1
|
Azer A, Kong K, Basta D, Modica SF, Gore A, Gorman E, Sutherland A, Tafesh Z, Horng H, Glass NE. Evaluation of coagulopathy in cirrhotic patients: A scoping review of the utility of viscoelastic testing. Am J Surg 2024; 227:34-43. [PMID: 37722936 DOI: 10.1016/j.amjsurg.2023.09.001] [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: 06/30/2023] [Revised: 08/17/2023] [Accepted: 09/01/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Cirrhosis causes significant coagulopathy. Traditional coagulation tests may not accurately measure coagulopathy in well-compensated patients with cirrhosis. Viscoelastic tests are functional tests that may better assess coagulopathy in cirrhotic patients. METHODS We searched PubMed, ScienceDirect, Google Scholar, and grey literature using terms meaning viscoelastic testing and cirrhosis. After reviewing over 500 titles and abstracts, 40 full-text papers met inclusion criteria. RESULTS Twenty-two papers found viscoelastic testing was a better indicator of baseline coagulation than traditional testing in cirrhosis. Nineteen additional papers evaluated the utility of peri-procedural viscoelastic testing and found they led to a reduction in blood product administration without increasing risk of hemorrhage, thrombotic events, or other complications. CONCLUSIONS The usage of viscoelastic testing in patients with cirrhosis allows for better assessment of coagulopathy, resulting in improved outcomes. Educating physicians to optimize care of this high-risk group is necessary to further improve their treatment.
Collapse
Affiliation(s)
| | | | | | | | - Amy Gore
- Rutgers New Jersey Medical School, USA
| | | | | | | | | | | |
Collapse
|
2
|
Kampelos G, Alexopoulos T, Vasilieva L, Mani I, Hadziyannis E, Giannouli S, Manioudaki S, Nomikou E, Alexopoulou A. A combination of clot formation abnormalities in thromboelastometry has a high prognostic value in patients with acute-on-chronic liver failure. Eur J Gastroenterol Hepatol 2024; 36:76-82. [PMID: 37823404 DOI: 10.1097/meg.0000000000002630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
BACKGROUND Global coagulation tests offer a better tool to assess procoagulant and anticoagulant pathways, fibrinolysis and clot firmness and evaluate more accurately coagulation defects compared to conventional coagulation tests. Their prognostic role in acute-on-chronic liver disease (ACLF) or acute decompensation (AD) has not been well established. AIMS To assess the properties and prognostic value of the coagulation profile measured by rotational thromboelastometry (ROTEM) in ACLF and AD. METHODS 84 consecutive patients (35 ACLF and 49 AD) were prospectively studied. Twenty healthy persons matched for age and gender were used as controls. 'Hypocoagulable' or 'hypercoagulable' profiles on admission were assessed based on nine ROTEM parameters and mortality was recorded at 30 and 90 days. RESULTS Individual ROTEM parameters denoted significantly more hypocoagulability in patients compared to controls. 'Hypocoagulable' profile (defined as a composite of 4 or more ROTEM parameters outside the range) was associated with more severe liver disease assessed either as MELD or Child-Pugh scores ( P < 0.001 for both) and higher 30-day mortality (Log-rank P = 0.012). 'Hypocoagulable' profile (HR 3.160, 95% CI 1.003-9.957, P = 0.049) and ACLF status (HR 23.786, 95% CI 3.115-181.614, P = 0.002) were independent predictors of 30-day mortality, in multivariate model. A higher early mortality rate was shown in ACLF patients with 'hypocoagulable' phenotype compared to those without (Log-rank P = 0.017). 'Hypocoagulable' profile was not associated with mortality in AD. CONCLUSION 'Hypocoagulable' profile was associated with more advanced liver disease and higher short-term mortality in patients with ACLF.
