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Guo Q, Lian H, Wang G, Zhang H, Wang X. Prospective Evaluation of the Peripheral Perfusion Index in Assessing the Organ Dysfunction and Prognosis of Adult Patients With Sepsis in the ICU. J Intensive Care Med 2024:8850666241252758. [PMID: 38748544 DOI: 10.1177/08850666241252758] [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: 06/01/2024]
Abstract
Background: The peripheral perfusion index (PI) reflects microcirculatory blood flow perfusion and indicates the severity and prognosis of sepsis. Method: The cohort comprised 208 patients admitted to the intensive care unit (ICU) with infection, among which 117 had sepsis. Demographics, medication history, ICU variables, and laboratory indexes were collected. Primary endpoints were in-hospital mortality and 28-day mortality. Secondary endpoints included organ function variables (coagulation function, liver function, renal function, and myocardial injury), lactate concentration, mechanical ventilation time, and length of ICU stay. Univariate and multivariate analyses were conducted to assess the associations between the PI and clinical outcomes. Sensitivity analyses were performed to explore the associations between the PI and organ functions in the sepsis and nonsepsis groups. Result: The PI was negatively associated with in-hospital mortality (odds ratio [OR] 0.29, 95% confidence interval [CI] 0.15 to 0.55), but was not associated with 28-day mortality. The PI was negatively associated with the coagulation markers prothrombin time (PT) (β -0.36, 95% CI -0.59 to 0.13) and activated partial thromboplastin time (APTT) (β -1.08, 95% CI -1.86 to 0.31), and the myocardial injury marker cardiac troponin I (cTnI) (β -2085.48, 95% CI -3892.35 to 278.61) in univariate analysis, and with the PT (β -0.36, 95% CI -0.60 to 0.13) in multivariate analysis. The PI was negatively associated with the lactate concentration (β -0.57, 95% CI -0.95 to 0.19), mechanical ventilation time (β -23.11, 95% CI -36.54 to 9.69), and length of ICU stay (β -1.28, 95% CI -2.01 to 0.55). Sensitivity analyses showed that the PI was significantly associated with coagulation markers (PT and APTT) and a myocardial injury marker (cTnI) in patients with sepsis, suggesting that the associations between the PI and organ function were stronger in the sepsis group than the nonsepsis group. Conclusion: The PI provides new insights for assessing the disease severity, short-term prognosis, and organ function damage in ICU patients with sepsis, laying a theoretical foundation for future research.
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Affiliation(s)
- Qirui Guo
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Lian
- Department of Health Care, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guangjian Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongmin Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Bajwa RK, Kleb C, Faisal MS, Khan MZ, Khan A, Lyu R, Angelini D, Sims OT, Modaresi Esfeh J. Thromboelastography characteristics in critically ill patients with liver disease. Eur J Gastroenterol Hepatol 2024; 36:190-196. [PMID: 38131425 DOI: 10.1097/meg.0000000000002673] [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: 12/23/2023]
Abstract
OBJECTIVE The purpose of this study was to determine how thromboelastography (TEG) parameters differ by various clinical conditions that commonly occur in patients with cirrhosis, including sepsis, acute on chronic liver failure (ACLF), alcohol-associated hepatitis (AAH) and portal vein thrombosis (PVT). BACKGROUND TEG, a whole blood assay, is used to assess several parameters of coagulation and is becoming increasingly used in clinical practice. STUDY This study was a retrospective chart review of 155 patients admitted to the ICU with decompensated cirrhosis from 2017 to 2019. RESULTS The R time was significantly shorter in patients when they were septic compared to when they were not and longer in patients with vs. without ACLF grade 3. Alpha angle and maximum amplitude was decreased in patients with severe AAH compared to those without severe AAH; and maximum amplitude was increased in patients with acute PVT compared to those with chronic PVT. R time was positively correlated with Chronic Liver Failure Consortium Organ Failure and Chronic Liver Failure Consortium ACLF scores (rho = 0.22, P = 0.020), while alpha angle and maximum amplitude were negatively correlated with MELD-NA. CONCLUSION Findings suggest TEG parameters vary in several clinical conditions in patients with decompensated cirrhosis who are admitted to the ICU. Prospective research is needed to confirm our findings and to determine how this knowledge can be used to guide clinical practice, as well as blood product transfusions in the setting of bleeding or prior to invasive procedures.
