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Ohlendorf J, Kiene H, Wiegandt J, Karch A, Jaeger VK, Laue T, Junge N, Mutschler F, Goldschmidt I, Pfister ED, Leiskau C, Petersen C, Madadi-Sanjani O, Kuebler JF, Götz JK, Baumann U. The Impact of Male Gender and Thrombophilia on Disease Progression in Children with Biliary Atresia—A Single-Centre Cohort Study. J Clin Med 2023; 12:jcm12062108. [PMID: 36983111 PMCID: PMC10059690 DOI: 10.3390/jcm12062108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 02/26/2023] [Accepted: 03/04/2023] [Indexed: 03/11/2023] Open
Abstract
Epidemiological evidence suggests that thrombophilic factors, including male sex, non-O blood type, MTHFRnt677TT mutation, factor V Leiden G1691A mutation, and prothrombin G20210A polymorphism, may contribute to the progression of fibrosis and occurrence of portal vein thrombosis in liver disease. We retrospectively investigated the effect of potentially thrombophilic factors on native liver survival as a patient-relevant endpoint of disease progression in a cohort of 142 children being followed up for biliary atresia at Hannover Medical School from April 2017 to October 2019. No significant association could be determined. There was no evidence for relevant differences in native liver survival for the Factor V Leiden G1691A mutation (hazard ratio [HR] = 0.86, 95% confidence interval [CI] 0.38–1.98, p = 0.73), prothrombin G20210A polymorphism (HR = 0.96, 95%CI 0.24–3.65, p = 0.96), non-O blood type (HR = 0.79, 95%CI 0.51–1.21, p = 0.28) or MTHFRnt677TT mutation (HR = 1.24, 95%CI 0.60–2.56, p = 0.56). A certain, albeit not strong, evidence of reduced native liver survival in male patients after Kasai hepatoportoenterostomy, particularly during the first 2000 days (42%; HR = 1.41, 95%CI 0.92–2.18, p = 0.11) was found. All children with pre-transplant portal vein thrombosis (n = 7) had non-O blood types. Larger multi-centre studies are necessary to show if the male sex or other thrombophilic factors could be potentially associated with reduced native liver survival.
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Affiliation(s)
- Johanna Ohlendorf
- Paediatric Gastroenterology, Hepatology and Liver Transplantation, Hanover Medical School, 30625 Hanover, Germany
- Correspondence: ; Tel.: +49-511-532-3220
| | - Hella Kiene
- Paediatric Gastroenterology, Hepatology and Liver Transplantation, Hanover Medical School, 30625 Hanover, Germany
| | - Jessica Wiegandt
- Paediatric Gastroenterology, Hepatology and Liver Transplantation, Hanover Medical School, 30625 Hanover, Germany
| | - André Karch
- Institute of Epidemiology and Social Medicine, University of Muenster, 48149 Muenster, Germany
| | - Veronika K. Jaeger
- Institute of Epidemiology and Social Medicine, University of Muenster, 48149 Muenster, Germany
| | - Tobias Laue
- Paediatric Gastroenterology, Hepatology and Liver Transplantation, Hanover Medical School, 30625 Hanover, Germany
| | - Norman Junge
- Paediatric Gastroenterology, Hepatology and Liver Transplantation, Hanover Medical School, 30625 Hanover, Germany
| | - Frauke Mutschler
- Paediatric Gastroenterology, Hepatology and Liver Transplantation, Hanover Medical School, 30625 Hanover, Germany
| | - Imeke Goldschmidt
- Paediatric Gastroenterology, Hepatology and Liver Transplantation, Hanover Medical School, 30625 Hanover, Germany
| | - Eva-Doreen Pfister
- Paediatric Gastroenterology, Hepatology and Liver Transplantation, Hanover Medical School, 30625 Hanover, Germany
| | - Christoph Leiskau
- Department of Paediatrics and Adolescent Medicine, University Medical Centre Goettingen, Georg August University, 37075 Goettingen, Germany
| | - Claus Petersen
- Paediatric Surgery, Hannover Medical School, 30625 Hanover, Germany
| | | | | | - Juliane Katharina Götz
- Paediatric Gastroenterology, Hepatology and Liver Transplantation, Hanover Medical School, 30625 Hanover, Germany
| | - Ulrich Baumann
- Paediatric Gastroenterology, Hepatology and Liver Transplantation, Hanover Medical School, 30625 Hanover, Germany
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
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2
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Impact of prothrombin and factor V Leiden mutations on the progression of fibrosis in patients with chronic hepatitis C. PLoS One 2022; 17:e0276592. [DOI: 10.1371/journal.pone.0276592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 10/11/2022] [Indexed: 11/12/2022] Open
Abstract
Background
The role of thrombotic factors in the pathogenesis and progression of liver fibrosis remains obscure. We aimed to study the relationship between prothrombin G20210A (PT20210) and factor V Leiden (FVL) mutations and the progression of fibrosis and liver function in chronic HCV patients.
