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Nomogram model for predicting esophsagogastric varices in hepatocellular carcinoma with cirrhosis. Eur J Gastroenterol Hepatol 2023; 35:342-348. [PMID: 36708306 DOI: 10.1097/meg.0000000000002496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND/AIMS The prognosis for hepatocellular carcinoma (HCC) with cirrhosis is poor. The risk of death also increases in patients with esophagogastric varices (EGV). Based on routine clinical features and related noninvasive parameters, a nomogram prediction model was developed in this study to facilitate the early identification of EGV in HCC patients. METHODS A retrospective cohort analysis of patients with HCC in the Renmin Hospital of Wuhan University from 2020 to 2021 was performed. Clinical and noninvasive parameters closely related to EGV risk were screened by univariate and multivariate logistic regression analysis and integrated into a nomogram. The nomogram was validated internally and externally by calibration, receiver operating characteristic curve and decision curve analysis (DCA). RESULTS A total of 165 patients with HCC-related cirrhosis were recruited. In the raining cohort, multivariate logistic regression analysis identified platelet (PLT) [odds ratio (OR), 0.950; 95% confidence interval (CI), 0.925-0.977; P < 0.001], D-dimer (OR. 3.341; 95% CI, 1.751-6.376, P < 0.001), spleen diameter (SD) (OR, 2.585; 95% CI, 1.547-4.318; P < 0.001) as independent indicators for EGV. The nomogram for predicting EGV risk was well calibrated with a favorable discriminative ability and an area under curve of 0.961. In addition, the nomogram showed better net benefits in the DCA. The results were validated in the validation cohort. CONCLUSIONS The proposed nomogram model based on three indicators (PLT, D-dimer and SD) showed an excellent predictive effect, leading to the avoidance of unnecessary esophagogastroduodenoscopy.
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Zanetto A, Northup P, Roberts L, Senzolo M. Haemostasis in cirrhosis: Understanding destabilising factors during acute decompensation. J Hepatol 2023; 78:1037-1047. [PMID: 36708812 DOI: 10.1016/j.jhep.2023.01.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 01/03/2023] [Accepted: 01/17/2023] [Indexed: 01/27/2023]
Abstract
Hospitalised patients with decompensated cirrhosis are in a rebalanced haemostatic state due to a parallel decline in both pro- and anti-haemostatic pathways. However, this rebalanced haemostatic state is highly susceptible to perturbations and may easily tilt towards hypocoagulability and bleeding. Acute kidney injury, bacterial infections and sepsis, and progression from acute decompensation to acute-on-chronic liver failure are associated with additional alterations of specific haemostatic pathways and a higher risk of bleeding. Unfortunately, there is no single laboratory method that can accurately stratify an individual patient's bleeding risk and guide pre-procedural prophylaxis. A better understanding of haemostatic alterations during acute illness would lead to more rational and individualised management of hospitalised patients with decompensated cirrhosis. This review will outline the latest findings on haemostatic alterations driven by acute kidney injury, bacterial infections/sepsis, and acute-on-chronic liver failure in these difficult-to-treat patients and provide evidence supporting more tailored management of bleeding risk.
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Affiliation(s)
- Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale - Università Padova, Padova, Italy; Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Patrick Northup
- Division of Gastroenterology and Hepatology, NYU Grossman School of Medicine, NYU Transplant Institute, New York, NY, USA
| | - Lara Roberts
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital, London, UK
| | - Marco Senzolo
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale - Università Padova, Padova, Italy; Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy.
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Seo JS, Kim Y, Lee Y, Chung HY, Kim TY. Usefulness of the d-dimer to albumin ratio for risk assessment in patients with acute variceal bleeding at the emergency department: retrospective observational study. BMC Emerg Med 2022; 22:135. [PMID: 35879671 PMCID: PMC9311345 DOI: 10.1186/s12873-022-00696-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 07/20/2022] [Indexed: 11/29/2022] Open
Abstract
Background Acute variceal bleeding (AVB) is a severe complication of portal hypertension that is caused by rupture of the esophageal or gastric varix. Scoring system for risk stratification of AVB is difficult to use because various variables must be entered, and it is difficult to apply early in the emergency department (ED). We compared and analyzed the usefulness of the D-dimer to albumin ratio (DAR) for risk stratification of AVB. Methods In this retrospective observational study, medical records of patients with AVB Between January 2019 and December 2020 were assessed. The primary endpoint was to evaluate whether DAR was a predictor of clinical outcomes for AVB. Receiver operating characteristic (ROC) curves were constructed using cut-off values determined by the Youden Index. Univariate and multivariate logistic regression analyses were performed to assess the factors contributing to the development of outcomes. Results Overall, 67 patients required intensive care. The cut-off value of DAR for patients requiring intensive care was 400. A DAR > 400 (adjusted HR: 5.636 [95% CI: 2.216–14.332]) independently predicted the need for ICU admission in these patients. Overall, 13 patients required long-term hospitalization. The cut-off value of DAR for patients requiring long-term hospitalization was 403. A DAR > 403 (adjusted HR: 9.899 [95% CI: 2.012–48.694]) independently predicted the need for long-term hospitalization. Overall, 95 patients required transfusion. The cut-off value of DAR for patients requiring transfusion was 121. A DAR > 121 (adjusted HR: 4.680 [95% CI: 1.703–12.862]) independently predicted the need for transfusion. Overall, 11 patients died during study period. The cut-off value of DAR for mortality was 450. A DAR > 450 (adjusted HR: 26.261 [95% CI: 3.054–225.827]) independently predicted mortality. Conclusions The DAR can be used for outcome assessment in patients with AVB with various scoring systems, but its explanatory power is not high. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-022-00696-4.