Collapse
Affiliation(s)
- George Kampelos
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, National & Kapodistrian University of Athens, Hippokration General Hospital
| | - Theodoros Alexopoulos
- Gastroenterology Department, National & Kapodistrian University of Athens, Medical School, Laiko General Hospital
| | | | - Iliana Mani
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, National & Kapodistrian University of Athens, Hippokration General Hospital
| | - Emilia Hadziyannis
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, National & Kapodistrian University of Athens, Hippokration General Hospital
| | - Stavroula Giannouli
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, National & Kapodistrian University of Athens, Hippokration General Hospital
| | | | - Efrosyni Nomikou
- Blood Bank and Haemophilia Unit, Hippokratio General Hospital of Athens, Athens, Greece
| | - Alexandra Alexopoulou
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, National & Kapodistrian University of Athens, Hippokration General Hospital
| |
Collapse
|
3
|
Viscoelastic versus conventional coagulation tests to reduce blood product transfusion in patients undergoing liver transplantation: A systematic review and meta-analysis. Eur J Anaesthesiol 2023; 40:39-53. [PMID: 36412263 DOI: 10.1097/eja.0000000000001780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Recent literature suggests viscoelastic test (VET)-guided transfusion management could be associated with reduced blood product administration in patients undergoing liver transplantation. OBJECTIVES To assess the effectiveness of coagulation management guided by VETs compared with conventional coagulation tests (CCTs) in reducing blood product transfusion in patients undergoing liver transplantation. DESIGN Systematic review and meta-analysis of randomised (RCTs) and nonrandomised clinical trials performed according to PRISMA guidelines. The protocol was previously published (PROSPERO: CRD42021230213). DATA SOURCES The Cochrane Central Library, PubMed/MEDLINE, Embase and the Transfusion Evidence Library were searched up to 30 th January 2022. ELIGIBILITY CRITERIA Setting: operating room. Patients: liver transplantation recipients. Intervention: use of VETs versus CCTs. Main outcome measures: the primary outcome was the mean number of transfused units for each blood product including red blood cells (RBCs), fresh frozen plasma (FFP), platelets (PLTs) and cryoprecipitate. Secondary outcomes included mortality rate, intensive care unit (ICU) and hospital length of stay (LOS). RESULTS Seventeen studies ( n = 5345 patients), 15 observational and two RCTs, were included in this review. There was a mean difference reduction in RBCs [mean difference: -1.40, 95% confidence interval (95% CI), -1.87 to -0.92; P < 0.001, I2 = 61%) and FFP units (mean difference: -2.98, 95% CI, -4.61 to -1.35; P = < 0.001; I2 = 98%) transfused in the VETs group compared with the CCTs one. A greater amount of cryoprecipitate was administered in the VETs group (mean difference: 2.71, 95% CI, 0.84 to 4.58; P = 0.005; I2 = 91%). There was no significant difference in the mean number of PLT units, mortality, hospital and ICU-LOS. CONCLUSION Our meta-analysis demonstrated that VETs implementation was associated with reduced RBC and FFP consumption in liver transplantation patients without effects on mortality and hospital and ICU-LOS. The certainty of evidence ranged from moderate to very low. Further well conducted RCTs are needed to improve the certainty of evidence.
Collapse
|
4
|
Dumitrescu G, Januszkiewicz A, Ågren A, Magnusson M, Sparrelid E, Rooyackers O, Wernerman J. Fibrinogen and albumin synthesis rates in major upper abdominal surgery. PLoS One 2022; 17:e0276775. [PMID: 36301906 PMCID: PMC9612515 DOI: 10.1371/journal.pone.0276775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 10/13/2022] [Indexed: 11/22/2022] Open
Abstract
Plasma fibrinogen and albumin concentrations initially decrease after abdominal surgery. On postoperative days 3-5 fibrinogen concentration returns to the preoperative level or even higher, while albumin stays low. It is not known if these altered plasma concentrations reflect changes in synthesis rate, utilization, or both. In particular a low albumin plasma concentration has often been attributed to a low synthesis rate, which is not always the case. The objective of this study was to determine fibrinogen and albumin quantitative synthesis rates in patients undergoing major upper abdominal surgery with and without intact liver size. Patients undergoing liver or pancreatic resection (n = 9+6) were studied preoperatively, on postoperative days 1 and 3-5. De novo synthesis of fibrinogen and albumin was determined; in addition, several biomarkers indicative of fibrinogen utilization were monitored. After hemihepatectomy, fibrinogen synthesis was 2-3-fold higher on postoperative day 1 than preoperatively. On postoperative days 3-5 the synthesis level was still higher than preoperatively. Following major liver resections albumin synthesis was not altered postoperatively compared to preoperative values. After pancreatic resection, on postoperative day 1 fibrinogen synthesis was 5-6-fold higher than preoperatively and albumin synthesis 1.5-fold higher. On postoperative days 3-5, synthesis levels returned to preoperative levels. Despite decreases in plasma concentrations, de novo synthesis of fibrinogen was markedly stimulated on postoperative day 1 after both hemihepatectomies and pancreatectomies, while de novo albumin synthesis remained grossly unchanged. The less pronounced changes seen following hepatectomies were possibly related to the loss of liver tissue.