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Affiliation(s)
- Ramanpreet K Bajwa
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Cerise Kleb
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Muhammad Salman Faisal
- Department of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan
| | - Muhammad Zarrar Khan
- Department of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan
| | - Afshin Khan
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ruishen Lyu
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation
| | - Dana Angelini
- Department of Hematology, Cleveland Clinic Foundation
| | - Omar T Sims
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jamak Modaresi Esfeh
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Premkumar M, Mehtani R, Kulkarni AV, Duseja AK, De A, Taneja S, Singh V, Verma N, Ahluwalia J, Kajal K, Divyaveer S, Roy A, Gandotra A, Kalson N, Kekan K, Kaur H, Kaur H. Association of Heparin-Like Effect, Factor VII/XIII Deficiency and Fibrinolysis with Rebleeding Risk in Cirrhosis with Acute Variceal Bleeding. Dig Dis Sci 2023; 68:497-513. [PMID: 35984611 PMCID: PMC9389477 DOI: 10.1007/s10620-022-07656-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 07/31/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Hyperfibrinolysis and coagulation dysfunction may occur in cirrhotic patients with acute variceal bleed (AVB) despite successful endotherapy. AIMS To prospectively study the association of endogenous heparinoids and coagulation dysfunction with variceal rebleeding and outcome in cirrhosis. METHODS Consecutive patients were assessed with conventional coagulation tests, SONOCLOT™ [(global(gb) and heparinase(h) treated] and factors VII, VIII, XIII, X, tissue plasminogen activator, and plasminogen activator inhibitor ELISA assays in a university hospital. Heparin-like-effect (HLE) was defined as ≥ 20% difference in paired gb/h-SONOCLOT™ traces for activated clotting time (ACT). RESULTS Of 143 patients screened, 90 (46.4 ± 11.7 years, males 82.2%, ethanol-related 58.8%) were recruited, who bled from esophageal varices (81,90.0%), gastric varices (6,6.6%), or esophageal varices with portal hypertensive gastropathy (3,3.3%). Twenty (21.7%) had early rebleeding, mainly post-variceal ligation ulcer related (70%). Patients who rebled had low Factor XIII [1.6 (1.2-2.1) vs 2.4 ng/ml (2.0-2.8) P = 0.035] and Factor VII (94.1 ± 46.9 vs. 124.0 ± 50.4, P = 0.023). On receiver operating curve analysis, the gbACT > 252 s (sensitivity 86.8%, specificity 76.9%, P < 0.001), hACT > 215 s (sensitivity 71.1%, specificity 70.3%, P < 0.001), and HLE > 50% (sensitivity 69.5%, specificity 70.3%, P = 0.006) predicted rebleeding. Baseline Factor VIII (HR 1.26; 95% CI 1.17-1.34, P < 0.001), low factor VII (HR 0.89; 95% CI 0.76-0.98, P = 0.035), and lysis (HR 1.25, 95% CI 1.17-1.33, P < 0.001) predicted mortality. Endogenous heparinoids at baseline predicted sepsis (HR 1.8; 95% CI 1.4-6.5; P = 0.022), rebleeding events (HR 1.2; 95% CI 1.1-6.3; P = 0.030), and mortality (HR 1.1; 95% CI 1.0-4.6; P = 0.030). CONCLUSIONS Hyperfibrinolysis, Factor VII/XIII deficiency, and HLE are associated with rebleeding after AVB. Trial Registration NCT04111120 available from https://clinicaltrials.gov/ct2/show/NCT04111120 .
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Affiliation(s)
- Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.
