1
|
Velarde-Ruiz Velasco JA, Crespo J, Montaño-Loza A, Aldana-Ledesma JM, Cano-Contreras AD, Cerda-Reyes E, Fernández Pérez NJ, Castro-Narro GE, García-Jiménez ES, Lira-Vera JE, López-Méndez YI, Meza-Cardona J, Moreno-Alcántar R, Pérez-Escobar J, Pérez-Hernández JL, Tapia-Calderón DK, Higuera-de-la-Tijera F. Position paper on perioperative management and surgical risk in the patient with cirrhosis. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2024:S2255-534X(24)00057-4. [PMID: 39003101 DOI: 10.1016/j.rgmxen.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/02/2024] [Indexed: 07/15/2024]
Abstract
INTRODUCTION Management of the patient with cirrhosis of the liver that requires surgical treatment has been relatively unexplored. In Mexico, there is currently no formal stance or expert recommendations to guide clinical decision-making in this context. AIMS The present position paper reviews the existing evidence on risks, prognoses, precautions, special care, and specific management or procedures for patients with cirrhosis that require surgical interventions or invasive procedures. Our aim is to provide recommendations by an expert panel, based on the best published evidence, and consequently ensure timely, quality, efficient, and low-risk care for this specific group of patients. RESULTS Twenty-seven recommendations were developed that address preoperative considerations, intraoperative settings, and postoperative follow-up and care. CONCLUSIONS The assessment and care of patients with cirrhosis that require major surgical or invasive procedures should be overseen by a multidisciplinary team that includes the anesthesiologist, hepatologist, gastroenterologist, and clinical nutritionist. With respect to decompensated patients, a nephrology specialist may be required, given that kidney function is also a parameter involved in the prognosis of these patients.
Collapse
Affiliation(s)
- J A Velarde-Ruiz Velasco
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - J Crespo
- Servicio de Aparato Digestivo, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - A Montaño-Loza
- División de Gastroenterología y Hepatología, Hospital de la Universidad de Alberta, Alberta, Canada
| | - J M Aldana-Ledesma
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - A D Cano-Contreras
- Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, Mexico
| | | | | | - G E Castro-Narro
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - E S García-Jiménez
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - J E Lira-Vera
- Servicio de Gastroenterología y Hepatología, Hospital Central «Dr. Ignacio Morones Prieto», San Luis Potosí, San Luis Potosí, Mexico
| | - Y I López-Méndez
- Departamento de Gastroenterología, Medica Sur, Mexico City, Mexico
| | - J Meza-Cardona
- Departamento de Gastroenterología, Hospital Español, Mexico City, Mexico
| | - R Moreno-Alcántar
- Departamento de Gastroenterología, Hospital de Especialidades «Dr. Bernando Sepúlveda», UMAE Centro Médico Nacional Siglo XXI, IMSS, Mexico City, Mexico
| | - J Pérez-Escobar
- Servicio de Gastroenterología y Unidad de Trasplante Hepático, Hospital Juárez de México, Mexico City, Mexico
| | - J L Pérez-Hernández
- Servicio de Gastroenterología y Hepatología, Hospital General de México «Dr. Eduardo Liceaga», Mexico City, Mexico
| | - D K Tapia-Calderón
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - F Higuera-de-la-Tijera
- Servicio de Gastroenterología y Hepatología, Hospital General de México «Dr. Eduardo Liceaga», Mexico City, Mexico.
