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Sinegre T, Abergel A, Lebreton A, Lecompte T. "Prothrombin conversion and thrombin decay in patients with cirrhosis-role of prothrombin and antithrombin deficiencies": comment. J Thromb Haemost 2024; 22:2366-2370. [PMID: 39048270 DOI: 10.1016/j.jtha.2024.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 07/27/2024]
Affiliation(s)
- Thomas Sinegre
- Service Hématologie biologique, Centre Hospitalo-Universitaire, Clermont-Ferrand, France
| | - Armand Abergel
- Service de Médecine Digestive et Hépato-biliaire, Centre Hospitalo-Universitaire, Clermont-Ferrand, France; Unité Mixte de Recherche 6602, Centre National de la Recherche Scientifique - Sigma - Université Clermont Auvergne, Clermont-Ferrand, France
| | - Aurélien Lebreton
- Service Hématologie biologique, Centre Hospitalo-Universitaire, Clermont-Ferrand, France; Institut National de la Recherche pour l'agriculture, l'Alimentation et l'Environnement, Unité Mixte de Recherche 1019 Unité de Nutrition Humaine, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Thomas Lecompte
- Faculté de médecine de Nancy, Université de Lorraine, Lorraine, France; Vascular Medicine Division and National Referral Center for Rare Vascular and Systemic Autoimmune Diseases, University Hospital of Nancy, Nancy, France.
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Pereira Portela C, Gautier LA, Zermatten MG, Fraga M, Moradpour D, Bertaggia Calderara D, Aliotta A, Veuthey L, De Gottardi A, Stirnimann G, Alberio L. Direct oral anticoagulants in cirrhosis: Rationale and current evidence. JHEP Rep 2024; 6:101116. [PMID: 39100819 PMCID: PMC11296254 DOI: 10.1016/j.jhepr.2024.101116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 04/19/2024] [Accepted: 04/30/2024] [Indexed: 08/06/2024] Open
Abstract
Cirrhosis is a major health concern worldwide with a complex pathophysiology affecting various biological systems, including all aspects of haemostasis. Bleeding risk is mainly driven by portal hypertension, but in end-stage liver disease it is further increased by alterations in haemostatic components, including platelet function, coagulation, and fibrinolysis. Concurrently, patients with cirrhosis are prone to venous thromboembolic events (VTE) because of the altered haemostatic balance, in particular an increase in thrombin generation. In patients with cirrhosis, vitamin K antagonists (VKA) and low molecular weight heparins (LMWH) are currently the standard of care for VTE prevention, with VKA also being standard of care for stroke prevention in those with atrial fibrillation. However, direct oral anticoagulants (DOAC) could have specific advantages in this patient population. Clinical experience suggests that DOAC are a safe and possibly more effective alternative to traditional anticoagulants for the treatment of VTE in patients with compensated cirrhosis. In addition, emerging data suggest that primary prophylactic treatment with anticoagulants may improve clinical outcomes in patients with cirrhosis by reducing the risk of hepatic decompensation. The selection of the most appropriate DOAC remains to be clarified. This review focuses on the rationale for the use of DOAC in patients with cirrhosis, the specific effects of the different DOAC (as assessed by in vitro and in vivo pharmacokinetic and pharmacodynamic studies), as well as clinical outcomes in patients with cirrhosis on DOAC.
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Affiliation(s)
- Cindy Pereira Portela
- Hemostasis and Platelet Research Laboratory, Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), CH-1010 Lausanne, Switzerland
| | - Lucas A. Gautier
- Hemostasis and Platelet Research Laboratory, Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), CH-1010 Lausanne, Switzerland
| | - Maxime G. Zermatten
- Hemostasis and Platelet Research Laboratory, Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), CH-1010 Lausanne, Switzerland
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), CH-1010 Lausanne, Switzerland
| | - Montserrat Fraga
- Division of Gastroenterology and Hepatology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), CH-1010 Lausanne, Switzerland
| | - Darius Moradpour
- Division of Gastroenterology and Hepatology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), CH-1010 Lausanne, Switzerland
| | - Debora Bertaggia Calderara
- Hemostasis and Platelet Research Laboratory, Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), CH-1010 Lausanne, Switzerland
| | - Alessandro Aliotta
- Hemostasis and Platelet Research Laboratory, Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), CH-1010 Lausanne, Switzerland
| | - Lucas Veuthey
- Hemostasis and Platelet Research Laboratory, Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), CH-1010 Lausanne, Switzerland
| | - Andrea De Gottardi
- Luzerner Kantonsspital, Lucerne, Switzerland
- Gastroenterology and Hepatology, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Guido Stirnimann
- University Clinic for Visceral Surgery and Medicine, University Hospital Inselspital and University of Bern, Bern, Switzerland
| | - Lorenzo Alberio
- Hemostasis and Platelet Research Laboratory, Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), CH-1010 Lausanne, Switzerland
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), CH-1010 Lausanne, Switzerland
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Sinegre T, Abergel A, Lecompte T, Lebreton A. Prothrombin conversion and thrombin decay in patients with cirrhosis-role of prothrombin and antithrombin deficiencies. J Thromb Haemost 2024; 22:1347-1357. [PMID: 38309434 DOI: 10.1016/j.jtha.2024.01.016] [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: 09/19/2023] [Revised: 01/23/2024] [Accepted: 01/23/2024] [Indexed: 02/05/2024]
Abstract
BACKGROUND Thrombin generation (TG) in the presence of thrombomodulin (TG-TM) in the plasma of patients with cirrhosis (PWC) is tilted toward a hypercoagulable phenotype. Low protein C and elevated factor VIII levels play a role, but other determinants, such as the prothrombin/antithrombin pair, must also be studied. OBJECTIVES The objectives were (i) to quantitatively assess the subprocesses (prothrombin conversion and thrombin decay) and (ii) to understand the underlying mechanism by studying TG dynamics after prothrombin and antithrombin plasma level correction in PWC. METHODS We studied TG-TM in plasma samples of 36 healthy controls (HCs) and 41 PWC with prothrombin and antithrombin levels of <70% and after their correction. We initiated coagulation with an intermediate picomolar concentration of tissue factor. We determined the overall thrombin potential, prothrombin conversion, and thrombin decay. RESULTS TG-TM was increased in PWC compared with HC due to impaired thrombin inhibition. Indeed, thrombin decay capacity (min-1) decreased from 0.37 (0.35-0.40) in HC to 0.33 (0.30-0.37) in the Child-Turcotte-Pugh A (CTP-A; P = .09), 0.27 (0.26-0.30) in the CTP-B (P < .001), and 0.20 (0.19-0.20) in the CTP-C (P < .001) group. Concomitant correction of prothrombin and antithrombin increased endogenous thrombin potential with prothrombin conversion surpassing thrombin decay. By contrast, when we corrected only antithrombin, TG-TM was normalized and even consistent with a hypocoagulable phenotype in the CTP-C group. CONCLUSION Our results highlight that in PWC, hypercoagulability (evidenced in the presence of TM) is due to impaired thrombin decay, whereas low prothrombin levels do not translate into decreased prothrombin conversion, likely due to altered TM-activated protein C negative feedback.
