Transplant Unit, Austin Health, Heidelberg, Australia
- Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, Australia
| | - William Kemp
- Department of Gastroenterology, Alfred Health, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - Stuart K Roberts
- Department of Gastroenterology, Alfred Health, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
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Fernández J, Blasi A, Hidalgo E, Karvellas CJ. Bridging the critically ill patient with acute to chronic liver failure to liver transplantation. Am J Transplant 2024; 24:1348-1361. [PMID: 38548058 DOI: 10.1016/j.ajt.2024.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/16/2024] [Accepted: 03/18/2024] [Indexed: 04/14/2024]
Abstract
Liver transplantation (LT) has emerged as an effective therapy for severe forms of acute-on-chronic liver failure (ACLF), an entity characterized by the development of multiorgan failure and high short-term mortality. The aim of critical care management of ACLF patients is to rapidly treat precipitating events and aggressively support failing organs to ensure that patients may successfully undergo LT or, less frequently, recover. Malnutrition and sarcopenia are frequently present, adversely impacting the prognosis of these patients. Management of critical care patients with ACLF is complex and requires the participation of different specialties. Once the patient is stabilized, a rapid evaluation for salvage LT should be performed because the time window for LT is often narrow. The development of sepsis and prolonged organ support may preclude LT or diminish its chances of success. The current review describes strategies to bridge severe ACLF patients to LT, highlights the minimal evaluation required for listing and the currently suggested contraindications to proceed with LT, and addresses different aspects of management during the perioperative and early posttransplant period.
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Affiliation(s)
- Javier Fernández
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain; EF Clif, EASL-CLIF Consortium, Barcelona, Spain.
| | - Annabel Blasi
- Anesthesiology Department, Hospital Clínic, and University of Barcelona, Spain
| | - Ernest Hidalgo
- Hepatolobiliary Surgery Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Constantine J Karvellas
- Department of Critical Care Medicine, University of Alberta, Edmonton, Canada; Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada
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Balaceanu LA, Dina I. D-dimers in advanced liver cirrhosis: Useful biomarker or not? Am J Med Sci 2024:S0002-9629(24)01264-3. [PMID: 38788925 DOI: 10.1016/j.amjms.2024.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 02/03/2024] [Accepted: 05/20/2024] [Indexed: 05/26/2024]
Abstract
In clinical practice, the d-dimer levels rule out venous thromboembolism and diagnose disseminated intravascular coagulation. d-dimers increase in both physiological and pathological conditions. Liver cirrhosis, especially in the final stages, is characterized by complex coagulation and fibrinolysis factor disorders. Multiple mechanisms tried to explain the increased d-dimer levels in patients with liver cirrhosis and ascites. The d-dimer cut-off level used to rule out venous thromboembolism in cirrhosis is higher than that used to confirm the diagnosis of VTE or DIC in noncirrhotic patients. The cut-off d-dimer level used for the prognosis of thrombotic events is not standardized in advanced liver cirrhosis. Thus, it is necessary to update the clinical guidelines regarding the usefulness of d-dimer testing in advanced liver cirrhosis and the cut-off d-dimer levels, which should vary based on the detection method.
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Affiliation(s)
- Lavinia Alice Balaceanu
- Internal Medicine Department, "Carol Davila" University of Medicine and Pharmacy, Emergency Clinical Hospital "Sf. Ioan," Bucharest, Romania.
| | - Ion Dina
- Gastroenterology Department, "Carol Davila" University of Medicine and Pharmacy, Emergency Clinical Hospital "Sf. Ioan," Bucharest, Romania
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Aggarwal A, Biswas S, Arora U, Vaishnav M, Shenoy A, Swaroop S, Agarwal A, Elhence A, Kumar R, Goel A, Shalimar. Definitions, Etiologies, and Outcomes of Acute on Chronic Liver Failure: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00425-7. [PMID: 38750869 DOI: 10.1016/j.cgh.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 04/02/2024] [Accepted: 04/02/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND & AIMS Acute-on-chronic liver failure (ACLF) is a major public health concern. We aimed to assess the definitions, etiologic spectrum, organ failure (OF), and outcomes of ACLF globally. METHODS Three databases were searched for studies on ACLF from 1990 until September 2022. Information regarding definitions, acute precipitants, underlying chronic liver disease (CLD), OF, and mortality were extracted. Meta-analyses were performed for pooled prevalence rates (95% confidence interval [CI]) using random-effects model for each definition of ACLF. RESULTS Of the 11,451 studies identified, 114 articles (142 cohorts encompassing 210,239 patients) met the eligibility criteria. Most studies (53.2%) used the European Association for the Study of the Liver (EASL) definition, followed by Asia-Pacific Association for the Study of the Liver (APASL) (33.3%). Systemic infection was the major acute precipitant, and alcohol use was the major cause of CLD in EASL-defined studies, whereas alcohol was both the major acute precipitant and cause of CLD in APASL-defined studies. Liver failure was the major OF in APASL-based studies, whereas renal failure was predominant in EASL-based studies. Thirty-day mortality varied across definitions: APASL: 38.9%, 95% CI, 31.2%-46.9%; EASL: 47.9%, 95% CI, 42.2%-53.5%; and NACSELD: 52.2%, 95% CI, 51.9%-52.5%. Diagnostic overlap between definitions ranged from 7.7% to 80.2%. Meta-regression suggested that the World Health Organization region influenced 30-day mortality in studies using EASL definition. CONCLUSIONS Heterogeneity in the definition of ACLF proposed by different expert societies and regional preferences in its use result in differences in clinical phenotype and outcomes. A uniform definition would enhance the comparability and interpretation of global data.
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Affiliation(s)
- Arnav Aggarwal
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Sagnik Biswas
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Umang Arora
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Manas Vaishnav
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Abhishek Shenoy
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Shekhar Swaroop
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Ayush Agarwal
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Anshuman Elhence
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Amit Goel
- Department of Hepatology, Sanjay Gandhi Institute of Medical Sciences, Lucknow, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India.
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8
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Xu M, Chen Y, Artru F. Acute decompensation of cirrhosis versus acute-on-chronic liver failure: What are the clinical implications? United European Gastroenterol J 2024; 12:194-202. [PMID: 38376886 PMCID: PMC10954432 DOI: 10.1002/ueg2.12538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 12/20/2023] [Indexed: 02/21/2024] Open
Abstract
It is essential to identify the subgroup of patients who experience poorer outcomes in order to adapt clinical management effectively. In the context of liver disease, the earlier the identification occurs, the greater the range of therapeutic options that can be offered to patients. In the past, patients with acute decompensation (AD) of chronic liver disease were treated as a homogeneous group, with emphasis on identifying those at the highest risk of death. In the last 15 years, a differentiation has emerged between acute-on-chronic liver failure syndrome (ACLF) and AD, primarily due to indications that the latter is linked to a less favorable short-term prognosis. Nevertheless, the definition of ACLF varies among the different knowledge societies, making it challenging to assess its true impact compared with AD. Therefore, the purpose of this review is to provide a detailed analysis emphasizing the critical importance of identifying ACLF in the field of advanced liver disease. We will discuss the differences between Eastern and Western approaches, particularly in relation to the occurrence of liver failure and disease onset. Common characteristics, such as the dynamic nature of the disease course, will be highlighted. Finally, we will focus on two key clinical implications arising from these considerations: the prevention of ACLF before its onset and the clinical management strategies once it develops, including liver transplantation and withdrawal of care.
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Affiliation(s)
- Manman Xu
- Fourth Department of Liver Disease (Difficult & Complicated Liver Diseases and Artificial Liver Center), Beijing You'an Hospital Affiliated to Capital, Medical University, Beijing, China
- Beijing Municipal Key Laboratory of Liver Failure and Artificial Liver Treatment Research, Beijing, China
| | - Yu Chen
- Fourth Department of Liver Disease (Difficult & Complicated Liver Diseases and Artificial Liver Center), Beijing You'an Hospital Affiliated to Capital, Medical University, Beijing, China
- Beijing Municipal Key Laboratory of Liver Failure and Artificial Liver Treatment Research, Beijing, China
| | - Florent Artru
- Institute of Liver Studies, King's College Hospital, London, UK
- Liver Disease Department, Rennes University Hospital, Rennes, France
- Rennes University and Inserm NuMeCan UMR 1317, Rennes, France
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Saner FH, Raptis DA, Alghamdi SA, Malagó MM, Broering DC, Bezinover D. Navigating the Labyrinth: Intensive Care Challenges for Patients with Acute-on-Chronic Liver Failure. J Clin Med 2024; 13:506. [PMID: 38256640 PMCID: PMC10816826 DOI: 10.3390/jcm13020506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/07/2024] [Accepted: 01/14/2024] [Indexed: 01/24/2024] Open
Abstract
Acute-on-chronic liver failure (ACLF) refers to the deterioration of liver function in individuals who already have chronic liver disease. In the setting of ACLF, liver damage leads to the failure of other organs and is associated with increased short-term mortality. Optimal medical management of patients with ACLF requires implementing complex treatment strategies, often in an intensive care unit (ICU). Failure of organs other than the liver distinguishes ACLF from other critical illnesses. Although there is growing evidence supporting the current approach to ACLF management, the mortality associated with this condition remains unacceptably high. In this review, we discuss considerations for ICU care of patients with ACLF and highlight areas for further research.
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Affiliation(s)
- Fuat H. Saner
- Organ Transplant Center of Excellence, King Faisal Specialized Hospital & Research Center, Riyadh 12111, Saudi Arabia; (D.A.R.); (S.A.A.); (M.M.M.); (D.C.B.)
| | - Dimitri A. Raptis
- Organ Transplant Center of Excellence, King Faisal Specialized Hospital & Research Center, Riyadh 12111, Saudi Arabia; (D.A.R.); (S.A.A.); (M.M.M.); (D.C.B.)
| | - Saad A. Alghamdi
- Organ Transplant Center of Excellence, King Faisal Specialized Hospital & Research Center, Riyadh 12111, Saudi Arabia; (D.A.R.); (S.A.A.); (M.M.M.); (D.C.B.)
| | - Massimo M. Malagó
- Organ Transplant Center of Excellence, King Faisal Specialized Hospital & Research Center, Riyadh 12111, Saudi Arabia; (D.A.R.); (S.A.A.); (M.M.M.); (D.C.B.)
| | - Dieter C. Broering
- Organ Transplant Center of Excellence, King Faisal Specialized Hospital & Research Center, Riyadh 12111, Saudi Arabia; (D.A.R.); (S.A.A.); (M.M.M.); (D.C.B.)
| | - Dmitri Bezinover
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA;
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10
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Aiza-Haddad I, Cisneros-Garza LE, Morales-Gutiérrez O, Malé-Velázquez R, Rizo-Robles MT, Alvarado-Reyes R, Barrientos-Quintanilla LA, Betancourt-Sánchez F, Cerda-Reyes E, Contreras-Omaña R, Dehesa-Violante MB, Flores-García NC, Gómez-Almaguer D, Higuera-de la Tijera MF, Lira-Pedrin MA, Lira-Vera JE, Manzano-Cortés H, Meléndez-Mena DE, Muñoz-Ramírez MR, Pérez-Hernández JL, Ramos-Gómez MV, Sánchez-Ávila JF. Guidelines for the management of coagulation disorders in patients with cirrhosis. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2024; 89:144-162. [PMID: 38600006 DOI: 10.1016/j.rgmxen.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 08/07/2023] [Indexed: 04/12/2024]
Abstract
Coagulation management in the patient with cirrhosis has undergone a significant transformation since the beginning of this century, with the concept of a rebalancing between procoagulant and anticoagulant factors. The paradigm that patients with cirrhosis have a greater bleeding tendency has changed, as a result of this rebalancing. In addition, it has brought to light the presence of complications related to thrombotic events in this group of patients. These guidelines detail aspects related to pathophysiologic mechanisms that intervene in the maintenance of hemostasis in the patient with cirrhosis, the relevance of portal hypertension, mechanical factors for the development of bleeding, modifications in the hepatic synthesis of coagulation factors, and the changes in the reticuloendothelial system in acute hepatic decompensation and acute-on-chronic liver failure. They address new aspects related to the hemorrhagic complications in patients with cirrhosis, considering the risk for bleeding during diagnostic or therapeutic procedures, as well as the usefulness of different tools for diagnosing coagulation and recommendations on the pharmacologic treatment and blood-product transfusion in the context of hemorrhage. These guidelines also update the knowledge regarding hypercoagulability in the patient with cirrhosis, as well as the efficacy and safety of treatment with the different anticoagulation regimens. Lastly, they provide recommendations on coagulation management in the context of acute-on-chronic liver failure, acute liver decompensation, and specific aspects related to the patient undergoing liver transplantation.