| |
Collapse
|
2
|
Weng T, Zhang X, He J, Yang Y, Li C. Bioinformatics-based analysis of the relationship between plasminogen regulatory genes and photoaging. J Cosmet Dermatol 2024; 23:2270-2278. [PMID: 38634239 DOI: 10.1111/jocd.16266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 02/08/2024] [Accepted: 02/23/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Ultraviolet radiation causes skin photoaging by producing a variety of enzymes, which impact both skin health and hinder beauty. Currently, the early diagnosis and treatment of photoaging remain a challenge. Bioinformatics analysis has strong advantages in exploring core genes and the biological pathways of photoaging. AIMS To screen and validate key risk genes associated with plasminogen in photoaging and to identify potential target genes for photoaging. METHODS Two human transcriptome datasets were obtained by searching the Gene Expression Omnibus (GEO) database, and the mRNAs in the GSE131789 dataset were differentially analyzed, and then the weighted gene co-expression network analysis (WGCNA) was performed to find out the strongest correlations. Template genes, interaction analysis of differentially expressed genes (DEGs), modular genes with the most WGCNA correlations, and genecard database genes related to plasminogen were performed, and further Kyoto genes and Genome Encyclopedia (KEGG) pathway analysis. Two different algorithms, least absolute shrinkage and selection operator (LASSO) and support vector machines-recursive feature elimination (SVM-RFE), were used to find key genes. Then the data set (GSE206495) was validated and analyzed. Real-time PCR was performed to validate the expression of key genes through in vitro cellular experiments. RESULTS IFI6, IFI44L, HRSP12, and BMP4 were screened from datasets as key genes for photoaging and further analysis showed that these genes have significant diagnostic value for photoaging. CONCLUSION IFI6, IFI44L, HRSP12, and BMP4 play a key role in the pathogenesis of photoaging, and serve as promising potential predictive biomarkers for photoaging.
Collapse
Affiliation(s)
- Tengyu Weng
- Department of Dermatology, First Medical Center of PLA General Hospital, Beijing, China
| | - Xiaoning Zhang
- Department of Dermatology, First Medical Center of PLA General Hospital, Beijing, China
| | - Juan He
- Department of Dermatology, First Medical Center of PLA General Hospital, Beijing, China
| | - Yi Yang
- Department of Dermatology, Third Medical Center of PLA General Hospital, Beijing, China
| | - Chengxin Li
- Department of Dermatology, First Medical Center of PLA General Hospital, Beijing, China
| |
Collapse
|
3
|
Afzal A, Gage BF, Suhong L, Schoen M, Sanfilippo KM. Modest performance of risk-prediction models for anticoagulant-related bleeding in patients with chronic liver disease. Thromb Res 2024; 237:138-140. [PMID: 38583311 DOI: 10.1016/j.thromres.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/11/2024] [Accepted: 04/02/2024] [Indexed: 04/09/2024]
Affiliation(s)
- Amber Afzal
- Department of Medicine, Washington University in St Louis, St Louis, MO, United States of America.
| | - Brian F Gage
- Department of Medicine, Washington University in St Louis, St Louis, MO, United States of America
| | - Luo Suhong
- Department of Medicine, St. Louis Veterans Administration Medical Center, St Louis, MO, United States of America
| | - Martin Schoen
- Department of Medicine, St. Louis Veterans Administration Medical Center, St Louis, MO, United States of America
| | - Kristen M Sanfilippo
- Department of Medicine, Washington University in St Louis, St Louis, MO, United States of America; Department of Medicine, St. Louis Veterans Administration Medical Center, St Louis, MO, United States of America
| |
Collapse
|
4
|
Lester W, Bent C, Alikhan R, Roberts L, Gordon-Walker T, Trenfield S, White R, Forde C, Arachchillage DJ. A British Society for Haematology guideline on the assessment and management of bleeding risk prior to invasive procedures. Br J Haematol 2024; 204:1697-1713. [PMID: 38517351 DOI: 10.1111/bjh.19360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 02/12/2024] [Accepted: 02/13/2024] [Indexed: 03/23/2024]
Affiliation(s)
- Will Lester
- Department of Haematology, University Hospitals Birmingham, Birmingham, UK
| | - Clare Bent
- Department of Radiology, University Hospitals Dorset, Dorset, UK
| | - Raza Alikhan
- Department of Haematology, University Hospitals of Cardiff, Cardiff, UK
| | - Lara Roberts
- Department of Haematology, King College London, London, UK
| | - Tim Gordon-Walker
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Sarah Trenfield
- Department of Anaesthesia and Critical Care, Royal Brompton Hospital, London, UK
| | - Richard White
- Department of Radiology, Cardiff and Vale UHB, Cardiff, UK
| | - Colm Forde
- Department of Radiology, University Hospitals Birmingham, Birmingham, UK
| | - Deepa J Arachchillage
- Department of Immunology and Inflammation, Centre for Haematology, Imperial College London, London, UK
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
| |
Collapse
|
5
|