Collapse
Affiliation(s)
- Gabriel Dumitrescu
- Division of Anaesthesia, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | - Anna Januszkiewicz
- Division of Anaesthesia, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Anna Ågren
- Department of Molecular Medicine and Surgery, MMK, Clinical Chemistry and Coagulation, Karolinska Institutet, Stockholm, Sweden
| | - Maria Magnusson
- Department of Molecular Medicine and Surgery, MMK, Clinical Chemistry and Coagulation, Karolinska Institutet, Stockholm, Sweden
- Division of Paediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Ernesto Sparrelid
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Olav Rooyackers
- Division of Anaesthesia, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Jan Wernerman
- Division of Anaesthesia, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
5
|
Tangcheewinsirikul N, Moonla C, Uaprasert N, Pittayanon R, Rojnuckarin P. Viscoelastometric versus standard coagulation tests to guide periprocedural transfusion in adults with cirrhosis: A meta-analysis of randomized controlled trials. Vox Sang 2021; 117:553-561. [PMID: 34911140 DOI: 10.1111/vox.13225] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/23/2021] [Accepted: 11/08/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Due to rebalanced haemostasis in cirrhosis, viscoelastometric testing (VET) is more accurate than standard coagulation tests (SCTs) in preprocedural haemostatic evaluation, resulting in decreased unnecessary transfusion. We aimed to determine the impact of VET-guided strategy on postprocedural bleeding, periprocedural transfusion rates and quantities, transfusion-related adverse events (TRAEs), lengths of stay (LOS) and mortality from randomized controlled trials (RCTs) of cirrhotic patients. METHODS PubMed and EMBASE were searched for RCTs comparing VET-guided with SCT-guided transfusion in cirrhotic adults undergoing esophagogastroduodenoscopy, liver transplantation or other invasive interventions. Using random-effects models, the pooled risk ratios (RRs) and/or mean differences (MDs) of postprocedural bleeding-free events and the other outcomes were estimated alongside 95% confidence intervals (CIs). RESULTS Of seven included RCTs (n = 421; 72.2% men; mean age 49.1 years), VET-guided transfusion did not change postprocedural bleeding-free statuses (RR 1.05; 95% CI 0.94-1.17). However, VET-based algorithms decreased the rates of fresh frozen plasma (FFP; RR 0.52; 95% CI 0.35-0.77) and platelet transfusions (RR 0.34; 95% CI 0.16-0.73), the quantities of transfused FFP (MD -1.39 units; 95% CI -2.18 to -0.60), platelets (MD -1.06 units; 95% CI -2.01 to -0.12) and cryoprecipitate (MD -7.13 units; 95% CI -14.20 to -0.07) and the risk of TRAEs (RR 0.42; 95% CI 0.27-0.65). The overall mortality rates and LOS were not significantly different between two groups. CONCLUSION Compared with conventional SCT-guided, VET-guided strategy decreases periprocedural plasma and platelet transfusions and TRAEs, without increasing haemorrhagic complications, LOS or mortality in cirrhosis.
Collapse
Affiliation(s)
- Nuanrat Tangcheewinsirikul
- Division of Haematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Research Unit in Translational Haematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Chatphatai Moonla
- Research Unit in Translational Haematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Division of General Internal Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Noppacharn Uaprasert
- Division of Haematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Research Unit in Translational Haematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Rapat Pittayanon
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Ponlapat Rojnuckarin
- Division of Haematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Research Unit in Translational Haematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| |
Collapse
|
6
|
Raeven P, Baron-Stefaniak J, Simbrunner B, Stadlmann A, Schwabl P, Scheiner B, Schaden E, Eigenbauer E, Quehenberger P, Mandorfer M, Baron DM, Reiberger T. Thromboelastometry in patients with advanced chronic liver disease stratified by severity of portal hypertension. Hepatol Int 2020; 14:1083-1092. [PMID: 33000389 PMCID: PMC7803675 DOI: 10.1007/s12072-020-10093-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 09/06/2020] [Indexed: 02/07/2023]
Abstract
Background Rotational thromboelastometry (ROTEM) has been studied in patients with advanced chronic liver disease (ACLD) without considering the impact of portal hypertension. We evaluated the influence of the hepatic venous pressure gradient (HVPG) on ROTEM results in patients with ACLD.
