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Boster JM, Adams MA, Moore HB. Commentary on "Robust coagulation activation and coagulopathy in mice with experimental acetaminophen-induced liver failure". J Thromb Haemost 2023; 21:2365-2366. [PMID: 37597895 DOI: 10.1016/j.jtha.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 08/21/2023]
Affiliation(s)
- Julia M Boster
- Division of Hepatology, Department of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Megan A Adams
- Division of Transplant Surgery, Department of Surgery, Children's Hospital Colorado, Aurora, Colorado, USA; Division of Transplant Surgery, Department of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Hunter B Moore
- Division of Transplant Surgery, Department of Surgery, Children's Hospital Colorado, Aurora, Colorado, USA; Division of Transplant Surgery, Department of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, 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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Hwang C, Piano MR, Phillips SA. The effects of alcohol consumption on flow-mediated dilation in humans: A systematic review. Physiol Rep 2021; 9:e14872. [PMID: 34042304 PMCID: PMC8157766 DOI: 10.14814/phy2.14872] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 04/07/2021] [Accepted: 04/16/2021] [Indexed: 12/16/2022] Open
Abstract
Changes in endothelial function may contribute to the positive and negative effects of alcohol consumption on cardiovascular conditions, such as hypertension and coronary artery disease. Numerous studies have used brachial artery flow-mediated dilation (FMD) to examine the effects of alcohol consumption on endothelial function in humans. However, the findings are inconsistent and may be due to multiple factors such as heterogeneity in subject characteristics, the alcohol use pattern, and amount/dose of alcohol consumed. Therefore, the aim of this systematic review was to investigate the effect of alcohol consumption on brachial artery FMD in humans considering the above-mentioned factors. This review found that while light to moderate alcohol consumption may have minimal effects on FMD, heavy alcohol consumption was associated with a decrease in FMD. However, most of the published studies included healthy, younger, and male individuals, limiting generalizability to other populations. Future studies should include more women, older subjects, and those from diverse and underrepresented backgrounds.
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Affiliation(s)
- Chueh‐Lung Hwang
- Department of Physical TherapyCollege of Applied Health SciencesUniversity of Illinois at ChicagoChicagoILUSA
| | | | - Shane A. Phillips
- Department of Physical TherapyCollege of Applied Health SciencesUniversity of Illinois at ChicagoChicagoILUSA
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Premkumar M, Bihari C, Saxena P, Devurgowda DR, Vyas T, Mirza R, Jain P, Kumar G, Bhatia P, Baweja S, Choudhury A, Sarin SK. Heparin-like Effect Associated With Risk of Bleeding, Sepsis, and Death in Patients With Severe Alcohol-Associated Hepatitis. Clin Gastroenterol Hepatol 2020; 18:486-495.e3. [PMID: 31077821 DOI: 10.1016/j.cgh.2019.04.057] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 03/04/2019] [Accepted: 04/26/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endogenous heparinoids or heparin-like effects (HLEs) can cause coagulation failure in patients with cirrhosis and sepsis. We performed a prospective study of the association between HLE and bleeding events, sepsis, and outcomes of patients with severe alcohol-associated hepatitis. METHODS Our final analysis comprised 78 patients with severe alcohol-associated hepatitis (44.3 ± 11.7 years; all male; discriminant function >32) who presented without sepsis at a single center in India from August 2015 through August 2016. Blood samples were collected at days 0, 3, and 7 after presentation and assessed by a global coagulation assay; by SONOCLOT (global and heparinase treated); and in assays for factor VIII, von Willebrand factor, protein C, and antithrombin. Patients were followed for sepsis, bleeding and outcome. The primary outcome was association of HLE with survival 28 days after presentation. RESULTS HLEs were observed in 32 patients (41%) at day 0, 27 patients (34.6%) at day 3, and 28 patients (35.9%) patients at day 7. Factors associated with mortality at day 0 were factor VIII activity >160% (hazard ratio [HR], 3.1; 95% CI, 1.4-9.5; P = .026), level of protein C <34% (HR, 0.7; 95% CI, 0.5-0.8; P = .037), antithrombin activity <28% (HR, 0.7; 95% CI, 0.3-1.1; P = .008) and international normalized ratio >2.6 (HR, 2.3; 95% CI, 1.8-9.7; P = .010). In multivariate analyses, only factor VIII activity (HR, 2.3; 95% CI, 1.6-7.8; P = .046), international normalized ratio (1.9; 95% CI, 1.2-4.3; P = .039), level of protein C (HR, 0.9; 95% CI, 0.7-1.1; P = .052) and model for end-stage liver disease score (HR, 3.2; 95% CI, 1.9-10.2; P = .042) were associated with mortality. Episodes of epistaxis, hemorrhoid bleeding, hemoperitoneum, and pulmonary hemorrhage occurred in 10.2%, 12.3%, 3.4%, and 4.5% of patients respectively. The presence of HLE at day 0 increased the risk of sepsis (HR, 2.5; 95% CI, 2.2-4.3; P = .002), bleeding (HR, 1.4; 95% CI, 1.2-5.3; P = .004) and death (HR, 1.2; 95% CI, 1.4-1.7; P = .044). CONCLUSIONS In a prospective study of patients with severe alcohol-associated hepatitis, we associated HLE with coagulation abnormalities, risk of sepsis, and mortality. Clinicaltrials.govNCT02307409.