Elkrief L, Denecheau-Girard C, Magaz M, Praktiknjo M, Colucci N, Ollivier-Hourmand I, Dumortier J, Simon Talero M, Tellez L, Artru F, Meszaros M, Verhelst X, Tabchouri N, Beires F, Andaluz I, Leo M, Diekhöner M, Dokmak S, Fundora Y, Vidal-Gonzalez J, Toso C, Plessier A, Carlos Garcia Pagan J, Rautou PE. Abdominal surgery in patients with chronic noncirrhotic extrahepatic portal vein obstruction: A multicenter retrospective study. Hepatology 2024:01515467-990000000-00867. [PMID: 38683626 DOI: 10.1097/hep.0000000000000901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 03/22/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND AND AIMS In patients with noncirrhotic chronic extrahepatic portal vein obstruction (EHPVO), data on the morbimortality of abdominal surgery are scarce. APPROACH AND RESULTS We retrospectively analyzed the charts of 76 patients (78 interventions) with EHPVO undergoing abdominal surgery within the Vascular Disease Interest Group network. Fourteen percent of the patients had ≥1 major bleeding (unrelated to portal hypertension) and 21% had ≥1 Dindo-Clavien grade ≥3 postoperative complications within 1 month after surgery. Fifteen percent had ≥1 portal hypertension-related complication within 3 months after surgery. Three patients died within 12 months after surgery. An unfavorable outcome (ie, ≥1 abovementioned complication or death) occurred in 37% of the patients and was associated with a history of ascites and with nonwall, noncholecystectomy surgical intervention: 17% of the patients with none of these features had an unfavorable outcome, versus 48% and 100% when one or both features were present, respectively. We then compared 63/76 patients with EHPVO with 126 matched (2:1) control patients without EHPVO but with similar surgical interventions. As compared with control patients, the incidence of major bleeding ( p <0.001) and portal hypertension-related complication ( p <0.001) was significantly higher in patients with EHPVO, but not that of grade ≥3 postoperative complications nor of death. The incidence of unfavorable postoperative outcomes was significantly higher in patients with EHPVO than in those without (33% vs. 18%, p =0.01). CONCLUSIONS Patients with EHPVO are at high risk of major perioperative or postoperative bleeding and postoperative complications, especially in those with ascites or undergoing surgery other than wall surgery or cholecystectomy.
Collapse
Affiliation(s)
- Laure Elkrief
- Faculté de médecine et service d'hépato-gastroentérologie, CHRU de Tours, ERN RARE-LIVER, France
- Inserm, Centre de recherche sur l'inflammation, UMR, Paris, France
| | | | - Marta Magaz
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Departament de Medicina i Ciències de la Salut, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Universitat de Barcelona
| | | | - Nicola Colucci
- Service de chirurgie viscérale, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | | | - Jérôme Dumortier
- Service d'Hépatogastroentérologie, Hôpital Edouard Herriot, Lyon
| | - Macarena Simon Talero
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Luis Tellez
- Departamento de Gastroenterología y Hepatología Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Florent Artru
- Service d'hépato-gastroentérologie, CHUV, Lausanne, Switzerland
| | | | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Belgium
| | - Nicolas Tabchouri
- Service de chirurgie digestive et de transplantation hépatique, CHRU de Tours, France
| | - Francisca Beires
- AP-HP, Service d'Hépatologie, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Irene Andaluz
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Departament de Medicina i Ciències de la Salut, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Universitat de Barcelona
| | - Massimo Leo
- AP-HP, Service d'Hépatologie, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Mara Diekhöner
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Safi Dokmak
- AP-HP, Service de chirurgie hépato-biliaire et pancréatique, Hôpital Beaujon, DMU DIGEST, Clichy, France
| | - Yliam Fundora
- Department of General & Digestive Surgery, Institut de Malalties Digestives I Metabòliques, Hospital Clínic, University of Barcelona, IDIBAPS, Spain
| | - Judit Vidal-Gonzalez
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Christian Toso
- Service de chirurgie viscérale, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Aurélie Plessier
- Inserm, Centre de recherche sur l'inflammation, UMR, Paris, France
- AP-HP, Service d'Hépatologie, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Juan Carlos Garcia Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Departament de Medicina i Ciències de la Salut, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Universitat de Barcelona
| | - Pierre-Emmanuel Rautou
- Inserm, Centre de recherche sur l'inflammation, UMR, Paris, France
- AP-HP, Service d'Hépatologie, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| |
Collapse
|
6
|
Tiede A, Susen S, Lisman T. Acquired bleeding disorders. Haemophilia 2024; 30 Suppl 3:29-38. [PMID: 38562115 DOI: 10.1111/hae.14995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 04/04/2024]
Abstract
Acquired bleeding disorders can develop in previously healthy people irrespective of age or gender but are particularly common in patients with certain underlying conditions. Here, we review recent advances in the management of acquired haemophilia A (AHA), acquired von Willebrand syndrome (AVWS), and patients with hemostatic abnormalities due to chronic liver disease (CLD). Patients with AHA can now benefit from prophylaxis with emicizumab, a therapeutic antibody that mimics the function of activated coagulation factor VIII. The treatment of AVWS remains challenging in many situations and requires careful consideration of the underlying condition. Haemostatic abnormalities in CLD are often compensated by proportional reduction in pro and anti-haemostatic factors resulting in sustained or even increased thrombin generation. Consequently, bleeding in CLD is rarely caused by haemostatic failure and infusion of plasma or coagulation factor concentrates may not be effective.