| | - Rohit Mehtani
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Ajay Kumar Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Arka De
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Virendra Singh
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Nipun Verma
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Jasmina Ahluwalia
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Kamal Kajal
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Smita Divyaveer
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Akash Roy
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Akash Gandotra
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Narender Kalson
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Kushal Kekan
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Harmanpreet Kaur
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Harpreet Kaur
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
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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: 15] [Impact Index Per Article: 15.0] [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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Premkumar M, Loganathan S, Kajal K, Hazarika A, Soni S, Puri GD, Sehgal IS, Suri V, Malhotra P, Singh V, Duseja A, Bhalla A, Ahluwalia J, Kumar N, Kekan K, Ram S, Singla K, Mahajan V, Yaddanapudi N. COVID-19-related dynamic coagulation disturbances and anticoagulation strategies using conventional D-dimer and point-of-care Sonoclot tests: a prospective cohort study. BMJ Open 2022; 12:e051971. [PMID: 35501097 PMCID: PMC9062462 DOI: 10.1136/bmjopen-2021-051971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES Coagulation changes associated with COVID-19 suggest the presence of a hypercoagulable state with pulmonary microthrombosis and thromboembolic complications. We assessed the dynamic association of COVID-19-related coagulation abnormalities with respiratory failure and mortality. DESIGN Single-centre, prospective cohort study with descriptive analysis and logistic regression. SETTING Tertiary care hospital, North India. PARTICIPANTS Patients with COVID-19 pneumonia requiring intensive care unit (ICU) admission between August 2020 and November 2020. PRIMARY AND SECONDARY OUTCOME MEASURES We compared the coagulation abnormalities using standard coagulation tests like prothrombin time, D-dimer, platelet count, etc and point-of-care global coagulation test, Sonoclot (glass beaded(gb) and heparinase-treated(h)). Incidence of thromboembolic or bleeding events and presence of endogenous heparinoids were assessed. Cox proportional Hazards test was used to assess the predictors of 28-day mortality. MEASUREMENT All patients underwent Sonoclot (glass beaded) test at admission apart from the routine investigations. In patients at risk of thromboembolic or bleeding phenomena, paired tests were performed at day 1 and 3 with Sonoclot. Activated clotting time (ACT) <110 s and peak amplitude >75 units were used as the cut-off for hypercoagulable state. Presence of heparin-like effect (HLE) was defined by a correction of ACT ≥40 s in h-Sonoclot. RESULTS Of 215 patients admitted to ICU, we included 74 treatment naive subjects. A procoagulant profile was seen in 45.5% (n=5), 32.4% (n=11) and 20.7% (n=6) in low-flow, high-flow and invasive ventilation groups. Paired Sonoclot assays in a subgroup of 33 patients demonstrated the presence of HLE in 17 (51.5%) and 20 (62.5%) at day 1 and 3, respectively. HLE (day 1) was noted in 59% of those who bled during the disease course. Mortality was observed only in the invasive ventilation group (16, 55.2%) with overall mortality of 21.6%. HLE predicted the need for mechanical ventilation (HR 1.2 CI 1.04 to 1.4 p=0.00). On multivariate analysis, the presence of HLE (HR 1.01; CI 1.006 to 1.030; p=0.025), increased C reactive protein (HR 1.040; CI 1.020 to 1.090; p=0.014), decreased platelet function (HR 0.901; CI 0.702 to 1.100 p=0.045) predicted mortality at 28days. CONCLUSION HLE contributed to hypocoagulable effect and associated with the need for invasive ventilation and mortality in patients with severe COVID-19 pneumonia. TRIAL REGISTRATION NCT04668404; ClinicalTrials.gov.in. Available from https://clinicaltrials.gov/ct2/show/NCT04668404.
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Affiliation(s)
- Madhumita Premkumar
- Department of Hepatology, Postgraguate Institute of Medical Education and Research, Chandigarh, India
| | - Sekar Loganathan
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kamal Kajal
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amarjyoti Hazarika
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shiv Soni
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Goverdhan Dutt Puri
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Suri
- Deapartment of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Malhotra
- Department of Clinical Haematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Virendra Singh
- Department of Hepatology, Postgraguate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Duseja
- Department of Hepatology, Postgraguate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Bhalla
- Deapartment of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jasmina Ahluwalia
- Department of Haematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Narender Kumar
- Department of Haematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kushal Kekan
- Department of Hepatology, Postgraguate Institute of Medical Education and Research, Chandigarh, India
| | - Sant Ram
- Department of Biochemistry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Karan Singla
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Varun Mahajan
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Narayana Yaddanapudi
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Premkumar M, Kulkarni AV, Kajal K, Divyaveer S. Principles, Interpretation, and Evidence-Based Role of Viscoelastic Point-of-Care Coagulation Assays in Cirrhosis and Liver Failure. J Clin Exp Hepatol 2022; 12:533-543. [PMID: 35535095 PMCID: PMC9077199 DOI: 10.1016/j.jceh.2021.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/02/2021] [Indexed: 12/12/2022] Open
Abstract
Background and Aims Standard coagulation tests such as prothrombin time, activated partial thromboplastin time, and international normalized ratio are determined by liver-synthesized coagulation factors. Despite an increased international normalized ratio, patients with cirrhosis are in a "rebalanced" state of hemostasis as the concomitant effect of reduced protein C, protein S, and thrombomodulin is not evaluated in standard coagulation tests. The cell-based model of hemostasis indicates additional mechanisms such as systemic inflammation, sepsis, and organ failures tip the delicate coagulation balance to an anticoagulant type in acute-on-chronic liver failure. In acute liver failure, thrombin generation and platelet function remain intact despite a marked prolongation in prothrombin time. We aimed to explain the principles, application, and utility of viscoelastic tests such as thromboelastography, rotational thromboelastometry, and Sonoclot. Methods We reviewed the available literature from MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trial with the search terms 'coagulation', 'cirrhosis', 'acute-on-chronic liver failure', 'thromboelastography', 'thromboelastometry' and 'sonoclot' for cross sectional studies, cohort studies and randomized trials. Results The point-of-care viscoelastic tests provide actionable targets for correcting the coagulation defect in a patient with bleeding and provide evidence-based algorithms for use in liver disease. A limitation of these tests is the inability to assess vessel injury and endothelial elements. Conclusion Global coagulation tests provide a comprehensive estimate of coagulation in vitro; however, their use has only been validated in the setting of liver transplantation. Newer guidelines for hemostatic resuscitation are now accepting these POC tests, but additional data are required to validate their use as standard of care.