Methods Cross-sectional study; ACLD patients undergoing HVPG measurement within the prospective Vienna Cirrhosis Study (NCT03267615) underwent concomitant ROTEM testing. Results Among 159 patients (68% male; Child–Pugh-A: 53%, Child–Pugh-B: 34%, Child–Pugh-C: 13%), 21 patients (13%) had a HVPG between 6 and 10 mmHg, 84 patients (53%) between 10 and 19 mmHg, and 54 patients (34%) ≥ 20 mmHg. Child–Pugh-C patients (vs. Child–Pugh-A and vs. Child–Pugh-B patients, respectively) showed longer clot formation time (CFT: median 187 s vs. 122 s vs. 122 s, p = 0.007) and lower maximum clot firmness (MCF: median: 45 mm vs. 56 mm vs. 56 mm, p = 0.002) in extrinsic thromboelastometry (EXTEM), while platelet counts were similar across Child–Pugh stages. In the overall cohort, ROTEM parameters did not differ by severity of portal hypertension. However, among compensated Child–Pugh-A patients, MCF decreased with increasing portal pressure, i.e. in higher HVPG strata (HVPG 9–10 mmHg: median MCF: 59 mm vs. HVPG 10–19 mmHg: 56 mm vs HVPG ≥ 20 mmHg: 54 mm, p = 0.023). Furthermore, patients with short CFT and high MCF in EXTEM had higher levels of lipopolysaccharide-binding protein, C-reactive protein, and procalcitonin, as well as higher leukocyte counts (all p < 0.05). Conclusions Portal hypertension seems to impact ROTEM results only in compensated Child–Pugh-A patients. Bacterial translocation and systemic inflammation may trigger a procoagulant state in patients with ACLD. Electronic supplementary material The online version of this article (10.1007/s12072-020-10093-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Pierre Raeven
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Joanna Baron-Stefaniak
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Benedikt Simbrunner
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria.,Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Alexander Stadlmann
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria.,Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Philipp Schwabl
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria.,Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Bernhard Scheiner
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria.,Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Eva Schaden
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Peter Quehenberger
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria.,Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - David Marek Baron
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria. .,Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| |
Collapse
|
7
|
Rashidi-Alavijeh J, Ceylan AS, Wedemeyer H, Kleefisch M, Willuweit K, Lange CM. Standard coagulation tests are superior to thromboelastometry in predicting outcome of patients with liver cirrhosis. PLoS One 2020; 15:e0236528. [PMID: 32722691 PMCID: PMC7386616 DOI: 10.1371/journal.pone.0236528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 07/07/2020] [Indexed: 12/12/2022] Open
Abstract
Background and aims Thromboelastometry (TEM) is superior to standard coagulation tests in the management of bleedings / invasive procedures in patients with liver cirrhosis. In contrast, the role of TEM as a prognostic parameter in liver cirrhosis is not well established. We therefore aimed to assess the role of TEM in predicting survival of outpatients with liver cirrhosis. Methods TEM was performed in consecutive outpatients with liver cirrhosis admitted in 2018 and 2019 to the University Hospital Essen. Associations with transplant-free survival were assessed in regression models. Results A number of 145 outpatients with liver cirrhosis were included, of whom 27 received a liver transplant (N = 7) or died (N = 20) within 6 months of follow-up. None of the TEM values was associated with transplant-free survival in this cohort. However, as expected, the classical coagulation tests INR (OR = 8.69 (95% CI 1.63–46.48), P = 0.01), PTT (OR = 1.15 (95% CI 1.04–1.27), P<0.01), as well as antithrombin (OR = 0.96 (95% CI 0.94–0.99), P<0.01), and protein C (OR = 0.96 (95% CI 0.92–0.99), P<0.01) were significantly associated with transplant-free survival. Conclusion In contrast to the superiority of TEM over classical coagulation tests to guide transfusion of blood products in patients with liver cirrhosis, TEM has no relevance in predicting mortality in outpatients with liver cirrhosis.