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Affiliation(s)
- Madhumita Premkumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Chhagan Bihari
- Department of Hematology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Priyanka Saxena
- Department of Hematology, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Tanmay Vyas
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Roshni Mirza
- Department of Hematology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Priyanka Jain
- Department of Epidemiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Epidemiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Puja Bhatia
- Department of Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Sukriti Baweja
- Department of Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ashok Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
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Shahramian I, Tabrizian K, Delaramnasab M, Khosravi Bonjar A, Dehghani SM, Sargazi-Aval O, Bazi A. A Review on Clinical, Pathophysiological, and Diagnostic Hematological Features in Children With Liver Cirrhosis. INTERNATIONAL JOURNAL OF BASIC SCIENCE IN MEDICINE 2019. [DOI: 10.15171/ijbsm.2019.17] [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] Open
Abstract
Appropriate diagnostic and therapeutic measures for liver cirrhosis is critical, particularly in children. In the present review, a comprehensive approach was provided toward hematological parameters in pediatric liver cirrhosis. The literature search included MeSH terms "liver cirrhosis" and "hepatic cirrhosis" and databases such as PubMed, Web of Science, Scopus, and Google Scholar were searched up until December 2017. Hematologic changes in the liver cirrhosis mainly encompassed anemia and coagulopathies. In addition, bleeding diathesis was considered as the most clinical complication in these patients. In addition to reduced coagulation factors, hyperfibrinolysis is a common feature in childhood cirrhosis and may be an important contributor to the risk of bleeding. Based on the results, children with liver cirrhosis also demonstrated a procoagulant state at laboratory and clinical levels. This may be partly due to a reduction in coagulation inhibitors such as anti-thrombin, C1 inhibitor, and α1-antitrypsin in children with cirrhosis. The portal vein thrombosis and portal hypertension are considered as the most clinical presentations of the hypercoagulable state. Further, children with liver cirrhosis complicated with portal hypertension usually show leukopenia, anemia, and thrombocytopenia due to hypersplenism. Although the etiology of childhood and adult cirrhosis may be different, their hematological compilations and clinicopathological features are somehow similar.
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Affiliation(s)
- Iraj Shahramian
- Pediatric Digestive and Hepatic Diseases Research Center, Zabol University of Medical Sciences, Zabol, Iran
| | - Kaveh Tabrizian
- Department of Pharmacology, Zabol University of Medical Sciences, Zabol, Iran
| | - Mojtaba Delaramnasab
- Faculty of Allied Medical Sciences, Zabol University of Medical Sciences, Zabol, Iran
| | - Ali Khosravi Bonjar
- Faculty of Allied Medical Sciences, Zabol University of Medical Sciences, Zabol, Iran
| | - Seyed Mohsen Dehghani
- Shiraz Organ Transplantation Center, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Ali Bazi
- Faculty of Allied Medical Sciences, Zabol University of Medical Sciences, Zabol, Iran
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Premkumar M, Saxena P, Rangegowda D, Baweja S, Mirza R, Jain P, Bhatia P, Kumar G, Bihari C, Kalal C, Vyas T, Choudhury A, Sarin SK. Coagulation failure is associated with bleeding events and clinical outcome during systemic inflammatory response and sepsis in acute-on-chronic liver failure: An observational cohort study. Liver Int 2019; 39:694-704. [PMID: 30589495 DOI: 10.1111/liv.14034] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 12/12/2018] [Accepted: 12/12/2018] [Indexed: 02/13/2023]
Abstract