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Affiliation(s)
- Jun Seok Seo
- Department of Emergency Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, 27, Dongguk-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, Republic of Korea.,Department of Medical Informatics, Kyungpook National University School of Medicine, Daegu, Republic of Korea
| | - Yongwon Kim
- Department of Emergency Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, 27, Dongguk-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Yoonsuk Lee
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Ho Young Chung
- Department of Medical Informatics, Kyungpook National University School of Medicine, Daegu, Republic of Korea
| | - Tae Youn Kim
- Department of Emergency Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, 27, Dongguk-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, Republic of Korea.
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Curakova Ristovska E, Genadieva-Dimitrova M. Prognostic value of von-Willebrand factor in patients with liver cirrhosis and its relation to other prognostic indicators. World J Hepatol 2022; 14:812-826. [PMID: 35646274 PMCID: PMC9099105 DOI: 10.4254/wjh.v14.i4.812] [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: 06/09/2021] [Revised: 07/18/2021] [Accepted: 03/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Von-Willebrand factor (vWF) disposes certain prognostic value in patients with liver cirrhosis, but its relation to other prognostic indicators has not been fully investigated.
AIM To analyze the relation between vWF and other prognostic indicators in cirrhotic patients and to evaluate its prognostic value for mortality.
METHODS This analytic prospective study was carried out in a tertiary center and initially enrolled 71 patients with liver cirrhosis and portal hypertension. It analyzed the relation between vWF and the stage of the disease and several inflammatory and prognostic indicators. The prospective analysis, performed on a sample of 63 patients, evaluated the association between the selected variables [vWF, Model for End-stage Liver Disease (MELD) score, C-reactive protein (CRP), ferritin, vitamin D, activated partial thromboplastin time, thrombin time, D-dimer concentration] and the survival time as well as their predictive value in terms of 3-mo, 6-mo and 1-year mortality.
RESULTS vWF was significantly higher in patients with higher Child-Turcotte-Pugh class (P = 0.0045), MELD group (P = 0.0057), ferritin group (P = 0.0278), and D-dimer concentration (P = 0.0232). vWF significantly correlated with D-dimer concentration, ferritin, CRP, International Normalized Ratio, and MELD, Child-Turcotte-Pugh, Sequential Organ Failure Assessment, and CLIF-consortium organ failure (CLIF-C OF) scores. vWF, MELD score, and CRP were significantly associated with death and were significant predictors of 3-mo, 6-mo, and 1-year mortality. Each vWF unit significantly increased the probability for 3-mo mortality by 1.005 times (P = 0.008), for 6-mo mortality by 1.006 times (P = 0.005), and for 1-year mortality by 1.007 times (P = 0.002). There was no significant difference between the diagnostic performance of vWF and MELD score and also between vWF and CRP regarding the 3-mo, 6-mo, and 1-year mortality.
CONCLUSION In patients with liver cirrhosis, vWF is significantly related to other prognostic indicators and is a significant predictor of 3-mo, 6-mo, and 1-year mortality similar to MELD score and CRP.