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Affiliation(s)
- Thomas Sinegre
- Service Hématologie biologique, CHU Clermont Ferrand, Clermont-Ferrand, France.
| | - Armand Abergel
- Service de Médecine Digestive et Hépato-biliaire, CHU, Clermont Ferrand, France; UMR 6602 CNRS-Sigma-Université Clermont Auvergne, Clermont-Ferrand, France
| | - Thomas Lecompte
- Université de Lorraine, Faculté de médecine de Nancy, Nancy, France
| | - Aurélien Lebreton
- Service Hématologie biologique, CHU Clermont Ferrand, Clermont-Ferrand, France; Université Clermont Auvergne, INRAE, UMR 1019 Unité de Nutrition Humaine, Clermont-Ferrand, France. https://twitter.com/aurelebre
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Lebreton A, Mandorfer M. Thrombin generation in cirrhosis: whole blood, whole truth? J Thromb Haemost 2024; 22:356-358. [PMID: 38309810 DOI: 10.1016/j.jtha.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 11/05/2023] [Accepted: 11/06/2023] [Indexed: 02/05/2024]
Affiliation(s)
- Aurélien Lebreton
- Service d'Hématologie, Centre hospitalo-universitaire Clermont-Ferrand, Clermont-Ferrand, France; Unité de Nutrition Humaine, Unité Mixte de Recherche, Institut National de Recherche pour l'Agriculture, l'Alimentation et l'Environnement, Université Clermont Auvergne 1019, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Mattias Mandorfer
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.
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Intraindividual variability over time of thrombin generation in patients with cirrhosis. J Thromb Haemost 2023; 21:1441-1452. [PMID: 36758726 DOI: 10.1016/j.jtha.2023.02.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 02/02/2023] [Accepted: 02/02/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND Patients with cirrhosis are at high risk of thrombotic events, including portal vein thrombosis and venous thromboembolism. In such patients, hypercoagulability is not detected by conventional coagulation tests, but only by the thrombin generation assay (TGA) that integrates the role of pro- and anticoagulant factors. However, TGA use to predict clinical events depends on thrombin generation variability over time. OBJECTIVES The aim of this study was to compare TGA intraindividual variability over time in patients with cirrhosis and in healthy controls. METHODS Blood samples were prospectively collected from 34 healthy controls and 52 patients with cirrhosis at week 0 (inclusion), 6, and 12. TGA was performed with the calibrated automated thrombogram method, tissue factor (5 pM), phospholipids, and with and without thrombomodulin (4 nM) or activated protein C (1 nM). RESULTS When TGA was performed with thrombomodulin, endogenous thrombin potential in patients with cirrhosis was higher compared with controls and increased with cirrhosis severity. Stability over time of all thrombin generation parameters was excellent in healthy controls, good in Child-Turcotte-Pugh (CTP)-A patients, and poor in CTP-B/C patients (severe cirrhosis). In CTP-B/C patients, the phenotype was more variable because one-third of patients switched to normal or hypercoagulability during the 3-month follow-up. CONCLUSION A study with longer monitoring is needed to correlate the hypercoagulable phenotype of patients with cirrhosis with the occurrence of thrombotic events.
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Comparison of Acquired Activated Protein C Resistance, Using the CAT and ST-Genesia® Analysers and Three Thrombin Generation Methods, in APS and SLE Patients. J Clin Med 2021; 11:jcm11010069. [PMID: 35011808 PMCID: PMC8745056 DOI: 10.3390/jcm11010069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 12/20/2021] [Accepted: 12/22/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Acquired activated protein C resistance (APCr) has been identified in antiphospholipid syndrome (APS) and systemic lupus erythematosus (SLE). Objective: To assess agreement between the ST-Genesia® and CAT analysers in identifying APCr prevalence in APS/SLE patients, using three thrombin generation (TG) methods. Methods: APCr was assessed with the ST-Genesia using STG-ThromboScreen and with the CAT using recombinant human activated protein C and Protac® in 105 APS, 53 SLE patients and 36 thrombotic controls. Agreement was expressed in % and by Cohen’s kappa coefficient. Results: APCr values were consistently lower with the ST-Genesia® compared to the CAT, using either method, in both APS and SLE patients. Agreement between the two analysers in identifying APS and SLE patients with APCr was poor (≤65.9%, ≤0.20) or fair (≤68.5%, ≥0.29), regardless of TG method, respectively; no agreement was observed in thrombotic controls. APCr with both the ST Genesia and the CAT using Protac®, but not the CAT using rhAPC, was significantly greater in triple antiphospholipid antibody (aPL) APS patients compared to double/single aPL patients (p < 0.04) and in thrombotic SLE patients compared to non-thrombotic SLE patients (p < 0.05). Notably, the ST-Genesia®, unlike the CAT, with either method, identified significantly greater APCr in pregnancy morbidity (median, confidence intervals; 36.9%, 21.9–49.0%) compared to thrombotic (45.7%, 39.6–55.5%) APS patients (p = 0.03). Conclusion: Despite the broadly similar methodology used by CAT and ST-Genesia®, agreement in APCr was poor/fair, with results not being interchangeable. This may reflect differences in the TG method, use of different reagents, and analyser data handling.