Collapse
Affiliation(s)
- Jassin Rashidi-Alavijeh
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ayse S. Ceylan
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Heiner Wedemeyer
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Martin Kleefisch
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Katharina Willuweit
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Christian M. Lange
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- * E-mail:
| |
Collapse
|
8
|
Reshetnyak VI, Maev IV, Reshetnyak TM, Zhuravel SV, Pisarev VM. Liver Disease and Hemostasis (Review) Part 2. Cholestatic Liver Disease and Hemostasis. ACTA ACUST UNITED AC 2019. [DOI: 10.15360/1813-9779-2019-6-80-93] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The presence or development of liver disorders can significantly complicate the course of critical illness and terminal conditions. Systemic hemostatic disorders are common in Intensive Care Units patients with cholestatic liver diseases, so the study of the mechanisms of their development can contribute to the understanding of the development of multiorgan failure in critical illness.The review discusses current data on changes in hemostatic parameters in patients with cholestatic liver diseases, proposes a mechanism for the development of such disorders, which involve interactions of phospholipids with platelet and endotheliocyte membranes. It is suggested that a trend for thrombosis in patients with cholestatic liver disease is due to increased accumulation of bile acids in the systemic circulation. Available data demonstrate that the antiphospholipid syndrome may predispose to the formation of blood clots due to alterations of phospholipid composition of membranes of platelets and vascular endothelial cells by circulating antiphospholipid antibodies. Clarifying the mechanisms contributing to changes of the blood coagulation system parameters in liver disorders will aid to development of optimal correction of hemostatic disorders in patients with chronic liver diseases.
Collapse
Affiliation(s)
- Vasiliy I. Reshetnyak
- A. I. Evdokimov Moscow State University of medicine and dentistry, Ministry of Health of Russia
| | - Igor V. Maev
- A. I. Evdokimov Moscow State University of medicine and dentistry, Ministry of Health of Russia
| | | | - Sergei V. Zhuravel
- N. V. Sklifosovsky Research Institute of Emergency Care, Moscow Healthcare Department
| | - Vladimir M. Pisarev
- V. A. Negovsky Research Institute of General Reanimatology, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology
| |
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|
10
|
Abstract
Evaluation of coagulation is vital in the care of the orthopaedic patients, particularly in the subspecialties of trauma, spine, arthroplasty, and revision surgery resulting from blood loss and coagulopathies. Although conventional tests (prothrombin time/international normalized ratio, activated partial thromboplastin time, platelet count, and fibrinogen) are most commonly used, others like thromboelastography (TEG) are also available to the orthopaedic surgeons. TEG is a blood test developed in the 1950s, which provides a snapshot of a patient's coagulation profile by evaluating clot formation and lysis. Recently, TEG has been used to assess traumatic coagulopathy. The coagulation parameters measured by the TEG are reaction time (R-time), time to reach a certain clot strength (K-value), speed of fibrin build up (α-angle), maximum clot amplitude, and percentage decrease of clot in 30 minutes (LY30). Using these values, traumatologists have developed a better, faster, and more accurate overview of a patient's resuscitation and more successfully direct blood product use. However, many orthopaedic surgeons-despite performing surgical procedures that risk notable blood loss and postoperative clotting complications-are unaware of the existence of the TEG blood test and the critical information it provides. Increasing awareness of the TEG among orthopaedic surgeons could have a notable effect on numerous aspects of musculoskeletal care.
Collapse
|
11
|
Yokoyama APH, Kutner JM, Sakashita AM, Nakazawa CY, de Paula TAO, Zamper RPC, Pedroso PT, de Almeida MD, Meira Filho SP, Orsi FA. Risk Factors for Transfusion after Orthotopic Liver Transplantation. Transfus Med Hemother 2019; 46:431-439. [PMID: 31933573 DOI: 10.1159/000499120] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 02/25/2019] [Indexed: 12/13/2022] Open
Abstract
Background Transfusion of blood products during orthotopic liver transplantation (OLT) is associated with increased morbidity and mortality. Although risk factors associated with intraoperative transfusion requirements have been widely assessed, published data on the prediction of postoperative transfusion requirements are sparse. Objectives The aim of this study was to evaluate risk factors for postoperative allogeneic transfusion requirements in OLT. Methods Clinical characteristics and intraoperative parameters of 645 consecutive adult patients undergoing OLT were retrospectively reviewed. Multivariate logistic regression was used to determine the main determinants for postoperative transfusion requirements. Results Determinants of postoperative transfusion requirements of any blood product in the postoperative period were the number of blood products transfused in the intraoperative period (OR 1.17, 95% CI 1.08-1.28), warm ischemia time (OR 1.05, 95% CI 1.02-1.08), MELD score (OR 1.05, 95% CI 1.01-1.08) and hepatocellular carcinoma (OR 0.45, 95% CI 0.28-0.72). A dose-dependent effect between the number of units transfused in the intraoperative period and transfusion requirements in the postoperative period was also observed. The relative risk of postoperative allogeneic transfusion of any blood component was 5.9 (95% CI 3.4-10.4) for patients who received 1-2 units in the intraoperative period, 7.3 (95% CI 3.6-14.7) for those who received 3-5 units in the intraoperative period, and 11.1 (95% CI 4.7-26.4) for those who received 6 or more units, when compared to no intraoperative blood transfusion. Conclusion Our study demonstrated an association between intraoperative transfusion and warm ischemia time with postoperative transfusion requirements. The identification of risk factors for transfusion in the postoperative period may improve management of these patients by increasing awareness to bleeding complications in this high-risk population and by expanding hemostasis monitoring to the postoperative period.