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Affiliation(s)
- Elena Curakova Ristovska
- Intensive Care Unit, University Clinic for Gastroenterohepatology, Skopje 1000, North Macedonia
- Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Skopje 1000, North Macedonia
| | - Magdalena Genadieva-Dimitrova
- Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Skopje 1000, North Macedonia
- Hepatology Department, University Clinic for Gastroenterohepatology, Skopje 1000, North Macedonia
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Chen L, Zheng H, Wang S. Prediction model of emergency mortality risk in patients with acute upper gastrointestinal bleeding: a retrospective study. PeerJ 2021; 9:e11656. [PMID: 34221734 PMCID: PMC8236237 DOI: 10.7717/peerj.11656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 05/31/2021] [Indexed: 11/24/2022] Open
Abstract
Background Upper gastrointestinal bleeding is a common presentation in emergency departments and carries significant morbidity worldwide. It is paramount that treating physicians have access to tools that can effectively evaluate the patient risk, allowing quick and effective treatments to ultimately improve their prognosis. This study aims to establish a mortality risk assessment model for patients with acute upper gastrointestinal bleeding at an emergency department. Methods A total of 991 patients presenting with acute upper gastrointestinal bleeding between July 2016 and June 2019 were enrolled in this retrospective single-center cohort study. Patient demographics, parameters assessed at admission, laboratory test, and clinical interventions were extracted. We used the least absolute shrinkage and selection operator regression to identify predictors for establishing a nomogram for death in the emergency department or within 24 h after leaving the emergency department and a corresponding nomogram. The area under the curve of the model was calculated. A bootstrap resampling method was used to internal validation, and decision curve analysis was applied for evaluate the clinical utility of the model. We also compared our predictive model with other prognostic models, such as AIMS65, Glasgow-Blatchford bleeding score, modified Glasgow-Blatchford bleeding score, and Pre-Endoscopic Rockall Score. Results Among 991 patients, 41 (4.14%) died in the emergency department or within 24 h after leaving the emergency department. Five non-zero coefficient variables (transfusion of plasma, D-dimer, albumin, potassium, age) were filtered by the least absolute shrinkage and selection operator regression analysis and used to establish a predictive model. The area under the curve for the model was 0.847 (95% confidence interval [0.794–0.900]), which is higher than that of previous models for mortality of patients with acute upper gastrointestinal bleeding. The decision curve analysis indicated the clinical usefulness of the model. Conclusions The nomogram based on transfusion of plasma, D-dimer, albumin, potassium, and age effectively assessed the prognosis of patients with acute upper gastrointestinal bleeding presenting at the emergency department.
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Affiliation(s)
- Lan Chen
- Nursing Education Department, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua Municipal Central Hospital, Jinhua, ZheJiang, China
| | - Han Zheng
- Emergency Department, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua Municipal Central Hospital, Jinhua, ZheJiang, China
| | - Saibin Wang
- Department of Respiratory Medicine, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua Municipal Central Hospital, Jinhua, ZheJiang, China
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Brenner A, Afolabi A, Ahmad SM, Arribas M, Chaudhri R, Coats T, Cuzick J, Gilmore I, Hawkey C, Jairath V, Javaid K, Kayani A, Mutti M, Nadeem MA, Shakur-Still H, Stanworth S, Veitch A, Roberts I. Tranexamic acid for acute gastrointestinal bleeding (the HALT-IT trial): statistical analysis plan for an international, randomised, double-blind, placebo-controlled trial. Trials 2019; 20:467. [PMID: 31362765 PMCID: PMC6668177 DOI: 10.1186/s13063-019-3561-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 07/08/2019] [Indexed: 12/29/2022] Open
Abstract
Background Acute gastrointestinal (GI) bleeding is an important cause of mortality worldwide. Bleeding can occur from the upper or lower GI tract, with upper GI bleeding accounting for most cases. The main causes include peptic ulcer/erosive mucosal disease, oesophageal varices and malignancy. The case fatality rate is around 10% for upper GI bleeding and 3% for lower GI bleeding. Rebleeding affects 5–40% of patients and is associated with a four-fold increased risk of death. Tranexamic acid (TXA) decreases bleeding and the need for blood transfusion in surgery and reduces death due to bleeding in patients with trauma and postpartum haemorrhage. It reduces bleeding by inhibiting the breakdown of fibrin clots by plasmin. Due to the methodological weaknesses and small size of the existing trials, the effectiveness and safety of TXA in GI bleeding is uncertain. The Haemorrhage ALleviation with Tranexamic acid – Intestinal system (HALT-IT) trial aims to provide reliable evidence about the effects of TXA in acute upper and lower GI bleeding. Methods The HALT-IT trial is an international, randomised, double-blind, placebo-controlled trial of tranexamic acid in 12,000 adults (increased from 8000) with acute upper or lower GI bleeding. Eligible patients are randomly allocated to receive TXA (1-g loading dose followed by 3-g maintenance dose over 24 h) or matching placebo. The main analysis will compare those randomised to TXA with those randomised to placebo on an intention-to-treat basis, presenting the results as effect estimates (relative risks) and confidence intervals. The