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Brodard J, Calzavarini S, Quarroz C, Berzigotti A, De Gottardi A, Angelillo-Scherrer A. Resistance to thrombomodulin correlates with liver stiffness in chronic liver disease a prospective single-center cohort study. Thromb Res 2021; 207:40-49. [PMID: 34536665 DOI: 10.1016/j.thromres.2021.09.007] [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: 06/28/2021] [Revised: 08/19/2021] [Accepted: 09/10/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Chronic liver disease (CLD) is characterized by changes in haemostasis, embracing both hypo- and hypercoagulability. Global hemostatic tests such as thrombin generation assays evaluate the hemostatic balance, to better assess bleeding and thrombotic risks. In addition, procoagulant state in patients with CLD has been demonstrated using modified thrombin generation assays with thrombomodulin, a cofactor for protein C activation. In this study, we prospectively determined thrombin generation and thrombomodulin resistance in patients with CLD staged with liver stiffness measurement (LSM), using both the fully automated analyzer ST Genesia® Thrombin Generation System (STG) and the calibrated automated thrombogram assay (CAT). MATERIALS AND METHODS Demographic, clinical and laboratory characteristics, and blood samples were collected from 65 patients with CLD. Liver stiffness was measured by transient elastography, and thrombin generation and thrombomodulin resistance, by STG and CAT. RESULTS Patients were separated based on LSM of <21 and ≥21 kilopascals (kPa). The propagation rate of thrombin generation was higher in patients with LSM ≥21 kPa and the thrombin generation rate increased as LSM increased. In addition, thrombomodulin resistance assessed by STG and CAT was higher in patients with LSM ≥21 kPa. However, ETP inhibition by activated protein C was comparable in patients with LSM <21 and ≥21 kPa. Finally, LSM correlated with most thrombin generation parameters. CONCLUSION The STG automated system may have value in the assessment of patients with chronic liver disease in the routine coagulation laboratory. LSM ≥21 kPa identify a procoagulant phenotype in these patients, including thrombomodulin resistance.
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Affiliation(s)
- Justine Brodard
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Switzerland; Department for BioMedical Research, University of Bern, Switzerland
| | - Sara Calzavarini
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Switzerland; Department for BioMedical Research, University of Bern, Switzerland
| | - Claudia Quarroz
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Switzerland; Department for BioMedical Research, University of Bern, Switzerland
| | - Annalisa Berzigotti
- Hepatology, Clinic of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland; Gastroenterology and Hepatology, Ente Ospedaliero Cantonale and Università della Svizzera Italiana, Lugano, Switzerland
| | - Andrea De Gottardi
- Department for BioMedical Research, University of Bern, Switzerland; Hepatology, Clinic of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland; Gastroenterology and Hepatology, Ente Ospedaliero Cantonale and Università della Svizzera Italiana, Lugano, Switzerland
| | - Anne Angelillo-Scherrer
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Switzerland; Department for BioMedical Research, University of Bern, Switzerland.
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Thrombin Generation in Chronic Liver Diseases-A Pilot Study. Healthcare (Basel) 2021; 9:healthcare9050550. [PMID: 34066706 PMCID: PMC8151360 DOI: 10.3390/healthcare9050550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 11/17/2022] Open
Abstract
The knowledge about coagulation disorders in patients with chronic liver disease changed in the last decade. The aim of this study was to analyze the parameters of thrombin generation in patients with chronic liver disease, as they are the most appropriate biomarkers to explore coagulation. (1) Background: The knowledge about coagulation disorders in patients with chronic liver disease changed in the last decade. The study of thrombin generation in patients with chronic liver disease provides a much more accurate assessment of the coagulation cascade; (2) Methods: This study is a prospective observational pilot study on hospitalized patients with chronic liver diseases that analyzed thrombin generation performed from their platelet-poor plasma versus that of control subjects. We analyzed a group of 59 patients with chronic liver disease and 62 control subjects; (3) Results: Thrombin generation was lower in hepatitis and cirrhosis patients compared to controls and decreases as the disease progressed. Lag time was higher in ethanolic etiology compared to the control group. Peak thrombin and endogenous thrombin potential were shorter in all etiologies when compared to the control group. The velocity index was significantly lower in HCV hepatopathies, ethanolic, and mixed etiology when compared with normal individuals; (4) Conclusions: Given the variability of thrombin generation in patients with chronic liver disease, its assay could serve to identify patients with high thrombotic and hemorrhagic risk and establish personalized conduct toward them.
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Bos S, van den Boom B, Ow T, Prachalias A, Adelmeijer J, Phoolchund A, Dunsire F, Milan Z, Roest M, Heaton N, Bernal W, Lisman T. Efficacy of pro- and anticoagulant strategies in plasma of patients undergoing hepatobiliary surgery. J Thromb Haemost 2020; 18:2840-2851. [PMID: 33124784 PMCID: PMC7693071 DOI: 10.1111/jth.15060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 08/07/2020] [Accepted: 08/10/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND In vitro efficacy of pro- and antihemostatic drugs is profoundly different in patients with compensated cirrhosis and in those who have cirrhosis and are critically ill. OBJECTIVES Here we assessed the efficacy of pro- and anticoagulant drugs in plasma of patients undergoing hepato-pancreato-biliary (HPB) surgery, which is associated with unique hemostatic changes. METHODS We performed in vitro analyses on blood samples of 60 patients undergoing HPB surgery and liver transplantation: 20 orthotopic liver transplantations, 20 partial hepatectomies, and 20 pylorus-preserving pancreaticoduodenectomies. We performed thrombin generation experiments before and after in vitro addition of fresh frozen plasma (FFP), prothrombin complex concentrate (PCC), recombinant factor VIIa (rFVIIa), low molecular weight heparin (LMWH), unfractionated heparin, dabigatran, and rivaroxaban. RESULTS We showed that patients undergoing HPB surgery are in a hypercoagulable state by thrombin generation testing. FFP and rFVIIa had minimal effects on thrombin generation, whereas PCC had a more pronounced procoagulant effect in patients compared with controls. Dabigatran showed a more pronounced anticoagulant effect in patients compared with controls, whereas rivaroxaban and LMWH had a decreased anticoagulant effect in patients. CONCLUSION We demonstrate profoundly altered in vitro efficacy of commonly used anticoagulants, in patients undergoing HPB surgery compared with healthy controls, which may have implications for anticoagulant dosing in the early postoperative period. In the correction of perioperative bleeding complications, PCCs appear much more potent than FFP or rFVIIa, and PCCs may require conservative dosing and caution in use in patients undergoing HPB surgery.