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Affiliation(s)
- I Aiza-Haddad
- Clínica de Enfermedades Hepáticas, Hospital Ángeles Lomas, Mexico City, Mexico.
| | - L E Cisneros-Garza
- Departamento de Gastroenterología y Hepatología, Hospital Christus Muguerza Alta Especialidad, Monterrey, Mexico
| | - O Morales-Gutiérrez
- Departamento de Gastroenterología y Hepatología, Hospital General de México «Dr. Eduardo Liceaga», Mexico City, Mexico
| | | | - M T Rizo-Robles
- Departamento de Gastroenterología y Hepatología, Instituto Mexicano del Seguro Social Centro Médico Nacional «La Raza», Mexico City, Mexico
| | - R Alvarado-Reyes
- Departamento de Hepatología, Hospital San José Tec Salud, Monterrey, Mexico
| | | | | | - E Cerda-Reyes
- Servicio de Gastroenterología, Hospital Central Militar, Mexico City, Mexico
| | - R Contreras-Omaña
- Centro de Investigación en Enfermedades Hepáticas y Gastroenterología (CIEHG) Pachuca, Hidalgo, México
| | | | - N C Flores-García
- Escuela de Medicina y Ciencias de la Salud. Tecnológico de Monterrey, Monterrey Nuevo Leon, México
| | | | - M F Higuera-de la Tijera
- Departamento de Gastroenterología y Hepatología, Hospital General de México «Dr. Eduardo Liceaga», Mexico City, Mexico
| | - M A Lira-Pedrin
- Departamento de Gastroenterología, Endoscopía Digestiva, Motilidad y Hepatología, Centro Médico Corporativo Galeana, Tijuana, México
| | - J E Lira-Vera
- Departamento de Gastroenterología y Hepatología, Hospital General de México «Dr. Eduardo Liceaga», Mexico City, Mexico
| | | | - D E Meléndez-Mena
- Hospital General de Especialidades «Maximino Ávila Camacho», IMSS, UMAE, Puebla, México
| | - M R Muñoz-Ramírez
- Departamento de Hepatología, Hospital San José Tec Salud, Monterrey, Mexico
| | - J L Pérez-Hernández
- Departamento de Gastroenterología y Hepatología, Hospital General de México «Dr. Eduardo Liceaga», Mexico City, Mexico
| | - M V Ramos-Gómez
- Departamento Hepatología, ISSSTE, Centro Médico Nacional «20 de noviembre», Ciudad de México, México
| | - J F Sánchez-Ávila
- Escuela de Medicina y Ciencias de la Salud. Tecnológico de Monterrey, Monterrey Nuevo Leon, México
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11
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Vandyck KB, Rusin W, Mondal S, Tanaka KA. Coagulation management during liver transplantation: monitoring and decision making for hemostatic interventions. Curr Opin Organ Transplant 2023; 28:404-411. [PMID: 37728052 DOI: 10.1097/mot.0000000000001101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
PURPOSE OF REVIEW Rebalanced hemostasis describes the precarious balance of procoagulant and antithrombotic proteins in patients with severe liver failure. This review is aimed to discuss currently available coagulation monitoring tests and pertinent decision-making process for plasma coagulation factor replacements during liver transplantation (LT). RECENT FINDINGS Contemporary viscoelastic coagulation monitoring systems have demonstrated advantages over conventional coagulation tests in assessing the patient's coagulation status and tailoring hemostatic interventions. There is increasing interest in the use of prothrombin complex and fibrinogen concentrates, but it remains to be proven if purified factor concentrates are more efficacious and safer than allogeneic hemostatic components. Furthermore, the decision to use antifibrinolytic therapy necessitates careful considerations given the risks of venous thromboembolism in severe liver failure. SUMMARY Perioperative hemostatic management and thromboprophylaxis for LT patients is likely to be more precise and patient-specific through a better understanding and monitoring of rebalanced coagulation. Further research is needed to refine the application of these tools and develop more standardized protocols for coagulation management in LT.
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Affiliation(s)
- Kofi B Vandyck
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Walter Rusin
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Samhati Mondal
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Driever EG, Muntz I, Patel V, Adelmeijer J, Bernal W, Koenderink GH, Lisman T. Fibrin clots from patients with acute-on-chronic liver failure are weaker than those from healthy individuals and patients with sepsis without underlying liver disease. J Thromb Haemost 2023; 21:2747-2758. [PMID: 37336436 DOI: 10.1016/j.jtha.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/09/2023] [Accepted: 06/04/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Previous studies identified decreased clot permeability, without differences in fibrin fiber density in clots, from patients with cirrhosis compared with those from healthy controls (HCs). Fibrinogen hypersialylation could be the reason for this discrepancy. OBJECTIVES The aim of this work was to study mechanical properties of clots and reassess clot permeability in relation to hypersialylation in patients with stable cirrhosis, acute decompensation, and acute-on-chronic liver failure (ACLF). Sepsis patients without liver disease were included to distinguish between liver-specific and inflammation-driven phenotypes. METHODS Pooled plasma was used for rheology and permeability experiments. Permeability was assessed with compression using a rheometer and by liquid permeation. Purified fibrinogen treated with neuraminidase was used to study the effects of fibrinogen hypersialylation on liquid permeation. RESULTS Mechanical properties of clots from patients with stable cirrhosis and acute decompensation were similar to those of clots from HCs, but clots from patients with ACLF were softer and ruptured at lower shear stress. Clots from sepsis patients without liver disease were stiffer than those from the other groups, but this effect disappeared after adjusting for increased plasma fibrinogen concentrations. Permeability was similar between clots under compression from HCs and clots under compression from patients but decreased with increasing disease severity in liquid permeation. Removal of fibrinogen sialic acid residues increased permeability more in patients than in controls. CONCLUSION Clots from patients with ACLF have weak mechanical properties despite unaltered fibrin fiber density. Previous liquid permeation experiments may have erroneously concluded that clots from patients with ACLF are prothrombotic as fibrinogen hypersialylation leads to underestimation of clot permeability in this setting, presumably due to enhanced water retention.
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Affiliation(s)
- Ellen G Driever
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Iain Muntz
- Department of Bionanoscience, Kavli Institute of Nanoscience, Delft University of Technology, Delft, the Netherlands
| | - Vishal Patel
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Jelle Adelmeijer
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - William Bernal
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Gijsje H Koenderink
- Department of Bionanoscience, Kavli Institute of Nanoscience, Delft University of Technology, Delft, the Netherlands.
| | - Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
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13
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Hvas CL, Larsen JB. The Fibrinolytic System and Its Measurement: History, Current Uses and Future Directions for Diagnosis and Treatment. Int J Mol Sci 2023; 24:14179. [PMID: 37762481 PMCID: PMC10532028 DOI: 10.3390/ijms241814179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/13/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
The fibrinolytic system is a key player in keeping the haemostatic balance, and changes in fibrinolytic capacity can lead to both bleeding-related and thrombosis-related disorders. Our knowledge of the fibrinolytic system has expanded immensely during the last 75 years. From the first successful use of thrombolysis in myocardial infarction in the 1960s, thrombolytic therapy is now widely implemented and has reformed treatment in vascular medicine, especially ischemic stroke, while antifibrinolytic agents are used routinely in the prevention and treatment of major bleeding worldwide. Despite this, this research field still holds unanswered questions. Accurate and timely laboratory diagnosis of disturbed fibrinolysis in the clinical setting remains a challenge. Furthermore, despite growing evidence that hypofibrinolysis plays a central role in, e.g., sepsis-related coagulopathy, coronary artery disease, and venous thromboembolism, there is currently no approved treatment of hypofibrinolysis in these settings. The present review provides an overview of the fibrinolytic system and history of its discovery; measurement methods; clinical relevance of the fibrinolytic system in diagnosis and treatment; and points to future directions for research.
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Affiliation(s)
- Christine Lodberg Hvas
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, 8200 Aarhus N, Denmark;
- Department of Clinical Medicine, Faculty of Health Sciences, Aarhus University, 8200 Aarhus N, Denmark
| | - Julie Brogaard Larsen
- Department of Clinical Medicine, Faculty of Health Sciences, Aarhus University, 8200 Aarhus N, Denmark
- Department of Clinical Biochemistry, Regional Hospital Horsens, 8700 Horsens, Denmark
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14
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张 雪, 陈 思, 郭 军, 张 中, 胡 海, 杨 家, 康 焰. [Application Value of Novel Coagulation Markers in Predicting Postoperarative Complications in the Early Stage After Liver Transplantation]. SICHUAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF SICHUAN UNIVERSITY. MEDICAL SCIENCE EDITION 2023; 54:1024-1029. [PMID: 37866963 PMCID: PMC10579085 DOI: 10.12182/20230960105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Indexed: 10/24/2023]
Abstract
Objective To investigate the relationship between thrombin-antithrombin complex (TAT), plasmin-α 2-plasmininhibitor complex (PIC), soluble thrombomodulin (sTM), and tissue plasminogen activator-inhibitor complex (tPAIC) and postoperative complications in the early stage after liver transplantation (LT). Methods We analyzed the perioperative clinical data, including plasma TAT, PIC, sTM, and tPAIC, of 130 post-LT patients admitted to the intensive care unit (ICU), West China Hospital, Sichuan University between December 2021 and November 2022. Patients were divided into two groups, a complication group and a non-complication group, according to whether they experienced complications of Clavien-Dindo (CD) grade Ⅲb and above within 30 days after the surgery. Univariate analysis and binary multivariate logistic regression models were used to determine the risk factors for complications within 30 days post-LT. Results The incidence of complications of CD grade Ⅲb and above within 30 days post-LT was 33.1% (43/130). Patients in the complication group had significantly higher scores for the Model for End-Stage Liver Disease (MELD), operative time, intraoperative red blood cell transfusion volume, intraoperative plasma transfusion volume, and plasma TAT, PIC, sTM and tPAIC measured at the time of admission to ICU after the operation than those in the non-complication group did (all P<0.05). Logistic regression showed that for every single U of red blood cells transfused during the transplant surgery, the probabilities of complications within 30 days post-LT increased by 15.1% (95% confidence interval [ C I]: 1.070-1.239, P<0.001) and for the increase of every single TU/mL of plasma sTM measured upon post-LT admission to ICU, the probabilities of complications increased by 13.7% (95% CI: 1.060-1.220, P<0.001). Conclusion Plasma sTM measured upon admission to ICU after LT is an independent risk factor for complications within 30 days post-LT, and additional assessment of sTM may help predict complications in the early stage post-LT.
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Affiliation(s)
- 雪 张
- 四川大学华西医院 重症医学科 (成都 610041)Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 思敏 陈
- 四川大学华西医院 重症医学科 (成都 610041)Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 军 郭
- 四川大学华西医院 重症医学科 (成都 610041)Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 中伟 张
- 四川大学华西医院 重症医学科 (成都 610041)Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 海 胡
- 四川大学华西医院 重症医学科 (成都 610041)Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 家印 杨
- 四川大学华西医院 重症医学科 (成都 610041)Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 焰 康
- 四川大学华西医院 重症医学科 (成都 610041)Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
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15
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Perricone G, Artzner T, De Martin E, Jalan R, Wendon J, Carbone M. Intensive care management of acute-on-chronic liver failure. Intensive Care Med 2023; 49:903-921. [PMID: 37552333 DOI: 10.1007/s00134-023-07149-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/21/2023] [Indexed: 08/09/2023]
Abstract
Acute-on-chronic liver failure (ACLF) is a clinical syndrome defined by an acute deterioration of the liver function associated with extrahepatic organ failures requiring intensive care support and associated with a high short-term mortality. ACLF has emerged as a major cause of mortality in patients with cirrhosis and chronic liver disease. ACLF has a unique pathophysiology in which systemic inflammation plays a key role; this provides the basis of novel therapies, several of which are now in clinical trials. Intensive care unit (ICU) therapy parallels that applied in the general ICU population in some organ failures but has peculiar differential characteristics in others. Critical care management strategies and the option of liver transplantation (LT) should be balanced with futility considerations in those with a poor prognosis. Nowadays, LT is the only life-saving treatment that can radically improve the long-term prognosis of patients with ACLF. This narrative review will provide insights on the current understanding of ACLF with emphasis on intensive care management.