primary outcome is death due to bleeding within 5 days of randomisation and secondary outcomes are: rebleeding; all-cause and cause-specific mortality; thromboembolic events; complications; endoscopic, radiological and surgical interventions; blood transfusion requirements; disability (defined by a measure of patient’s self-care capacity); and number of days spent in intensive care or high-dependency units. Subgroup analyses for the primary outcome will consider time to treatment, location of bleeding, cause of bleed and clinical Rockall score. Discussion We present the statistical analysis of the HALT-IT trial. This plan was published before the treatment allocation was unblinded. Trial registration Current Controlled Trials, ID: ISRCTN11225767. Registered on 3 July 2012; Clinicaltrials.gov, ID: NCT01658124. Registered on 26 July 2012. Electronic supplementary material The online version of this article (10.1186/s13063-019-3561-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Amy Brenner
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Adefemi Afolabi
- Department of Surgery, College of Medicine, University of Ibadan, University College Hospital, Queen Elizabeth Road, Ibadan, 200001, Nigeria
| | - Syed Masroor Ahmad
- Department of Medicine Unit III, Jinnah Postgraduate Medical Centre, Rafiq Shaheed Road, Karachi, 75510, Pakistan
| | - Monica Arribas
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Rizwana Chaudhri
- Rawalpindi Medical University, Holy Family Hospital, Rawalpindi, Pakistan
| | - Timothy Coats
- Department of Cardiovascular Sciences, University of Leicester, Infirmary Square, Leicester, LE1 5WW, UK
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, EC1M 6BQ, UK
| | | | - Christopher Hawkey
- Faculty of Medicine and Health Sciences, University of Nottingham, Queens Medical Centre, Nottingham, NG7 2UH, UK
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, University Hospital, Western University, London, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Kiran Javaid
- Rawalpindi Medical University and London School of Hygiene and Tropical Medicine (RMU-LSHTM) Collaboration, Room No 294, Holy family Hospital, Said Pur Road, Rawalpindi, Pakistan
| | - Aasia Kayani
- Rawalpindi Medical University and London School of Hygiene and Tropical Medicine (RMU-LSHTM) Collaboration, Room No 294, Holy family Hospital, Said Pur Road, Rawalpindi, Pakistan
| | - Muttiullah Mutti
- Rawalpindi Medical University, Holy Family Hospital, Rawalpindi, Pakistan
| | - Muhammad Arif Nadeem
- Department of Medicine, Services Hospital Unit III, Medical Unit III, Jail Road, Lahore, Pakistan
| | - Haleema Shakur-Still
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Simon Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and Oxford BRC Haematology Theme, Oxford, UK
| | - Andrew Veitch
- Department of Gastroenterology, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Ian Roberts
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Hori YS, Ebisudani Y, Aoi M, Fukuhara T. Elevated Serum Fibrinogen Degradation Products on Admission Is a Novel Predictive Factor for Recurrence of Chronic Subdural Hematoma. World Neurosurg 2018; 118:e753-e757. [DOI: 10.1016/j.wneu.2018.07.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/03/2018] [Accepted: 07/05/2018] [Indexed: 12/29/2022]
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Elevated liver stiffness is linked to increased biomarkers of inflammation and immune activation in HIV/hepatitis C virus-coinfected patients. AIDS 2018; 32:1095-1105. [PMID: 29438197 DOI: 10.1097/qad.0000000000001787] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Immune dysregulation is a hallmark of HIV and hepatitis C virus (HCV) infections. We aimed to evaluate the relationship between liver stiffness measurement (LSM) and biomarkers of T-cell activation, bacterial translocation, inflammation, endothelial dysfunction, and coagulopathy in HIV/HCV-coinfected patients. DESIGN Cross-sectional study. METHODS We studied 238 HIV/HCV-coinfected patients, 32 healthy controls, and 39 HIV-monoinfected patients. Patients were stratified according to LSM into four groups: less than 12.5, 12.5-25, 25-40, and more than 40 kPa. T-cell subsets were measured using flow cytometry and plasma biomarkers using immunoassays. RESULTS HIV/HCV-coinfected patients had higher biomarker levels of immune activation in peripheral blood [T-cell activation (CD4CD38 and CD8CD38), bacterial translocation (soluble CD14), inflammation [IL-1b, IL-6, IL-8, IL-18, IFN-γ-inducible protein 10 (IP-10)] endothelial dysfunction [soluble vascular cell adhesion molecule 1 (sVCAM1), soluble intercellular cell adhesion molecule 1 (sICAM1), and soluble tumor necrosis factor receptor 1 (sTNFR1)], and coagulopathy (plasminogen activator inhibitor-1)] than healthy controls and HIV-monoinfected patients. Moreover, in HIV/HCV-coinfected patients, a direct relationship between LSM and immune activation [T-cell activation (CD8CD38 bacterial translocation (lipopolysaccharide), inflammation (IL-8, IP-10), endothelial dysfunction (sVCAM1, sICAM1, and sTNFR1), and coagulopathy (D-dimer)] was found. Subsequently, patients were stratified into different fibrosis stages, finding that patients with cirrhosis who had LSM at least 40 kPa showed higher biomarker values of immune activation [T-cell activation (CD4CD38 and CD8CD38), bacterial translocation (lipopolysaccharide), inflammation (IL-8, IL-6, IP-10), endothelial dysfunction (sVCAM1, sICAM1, and sTNFR1), and coagulopathy (D-dimer)] than patients from the other three groups (<12.5, 12.5-25, and 25-40 kPa). CONCLUSION T-cell activation, bacterial translocation, inflammation, endothelial dysfunction, and coagulopathy increased with the severity of liver fibrosis in HIV/HCV-coinfected patients, particularly in patients who had LSM at least 40 kPa.
