Hemostatic function in hyperfibrinolytic disseminated intravascular coagulation

Rotational Thromboelastometry and Clot Waveform Analysis as Point-of-Care Tests for Diagnosis of Disseminated Intravascular Coagulation in Critically Ill Children in Thailand

OBJECTIVES

This study aimed to determine the test performances of rotational thromboelastometry (ROTEM) and activated partial thromboplastin time-based clot waveform analysis (aPTT-CWA) compared with the International Society on Thrombosis and Hemostasis disseminated intravascular coagulation (ISTH-DIC) score for diagnosis of overt disseminated intravascular coagulation (ODIC) in critically ill children. Prognostic indicators of DIC complications were also evaluated.

DESIGN

A prospective cross-sectional observational study was conducted. ROTEM and aPTT-CWA were assessed alongside standard parameters based on the ISTH-DIC score and natural anticoagulants. Both conventional and global hemostatic tests were repeated on days 3-5 for nonovert DIC.

SETTING

PICU of the Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.

SUBJECTS

Infants and children who were admitted to PICU with underlying diseases predisposed to DIC, such as sepsis, malignancy, major surgery, trauma, or severe illness, were included in the study between July 1, 2021, and November 30, 2022.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Sixty-four children were enrolled in this study. The prevalence of ODIC was 20.3%. Regarding ROTEM parameters, using EXTEM clot formation time (CFT) cutoff of greater than 102 seconds provided sensitivity and specificity of 90.9% and 80.9%, respectively, for diagnosing ODIC, with the area under the curve (AUC) of 0.86. In the case of aPTT-CWA performance, no biphasic waveform was observed, whereas both maximum coagulation acceleration (Min2) of less than 0.35%/s 2 and maximum coagulation deceleration of less than 0.25%/s 2 demonstrated identical sensitivities of 76.9% and specificities of 79.6%. Combining two global hemostatic tests significantly improved the diagnostic performance (INTEM CFT + EXTEM CFT + Min2 AUC 0.92 [95% CI, 0.80-1.00] vs. EXTEM CFT AUC 0.86 [95% CI, 0.75-0.96], p = 0.034). Bleeding was the most common consequence. In multivariable logistic regression analysis, Min2 of less than 0.36%/s 2 was an independent risk factor for bleeding complications, with an adjusted odds ratio of 15.08 (95% CI, 1.08-211.15, p = 0.044).

CONCLUSIONS

ROTEM and aPTT-CWA were valuable diagnostic tools in critically ill children who might require point-of-care tests. Min2 showed significant clinical implications for predicting bleeding events in this population.

Characterization of thrombophilia-related plasmas evaluated by anticoagulants-mediated thrombin and plasmin generation assays

Disturbances in the balance between coagulation, anticoagulation and fibrinolysis may lead to thrombosis or haemorrhage. Simultaneous assessments of thrombin and plasmin facilitate overall understandings of pathological haemostasis, especially for thrombophilia. Here, we characterized coagulation-fibrinolysis potentials in plasmas with thrombophilia using anticoagulants-mediated thrombin-plasmin generation assay (T/P-GA). T/P-GA was initiated by adding tissue factor, tissue-type plasminogen activator and anticoagulants [recombinant-thrombomodulin (rTM), activated protein (P)C (APC) and antithrombin (AT)], followed by simultaneous thrombin generation and plasma generation monitoring. Patients' plasmas with PC-deficiency (PC-def), PS-deficiency (PS-def), AT-deficiency (AT-def), factor VLeiden (FVL) and antiphospholipid syndrome (APS) were evaluated. A ratio of peak-thrombin (or peak-plasmin) with and without anticoagulants was calculated as anticoagulants (+)/anticoagulants (-). First, TG, in rTM-mediated, PC-def, PS-def and FVL showed higher peak-thrombin ratios than the controls, whereas AT-def and APS exhibited no differences from the controls. In APC-mediated, PC-def, PS-def and AT-def showed low peak-thrombin ratios, similar to the controls, but immune-depleted PS-def (<1%) showed the higher ratio than the controls. FVL and APS showed higher peak-thrombin ratios than the controls. In AT-mediated, peak-thrombin ratios in PS-def, PC-def and APS were lower than in controls, but those in AT-def and FVL was not significantly different from the controls. Second, PG, in rTM-mediated, all thrombophilia plasmas showed low peak-plasmin ratios (∼0.5), but no significant difference was observed, relative to the controls. In APC and AT-mediated, peak-plasmin ratios in thrombophilia-related plasmas were similar to the controls (∼1.0). Anticoagulants-mediated T/P-GA may classify thrombin generation characteristics in thrombophilia-related plasmas upon adding anticoagulants.

Analysis of Risk Factors of Coagulation Dysfunction and Hemorrhage in Newly Diagnosed Hyperleukocytic Acute Myeloma Leukemia

Purpose

To explore whether and why abnormal coagulation function and hemorrhage can appear in patients with hyperleukocytic acute myeloid leukemia (HAML).

