Recombinant factor VIIa improves coagulopathy caused by liver failure

Comparison of Fresh-Frozen Plasma, Four-Factor Prothrombin Complex Concentrates, and Recombinant Factor VIIa to Facilitate Procedures in Critically Ill Patients with Coagulopathy from Liver Disease: A Retrospective Cohort Study

STUDY OBJECTIVE

To evaluate fresh-frozen plasma (FFP), four-factor prothrombin complex concentrates (PCCs), and recombinant factor VIIa (rFVIIa) for lowering international normalized ratio (INR) and facilitating procedures in critically ill patients with hepatic impairment.

DESIGN

Retrospective cohort study.

SETTING

Intensive care units at a large university-affiliated teaching hospital.

PATIENTS

Forty-five adults with hepatic impairment who were admitted between September 1, 2011, and December 31, 2015, and had an admission INR of 1.5 or greater, required an invasive intervention or minor surgical procedure, and received FFP alone (15 patients), PCCs (15 patients), or rFVIIa (15 patients).

MEASUREMENTS AND MAIN RESULTS

The primary outcomes were rates of achieving an INR less than 1.5 at the time of the procedure and an absolute change in INR from 12 hours before the procedure to the time of the procedure. Secondary outcomes were the time to the procedure, blood product use, bleeding rates, and adverse events. The mean ± SD doses of FFP, PCCs, and rFVIIa were 1.1 ± 0.5 units, 2523 ± 861 units, and 2.6 ± 0.9 mg, respectively, administered 2.1 ± 1.4 hours (p<0.05, FFP vs PCCs or rFVIIa), 1.3 ± 0.5 hours, and 1.3 ± 0.6 hours before the procedure, respectively. Achieving an INR less than 1.5 was more likely to occur with PCCs (80%, p=0.03) and rFVIIa (87%, p=0.01) compared with FFP (27%). INR reduction was greater with PCCs (1.6 ± 0.9, p<0.05) and rFVIIa (1.8 ± 0.7, p<0.01) compared with FFP (0.5 ± 0.8). Use of blood products (FFP, cryoprecipitate, packed red blood cells, and platelets) was significantly greater in the FFP group both before and after the procedural intervention. Hypervolemia was less likely to occur in the PCCs (40%, p=0.02) or rFVIIa (33%, p<0.01) groups than in the FFP group (93%). Overall, 33 (73%) of the 45 patients experienced minor bleeding. Three patients (7%) experienced clotting of a central line or dialysis filter, and all were in the PCCs or rFVIIa groups.

CONCLUSION

Unlike FFP, PCCs and rFVIIa effectively and safely reduced INR in critically ill patients with coagulopathy associated with liver impairment to expedite interventions. The amount of blood products used was significantly lower in the PCC and rFVIIa groups, possibly reducing the risk of hypervolemia. Bleeding rates, however, were similar across groups.

Evaluation of Off-Label Recombinant Activated Factor VII for Multiple Indications in Children

Despite a paucity of safety and efficacy data, the use of recombinant activated factor VII in children for off-label indications has now surpassed its use in hemophilia. A retrospective chart review was conducted of 46 subjects (age, 6.7 ± 6 years; weight, 26 ± 20 kg) who received recombinant activated factor VII for nonhemophiliac indications between January 1, 2004, and September 1, 2005. Indications for use included prevention (n = 6) or treatment (n = 40) of bleeding due to general surgery, hepatic failure, gastrointestinal bleeding, severe traumatic brain injury, bone marrow transplant, cardiac, acetaminophen overdose, and multiorgan system failure. Decreases in prothrombin time, partial thromboplastin time, and international normalized ratio were observed. No inappropriate thrombotic events were noted. Administration of recombinant activated factor VII was associated with a reduction in coagulation markers without obvious adverse thrombotic events at cost of $4189 per dose. These findings should be confirmed in a prospective trial.

Liver biopsy in children: position paper of the ESPGHAN Hepatology Committee

Liver biopsy (LB) is still the criterion standard procedure for obtaining liver tissue for histopathological examination and a valuable tool in the diagnosis, prognosis, and management of many parenchymal liver diseases. The aim of this position paper is to summarise the present practice of paediatric LB and make recommendations about its performance. Although histological evaluation of the liver is important in assessing prognosis and exploring treatment, noninvasive techniques (ie, imaging, laboratory markers) may replace use of liver histology. The indications for LB are changing as present knowledge of aetiologies, pathomechanism, and therapeutic options in paediatric liver disease is evolving. Adult and paediatric literature was reviewed to assess the existing clinical practice of LB with focus on the technique, indications, risk of complications, and contraindications in paediatrics. This position paper presents types of LB, indications, complications, contraindications, and an essential checklist for paediatric LB.

Predicting response to rFVIIa in neonates with intractable bleeding or severe coagulation disturbances

BACKGROUND

To date, clinical experience with recombinant factor VIIa (rFVIIa) in neonates is rather limited because of the lack of controlled studies. ΑIM: The objective of this study was to present further experience from our center with regard to the use of rFVIIa in newborns with severe bleeding or coagulopathy resistant to conventional therapy and to determine factors affecting the clinical outcome.

METHODOLOGY

We performed a retrospective data analysis of 29 neonates with intractable bleeding or severe coagulation disturbances. All patients received 100 μg/kg of rFVIIa per dose bolus intravenously (maximum of 23 doses), as rescue procedure after other interventions had failed to achieve hemostasis.