BACKGROUND Patients with acute-on-chronic liver failure (ACLF) have coagulation failure in the setting of systemic inflammatory syndrome (SIRS), sepsis and extra-hepatic organ failures. METHODS Consecutive ACLF patients without sepsis at baseline were assessed at days 0, 3 and 7 with thromboelastography (TEG) and specific assays (Factor VIII, von Willebrand factor [vWF], protein C and antithrombin III [ATIII]) and followed for development of sepsis, bleeding and outcome. RESULTS Of 243 patients, 114 (63% ethanol related; mean age 44.3 ± 11.7 years; 90% male) were recruited. SIRS was noted in 39 (34.2%), 45 (39.5%) and 46 (40%) patients at days 0, 3 and 7 and sepsis in 28 (24%) and 52 (56.1%) patients at days 3 and 7 respectively. The 28- and 90-day survivals were 62% and 51% respectively. A hypocoagulable TEG at baseline was a predictor of bleeding (hazard ratio [HR] 2.1; CI 1.6-4.9; P = 0.050) and mortality (HR 1.9; CI 1.3-7.9; P = 0.043). ACLF patients had increased Factor VIII, vWF, tissue factor levels and tissue plasminogen activator (tPA) activity with reduced protein C and ATIII. Coagulation parameters like Coagulation Index (HR 2.1; CI 1.1-4.5; P = 0.044),clot lysis (HR 3.2; CI 1.9-3.4; P = 0.033), low protein C < 30% (HR 2.1; CI 1.5-2.8; P = 0.017), ATIII (HR 1.4; CI 1.7-3.1; P = 0.052) and tPA (HR 1.5; CI 1.1-2.4; P = 0.052) were predictors of mortality at day 28. Protein C activity <30% (HR 1.3; CI 1.0-2.9; P = 0.042) and tPA >20 ng/mL (HR 1.2; CI 1.1-2.1; P = 0.040) predicted mortality when adjusted for age, gender and baseline MELD. CONCLUSIONS Dynamic coagulation derangements, measured by TEG, determine the likelihood of bleeding and mortality in ACLF.
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Affiliation(s)
- Madhumita Premkumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Priyanka Saxena
- Department of Hematology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Devaraja Rangegowda
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Sukriti Baweja
- Department of Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Roshni Mirza
- Department of Hematology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Priyanka Jain
- Department of Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Puja Bhatia
- Department of Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Chhagan Bihari
- Department of Hematology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Chetan Kalal
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Tanmay Vyas
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ashok Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Abstract
Abstract
Background: Bleeding is an important complication of cirrhosis. Currently, there is no coagulation test that can reliably predict clinical hemorrhage. However, previous studies demonstrated significant correlations between hyperfibrinolysis and following bleeding in advanced cirrhotic patients. Objectives: Estimate the prevalence of hyperfibrinolysis in cirrhotic patients at stable conditions and to assess its role in predicting subsequent hemorrhage. Methods: The prospective cohort study included 58 consecutive cirrhotic patients at the Liver Clinic, Chulalongkorn Hospital. Assays for liver functions, PT, APTT, fibrinogen, fibrin degradation products (FDPs) and euglobulin lysis time (ELT) were performed at baseline. The subjects were followed-up for 10 months to observe clinical hemorrhage and survival. Results: The mean age was 56.4 years and 47% were male. The etiologies of liver diseases were virus (62.1%), alcohol (24.1%) or unknown (8.6%). Hyperfibrinolysis as reflected by ELT<120 minutes or FDPs>10 μg/mL was present in 32.8% and 74.1%, respectively. Fibrinolytic activity was significantly correlated with platelet counts and coagulation times, but not as much with liver function tests. By 10 months, 13 cases (22.4%) showed hemorrhagic episodes and 7 (12.1%) were expired, including 2 from bleeding. The significant predictors for death were Child class B or C, presence of ascites, hyperbilirubinemia, hypoalbuminemia, and prolonged APTT. However, none of the clinical, biochemical, or hemostatic factors was associated with clinical bleeding. Conclusion: Hyperfibrinolysis is common in cirrhotic outpatients. However, it cannot predict subsequent hemorrhage or survival. Novel hemostatic tests are required to assess the probability of bleeding in this disorder.