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Wu X, Ren J, Gao Z, Xu Y, Xie H, Li T, Cheng Y, Hu F, Liu H, Gong Z, Liang J, Shen J, Liu Z, Wu F, Sun X, Niu Z, Ning A. Plasma D-dimer Can Effectively Predict the Prospective Occurrence of Ascites in Advanced Schistosomiasis Japonica Patients. THE KOREAN JOURNAL OF PARASITOLOGY 2017; 55:167-174. [PMID: 28506039 PMCID: PMC5450959 DOI: 10.3347/kjp.2017.55.2.167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 02/13/2017] [Accepted: 02/14/2017] [Indexed: 12/29/2022]
Abstract
China still has more than 30,000 patients of advanced schistosomiasis while new cases being reported consistently. D-dimer is a fibrin degradation product. As ascites being the dominating symptom in advanced schistosomiasis, the present study aimed to explore a prediction model of ascites with D-dimer and other clinical easy-achievable indicators. A case-control study nested in a prospective cohort was conducted in schistosomiasis-endemic area of southern China. A total of 291 patients of advanced schistosomiasis were first investigated in 2013 and further followed in 2014. Information on clinical history, physical examination, and abdominal ultrasonography, including the symptom of ascites was repeatedly collected. Result showed 44 patients having ascites. Most of the patients’ ascites were confined in the kidney area with median area of 20 mm2. The level of plasma D-dimer and pertinent liver function indicators were measured at the initial investigation in 2013. Compared with those without ascites, cases with ascites had significantly higher levels of D-dimer (0.71±2.44 μg/L vs 0.48±2.12 μg/L, P=0.005), as well ALB (44.5 vs 46.2, g/L) and Type IV collagen (50.04 vs 44.50 μg/L). Receiver operating characteristic curve analyses indicated a moderate predictive value of D-dimer by its own area under curve (AUC) of 0.64 (95% CI: 0.54–0.73) and the cutoff value as 0.81 μg/L. Dichotomized by the cutoff level, D-dimer along with other categorical variables generated a prediction model with AUC of 0.76 (95% CI: 0.68–0.89). Risks of patients with specific characteristics in the prediction model were summarized. Our study suggests that the plasma D-dimer level is a reliable predictor for incident ascites in advanced schistosomiasis japonica patients.
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Affiliation(s)
- Xiaoying Wu
- School of Public Health, Fudan University, Shanghai, China
| | - Jianwei Ren
- Health Department of Guard Bureau of General Office of the Communist Party of China, Beijing, P. R. China
| | - Zulu Gao
- Jiangxi Provincial Institute of Parasitic Diseases, Nanchang, P. R. China
| | - Yun Xu
- Jiangxi Provincial Institute of Parasitic Diseases, Nanchang, P. R. China
| | - Huiqun Xie
- Jiangxi Provincial Institute of Parasitic Diseases, Nanchang, P. R. China
| | - Tingfang Li
- Schistosomiasis Control Station of Yugan County, Shangrao, P. R. China
| | - Yanhua Cheng
- Jiangxi Provincial Institute of Parasitic Diseases, Nanchang, P. R. China
| | - Fei Hu
- Jiangxi Provincial Institute of Parasitic Diseases, Nanchang, P. R. China
| | - Hongyun Liu
- Jiangxi Provincial Institute of Parasitic Diseases, Nanchang, P. R. China
| | - Zhihong Gong
- Jiangxi Provincial Institute of Parasitic Diseases, Nanchang, P. R. China
| | - Jinyi Liang
- Key Laboratory of Tropical Diseases and Control of the Ministry of Education, Guangzhou, P. R. China.,Department of Parasitology, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, P. R. China
| | - Jia Shen
- Key Laboratory of Tropical Diseases and Control of the Ministry of Education, Guangzhou, P. R. China.,Department of Parasitology, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, P. R. China
| | - Zhen Liu
- Key Laboratory of Tropical Diseases and Control of the Ministry of Education, Guangzhou, P. R. China.,Department of Parasitology, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, P. R. China
| | - Feng Wu
- Key Laboratory of Tropical Diseases and Control of the Ministry of Education, Guangzhou, P. R. China.,Department of Parasitology, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, P. R. China
| | - Xi Sun
- Key Laboratory of Tropical Diseases and Control of the Ministry of Education, Guangzhou, P. R. China.,Department of Parasitology, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, P. R. China
| | - Zhongzheng Niu
- School of Community and Global Health, Claremont Graduate University, Claremont, California, USA
| | - An Ning
- Jiangxi Provincial Institute of Parasitic Diseases, Nanchang, P. R. China
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Li Y, Qi X, Li H, Dai J, Deng H, Li J, Peng Y, Liu X, Sun X, Guo X. D-dimer level for predicting the in-hospital mortality in liver cirrhosis: A retrospective study. Exp Ther Med 2017; 13:285-289. [PMID: 28123503 PMCID: PMC5245161 DOI: 10.3892/etm.2016.3930] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Accepted: 09/22/2016] [Indexed: 02/07/2023] Open
Abstract
The present study aimed to examine the correlation of D-dimer levels with the Child-Pugh and MELD scores, as well as to determine the predictive ability of D-dimer level for the in-hospital mortality of liver cirrhosis patients. All cirrhotic patients who were consecutively admitted to our hospital between January 2011 and June 2014, and underwent D-dimer tests on admission were retrospectively analyzed. Pearson's χ2 tests were employed to evaluate the correlations of D-dimer levels with Child-Pugh and MELD scores. In addition, receiver operating curve (ROC) analysis was employed to evaluate the specificity and sensitivity of D-dimer levels for predicting the in-hospital mortality. In total, 703 cirrhotic patients were included in the study, with an in-hospital mortality of 5.4% (38/703). The D-dimer levels were correlated with Child-Pugh (correlation coefficient, 0.219; P<0.001) and MELD scores (correlation coefficient, 0.207; P<0.001). The highest D-dimer level was observed in the Child-Pugh class C patients, followed by the class B and A patients. Furthermore, D-dimer was significantly higher in the MELD score >15 group compared with the MELD score <15 group. The area under the ROC of D-dimer levels for predicting the in-hospital mortality of liver cirrhosis was 0.729 (P<0.0001), while the best cut-off D-dimer value was 0.28 µg/ml with a sensitivity of 86.84% and a specificity of 49.17%. In conclusion, the D-dimer level is significantly associated with the degree of liver dysfunction. Therefore, D-dimer testing could be employed for the prognostic stratification of liver cirrhosis.