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Affiliation(s)
- Sarah Bos
- Department of Internal MedicineUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Bente van den Boom
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver transplantationDepartment of SurgeryUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Tsai‐Wing Ow
- Liver Intensive Care UnitInstitute of Liver StudiesKing College HospitalLondonUK
| | - Andreas Prachalias
- Liver Transplant SurgeryInstitute of Liver StudiesKings College HospitalLondonUK
| | - Jelle Adelmeijer
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver transplantationDepartment of SurgeryUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Anju Phoolchund
- Liver Intensive Care UnitInstitute of Liver StudiesKing College HospitalLondonUK
| | - Fraser Dunsire
- Anesthetics DepartmentInstitute of Liver studiesKings College Hospital LondonLondonUK
| | - Zoka Milan
- Anesthetics DepartmentInstitute of Liver studiesKings College Hospital LondonLondonUK
| | - Mark Roest
- Synapse Research InstituteCardiovascular Research Institute MaastrichtMaastricht University Medical CenterMaastrichtThe Netherlands
| | - Nigel Heaton
- Liver Transplant SurgeryInstitute of Liver StudiesKings College HospitalLondonUK
| | - William Bernal
- Liver Intensive Care UnitInstitute of Liver StudiesKing College HospitalLondonUK
| | - Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver transplantationDepartment of SurgeryUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
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Anticoagulant activity of edoxaban in patients with cirrhosis. Blood 2020; 136:1561-1564. [DOI: 10.1182/blood.2020005319] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 04/28/2020] [Indexed: 12/31/2022] Open
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Extrahepatic portal vein obstruction (EHPVO) in cirrhosis. Clin Res Hepatol Gastroenterol 2020; 44:497-502. [PMID: 32312599 DOI: 10.1016/j.clinre.2020.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/03/2020] [Indexed: 02/04/2023]
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Talon L, Sinegre T, Lecompte T, Pereira B, Massoulié S, Abergel A, Lebreton A. Hypercoagulability (thrombin generation) in patients with cirrhosis is detected with ST-Genesia. J Thromb Haemost 2020; 18:2177-2190. [PMID: 32558351 DOI: 10.1111/jth.14963] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 05/06/2020] [Accepted: 06/03/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Thrombin generation assays (TGAs) performed with calibrated automated thrombography (CAT) in the presence of thrombomodulin (TM) indicate plasma hypercoagulability in cirrhosis. OBJECTIVE To evaluate, in the presence of TM, the new ST-Genesia automated device developed for improving TGA vs the previously used CAT method, with plasma samples of patients with cirrhosis. PATIENTS/METHODS Platelet-poor plasma samples were prepared from citrated blood samples of 52 healthy controls and 85 patients with cirrhosis (severity evaluated using the Child-Pugh score [CP]). TGAs were performed using CAT with PPP-Reagent and ST-Genesia with the STG-ThromboScreen reagent, in the presence of TM. Endogenous thrombin potential (ETP) was chosen as the main parameter. RESULTS Whatever the method, ETP values were higher in patients than in healthy controls. All patients identified as hypercoagulable with ST-Genesia and STG-ThromboScreen were found hypercoagulable with CAT and PPP-Reagent. Conversely, eight and ten patients in the CP-A and CP-B classes respectively were identified as hypercoagulable only with CAT. The use of ST-Genesia with the STG-ThromboScreen reagent with TM led to a bias, with higher ETP values for healthy controls and lower for patients compared with CAT. Crossover analysis (CAT with the STG-ThromboScreen reagent) evidenced a substantial effect of the STG-ThromboScreen reagent; the analyzer (including calibration and data analysis) plays a lesser role. CONCLUSION ST-Genesia evidences hypercoagulability in patients with cirrhosis when TG is studied in the presence of TM, but the results are not interchangeable with those obtained with CAT.
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Affiliation(s)
- Laurie Talon
- Service d'hématologie biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Thomas Sinegre
- Service d'hématologie biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Thomas Lecompte
- Hôpitaux Universitaires de Genève, Unité d'hémostase, Département de médecine, faculté de Médecine - GpG, Université de Genève, Geneva, Switzerland
| | - Bruno Pereira
- Unité de Biostatistiques (Direction de la recherche clinique et de l'innovation), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Sylvie Massoulié
- Service d'Hépato-Gastro-Entérologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Armand Abergel
- Service d'Hépato-Gastro-Entérologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Aurélien Lebreton
- Service d'hématologie biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
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Lebreton A, Sinegre T, Lecompte T, Talon L, Abergel A, Lisman T. Thrombin Generation and Cirrhosis: State of the Art and Perspectives. Semin Thromb Hemost 2020; 46:693-703. [PMID: 32820480 DOI: 10.1055/s-0040-1715102] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Epidemiological and laboratory studies performed in the last decades have changed our understanding of coagulopathy in cirrhosis, from a condition at increased risk of hemorrhagic events to one at higher thrombotic risk. However, it is not clear whether the decrease in factors that promote (except factor [F] VIII) versus inhibit coagulation in patients with cirrhosis results in a rebalanced state or in a hypercoagulable phenotype. This issue can be partially addressed using thrombin generation assays (TGA), which unlike routine clotting tests (prothrombin time or activated partial thromboplastin time) are sensitive to both procoagulant factors and coagulation inhibitors. However, many preanalytical issues and variable analytical methodologies used in TGAs complicate data analysis and interlaboratory comparisons. The introduction of TGAs in which activators of the protein C pathway (particularly soluble forms of thrombomodulin [TM]) are added has allowed detection of a reduced anticoagulant effect of TM or even a hypercoagulable phenotype as judged by endogenous thrombin potential. However, inter- and intra-assay variability may be greater with this TGA variant compared with "standard" TGAs. TGAs also allowed identifying main determinants of the hypercoagulability phenotype in the presence of TM: acquired antithrombin and protein C deficiencies, and elevated FVIII levels. The aim of this narrative review is to summarize the preanalytical and methodological variables of TGAs and also the findings of the main studies that have evaluated TGAs in patients with cirrhosis. The review also provides some propositions for future studies and outlines some perspectives on the potential implementation of this promising tool in clinical practice for the study of coagulation in patients with cirrhosis.