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Affiliation(s)
- Giovanni Perricone
- Hepatology and Gastroenterology Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.
| | - Thierry Artzner
- Hôpitaux Universitaires de Strasbourg, 67000, Strasbourg, France
| | - Eleonora De Martin
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Inserm UMR-S 1193, Université Paris-Saclay, Villejuif, France
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Julia Wendon
- Liver Intensive Therapy Unit, Division of Inflammation Biology, King's College London, London, UK
| | - Marco Carbone
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- European Reference Network On Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
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16
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Amer K, Flikshteyn B, Lingiah V, Tafesh Z, Pyrsopoulos NT. Mechanisms of Disease and Multisystemic Involvement. Clin Liver Dis 2023; 27:563-579. [PMID: 37380283 DOI: 10.1016/j.cld.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Affiliation(s)
- Kamal Amer
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers University, 185 South Orange Avenue, MSB H Room - 538, Newark, NJ 07101-1709, USA
| | - Ben Flikshteyn
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers University, 185 South Orange Avenue, MSB H Room - 538, Newark, NJ 07101-1709, USA
| | - Vivek Lingiah
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers University, 185 South Orange Avenue, MSB H Room - 538, Newark, NJ 07101-1709, USA
| | - Zaid Tafesh
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers University, 185 South Orange Avenue, MSB H Room - 53, Newark, NJ 07101-1709, USA
| | - Nikolaos T Pyrsopoulos
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers University, 185 South Orange Avenue, MSB H Room - 536, Newark, NJ 07101-1709, USA.
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17
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Scheinberg AR, Martin P, Bhamidimarri KR. The Clinical Spectrum and Manifestations of Acute-on-Chronic Liver Failure. Clin Liver Dis 2023; 27:671-680. [PMID: 37380290 DOI: 10.1016/j.cld.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
Acute-on-chronic liver failure (ACLF) is characterized by abrupt decompensation in a patient with chronic liver disease with extrahepatic organ dysfunction and is implicated in an increased risk of mortality. ACLF may be present in approximately 20% to 40% of hospitalized cirrhosis. There are several diagnostic scoring systems for ACLF; one defined by the North American Consortium for Study of End-stage Liver Disease is the presence of acutely decompensated cirrhosis complicated by failure of two or more organ systems: circulatory, renal, neurological, coagulopathy, and/or pulmonary.
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Affiliation(s)
- Andrew R Scheinberg
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, 1120 Northwest 14th Street, Miami, FL 33136, USA
| | - Paul Martin
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, 1120 Northwest 14th Street, Miami, FL 33136, USA.
| | - Kalyan Ram Bhamidimarri
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, 1120 Northwest 14th Street, Miami, FL 33136, USA
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18
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Moore HB. Fibrinolysis Shutdown and Hypofibrinolysis Are Not Synonymous Terms: The Clinical Significance of Differentiating Low Fibrinolytic States. Semin Thromb Hemost 2023; 49:433-443. [PMID: 36318960 PMCID: PMC10366941 DOI: 10.1055/s-0042-1758057] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Low fibrinolytic activity has been associated with pathologic thrombosis and multiple-organ failure. Low fibrinolytic activity has two commonly associated terms, hypofibrinolysis and fibrinolysis shutdown. Hypofibrinolysis is a chronic state of lack of ability to generate an appropriate fibrinolytic response when anticipated. Fibrinolysis shutdown is the shutdown of fibrinolysis after systemic activation of the fibrinolytic system. There has been interchanging of these terms to describe critically ill patients in multiple settings. This is problematic in understanding the pathophysiology of disease processes related to these conditions. There is also a lack of research on the cellular mediators of these processes. The purpose of this article is to review the on and off mechanisms of fibrinolysis in the context of low fibrinolytic states to define the importance in differentiating hypofibrinolysis from fibrinolysis shutdown. In many clinical scenarios, the etiology of a low fibrinolytic state cannot be determined due to ambiguity if a preceding fibrinolytic activation event occurred. In this scenario, the term "low fibrinolytic activity" or "fibrinolysis resistance" is a more appropriate descriptor, rather than using assumptive of hypofibrinolysis and fibrinolysis shutdown, particularly in the acute setting of infection, injury, and surgery.
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Affiliation(s)
- Hunter B. Moore
- Division of Transplant Surgery, Department of Surgery, University of Colorado Denver, Aurora, Colorado Semin Thromb Hemost
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19
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Lisman T. Bleeding and Thrombosis in Patients With Cirrhosis: What's New? Hemasphere 2023; 7:e886. [PMID: 37234821 PMCID: PMC10208707 DOI: 10.1097/hs9.0000000000000886] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 04/04/2023] [Indexed: 05/28/2023] Open
Affiliation(s)
- Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, The Netherlands
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20
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Reverter E, Toapanta D, Bassegoda O, Zapatero J, Fernandez J. Critical Care Management of Acute-on-Chronic Liver Failure: Certainties and Unknowns. Semin Liver Dis 2023; 43:206-217. [PMID: 37369227 DOI: 10.1055/s-0043-1769907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
Intensive care unit (ICU) admission is frequently required in patients with decompensated cirrhosis for organ support. This entity, known as acute-on-chronic liver failure (ACLF), is associated with high short-term mortality. ICU management of ACLF is complex, as these patients are prone to develop new organ failures and infectious or bleeding complications. Poor nutritional status, lack of effective liver support systems, and shortage of liver donors are also factors that contribute to increase their mortality. ICU therapy parallels that applied in the general ICU population in some complications but has differential characteristics in others. This review describes the current knowledge on critical care management of patients with ACLF including organ support, prognostic assessment, early liver transplantation, and futility rules. Certainties and knowledge gaps in this area are also discussed.
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Affiliation(s)
- Enric Reverter
- Liver ICU, Liver Unit, Hospital Clinic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - David Toapanta
- Liver ICU, Liver Unit, Hospital Clinic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Octavi Bassegoda
- Liver ICU, Liver Unit, Hospital Clinic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Juliana Zapatero
- Liver ICU, Liver Unit, Hospital Clinic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Javier Fernandez
- Liver ICU, Liver Unit, Hospital Clinic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
- European Foundation for the Study of Chronic Liver Failure, EASL-CLIF, Consortium, Barcelona, Spain
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21
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Ker K, Mansukhani R, Shakur-Still H, Arribas M, Beaumont D, Roberts I. Tranexamic acid for gastrointestinal bleeding: can a reduction in the risk of death be discounted? A systematic review and meta-analysis of individual patient data from 64 724 bleeding patients. BMJ Open 2023; 13:e059982. [PMID: 36813490 PMCID: PMC9950890 DOI: 10.1136/bmjopen-2021-059982] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/30/2023] [Indexed: 02/24/2023] Open
Abstract
OBJECTIVES HALT-IT was an international, randomised trial which assessed the effects of tranexamic acid (TXA) in 12 009 patients with gastrointestinal (GI) bleeding. The results found no evidence that TXA reduces death. It is widely accepted that results of trials should be interpreted in the context of other relevant evidence. We conducted a systematic review and individual patient data (IPD) meta-analysis to assess if the results of HALT-IT are compatible with evidence for TXA in other bleeding conditions. DESIGN Systematic review and IPD meta-analysis of randomised trials involving ≥5000 patients assessing TXA for bleeding. We searched our Antifibrinolytics Trials Register on 1 November 2022. Two authors extracted data and assessed risk of bias. DATA SYNTHESIS We used a one-stage model to analyse IPD in a regression model stratified by trial. We assessed heterogeneity of the effect of TXA on death within 24 hours and vascular occlusive events (VOEs). RESULTS We included IPD for 64 724 patients from four trials involving patients with traumatic, obstetric and GI bleeding. Risk of bias was low. There was no evidence for heterogeneity between trials for the effect of TXA on death or for the effect of TXA on VOEs. TXA reduced the odds of death by 16% (OR=0.84, 95% CI: 0.78 to 0.91, p<0.0001; p-heterogeneity=0.40). In patients treated within 3 hours of bleeding onset, TXA reduced the odds of death by 20% (0.80, 0.73 to 0.88, p<0.0001; p-heterogeneity=0.16). TXA did not increase the odds of VOEs (0.94, 0.81 to 1.08, p for effect=0.36; p-heterogeneity=0.27). CONCLUSIONS There is no evidence for statistical heterogeneity between trials assessing the effect of TXA on death or VOEs in different bleeding conditions. When the HALT-IT results are considered in the context of other evidence, a reduction in the risk of death cannot be discounted. TRIAL REGISTRATION NUMBER PROSPERO CRD42019128260.Cite Now.
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Affiliation(s)
- Katharine Ker
- Global Health Trials Group, Clinical Trials Unit, LSHTM, London, UK
| | - Raoul Mansukhani
- Global Health Trials Group, Clinical Trials Unit, LSHTM, London, UK
| | | | - Monica Arribas
- Global Health Trials Group, Clinical Trials Unit, LSHTM, London, UK
| | | | - Ian Roberts
- Global Health Trials Group, Clinical Trials Unit, LSHTM, London, UK
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22
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Zanetto A, Pelizzaro F, Campello E, Bulato C, Balcar L, Gu W, Gavasso S, Saggiorato G, Zeuzem S, Russo FP, Mandorfer M, Reiberger T, Trebicka J, Burra P, Simioni P, Senzolo M. Severity of systemic inflammation is the main predictor of ACLF and bleeding in individuals with acutely decompensated cirrhosis. J Hepatol 2023; 78:301-311. [PMID: 36150575 DOI: 10.1016/j.jhep.2022.09.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 09/02/2022] [Accepted: 09/06/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND & AIMS Hypercoagulability and hypofibrinolysis in acutely decompensated cirrhosis (AD) may be implicated in disease progression and haemostatic complications. We conducted a prospective study to: (1) characterise haemostatic alterations in AD; (2) evaluate whether such alterations can predict acute-on-chronic liver failure (ACLF) and bleeding/thrombosis. METHODS Hospitalised individuals with AD were prospectively recruited and underwent an extensive haemostatic profiling including coagulation factors, thrombomodulin-modified thrombin generation assay with evaluation of endogenous thrombin potential (ETP; marker for plasmatic hypercoagulability), fibrinolytic factors, and plasmin-antiplasmin complex (fibrinolysis activation marker). Inflammation severity was assessed by C-reactive protein (CRP). In part 1 of the study, we compared haemostasis in AD vs. controls (stable decompensated and compensated cirrhosis). In part 2 of the study, we prospectively followed individuals with AD for 1 year and investigated predictors of ACLF and bleeding/thrombosis. RESULTS A total of 169 individuals with AD were recruited (median model for end-stage liver disease score 20; CLIF-C AD 54). Compared with controls, AD was associated with more pronounced hypercoagulability (ETP: 871 vs. 750 vs. 605 nmol/L per min; p <0.0001), without differences in fibrinolysis activation. During follow-up, 55 individuals developed ACLF. CLIF-C AD, CRP, and Child-Pugh were independently associated with ACLF. A predictive model combining these variables (Padua model) accurately identified individuals at higher risk of ACLF (AUROC 0.857; 95% CI 0.798-0.915; sensitivity 74.5%, specificity 83.3%). Notably, CRP and progression to ACLF, but not baseline coagulopathy, were associated with bleeding (n = 11); CRP and antifibrinolytic factor PAI-1 >50 ng/ml were associated with thrombosis (n = 14). The prognostic value of the Padua model was validated in an independent, bicentric European cohort (N = 301). CONCLUSIONS Inflammation severity, and not coagulopathy, is the most important predictor of ACLF and bleeding in AD. The Padua model can be used to identify individuals with AD at risk of ACLF. IMPACT AND IMPLICATIONS A better understanding of haemostasis in individuals with acutely decompensated cirrhosis may help to identify those at higher risk of progression and complications. In this prospective study, we found no significant association between alterations of haemostasis and cirrhosis progression, indicating that the assessment of haemostatic alterations is not useful to identify those at risk. However, we found that C-reactive protein (a simple blood test that reflects severity of inflammation) and severity of chronic liver disease itself (as assessed by specific scores) were associated with cirrhosis progression and development of bleeding complications. Therefore, we developed a simple predictive model - based on C-reactive protein and liver disease scores - that, if validated by independent studies, could be used in clinical practice to assist physicians in identifying individuals with decompensated cirrhosis at higher risk of disease progression and death (i.e. in whom to consider an expedited evaluation for liver transplantation).
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Affiliation(s)
- Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale - Università Padova, Padova, Italy; Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Filippo Pelizzaro
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale - Università Padova, Padova, Italy; Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Elena Campello
- General Internal Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padova University Hospital, Padova, Italy
| | - Cristiana Bulato
- General Internal Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padova University Hospital, Padova, Italy
| | - Lorenz Balcar
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Wenyi Gu
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany; Department of Internal Medicine B, University Clinic Münster and Westfalen Wilhelms University, Münster, Germany
| | - Sabrina Gavasso
- General Internal Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padova University Hospital, Padova, Italy
| | - Graziella Saggiorato
- General Internal Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padova University Hospital, Padova, Italy
| | - Stefan Zeuzem
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Francesco Paolo Russo
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale - Università Padova, Padova, Italy; Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Mattias Mandorfer
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Jonel Trebicka
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany; Department of Internal Medicine B, University Clinic Münster and Westfalen Wilhelms University, Münster, Germany; European Foundation for Study of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | - Patrizia Burra
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale - Università Padova, Padova, Italy; Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Paolo Simioni
- General Internal Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padova University Hospital, Padova, Italy.
| | - Marco Senzolo
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale - Università Padova, Padova, Italy; Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy.