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Affiliation(s)
- Yun Li
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, Liaoning 110840, P.R. China
- Postgraduate College, Dalian Medical University, Dalian, Liaoning 110016, P.R. China
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, Liaoning 110840, P.R. China
- Correspondence to: Professor Hongyu Li or Dr Xingshun Qi, Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, 83 Wenhua Road, Shenyang, Liaoning 110840, P.R. China, E-mail: , E-mail:
| | - Hongyu Li
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, Liaoning 110840, P.R. China
- Correspondence to: Professor Hongyu Li or Dr Xingshun Qi, Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, 83 Wenhua Road, Shenyang, Liaoning 110840, P.R. China, E-mail: , E-mail:
| | - Junna Dai
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, Liaoning 110840, P.R. China
- Postgraduate College, Dalian Medical University, Dalian, Liaoning 110016, P.R. China
| | - Han Deng
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, Liaoning 110840, P.R. China
- Postgraduate College, Dalian Medical University, Dalian, Liaoning 110016, P.R. China
| | - Jing Li
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, Liaoning 110840, P.R. China
- Postgraduate College, Dalian Medical University, Dalian, Liaoning 110016, P.R. China
| | - Ying Peng
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, Liaoning 110840, P.R. China
- Postgraduate College, Dalian Medical University, Dalian, Liaoning 110016, P.R. China
| | - Xu Liu
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, Liaoning 110840, P.R. China
| | - Xiaolin Sun
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, Liaoning 110840, P.R. China
| | - Xiaozhong Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, Liaoning 110840, P.R. China
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Dai J, Qi X, Peng Y, Hou Y, Chen J, Li H, Guo X. Association between D-dimer level and portal venous system thrombosis in liver cirrhosis: a retrospective observational study. Int J Clin Exp Med 2015; 8:15296-301. [PMID: 26629017 DOI: pmid/26629017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 09/10/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This study aimed to explore the association between D-dimer levels and presence of portal venous system thrombosis (PVST) in liver cirrhosis. METHODS All consecutive patients with a diagnosis of liver cirrhosis who underwent D-dimer test were retrospectively enrolled. Normal reference range of D-dimer level was 0-0.3 µg/mL. PVST was diagnosed on the basis of contrast-enhanced computed tomography and/or magnetic resonance imaging scans. RESULTS Of the 66 included patients, 24 were diagnosed with PVST. Mean D-dimer level was 0.51±0.72 µg/mL (range: 0.10-3.44). Mean D-dimer level was not significantly different between PVST and non-PVST groups (0.68±0.93 µg/mL versus 0.41±0.56 µg/mL, P=0.146). Area under the receiver operating curve for D-dimer level for predicting the presence of PVT was 0.606 (95% confidence interval: 0.478-0.724, P=0.1393). The optimal cut-off value for D-dimer was 0.22 with a sensitivity of 58.3% and a specificity of 69.0%. The subgroup analyses of patients without splenectomy or those with different Child-Pugh classes demonstrated no significant difference in the D-dimer level between PVST and non-PVST groups. CONCLUSION D-dimer might not be useful to identify the presence of PVST in liver cirrhosis. However, given the retrospective nature of this study, further well-designed prospective study should be necessary to confirm this finding.