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Affiliation(s)
- Aurélien Lebreton
- Service d'hématologie biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France.,Université Clermont Auvergne, INRA, UNH, Unité de Nutrition Humaine, CRNH Auvergne, Clermont-Ferrand, France
| | - Thomas Sinegre
- Service d'hématologie biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France.,Université Clermont Auvergne, INRA, UNH, Unité de Nutrition Humaine, CRNH Auvergne, Clermont-Ferrand, France
| | - Thomas Lecompte
- Hôpitaux Universitaires de Genève, Unité d'hémostase, Département de médecine, Genève; Université de Genève, faculté de Médecine - GpG, Switzerland
| | - Laurie Talon
- Service d'hématologie biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Armand Abergel
- Service d'Hépato-Gastro-Entérologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Ton Lisman
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Morrow GB, Beavis J, Harper S, Baker P, Desborough MJR, Curry N, Stanworth SJ, Laffan MA. Coagulation status of critically ill patients with and without liver disease assessed using a novel thrombin generation analyzer. J Thromb Haemost 2020; 18:1576-1585. [PMID: 32196929 DOI: 10.1111/jth.14802] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/13/2020] [Accepted: 03/16/2020] [Indexed: 12/11/2022]
Abstract
The liver synthesizes the majority of pro- and anti-coagulant and fibrinolytic proteins, and during liver dysfunction synthesis of these proteins is reduced. The end point of conventional hemostatic tests, such as the prothrombin time (PT), occurs when only 5% of thrombin generation (TG) has taken place and is not sensitive to the effects of natural anti-coagulants. The aim of this study was to determine whether TG in the presence of thrombomodulin (TM) provides more useful information about coagulation potential, in comparison to the PT. Analysis was performed on ST Genesia, a novel TG analyzer from Diagnostica Stago. TG was measured using STG-Thromboscreen, a reagent containing an intermediate concentration of human tissue factor (TF) ± rabbit TM to account for anti-coagulant protein C (PC) activity. Platelet-poor plasma (PPP) samples were from the Intensive Care Study of Coagulopathy-2 (ISOC-2), which recruited patients admitted to critical care with a prolonged PT (3 seconds above the reference range). Despite a prolonged PT, 48.0% and 60.7% of patients in the liver and non-liver groups had TG parameters within the normal range. Addition of TM reduced TG by 34.5% and 41.8% in the liver and non-liver groups, respectively. Interestingly, fresh frozen plasma (FFP) transfusion had no impact on TG. Measurement of TG with addition of TM provides a more informative assessment of coagulation capacity and indicates that hemostasis is balanced in patients with liver disease during critical illness, despite conventional tests suggesting that bleeding risk is increased.
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Affiliation(s)
- Gael B Morrow
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - James Beavis
- Oxford Haemophilia and Thrombosis Centre, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sarah Harper
- Oxford Haemophilia and Thrombosis Centre, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Peter Baker
- Oxford Haemophilia and Thrombosis Centre, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Nicola Curry
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Oxford Haemophilia and Thrombosis Centre, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Simon J Stanworth
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Transfusion Medicine, NHS Blood and Transplant, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mike A Laffan
- Oxford Haemophilia and Thrombosis Centre, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Centre for Haematology, Imperial College London, London, UK
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15
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Zermatten MG, Fraga M, Calderara DB, Aliotta A, Moradpour D, Alberio L. Biomarkers of liver dysfunction correlate with a prothrombotic and not with a prohaemorrhagic profile in patients with cirrhosis. JHEP Rep 2020; 2:100120. [PMID: 32715285 PMCID: PMC7369360 DOI: 10.1016/j.jhepr.2020.100120] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 04/08/2020] [Accepted: 04/21/2020] [Indexed: 02/07/2023] Open
Abstract
Background & Aims Different liver dysfunction biomarkers are used to assess the bleeding risk of patients with cirrhosis, either as such or included in bleeding risk assessment scores. Since the current model of coagulation in patients with cirrhosis describes a procoagulant tendency with increasing severity according to Child-Pugh stage, we decided to investigate the relation between liver dysfunction biomarkers and thrombin generation. Our aim was to verify their adequacy for bleeding risk assessment. Methods We performed a prospective single-centre study including 260 patients with liver cirrhosis. Thrombin generation was measured using ST Genesia® Thrombin Generation System without and with thrombomodulin in order to assess the role of proteins C and S. Relations between thrombin generation and Child-Pugh/model for end-stage liver disease (MELD) scores, prothrombin time (PT)/international normalised ratio (INR), activated partial thromboplastin time (aPTT), factor V activity, albumin, and total bilirubin were assessed. Results Thrombomodulin-mediated inhibition of thrombin generation was significantly decreased in patients with liver cirrhosis compared with healthy donors (p <0.0001) and in Child-Pugh B and C compared with A (p <0.0001 [A–B], 0.4515 [B–C], <0.0001 [A–C]). Thrombomodulin-mediated inhibition significantly decreased with increasing PT/INR, aPTT, and total bilirubin levels and with decreasing factor V activity and albumin levels. Conclusions Worsening liver dysfunction biomarkers reflect an increasing prothrombotic profile in patients with liver cirrhosis. In particular, prolonged PT/INR and aPTT as well as decreasing factor V activity are related to an increasing thrombotic risk and not to an increasing bleeding risk. These parameters should not be used to assess bleeding risk due to haemostatic anomalies in patients with liver cirrhosis. Alternative biomarkers for bleeding risk assessment in patients with liver cirrhosis need to be developed. Lay summary We demonstrate that the laboratory parameters used to assess bleeding risk of patients with liver disease, e.g. prothrombin time/international normalised ratio (PT/INR) and activated partial thromboplastin time (aPTT), are inadequate for this purpose because they are correlated with a prothrombotic coagulation profile. In this article, we highlight the need for alternative parameters to assess bleeding risk in patients with liver disease. Patients with cirrhosis display a prothrombotic coagulation profile. This is due to a relative decrease of natural anticoagulants compared with procoagulants. In cirrhosis, PT and aPTT correlate with a prothrombotic state, and are inadequate as bleeding risk biomarkers.