Collapse
Affiliation(s)
- Andreas Tiede
- Department of Haematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Sophie Susen
- Hemostasis and Transfusion Department, University of Lille, Lille University Hospital, Lille, France
| | - Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| |
Collapse
|
7
|
Maynard S, Marrinan E, Roberts L, Stanworth S. Does the Use of Viscoelastic Hemostatic Assays for Periprocedural Hemostasis Management in Liver Disease Improve Clinical Outcomes? Transfus Med Rev 2024:150823. [PMID: 38616454 DOI: 10.1016/j.tmrv.2024.150823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/05/2024] [Accepted: 02/14/2024] [Indexed: 04/16/2024]
Abstract
Routine hemostasis parameters such as prothrombin time and fibrinogen are frequently abnormal in patients with chronic liver disease and have been demonstrated to be poor predictors for periprocedural bleeding. Alterations in procoagulant and anticoagulant factors in this population result in a state of rebalanced hemostasis, which is not reflected by routine hemostatic measures. Viscoelastic hemostatic assays (VHA) present a point of care measure of global hemostasis with an emerging role in guiding transfusion in the liver transplant setting. The potential role for VHA in guiding periprocedural transfusion is unknown. Here we critically appraise the available limited evidence on the use of VHA to guide prophylactic treatment in patients with cirrhosis undergoing procedures. We assess whether the impact of a VHA-guided approach improves clinical outcomes. Suggested areas for future research with a focus on clinically relevant outcomes, particularly periprocedural bleeding, are highlighted.
Collapse
Affiliation(s)
- Suzanne Maynard
- NIHR Blood and Transplant Research Unit in Data Driven Transfusion Practice, Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Elizabeth Marrinan
- Institute of Pharmaceutical Sciences, King's College London, UK; Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK.
| | - Lara Roberts
- Institute of Pharmaceutical Sciences, King's College London, UK; Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Simon Stanworth
- NIHR Blood and Transplant Research Unit in Data Driven Transfusion Practice, Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Department of Haematology and Transfusion Medicine, NHSBT and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| |
Collapse
|
8
|
Riescher-Tuczkiewicz A, Caldwell SH, Kamath PS, Villa E, Rautou PE. Expert opinion on bleeding risk from invasive procedures in cirrhosis. JHEP Rep 2024; 6:100986. [PMID: 38384669 PMCID: PMC10879786 DOI: 10.1016/j.jhepr.2023.100986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 02/23/2024] Open
Abstract
Background & Aims Despite several recent international guidelines, no consensus exists on the bleeding risk nor haemostatic parameter thresholds that define the safety of invasive procedures in patients with cirrhosis. The aim of this study was to establish a position paper on the bleeding risk associated with invasive procedures in patients with cirrhosis among the experts involved in various guidelines. Methods All experts involved in recent guidelines on the management of invasive procedures in patients with cirrhosis were invited to classify 80 procedures as "high risk" or "low risk" with respect to bleeding. Procedures were considered high risk when the estimated risk of major bleeding was 1.5% or more, or when even minor bleeding might lead to significant morbidity or death. The experts were also asked to choose safety thresholds for laboratory test values at which elective invasive procedures could be safely performed. The predetermined threshold considered as "consensus" was ≥75% agreement. Results Fifty-two experts participated in the study. Out of 80 procedures, a consensus opinion was reached for 52 procedures (65%): 17 procedures were classified as "high risk", primarily interventional endoscopic procedures, percutaneous organ biopsies, or procedures involving the central nervous system; and 35 as "low risk", primarily "diagnostic" procedures. The lowest