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23
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Zanetto A, Northup P, Roberts L, Senzolo M. Haemostasis in cirrhosis: Understanding destabilising factors during acute decompensation. J Hepatol 2023; 78:1037-1047. [PMID: 36708812 DOI: 10.1016/j.jhep.2023.01.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 01/03/2023] [Accepted: 01/17/2023] [Indexed: 01/27/2023]
Abstract
Hospitalised patients with decompensated cirrhosis are in a rebalanced haemostatic state due to a parallel decline in both pro- and anti-haemostatic pathways. However, this rebalanced haemostatic state is highly susceptible to perturbations and may easily tilt towards hypocoagulability and bleeding. Acute kidney injury, bacterial infections and sepsis, and progression from acute decompensation to acute-on-chronic liver failure are associated with additional alterations of specific haemostatic pathways and a higher risk of bleeding. Unfortunately, there is no single laboratory method that can accurately stratify an individual patient's bleeding risk and guide pre-procedural prophylaxis. A better understanding of haemostatic alterations during acute illness would lead to more rational and individualised management of hospitalised patients with decompensated cirrhosis. This review will outline the latest findings on haemostatic alterations driven by acute kidney injury, bacterial infections/sepsis, and acute-on-chronic liver failure in these difficult-to-treat patients and provide evidence supporting more tailored management of bleeding risk.
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Affiliation(s)
- Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale - Università Padova, Padova, Italy; Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Patrick Northup
- Division of Gastroenterology and Hepatology, NYU Grossman School of Medicine, NYU Transplant Institute, New York, NY, USA
| | - Lara Roberts
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital, London, UK
| | - Marco Senzolo
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale - Università Padova, Padova, Italy; Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy.
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24
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Driever EG, Lisman T. Fibrin clot properties and thrombus composition in cirrhosis. Res Pract Thromb Haemost 2023; 7:100055. [PMID: 36798901 PMCID: PMC9925609 DOI: 10.1016/j.rpth.2023.100055] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/28/2022] [Accepted: 11/30/2022] [Indexed: 01/21/2023] Open
Abstract
Patients with cirrhosis frequently acquire profound hemostatic alterations, which may affect thrombus quality and composition-factors that determine the susceptibility to embolization and fibrinolysis. In this narrative review, we describe in vitro studies on fibrin clot formation and quantitative and qualitative changes in fibrinogen in patients with cirrhosis, and describe recent findings on the composition of portal vein thrombi in patients with cirrhosis. Patients with mild cirrhosis have increased thrombin generation capacity and plasma fibrinogen levels, which may be balanced by delayed fibrin polymerization and decreased factor XIII levels. With progressing illness, plasma fibrinogen levels decrease, but thrombin generation capacity remains elevated. Fibrinogen is susceptible to posttranslational protein modifications and is, for example, hypersialylated and carbonylated in patients with cirrhosis. Despite changes in thrombin generation, factor XIII levels and the fibrinogen molecule, fibrin fiber thickness, and density are normal in patients with cirrhosis. Paradoxically, fibrin clot permeability in patients with cirrhosis is decreased, possibly because of posttranslational protein modifications. Most patients have normal fibrinolytic potential. We have recently demonstrated that portal vein thrombosis is likely a misnomer as the material that may obstruct the cirrhotic portal vein frequently consists of a thickened portal vein wall, rather than a true thrombus. Patients with cirrhosis often have thrombocytopenia and anemia, which may also affect clot stability and composition, but the role of cellular components in clot quality in cirrhosis has not been extensively studied. Finally, we summarize abstracts on fibrin formation and clot quality that were presented at the ISTH 2022 meeting in London.
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Affiliation(s)
| | - Ton Lisman
- Correspondence Ton Lisman, University Medical Center Groningen, Department of Surgery, BA33, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
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25
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Larsen JB, Hvas CL, Hvas AM. Modified Rotational Thromboelastometry Protocol Using Tissue Plasminogen Activator for Detection of Hypofibrinolysis and Hyperfibrinolysis. Methods Mol Biol 2023; 2663:763-773. [PMID: 37204751 DOI: 10.1007/978-1-0716-3175-1_51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Viscoelastic testing includes thromboelastography (TEG®) and thromboelastometry (ROTEM®) and is widely used in bleeding patients to detect hypocoagulability and guide transfusion therapy. However, the ability of standard viscoelastic tests to assess fibrinolytic capacity is limited. We here describe a modified ROTEM® protocol with addition of tissue plasminogen activator that can be used to identify hypofibrinolysis or hyperfibrinolysis.
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Affiliation(s)
- Julie Brogaard Larsen
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Christine Lodberg Hvas
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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26
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Calvo A, Torrente MA, Görlinger K, Fernandez J, Reverter E, Vidal J, Tassies D, Colmenero J, Blasi A, Reverter JC. Haemostasis patterns in patients with acute-on-chronic liver failure and acute decompensation of cirrhosis including thromboelastometric tests with and without the addition of Protac: a pilot study. Thromb J 2022; 20:75. [PMID: 36510196 PMCID: PMC9744590 DOI: 10.1186/s12959-022-00438-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Thromboelastometry is considered the best method to assesses hemostasis in liver disease. Diagnostic performance could be improved by adding protein C activators such as thrombomodulin or Protac®. We assessed changes in ROTEM parameters after the addition of Protac® in patients with acute-on-chronic liver failure (ACLF), acute decompensation (AD), and healthy individuals (HI) to define different hemostasis patterns, considering standard and velocity ROTEM parameters, and assess whether Protac® can improve the definition of the pattern. METHODS Pre-test, we investigated whether diluted EXTEM reagent improved the effect of Protac® on the clotting time (CT)-ratio with and without Protac®. Ten ACLF and 20 AD patients and 21 HI were included in the main study. RESULTS Standard EXTEM was used in the main study. INTEM CFT, INTEM A5 (inverse), and INTEM TPI (inverse) were the parameters that best differentiated liver disease from HI (ROC AUC, 0.921, 0.906, and 0.928, respectively; all P-values < 0.001). Combining INTEM CFT with EXTEM LI60-ratio only slightly improved the diagnostic performance (ROC AUC, 0.948; P < 0.001). EXTEM LI60 and INTEM maxV-t were the parameters that best differentiated between ACLF and AD patients (ROC AUC, 0.743, P = 0.033; and 0.723, P = 0.050; respectively). Combining EXTEM LI60 + INTEM maxV-t moderately improved the diagnostic performance (ROC AUC, 0.81, P < 0.001). CONCLUSIONS ROTEM velocity, fibrinolysis parameters and the indices calculated improve the diagnosis in combination with standard parameters (e.g., CFT and A5). Ratios calculated with and without Protac® (e.g., EXTEM LI60-ratio) only slightly increased the diagnostic performance in discriminating hemostasis patterns.
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Affiliation(s)
- Andrea Calvo
- grid.5841.80000 0004 1937 0247Anaesthesiology and Critical Care Department, Hospital Clínic, Institute d’Investigacions Biomédica AgustPi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Miguel Angel Torrente
- grid.410458.c0000 0000 9635 9413Haematology Department, Hospital Clínic and University of Barcelona, Barcelona, Spain
| | - Klaus Görlinger
- grid.5718.b0000 0001 2187 5445Department of Anaesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany ,Medical Department, Tem Innovations GmbH, Munich, Germany
| | - Javier Fernandez
- grid.410458.c0000 0000 9635 9413Institut d’Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) Y Ciber de Enfermedades Hepáticas Y Digestivas (CIBEREHD), Liver Unit, Institut de Malalties Digestives I Metabòliques, Hospital Clínic and University of Barcelona, Barcelona, Spain
| | - Enric Reverter
- grid.410458.c0000 0000 9635 9413Institut d’Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) Y Ciber de Enfermedades Hepáticas Y Digestivas (CIBEREHD), Liver Unit, Institut de Malalties Digestives I Metabòliques, Hospital Clínic and University of Barcelona, Barcelona, Spain
| | - Julia Vidal
- grid.410458.c0000 0000 9635 9413Anaesthesiology Department, Hospital Clínic, Barcelona, Spain
| | - Dolors Tassies
- grid.410458.c0000 0000 9635 9413Haematology Department, Hospital Clínic and University of Barcelona, Barcelona, Spain
| | - Jordi Colmenero
- grid.410458.c0000 0000 9635 9413Institut d’Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) Y Ciber de Enfermedades Hepáticas Y Digestivas (CIBEREHD), Liver Unit, Institut de Malalties Digestives I Metabòliques, Hospital Clínic and University of Barcelona, Barcelona, Spain
| | - Annabel Blasi
- grid.10403.360000000091771775Anaesthesiology Department, Hospital Clínic and University of Barcelona, Spain, Institut d’Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) Y Ciber de Enfermedades Hepáticas Y Digestivas (CIBEREHD), 08036 Barcelona, Spain
| | - Juan Carlos Reverter
- grid.410458.c0000 0000 9635 9413Haematology Department, Hospital Clínic and University of Barcelona, Barcelona, Spain
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27
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La Mura V, Bitto N, Tripodi A. Rational hemostatic management in cirrhosis: from old paradigms to new clinical challenges. Expert Rev Hematol 2022; 15:1031-1044. [PMID: 36342412 DOI: 10.1080/17474086.2022.2144217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Patients with cirrhosis are at risk of both thrombotic and hemorrhagic events. Traditional hemostatic tests are inadequate to assess the complex and fragile balance of hemostasis in this setting, especially in advanced stages of disease such as decompensated cirrhosis or acute on chronic liver failure (ACLF). Furthermore, the indiscriminate use of pro-hemostatic agents for prophylaxis and treatment of bleeding episodes is still debated and often contraindicated. Alongside, splanchnic, and peripheral thrombotic events are frequent in this population and require management that involves a careful balance between risks and benefits of antithrombotic therapy. AREAS COVERED This review aims to address the state of the art on the clinical management of the hemostatic balance of cirrhosis in terms of established knowledge and future challenges. EXPERT OPINION The old paradigm of cirrhosis as a naturally anticoagulated condition has been challenged by more sophisticated global tests of hemostasis. Integrating this information in the clinical decision-making is still challenging for physicians and experts in hemostasis.
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Affiliation(s)
- Vincenzo La Mura
- Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Niccolò Bitto
- Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.,Department of Biomedical Sciences for Health, Università degli studi di Milano, Milan, Italy
| | - Armando Tripodi
- Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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28
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Pillai AA, Kriss M, Al‐Adra DP, Chadha RM, Cushing MM, Farsad K, Fortune BE, Hess AS, Lewandowski R, Nadim MK, Nydam T, Sharma P, Karvellas CJ, Intagliata N. Coagulopathy and hemostasis management in patients undergoing liver transplantation: Defining a dynamic spectrum across phases of care. Liver Transpl 2022; 28:1651-1663. [PMID: 35253365 PMCID: PMC9790275 DOI: 10.1002/lt.26451] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 01/10/2023]
Abstract
Patients with acute and chronic liver disease present with a wide range of disease states and severity that may require liver transplantation (LT). Physiologic alterations occur that are dynamic throughout all phases of perioperative care, creating complex management scenarios that necessitate multidisciplinary clinical care. Specifically, alterations in hemostasis in liver disease can be pronounced and evolve with disease progression over time. Recent studies and society guidance address this emerging paradigm and offer recommendations to assist with hemostatic management in patients with liver disease. However, patients undergoing LT are unique and diverse, often with unstable disease that requires specialized approaches. Our aim is to provide a focused review of hemostatic management of the LT patient, distinguish unique aspects of the three main phases of care (before LT, perioperative, and after LT), and identify knowledge gaps and critical areas of future research.