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Affiliation(s)
- Maxime G Zermatten
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Montserrat Fraga
- Division of Gastroenterology and Hepatology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Debora Bertaggia Calderara
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Alessandro Aliotta
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Darius Moradpour
- Division of Gastroenterology and Hepatology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Lorenzo Alberio
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
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16
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Werner MJM, de Meijer VE, Adelmeijer J, de Kleine RHJ, Scheenstra R, Bontemps STH, Reyntjens KMEM, Hulscher JBF, Lisman T, Porte RJ. Evidence for a rebalanced hemostatic system in pediatric liver transplantation: A prospective cohort study. Am J Transplant 2020; 20:1384-1392. [PMID: 31841272 PMCID: PMC7216958 DOI: 10.1111/ajt.15748] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/12/2019] [Accepted: 12/04/2019] [Indexed: 01/25/2023]
Abstract
In adults with end-stage liver disease concurrent changes in pro- and antihemostatic pathways result in a rebalanced hemostasis. Children though, have a developing hemostatic system, different disease etiologies, and increased risk of thrombosis. This study aimed to assess the hemostatic state of children during and after liver transplantation. Serial blood samples were obtained from 20 children (≤16 years) undergoing primary liver transplantation (September 2017-October 2018). Routine hemostasis tests, thrombomodulin-modified thrombin generation, clot lysis times, and hemostatic proteins were measured. Reference values were established using an age-matched control group of 30 children. Thrombocytopenia was present in study patients. Von Willebrand factors were doubled and ADAMTS13 levels decreased during and after transplantation up until day 30, when platelet count had normalized. Whereas prothrombin time and activated partial thromboplastin time were prolonged during transplantation, thrombin generation was within normal ranges, except during perioperative heparin administration. Fibrinogen, factor VIII levels, and clot lysis time were elevated up until day 30. In conclusion, children with end-stage liver disease are in tight hemostatic balance. During transplantation a temporary heparin-dependent hypocoagulable state is present, which rapidly converts to a hemostatic balance with distinct hypercoagulable features that persist until at least day 30. This hypercoagulable state may contribute to the risk of posttransplant thrombosis.
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Affiliation(s)
- Maureen J. M. Werner
- Department of SurgerySection of Hepatobiliary Surgery and Liver TransplantationUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands,Department of SurgerySurgical Research LaboratoryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Vincent E. de Meijer
- Department of SurgerySection of Hepatobiliary Surgery and Liver TransplantationUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Jelle Adelmeijer
- Department of SurgerySurgical Research LaboratoryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Ruben H. J. de Kleine
- Department of SurgerySection of Hepatobiliary Surgery and Liver TransplantationUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - René Scheenstra
- Department of Pediatric Gastroenterology and HepatologyUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Sander T. H. Bontemps
- Department of Pediatric Intensive CareUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Koen M. E. M. Reyntjens
- Department of AnesthesiologyUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Jan B. F. Hulscher
- Department of SurgerySection of Pediatric SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Ton Lisman
- Department of SurgerySection of Hepatobiliary Surgery and Liver TransplantationUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands,Department of SurgerySurgical Research LaboratoryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Robert J. Porte
- Department of SurgerySection of Hepatobiliary Surgery and Liver TransplantationUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands,Department of SurgerySurgical Research LaboratoryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
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17
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Wan J, Roberts LN, Hendrix W, Konings J, Ow T, Rabinowich L, Barbouti O, de Laat B, Arya R, Patel VC, Roest M, Lisman T, Bernal W. Whole blood thrombin generation profiles of patients with cirrhosis explored with a near patient assay. J Thromb Haemost 2020; 18:834-843. [PMID: 31997515 PMCID: PMC7186949 DOI: 10.1111/jth.14751] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/20/2020] [Accepted: 01/27/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS Patients with cirrhosis have a rebalanced hemostasis, often with normal or elevated thrombin-generating (TG) capacity in plasma. Whole blood (WB) TG allows faster determination and, importantly, includes the influence of all circulating blood cells. We aimed to study the TG profile of patients with cirrhosis in WB and in platelet poor plasma. METHODS Thrombin-generating capacity in WB and plasma were assessed with a near-patient WB-TG assay and the calibrated automated thrombinography assay, respectively. TG assays were tested in presence and absence of thrombomodulin. Conventional coagulation tests were also performed. RESULTS Thirty-four patients with cirrhosis and twenty-two controls were analyzed. Compared with controls, patients had substantially deranged results in conventional coagulation tests. Comparable WB-TG capacity (endogenous thrombin potential until peak, ETPp) but significantly lower peak thrombin were found in patients, and these results persisted when thrombomodulin was present. TG of the patients was more resistant to thrombomodulin than controls in both WB and plasma, although the inhibitory effect of thrombomodulin was drastically weaker in WB than in plasma. The peak of WB-TG in patients correlated moderately with their hematocrit and platelet count. Significant correlations were found between TG results in WB and plasma. CONCLUSIONS The WB-TG assay shows a normal to hypocoagulable state in patients with cirrhosis with a decreased anticoagulant activity of TM compared to plasma-TG. The clinical value of this assay needs further validation.
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Affiliation(s)
- Jun Wan
- Synapse Research InstituteMaastrichtthe Netherlands
- Cardiovascular Research InstituteMaastricht UniversityMaastrichtthe Netherlands
| | - Lara N. Roberts
- King's Thrombosis CentreDepartment of Haematological MedicineKing's College HospitalLondonUK
| | | | - Joke Konings
- Synapse Research InstituteMaastrichtthe Netherlands
- Cardiovascular Research InstituteMaastricht UniversityMaastrichtthe Netherlands
| | - Tsai‐Wing Ow
- Institute of Liver StudiesKing's College HospitalLondonUK
| | | | - Omar Barbouti
- Institute of Liver StudiesKing's College HospitalLondonUK
| | - Bas de Laat
- Synapse Research InstituteMaastrichtthe Netherlands
- Cardiovascular Research InstituteMaastricht UniversityMaastrichtthe Netherlands
| | - Roopen Arya
- King's Thrombosis CentreDepartment of Haematological MedicineKing's College HospitalLondonUK
| | - Vishal C. Patel
- Institute of Liver StudiesKing's College HospitalLondonUK
- School of Immunology and Microbial SciencesFaculty of Life Sciences and MedicineKing's College LondonLondonUK
- Institute of Hepatology LondonFoundation for Liver ResearchLondonUK
| | - Mark Roest
- Synapse Research InstituteMaastrichtthe Netherlands
- Cardiovascular Research InstituteMaastricht UniversityMaastrichtthe Netherlands
| | - Ton Lisman
- Surgical Research LaboratorySection of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - William Bernal
- Institute of Liver StudiesKing's College HospitalLondonUK
- School of Immunology and Microbial SciencesFaculty of Life Sciences and MedicineKing's College LondonLondonUK
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18
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Interpreting Hemostatic Profiles Assessed With Viscoelastic Tests in Patients With Cirrhosis. J Clin Gastroenterol 2020; 54:389-391. [PMID: 32028285 DOI: 10.1097/mcg.0000000000001327] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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19
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Douxfils J, Morimont L, Delvigne AS, Devel P, Masereel B, Haguet H, Bouvy C, Dogné JM. Validation and standardization of the ETP-based activated protein C resistance test for the clinical investigation of steroid contraceptives in women: an unmet clinical and regulatory need. ACTA ACUST UNITED AC 2019; 58:294-305. [DOI: 10.1515/cclm-2019-0471] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 07/30/2019] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Regulatory bodies recommend the use of an assay based on the assessment of the endogenous thrombin potential (ETP) for the investigation of the activated protein C resistance (APCr) in the development of steroid contraceptives in women. However, the assays described in the literature are home-made and not standardized regarding the method, the reagents, the reference plasma and the quality controls. In the absence of any commercially available method, we aimed at validating the ETP-based APCr assay.