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Affiliation(s)
- Junna Dai
- Postgraduate College, Dalian Medical University Dalian, Liaoning, P.R. China
| | - Xingshun Qi
- Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Shenyang Military Area Shenyang 110840, P.R. China
| | - Ying Peng
- Postgraduate College, Dalian Medical University Dalian, Liaoning, P.R. China
| | - Yue Hou
- Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Shenyang Military Area Shenyang 110840, P.R. China
| | - Jiang Chen
- Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Shenyang Military Area Shenyang 110840, P.R. China
| | - Hongyu Li
- Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Shenyang Military Area Shenyang 110840, P.R. China
| | - Xiaozhong Guo
- Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Shenyang Military Area Shenyang 110840, P.R. China
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12
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Hsu SC, Chen CY, Weng YM, Chen SY, Lin CC, Chen JC. Comparison of 3 scoring systems to predict mortality from unstable upper gastrointestinal bleeding in cirrhotic patients. Am J Emerg Med 2014; 32:417-20. [DOI: 10.1016/j.ajem.2014.01.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Revised: 01/09/2014] [Accepted: 01/11/2014] [Indexed: 12/14/2022] Open
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Leite LAC, Pimenta Filho AA, da Fonseca CSM, dos Santos BS, Ferreira RDCDS, Montenegro SML, Lopes EP, Domingues ALC, Owen JS, Lima VLDM. Hemostatic dysfunction is increased in patients with hepatosplenic schistosomiasis mansoni and advanced periportal fibrosis. PLoS Negl Trop Dis 2013; 7:e2314. [PMID: 23875049 PMCID: PMC3715409 DOI: 10.1371/journal.pntd.0002314] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Accepted: 06/03/2013] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Schistosomiasis mansoni is an endemic parasitic disease and a public health problem in Northeast Brazil. In some patients, hepatic abnormalities lead to periportal fibrosis and result in the most severe clinical form, hepatosplenic schistosomiasis. This study aimed to evaluate whether abnormal blood coagulation and liver function tests in patients with hepatosplenic schistosomiasis (n = 55) correlate with the severity of their periportal fibrosis. METHODOLOGY/PRINCIPAL FINDINGS Blood samples were used for liver function tests, hemogram and prothrombin time (International Normalized Ratio, INR). The blood coagulation factors (II, VII, VIII, IX and X), protein C and antithrombin IIa (ATIIa), plasminogen activator inhibitor 1 (PAI-1) and D-dimer were measured by photometry or enzyme linked immunosorbent assay. Hyperfibrinolysis was defined on the basis of PAI-1 levels and a D-dimer concentration greater than a standard cut-off of 483 ng/mL. Standard liver function tests were all abnormal in the patient group compared to healthy controls (n = 29), including raised serum transaminases (p<0.001) and lower levels of albumin (p = 0.0156). Platelet counts were 50% lower in patients, while for coagulation factors there was a 40% increase in the INR (p<0.001) and reduced levels of Factor VII and protein C in patients compared to the controls (both p<0.001). Additionally, patients with more advanced fibrosis (n = 38) had lower levels of protein C compared to those with only central fibrosis (p = 0.0124). The concentration of plasma PAI-1 in patients was one-third that of the control group (p<0.001), and D-dimer levels 2.2 times higher (p<0.001) with 13 of the 55 patients having levels above the cut-off. CONCLUSION/SIGNIFICANCE This study confirms that hemostatic abnormalities are associated with reduced liver function and increased liver fibrosis. Of note was the finding that a quarter of patients with hepatosplenic schistosomiasis and advanced periportal fibrosis have hyperfibrinolysis, as judged by excessive levels of D-dimer, which may predispose them to gastrointestinal bleeding.
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Affiliation(s)
- Luiz Arthur Calheiros Leite
- Departamento de Bioquímica, Centro de Ciências Biológicas, Universidade Federal de Pernambuco (UFPE), Recife, Brazil
| | - Adenor Almeida Pimenta Filho
- Departamento de Bioquímica, Centro de Ciências Biológicas, Universidade Federal de Pernambuco (UFPE), Recife, Brazil
| | | | - Bianka Santana dos Santos
- Departamento de Bioquímica, Centro de Ciências Biológicas, Universidade Federal de Pernambuco (UFPE), Recife, Brazil
| | | | | | - Edmundo Pessoa Lopes
- Departamento de Medicina Clínica, Centro de Ciências da Saúde, Hospital das Clinicas, UFPE, Recife, Brazil
| | | | - James Stuart Owen
- Division of Medicine, University College London Medical School, Royal Free Campus, London, United Kingdom
| | - Vera Lúcia de Menezes Lima
- Departamento de Bioquímica, Centro de Ciências Biológicas, Universidade Federal de Pernambuco (UFPE), Recife, Brazil
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Hsu YC, Liou JM, Chung CS, Tseng CH, Lin TL, Chen CC, Wu MS, Wang HP. Early risk stratification with simple clinical parameters for cirrhotic patients with acute upper gastrointestinal bleeding. Am J Emerg Med 2010; 28:884-90. [DOI: 10.1016/j.ajem.2009.04.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2009] [Revised: 04/24/2009] [Accepted: 04/24/2009] [Indexed: 12/12/2022] Open
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Koracevic GP. Pragmatic classification of the causes of high D-dimer. Am J Emerg Med 2009; 27:1016.e5-7. [PMID: 19857427 DOI: 10.1016/j.ajem.2008.11.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2008] [Accepted: 11/15/2008] [Indexed: 12/29/2022] Open
Abstract
Venous thromboembolism (VTE) remains the most common preventable cause of in-hospital death and D-dimer (DD) is one of the essential diagnostic tools for it. Each risk factor for VTE can raise DD and they are numerous: 24 listed in 2008 European Guidelines. Acute coronary syndrome and stroke increase DD concentration, too. Thus, all three most important causes of cardiovascular death are capable of raising DD. Recent evidence suggests DD as a sensitive marker also for acute aortic dissection. Many other processes may raise DD concentration: atrial fibrillation, congestive heart failure, disseminated intravascular coagulation, etc. The adequate DD interpretation is additionally important due to the frequent usage of the test (probably millions of times a year in the world). Simple and concise classification is much easier to remember and such one is suggested.
