Coagulopathy and the prognostic potential of D-dimer in hyperlipidemia-induced acute pancreatitis

Alterations of oral microbiota are associated with the development and severity of acute pancreatitis

Acute pancreatitis (AP) is a common abdomen clinical emergency. Most APs have mild clinical symptoms and a good prognosis. However, about 20% of patients develop severe acute pancreatitis (SAP), increasing morbidity and mortality. The microbiome's impact on AP pathophysiology has received increasing attention. Hence, to explore changes in oral microbial composition in acute pancreatitis, we collected clinical information and oral saliva samples from 136 adult participants: 47 healthy controls, 43 acute mild AP (MAP), 29 moderate AP (MSAP), and 17 severe AP (SAP). Using 16S rRNA gene sequencing, 663,175 high-quality sequences were identified. The relative abundance and diversity of oral microorganisms in AP patients increased, with decreased beneficial bacteria such as Streptococcus, Neisseria, and Gemella, and increased Prevotella, Veillonella, Granulicatella, Actinomyces, and Peptostreptococcus in the AP group. Further changes in microbial composition occurred with increasing disease severity, including a decreased abundance of beneficial bacteria such as Neisseria, Haemophilus, and Gemella in MSAP and SAP compared to MAP. Moreover, the Lefse analysis showed that Prevotella, Peptostreptococcus, Actinomyces, and Porphyromonas were better microbial markers for AP. Therefore, oral microbiome changes could distinguish AP from healthy individuals and serve as an early novel predictor of disease severity in AP patients.

Predictive Value of Antithrombin III and d -Dimer in the Development of Moderate-To-Severe Acute Pancreatitis : A Prospective, Observational Study (AT-PROPANC)

OBJECTIVES

To analyze if antithrombin III (AT-III) and d -dimer levels at admission and at 24 hours can predict acute pancreatitis (AP) progression to moderately severe AP (MSAP) to severe AP (SAP) and to determine their predictive value on the development of necrosis, infected necrosis, organ failure, and mortality.

METHODS

Prospective observational study conducted in patients with mild AP in 2 tertiary hospitals (2015-2017).

RESULTS

Three hundred forty-six patients with mild AP were included. Forty-four patients (12.7%) evolved to MSAP/SAP. Necrosis was detected in 36 patients (10.4%); in 10 (2.9%), infection was confirmed. Organ failure was recorded in 9 patients (2.6%), all of whom died. Those who progressed to MSAP/SAP showed lower AT-III levels; d -dimer and C-reactive protein (CRP) levels increased. The best individual marker for MSAP/SAP at 24 hours is CRP (area under the curve [AUC], 0.839). Antithrombin III (AUC, 0.641), d -dimer (AUC, 0.783), and creatinine added no benefit compared with CRP alone. Similar results were observed for patients who progressed to necrosis, infected necrosis, and organ failure/death.

CONCLUSION

Low AT-III and high d -dimer plasma levels at 24 hours after admission were significantly associated with MSAP/SAP, although their predictive ability was low. C-reactive protein was the best marker tested.

CLINICAL STUDY IDENTIFIER

ClinicalTrials.gov NCT02373293.

Effects of nitroglycerin combined with continuous regional arterial infusion on severe acute pancreatitis, triglyceride, inflammatory factors and prognosis

Background: To evaluate the effects of nitroglycerin combined with continuous regional arterial infusion (CRAI) on severe acute pancreatitis (SAP), triglyceride (TG), inflammatory factors and prognosis.

Methods: SAP patients were randomly divided into control and observation groups (n=169). The control group was treated with intravenous infusion of nitroglycerin once daily for 2 d, while the observation group was treated with nitroglycerin combined with CRAI for 7 d. Their hospitalization time, abdominal pain relief time, abdominal distension relief time and intestinal function recovery time were recorded. The levels of inflammatory factors, and TG were measured. Their liver and kidney functions, hemorheological indices, prognosis, and adverse reactions were evaluated.

Results: The observation group had significantly shorter hospitalization time, abdominal pain relief time, abdominal distension relief time, and intestinal function recovery time than those of the control group (P<0.05). After treatment, the levels of interleukin-6, tumor necrosis factor-alpha, endothelin, thromboxane A2 and TG significantly decreased in contrast with those before treatment in both groups, especially in the observation group (P<0.05). The hemorheological indices were significantly improved after treatment compared with those before treatment in both groups, and the observation group had better indices (P<0.05). The Acute Physiology and Chronic Health Evaluation-II score declined significantly in both groups after treatment, and the observation group had a more obvious decrease (P<0.05). During follow-up, similar incidence rates of adverse reactions were observed for both groups (P>0.05).

Conclusion: Nitroglycerin combined with CRAI is prominently effective for treating SAP, which can facilitate the health recovery and reduce the incidence of microcirculation disturbance-induced adverse events such as organ failure.