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Key Words
- ACLF, acute-on-chronic liver failure
- ACT, activated clotting time
- ALF, acute liver failure
- CR, clot rate
- INR, international normalized ratio
- MA, maximum amplitude
- R, reaction time
- ROTEM
- ROTEM, rotational thromboelastometry
- SCT, standard coagulation tests
- TEG, thromboelastography
- VWF, von Willebrand factor
- aPTT, activated partial thromboplastin time
- cirrhosis
- coagulation
- sonoclot
- thromboelastography
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Affiliation(s)
- Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Anand V. Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Kamal Kajal
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Smita Divyaveer
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
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Pazgan-Simon M, Kucharska M, Górka-Dynysiewicz J, Simon K. Impact of SARS CoV-2 /COVID-19 infection on the course of advanced chronic liver disease and hepatocellular carcinoma. Pharmacol Rep 2022; 74:1306-1314. [PMID: 36394820 PMCID: PMC9669525 DOI: 10.1007/s43440-022-00434-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND About 20% of patients infected with SARS-CoV-2 develop COVID-19-the disease that has dominated health care in the last two years. The course of COVID-19 in patients with advanced liver disease tends to be severe, patients also suffer from a higher risk of complications and death. The primary object of this study was to assess the risk and causes of death in patients with cirrhosis and hepatocellular carcinoma (HCC). MATERIALS AND METHODS From a group of 4,314 patients hospitalized at Jerzy Gromkowski Regional Specialist Hospital in Wroclaw (Poland) due to SARS-CoV-2/COVID-19 infection between March 15, 2020, and January 31, 2022, we selected a cohort of 31 patients with liver cirrhosis (12 women and 19 men) and 7 patients with HCC developed on the cirrhotic liver (1 woman, 6 men). The control group included 123 patients without liver disease. In the entire cohort, we analyzed the course of COVID-19 infection, baseline oxygen demand, liver function (assessed using the CTP-Child-Turoctte-Pugh score and MELD-Model of End-Stage Liver Disease scales), length of hospitalization, development of acute-on-chronic liver failure, and deaths. RESULTS The mean age of the patients was 56.6 years in the liver cirrhosis group, 63.3 years for patients with (HCC) hepatocellular carcinoma, and 64 years in the control group. Time of hospitalization averaged 15.52 days and 11.14 days for patients with liver cirrhosis and liver cancer, respectively. For the control group, the average duration of the hospital stay was 11.61 days. With respect to baseline liver function assessed using the CTP score, in the cirrhosis group 10 patients were CTP class A, 19 patients were class B and 9 patients were class C. The cancer group included 3 patients with class A, 2 patients with class B, and 2 patients with class C. In the studied cohort, 22 patients had a baseline MELD score < 12 points, and in 15 patients was > 12. In the HCC group, it was, respectively, CTP A:3, B: 2, C: 2, and MELD < 12: 3, ≥12: 4 people. Most of these patients presented with a progression of liver disease. Fifteen patients died, including 12 with cirrhosis and 3 with HCC, accounting for 39.47% in the entire cohort, 39% in the cirrhotic group and 43% in the HCC group, and 13 in the control group (10.6%), There was a clear statistical difference between the mortality rate in the group with liver disease and in the control group. CONCLUSIONS Infection with SARS-CoV-2/COVID-19 in patients with cirrhosis and HCC tends to have a more severe course and leads to exacerbation of the liver disease. The most common cause of death in the analyzed cohort infected with SARS-CoV-2/COVID-19 was the progression of liver disease, complicated by liver failure.