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González-Reimers E, Quintero-Platt G, Martín-González C, Pérez-Hernández O, Romero-Acevedo L, Santolaria-Fernández F. Thrombin activation and liver inflammation in advanced hepatitis C virus infection. World J Gastroenterol 2016; 22:4427-4437. [PMID: 27182154 PMCID: PMC4858626 DOI: 10.3748/wjg.v22.i18.4427] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 03/30/2016] [Accepted: 04/15/2016] [Indexed: 02/06/2023] Open
Abstract
Hepatitis C virus (HCV) infection is associated with increased thrombotic risk. Several mechanisms are involved including direct endothelial damage by the HCV virus, with activation of tissue factor, altered fibrinolysis and increased platelet aggregation and activation. In advanced stages, chronic HCV infection may evolve to liver cirrhosis, a condition in which alterations in the portal microcirculation may also ultimately lead to thrombin activation, platelet aggregation, and clot formation. Therefore in advanced HCV liver disease there is an increased prevalence of thrombotic phenomena in portal vein radicles. Increased thrombin formation may activate hepatic stellate cells and promote liver fibrosis. In addition, ischemic changes derived from vascular occlusion by microthrombi favor the so called parenchymal extinction, a process that promotes collapse of hepatocytes and the formation of gross fibrous tracts. These reasons may explain why advanced HCV infection may evolve more rapidly to end-stage liver disease than other forms of cirrhosis.
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Kuiper GJAJM, Kleinegris MCF, van Oerle R, Spronk HMH, Lancé MD, Ten Cate H, Henskens YMC. Validation of a modified thromboelastometry approach to detect changes in fibrinolytic activity. Thromb J 2016; 14:1. [PMID: 26770073 PMCID: PMC4712545 DOI: 10.1186/s12959-016-0076-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 01/10/2016] [Indexed: 11/24/2022] Open
Abstract
Background Thus far, validated whole blood assays used in in vitro fibrinolysis experiments using thromboelastometry (ROTEM) are lacking or have yet to be tested in humans. The objective was first, to establish a standardized modified ROTEM approach to detect both hypo- and hyperfibrinolysis. And second, to perform a technical and clinical validation of the assay. Methods Blood was used of healthy volunteers, patients with sepsis, patients after cardiothoracic surgery, pregnant women, and cirrhotic liver disease patients. A whole blood tissue factor (TF) activated ROTEM assay with and without the addition of recombinant tissue plasminogen activator (rTPA) was developed. Plasma fibrinolysis determinants were measured in all volunteers and patients. Results Thirty five pM TF and additions of 125 and 175 ng/ml rTPA resulted in full lysis within 60 min in healthy volunteers. Coefficients of variation were below 10 % without and below 20 % with rTPA addition. In sepsis the hypofibrinolytic ROTEM profiles with 175 ng/ml rTPA were in line with the plasma determinants (high PAI-1, high fibrinogen, low tPA activity, and high d-dimers). After cardiothoracic surgery, reduced fibrinogen and platelet levels accounted for the reduced maximum clot firmness. The hypofibrinolytic profile is attributed to tranexamic acid use and elevated PAI-1 levels. The lowest rTPA concentration in cirrhosis resulted in hyperfibrinolysis in only few of the patients. In pregnancy normal profiles were found. Discussion Our high rTPA concentration demonstrates hypofibrinolytic profiles adequately in sepsis and after cardiothoracic surgery. Our low rTPA concentration of 125 ng/ml seems too high for demonstrating hyperfibrinolysis in cirrhotic liver disease. Conclusions We were able to present a validated whole blood ROTEM approach to fibrinolysis testing using added rTPA, which can be of added value next to classical plasma based fibrinolysis assays.
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Affiliation(s)
- Gerhardus J A J M Kuiper
- Department of Anaesthesiology and Pain Treatment, Maastricht University Medical Center (MUMC+), P. Debyelaan 25, PO Box 5800, 6202 AZ Maastricht, The Netherlands ; Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Laboratory for Clinical Thrombosis and Haemostasis, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Marie-Claire F Kleinegris
- Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Laboratory for Clinical Thrombosis and Haemostasis, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - René van Oerle
- Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Laboratory for Clinical Thrombosis and Haemostasis, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands ; Central Diagnostic Laboratory, Cluster for Hemostasis and transfusion, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Henri M H Spronk
- Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Laboratory for Clinical Thrombosis and Haemostasis, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Marcus D Lancé
- Department of Anaesthesiology and Pain Treatment, Maastricht University Medical Center (MUMC+), P. Debyelaan 25, PO Box 5800, 6202 AZ Maastricht, The Netherlands
| | - Hugo Ten Cate
- Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Laboratory for Clinical Thrombosis and Haemostasis, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Yvonne M C Henskens