Methods
The study included 100 subjects, 88 patients with HCV-related cirrhosis (compensated: 38, decompensated: 50), and 12 controls. Patients with other viral hepatitis or coinfection, inherited metabolic disease, autoimmune hepatitis, hepatic or extrahepatic malignancy, in addition to patients with causes of hypoalbuminemia, elevated bilirubin or prolonged INR not related to cirrhosis were excluded from the study. Relevant clinical data were collected and basic laboratory tests were performed. Liver fibrosis was assessed using APRI and FIB-4 scores. FVL and PT20210 mutations were analyzed.
Results
FVL and PT20210 mutations were significantly higher in decompensated vs. compensated patients (32% vs. 5.3%, P = 0.001; 20% vs. 5.3%, 0.043, respectively) and absent in controls. Both mutations significantly correlated to the duration of infection, platelet count and fibrosis scores. PT20210 mutation significantly correlated to serum albumin and INR. Both mutations significantly predicted fibrosis scores, especially PT20210 (AUROC: 0.833 for APRI and 0.895 for FIB-4).
Conclusions
Both mutations are significantly correlated to fibrosis progression and liver profile and could be considered as markers predicting the need for early and different intervention.
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3
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Bitto N, Liguori E, La Mura V. Coagulation, Microenvironment and Liver Fibrosis. Cells 2018; 7:E85. [PMID: 30042349 PMCID: PMC6115868 DOI: 10.3390/cells7080085] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 07/19/2018] [Accepted: 07/20/2018] [Indexed: 12/12/2022] Open
Abstract
Fibrosis is the main consequence of any kind of chronic liver damage. Coagulation and thrombin generation are crucial in the physiological response to tissue injury; however, the inappropriate and uncontrolled activation of coagulation cascade may lead to fibrosis development due to the involvement of several cellular types and biochemical pathways in response to thrombin generation. In the liver, hepatic stellate cells and sinusoidal endothelial cells orchestrate fibrogenic response to chronic damage. Thrombin interacts with these cytotypes mainly through protease-activated receptors (PARs), which are expressed by endothelium, platelets and hepatic stellate cells. This review focuses on the impact of coagulation in liver fibrogenesis, describes receptors and pathways involved and explores the potential antifibrotic properties of drugs active in hemostasis in studies with cells, animal models of liver damage and humans.
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Affiliation(s)
- Niccolò Bitto
- Medicina Interna, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Donato, Università Degli Studi di Milano, 20097 San Donato Milanese (MI), Italy.
| | - Eleonora Liguori
- Medicina Interna, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Donato, Università Degli Studi di Milano, 20097 San Donato Milanese (MI), Italy.
| | - Vincenzo La Mura
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Medicina Generale-Emostasi e Trombosi, 20122 Milano, Italy.
- Dipartimento di Scienze biomediche per la Salute, Università degli Studi di Milano, 20122 Milano, Italy.