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Affiliation(s)
- Monika Pazgan-Simon
- I Department of Infectious Diseases, Jerzy Gromkowski Regional Specialist Hospital, ul Koszarowa 5, 51-149 Wrocław, Poland ,grid.4495.c0000 0001 1090 049XDepartment of Infectious Diseases and Hepatology, Wroclaw Medical University, Wrocław, Poland
| | - Marta Kucharska
- I Department of Infectious Diseases, Jerzy Gromkowski Regional Specialist Hospital, ul Koszarowa 5, 51-149 Wrocław, Poland ,grid.4495.c0000 0001 1090 049XDepartment of Infectious Diseases and Hepatology, Wroclaw Medical University, Wrocław, Poland
| | - Joanna Górka-Dynysiewicz
- grid.4495.c0000 0001 1090 049XDepartment of Pharmaceutical Biochemistry, Wroclaw Medical University, Wrocław, Poland
| | - Krzysztof Simon
- I Department of Infectious Diseases, Jerzy Gromkowski Regional Specialist Hospital, ul Koszarowa 5, 51-149 Wrocław, Poland ,grid.4495.c0000 0001 1090 049XDepartment of Infectious Diseases and Hepatology, Wroclaw Medical University, Wrocław, Poland
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8
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Abstract
BACKGROUND Cirrhosis is the outcome of chronic liver disease of any etiology due to progressive liver injury and fibrosis. Consequently, cirrhosis leads to portal hypertension and liver dysfunction, progressing to complications like ascites, variceal bleeding, hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, cirrhotic cardiomyopathy, sarcopenia, hepatocellular carcinoma, and coagulation disorders. End-stage liver disease leads to an impaired quality of life, loss of social and economic productivity, and reduced survival. METHODS This narrative review explains the pathophysiology of complications of cirrhosis, the diagnostic approach and innovative management, with focus on data from India. A comprehensive literature search of the published data was performed in regard with the spectrum, diagnosis, and management of cirrhosis and its complications. RESULTS There is a change in the epidemiology of metabolic syndrome, lifestyle diseases, alcohol consumption and the spectrum of etiological diagnosis in patients with cirrhosis. With the advent of universal vaccination and efficacious long-term viral suppression agents for chronic hepatitis B, availability of direct-acting antiviral agents for chronic hepatitis C, and a booming liver transplantation programme across the country, the management of complications is essential. There are several updates in the standard of care in the management of complications of cirrhosis, such as hepatorenal syndrome, hepatocellular carcinoma, and hepatic encephalopathy, and new therapies that address supportive and palliative care in advanced cirrhosis. CONCLUSION Prevention, early diagnosis, appropriate management of complications, timely transplantation are cornerstones in the management protocol of cirrhosis and portal hypertension. India needs improved access to care, outreach of public health programmes for viral hepatitis care, health infrastructure, and disease registries for improved healthcare outcomes. Low-cost initiatives like immunization, alcohol cessation, awareness about liver diseases, viral hepatitis elimination, and patient focused decision-making algorithms are essential to manage liver disease in India.
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Key Words
- AIH, autoimmune hepatitis
- ALP, alkaline phosphatase
- AVB, acute variceal bleeding
- BMI, body mass index
- CLD, chronic liver disease
- CSPH, clinically significant portal hypertension
- CTP, Child Turcotte Pugh Score
- DAAs, direct-acting antiviral agents
- GGT, gamma glutamyl transpeptidase
- HBV, hepatitis B virus
- HCC, hepatocellular carcinoma
- HCV, hepatitis C virus
- HE, hepatic encephalopathy
- HR, hazard ratio
- HRQoL, health-related quality of life
- HVPG, hepatic vein pressure gradient
- MELD, Model for End Stage Liver disease
- MetS, metabolic syndrome
- NAFLD, non-alcoholic fatty liver disease
- NASH, non-alcoholic steatohepatitis
- NSBB, Non-selective beta blockers
- NVHCP, National Viral Hepatitis Control programme
- SAAG, Serum-ascites albumin gradient
- SBP, spontaneous bacterial peritonitis
- WHO, World Health Organization
- cirrhosis, ascites
- hepatic encephalopathy
- hepatocellular carcinoma
- portal hypertension
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9
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Min J, Wan P, Liu G, Yu M, Su L. Sonoclot Signature Analysis: A New Point-of-Care Testing Method for Defining Heat Stroke-Induced Coagulopathy. Int J Gen Med 2021; 14:6925-6933. [PMID: 34707386 PMCID: PMC8542569 DOI: 10.2147/ijgm.s321982] [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: 06/03/2021] [Accepted: 09/28/2021] [Indexed: 12/28/2022] Open
Abstract