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Affiliation(s)
- Anjana A. Pillai
- Department of MedicineUniversity of Chicago MedicineChicagoIllinoisUSA
| | - Michael Kriss
- Department of Internal MedicineUniversity of ColoradoAuroraColoradoUSA
| | - David P. Al‐Adra
- Department of SurgerySchool of Medicine and Public HealthUniversity of WisconsinMadisonWisconsinUSA
| | - Ryan M. Chadha
- Department of Anesthesiology and Perioperative MedicineMayo ClinicJacksonvilleFloridaUSA
| | - Melissa M. Cushing
- Department of Pathology and Laboratory MedicineWeill Cornell MedicineNew YorkNew YorkUSA
| | - Khashayar Farsad
- Department of Interventional RadiologyOregon Health & Science UniversityPortlandOregonUSA
| | | | - Aaron S. Hess
- Department of AnesthesiologyUniversity of WisconsinMadisonWisconsinUSA,Department of Pathology & Laboratory MedicineUniversity of WisconsinMadisonWisconsinUSA
| | | | - Mitra K. Nadim
- Department of MedicineUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Trevor Nydam
- Department of SurgeryUniversity of ColoradoAuroraColoradoUSA
| | - Pratima Sharma
- Department of MedicineUniversity of MichiganAnn ArborMichiganUSA
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29
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Wiggins BT, Ramirez D, Taylor D, Reichardt W, Kipke A, Minaudo M. Medication-Induced Factor V Inhibition in the Setting of Refractory Coagulopathy. Hematol Rep 2022; 14:290-293. [PMID: 36278518 PMCID: PMC9590024 DOI: 10.3390/hematolrep14040041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 07/27/2022] [Accepted: 08/29/2022] [Indexed: 11/25/2022] Open
Abstract
Liver cirrhosis is commonly associated with coagulopathies, typically demonstrated by elevated prothrombin time, international normalized ratio, and partial thromboplastin time. In the setting of bleeding related to coagulopathies, oftentimes physicians try to reverse coagulopathy through a variety of methods including the use of vitamin K and fresh frozen plasma. Rarely, attempts at reversing coagulopathy are unsuccessful due to severe disease or factor inhibitors. The treatment of acquired factor V inhibitors is primarily performed through immunosuppression and supportive care for the initial bleeding episode. Early detection and treatment of factor V inhibition is challenging in a setting of underlying cirrhosis-related coagulopathy.
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Affiliation(s)
- Brandon Travis Wiggins
- Department of Internal Medicine, Ascension Genesys Hospital, Grand Blanc, MI 48439, USA
- Correspondence:
| | - Daniel Ramirez
- Division of Gastroenterology, Department of Internal Medicine, Ascension Genesys Hospital, Grand Blanc, MI 48439, USA
| | - Daniel Taylor
- Division of Hematology and Oncology, Department of Internal Medicine, Ascension Genesys Hospital, Grand Blanc, MI 48439, USA
| | - William Reichardt
- Division of Hematology and Oncology, Department of Internal Medicine, Ascension Genesys Hospital, Grand Blanc, MI 48439, USA
| | - Alyssa Kipke
- Division of Hematology and Oncology, Department of Internal Medicine, Ascension Genesys Hospital, Grand Blanc, MI 48439, USA
| | - Mark Minaudo
- Division of Gastroenterology, Department of Internal Medicine, Ascension Genesys Hospital, Grand Blanc, MI 48439, USA
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30
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Jiang X, Chai S, Huang Y, Huang Z, Tan W, Gao Y, Lu X, Meng Z, Zhou H, Kong W, Tang X, Tang Y, Qi T, Liao C, Gan Q, Xiang X, Zhang Y, Wang S, Chen Y, Chen J. Design for a Multicentre Prospective Cohort for the Assessment of Platelet Function in Patients with Hepatitis-B-Virus-Related Acute-on-Chronic Liver Failure. Clin Epidemiol 2022; 14:997-1011. [PMID: 36042872 PMCID: PMC9420418 DOI: 10.2147/clep.s376068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 08/15/2022] [Indexed: 11/23/2022] Open
Abstract
Background Acute-on-chronic liver failure (ACLF) has high short-term mortality and lacks sufficient medical therapy. Available algorithms are unable to precisely predict short-term outcomes or safely stratify patients with ACLF as emergent liver transplantation candidates. Therefore, a personalized prognostic tool is urgently needed. Purpose Platelet function and its clinical significance in ACLF patients with chronic hepatitis B virus (HBV) infection have not been investigated. This study aimed to assess changes in platelet function using thromboelastography (TEG) and platelet mapping (TEG-PM) in HBV-related ACLF patients. Methods Chronic liver disease patients with acute decompensation or acute hepatic injury were recruited. The derivation cohort enrolled HBV-related patients at Nanfang Hospital. HBV-related and non-HBV-related patients were both enrolled in internal and external validation cohorts at seven university hospitals. TEG and TEG-PM were performed at baseline in the derivation cohort and baseline, day 7, and day 14 in the validation cohorts. The primary outcome was all-cause 28-day mortality. Status check and new-onset complications were recorded during the 3-month follow-up, but status check will extend to 5 years. Conclusion and Future Plans In this study, 586 participants were enrolled, including 100 in derivation cohort, 133 in internal validation cohort, and 353 in external validation cohort. Biomaterials, including plasma, serum, urine, and some explanted liver tissues, were collected from these patients. A 3-month follow-up with survival status was completed. The baseline characteristics indicated that 51% of the patients had adenosine diphosphate (ADP)-hyporesponsive circulating platelets. The prognostic potential of platelet function will be explored in the derivation cohort (HBV-related ACLF patients) and further substantiated in the validation cohorts (HBV-related and non-HBV-related ACLF patients). Biosamples are currently used to explore the underlying mechanisms related to ADP-hyporesponsive platelets. The ongoing proteomic and metabolic analyses will provide new insights into the pathogenesis of extrahepatic organ failures in ACLF patients.
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Affiliation(s)
- Xiuhua Jiang
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Shiqi Chai
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Yan Huang
- Department of Infectious Diseases, Hunan Key Laboratory of Viral Hepatitis, Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Zuxiong Huang
- Department of Hepatology, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, People's Republic of China
| | - Wenting Tan
- Department of Infectious Diseases, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
| | - Yanhang Gao
- Department of Hepatology, the First Hospital of Jilin University, Changchun, People's Republic of China
| | - Xiaobo Lu
- Infectious Disease Center, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, People's Republic of China
| | - Zhongji Meng
- Department of Infectious Diseases, Hubei Clinical Research Center for Precise Diagnosis and Treatment of Liver Cancer, Taihe Hospital, Hubei University of Medicine, Shiyan, People's Republic of China
| | - Huayou Zhou
- Department of Blood Transfusion, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Wenbing Kong
- Department of Blood Transfusion, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Xiaoting Tang
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Yujun Tang
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Tingting Qi
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Chengjin Liao
- Department of Infectious Diseases, Hunan Key Laboratory of Viral Hepatitis, Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Qiaorong Gan
- Department of Hepatology, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, People's Republic of China
| | - Xiaomei Xiang
- Department of Infectious Diseases, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
| | - Yanan Zhang
- Department of Hepatology, the First Hospital of Jilin University, Changchun, People's Republic of China
| | - Shuai Wang
- Infectious Disease Center, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, People's Republic of China
| | - Yuanyuan Chen
- Department of Infectious Diseases, Hubei Clinical Research Center for Precise Diagnosis and Treatment of Liver Cancer, Taihe Hospital, Hubei University of Medicine, Shiyan, People's Republic of China
| | - Jinjun Chen
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China.,Hepatology Unit, Zengcheng Branch, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China
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31
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Lisman T, Caldwell SH, Intagliata NM. Haemostatic alterations and management of haemostasis in patients with cirrhosis. J Hepatol 2022; 76:1291-1305. [PMID: 35589251 DOI: 10.1016/j.jhep.2021.11.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/31/2021] [Accepted: 11/02/2021] [Indexed: 12/12/2022]
Abstract
Patients with cirrhosis frequently acquire complex changes in their haemostatic system including a decreased platelet count and decreased levels of various haemostatic proteins. Although historically patients with cirrhosis were thought to have a haemostasis-related bleeding tendency, it is now widely accepted that the haemostatic system of patients with cirrhosis remains in balance as a result of simultaneous changes in pro- and anti-haemostatic systems. The concept of rebalanced haemostasis has led to changes in clinical management, although firm evidence from well-designed clinical studies is largely lacking. For example, many invasive procedures in patients with cirrhosis and a prolonged prothrombin time are now performed without prophylaxis with fresh frozen plasma. Conversely, clinicians have become more aware of the need for anti-thrombotic therapy, even in those patients with abnormal routine coagulation tests. This paper will outline recent advances in pathogenesis, prevention and treatment of both bleeding and thrombotic complications in patients with cirrhosis. Among other topics, we will discuss the haemostatic status of acutely ill patients with cirrhosis, the various causes of bleeding in patients with cirrhosis, and how best to prevent or treat bleeding. In addition, we will discuss the hypercoagulable features of patients with cirrhosis, new insights into the pathogenesis of portal vein thrombosis, and how best to prevent or treat thromboses.
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Affiliation(s)
- Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - Stephen H Caldwell
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Coagulation in Liver Disease, University of Virginia Medical Center, Charlottesville VA, United States
| | - Nicolas M Intagliata
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Coagulation in Liver Disease, University of Virginia Medical Center, Charlottesville VA, United States
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32
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Tiede A, Zieger B, Lisman T. Acquired bleeding disorders. Haemophilia 2022; 28 Suppl 4:68-76. [PMID: 35521729 DOI: 10.1111/hae.14548] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/23/2020] [Indexed: 12/19/2022]
Abstract
Acquired bleeding disorders can accompany hematological, neoplastic, autoimmune, cardiovascular or liver diseases, but can sometimes also arise spontaneously. They can manifest as single factor deficiencies or as complex hemostatic abnormalities. This review addresses (a) acquired hemophilia A, an autoimmune disorder characterized by inhibitory autoantibodies against coagulation factor VIII; (b) acquired von Willebrand syndrome in patients with cardiovascular disorders, where shear stress abnormalities result in destruction of von Willebrand factor; and (c) liver function disorders that comprise complex changes in pro- and anti-hemostatic factors, whose clinical implications are often difficult to predict. The article provides an overview on the pathophysiology, diagnostic tests and state-of-the-art treatment strategies.
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Affiliation(s)
- Andreas Tiede
- Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Barbara Zieger
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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33
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EASL Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis. J Hepatol 2022; 76:1151-1184. [PMID: 35300861 DOI: 10.1016/j.jhep.2021.09.003] [Citation(s) in RCA: 122] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 09/13/2021] [Indexed: 12/11/2022]
Abstract
The prevention and management of bleeding and thrombosis in patients with cirrhosis poses several difficult clinical questions. These Clinical Practice Guidelines have been developed to provide practical guidance on debated topics, including current views on haemostasis in liver disease, controversy regarding the need to correct thrombocytopenia and abnormalities in the coagulation system in patients undergoing invasive procedures, and the need for thromboprophylaxis in hospitalised patients with haemostatic abnormalities. Multiple recommendations in this document are based on interventions that the panel feels are not useful, even though widely applied in clinical practice.
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McPhetridge JB, Lynch AM, Webster CRL, McCobb E, de Laforcade AM, O'Toole TE. Pre-operative Hemostatic Status in Dogs Undergoing Splenectomy for Splenic Masses. Front Vet Sci 2022; 9:686225. [PMID: 35548053 PMCID: PMC9083103 DOI: 10.3389/fvets.2022.686225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 03/30/2022] [Indexed: 11/22/2022] Open
Abstract
Portal system thrombosis is a rare but potentially fatal complication of splenectomy in dogs. The mechanism behind development of post-operative portal system thrombosis is unclear but may include alterations of portal blood flow following surgery, acquired hypercoagulability and endothelial dysfunction. The aim of the study was to evaluate hemostatic biomarkers in hemodynamically stable (heart rate <130 beats/min, blood lactate < 2.5 mMol/L) and non-anemic (hematocrit >35%) dogs prior to splenectomy for splenic masses. Our hypothesis was that this population of stable dogs would have pre-existing laboratory evidence of hypercoagulability unrelated to shock, bleeding, anemia, or other pre-operative comorbidities. Pre-operatively, abdominal ultrasonography was performed and blood was collected for platelet enumeration, prothrombin time (PT), activated partial thromboplastin time (aPTT), kaolin-activated thromboelastography (TEG), fibrinogen, von Willebrand factor activity (vWF:Ag), antithrombin and thrombin-antithrombin complex (TAT). Histopathological diagnosis and 30-day survival were recorded. None of the 15 enrolled dogs had pre-operative sonographic evidence of portal system thrombosis. Three of fifteen dogs were thrombocytopenic, three had thrombocytosis, three were hyperfibrinogenemic, one had low vWF:Ag, three had mild prolongations of PT and none had abnormal aPTT. Based on the TEG G value, 13/15 dogs were hypercoagulable (mean ± SD 13.5 ± 5.4 kd/s). Antithrombin deficiency was identified in 9/15 dogs (mean ± SD 68.7 ± 22.7%) with 5/9 having concurrently elevated TAT suggesting active thrombin generation. No dogs developed portal system thrombosis and all achieved 30-day survival. Pre-operative hypercoagulability was recognized commonly but its association with post-operative thrombosis remains undetermined.