Methods
The validation was performed according to regulatory standards. The method targets a 90% inhibition of the ETP in healthy donors in the presence of APC compared to the same condition in the absence of APC. As a large-scale production of a pool of plasma from well-selected healthy donors is impossible, algorithms were applied to a commercial reference plasma to correlate with the selected pool.
Results
Repeatability and intermediate precision passed the acceptance criteria. The assay demonstrated a curvilinear dose response to protein S and APC concentrations (R2 > 0.99). Analysis of plasma samples from 47 healthy individuals (22 women not taking combined hormonal contraceptives [CHC], and 25 men not Factor V Leiden carriers) confirmed the validity of the test, with a mean inhibition percentage of 90%. Investigations in 15 women taking different contraceptives and in two subjects with Factor V Leiden confirmed the good sensitivity and performance of the assay.
Conclusions
This validation provides the pharmaceutical industry, the regulatory bodies and physicians with a reproducible, sensitive and validated gold-standard ETP-based APCr assay.
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Affiliation(s)
- Jonathan Douxfils
- Qualiblood sa , Namur , Belgium
- University of Namur , Department of Pharmacy, Namur Thrombosis and Hemostasis Center, NAmur Research Institute for LIfe Sciences , Namur , Belgium
| | - Laure Morimont
- University of Namur , Department of Pharmacy, Namur Thrombosis and Hemostasis Center, NAmur Research Institute for LIfe Sciences , Namur , Belgium
| | | | - Philippe Devel
- University of Namur , Department of Pharmacy, Namur Thrombosis and Hemostasis Center, NAmur Research Institute for LIfe Sciences , Namur , Belgium
| | - Bernard Masereel
- Qualiblood sa , Namur , Belgium
- University of Namur , Department of Pharmacy, Namur Thrombosis and Hemostasis Center, NAmur Research Institute for LIfe Sciences , Namur , Belgium
| | - Hélène Haguet
- University of Namur , Department of Pharmacy, Namur Thrombosis and Hemostasis Center, NAmur Research Institute for LIfe Sciences , Namur , Belgium
| | | | - Jean-Michel Dogné
- University of Namur , Department of Pharmacy, Namur Thrombosis and Hemostasis Center, NAmur Research Institute for LIfe Sciences , Namur , Belgium
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20
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Tarandovskiy ID, Buehler PW, Ataullakhanov FI, Karnaukhova E. C1-esterase inhibitor enhances thrombin generation and spatial fibrin clot propagation in the presence of thrombomodulin. Thromb Res 2019; 176:54-60. [PMID: 30784776 DOI: 10.1016/j.thromres.2019.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 01/29/2019] [Accepted: 02/11/2019] [Indexed: 10/27/2022]
Abstract
Package inserts for C1-esterase inhibitor (C1INH) products include warnings for an elevated risk of possible thrombosis in certain individuals, referring to thromboembolic events (TEEs) that were reported to occur after C1INH infusions. However, the mechanism(s) that could explain possible development of TEEs due to C1INH remains unknown. In this work, we evaluated plausible impact of C1INH on the protein C (PC) anticoagulant system. We performed thrombin generation (TG) assays (TGA) and analyzed spatial fibrin clot propagation using thrombodynamics in plasma of individual donors after the addition of thrombomodulin (TM) and C1INH. The addition of C1INH was consistent with the plasma concentrations resulting from doses currently approved for the HAE treatment up to ones consistent with off-label use in patients with risk of inflammation. 16 IU/ml of C1INH significantly enhanced thrombin peak (TP) generation in the presence of 12 and 15 nM TM. TG enhancement was observed by the addition of C1INH to make concentrations equal to 2 and 4 IU/ml in some donor plasmas. C1INH addition in the presence of TM enhanced the stop time of spatial clot growth in Thrombodynamics assay. A chromogenic activity assay demonstrated that C1INH inhibited PC activation by thrombin in the presence of TM. Substitution of TM with APC in TGA attenuated the TP enhancing effect of C1INH. The collective results of the present study suggest a concentration dependent C1INH interaction with the PC system. This study introduces a plausible TM-dependent mechanism, that may explain reported TEEs via suppressed production of APC in the presence of C1INH.
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Affiliation(s)
- Ivan D Tarandovskiy
- Laboratory of Biochemistry and Vascular Biology, Center for Biologics Evaluation Research, US Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, MD, United States.
| | - Paul W Buehler
- Laboratory of Biochemistry and Vascular Biology, Center for Biologics Evaluation Research, US Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, MD, United States
| | - Fazoil I Ataullakhanov
- Center for Theoretical Problems of Physicochemical Pharmacology, Russian Academy of Sciences, Kosygina str., 4, Moscow 119334, Russia
| | - Elena Karnaukhova
- Laboratory of Biochemistry and Vascular Biology, Center for Biologics Evaluation Research, US Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, MD, United States
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21
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Russo FP, Zanetto A, Campello E, Bulato C, Shalaby S, Spiezia L, Gavasso S, Franceschet E, Radu C, Senzolo M, Burra P, Lisman T, Simioni P. Reversal of hypercoagulability in patients with HCV-related cirrhosis after treatment with direct-acting antivirals. Liver Int 2018; 38:2210-2218. [PMID: 29738632 DOI: 10.1111/liv.13873] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 04/20/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS The long-term impact of sustained virological response (SVR) after direct-acting antivirals (DAAs) on the hypercoagulability associated with HCV cirrhosis is unknown. We longitudinally evaluated the effect of DAAs treatment on cirrhotic coagulopathy. METHODS Pro- and anticoagulant factor levels and thrombin generation were assessed in patients with HCV-related cirrhosis at baseline, end of therapy (EOT), at 12, 24 and 48 weeks (W) after EOT. RESULTS Fifty-eight patients were enrolled (86% Child's A). SVR was 100%. Median factor VIII activity significantly decreased at EOT, 12 weeks and 24 weeks compared with baseline, whereas protein C significantly increased at 24 weeks and 48 weeks. Cirrhotic patients showed a slight but sustained increase in endogenous thrombin potential (ETP) with a statistically significant difference at EOT, 12 weeks, 24 weeks and 48 weeks compared with baseline. Conversely, thrombomodulin-modified ETP was elevated before treatment and decreased over time to normal levels at 24 weeks and 48 weeks. The ETP ratio decreased slowly at EOT and 12 weeks, and was significantly decreased at 24 weeks and 48 weeks compared with baseline (P < .001 for both comparisons), being not statistically different from ETP ratio measured in healthy controls. Child's B patients showed a significantly higher ETP ratio compared to Child's A at baseline and did not show any significant improvement in ETP ratio through 12 weeks. Two Child's B patients developed PVT with an incidence rate of 1.1% p-yrs (95%CI, 0.18 to 3.58). CONCLUSIONS DAAs therapy in HCV-related cirrhotic patients is associated with significant changes in thrombin generation suggesting a reversal of hypercoagulability particularly in Child's A patients.