RESULTS

Fourteen neonates survived (group A), whereas 15 died (group B). There was no difference in birth weight, gestational age, and bleeding site and causes between the 2 groups. In the neonates who survived, rFVIIa had been administered earlier in the disease process (<24 h of beginning of bleeding) compared with those who died (P=0.009). In all 29 neonates, international normalized ratio was directly restored (from 2.99±1.4 before rFVIIa administration to 1.6±1.1 afterward, P<0.001) and prothrombin time and activated partial thromboplastin time were significantly decreased after administration of rFVIIa (from 28 to 16.4 and from 180 to 67, respectively; P=0.001 and 0.05, respectively). Blood products administered were significantly less in group A than in group B, as time from the beginning of bleeding to the administration of rFVIIa was significantly less in group A than in group B. Neither acute adverse events nor thromboembolic complications were observed.

CONCLUSIONS

In this neonatal group with intractable bleeding and/or severe coagulation disturbances, rFVIIa was more effective in early intervention as rescue therapy, without any adverse events in all neonates. Upon failure to achieve hemostasis with initial administration of blood products, fast intervention with rFVIIa could be considered in neonates with serious bleeding and coagulation disorders.

Human recombinant activated factor VII for upper gastrointestinal bleeding in patients with liver diseases

BACKGROUND

Mortality from upper gastrointestinal bleeding in patients with liver disease is high. Recombinant human activated factor VII (rHuFVIIa) has been suggested for patients with liver disease and upper gastrointestinal bleeding.

OBJECTIVES

To assess the beneficial and harmful effects of rHuFVIIa in patients with liver disease and upper gastrointestinal bleeding.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register (December 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 4, 2011), MEDLINE (1948 to December 2011), EMBASE (1980 to December 2011), Science Citation Index Expanded (1900 to December 2011), and LILACS (December 2011). We sought additional randomised trials from the reference lists of the trials and reviews identified through the electronic searches.

SELECTION CRITERIA

Randomised clinical trials.

DATA COLLECTION AND ANALYSIS

Outcome data from randomised clinical trials were extracted and were presented using random-effects model meta-analyses. Data on the risk of bias in the included trials were also extracted.

MAIN RESULTS

We included two trials with 493 randomised participants with various Child-Pugh scores. The trials had a low risk of bias. The rHuFVIIa administration did not reduce the risk of mortality within five days (21/288 (7.3%) versus 15/205 (7.3%); risk ratio (RR) 0.88, 95% confidence interval (CI) 0.48 to 1.64, I(2) = 49%) and within 42 days (5/286 (1.7%) versus 36/205 (17.6%); RR 1.01, 95% CI 0.55 to 1.87, I(2) = 55%) when compared with placebo. Trial sequential analysis demonstrated that there is sufficient evidence to exclude that rHuFVIIa decreases mortality by 80%, but there is insufficient evidence to exclude smaller effects. The rHuFVIIa did not increase the risk of adverse events by number of patients (218/297 (74%) and 164/210 (78%); RR 0.94, 95% CI 0.84 to 1.04, I(2) = 1%), serious adverse events by adverse events reported (164/590 (28%) versus 123/443 (28%); RR 0.91, 95% CI 0.75 to 1.11, I(2) = 0%), and thromboembolic adverse events (16/297 (5.4%) versus 14/210 (6.7%); RR 0.80, 95% CI 0.40 to 1.60, I(2) = 0%) when compared with placebo.

AUTHORS' CONCLUSIONS

We found no evidence to support or reject the administration of rHuFVIIa for patients with liver disease and upper gastrointestinal bleeding. Further adequately powered randomised clinical trials are needed in order to evaluate the proper role of rHuFVIIa for treating upper gastrointestinal bleeding in patients with liver disease. Although the results are based on trials with low risk of bias, the heterogeneity and the small sample size result in rather large confidence intervals that cannot exclude the possibility that the intervention has some beneficial or harmful effect. Further trials with alow risk of bias are required to make more confident conclusions about the effects of the intervention.

Clinical Usefulness of Recombinant Activated Factor VII in Patients with Liver Failure Undergoing Invasive Procedures

Objective:

To evaluate the use of recombinant activated factor VII (rFVIIa) in patients with liver failure undergoing invasive procedures.

Methods:

An OVID/MEDUNE and PubMed search (1997-June 2011) was performed to identify literature on the use of rFVIIa to reduce bleeding risk in patients with liver failure undergoing invasive procedures.

Study Selection and Data Extraction:

English-language data evaluating the efficacy of rFVIIa to reverse coagulopathies prior to invasive procedures in patients with liver disease were included.

Data Synthesis:

Following administration of rFVIIa, prothrombin time (PT) and international normalized ratio (INR) response is within 30 minutes. Doses ranging from 20 to 120 μg/kg have been studied, with a reduction in PT seen in a dose-dependent manner. One study in patients with no bleeding administered 5, 20, and 80 μg/kg sequentially during a 24-day period. All doses provided reversal of prolonged PT within 10 minutes, and the duration was dose-dependent. In a study of 15 patients with fulminant liver failure, requiring intracranial pressure monitor placement, a rFVIIa dose of 40 μg/kg was compared to fresh frozen plasma. In patients who received rFVIIa, the PT and INR normalized, compared to none of the patients in the fresh frozen plasma group.

Conclusions:

Retrospective and prospective data demonstrate that rFVIIa effectively reverses elevated PT and INR, reducing the risk of bleeding and safely facilitating invasive procedures. Based on available data, a dose of 20-40 μg/kg 30 minutes prior to an invasive procedure should be considered in patients with acute or chronic liver failure at risk for bleeding complications. A major limitation of rFVIIa use is the high cost of therapy. A prospective, randomized trial could help determine the appropriate dose of rFVIIa, timing of dose in relationship to procedure, and usefulness of subsequent doses.