- Central Diagnostic Laboratory, Cluster for Hemostasis and transfusion, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
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Martí‐Carvajal AJ, Solà I. Antifibrinolytic amino acids for upper gastrointestinal bleeding in people with acute or chronic liver disease. Cochrane Database Syst Rev 2015; 2015:CD006007. [PMID: 26058965 PMCID: PMC7390485 DOI: 10.1002/14651858.cd006007.pub4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Upper gastrointestinal bleeding is one of the most frequent causes of morbidity and mortality in the course of liver cirrhosis. People with liver disease frequently have haemostatic abnormalities such as hyperfibrinolysis. Therefore, antifibrinolytic amino acids have been proposed to be used as supplementary interventions alongside any of the primary treatments for upper gastrointestinal bleeding in people with liver diseases. This is an update of this Cochrane review. OBJECTIVES To assess the beneficial and harmful effects of antifibrinolytic amino acids for upper gastrointestinal bleeding in people with acute or chronic liver disease. SEARCH METHODS We searched The Cochrane Hepato-Biliary Controlled Trials Register (February 2015), Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2 of 12, 2015), MEDLINE (Ovid SP) (1946 to February 2015), EMBASE (Ovid SP) (1974 to February 2015), Science Citation Index EXPANDED (1900 to February 2015), LILACS (1982 to February 2015), World Health Organization Clinical Trials Search Portal (accessed 26 February 2015), and the metaRegister of Controlled Trials (accessed 26 February 2015). We scrutinised the reference lists of the retrieved publications. SELECTION CRITERIA Randomised clinical trials irrespective of blinding, language, or publication status for assessment of benefits and harms. Observational studies for assessment of harms. DATA COLLECTION AND ANALYSIS We planned to summarise data from randomised clinical trials using standard Cochrane methodologies and assessed according to the GRADE approach. MAIN RESULTS We found no randomised clinical trials assessing antifibrinolytic amino acids for treating upper gastrointestinal bleeding in people with acute or chronic liver disease. We did not identify quasi-randomised, historically controlled, or observational studies in which we could assess harms. AUTHORS' CONCLUSIONS This updated Cochrane review identified no randomised clinical trials assessing the benefits and harms of antifibrinolytic amino acids for upper gastrointestinal bleeding in people with acute or chronic liver disease. The benefits and harms of antifibrinolytic amino acids need to be tested in randomised clinical trials. Unless randomised clinical trials are conducted to assess the trade-off between benefits and harms, we cannot recommend or refute antifibrinolytic amino acids for upper gastrointestinal bleeding in people with acute or chronic liver diseases.
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Affiliation(s)
| | - Ivan Solà
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 171 ‐ Edifici Casa de ConvalescènciaBarcelonaCatalunyaSpain08041
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Balser D, Farooq S, Mehmood T, Reyes M, Samadani U. Actual and projected incidence rates for chronic subdural hematomas in United States Veterans Administration and civilian populations. J Neurosurg 2015; 123:1209-15. [PMID: 25794342 DOI: 10.3171/2014.9.jns141550] [Citation(s) in RCA: 178] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Chronic subdural hematomas (SDHs) are more common among veterans and elderly persons than among members of the general population; however, precise incidence rates are unknown. The purposes of this study were 1) to determine the current incidence of chronic SDH in a US Veterans Administration (VA) population and 2) to create a mathematical model for determining the current and future incidence of chronic SDH as a function of population age, sex, and comorbidity in the United States VA and civilian populations. METHODS To determine the actual number of veterans who received a radiographic diagnosis and surgical treatment for SDH during 2000-2012, the authors used the VISN03 VA database. On the basis of this result and data from outside the United States, they then created a mathematical model accounting for age, sex, and alcohol consumption to predict the incidence of SDH in the VA and civilian populations during 2012-2040. RESULTS Of 875,842 unique (different patient) visits to a VA hospital during the study period, 695 new SDHs were identified on CT images. Of these 695 SDHs, 203 (29%) required surgical drainage. The incidence rate was 79.4 SDHs per 100,000 persons, and the age-standardized rate was 39.1±4.74 SDHs per 100,000 persons. The authors' model predicts that incidence rates of chronic SDH in aging United States VA and civilian populations will reach 121.4 and 17.4 cases per 100,000 persons, respectively, by 2030, at which time, approximately 60,000 cases of chronic SDH will occur each year in the United States. CONCLUSIONS The incidence of chronic SDH is rising; SDH is projected to become the most common cranial neurosurgical condition among adults by the year 2030.