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Affiliation(s)
- Goran Pante Koracevic
- Medical Faculty, Department of Cardiovascular Diseases, University Clinical Centre, Nis, Serbia.
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Hsu YC, Chung CS, Tseng CH, Lin TL, Liou JM, Wu MS, Hu FC, Wang HP. Delayed endoscopy as a risk factor for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage. J Gastroenterol Hepatol 2009; 24:1294-9. [PMID: 19682197 DOI: 10.1111/j.1440-1746.2009.05903.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Risk factors for mortality in acute variceal hemorrhage remain incompletely understood. Whether endoscopy timing is associated with risk of mortality has not been investigated. We aimed to investigate risk factors for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage, with emphasis on endoscopy timing. METHODS Three hundred and eleven (73% male and 23% female) consecutive cirrhotic patients presenting with acute variceal hemorrhage from July 2004 to July 2007 were investigated. The univariate association of endoscopy timing as the predictor for in-hospital mortality was examined. Independent risk factors for mortality were determined by multivariate logistic regression analysis consisting of clinical, laboratory and endoscopic parameters. RESULTS Twenty-five (8.04%) patients died within admission. By plotting the receiver operating curve of endoscopy timing for mortality, we selected 15 h as the optimal cut-off point to define delayed endoscopy. Multivariate regression analysis revealed that independent risk factors predictive for in-hospital mortality included delayed endoscopy performed 15 h after admission (adjusted odds ratio [aOR] = 3.67; 95% confidence interval [CI], 1.27-10.39), every point increment of model for end-stage liver disease (MELD) score (aOR = 1.16; 95% CI, 1.07-1.25), failure of the first endoscopy (aOR = 4.36; 95% CI, 1.54-12.30) and hematemesis as the chief complaint (compared with melena, aOR = 8.66; 95% CI, 1.06-70.94). CONCLUSION Delayed endoscopy for more than 15 h, high MELD score, failure of the first endoscopy and hematemesis are independent risk factors for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage.
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Affiliation(s)
- Yao-Chun Hsu
- Division of Gastroenterology, Department of Internal Medicine, Lotung Poh-Ai Hospital, Yilan, Taiwan
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Aref S, Abdel-Khalek EE, Abdel-Aal IA, Refaie ME. Circadian pattern of acute variceal bleeding among cirrhotic Egyptian patients. Indian J Hematol Blood Transfus 2009; 25:53-8. [PMID: 23100976 DOI: 10.1007/s12288-009-0014-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Accepted: 04/15/2009] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Liver cirrhosis is the most common cause of portal hypertension which may end in serious bleeding from gastro-esophageal varices. Recent studies have demonstrated a daily pattern of acute upper gastrointestinal bleeding in patients with liver cirrhosis evidenced by one or two peaks throughout the day. AIM The assessment of the circadian rhythm of acute variceal bleeding with the possible participation of circadian changes of the fibrinolytic parameters. PATIENTS AND METHODS The study included 264 patients with liver cirrhosis and upper gastrointestinal bleeding in addition to 20 healthy subjects as a control group. A series of hemostatic tests and parameters including prothrombin (PT), activated partial thromboplastin time (APTT), fibrinogen (Fib), Factors II, V, VII, IX, X, XI, platelets counts and fibrinolytic parameters assessement were completed in 60 patients in addition to the control group. The fibrinolytic activity was assessed by estimation of plasminogen, tissue plasminogen activator antigen (tPA: Ag) and plasminogen activator inhibitor antigen (PAI-1: Ag) at hour 09:00 and hour 17:00. The hemostatic tests and liver function tests were assessed once at hour 09.00. RESULTS We observed statistically significant two time peaks of upper gastrointestinal bleeding at hour 04:00 and hour 17:00 with a peak of the fibrinolytic parameter, tissue plasminogen activator antigen, with the night peak of bleeding. A significant correlation between the levels of fibrinolytic parameters and hemostatic factors as well as liver function tests were detected. CONCLUSION There are two time peaks of upper gastrointestinal bleeding with a temporal association between the night peak and a relative hyperfibrinolytic state.
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Affiliation(s)
- Salah Aref
- Internal Medicine Faculty of Medicine, Mansoura University, Mansoura, Egypt ; Hematology Unit, Clinical Pathology Departments Faculty of Medicine, Mansoura University, Mansoura, Egypt ; Institute of Immunogenetic, Menofyia University, Menofyia, Egypt
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