Coagulopathy in liver disease

The liver plays a central role in hemostasis, as it is the site of synthesis of clotting factors, coagulation inhibitors, and fibrinolytic proteins. The most common coagulation disturbances occurring in liver disease include thrombocytopenia and impaired humoral coagulation. Therapy's overall goal is not to achieve complete correction of laboratory value abnormalities but to gain hemostasis. Therapy with vitamin K may be a useful option in patients with increased prothrombin time due to vitamin K deficiency; in patients with malnutrition; in patients using antibiotics; and in patients with cholestatic liver disease, particularly prior to invasive procedures. Infusion of fresh frozen plasma is more often effective and is recommended in patients with liver disease before invasive procedures or surgery, as such patients require transient correction in their prothrombin time. Therapy with plasma exchange may be considered in patients who cannot be treated with fresh frozen plasma due to volume overload risk. In patients with severe coagulopathy and hypofibrinogenemia, cryoprecipitate therapy is ideal. Therapy with prothrombin-complex concentrate is seldom pursued in patients with liver disease due to high risk of thrombotic complications. Transfusions of platelets are appropriate for patients with thrombocytopenia (< 50,000/mm(3)) associated with active bleeding or before invasive procedures in which a short-term platelet count increase is noted. Trial with desmopressin may be considered before invasive procedures in patients with liver disease and with refractory and prolonged bleeding time. Recombinant activated factor VIIa administration is suggested for patients with significantly prolonged prothrombin time and contraindications to fresh frozen plasma therapy; however, this is expensive. Thrombopoietin and interleukin-11 are currently investigational for patients with thrombocytopenia of chronic liver disease. Liver transplantation completely restores impaired coagulation abnormalities and is the ultimate intervention that corrects coagulopathy of advanced liver disease and liver failure.

Recombinant activated factor VII in liver patients: a retrospective cohort study from Australia and New Zealand

Recombinant factor VIIa (rFVIIa) is used in the treatment of life-threatening haemorrhage that is refractory to conventional treatment. The evidence supporting this practice in patients with liver disease is very limited. It has been used as a salvage therapy in end-stage liver disease (ESLD), in orthotopic liver transplant (OLT), other surgery, and upper gastrointestinal bleeding (UGIB) subpopulations. It has also been used prior to procedures in patients with ESLD. Data were collected by the Australia and New Zealand Haemostasis Registry (ANZHR) to perform a retrospective cohort study on the different subgroups of liver patients. This included 115 cases of use of rFVIIa in liver patients from 20 hospitals. A retrospective cohort study on the different subgroups of liver patients was performed. Main outcome measures were reduction or cessation of bleeding and 28-day mortality. Variables previously shown to predict response to bleeding after administration of rFVIIa were examined to determine whether correlations exist. Salvage therapy with rFVIIa was associated with reduction or cessation in bleeding in 24 of 36 OLT patients, 24 of 36 UGIB patients and 15 of 26 of other surgery patients. Clinical response to rFVIIa in OLT patients and other surgery patients was associated with a significantly lower mortality compared to nonresponders (P = 0.003 and 0.022, respectively). There was no relationship between mortality and bleeding response in patients with UGIB. Variables including acidosis, hypothermia, hypofibrinogenaemia, thrombocytopenia and Model of End-Stage Liver Disease (MELD) score were not associated with clinical response to rFVIIa. Five cases of use prior to procedures are described. Recombinant FVIIa is used as rescue therapy in surgical patients with ESLD and refractory haemorrhage in Australia and New Zealand. Traditional haemostasis variables were not associated with clinical response to rFVIIa in this cohort. Response to rFVIIa is associated with decreased mortality in ESLD patients undergoing OLT and other surgery, but not in UGIB.

Thrombotic events in neonates receiving recombinant factor VIIa or fresh frozen plasma

BACKGROUND

Numerous recent reports have described the use of recombinant factor VIIa (rFVIIa) in non-hemophilia bleeding situations for achievement of hemostasis. However, its use in clinical situations other than hemophilia patients with inhibitors has been complicated by some reports of thrombotic events. rFVIIa has been used successfully to treat coagulopathic and/or bleeding neonates. The prevalence of thrombotic events in these neonates is completely unknown. This study was initiated to determine the risk of thrombotic events associated with rFVIIa use in neonates.

PROCEDURE

All published literature in non-hemophilic, non-congenital factor VII deficient neonates receiving rFVIIa was reviewed. In addition, all data submitted to the SeveN Bleep Registry, a web-based registry of rFVIIa uses in non-hemophilic children was analyzed. As the baseline risk of thrombotic events in bleeding and/or coagulopathic neonates is not known, we also reviewed the records of 100 consecutive neonates from a single institution who received fresh frozen plasma (FFP) alone to treat their coagulopathy and/or bleeding episode.

RESULTS

A total of 134 neonates received rFVIIa. Of these, 10 (7.5%) had a thrombotic event. The baseline risk of thrombotic events in neonates receiving FFP was 7%.

CONCLUSIONS

Overall the prevalence of thrombotic events in bleeding and/or coagulopathic neonates appears to be around 7%, whether or not they receive rFVIIa.

Recombinant Factor VIIa for Bleeding in Non-hemophiliac Pediatric Patients

OBJECTIVE To evaluate the use of recombinant factor VIIa (rFVIIa) for the treatment of bleeding in nonhemophiliac children.

METHODS This was a retrospective chart review of all patients &lt; 18 years of age who received rFVIIa over a 2 year period.

RESULTS Twenty-four pediatric patients received a total of 240 doses of rFVIIa for treatment of bleeding. Recombinant factor VIIa was effective in achieving bleeding resolution in 54% of patients. The mean age of patients in the bleeding non-resolution versus resolution group was 50% younger (5.5 vs. 10.3 years, P = 0.104).

CONCLUSIONS Bleeding resolution can be achieved with recombinant factor VIIa using similar doses to those recommended for children with hemophilia. Widespread use of rFVIIa for bleeding in children without hemophilia is not warranted given this efficacy data. Further safety studies are needed with rFVIIa in this population to clarify thrombotic risks.