platelet counts at which performance of a low-risk procedure or a high-risk procedure/surgery were deemed acceptable were 30 × 109/L and 50 × 109/L, respectively. Experts did not believe that international normalised ratio should be considered before performing low-risk procedures; 71% also indicated that it should not be considered before performing high-risk procedures. Conclusions This experience-based classification may be helpful to refine future study designs and to guide clinical decision making regarding invasive procedures in patients with cirrhosis. Impact and implications Several risk classifications and management guidelines for invasive procedures in patients with cirrhosis have been proposed, but with conflicting recommendations. By providing a position paper, based on the opinion of a broad panel of experts, on the bleeding risk associated with 52 invasive procedures in patients with cirrhosis, this survey will help to provide a framework for future study design. The consensus on platelet count, international normalised ratio, fibrinogen and activated partial thromboplastin time identified in this survey will inform physicians regarding the laboratory test values considered acceptable by the experts prior to the performance of an elective invasive procedure in patients with cirrhosis.
Collapse
Affiliation(s)
| | - Stephen H. Caldwell
- Division of Gastroenterology & Hepatology, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - Patrick S. Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Erica Villa
- Gastroenterology Unit, Chimomo Department, University of Modena and Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Pierre-Emmanuel Rautou
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| |
Collapse
|
9
|
Zanetto A, Campello E, Bulato C, Willems R, Konings J, Roest M, Gavasso S, Nuozzi G, Toffanin S, Zanaga P, Burra P, Russo FP, Senzolo M, de Laat B, Simioni P. Whole blood thrombin generation shows a significant hypocoagulable state in patients with decompensated cirrhosis. J Thromb Haemost 2024; 22:480-492. [PMID: 37866518 DOI: 10.1016/j.jtha.2023.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/20/2023] [Accepted: 10/09/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Patients with cirrhosis have a normal to increased thrombin generation (TG) capacity in platelet-poor plasma (PPP). By reflecting the contribution of all circulating blood cells, whole blood (WB) TG may allow a more physiological assessment of coagulation. OBJECTIVES We compared WB-TG vs PPP-TG in patients with cirrhosis. METHODS Assessment of coagulation included routine tests, factor VIII, natural anticoagulants, PPP-TG, and WB-TG. TG assays were performed with and without thrombomodulin. Twenty-five healthy subjects were included as controls. RESULTS We included 108 patients (Child-Pugh A/B/C, 44/24/40). Compared with controls, patients had significantly lower platelet count, longer international normalized ratio, higher FVIII, and lower levels of protein C/S and antithrombin. Regarding thrombomodulin-modified TG assays, in compensated cirrhosis, both PPP-TG and WB-TG indicated an increased TG capacity, as reflected by an endogenous thrombin potential (ETP) significantly higher than controls. In contrast, in decompensated cirrhosis, PPP-TG indicated a hypercoagulable state with increased ETP, higher peak height, and shorter time-to-peak than controls, whereas WB-TG revealed a progressive impairment of TG kinetics and total capacity, ultimately resulting in a profound hypocoagulable state in patients with Child-Pugh C cirrhosis (ie, significant prolongation of lag time and time-to-peak with reduction of both ETP and peak height). In decompensated patients, bacterial infections and severity of anemia were associated with a further reduction of both ETP and peak height. CONCLUSION Compensated cirrhosis is associated with an increased TG capacity. In decompensated cirrhosis, contrary to PPP-TG, which indicates hypercoagulability, WB-TG shows a significant hypocoagulable state. The clinical value of these findings deserves further investigation.