Method

We retrospectively reviewed the charts of 724 acute myeloid leukemia (AML) patients admitted with a white blood cell count of >100 × 10⁹/L between 2010 and 2019 in order to analyze the coagulation index of patients with HAML and explore the correlation of abnormal coagulation.

Result

Prothrombin time (PT) was extended in group HAML compared with group non-HAML. Respiratory failure, intracranial hemorrhage, and infection were more common in the HAML group. Among the 76 HAML patients, there were 33 patients who had ≥3 abnormal items of coagulation index, and 51.5% of them had level 2 hemorrhage which was more than level 0 hemorrhage, and the difference is statistically significant (P < 0.01). Similarly, we can discover that 40.9% of patients with 2 abnormal items had level 2 hemorrhage in contrast to 0 abnormal items. The use of hydroxyurea had a significant effect on PT and D-dimer (DD). Survival analysis by the Kaplan–Meier method showed that there were statistically significant differences in white blood cell (WBC) count＞200 × 10⁹//L and DD. Abnormal PT is associated with WBC count＞200 × 10⁹//L, and abnormal activated partial thromboplastin time (APTT) is associated with HLA-DR mutation. Infection and respiratory failure were independent influencing factors for the coagulation of patients.

Conclusion

DD had a marked effect on the survival rate. Infection and respiratory failure were independent influencing factors for the coagulation of patients.

Developments in pediatrics in 2020: choices in allergy, autoinflammatory disorders, critical care, endocrinology, genetics, infectious diseases, microbiota, neonatology, neurology, nutrition, ortopedics, respiratory tract illnesses and rheumatology

In this article, we describe the advances in the field of pediatrics that have been published in the Italian Journal of Pediatrics in 2020. We report progresses in understanding allergy, autoinflammatory disorders, critical care, endocrinology, genetics, infectious diseases, microbiota, neonatology, neurology, nutrition, orthopedics, respiratory tract illnesses, rheumatology in childhood.

Coagulation and fibrinolysis balance in disseminated intravascular coagulation

BACKGROUND

Sepsis is a common underlying disease associated with disseminated intravascular coagulation (DIC). We have recently determined hemostatic pathological states at diagnosis through simultaneous assessment of coagulation and fibrinolysis potentials in sepsis-associated DIC using clot-fibrinolysis waveform analysis. Here we aimed to investigate hemostatic pathological states, focusing on the balance between coagulation and fibrinolysis dynamics during the clinical course in pediatric sepsis-associated DIC.

METHODS

Coagulation and fibrinolysis potential functions in three pediatric patients with sepsis-associated DIC during their clinical course were quantified using clot-fibrinolysis waveform analysis. A maximum coagulation velocity (|min1|) and maximum fibrinolysis velocity (|FL-min1|) was calculated as a ratio relative to normal plasma.

RESULTS

In case 1, coagulation-enhanced and fibrinolysis-depressed state (|min1|-ratio 2.22 and |FL-min1|-ratio 0.42) was observed on day 1. This discrepancy significantly reduced after anticoagulant therapy and plasma exchange on day 2. A well-balanced hemostatic state (0.70 and 0.62, respectively) was restored on day 7. In case 2, fibrinolysis-impaired state (|min1|-ratio 1.09 and |FL-min1|-ratio 0.21) was seen on day 1. The |min1| ratio was slightly prolonged and the |FL-min1| ratio was severely decreased. Both were restored on day 7 and returned to normal levels on day 12. In case 3, twofold coagulation- and fibrinolysis-enhanced states (|min1|-ratio 1.99 and |FL-min1|-ratio 1.11) were seen on day 1. However, both potentials rapidly decreased on day 2 (0.49 and 0.0, respectively). She died on day 5.

CONCLUSIONS

The hemostatic pathological states in sepsis-associated DIC depend on disease progression. Comprehensive assessment of coagulation-fibrinolysis potentials over time may therefore be helpful in considering optimal treatment plans for sepsis-associated DIC.

A Pathological Clarification of Sepsis-Associated Disseminated Intravascular Coagulation Based on Comprehensive Coagulation and Fibrinolysis Function

BACKGROUND

 The functional dynamics of coagulation and fibrinolysis in patients with disseminated intravascular coagulation (DIC) vary due to the pathology and severity of various underlying diseases. Conventional measurements of hemostasis such as thrombin-antithrombin complex, plasmin-α2-plasmin-inhibitor complex, and fibrinogen-fibrin degradation products may not always reflect critical pathophysiologic mechanisms in DIC. This article aims to clarify the pathology of sepsis-associated DIC using assessment of comprehensive coagulation and fibrinolysis.

METHODS

 Plasma samples were obtained from 57 patients with sepsis-associated DIC at the time of initial diagnosis. Hemostasis parameters were quantified by clot-fibrinolysis waveform analysis (CFWA) and thrombin/plasmin generation assays (T/P-GA). The results were expressed as ratios relative to normal plasma.