Applicability and safety of recombinant activated factor VII to control non-haemophilic haemorrhage: investigational experience in 265 children

Experience of recombinant activated factor VII (rFVIIa, NovoSeven; Novo Nordisk A/S, Bagsvaerd, Denmark) to control haemorrhage in non-haemophilic children is limited. The object of this study was to examine the applicability and safety of rFVIIa amongst a group of non-haemophilic paediatric subjects. Details of all non-haemophilic children < or =16 years receiving rFVIIa whose data were recorded in the investigational, internet-based registry, haemostasis.com were analysed. A total of 265 children (mean age 7.7 years) were treated with rFVIIa; the median dose administered was 78.4 microg kg(-1) body weight (range 9.0-393.4) and the median total dose received 100.0 microg kg(-1) body weight (range 10.9-1341.2). Therapeutic areas included surgery (34.5%), coagulopathy (including thrombocytopenia; 29.0%), spontaneous bleeding (17.2%), trauma (8.4%) and intracranial haemorrhage (4.5%). Two patients experienced thromboembolic events following administration of rFVIIa. Thirty-nine patients died on account of haemorrhage or complications relating to their underlying condition; neither the thromboembolic events nor the deaths were related to rFVIIa administration. Bleeding stopped in 118/237 (49.8%), markedly decreased in 54/237 (22.8%), decreased in 51/237 (21.5%), remained unchanged in 13/237 (5.5%) and increased in 1/237 (0.4%) patients. These results suggest that rFVIIa is safe and widely applicable in children to control non-haemophilic haemorrhage.

Is the use of rFVIIa safe and effective in bleeding neonates? A retrospective series of 8 cases

BACKGROUND

Recombinant activated factor VII (rFVIIa), originally developed for the treatment of life-threatening bleeding in hemophilic patients with inhibitors to factors VIII or IX, has been increasingly used to control hemorrhage unresponsive to conventional treatment, in the absence of a defined coagulopathy or thrombocytopathy. To date, clinical experience of rFVIIa administration in neonates, especially preterms, is rather limited, because of the lack of controlled studies and based solely on some published case reports and 1 prospective pilot study. The objective of this study was to retrospectively evaluate the clinical outcome of newborns treated with recombinant activated factor VII for intractable bleeding or severe coagulation disturbances, resistant to conventional hemostatic therapy.

METHODS

The medical records of 8 neonates treated with rFVIIa (100 micro g/kg) were retrospectively reviewed for the course of hemorrhage and the hemostatic interventions performed before and up to 24 hours after the administration rFVIIa. Coagulation parameters of 3 different time-points were assessed and compared: before administration of any blood product (time-point 1), before administration of the first dose of rFVIIa (time-point 2), and 4 hours after the administration of the last dose of rFVIIa (time-point 3). The safety and tolerability profile of rFVIIa in bleeding neonates was also evaluated.

RESULTS

Six preterm and 2 term patients were included in the study. Seven patients presented with refractory bleeding and 1 was diagnosed with severe coagulopathy unresponsive to the conventional treatment. Prompt hemostasis was achieved in half of the patients with their coagulation profile being restored within 4 hours after the administration of the first dose of rFVIIa. Improvement in prothrombin time, activated partial thromboplastin time, and fibrinogen after rFVIIa administration was statistically significant, as compared with that observed after conventional treatment. No major safety issues were observed during the study. All 8 patients survived and had their hemorrhage or coagulopathy controlled within 4 hours after transfusion of the last dose of rFVIIa.

CONCLUSIONS

In this study, the hemostatic agent rFVIIa was well-tolerated and behaved in a safe and efficacious manner in all infants treated for life-threatening bleeding and coagulation disorders. Future prospective controlled trials are needed to determine the efficacy, safety, tolerability, and possibly the optimal dose and timing of rFVIIa administration.

Human recombinant activated factor VII for upper gastrointestinal bleeding in patients with liver diseases

BACKGROUND

Mortality from upper gastrointestinal bleeding in patients with liver disease is high. The human recombinant activated factor VII is one of the suggested treatments for upper gastrointestinal bleeding in these patients.

OBJECTIVES

To assess the beneficial and harmful effects of human recombinant factor VIIa in patients with liver disease and upper gastrointestinal bleeding.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, ISI Web of Knowledge, and LILACS. The search strategies used are given in Table 01. We sought additional randomised trials from the reference lists of the trials and reviews identified through the electronic searches.

SELECTION CRITERIA

All randomised clinical trials irrespective of design, publication status, and language comparing human recombinant activated factor VII versus placebo, or any other control intervention for patients with liver disease and upper gastrointestinal bleeding, irrespectively of aetiology.

DATA COLLECTION AND ANALYSIS

We estimated relative risks (RR) for dichotomous outcomes and mean differences for continuous data. Since only one trial was identified, meta-analysis was not possible.

MAIN RESULTS

We included one trial with 242 adult patients. In this study, human recombinant activated factor VII administration did not reduce the risk of death (mortality within five days (RR 1.75, 95% confidence interval (CI) 0.53 to 5.82), and mortality within 42 days (RR 1.45, 95% CI 0.70 to 3.00)).

AUTHORS' CONCLUSIONS

We found no evidence that human recombinant activated factor VII reduces the risk of death in patients with liver disease and upper gastrointestinal bleeding. However, we made our conclusion on a single randomised clinical trial. More randomised clinical trials having low risk of bias are necessary in order to determine the role of human recombinant factor VIIa in clinical practice.