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Affiliation(s)
- Francesco Paolo Russo
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Elena Campello
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padua University Hospital, Padua, Italy
| | - Cristiana Bulato
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padua University Hospital, Padua, Italy
| | - Sarah Shalaby
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Luca Spiezia
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padua University Hospital, Padua, Italy
| | - Sabrina Gavasso
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padua University Hospital, Padua, Italy
| | - Enrica Franceschet
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Claudia Radu
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padua University Hospital, Padua, Italy
| | - Marco Senzolo
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Patrizia Burra
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Ton Lisman
- Section of Hepatobiliary Surgery and Liver Transplantation, Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Paolo Simioni
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padua University Hospital, Padua, Italy
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22
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Sinegre T, Duron C, Lecompte T, Pereira B, Massoulier S, Lamblin G, Abergel A, Lebreton A. Increased factor VIII plays a significant role in plasma hypercoagulability phenotype of patients with cirrhosis. J Thromb Haemost 2018; 16:1132-1140. [PMID: 29577605 DOI: 10.1111/jth.14011] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Indexed: 12/14/2022]
Abstract
Essentials The role of increased factor VIII in cirrhosis-induced hypercoagulability has never been demonstrated. Factor VIII and protein C effects were characterized by thrombin generation with thrombomodulin. Factor VIII elevation plays a significant role in cirrhosis-induced plasma hypercoagulability. Only protein C and factor VIII normalization led to thrombin generation similar to controls. SUMMARY Background In cirrhosis, thrombin generation (TG) studied in the presence of thrombomodulin (TM) indicates plasma hypercoagulability. Although the role of protein C (PC) deficiency has been investigated, the influence of an increase in the factor VIII level has never been addressed. Objectives We investigated the roles of high FVIII and low PC levels in increased TG in the presence of TM. Methods Blood samples were prospectively collected from 35 healthy controls and 93 patients with cirrhosis (Child-Turcotte-Pugh [CTP]-A, n = 61; CTP-B, n = 19; and CTP-C, n = 13) and FVIII levels > 150% (n = 48) and/or PC levels < 70% (n = 88). TG was performed with tissue factor (5 pm), phospholipids, and TM (4 nm). FVIII and PC levels were normalized by adding an inhibitory anti-FVIII antibody and exogenous PC, respectively. Results The endogenous thrombin potential (ETP) in the presence of TM was higher in patients than in controls. After FVIII normalization, the ETP (median) decreased from 929 nm min to 621 nm min (CTP-A), 1122 nm min to 1082 nm min (CTP-B), and 1221 nm min to 1143 nm min (CTP-C); after PC normalization, it decreased from 776 nm min to 566 nm min (CTP-A), 1120 nm min to 790 nm min (CTP-B), and 995 nm min to 790 nm min (CTP-C). The ETP was reduced by 17% and 30%, respectively, but normal TG was not restored. When both FVIII and PC levels were normalized, the ETP decreased from 929 nm min to 340 nm min (CTP-A), 1122 nm min to 506 nm min (CTP-B), and 1226 nm min to 586 nm min (CTP-C), becoming similar to control levels. Conclusion Cirrhosis-induced plasma hypercoagulability, as demonstrated in these experimental conditions, can be partly explained by opposite changes in two factors: PC level (decrease) and FVIII level (increase).
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Affiliation(s)
- T Sinegre
- Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, INRA, UMR 1019, Clermont-Ferrand, France
| | - C Duron
- Service d'Hépato-Gastro-Entérologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, CNRS, UMR 6284, Clermont-Ferrand, France
| | - T Lecompte
- Hôpitaux Universitaires de Genève, Unité d'hémostase, Département des spécialités de médecine, Geneva, Switzerland
- Université de Genève, GpG, Geneva, Switzerland
| | - B Pereira
- CHU Clermont-Ferrand, Unité de Biostatistiques (Direction de la recherche clinique et de l'innovation), Clermont-Ferrand, France
| | - S Massoulier
- Service d'Hépato-Gastro-Entérologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - G Lamblin
- Service d'Hépato-Gastro-Entérologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - A Abergel
- Service d'Hépato-Gastro-Entérologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, CNRS, UMR 6284, Clermont-Ferrand, France
| | - A Lebreton
- Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, INRA, UMR 1019, Clermont-Ferrand, France
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Lisman T, Porte RJ. Pathogenesis, prevention, and management of bleeding and thrombosis in patients with liver diseases. Res Pract Thromb Haemost 2017; 1:150-161. [PMID: 30046685 PMCID: PMC6058283 DOI: 10.1002/rth2.12028] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 06/21/2017] [Indexed: 12/14/2022] Open
Abstract
Patients with liver diseases may develop alterations in all components of the hemostatic system. Thrombocytopenia, low levels of coagulation factors and inhibitors, low levels of fibrinolytic proteins, and increased levels of endothelial-derived proteins such as von Willebrand factor are all part of the coagulopathy of liver disease. Due to concomitant changes in pro- and antihemostatic drivers, the net effects of these complex hemostatic changes have long been unclear. According to current concepts, the hemostatic system of patients with liver disease is in an unstable balance, which explains the occurrence of both bleeding and thrombotic complications. This review will discuss etiology and management of bleeding and thrombosis in liver disease and will outline unsolved clinical questions. In addition, we will discuss the role of intrahepatic activation of coagulation for progression of liver disease, a novel paradigm with potential consequences for the general management of patients with liver disease.
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Affiliation(s)
- Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Robert J. Porte
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
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