Collapse
Affiliation(s)
- Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy. https://twitter.com/azanetto
| | - Elena Campello
- General Internal Medicine Unit, Azienda Ospedale - Università Padova, Padova, Italy; Thrombotic and Haemorrhagic Disease Unit and Haemophilia Center, Department of Medicine, University of Padova, Italy
| | - Cristiana Bulato
- Thrombotic and Haemorrhagic Disease Unit and Haemophilia Center, Department of Medicine, University of Padova, Italy
| | - Ruth Willems
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands; Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Center, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht, School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Joke Konings
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands
| | - Mark Roest
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands
| | - Sabrina Gavasso
- Thrombotic and Haemorrhagic Disease Unit and Haemophilia Center, Department of Medicine, University of Padova, Italy
| | - Giorgia Nuozzi
- Thrombotic and Haemorrhagic Disease Unit and Haemophilia Center, Department of Medicine, University of Padova, Italy
| | - Serena Toffanin
- Thrombotic and Haemorrhagic Disease Unit and Haemophilia Center, Department of Medicine, University of Padova, Italy
| | - Paola Zanaga
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Patrizia Burra
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Francesco Paolo Russo
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Marco Senzolo
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Bas de Laat
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands
| | - Paolo Simioni
- General Internal Medicine Unit, Azienda Ospedale - Università Padova, Padova, Italy; Thrombotic and Haemorrhagic Disease Unit and Haemophilia Center, Department of Medicine, University of Padova, Italy.
| |
Collapse
|
10
|
Sohail MA, Vachharajani TJ, Lane JE, Huang S, Wang X, Mucha S, Kapoor A, Dugar S, Hanane T. Thromboelastography-Guided Correction of Coagulopathy Before Tunneled Central Venous Access in Critically Ill Patients With Liver Disease: A Propensity Score-Matched Study. Crit Care Explor 2023; 5:e1023. [PMID: 38115819 PMCID: PMC10730036 DOI: 10.1097/cce.0000000000001023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Abstract
Importance Optimal blood product transfusion strategies before tunneled central venous catheter (CVC) placement are required in critically ill coagulopathic patients with liver disease to reduce exposure to allogeneic blood products and mitigate bleeding and thrombotic complications. Objectives This study evaluated the safety and efficacy of a thromboelastography-guided transfusion strategy for the correction of coagulopathy in patients with liver disease compared with a conventional transfusion strategy (using international normalized ratio, platelet count, and fibrinogen) before tunneled CVC insertion. Design Setting and Participants A retrospective propensity score-matched single-center cohort study was conducted at a quaternary care academic medical center involving 364 patients with liver disease (cirrhosis and acute liver failure) who underwent tunneled CVC insertion in the ICU. Patients were stratified into two groups based on whether they received blood product transfusions based on a thromboelastography-guided or conventional transfusion strategy. Main Outcomes and Measures Primary outcomes that were evaluated included the volume, units and cost of blood products (fresh frozen plasma, cryoprecipitate, and platelets) when using a thromboelastography-guided or conventional approach to blood transfusions. Secondary outcomes included the frequency of procedure-related bleeding and thrombotic complications. Results The total number of units/volume/cost of fresh frozen plasma (12 U/3,000 mL/$684 vs. 32 U/7,500 mL/$1,824 [p = 0.019]), cryoprecipitate (60 U/1,500 mL/$3,240 vs. 250 U/6,250 mL/$13,500 [p < 0.001]), and platelets (5 U/1,500 mL/$2,610 vs. 13 units/3,900 mL/$6,786 [p = 0.046]) transfused were significantly lower in the thromboelastography-guided transfusion group than in the conventional transfusion group. No differences in the frequency of bleeding/thrombotic events were observed between the two groups. Conclusions and Relevance A thromboelastography-guided transfusion strategy for correction of coagulopathy in critically ill patients with liver disease before tunneled CVC insertion, compared with a conventional transfusion strategy, reduces unnecessary exposure to allogeneic blood products and associated costs without increasing the risk for peri-procedural bleeding and thrombotic complications.
Collapse
Affiliation(s)
- Mohammad A Sohail
- Department of Kidney Medicine, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Tushar J Vachharajani
- Department of Medicine, John D. Dingell Department of VA Medical Center, Detroit, MI
- Department of Medicine, Wayne State University School of Medicine, Detroit, MI
| | - James E Lane
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Shuaiqi Huang
- Department of Quantitative Health Sciences at Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Xiaofeng Wang
- Department of Quantitative Health Sciences at Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Simon Mucha
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Aanchal Kapoor
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Tarik Hanane
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, OH
| |
Collapse
|