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Affiliation(s)
- Jourdan B. McPhetridge
- Department of Clinical Sciences, North Carolina State University, Raleigh, NC, United States
| | - Alex M. Lynch
- Department of Clinical Sciences, North Carolina State University, Raleigh, NC, United States
- *Correspondence: Alex M. Lynch
| | - Cynthia R. L. Webster
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, Grafton, MA, United States
| | - Emily McCobb
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, Grafton, MA, United States
| | - A. M. de Laforcade
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, Grafton, MA, United States
| | - Therese E. O'Toole
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, Grafton, MA, United States
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van den Boom BP, Lisman T. Pathophysiology and management of bleeding and thrombosis in patients with liver disease. Int J Lab Hematol 2022; 44 Suppl 1:79-88. [PMID: 35446468 PMCID: PMC9540811 DOI: 10.1111/ijlh.13856] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 11/27/2022]
Abstract
Patients with liver disease often develop complex changes in their haemostatic system. Frequently observed changes include thrombocytopaenia and altered plasma levels of most of the proteins involved in haemostasis. Although liver disease was historically classified as a haemostasis‐related bleeding disorder, it has now been well established that the antihaemostatic changes that promote bleeding are compensated for by prohaemostatic changes. Conventional coagulation tests however do not accurately reflect these prohaemostatic changes, resulting in an underestimation of haemostatic potential. Novel coagulation tests, such as viscoelastic tests (VETs) and thrombin generation assays (TGAs) better reflect the net result of the haemostatic changes in patients with liver disease, and demonstrate a new, “rebalanced” haemostatic status. Although rebalanced, this haemostatic status is more fragile than in patients without liver disease. Patients with liver disease are therefore not only at risk of bleeding but also at risk of thrombosis. Notably, however, many haemostatic complications in liver disease are not related to the haemostatic failure. It is, therefore, crucial to identify the cause of the bleed or thrombotic complication in order to provide adequate treatment. In this paper, we will elaborate on the haemostatic changes that occur in liver disease, reflect on laboratory and clinical studies over the last few years, and explore the pathophysiologies of bleeding and thrombosis in this specific patient group.
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Affiliation(s)
- Bente P van den Boom
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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36
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[Management of acutely decompensated liver cirrhosis in emergency and critical care medicine]. Anaesthesist 2022; 71:403-412. [PMID: 35357555 DOI: 10.1007/s00101-022-01113-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/25/2021] [Accepted: 07/30/2021] [Indexed: 11/01/2022]
Abstract
Acute decompensation in patients with liver cirrhosis is characterized by the development of ascites, gastrointestinal bleeding, hepatic encephalopathy, or bacterial infection and is often accompanied by further extrahepatic organ dysfunction. Since critically ill patients with decompensated cirrhosis have a high mortality risk, rapid identification and treatment of the triggering event of decompensation (e.g., infection, hemorrhage, drugs) as well as specific measures for the treatment of concomitant extrahepatic organ dysfunctions are essential in order to improve the patient's prognosis and to prevent the development of acute-on-chronic liver failure (ACLF).
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37
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[Standard administration of tranexamic acid for prophylaxis in endoprosthetics: a good idea?]. DER ORTHOPADE 2022; 51:337-338. [PMID: 35258633 DOI: 10.1007/s00132-022-04236-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/03/2022] [Indexed: 10/18/2022]
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Driever EG, Lisman T. Effects of Inflammation on Hemostasis in Acutely Ill Patients with Liver Disease. Semin Thromb Hemost 2022; 48:596-606. [PMID: 35135033 DOI: 10.1055/s-0042-1742438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patients with liver diseases are in a rebalanced state of hemostasis, due to simultaneous decline in pro- and anticoagulant factors. This balance seems to remain even in the sickest patients, but is less stable and might destabilize when patients develop disease complications. Patients with acute decompensation of cirrhosis, acute-on-chronic liver failure, or acute liver failure often develop complications associated with changes in the hemostatic system, such as systemic inflammation. Systemic inflammation causes hemostatic alterations by adhesion and aggregation of platelets, release of von Willebrand factor (VWF), enhanced expression of tissue factor, inhibition of natural anticoagulant pathways, and inhibition of fibrinolysis. Laboratory tests of hemostasis in acutely-ill liver patients may indicate a hypocoagulable state (decreased platelet count, prolongations in prothrombin time and activated partial thromboplastin time, decreased fibrinogen levels) due to decreased synthetic liver capacity or consumption, or a hypercoagulable state (increased VWF levels, hypofibrinolysis in global tests). Whether these changes are clinically relevant and should be corrected with antithrombotic drugs or blood products is incompletely understood. Inflammation and activation of coagulation may cause local ischemia, progression of liver disease, and multiorgan failure. Anti-inflammatory treatment in acutely-ill liver patients may be of potential interest to prevent thrombotic or bleeding complications and halt progression of liver disease.
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Affiliation(s)
- Ellen G Driever
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Blasi A, Patel VC, Spanke ENHE, Adelmeijer J, Stamouli M, Zamalloa A, Corcoran E, Calvo A, Fernandez J, Bernal W, Lisman T. Fibrin clot quality in acutely ill cirrhosis patients: Relation with outcome and improvement with coagulation factor concentrates. Liver Int 2022; 42:435-443. [PMID: 34894081 PMCID: PMC9299765 DOI: 10.1111/liv.15132] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/13/2021] [Accepted: 12/02/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND & AIMS Patients with liver disease may acquire substantial changes in their hemostatic system, which are most pronounced in patients who are critically ill. Changes in the quality of the fibrin clot in critically ill patients have not been studied in detail. Here we assessed markers of fibrin clot quality and effects of coagulation factor concentrates in patients with acutely decompensated (AD) cirrhosis and acute on chronic liver failure (ACLF). METHODS We measured plasma levels of fibrinogen, factor XIII, prothrombin and performed thrombin generation assays in 52 AD patients, 58 ACLF patients and 40 controls. In addition, we examined the effects of coagulation factor concentrates on functional assays of fibrin quality. RESULTS We found increased thrombin generating capacity in both AD and ACLF in comparison with healthy controls. Plasma levels of prothrombin, fibrinogen, and factor XIII were lower in patients compared to controls, appeared lower in ACLF compared to AD patients, and were related to clinical outcomes. Fibrinogen concentrate, but not factor XIII or prothrombin complex concentrate, improved clot quality in vitro. Prothrombin complex concentrate increased the resistance of the clot to break down. CONCLUSIONS We have demonstrated elevated thrombin generation but decreased plasma levels of prothrombin, fibrinogen and FXIII in acutely ill patients with cirrhosis. In addition, we showed that fibrinogen concentrate and PCCs, but not factor XIII concentrate, improve clot properties in patient plasma. Whether there is true clinical benefit from coagulation factor concentrates in prevention or treatment of bleeding requires further study. LAY SUMMARY Patients with liver diseases are at risk of bleeding, but mechanisms involved in this bleeding risk are incompletely understood. We studied components that determine the stability of the blood clot and found that concentrations of certain proteins involved in clot stability are present in low levels in acutely ill patients with liver disease. We furthermore demonstrated that some clinically available drugs improve the stability of blood clots from these patients in a test tube.
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Affiliation(s)
- Annabel Blasi
- Anesthesiology DepartmentHospital Clínic and University of BarcelonaBarcelonaSpain,Institute d'Investigacions Biomèdica Agustí Pi i Sunyer (IDIBAPS)BarcelonaSpain
| | - Vishal C. Patel
- Institute of Liver Studies & TransplantationKing's College HospitalNHS Foundation TrustLondonUK,Liver SciencesSchool of Immunology & Microbial SciencesKing's College LondonUK,Institute of HepatologyFoundation for Liver ResearchLondonUK
| | - Eva N. H. E. Spanke
- Surgical Research LaboratoryDepartment of SurgeryUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Jelle Adelmeijer
- Surgical Research LaboratoryDepartment of SurgeryUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | | | - Ane Zamalloa
- Institute of Liver Studies & TransplantationKing's College HospitalNHS Foundation TrustLondonUK
| | - Eleanor Corcoran
- Department of Critical CareKing's College Hospital NHS Foundation TrustLondonUK
| | - Andrea Calvo
- Anesthesiology DepartmentHospital Clínic and University of BarcelonaBarcelonaSpain,Institute d'Investigacions Biomèdica Agustí Pi i Sunyer (IDIBAPS)BarcelonaSpain
| | - Javier Fernandez
- Liver UnitInstitut de Malalties Digestives i MetabòliquesHospital Clínic and University of BarcelonaBarcelonaSpain
| | - William Bernal
- Institute of Liver Studies & TransplantationKing's College HospitalNHS Foundation TrustLondonUK
| | - Ton Lisman
- Surgical Research LaboratoryDepartment of SurgeryUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands,Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
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Torp N, Israelsen M, Madsen B, Lutz P, Jansen C, Strassburg C, Mortensen C, Knudsen AW, Sorensen GL, Holmskov U, Schlosser A, Thiele M, Trebicka J, Krag A. Corrigendum to 'Level of MFAP4 in ascites independently predicts 1-year transplant-free survival in patients with cirrhosis' [JHEP Reports 3 (2021) 100287]. JHEP Rep 2021; 3:100353. [PMID: 34693237 PMCID: PMC8514409 DOI: 10.1016/j.jhepr.2021.100353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 03/11/2021] [Accepted: 03/18/2021] [Indexed: 11/29/2022] Open
Abstract
Background & Aims Prognostic models of cirrhosis underestimate disease severity for patients with cirrhosis and ascites. Microfibrillar-associated protein 4 (MFAP4) is an extracellular matrix protein linked to hepatic neoangiogenesis and fibrogenesis. We investigated ascites MFAP4 as a predictor of transplant-free survival in patients with cirrhosis and ascites. Methods A dual-centre observational study of patients with cirrhosis and ascites recruited consecutively in relation to a paracentesis was carried out. Patients were followed up for 1 year, until death or liver transplantation (LTx). Ascites MFAP4 was tested with the model for end-stage liver disease (MELD-Na), CLIF Consortium Acute Decompensation (CLIF-C AD), and Child-Pugh score in Cox regression models. Results Ninety-three patients requiring paracentesis were included. Median ascites MFAP4 was 29.7 U/ml [22.3–41.3], and MELD-Na was 19 [16–23]. A low MELD-Na score (<20) was observed in 49 patients (53%). During follow-up, 20 patients died (22%), and 6 received LTx (6%). High ascites MFAP4 (>29.7 U/ml) was associated with 1-year transplant-free survival (p = 0.002). In Cox regression, ascites MFAP4 and MELD-Na independently predicted 1-year transplant-free survival (hazard ratio [HR] = 0.97, p = 0.03, and HR = 1.08, p = 0.01, respectively). Ascites MFAP4 and CLIF-C AD also predicted survival independently (HR = 0.96, p = 0.02, and HR = 1.05, p = 0.03, respectively), whereas only ascites MFAP4 did, controlling for the Child-Pugh score (HR = 0.97, p = 0.03, and HR = 1.18, p = 0.16, respectively). For patients with MELD-Na <20, ascites MFAP4 but not ascites protein predicted 1-year transplant-free survival (HR 0.91, p = 0.02, and HR = 0.94, p = 0.17, respectively). Conclusions Ascites MFAP4 predicts 1-year transplant-free survival in patients with cirrhosis and ascites. In patients with low MELD-Na scores, ascites MFAP4, but not total ascites protein, significantly predicted 1-year transplant-free survival. Lay summary Patients with cirrhosis who have fluid in the abdomen, ascites, are at an increased risk of death and in need for liver transplantation. Our study identified patients with ascites and a poor prognosis by measuring microfibrillar associated protein 4 (MFAP4), a protein present in the abdominal fluid. Patients with low levels of the MFAP4 protein are at particularly increased risk of death or liver transplantation, suggesting that clinical care should be intensified in this group of patients. MFAP4 is a protein linked to liver fibrosis that can be found in the ascitic fluid in patients with cirrhosis. MFAP4 in the ascitic fluid correlates with MELD-Na, Child-Pugh, and CLIF-C AD. Ascites MFAP4 independently predicts 1-year transplant-free survival in patients with cirrhosis and ascites. Ascites MFAP4 but not total ascites protein is associated with transplant-free survival in patients with MELD-Na <20. Future prognostic models in decompensated cirrhosis may be enhanced by the incorporation of ascites MFAP4.