Purpose Data regarding the incidence of a coagulable state following heat stroke as assessed by Sonoclot signature analysis are limited. Our purpose was to appraise coagulopathy using a dynamic test capable of analyzing the entire coagulation cascade and to characterize coagulation in patients with heat stroke prior to transfusion. Materials and Methods The data of 106 patients were collected prospectively from the Critical Care Center of the General Hospital of Guangzhou Military Command. Coagulable state was defined as normal. Both hyper- and hypo-coagulable states were defined as coagulation defects. Hypercoagulability was defined as an activated clotting time (ACT) ≦195s and a clot rate (CR) >23, and hypocoagulability was defined as an ACT ≧119s and a CR < 7. The Sonoclot signature t examination was performed at the time of admission. Conventional tests, such as the prothrombin time (PT) and activated partial thromboplastin time (aPTT), were compared with Sonoclot monitoring to identify coagulation defects. Results The average age of the 106 patients was 23.2±2.5 years. There were 102 males (96.3%) and 4 females (3.7%). Thirty-four patients (32.1%) were hypercoagulable and 44 patients (41.5%) were hypocoagulable at the time of admission; 28 patients (26.4%) had no evidence of a coagulopathy. Patients with hypocoagulability, unlike patients with hypercoagulability, had a higher sequential Organ Failure Assessment score, indicating a more severe multiple organ dysfunction score. Mortality was 5.9% in patients with hypercoagulability compared with 3.5% in patients with normal coagulation, and 18.1% in patients with a hypocoagulable state (P < 0.05). ACT was a predictor of mortality, while the CR and platelet function did not show statistical significance. Conclusion This study determined the clinical outcomes and prognostic value of coagulability in patients with heat stroke, as defined by Sonoclot signature analysis at the time of admission.
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Affiliation(s)
- Jinyi Min
- Department of Critical Care Medicine, The People's Hospital, Dangyang City, Hubei, 444100, People's Republic of China
| | - Peng Wan
- Department of Critical Care Medicine, The People's Hospital of China Three Gorges University, Yichang City, Hubei, 443000, People's Republic of China
| | - Guiwei Liu
- Department of Critical Care Medicine, The People's Hospital, Dangyang City, Hubei, 444100, People's Republic of China
| | - Min Yu
- Department of Critical Care Medicine, The People's Hospital of China Three Gorges University, Yichang City, Hubei, 443000, People's Republic of China
| | - Lei Su
- Department of Critical Care Medicine, Guangzhou General Hospital of Guangzhou Military Command, The Military Key Laboratory of Trauma Care in Hot Zone and Tissue Repair in PLA, Guangzhou, 510000, People's Republic of China
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10
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Premkumar M, Mehtani R, Divyaveer S, Kajal K, Kulkarni AV, Ahmed S, Kaur H, Kaur H, Dhiman R, Duseja A, De A. Clinical Validation of Global Coagulation Tests to Guide Blood Component Transfusions in Cirrhosis and ACLF. J Clin Transl Hepatol 2021; 9:210-219. [PMID: 34007803 PMCID: PMC8111111 DOI: 10.14218/jcth.2020.00121] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/06/2021] [Accepted: 01/20/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND AIMS Patients with cirrhosis and acute-on-chronic liver failure (ACLF) may have bleeding complications and need for invasive procedures. Point-of-care (POC) coagulation tests like thromboelastography (TEG) and Sonoclot may be better for guiding patient management than the standard coagulation tests (SCTs), like prothrombin time, platelet count and international normalized ratio. METHODS We prospectively compared and validated the POC tests and SCTs in 70 persons with ACLF and 72 persons with decompensated cirrhosis who had clinical bleeding and checked for episodes of re-bleeding and transfusion requirements. We assessed pre-procedure requirement of blood components when correction was done based on an SCT or POC strategy. RESULTS Episodes of bleeding were seen in 45% and 28% of ACLF and cirrhosis patient, respectively (p=0.036), with the major site of bleeding being gastrointestinal (31% and 16%, respectively). Platelet counts correlated with TEG-maximum amplitude in cirrhosis (p=0.045) and prothrombin time correlated positively with TEG-reaction (R) time (p=0.032), TEG-Clot kinetics (K) time (p=0.042), Son-activated clotting time (p=0.038) and negatively with clot rate (p=0.043) in ACLF, making these correctable target variables in POC transfusion algorithms. Of 223 procedures, transfusion of fresh frozen plasma and platelet concentrate was reduced by 25% (p=0.035) and 20.8% (p=0.045) by using a POC strategy in 76 patients. Correction of deranged Son-activated clotting time and TEG-reaction time was noted in 68% and 72% after 24 h of fresh frozen plasma transfusion in ACLF and 85% and 80% in cirrhosis, respectively. CONCLUSIONS Our study clinically validates that POC tests can better detect coagulation defects and transfusion thresholds in ACLF and cirrhosis, whereas use of conventional tests appear to be less suitable in patients with clinical bleeding. TRIAL REGISTRATION NCT04332484.