Successful use of recombinant factor VIIa (NovoSeven) in children with compartment syndrome: two case reports

Compartment syndrome (CS) is an uncommon bleeding manifestation in patients with liver failure and end-stage renal disease (ESRD). Although prompt intervention is paramount in preventing the tissue necrosis and the permanent functional deficits that may be associated with untreated CS, the indications for initiating therapies for children with CS are not standardized. In this report, we present 2 children, one with ESRD and the other with liver failure, who have CS related to life-threatening bleeding complications and were treated with recombinant factor VIIa (rFVIIa). In conclusion, treatment decisions for patients with CS should be made on a case-by-case basis. The use of rFVIIa is an effective and safe treatment in children with liver failure and ESRD. Surgical treatment should be preferred in patients with CS. However, in patients who have a coagulation defect, the first priority is to correct the clotting deficiency. The use of rFVIIa is a treatment option in children with CS due to a coagulation defect.

Evaluation of Liver Support Systems for Preclinical Testing by Animal Trials

In the present review, various animal models of acute liver failure are reviewed with respect to their suitability for evaluating liver support systems (LSS) according to envisaged modes of therapy. In order to increase the value of the preclinical testing of LSS, it would be advantageous to include more than one animal model in the evaluation program. It is possible to identify appropriate sets of models, which make a suitable test system for particular clinical applications. A standardization of evaluation methods between testing groups would also be beneficial to the field of liver support.

Transfusion therapy in the intensive care unit

PURPOSE OF REVIEW

Transfusion therapy in the intensive care unit is an ever-growing field, with new understanding of potential complications, new drug therapies to reduce the need for transfusion, and new additions in component therapy. In addition to the risks of sepsis, ABO blood group mismatch, and other complications associated with transfusion, the intensivist needs to be familiar with alternative therapies to minimize transfusion.

RECENT FINDINGS

Transfusion-related acute lung injury and immunosuppression are two newly recognized complications in transfusion. Transfusion-related acute lung injury can lead to respiratory failure in an acute respiratory distress syndrome-like picture, often necessitating intubation and critical care services. Immunosuppression following transfusion has been linked to cytokine and complement activation. Recombinant erythropoietin (rHuEPO, Epogen, Procrit), by maximizing red cell counts, and aprotinin (Trasylol), by inhibiting fibrinolysis, are two old drugs being used with increasing frequency in a new setting: the intensive care unit. A new component therapy, recombinant factor VIIa (rFVIIa, NovoSeven), assists in turning on the extrinsic pathway of the coagulation cascade.

SUMMARY

Recognizing early signs of transfusion-related acute lung injury may aid in the treatment and reporting of this entity. Realizing the mechanism and severity of immunosuppression associated with transfusion may alter transfusion triggers in the intensive care unit. rHuEPO and aprotinin are now being used with increasing frequency to increase red cell counts and minimize the need for transfusion. Recombinant factor FVIIa targets coagulation cascade activation which helps to reduce the number of units of blood products transfused in the actively bleeding patient.

Recombinant factor VIIa in paediatric bleeding disorders ? a 2006 review

Recombinant factor VIIa (rFVIIa) has been used in haemophilia bleeding since its introduction in 1996. It has been found to be safe and effective in the majority of patients with haemophilia who have developed inhibitors. There is increasing use of rFVIIa in many off-label bleeding conditions, but there is a paucity of randomized studies regarding the use of rFVIIa in children. This review will attempt to address and summarize the studies focusing on the role of rFVIIa in both haemophilia and non-haemophilia bleeding conditions in children. rFVIIa has been administered as both bolus and continuous infusions, and at varying doses. Furthermore, adverse events have not reportedly increased in children despite growing experience with its use in the paediatric population.

Prophylactic recombinant factor VIIa administration to an infant with congenital systemic juvenile xanthogranuloma

We report the case of an infant affected with congenital systemic juvenile xanthogranuloma scheduled for central venous access system implantation (Port-a-Cath) and a liver and bone marrow biopsy. The patient had impaired liver function, thrombocytopenia, and coagulopathy which was refractory to daily fresh-frozen plasma and platelet infusions: 80 microg x kg(-1) dose(-1) of recombinant factor VIIa (rFVIIa) was administered i.v. every 2 h starting 30 min before the procedure and ending 6 h afterwards. Very minor bleeding was observed during the procedure. In conclusion, rFVIIa therapy was effective as prophylaxis for both invasive procedures in this patient with a coagulopathy which was refractory to other different therapies.

Use of recombinant factor VIIa prior to lumbar puncture in pediatric patients with acute leukemia

The persistence of abnormal coagulation test results after standard treatment with fresh frozen plasma (FFP) poses significant problems in children with acute leukemia requiring a diagnostic lumbar puncture and intrathecal chemotherapy. We report the prophylactic use of a single dose of 90 microg/kg recombinant activated factor VII (rFVIIa) in three children and the rapid correction of abnormal coagulation test results previously not corrected by FFP. Administration of rFVIIa was useful in avoiding a delay of diagnostic lumbar punctures and intrathecal chemotherapy. Hemorrhagic complications and adverse effects of rFVIIa were not observed. Prospective evaluation of this indication and dose appears warranted. (c) 2005 Wiley-Liss, Inc.

Prevention of intraventricular haemorrhage: a role for recombinant activated factor VII?

As the survival from extreme prematurity continues to improve, focus on the quality of this survival becomes increasingly important. Prevention of intraventricular haemorrhage (IVH) and its potential long-term sequelae remains one of the major challenges in the early management of these infants. Recombinant activated factor VII (rVIIa), a novel haemostatic agent with an ever-expanding list of potential applications, warrants consideration for use in this setting. This review examines the pathogenesis and prevention of IVH, current concepts of haemostasis both in adults and neonates, and the postulated mechanism of action and various uses of rVIIa. Published data specifically relating to use of rVIIa in neonates is summarised. The hypothesis that early (prophylactic) administration of rVIIa to extremely preterm infants (<28 weeks) would reduce the incidence of severe IVH is explored.