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Affiliation(s)
- David Balser
- New York Harbor Healthcare System, Manhattan Veterans Administration, New York;,Department of Neurosurgery, New York University School of Medicine; and
| | - Sameer Farooq
- New York Harbor Healthcare System, Manhattan Veterans Administration, New York;,Department of Neurosurgery, New York University School of Medicine; and
| | - Talha Mehmood
- Department of Neurosurgery, New York University School of Medicine; and
| | - Marleen Reyes
- Department of Neurosurgery, New York University School of Medicine; and
| | - Uzma Samadani
- New York Harbor Healthcare System, Manhattan Veterans Administration, New York;,Department of Neurosurgery, New York University School of Medicine; and.,Steven and Alexandra Cohen Veterans Center for the Study of Post-Traumatic Stress and Traumatic Brain Injury, NYU Langone Medical Center, New York, New York
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Kleinegris MC, Bos MHA, Roest M, Henskens Y, Ten Cate-Hoek A, Van Deursen C, Spronk HMH, Reitsma PH, De Groot PG, Ten Cate H, Koek G. Cirrhosis patients have a coagulopathy that is associated with decreased clot formation capacity. J Thromb Haemost 2014; 12:1647-57. [PMID: 25142532 DOI: 10.1111/jth.12706] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 07/24/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND The coagulopathy in cirrhosis is associated with thrombosis and bleeding. OBJECTIVES To gain better insights into the coagulopathy in patients with cirrhosis, we evaluated plasma thrombin generation and whole blood clot formation in a cross-sectional study. METHODS Blood was collected from 73 patients with all-cause cirrhosis (Child-Pugh-A n = 52, B n = 15, C n = 6) and 20 healthy controls. Activity of the coagulation pathways was measured with assays for factor (F) VIIa and FIXa-antithrombin and FXa-antithrombin complexes, respectively. Thrombin generation by calibrated automated thrombography was determined in platelet-poor plasma using a 1 or 5 pm tissue factor trigger with/without thrombomodulin. ROTEM measurements were performed in whole blood triggered with 35 pm tissue factor without/with 175 ng mL(-1) tissue plasminogen activator (the latter refered to as 'tPA-ROTEM'). RESULTS We observed an increased generation of FVIIa and a moderately elevated amount of FIXa (in complex with antithrombin) without apparent increase in FX activation in patients with cirrhosis. In accordance with this prothrombotic state, markers of thrombin generation potential were also increased upon increasing severity of cirrhosis. In the whole blood clotting assay we observed delayed clot formation and decreased clot strength associated with increased severity of cirrhosis. No significant differences were found for tPA-ROTEM parameters of clot degradation. CONCLUSION These results indicate that cirrhosis patients have an overall procoagulant plasma milieu but a decreased whole blood clot formation capacity with an apparently unaltered resistance to clot lysis.
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Affiliation(s)
- M-C Kleinegris
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
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13
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Rossetto V, Spiezia L, Senzolo M, Rodriguez-Castro KI, Gavasso S, Woodhams B, Simioni P. Does decreased fibrinolysis have a role to play in the development of non-neoplastic portal vein thrombosis in patients with hepatic cirrhosis? Intern Emerg Med 2014; 9:397-403. [PMID: 23504244 DOI: 10.1007/s11739-013-0929-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 03/02/2013] [Indexed: 01/26/2023]
Abstract
Hepatic cirrhosis is characterized by complex abnormalities of the fibrinolytic system. Little is known about the possible association between these alterations and thrombosis. The aim of this study was to evaluate the fibrinolytic profile in cirrhotic individuals with and without portal vein thrombosis (PVT). We measured thrombin activatable fibrinolysis inhibitor (TAFI), total amount of activated TAFI (TAFIa/ai), plasminogen activator inhibitor (PAI-1), plasminogen and fibrinogen plasma levels in 66 cirrhotic patients (33 with and 33 without PVT) and in 66 healthy volunteers. TAFI plasma levels (median [range]) were significantly lower in cirrhotic individuals (5.6 μg/ml [1.7-11.7]) than in controls (10.1 μg/ml [6.6-14.2], p < 0.0001), while TAFIa/ai levels were significantly higher in cases (18.3 ng/ml [0.3-35.4]) than in controls (15.9 ng/ml [7.4-41], p = 0.02). Cirrhotic patients with PVT had higher TAFI (6.6 μg/ml [2.9-10.1]), TAFIa/ai (19.2 ng/ml [11.6-35.4]) and PAI-1 (33.1 ng/ml [27.6-56.3]) plasma levels than those without PVT (3.9 μg/ml [1.7-11.7], p = 0.001; 15.6 ng/ml [10.3-33.9], p = 0.037; 15.9 ng/ml [2.5-29.1], p = 0.004. The fibrinolytic profile in cirrhotic individuals with PVT is characterized by higher levels of TAFI, TAFIa/ai and PAI-1 than in those without PVT. These alterations identify a hypofibrinolytic condition that may increase the risk of developing a thrombotic event.
