Assessment of coagulation and fibrinolysis in children with chronic liver disease

Fibrinogen level among children with liver cirrhosis

Introduction

The liver has a major role in the production of coagulation factors, and cirrhotic patients have a series of coagulopathy disorders. The present study aimed to measure plasma fibrinogen levels in children with hepatic cirrhosis.

Method

Patients younger than 18 years old after diagnosis of liver cirrhosis by biopsy were enrolled in the study. Laboratory data including hemoglobin, PT, PTT, INR, and liver function tests were recorded. Fibrinogen levels were measured using the Clauss method. PELD score for children less than 12 years and MELD Na for children over 12 years were used to measure the severity of the liver disease.

Results

Fifty children with cirrhosis were studied. The mean fibrinogen level in the “PELD < 15” group was significantly higher than the other group (P < 0.001). There was no significant relationship between bleeding and fibrinogen levels. There was no significant relationship between PELD and bleeding in subjects (P = 0.87). The results of the study showed neither of these two factors (fibrinogen level and PELD) can play a predictive role in causing hemorrhage in patients.

Conclusion

Our study has shown that fibrinogen level is significantly associated with severity of liver cirrhosis and decreases with more severe disease (PELD levels), but platelet and fibrinogen cannot predict the severity of bleeding in these patients.

Hemostatic parameters predict 90-day mortality in hospitalized cirrhotic patients with acute decompensation: a prospective cohort study

Hemostatic disturbances are common in patients with cirrhosis. Few studies have evaluated the prognostic role of hemostatic parameters in cirrhosis with acute decompensation. This study aims to determine the prognostic ability of standard hemostatic parameters in hospitalized cirrhotic patients with acute decompensation. Cirrhotic patients admitted with acute decompensation were prospectively enrolled. Hemostatic parameters were determined within 24 h, and the DIC (disseminated intravascular coagulation) score was calculated based on platelet count, prothrombin time (PT), fibrinogen, and D-dimer. New onset of in-hospital major bleeding and 90-day mortality were assessed. Eighty-nine patients were included (MELD 13.6 ± 5.7). The indications of admission were infection (38.2%), and portal hypertension-related bleeding (31.5%). 14.6% developed in-hospital major bleeding, and 90-day mortality rate was 21.3%. Major bleeding group and 90-day nonsurvivors had significantly higher activated partial thromboplastin time (aPTT), PT, and DIC score. The 90-day mortality rate was higher in major bleeding group (46.2 vs. 17.1%, P = 0.029). By multivariate logistic regression analysis, DIC score was associated with 90-day mortality. The AUROC of DIC score for 90-day mortality prediction was significantly higher than of MELD score (0.78 vs. 0.59, P = 0.04). DIC score at least 4 predicted 90-day mortality with a sensitivity of 88.9%. The cumulative 90-day survival was significantly lower in patients with DIC score at least 4 (57.2 vs. 93.6%, P = 0.0003). The development of in-hospital major bleeding significantly increases mortality in cirrhotic patients with acute decompensation. The DIC score within 24 h can be used as a simple and reliable predictor for 90-day mortality in these patients.

A Review on Clinical, Pathophysiological, and Diagnostic Hematological Features in Children With Liver Cirrhosis

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.

Coagulopathy in Zellweger spectrum disorders: a role for vitamin K

INTRODUCTION

Zellweger spectrum disorders (ZSDs) are caused by an impairment of peroxisome biogenesis, resulting in multiple metabolic abnormalities. This leads to a range of symptoms, including hepatic dysfunction and coagulopathy. This study evaluated the incidence and severity of coagulopathy and the effect of vitamin K supplementation orally and IV in ZSD.

METHODS

Data were retrospectively retrieved from the medical records of 30 ZSD patients to study coagulopathy and the effect of vitamin K orally on proteins induced by vitamin K absence (PIVKA-II) levels. Five patients from the cohort with a prolonged prothrombin time, low factor VII, and elevated PIVKA-II levels received 10 mg of vitamin K IV. Laboratory results, including thrombin generation, at baseline and 72 h after vitamin K administration were examined.

RESULTS

In the retrospective cohort, four patients (13.3%) experienced intracranial bleedings and 14 (46.7%) reported minor bleeding. No thrombotic events occurred. PIVKA-II levels decreased 38% after start of vitamin K therapy orally. In the five patients with a coagulopathy, despite treatment with oral administration of vitamin K, vitamin K IV caused an additional decrease (23%) of PIVKA-II levels and increased thrombin generation.

CONCLUSION

Bleeding complications frequently occur in ZSD patients due to liver disease and vitamin K deficiency. Vitamin K deficiency is partly corrected by vitamin K supplementation orally, and vitamin K administered IV additionally improves vitamin K status, as shown by further decrease of PIVKA-II and improved thrombin generation.

D-dimer level for predicting the in-hospital mortality in liver cirrhosis: A retrospective study

The present study aimed to examine the correlation of D-dimer levels with the Child-Pugh and MELD scores, as well as to determine the predictive ability of D-dimer level for the in-hospital mortality of liver cirrhosis patients. All cirrhotic patients who were consecutively admitted to our hospital between January 2011 and June 2014, and underwent D-dimer tests on admission were retrospectively analyzed. Pearson's χ² tests were employed to evaluate the correlations of D-dimer levels with Child-Pugh and MELD scores. In addition, receiver operating curve (ROC) analysis was employed to evaluate the specificity and sensitivity of D-dimer levels for predicting the in-hospital mortality. In total, 703 cirrhotic patients were included in the study, with an in-hospital mortality of 5.4% (38/703). The D-dimer levels were correlated with Child-Pugh (correlation coefficient, 0.219; P<0.001) and MELD scores (correlation coefficient, 0.207; P<0.001). The highest D-dimer level was observed in the Child-Pugh class C patients, followed by the class B and A patients. Furthermore, D-dimer was significantly higher in the MELD score >15 group compared with the MELD score <15 group. The area under the ROC of D-dimer levels for predicting the in-hospital mortality of liver cirrhosis was 0.729 (P<0.0001), while the best cut-off D-dimer value was 0.28 µg/ml with a sensitivity of 86.84% and a specificity of 49.17%. In conclusion, the D-dimer level is significantly associated with the degree of liver dysfunction. Therefore, D-dimer testing could be employed for the prognostic stratification of liver cirrhosis.

A conceptual and practical approach to haemostasis in paediatric liver disease

Children with liver disease can develop severe bleeding episodes and thrombosis. Liver failure usually results in decreased levels of procoagulant and anticoagulant factors. Additional risk factors, including changes in vascular flow and endothelial function, are of importance for the development of bleeding or thrombosis in individual vascular beds. Detailed studies of haemostatic disturbances in the setting of paediatric liver disease are sparse and extrapolation from adult studies is common. The spectrum of liver diseases and the haemostatic system differs between children and adults. Specific paediatric liver diseases are reported to have more distinctive effects on haemostasis and the risk of bleeding and/or thrombosis.

CONCLUSION

we propose a model regarding haemostasis in paediatric liver disease, taking into account a number of specific variables and mechanisms, as well as the type of liver disease, which will provide a framework for clinical decision-making in these complex patients.