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Affiliation(s)
- Madhumita Premkumar
- Departments of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
- Correspondence to: Madhumita Premkumar, Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, Pin 160012, India. ORCID: https://orcid.org/0000-0003-2961-4148. Tel: +91-172-2754777, E-mail:
| | - Rohit Mehtani
- Departments of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Smita Divyaveer
- Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kamal Kajal
- Anesthesia, and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anand V. Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Syed Ahmed
- Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harmanpreet Kaur
- Departments of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harpreet Kaur
- Departments of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Radhakrishna Dhiman
- Departments of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Duseja
- Departments of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arka De
- Departments of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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11
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Premkumar M, Kedarisetty CK. Cytokine Storm of COVID-19 and Its Impact on Patients with and without Chronic Liver Disease. J Clin Transl Hepatol 2021; 9:256-264. [PMID: 34007808 PMCID: PMC8111101 DOI: 10.14218/jcth.2021.00055] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/11/2021] [Accepted: 04/01/2021] [Indexed: 01/08/2023] Open
Abstract
The coronavirus pandemic has resulted in increased rates of hepatic decompensation, morbidity and mortality in patients suffering from existing liver disease, and deranged liver biochemistries in those without liver disease. In patients with cirrhosis with coronavirus disease 2019 (COVID-19), new onset organ failures manifesting as acute-on-chronic liver failure have also been reported. The severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) also directly binds to enterocytes and cholangiocytes via the angiotensin converting enzyme receptor 2, although the lung remains the portal of entry. Superadded with the COVID-19 related bystander hepatitis, a systemic inflammatory response is noted due to unregulated macrophage activation syndrome and cytokine storm. However, the exact definition and diagnostic criteria of the 'cytokine storm' in COVID-19 are yet unclear. In addition, inflammatory markers like C-reactive protein, ferritin, D-dimer and procalcitonin are frequently elevated. This in turn leads to disease progression, activation of the coagulation cascade, vascular microthrombi and immune-mediated injury in different organ systems. Deranged liver chemistries are also noted due to the cytokine storm, and synergistic hypoxic or ischemic liver injury, drug-induced liver injury, and use of hepatotoxic antiviral agents all contribute to deranged liver chemistry. Control of an unregulated cytokine storm at an early stage may avert disease morbidity and mortality. Several immunomodulator drugs and repurposed immunosuppressive agents have been used in COVID-19 with varying degrees of success.
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Affiliation(s)
- Madhumita Premkumar
- Departments of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Chandan Kumar Kedarisetty
- Department of Hepatology and Liver transplantation, Gleneagles Global Hospital, Hyderabad, India
- Correspondence to: Chandan Kumar Kedarisetty, Department of Hepatology and Liver Transplantation, Gleneagles Global Hospital, Lakdikapul, Hyderabad 500004, India. ORCID: https://orcid.org/0000-0002-7239-0293. Tel: +91-040-4592-8500, E-mail:
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12
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Rathinasamy R, Singh A, Premkumar M, Roy A, Chandel S, Singh V. Is it a real balance in hemostasis? J Thromb Haemost 2021; 19:867-868. [PMID: 33650248 DOI: 10.1111/jth.15193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 11/07/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Rakavi Rathinasamy
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Amandeep Singh
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Madhumita Premkumar
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Akash Roy
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shivani Chandel
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Virendra Singh
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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13
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Shamseddeen H, Patidar KR, Ghabril M, Desai AP, Nephew L, Kuehl S, Chalasani N, Orman ES. Features of Blood Clotting on Thromboelastography in Hospitalized Patients With Cirrhosis. Am J Med 2020; 133:1479-1487.e2. [PMID: 32473871 PMCID: PMC7704808 DOI: 10.1016/j.amjmed.2020.04.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/21/2020] [Accepted: 04/23/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Thromboelastography (TEG) provides a global assessment of hemostasis and may have value for patients with cirrhosis who have multiple hemostatic defects. We sought to examine the characteristics of TEG in hospitalized patients with cirrhosis and its relationship with outcomes. METHODS We performed a cohort study of all adults with cirrhosis hospitalized at Indiana University Hospital between November 2015 and October 2018 with a TEG. We examined the relationships among TEG, traditional measures of hemostasis, liver disease severity, and outcomes, including mortality, discharge to hospice, length of stay, and 30-day readmission. RESULTS A total of 344 patients met inclusion and exclusion criteria. R-value was elevated (≥10 min) in 4.5%, alpha angle was low (<45°) in 9.3%, and maximum amplitude (maximum amplitude) was low (<55 mm) in 72.1%. K-value, alpha angle, and maximum amplitude were all correlated with both platelet count and fibrinogen (absolute rho range 0.52-0.67); R-value and international normalized ratio (INR) were not strongly correlated with traditional measures or TEG, respectively. Patients with bleeding had hypercoagulable profiles, and patients with infection had increased R-value and decreased alpha angle. A total of 35.8% died or were discharged to hospice, and these patients had a greater R-value and smaller alpha angle. However, after adjustment for model for end-stage liver disease (MELD), neither R-value nor alpha angle were associated with discharge outcomes. CONCLUSIONS TEG provides insight into the hemostatic state of patients with cirrhosis beyond that of standard measures of hemostasis. It is associated with liver disease severity and outcomes and may play a role complementary to standard measures of hemostasis in this population.