RESULTS

 CFWA demonstrated that the maximum coagulation velocity (|min1|) ratio modestly increased to median 1.40 (min - max: 0.10 - 2.60) but the maximum fibrinolytic velocity (|FL-min1|) ratio decreased to 0.61 (0 - 1.19). T/P-GA indicated that the peak thrombin (Th-Peak) ratio moderately decreased to 0.71 (0.22 - 1.20), whereas the peak plasmin (Plm-Peak) ratio substantially decreased to 0.35 (0.02 - 1.43). Statistical comparisons identified a correlation between |min1| and Th-Peak ratios (ρ = 0.55, p < 0.001), together with a strong correlation between |FL-min1| and Plm-Peak ratios (ρ = 0.71, p < 0.001), suggesting that CFWA reflected the balance between thrombin and plasmin generation. With |min1| and |FL-min1| ratios, DIC was classified as follows: coagulation-predominant, coagulation/fibrinolysis-balanced, fibrinolysis-predominant, and consumption-impaired coagulation. The majority of patients in our cohort (80.7%) were coagulation-predominant.

CONCLUSION

 A pathological clarification of sepsis-associated DIC based on the assessment of coagulation and fibrinolysis dynamics may be useful for the hemostatic monitoring and management of optimal treatment in these individuals.

Application of clot-fibrinolysis waveform analysis to assessment of in vitro effects of direct oral anticoagulants on fibrinolysis

INTRODUCTION

Acceleration of fibrinolysis by direct oral anticoagulants (DOACs) has been reported by several groups, suggesting contribution of not only anticoagulant but also fibrinolytic effects to the therapeutic efficacy. The present study aims to evaluate the usability of clot-fibrinolysis waveform analysis (CFWA) for assessment of in vitro effects of DOACs on fibrinolysis.

METHODS

The experimental conditions were optimized according to how t-PA concentrations and a time length after t-PA adjustment affect parameters of CFWA. Addition of the activated partial thromboplastin time (APTT) reagent followed by that of calcium and t-PA was done to obtain clotting and fibrinolytic reaction curves which were mathematically differentiated for CFWA (APTT-CFWA). The positive and negative modes of waveforms were defined as the direction toward fibrin generation and that toward fibrin degradation, respectively. The maximum positive and negative values (Max_p 1 and Max_n 1) correspond to the maximum coagulation velocity and the maximum fibrinolysis velocity, respectively. Plasma spiked with each of DOACs (rivaroxaban, apixaban, edoxaban, and dabigatran) was subjected to APTT-CFWA.

RESULTS

Optimization of t-PA use was based on Max_n 1. Roughly biphasic effects of rivaroxaban and dabigatran but not apixaban or edoxaban on fibrinolysis were observed through Max_n 1 and the fibrinolysis peak time, which was defined as a time length from the time when Max_p 1 (Max_p 1 time) to the time when Max_n 1 appears (Max_n 1 time).

CONCLUSION

The results suggest the usability of CFWA for assessment of DOAC effects and provide insights into relevance of anticoagulation to therapeutic efficacy and bleeding risk from the perspective of fibrinolysis.

Disordered hemostasis associated with severely depressed fibrinolysis demonstrated using a simultaneous thrombin and plasmin generation assay during L-asparaginase induction therapy in pediatric acute lymphoblastic leukemia

BACKGROUND

L-asparaginase (L-Asp)-associated thromboembolisms are serious complications in pediatrics patients with acute lymphoblastic leukemia (ALL), especially at ≥10.0 years old, but the pathogenesis remains to be clarified.

PROCEDURE

We conducted a multicenter, prospective study of 72 patients with ALL aged 1.0 to 15.2 years treated with either a Berlin-Frankfurt-Münster (BFM) 95-ALL oriented regimen or Japan Association of Childhood Leukemia Study ALL-02 protocol. We divided patients into each treatment protocol and investigated the dynamic changes in coagulation and fibrinolysis using simultaneous thrombin and plasmin generation assay. Patients' plasma samples were collected at the prephase (T0), intermittent phase (T1), and postphase of L-Asp therapy (T2), and postinduction phase (T3). Measurements of endogenous thrombin potential (T-EP) and plasmin peak height (P-Peak) were compared to normal plasma.

RESULTS

None of the cases developed thromboembolisms. Median ratios of T-EP and P-Peak for the controls in the JACLS group were 1.06 and 0.87 (T0), 1.04 and 0.71 (T1), 1.02 and 0.69 (T2), and 1.20 and 0.92 (T3), respectively, while those in the BFM group were 1.06 and 1.00 (T0), 1.04 and 0.64 (T1), 1.16 and 0.58 (T2), and 1.16 and 0.85 (T3), respectively. In particular, P-Peak ratios were depressed at T1 and T2 compared to T0 in the BFM group (P < .01). Moreover, P-Peak ratios in patients ≥10.0 years old were lower at T1 in the BFM group (P = .02).

CONCLUSIONS

The results demonstrated that hemostatic dynamics appeared to shift to a hypercoagulable state with marked hypofibrinolysis associated with L-Asp therapy, especially in patients ≥10.0 years old following the BFM regimen.