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Affiliation(s)
- Valeria Rossetto
- Department of Cardiologic, Thoracic, and Vascular Sciences, 2nd Chair of Internal Medicine, University of Padua Medical School, Via Giustiniani 2, 35100, Padua, Italy
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14
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Muciño-Bermejo J, Carrillo-Esper R, Uribe M, Méndez-Sánchez N. Coagulation abnormalities in the cirrhotic patient. Ann Hepatol 2013. [DOI: 10.1016/s1665-2681(19)31312-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
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15
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Martí-Carvajal AJ, Solà I, Martí-Carvajal PI. Antifibrinolytic amino acids for upper gastrointestinal bleeding in patients with acute or chronic liver disease. Cochrane Database Syst Rev 2012:CD006007. [PMID: 22972089 DOI: 10.1002/14651858.cd006007.pub3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Upper gastrointestinal bleeding is one of the most frequent causes of morbidity and mortality in the course of liver cirrhosis. Patients with liver disease frequently have haemostatic abnormalities like hyperfibrinolysis. Therefore, antifibrinolytic amino acids have been proposed to be used as supplementary interventions alongside any of the primary treatments for upper gastrointestinal bleeding in patients with liver diseases. OBJECTIVES To assess the beneficial and harmful effects of antifibrinolytic amino acids for upper gastrointestinal bleeding in patients with acute or chronic liver disease. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register (11 June 2012), Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2012, Issue 5 of 12), MEDLINE (Ovid SP) (1946 to June 2012), EMBASE (Ovid SP) (1974 to June 2012), Science Citation Index EXPANDED (1900 to June 2012), LILACS (1982 to June 2012), Clinical Trials Search Portal of the WHO (accessed June 18, 2012), and the Metaregister of Controlled Trials (accessed June 18, 2012). We scrutinised the reference lists of the retrieved publications. SELECTION CRITERIA Randomised clinical trials irrespective of blinding, language, or publication status for assessment of benefits and harms. Observational studies for assessment of harms. DATA COLLECTION AND ANALYSIS Data from randomised clinical trials were to be summarised by standard Cochrane Collaboration methodologies. MAIN RESULTS We could not find any randomised clinical trials assessing antifibrinolytic amino acids for treating upper gastrointestinal bleeding in patients with acute or chronic liver disease. We could not identify quasi-randomised, historically controlled, or observational studies in which we could assess harms. AUTHORS' CONCLUSIONS No randomised clinical trials assessing the benefits and harms of antifibrinolytic amino acids for upper gastrointestinal bleeding in patients with acute or chronic liver disease were identified. The benefits and harms of antifibrinolytic amino acids need to be tested in randomised clinical trials. Unless randomised clinical trials are conducted to assess the trade off between benefits and harms, we cannot recommend nor refute antifibrinolytic amino acids for upper gastrointestinal bleeding in patients with acute or chronic liver diseases.
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Affiliation(s)
- Arturo J Martí-Carvajal
- Facultad de Ciencias de la Salud Eugenio Espejo, Universidad Tecnológica Equinoccial, Quito, Ecuador.
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Hsu TW, Chen YC, Wu MJ, Li AFY, Yang WC, Ng YY. Reinfusion of ascites during hemodialysis as a treatment of massive refractory ascites and acute renal failure. Int J Nephrol Renovasc Dis 2011; 4:29-33. [PMID: 21694946 PMCID: PMC3108789 DOI: 10.2147/ijnrd.s15792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Indexed: 12/29/2022] Open
Abstract
Refractory ascites can occur in patients with various conditions. Although several procedures based on the reinfusion of ascitic fluid have been reported after the failure of bed rest, salt and water restriction, diuretics, intravenous administration of albumin, and repeated paracentesis, these procedures are performed for ascitic fluid removal without dialytic effect. In this study, a flow control reinfusion of ascites during hemodialysis (HD) was performed to demonstrate the efficacy of this method in a lupus patient with massive refractory ascites and respiratory and acute renal failure (ARF). The alleviation of ascites and ARF attests to the success of the flow control reinfusion of ascites during HD. This procedure can control the rate of ascites and body fluid removal simultaneously during HD using the roller pump. In conclusion, with a normal coagulation profile, the procedure of flow control reinfusion of ascites during HD is an effective alternative treatment for the alleviation of refractory ascites with renal failure.