Pediatric hemostasis and use of plasma components

Indications for fresh frozen plasma (FFP), once used routinely in the support of critically ill infants and children, have become more specific as evolving evidence has confirmed or disproved the efficacy of plasma in various circumstances. FFP is currently indicated to treat the coagulopathies of massive hemorrhage, liver failure and disseminated intravascular coagulation and sepsis. Whole blood reconstituted from FFP and packed red cells is the product of choice for exchange transfusion, as well as for circuit priming. In the US, FFP remains the only approved source of factors V, XI, protein C, protein S and plasminogen. Cryoprecipitate is used chiefly as a source of fibrinogen, factor VIII and factor XIII in consumptive coagulopathy; recombinant or viral inactivated plasma derivatives are preferred for congenital deficiencies of factor VIII and von Willebrand factor. Recombinant and highly purified, viral inactivated, plasma-derived proteins are preferred over FFP for congenital and acquired deficiencies. This chapter reviews evidence to support the use of plasma and plasma derivatives for pediatric patients.

Acute liver failure in children

Acute liver failure (ALF) is a rare but devastating illness. Specific therapy to promote liver recovery is often not available, and the underlying cause of the liver failure is often unknown. This article examines current knowledge of the epidemiology, pathobiology, and treatment of ALF in children and identifies potential gaps in this knowledge for future study.

A prospective pilot study of prophylactic treatment of preterm neonates with recombinant activated factor VII during the first 72 hours of life

OBJECTIVE

Intraventricular hemorrhage (IVH) in the preterm infant is a devastating complication, causing marked mortality and morbidity. A general hemostatic agent such as recombinant activated factor VII (rFVIIa) might have the potential to reduce the extent of severe IVH.

DESIGN

Prospective, single-arm pilot study.

SETTING

Level III neonatal intensive care unit.

PATIENTS

Ten preterm infants between 23 and 28 wks of gestation.

INTERVENTION

Administration of a 100-microg/kg rFVIIa bolus injection within the first 2 hrs of life, followed by 100 microg/kg rFVIIa every 4 hrs, for the first 72 hrs of life.

MEASUREMENTS AND MAIN RESULTS

Cranial ultrasonography and flow studies of the major arteries and the venae cava, aorta, vena portae, and venae renales, was performed at study enrollment and at 12 hrs, 24 hrs, 48 hrs, and 72 hrs. Blood cell counts and coagulation studies were performed. End points of the study were occurrences of adverse events, with an emphasis on thrombotic events or disseminated intravascular coagulation (DIC). Ten preterm infants with a gestational age of 23 wks 1 day to 28 wks 3 days were included. None had venous thrombosis or cerebral infarction during or after the treatment. Neither platelet consumption nor DIC was observed. Two infants with an umbilical artery catheter had a thrombus at the catheter tip (one during infusion of the study drug), which was successfully treated with heparin. One had grade III IVH and died on day 6 of life; in another, grade II IVH progressed to grade III after termination of the drug.

CONCLUSION

One hundred microg/kg rFVIIa does not accumulate if administered prophylactically to preterm infants of <28 wks of gestation every 4 hrs in the first 72 hrs of life. In this population, rFVIIa does not cause DIC. Thrombus formation was observed in two infants with umbilical artery catheters but in none of the infants with venous catheters. Embolic events were not observed. In this pilot study, which did not provide the sample size to assess any effect of rFVIIa on the incidence of IVH, 20% of the neonates went on to have grade III or IV IVH, which is similar to the rate in studies in which rFVIIa was not given.

Safety of percutaneous liver biopsy in infants less than three months old

OBJECTIVES

To evaluate the safety, outcomes, and complications of percutaneous liver biopsies (PLB) in infants aged 0 to 3 months.

METHODS

We retrospectively reviewed the hospital records of all infants less than 3 months old who underwent PLB at Children's Memorial Hospital between July 1, 1997 and June 30, 2004 for complications surrounding the procedure and risk factors that might lead to complications.

RESULTS

Sixty-six PLBs were performed in 63 infants. Most patients tolerated the procedure without complications. Twelve complications were recorded, for an overall complication rate of 18%. Of these, five were directly related to the procedure, and seven were sedation related. Three patients experienced a drop in hemoglobin greater than 2 gm/dL, one patient developed a bile leak, and one developed a skin hematoma. Seven patients had respiratory difficulty related to sedation, which manifested as increased work of breathing or decreased respiratory rate with depression in pulse oximetry.

CONCLUSION

We conclude that PLB in young infants is associated with a somewhat higher risk of complications than in older children, particularly complications related to sedation.

A multicenter assessment of recombinant factor VIIa off-label usage: clinical experiences and associated outcomes

BACKGROUND

Off-label use of recombinant factor VIIa (rFVIIa) occurs despite minimal data. The purpose of this study was to describe prescribing practices and clinical outcomes for off-label rFVIIa use.

STUDY DESIGN AND METHODS

A retrospective, multicenter chart audit of 315 nonhemophiliac patients was performed.

RESULTS

Off-label indications included prevention of bleeding primarily related to procedural manipulation in 37.8 percent of patients and treatment of bleeding in 62.2 percent of patients. Baseline coagulopathy was present in 79.7 percent of patients. Prescriber specialty varied. The median doses for prevention and treatment were 75.6 and 89.4 microg per kg, respectively (p = 0.0006). The international normalized ratio (INR) decreased (p < 0.0001) from baseline in both groups. Transfusions of blood products were provided to 85.1 percent of patients before rFVIIa administration with considerable practice variation. Few patients received other procoagulant agents. In the prevention group, 14.3 percent of patients bled within 6 hours of their procedure. No variable was independently associated with bleeding prevention. In the treatment group, 52.6 percent of patients stopped bleeding within 6 hours of rFVIIa administration. The only independent variable associated with bleeding cessation was an arterial pH value of less than 7.20, which was a negative predictor (odds ratio, 0.207; 95% confidence interval, 0.084-0.507). Possible rFVIIa-associated adverse events occurred in 9.8 percent of patients and primarily involved undesirable clotting. No variable was independently associated with adverse events.