Plasma D-Dimer Level Is an Early Predictor of Severity of Acute Pancreatitis Based on 2012 Atlanta Classification

Background

Acute pancreatitis (AP) is a common digestive disorder. Its management depends on the severity; therefore, it is essential to stratify AP patients early. D-dimer, a coagulation indicator, appears to be associated with the pathogenesis of AP. The aim of this study was to evaluate D-dimer as an early predictor of the severity of AP.

Material/Methods

This was a single-center retrospective study of 1260 patients diagnosed based on the revised Atlanta classification. Only patients hospitalized within 24 h of onset were included, and 334 patients were enrolled. Blood was collected at admission and 3 times within 48 h of admission. Values at admission and average of the 3 blood samples were evaluated by univariate and multivariate analyses. Furthermore, the area under the receiver-operating characteristic curve (AUC) was used to estimate the validity of the predictor and to define optimal cut-off points for prediction.

Results

We found that 53.3% of the patients had mild AP (MAP), 24.3% had moderately severe AP (MSAP), and 22.4% had severe AP (SAP). D-dimer at admission and the average D-dimer could distinguish MAP patients from MSAP and SAP patients, with cut-off values of 3.355 mg/L and 4.868 mg/L, respectively. No difference in the parameters at admission was observed in multivariate analysis in distinguishing SAP from MSAP, but the average D-dimer level was significantly different with a cut-off value of 7.268 mg/L by comparing Ranson score, APACHE II score, and D-dimer level.

Conclusions

The average value of D-dimer levels could be used as a predictor of severity of AP. In general, patients with an average D-dimer level <4.868 could be diagnosed with MAP, >7.268 would develop into SAP, and between 4.868 and 7.268 would be MSAP.

Prognostic value of D-dimer in acute pancreatitis: A systematic review and meta-analysis

AIM

To investigate the prognostic value of D-dimer in patients with acute pancreatitis (AP).

METHODS

Medline, EMBASE, Cochrane library, CBM, CNKI and other resources (from the date of their establishment to October 2017) were searched systematically. Eligible cohort studies on the predictive value of D-dimer in AP patients were collected. Quality assessment and data extraction were performed in those clinical trials in line with the inclusion criteria. Meta Disc software was applied to carry out meta-analysis.

RESULTS

Eight studies were included in the quantitative analysis. The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio with corresponding 95%CI for prediction of severity of AP were 0.80 (0.74-0.80), 0.75 (0.72-0.79), 3.17 (2.74-3.66), and 0.30 (0.23-0.38), respectively. The area under the receiver operating characteristic curve was 0.8345 (diagnostic odds ratio = 11.47; 95%CI: 8.06-16.33), albeit with no significant heterogeneity (Q = 4.57, I² = 0.0%, P > 0.1).

CONCLUSION

D-dimer has the potential to serve as a prognostic marker on admission for differentiating disease severity of AP.

D-二聚体在急性胰腺炎中的特点

目的

回顾性分析无锡101医院近2年来急性胰腺炎(acute pancreatitis, AP)患者D-二聚体(D-dimer, DD)值与临床特点, 探讨DD与病情严重程度的相关性, 为其临床研究提供参考.

方法

收集解放军101医院2014-04-01/2016-04-01 AP患者, 记载临床特点, 根据病情分为轻、中、重3组, 分析AP患者DD水平、住院时间、费用、Rason评分及CT严重度指数(CT severity index, CTSI)评分.

结果

符合要求者共172例, 其中轻度急性胰腺炎(mild acute pancreatitis, MAP)组111例, 中度重症急性胰腺炎(moderately severe acute pancreatitis, MSAP)组52例, 重症急性胰腺炎(severe acute pancreatitis, SAP)组9例. DD水平在MSAP、SAP组中明显高于MAP组, 有统计学意义(P<0.01), 但MSAP组对比SAP组无明显差异; 另外住院天数及费用3组间呈递增, 有统计学差异. 将3组患者中年龄<60岁分为中青年组, 年龄≥60岁为老年组, 其中SAP、MSAP两组中老年患者明显高于中青年患者(P<0.05), SAP组中未见明显差异; 老年患者中MAP、MSAP、SAP 3组DD水平均无统计学差异. DD与住院天数、费用、CTSI分级、Ranson评分系统的相关系数分别为0.429、0.436、0.402、0.447, 呈正相关.

结论

DD在AP患者显著增高, 中、重度组尤为明显, 与住院时间、费用、评分呈正相关, 本研究表明血浆DD体对AP严重程度的早期判断有一定的意义, 但对于老年AP患者以及对MSAP和SAP患者的判断效果欠佳.