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Caldwell S, Northup PG. Bleeding complication with liver biopsy: is it predictable? Clin Gastroenterol Hepatol 2010; 8:826-9. [PMID: 20601136 DOI: 10.1016/j.cgh.2010.06.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Revised: 06/07/2010] [Accepted: 06/07/2010] [Indexed: 12/30/2022]
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18
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Aref S, Abdel-Khalek EE, Abdel-Aal IA, Refaie ME. Circadian pattern of acute variceal bleeding among cirrhotic Egyptian patients. Indian J Hematol Blood Transfus 2009; 25:53-8. [PMID: 23100976 DOI: 10.1007/s12288-009-0014-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Accepted: 04/15/2009] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Liver cirrhosis is the most common cause of portal hypertension which may end in serious bleeding from gastro-esophageal varices. Recent studies have demonstrated a daily pattern of acute upper gastrointestinal bleeding in patients with liver cirrhosis evidenced by one or two peaks throughout the day. AIM The assessment of the circadian rhythm of acute variceal bleeding with the possible participation of circadian changes of the fibrinolytic parameters. PATIENTS AND METHODS The study included 264 patients with liver cirrhosis and upper gastrointestinal bleeding in addition to 20 healthy subjects as a control group. A series of hemostatic tests and parameters including prothrombin (PT), activated partial thromboplastin time (APTT), fibrinogen (Fib), Factors II, V, VII, IX, X, XI, platelets counts and fibrinolytic parameters assessement were completed in 60 patients in addition to the control group. The fibrinolytic activity was assessed by estimation of plasminogen, tissue plasminogen activator antigen (tPA: Ag) and plasminogen activator inhibitor antigen (PAI-1: Ag) at hour 09:00 and hour 17:00. The hemostatic tests and liver function tests were assessed once at hour 09.00. RESULTS We observed statistically significant two time peaks of upper gastrointestinal bleeding at hour 04:00 and hour 17:00 with a peak of the fibrinolytic parameter, tissue plasminogen activator antigen, with the night peak of bleeding. A significant correlation between the levels of fibrinolytic parameters and hemostatic factors as well as liver function tests were detected. CONCLUSION There are two time peaks of upper gastrointestinal bleeding with a temporal association between the night peak and a relative hyperfibrinolytic state.
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Affiliation(s)
- Salah Aref
- Internal Medicine Faculty of Medicine, Mansoura University, Mansoura, Egypt ; Hematology Unit, Clinical Pathology Departments Faculty of Medicine, Mansoura University, Mansoura, Egypt ; Institute of Immunogenetic, Menofyia University, Menofyia, Egypt
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Marti-Carvajal AJ, Pérez-Requejo JL. Antifibrinolytic amino acids for acquired coagulation disorders in patients with liver disease. Cochrane Database Syst Rev 2007:CD006007. [PMID: 17253575 DOI: 10.1002/14651858.cd006007.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Upper gastrointestinal bleeding is one of the most frequent causes of morbidity and mortality in the course of liver cirrhosis. Patients with liver disease frequently have haemostatic abnormalities, which include accelerated fibrinolysis. Several primary treatments are used for upper gastrointestinal bleeding in patients with liver diseases. Supplementary interventions are often used as well. One of them could be antifibrinolytic amino acids administration. OBJECTIVES To assess the beneficial and harmful effects of antifibrinolytic amino acids for upper gastrointestinal bleeding in patients with acute or chronic liver disease plus acquired coagulation disorders. SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register (March 2006), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 1, 2006), MEDLINE (1950 to March 2006), EMBASE (1980 to March 2006), Science Citation Index EXPANDED (1945 to March 2006), LILACS (1982 to March 2006), ClinicalTrials.gov (at www.clinicaltrials.gov) (accessed August 2006), ISI Web of Science (April 2006), and the International Standard Randomised Controlled Trial Number Register (at http://controlled-trials.com/isrctn/search.asp) (accessed August 2006). We also checked the reference lists of all the trials identified by the above methods. SELECTION CRITERIA We searched for randomised clinical trials irrespective of blinding, language, or publication status. DATA COLLECTION AND ANALYSIS We intended to summarise data by standard Cochrane Collaboration methodologies. MAIN RESULTS We could not find any randomised clinical trials with antifibrinolytic amino acids for upper gastrointestinal bleeding in patients with acute or chronic liver disease plus acquired coagulation disorders. AUTHORS' CONCLUSIONS We were unable to identify randomised clinical trials on the safety and efficacy of antifibrinolytic amino acids for upper gastrointestinal bleeding in patients with liver disease (acute or chronic) plus acquired coagulation disorders. The effects of antifibrinolytic amino acids has to be tested in randomised clinical trials.
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Affiliation(s)
- A J Marti-Carvajal
- Departamento de Salud Pública, Universidad de Carabobo, Valencia, Edo. Carabobo, Venezuela, 2006.
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