CONCLUSIONS

Off-label use of rFVIIa includes prevention and treatment of bleeding. rFVIIa is associated with INR reduction. Bleeding is rare with prophylactic rFVIIa but the cessation of bleeding is less than reported in the literature and may be related to pH. Possible adverse events are related to undesirable clotting.

Hemostatic defects in end stage liver disease

End stage liver disease results in a complex and variably severe failure of hemostasis that predisposes to abnormal bleeding. The diverse spectrum of hemostatic defects includes impaired synthesis of clotting factors, excessive fibrinolysis, disseminated intravascular coagulation, thrombocytopenia, and platelet dysfunction. Hemostasis screening tests are used to assess disease severity and monitor the response to therapy. Correction of hemostatic defects is required in patients who are actively bleeding or require invasive procedures. Fresh frozen plasma, cryoprecipitate, and platelet transfusion remain the mainstays of therapy until larger trials confirm the safety and efficacy of recombinant factor VIIa in this population.

Uses of recombinant factor VIIa in trauma

PURPOSE OF REVIEW

Despite advances in the care of the injured, the morbidity and mortality of traumatic hemorrhage remain a significant problem. Traumatologists continue to look for ways to treat bleeding and prevent the sequelae of hemorrhagic shock. Recombinant factor VIIa, developed for the treatment of patients with hemophilia, has been used with some success in acute bleeding associated with injuries.

RECENT FINDINGS

The mechanism of action is via a tissue factor-dependent effect and/or platelet activation. Coagulation occurs at the site of tissue injury, where tissue factor is exposed. Case series have described the beneficial effects of recombinant factor VIIa in the treatment of acute hemorrhage, early treatment of traumatic brain injury, and reversal of premorbid anticoagulation. In addition, there have been numerous reports of recombinant factor VIIa use in acute bleeds secondary to other causes as well as some evidence that recombinant factor VIIa may be efficacious when used prophylactically in high-risk patients and for high-risk procedures. Typical doses range from 50 to 100 microg/kg as a single bolus. Although there has been concern over the risk of inappropriate thrombosis with recombinant factor VIIa administration, this complication has seldom been described in published series.

SUMMARY

Although case experience is encouraging, no level 1 evidence has been published that demonstrates clinical or economic benefit of the use of recombinant factor VIIa in trauma patients. Many questions remain to be answered, ideally through randomized, prospective clinical trials. In particular, the issues of patient selection, ideal dosing, and factors associated with futile administration need to be elucidated.

Emerging Off-Label Uses for Recombinant Activated Factor VII: Grading the Evidence

Recombinant activated factor VII (rFVIIa) is currently licensed in the United States for treatment of bleeding episodes in patients with deficiencies of factor VIII (FVIII) or IX (FIX) who are refractory to factor replacement because of circulating inhibitors. A 1999 report of its successful use to stop what was deemed to be lethal hemorrhage after an abdominal gunshot wound in a young soldier without pre-existing coagulopathy has prompted exploration of other uses for rFVIIa. The virtual explosion of proposed uses of rFVIIa raises issues not only regarding our understanding of the coagulation system, but also regarding its efficacy, cost-effectiveness, and safety.

Recombinant Factor VIIa in the Treatment of Non-Hemophiliac Bleeding

OBJECTIVE:

To review the clinical evidence for the use of recombinant factor VIIa (rFVIIa) in the prevention and/or treatment of bleeding in non-hemophiliac patients.

DATA SOURCES:

A MEDLINE search (1966–December 2004) was conducted to identify pertinent literature. Results were limited to English-language reports and clinical trials. References of relevant articles and selected abstracts presented at scientific meetings were also reviewed.

STUDY SELECTION AND DATA EXTRACTION:

Human data from prospective and retrospective studies that examined the hemostatic effect of rFVIIa in non-hemophiliac patients were reviewed, with a focus on surgical prophylaxis, liver disease, intractable bleeding associated with trauma and surgery, and anticoagulation reversal.

DATA SYNTHESIS:

Results from limited controlled trials on the use of rFVIIa as an adjunct for prevention of bleeding in surgery and liver diseases have not been consistent. For treatment of intractable bleeding, earlier use of rFVIIa in one trauma trial was shown to decrease the number of blood transfusions, but no differences in terms of clinical outcomes were observed in all trials. Controlled trials do not suggest an increased risk of thrombotic events. Optimal dosing and timing of administration have yet to be defined.

CONCLUSIONS:

Until further prospective controlled data are available, it is recommended that conventional intervention for prevention and control of hemorrhage in non-hemophiliac patients should remain the standard of care. Close monitoring of coagulation parameters is recommended before, during, and after therapy, especially in high-risk patients. Pharmacoeconomic analysis may be useful to help control costs and maximize clinical benefits.

Use of Recombinant Factor VIIa in Pediatric Patients With Liver Failure and Severe Coagulopathy

BACKGROUND

Several reports have suggested a benefit for recombinant Factor VIIa (rFVIIa) in nonhematological conditions, including liver disease and transplantation. However, there are few reports of its use in children with liver failure. Recently, we used rFVIIa in four patients with liver failure and severe coagulopathy with bleeding who demonstrated significant laboratory and clinical improvement following its use with no side effects.