Serum Concentrations of Angiopoietin-2 and Soluble fms-Like Tyrosine Kinase 1 (sFlt-1) Are Associated with Coagulopathy among Patients with Acute Pancreatitis

In severe acute pancreatitis (SAP), systemic inflammation leads to endothelial dysfunction and activation of coagulation. Thrombotic disorders in acute pancreatitis (AP) include disseminated intravascular coagulation (DIC). Recently, angiopoietin-2 and soluble fms-like tyrosine kinase 1 (sFlt-1) were proposed as markers of endothelial dysfunction in acute states. Our aim was to assess the frequency of coagulation abnormalities in the early phase of AP and evaluate the relationships between serum angiopoietin-2 and sFlt-1 and severity of coagulopathy. Sixty-nine adult patients with AP were recruited: five with SAP, 15 with moderately severe AP (MSAP) and 49 with mild AP. Six patients were diagnosed with DIC according to International Society on Thrombosis and Haemostasis (ISTH) score. All patients had at least one abnormal result of routine tests of hemostasis (low platelet count, prolonged clotting times, decreased fibrinogen, and increased D-dimer). The severity of coagulopathy correlated with AP severity according to 2012 Atlanta criteria, bedside index of severity in AP and duration of hospital stay. D-dimers correlated independently with C-reactive protein and studied markers of endothelial dysfunction. Angiopoietin-2, D-dimer, and ISTH score were best predictors of SAP, while sFlt-1 was good predictor of MSAP plus SAP. In clinical practice, routine tests of hemostasis may assist prognosis of AP.

Role of hyperlipidimia in pathogenesis of acute pancreatitis

Recently, many studies have focused on the relationship between hyperlipidemia (HL) and acute pancreatitis (AP). HL is a significant cause of AP, but it may also be secondary to AP. Hypertriglyceridemia (HTG) and hypercholesterolemia (HTC) are two types of HL. It is generally believed that HTG may induce AP and AP could increase the incidence of HTG. However, the relationship between HTC and AP has not yet confirmed. The diagnosis of hyperlipidemic acute pancreatitis (HLAP) needs not only the evidence of AP, but also an elevated level of serum lipids. Nevertheless, there still exist some divergent opinions regarding the level of serum lipids. Since the diagnosis of HLAP is critical for the therapy and prognosis, the lack of unified diagnostic criteria poses a great challenge for clinicians.

The Interplay between Inflammation, Coagulation and Endothelial Injury in the Early Phase of Acute Pancreatitis: Clinical Implications

Acute pancreatitis (AP) is an inflammatory disease with varied severity, ranging from mild local inflammation to severe systemic involvement resulting in substantial mortality. Early pathologic events in AP, both local and systemic, are associated with vascular derangements, including endothelial activation and injury, dysregulation of vasomotor tone, increased vascular permeability, increased leukocyte migration to tissues, and activation of coagulation. The purpose of the review was to summarize current evidence regarding the interplay between inflammation, coagulation and endothelial dysfunction in the early phase of AP. Practical aspects were emphasized: (1) we summarized available data on diagnostic usefulness of the markers of endothelial dysfunction and activated coagulation in early prediction of severe AP; (2) we reviewed in detail the results of experimental studies and clinical trials targeting coagulation-inflammation interactions in severe AP. Among laboratory tests, d-dimer and angiopoietin-2 measurements seem the most useful in early prediction of severe AP. Although most clinical trials evaluating anticoagulants in treatment of severe AP did not show benefits, they also did not show significantly increased bleeding risk. Promising results of human trials were published for low molecular weight heparin treatment. Several anticoagulants that proved beneficial in animal experiments are thus worth testing in patients.

Antithrombin III and D-dimer levels as indicators of disease severity in patients with hyperlipidaemic or biliary acute pancreatitis

Objective To assess changes in anticoagulation and fibrinolytic systems between biliary and hyperlipidaemic acute pancreatitis (AP). Methods Patients with biliary or hyperlipidaemic AP were enrolled. Demographic and clinical data were collected, and antithrombin III (ATIII), protein C, protein S, and D-dimer levels were investigated. Results A total of 45 patients with biliary AP and 50 patients with hyperlipidaemic AP were included (68 with mild AP and 27 with moderately-severe AP). ATIII and protein C levels in the mild AP group were significantly higher, but prothrombin time and D-dimer were significantly lower, versus the moderately-severe AP group. ATIII and D-dimer were found to be risk factors for moderately-severe AP. ATIII could predict AP severity, particularly in patients with biliary AP. D-dimer was a sensitive and specific predictor for disease severity in patients with AP, particularly in patients with hyperlipidaemic AP. Conclusion ATIII and protein C levels decreased as severity of AP increased, particularly in cases of biliary AP. D-dimer levels increased with severity of AP, particularly in hyperlipidaemic AP. ATIII and D-dimer may be useful biomarkers for assessing AP severity in patients with biliary and hyperlipidaemic AP, respectively.