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Key Words
- Biomarker
- CLIF-C AD, CLIF Consortium Acute Decompensation
- CPS, Child-Pugh score
- CRP, C-reactive protein
- CT, computed tomography
- Decompensated
- ECM, extracellular matrix
- Fibrosis
- GFR, glomerular filtration rate
- HR, hazard ratio
- INR, internationalised normal ratio
- LTx, liver transplantation
- Liver disease
- MELD-Na, model for end-stage liver disease
- MFAP4, microfibrillar associated protein 4
- Mortality
- NASH, non-alcoholic steatohepatitis
- Prognosis
- SBP, spontaneous bacterial peritonitis
- eGFR, estimated GFR
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Affiliation(s)
- Nikolaj Torp
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Mads Israelsen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Bjørn Madsen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Philipp Lutz
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - Christian Jansen
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | | | - Christian Mortensen
- Gastro Unit, Medical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - Anne Wilkens Knudsen
- Gastro Unit, Medical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - Grith Lykke Sorensen
- Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Uffe Holmskov
- Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Anders Schlosser
- Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Maja Thiele
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jonel Trebicka
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Internal Medicine I, University Hospital of Frankfurt, Frankfurt, Germany.,European Foundation for the Study of Chronic Liver Failure (EF-CLIF), Barcelona, Spain.,Institute for Bioengineering of Catalonia, Barcelona, Spain
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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Roberts I, Shakur-Still H, Afolabi A, Akere A, Arribas M, Austin E, Bal K, Bazeer N, Beaumont D, Brenner A, Carrington L, Chaudhri R, Coats T, Gilmore I, Halligan K, Hussain I, Jairath V, Javaid K, Kayani A, Lisman T, Mansukhani R, Miners A, Mutti M, Nadeem MA, Pollok R, Prowse D, Simmons J, Stanworth S, Veitch A, Williams J. A high-dose 24-hour tranexamic acid infusion for the treatment of significant gastrointestinal bleeding: HALT-IT RCT. Health Technol Assess 2021; 25:1-86. [PMID: 34663491 DOI: 10.3310/hta25580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Tranexamic acid reduces blood loss in surgery and the risk of death in trauma patients. Meta-analyses of small trials suggest that tranexamic acid decreases the number of deaths from gastrointestinal bleeding, but these meta-analyses are prone to selection bias. OBJECTIVE The trial provides reliable evidence of the effect of tranexamic acid on mortality, rebleeding and complications in significant acute gastrointestinal bleeding. DESIGN A multicentre, randomised, placebo-controlled trial and economic analysis. Patients were assigned by selecting one treatment pack from a box of eight, which were identical apart from the pack number. Patients, caregivers and outcome assessors were masked to allocation. The main analyses were by intention to treat. SETTING The setting was 164 hospitals in 15 countries, co-ordinated from the London School of Hygiene & Tropical Medicine. PARTICIPANTS Adults with significant upper or lower gastrointestinal bleeding (n = 12,009) were eligible if the responsible clinician was substantially uncertain about whether or not to use tranexamic acid. The clinical diagnosis of significant bleeding implied a risk of bleeding to death, including hypotension, tachycardia or signs of shock, or urgent transfusion, endoscopy or surgery. INTERVENTION Tranexamic acid (a 1-g loading dose over 10 minutes, then a 3-g maintenance dose over 24 hours) or matching placebo. MAIN OUTCOME MEASURES The primary outcome was death due to bleeding within 5 days of randomisation. Secondary outcomes were all-cause and cause-specific mortality; rebleeding; need for endoscopy, surgery or radiological intervention; blood product transfusion; complications; disability; and days spent in intensive care or a high-dependency unit. RESULTS A total of 12,009 patients were allocated to receive tranexamic acid (n = 5994, 49.9%) or the matching placebo (n = 6015, 50.1%), of whom 11,952 (99.5%) received the first dose. Death due to bleeding within 5 days of randomisation occurred in 222 (3.7%) patients in the tranexamic acid group and in 226 (3.8%) patients in the placebo group (risk ratio 0.99, 95% confidence interval 0.82 to 1.18). Thromboembolic events occurred in 86 (1.4%) patients in the tranexamic acid group and 72 (1.2%) patients in the placebo group (risk ratio 1.20, 95% confidence interval 0.88 to 1.64). The risk of arterial thromboembolic events (myocardial infarction or stroke) was similar in both groups (0.7% in the tranexamic acid group vs. 0.8% in the placebo group; risk ratio 0.92, 95% confidence interval 0.60 to 1.39), but the risk of venous thromboembolic events (deep-vein thrombosis or pulmonary embolism) was higher in tranexamic acid-treated patients than in placebo-treated patients (0.8% vs. 0.4%; risk ratio 1.85, 95% confidence interval 1.15 to 2.98). Seizures occurred in 38 patients who received tranexamic acid and in 22 patients who received placebo (0.6% vs. 0.4%, respectively; risk ratio 1.73, 95% confidence interval 1.03 to 2.93). In the base-case economic analysis, tranexamic acid was not cost-effective and resulted in slightly poorer health outcomes than no tranexamic acid. CONCLUSIONS Tranexamic acid did not reduce death from gastrointestinal bleeding and, although inexpensive, it is not cost-effective in adults with acute gastrointestinal bleeding. FUTURE WORK These results caution against a uniform approach to the management of patients with major haemorrhage and highlight the need for randomised trials targeted at specific pathophysiological processes. LIMITATIONS Although this is one of the largest randomised trials in gastrointestinal bleeding, we cannot rule out a modest increase or decrease in death due to bleeding with tranexamic acid. TRIAL REGISTRATION Current Controlled Trials ISRCTN11225767, ClinicalTrials.gov NCT01658124 and EudraCT 2012-003192-19. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 58. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Adefemi Afolabi
- Department of Surgery, University College Hospital Ibadan, Ibadan, Nigeria
| | - Adegboyega Akere
- Department of Medicine, University College Hospital Ibadan, Ibadan, Nigeria
| | - Monica Arribas
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Emma Austin
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Kiran Bal
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Nuha Bazeer
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK.,Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Danielle Beaumont
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Amy Brenner
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Laura Carrington
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Rizwana Chaudhri
- Department of Obstetrics and Gynaecology, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Timothy Coats
- Emergency Department, Leicester Royal Infirmary, Leicester, UK
| | - Ian Gilmore
- Liverpool Centre for Alcohol Research, University of Liverpool, Liverpool, UK
| | | | - Irshad Hussain
- Department of Medicine, King Edward Medical University, Mayo Hospital, Lahore, Pakistan
| | - Vipul Jairath
- Division of Gastroenterology, Western University and London Health Sciences Centre, London, ON, Canada
| | - Kiran Javaid
- Rawalpindi Medical University - Pakistan National Coordinating Centre (RMU-PNCC), Rawalpindi, Pakistan
| | - Aasia Kayani
- Rawalpindi Medical University - Pakistan National Coordinating Centre (RMU-PNCC), Rawalpindi, Pakistan
| | - Ton Lisman
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Raoul Mansukhani
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Alec Miners
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Muttiullah Mutti
- Department of Medicine, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Muhammad Arif Nadeem
- Medical Unit III, Services Institute of Medical Sciences, Services Hospital Gastrointestinal, Lahore, Pakistan
| | - Richard Pollok
- Gastroenterology and Hepatology Department, St George's Hospital, London, UK
| | - Danielle Prowse
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Jonathan Simmons
- Gastroenterology Department, Royal Berkshire Hospital, Reading, UK
| | - Simon Stanworth
- Transfusion Medicine, NHS Blood and Transplant (NHSBT), John Radcliffe Hospital, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Andrew Veitch
- Gastroenterology Department, New Cross Hospital, Wolverhampton, UK
| | - Jack Williams
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
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Ow TW, Fatourou E, Rabinowich L, van den Boom BP, Nair S, Patel VC, Hogan B, McPhail M, Roberts LN, Bernal W. Prevalence of bleeding and thrombosis in critically ill patients with chronic liver disease. Thromb Haemost 2021; 122:1006-1016. [PMID: 34638152 DOI: 10.1055/a-1667-7293] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Haemorrhage and venous thromboembolism (VTE) are recognised complications of chronic liver disease (CLD), but their prevalence and risk factors in critically ill patients is uncertain. PATIENTS AND METHODS We studied a retrospective cohort of patients with CLD non-electively admitted to a specialist intensive care unit determining the prevalence and timing of major bleeding and VTE (early, present on admission/diagnosed within 48h; later diagnosed >48h post ICU admission). Associations with baseline clinical and laboratory characteristics, multi-organ failure (MOF), blood product administration and mortality were explored. Odds ratios (OR) and 95% CIs were calculated using logistic regression. RESULTS Of 623 patients with median age 52, bleeding (>48 hours after admission) occurred in 87 (14%) patients. Bleeding was associated with greater illness severity and increased mortality. Gastrointestinal bleeding accounted for 72% of events, secondary to portal hypertension in >90%. Procedure-related bleeding was uncommon. VTE occurred in 125 (20%) patients: Early VTE in 80 (13%) and involving the portal vein (PVT) in 85%. Later VTE affected 45 (7.2%) patients. Hepatocellular Carcinoma (HCC) and non-alcoholic liver disease were independently associated with early VTE (OR 2.79, (95% CI 1.5 -5.2) and 2.32, (1.4 -3.9) respectively), and HCC, sepsis and cryoprecipitate use with late VTE (OR 2.45, (1.11-5.43), 2.26 (1.2-4.3) and 2.60 (1.3-5.1). CONCLUSION VTE was prevalent on admission to critical care and less commonly developed later. Bleeding was associated with MOF and increased mortality. Severe MOF was not associated with an increased rate of VTE which was linked with HCC, and specific etiologies of CLD.
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Affiliation(s)
- Tsai-Wing Ow
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Evangelia Fatourou
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Liane Rabinowich
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Bente Pernille van den Boom
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland.,2. Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Centre Groningen, Groningen, Netherlands
| | - Shirjit Nair
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Vishal C Patel
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland.,School of Immunology and Microbial Sciences, King's College London Faculty of Life Sciences and Medicine, London, United Kingdom of Great Britain and Northern Ireland.,Institute of Hepatology, Foundation for Liver Research, London, United Kingdom of Great Britain and Northern Ireland
| | - Brian Hogan
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Mark McPhail
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland.,School of Immunology and Microbial Sciences, King's College London Faculty of Life Sciences and Medicine, London, United Kingdom of Great Britain and Northern Ireland
| | - Lara N Roberts
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - William Bernal
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland.,School of Immunology and Microbial Sciences, King's College London Faculty of Life Sciences and Medicine, London, United Kingdom of Great Britain and Northern Ireland
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43
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[Management of acutely decompensated liver cirrhosis in emergency and critical care medicine]. Med Klin Intensivmed Notfmed 2021; 117:73-82. [PMID: 34636958 DOI: 10.1007/s00063-021-00876-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/25/2021] [Accepted: 07/30/2021] [Indexed: 10/20/2022]
Abstract
Acute decompensation in patients with liver cirrhosis is characterized by the development of ascites, gastrointestinal bleeding, hepatic encephalopathy, or bacterial infection and is often accompanied by further extrahepatic organ dysfunction. Since critically ill patients with decompensated cirrhosis have a high mortality risk, rapid identification and treatment of the triggering event of decompensation (e.g., infection, hemorrhage, drugs) as well as specific measures for the treatment of concomitant extrahepatic organ dysfunctions are essential in order to improve the patient's prognosis and to prevent the development of acute-on-chronic liver failure (ACLF).
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Campello E, Zanetto A, Bulato C, Maggiolo S, Spiezia L, Russo FP, Gavasso S, Mazzeo P, Tormene D, Burra P, Angeli P, Senzolo M, Simioni P. Coagulopathy is not predictive of bleeding in patients with acute decompensation of cirrhosis and acute-on-chronic liver failure. Liver Int 2021; 41:2455-2466. [PMID: 34219335 PMCID: PMC8518681 DOI: 10.1111/liv.15001] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 06/26/2021] [Accepted: 06/30/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Understanding factors responsible for the increased bleeding tendency in acute-on-chronic liver failure (ACLF) would improve the management of these complications. We investigated coagulation alterations in ACLF and assessed whether they were predictive of bleeding. METHODS Cirrhosis patients with ACLF (cases) and acute decompensation (AD, controls) were prospectively recruited and underwent an extensive haemostatic assessment including standard tests, pro and anticoagulant factors, thrombomodulin-modified thrombin generation (TG) and thromboelastometry (ROTEM® ). In study part 1 (case-control), we compared coagulation in ACLF vs AD. In study part 2 (prospective), all patients were followed for bleeding, and predictors of outcome were assessed. RESULTS Ninety-one patients were included (51 with ACLF, 40 with AD). Infections and ascites/renal dysfunction were the most common precipitating and decompensating events. Platelet count was lower while INR and activated partial thrombin time were longer in ACLF cohort vs AD. Regarding clotting factors, fibrinogen and factor VIII were comparable between groups while protein C and antithrombin were significantly reduced in ACLF. Endogenous thrombin potential by TG was comparable between groups. Clotting formation time and clot stability by ROTEM® were significantly lower in ACLF, indicative of a more hypocoagulable state. No haemostasis alteration could discriminate between patients who had bleeding complications during hospitalization and those who did not. CONCLUSION We found coagulation changes in ACLF to largely overlap with that of AD and evidence of preserved coagulation capacity in both groups. ROTEM alterations were indicative of a more pronounced hypocoagulable state in ACLF; however, no correlation was found between such alterations and bleeding.
