Liver stiffness and thrombin generation in compensated cirrhosis

Blood Disorders in Patients with Obstructive Jaundice: A Literature Review

BACKGROUND: Mechanical jaundice is a pathological syndrome consisting in a violation of the outflow of hepatic bile through the bile ducts into the duodenum due to mechanical obstacles. The most common causes of mechanical jaundice are gallstone disease, malignant tumors, as well as cicatricial stricture of the bile duct or the large duodenal papilla of the duodenum. All this leads to the development of renal-hepatic insufficiency. Thrombohemorrhagic changes develop in the vascular bed, leading to the development of disseminated intravascular coagulation syndrome. Prevention and treatment of cholemic bleeding in case of mechanical jaundice remains one of the complex problems of hepatobiliary surgery. This article is an overview of the causes and pathophysiological changes affecting hemostasis in mechanical jaundice, as well as the main points of treatment of hemostasis disorders in patients with mechanical jaundice. AIM: This study aims to study the literature on homeostasis in patients with mechanical jaundice. SEARCH STRATEGY: To conduct a systematic search for scientific information and to achieve this goal, an analysis of scientific publications in evidence-based medicine databases (PubMed), using specialized search engines (Google Scholar) and in electronic scientific libraries (CyberLeninka, e-library) was carried out from 2005 to 2020. INCLUSION CRITERIA: Research of high methodological quality: Meta-analysis, systematic review and cohort studies, as well as publications with clearly formulated and statistically proven conclusions in English, Russian, and Kazakh. EXCLUSION CRITERIA: Summaries of reports, reports in the form of abstracts, and advertising articles. RESULTS: The mechanisms that affect hemostasis in obstructive jaundice can be considered from four perspectives: The first relates to Vitamin K deficiency in obstructive jaundice, the second describes the effect of ongoing fibrosis and cirrhosis of the liver on hemostasis, the third analyzes the relationship between infectious-septic mechanisms and the hemostasis system, their clinical significance in patients with obstructive jaundice, and the latter involves the analysis of specific factors that manifest obstructive jaundice and may themselves affect the blood coagulation system. CONCLUSION: Understanding the pathophysiology of hemostatic changes in patients with cholestasis and, more generally, liver disease is a clear way to accurate diagnosis and treatment. The combination of good knowledge with careful examination of each patient can lead to the most promising result.

Resistance to thrombomodulin correlates with liver stiffness in chronic liver disease a prospective single-center cohort study

INTRODUCTION

Chronic liver disease (CLD) is characterized by changes in haemostasis, embracing both hypo- and hypercoagulability. Global hemostatic tests such as thrombin generation assays evaluate the hemostatic balance, to better assess bleeding and thrombotic risks. In addition, procoagulant state in patients with CLD has been demonstrated using modified thrombin generation assays with thrombomodulin, a cofactor for protein C activation. In this study, we prospectively determined thrombin generation and thrombomodulin resistance in patients with CLD staged with liver stiffness measurement (LSM), using both the fully automated analyzer ST Genesia® Thrombin Generation System (STG) and the calibrated automated thrombogram assay (CAT).

MATERIALS AND METHODS

Demographic, clinical and laboratory characteristics, and blood samples were collected from 65 patients with CLD. Liver stiffness was measured by transient elastography, and thrombin generation and thrombomodulin resistance, by STG and CAT.

RESULTS

Patients were separated based on LSM of <21 and ≥21 kilopascals (kPa). The propagation rate of thrombin generation was higher in patients with LSM ≥21 kPa and the thrombin generation rate increased as LSM increased. In addition, thrombomodulin resistance assessed by STG and CAT was higher in patients with LSM ≥21 kPa. However, ETP inhibition by activated protein C was comparable in patients with LSM <21 and ≥21 kPa. Finally, LSM correlated with most thrombin generation parameters.

CONCLUSION

The STG automated system may have value in the assessment of patients with chronic liver disease in the routine coagulation laboratory. LSM ≥21 kPa identify a procoagulant phenotype in these patients, including thrombomodulin resistance.

Hypercoagulability (thrombin generation) in patients with cirrhosis is detected with ST-Genesia

BACKGROUND

Thrombin generation assays (TGAs) performed with calibrated automated thrombography (CAT) in the presence of thrombomodulin (TM) indicate plasma hypercoagulability in cirrhosis.

OBJECTIVE

To evaluate, in the presence of TM, the new ST-Genesia automated device developed for improving TGA vs the previously used CAT method, with plasma samples of patients with cirrhosis.

PATIENTS/METHODS

Platelet-poor plasma samples were prepared from citrated blood samples of 52 healthy controls and 85 patients with cirrhosis (severity evaluated using the Child-Pugh score [CP]). TGAs were performed using CAT with PPP-Reagent and ST-Genesia with the STG-ThromboScreen reagent, in the presence of TM. Endogenous thrombin potential (ETP) was chosen as the main parameter.

RESULTS

Whatever the method, ETP values were higher in patients than in healthy controls. All patients identified as hypercoagulable with ST-Genesia and STG-ThromboScreen were found hypercoagulable with CAT and PPP-Reagent. Conversely, eight and ten patients in the CP-A and CP-B classes respectively were identified as hypercoagulable only with CAT. The use of ST-Genesia with the STG-ThromboScreen reagent with TM led to a bias, with higher ETP values for healthy controls and lower for patients compared with CAT. Crossover analysis (CAT with the STG-ThromboScreen reagent) evidenced a substantial effect of the STG-ThromboScreen reagent; the analyzer (including calibration and data analysis) plays a lesser role.

CONCLUSION

ST-Genesia evidences hypercoagulability in patients with cirrhosis when TG is studied in the presence of TM, but the results are not interchangeable with those obtained with CAT.