Collapse
Affiliation(s)
| | - José Mauro Kutner
- Hemotherapy and Cell Therapy Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Araci Massami Sakashita
- Hemotherapy and Cell Therapy Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | | | - Pamella Tung Pedroso
- Liver Transplantation Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | - Fernanda Andrade Orsi
- Department of Clinical Pathology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil
| |
Collapse
|
12
|
Hawkins RB, Raymond SL, Hartjes T, Efron PA, Larson SD, Andreoni KA, Thomas EM. Review: The Perioperative Use of Thromboelastography for Liver Transplant Patients. Transplant Proc 2018; 50:3552-3558. [PMID: 30577236 DOI: 10.1016/j.transproceed.2018.07.032] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/09/2018] [Accepted: 07/18/2018] [Indexed: 12/12/2022]
Abstract
Thromboelastography (TEG) is a viscoelastic test that allows rapid evaluation of clot formation and fibrinolysis from a sample of whole blood. TEG is increasingly utilized to guide blood product resuscitation in surgical patients and transfusions for liver transplant patients. Patients with severe liver failure have significant derangement of their clotting function due to impaired production of procoagulant and anticoagulant factors. Traditional coagulation studies are limited by the short time needed for the result and provide little information about the dynamics and strength of clot formation. In addition, traditional coagulation studies do not correlate well with bleeding episodes and may lead to over-transfusion of various blood products. Evidence is less robust regarding the use of TEG for transfusion management decisions in severe liver failure patients awaiting, undergoing, or immediately after liver transplant surgery. However, the available evidence suggests that systematic implementation of TEG rather than traditional coagulation studies results in the administration of fewer blood products without increased mortality or complications. The purpose of this study is to review the literature regarding the use of TEG in liver failure patients prior to liver transplant, intraoperatively, and postoperatively. Additional high-quality randomized controlled studies should be performed to evaluate the use of TEG to guide transfusion decisions, particularly in the postoperative period following liver transplantation.
Collapse
Affiliation(s)
- R B Hawkins
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - S L Raymond
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - T Hartjes
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA; University of Florida College of Nursing, Gainesville, FL, USA
| | - P A Efron
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - S D Larson
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - K A Andreoni
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - E M Thomas
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA.
| |
Collapse
|
13
|
Song JC. Monitoring and treatment of liver dysfunction-associated coagulopathy. Shijie Huaren Xiaohua Zazhi 2018; 26:1156-1160. [DOI: 10.11569/wcjd.v26.i19.1156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Liver dysfunction-associated coagulopathy may manifest as hypercoagulation, hypocoagulation or normal coagulation, resulting in reduced synthesis of most coagulation factors, protein C and protein S, drop of platelet count, and increase of coagulation factor Ⅷ, Von Willebrand factor and tissue plasminogen activator. The use of viscoelastic coagulation monitoring equipment can accurately determine the coagulation state of patients with liver failure and guide accurate replacement therapy or anticoagulant therapy.
Collapse
Affiliation(s)
- Jing-Chun Song
- Department of Intensive Medicine, The 94th Hospital of The Chinese People's Liberation Army, Nanchang 330002, Jiangxi Province, China
| |
Collapse
|
14
|
Erratum: Thromboelastometry: Relation to the severity of liver cirrhosis in patients considered for liver transplantation: Erratum. Medicine (Baltimore) 2017; 96:e7420. [PMID: 31305687 PMCID: PMC5500100 DOI: 10.1097/md.0000000000007420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
[This corrects the article DOI: 10.1097/MD.0000000000007101.].
Collapse
|