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Affiliation(s)
- Elena Campello
- Thrombotic and Hemorrhagic Diseases UnitGeneral Internal MedicinePadova University HospitalPadovaItaly
| | - Alberto Zanetto
- Gastroenterology and Multivisceral Transplant UnitDepartment of Surgery, Oncology, and GastroenterologyPadova University HospitalPadovaItaly
| | - Cristiana Bulato
- Thrombotic and Hemorrhagic Diseases UnitGeneral Internal MedicinePadova University HospitalPadovaItaly
| | - Sara Maggiolo
- Gastroenterology and Multivisceral Transplant UnitDepartment of Surgery, Oncology, and GastroenterologyPadova University HospitalPadovaItaly,Liver Unit, V Chair of Internal MedicineDepartment of MedicinePadova University HospitalPadovaItaly
| | - Luca Spiezia
- Thrombotic and Hemorrhagic Diseases UnitGeneral Internal MedicinePadova University HospitalPadovaItaly
| | - Francesco Paolo Russo
- Gastroenterology and Multivisceral Transplant UnitDepartment of Surgery, Oncology, and GastroenterologyPadova University HospitalPadovaItaly
| | - Sabrina Gavasso
- Thrombotic and Hemorrhagic Diseases UnitGeneral Internal MedicinePadova University HospitalPadovaItaly
| | - Pierluigi Mazzeo
- Thrombotic and Hemorrhagic Diseases UnitGeneral Internal MedicinePadova University HospitalPadovaItaly
| | - Daniela Tormene
- Thrombotic and Hemorrhagic Diseases UnitGeneral Internal MedicinePadova University HospitalPadovaItaly
| | - Patrizia Burra
- Gastroenterology and Multivisceral Transplant UnitDepartment of Surgery, Oncology, and GastroenterologyPadova University HospitalPadovaItaly
| | - Paolo Angeli
- Gastroenterology and Multivisceral Transplant UnitDepartment of Surgery, Oncology, and GastroenterologyPadova University HospitalPadovaItaly,Liver Unit, V Chair of Internal MedicineDepartment of MedicinePadova University HospitalPadovaItaly
| | - Marco Senzolo
- Gastroenterology and Multivisceral Transplant UnitDepartment of Surgery, Oncology, and GastroenterologyPadova University HospitalPadovaItaly
| | - Paolo Simioni
- Thrombotic and Hemorrhagic Diseases UnitGeneral Internal MedicinePadova University HospitalPadovaItaly
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Fibrin Network Formation and Lysis in Septic Shock Patients. Int J Mol Sci 2021; 22:ijms22179540. [PMID: 34502446 PMCID: PMC8431602 DOI: 10.3390/ijms22179540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/13/2021] [Accepted: 08/30/2021] [Indexed: 12/28/2022] Open
Abstract
Background: Septic shock patients are prone to altered fibrinolysis, which contributes to microthrombus formation, organ failure and mortality. However, characterisation of the individual patient’s fibrinolytic capacity remains a challenge due to a lack of global fibrinolysis biomarkers. We aimed to assess fibrinolysis in septic shock patients using a plasma-based fibrin clot formation and lysis (clot–lysis) assay and investigate the association between clot–lysis parameters and other haemostatic markers, organ dysfunction and mortality. Methods: This was a prospective cohort study including adult septic shock patients (n = 34). Clot–lysis was assessed using our plasma-based in-house assay. Platelet count, activated partial thromboplastin time (aPTT), international normalised ratio (INR), fibrinogen, fibrin D-dimer, antithrombin, thrombin generation, circulating fibrinolysis markers and organ dysfunction markers were analysed. Disseminated intravascular coagulation score, Sequential Organ Failure Assessment (SOFA) score and 30-day mortality were registered. Results: Three distinct clot–lysis profiles emerged in the patients: (1) severely decreased fibrin formation (flat clot–lysis curve), (2) normal fibrin formation and lysis and (3) pronounced lysis resistance. Patients with abnormal curves had lower platelet counts (p = 0.05), more prolonged aPTT (p = 0.04), higher lactate (p < 0.01) and a tendency towards higher SOFA scores (p = 0.09) than patients with normal clot–lysis curves. Fibrinogen and fibrin D-dimer were not associated with clot–lysis profile (p ≥ 0.37). Conclusion: Septic shock patients showed distinct and abnormal clot–lysis profiles that were associated with markers of coagulation and organ dysfunction. Our results provide important new insights into sepsis-related fibrinolysis disturbances and support the importance of assessing fibrinolytic capacity in septic shock.
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Lisman T, Procopet B. Fresh frozen plasma in treating acute variceal bleeding: Not effective and likely harmful. Liver Int 2021; 41:1710-1712. [PMID: 34273225 DOI: 10.1111/liv.14988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/04/2021] [Indexed: 12/11/2022]
Affiliation(s)
- Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Bogdan Procopet
- Regional Institute of Gastroenterology and Hepatology "Octavian Fodor", Hepatology Department and "Iuliu Hatieganu" University of Medicine and Pharmacy, 3rd Medical Clinic, Cluj-Napoca, Romania
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47
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Northup PG, Lisman T, Roberts LN. Treatment of bleeding in patients with liver disease. J Thromb Haemost 2021; 19:1644-1652. [PMID: 33974330 PMCID: PMC8362012 DOI: 10.1111/jth.15364] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/16/2021] [Accepted: 05/06/2021] [Indexed: 12/14/2022]
Abstract
Patients with cirrhosis frequently have complex alterations in their hemostatic system. Although routine diagnostic tests of hemostasis in cirrhosis (platelet count, prothrombin time, fibrinogen level) are suggestive of a bleeding tendency, it is now widely accepted that these tests do not reflect hemostatic competence in this population. Rather, patients with cirrhosis appear to have a rebalanced hemostatic system with hypercoagulable elements. Therefore, routine correction of hemostasis laboratory values, for example by fresh frozen plasma or platelet concentrates, with the aim to avoid spontaneous or procedure-related bleeding is not indicated as is outlined in recent clinical guidance documents. However, little guidance on how to manage patients with cirrhosis that are actively bleeding is available. Here we present three common bleeding scenarios, variceal bleeding, post-procedural bleeding and bleeding in a critically ill cirrhosis patient, with specific management suggestions. As patients with cirrhosis generally have adequate hemostatic competence and as bleeding complications may be unrelated to hemostatic failure, prohemostatic therapy is not the first line of management in bleeding patients with cirrhosis, even in the presence of markedly abnormal platelet counts and/or prothrombin times. We provide a rationale for the restrictive approach to prohemostatic therapy in bleeding patients with cirrhosis.
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Affiliation(s)
- Patrick G. Northup
- Center for the Study of Hemostasis and Coagulation in Liver DiseaseDivision of Gastroenterology and HepatologyUniversity of VirginiaCharlottesvilleVAUSA
| | - Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Lara N. Roberts
- Department of Haematological MedicineKing’s Thrombosis CentreKing’s College Hospital National Health Service (NHS) Foundation TrustLondonUK
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48
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Bernal W, Karvellas C, Saliba F, Saner FH, Meersseman P. Intensive care management of acute-on-chronic liver failure. J Hepatol 2021; 75 Suppl 1:S163-S177. [PMID: 34039487 DOI: 10.1016/j.jhep.2020.10.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 02/07/2023]
Abstract
The syndrome of acute-on-chronic liver failure combines deterioration of liver function in a patient with chronic liver disease, with the development of extrahepatic organ failure and high short-term mortality. Its successful management demands a rapid and coherent response to the development of dysfunction and failure of multiple organ systems in an intensive care unit setting. This response recognises the features that distinguish it from other critical illness and addresses the complex interplay between the precipitating insult, the many organ systems involved and the disordered physiology of underlying chronic liver disease. An evidence base is building to support the approaches currently adopted and outcomes for patients with this condition are improving, but mortality remains unacceptably high. Herein, we review practical considerations in critical care management, as well as discussing key knowledge gaps and areas of controversy that require further focussed research.
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Affiliation(s)
- William Bernal
- Liver Intensive Therapy Unit, Institute of Liver Studies, Kings College Hospital, Denmark Hill, London SE5 9RS, United Kingdom.
| | - Constantine Karvellas
- Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine, University of Alberta, 1-40 Zeidler Ledcor Building, Edmonton, Alberta T6G-2X8, Canada
| | - Faouzi Saliba
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris SACLAY, INSERM Unit 1193, Villejuif, France
| | - Fuat H Saner
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum Essen Hufelandstr. 55 45 147, Essen, Germany
| | - Philippe Meersseman
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium
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49
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Relke N, Chornenki NLJ, Sholzberg M. Tranexamic acid evidence and controversies: An illustrated review. Res Pract Thromb Haemost 2021; 5:e12546. [PMID: 34278187 PMCID: PMC8279901 DOI: 10.1002/rth2.12546] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/23/2021] [Accepted: 04/27/2021] [Indexed: 12/23/2022] Open
Abstract
Tranexamic acid (TXA) is an antifibrinolytic agent commonly used for the treatment or prevention of bleeding. Indications for TXA are diverse, including heavy menstrual bleeding, trauma, postpartum hemorrhage, traumatic brain injury, and surgical site bleeding. Despite decades of use and a robust body of evidence, hesitancy using TXA persists in many clinical settings. This illustrated review describes the history, pharmacology, and practical considerations of TXA use. We also describe the major landmark randomized controlled trials of TXA and their implications. Finally, we review the evidence around common controversies surrounding TXA such as the risk of thrombosis, prescription along with combined hormonal contraceptives, and use in patients with gross hematuria.
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Affiliation(s)
- Nicole Relke
- Department of MedicineQueen's UniversityKingstonONCanada
| | | | - Michelle Sholzberg
- Department of MedicineSt. Michael's HospitalUniversity of TorontoTorontoONCanada
- Department of Laboratory Medicine & PathobiologySt. Michael's HospitalUniversity of TorontoTorontoONCanada
- Division of HematologyDepartment of MedicineSt. Michael's HospitalUniversity of TorontoTorontoONCanada
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50
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Pavlick M, DeLaforcade A, Penninck DG, Webster CRL. Evaluation of coagulation parameters in dogs with gallbladder mucoceles. J Vet Intern Med 2021; 35:1763-1772. [PMID: 34196054 PMCID: PMC8295708 DOI: 10.1111/jvim.16203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 06/05/2021] [Accepted: 06/15/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Gallbladder mucocele (GBM) is a common biliary disorder in dogs. Limited information is available on the coagulation status of dogs with GBM. HYPOTHESIS/OBJECTIVES To determine patterns of coagulation alterations in dogs with GBM and correlate them with clinicopathologic abnormalities and ultrasonographic findings of disease severity. ANIMALS Twenty-three dogs with GBM identified on ultrasound examination were prospectively enrolled. METHODS At the time of GBM identification, blood and urine were collected for CBC, serum biochemical panel, urinalysis, prothrombin time, activated partial thromboplastin time (aPTT), factor VIII, protein C (PC), von Willebrand's factor (vWF), antithrombin activity, fibrinogen, D-dimers, and thromboelastrography (TEG). Gallbladder mucoceles were classified into ultrasound types 1 to 5. Medical records were reviewed for clinical presentation, underlying conditions and to determine if systemic inflammatory response syndrome (SIRS) was present. RESULTS Based on TEG parameters, maximal amplitude, and G, 19/23 (83%) of dogs with GBM had evaluations consistent with hypercoagulability. On plasma-based coagulation testing, dogs with GBM had increased total PC activity (20/23, 87%), fibrinogen (9/23, 39%), platelet count (9/23, 39%), and D-dimers (6/15, 40%) as well as prolongations in aPTT (9/22, 41%) and low vWF activity (5/21, 24%). No correlation was found between TEG G value and any coagulation or clinical pathology variables, ultrasound stage of GBM or disease severity as assessed by the presence of SIRS. CONCLUSIONS AND CLINICAL IMPORTANCE Dogs with ultrasonographically identified GBM have changes in whole blood kaolin-activated TEG supporting a hypercoagulable state although traditional plasma-based coagulation testing suggests that a complex state of hemostasis exists.
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Affiliation(s)
- Michelle Pavlick
- Cummings School of Veterinary Medicine at Tufts University, Grafton, Massachusetts, USA
| | - Armelle DeLaforcade
- Cummings School of Veterinary Medicine at Tufts University, Grafton, Massachusetts, USA
| | - Dominique G Penninck
- Cummings School of Veterinary Medicine at Tufts University, Grafton, Massachusetts, USA
| | - Cynthia R L Webster
- Cummings School of Veterinary Medicine at Tufts University, Grafton, Massachusetts, USA
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