PATIENTS AND METHODS

All four patients were hospitalized with liver failure, coagulopathy, and bleeding that was controlled with fresh frozen plasma, platelets, and other therapies, as indicated. Their international normalization ratios (INR) ranged from 1.7 to 5.8 (normal 0.9-1.1). All four patients received rFVIIa for bleeding episodes that were not responding to their usual therapy, for procedures with a high risk of bleeding, or both. The dose of rFVIIa ranged from 0.067 to 0.3 mg/kg. The INR improved to normal or near normal in all four patients. In all cases, bleeding stopped within 10 minutes of receiving the rFVIIa, and there were no complications observed.

CONCLUSIONS

rFVIIa provided significant benefit in these children with liver failure and severe coagulopathy, in terms of clinical and laboratory improvement in their bleeding and coagulation profiles. There were no obvious side effects from the rFVIIa. This drug may be an important tool in the treatment of children with liver failure and more study is needed to define the optimal dosing for children.

Recombinant FVIIa in children with liver disease

INTRODUCTION

The aim of this study was to investigate the clinical and biochemical effects of recombinant activated factor VII (rFVIIa) in the treatment of bleeding in children with liver disease.

PATIENTS AND METHODS

12 patients (0.3-15.9 years) with chronic liver disease were included. The indication for treatment was life threatening bleeding and failing conventional therapy (group A, 7 patients) or as prophylaxis before invasive procedures (group B, 6 patients). One patient received treatment on both indications. rFVIIa was administered as intravenous bolus doses of 34-163 microg/kg (median 66 mug/kg) alone or in combination with packed red cells and/or octreotide and/or fresh frozen plasma. The follow-up included repeated INR and haemoglobin measurements as well as clinical evaluation.

RESULTS

In group A rFVIIa was given on 22 occasions and bleeding decreased, was unchanged, increased or could not be evaluated on 10, 7, 2 and 3 occasions respectively. On 14 occasions rFVIIa and octreotide were administered simultaneously, in 8 of those bleeding decreased. In group B no bleeding complication was seen, interpreted as a positive effect. One thrombotic event was suspected but could not be verified by computerized tomography.

CONCLUSIONS

rFVIIa may be beneficial in the short-term management of life threatening bleeding in some children with liver disease. This effect may be further enhanced with the additional use of octreotide. Furthermore, rFVIIa is useful for prophylaxis at invasive procedures, even without additional treatment with fresh frozen plasma. The possible risk of portal vein thrombosis needs to be considered.

Approaches to acute liver failure in children

Acute liver failure (ALF) is a rare but often fatal disorder in childhood. Its aetiology includes infections, toxins, metabolic disorders, infiltrative diseases, autoimmune hepatitis, ischaemia, irradiation damage, but in a high proportion of cases it remains unknown. In contrast to adults, in children with ALF hepatic encephalopathy can be a late event, and may not develop at all, despite a lethal outcome, particularly in infants. Children with ALF should be managed in experienced centres with facilities for liver transplantation. Transplantation should be offered only if the underlying disease is treatable by liver replacement and if the prognosis of transplant is better than that of the underlying disease, as in many cases of ALF the liver has the potential to recover with supportive treatment, if the child is kept alive and stable long enough. Universally accepted criteria for listing for transplantation have not been defined as yet. In our centre, maximum INR, bilirubin level, and white cell count, together with age have proven to be reliable predictors of outcome. Future efforts in the management of ALF should concentrate on designing efficient supportive therapy and specific treatments to provide effective non-transplant therapeutic options.

Recombinant factor VIIa

Human coagulation factor (F) VII is a single chain protease that circulates in the blood as a weakly active zymogen at concentrations of approximately 10 nmol/L. When converted to the active 2 chain form (FVIIa), it is a powerful initiator of haemostasis. Recombinant factor VIIa (rFVIIa, eptacog alfa, NovoSeven) is a genetically engineered product that was first introduced in 1988 for the treatment of patients with haemophilia A and B with high inhibitory antibody titres to factors VIII and IX. Recent reports in the form of case studies and series, and early trial data, have suggested a role for rFVIIa across a diverse range of indications including bleeding associated with trauma, surgery, thrombocytopaenia, liver disease and oral anticoagulant toxicity. This review describes the physiology of the coagulation pathway and in particular the role of recombinant factor VIIa. It will also focus on the emerging role of rFVIIa in both trauma and non-trauma bleeding and its potential use in the ED.

[Acute liver failure. Current aspects of diagnosis and therapy]

Disturbances of some partial liver functions, such as synthesis, excretion, or biotransformation of xenobiotics, are important for prognosis and ultimate survival in patients presenting with multiple organ dysfunction on the intesive care unit (ICU). The incidence of liver dysfunction is underestimated when traditional "static" measures such as serum-transaminases or bilirubin as opposed to "dynamic" tests, such as clearance tests, are used to diagnose liver dysfunction. Similar to the central role of the failing liver in MODS, extrahepatic complications, such as hepatorenal syndrome and brain edema develop in acute or fulminant hepatic failure and determine the prognosis of the patient. This is reflected in the required presence of hepatic encephalopathy in addition to hyperbilirubinemia and coagulopathy for the diagnosis of acute liver failure. In addition to these clinical signs, dynamic tests, such as indocyanine green clearance, which is available at the bed-side, are useful for the monitoring of perfusion and global liver function. In addition to specific and causal therapeutic interventions, e.g. N-acetylcysteine for paracetamol poisoning or termination of pregnancy for the HELLP-syndrome, new therapeutic measures, e.g. terlipressin/albumin or albumin dialysis are likely to improve the poor prognosis of acute-on-chronic liver failure. Nevertheless, liver transplantation remains the treatment of choice for fulminant hepatic failure when the expected survival is <20%.