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Affiliation(s)
- Hani Shamseddeen
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis
| | - Kavish R Patidar
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis
| | - Archita P Desai
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis
| | - Lauren Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis
| | - Sandra Kuehl
- Pharmacy, Indiana University Health University Hospital, Indianapolis
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis
| | - Eric S Orman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis.
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14
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Premkumar M, Sarin SK. Current Concepts in Coagulation Profile in Cirrhosis and Acute-on-Chronic Liver Failure. Clin Liver Dis (Hoboken) 2020; 16:158-167. [PMID: 33163169 PMCID: PMC7609701 DOI: 10.1002/cld.976] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 04/03/2020] [Accepted: 04/22/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Madhumita Premkumar
- Department of HepatologyInstitute of Liver and Biliary SciencesNew DelhiIndia
| | - Shiv Kumar Sarin
- Department of HepatologyInstitute of Liver and Biliary SciencesNew DelhiIndia
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15
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Yu Y, Bruzdoski K, Kostousov V, Hensch L, Hui SK, Siddiqui F, Farooqui A, Kouta A, Zhang F, Fareed J, Teruya J, Linhardt RJ. Structural characterization of a clinically described heparin-like substance in plasma causing bleeding. Carbohydr Polym 2020; 244:116443. [PMID: 32536393 DOI: 10.1016/j.carbpol.2020.116443] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 05/05/2020] [Accepted: 05/11/2020] [Indexed: 01/27/2023]
Abstract
Heparin-like substances (HLS) have been described in various clinical situations, including in settings of liver disease associated with infection, transplant, and metastasis. HLS are generally attributed to circulating glycosaminoglycans. Initial results for this patient showed coagulopathy due to liver disease without HLS. Two weeks after liver transplantation, a 10 year-old female with liver failure patient began to bleed from catheter insertion sites, mouth, and nares and HLS was suspected. The patient subsequently died and these clinical samples resulted in the isolation of a single heparan sulfate (HS) present at high concentrations in the plasma. Analysis of this HS showed it had an intermediate between heparin and HS with low antithrombin-mediated anticoagulant activity. We speculate that this 10-year old patient might have a platelet function defect influenced by this unusual HS. Endothelial defects not measurable by our methods might have also contributed to the observed bleeding complications.
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Affiliation(s)
- Yanlei Yu
- Department of Chemistry and Chemical Biology, Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, NY, 12180, USA
| | - Karen Bruzdoski
- Division of Transfusion Medicine & Coagulation, Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Vadim Kostousov
- Division of Transfusion Medicine & Coagulation, Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Lisa Hensch
- Division of Transfusion Medicine & Coagulation, Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Shiu-Ki Hui
- Division of Transfusion Medicine & Coagulation, Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Fakiha Siddiqui
- Department of Pathology and Laboratory Medicine, Loyola University Medical Center, Maywood, IL, 60153, USA
| | - Amber Farooqui
- Department of Pathology and Laboratory Medicine, Loyola University Medical Center, Maywood, IL, 60153, USA
| | - Ahmed Kouta
- Department of Pathology and Laboratory Medicine, Loyola University Medical Center, Maywood, IL, 60153, USA
| | - Fuming Zhang
- Department of Chemical and Biological Engineering, Rensselaer Polytechnic Institute, Troy, NY, 12180, USA
| | - Jawed Fareed
- Department of Pathology and Laboratory Medicine, Loyola University Medical Center, Maywood, IL, 60153, USA
| | - Jun Teruya
- Division of Transfusion Medicine & Coagulation, Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Robert J Linhardt
- Department of Chemistry and Chemical Biology, Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, NY, 12180, USA; Department of Chemical and Biological Engineering, Rensselaer Polytechnic Institute, Troy, NY, 12180, USA; Department of Biology, Rensselaer Polytechnic Institute, Troy, NY, 12180, USA; Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, NY, 12180, USA.
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