- A. M. and A. Migliavacca per lo studio delle Malattie del Fegato, 20122 Milano, Italy.
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4
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Lisman T, Porte RJ. Pathogenesis, prevention, and management of bleeding and thrombosis in patients with liver diseases. Res Pract Thromb Haemost 2017; 1:150-161. [PMID: 30046685 PMCID: PMC6058283 DOI: 10.1002/rth2.12028] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 06/21/2017] [Indexed: 12/14/2022] Open
Abstract
Patients with liver diseases may develop alterations in all components of the hemostatic system. Thrombocytopenia, low levels of coagulation factors and inhibitors, low levels of fibrinolytic proteins, and increased levels of endothelial-derived proteins such as von Willebrand factor are all part of the coagulopathy of liver disease. Due to concomitant changes in pro- and antihemostatic drivers, the net effects of these complex hemostatic changes have long been unclear. According to current concepts, the hemostatic system of patients with liver disease is in an unstable balance, which explains the occurrence of both bleeding and thrombotic complications. This review will discuss etiology and management of bleeding and thrombosis in liver disease and will outline unsolved clinical questions. In addition, we will discuss the role of intrahepatic activation of coagulation for progression of liver disease, a novel paradigm with potential consequences for the general management of patients with liver disease.
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Affiliation(s)
- Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Robert J. Porte
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
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5
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Starostina EE, Samokhodskaya LM, Rozina TP, Krasnova TN, Yarovaya EB, Mukhin NA. [Role of polymorphic markers for the genes of hemostasis and platelet receptors in liver fibrosis progression in patients with chronic hepatitis C]. TERAPEVT ARKH 2017; 88:93-98. [PMID: 27636933 DOI: 10.17116/terarkh201688893-98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM to estimate the clinical and prognostic value of the carriage of different allele variants of the gene polymorphisms of the coagulation system and platelet receptors in the progression of liver fibrosis (LF) in patient with chronic hepatitis C (CHC). SUBJECTS AND METHODS The investigation enrolled 177 patients with CHC and liver cirrhosis at its outcome who were divided into 2 groups according to the rate of LF progression: 1) 89 patients with rapid (rapid fibrosis) and 2) 88 patients with slow (slow fibrosis) progression. The polymorphism of the study genes was studied using a real-time polymerase chain reaction and a melting curve analysis. RESULTS In CHC patients, the FV 1691G/A genotype was more often in the rapid progressors than that in the slow progressors (10.11% vs 1.14%; p=0.011). The A allele of the 1691 G/A FV gene was more common in the rapid fibrosis group than that in the slow fibrosis group (1.7% vs 5.56%, odd ratio 9.787; p=0.139). In our investigation, the polymorphic marker GA in the FII 20210 G/A gene, as well as the 4G allele (5G4G + 4G4G genotypes) and the 4G allele of PAI-I -675 5G/4G were more often seen in the rapid fibrosis group than that in the slow fibrosis group; the detection rate was only at the trend level (p=0.118, p=0.112, and p=0.117 respectively). There were no significant differences between the groups in the spread of variant genotypes and alleles of other study genes. Integral model construction by coding «profibrogenic» genotypes (FV 1691 G/A, FII 20210 G/A, PAI-I -675 5G/4G) showed that the fibrosis progression rate expressed as fibrosis units annually also increased with higher total scores (p=0.039), indicating the combined effect of these genes. CONCLUSION The carriage of mutant genotypes of FV 1691 G/A, FII 20210 G/A, and PAI-I -675 5G/4G genes is a prognostic factor for rapid CHC progression.
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Affiliation(s)
| | | | - T P Rozina
- M.V. Lomonosov Moscow State University, Moscow, Russia; I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - T N Krasnova
- M.V. Lomonosov Moscow State University, Moscow, Russia; I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - E B Yarovaya
- M.V. Lomonosov Moscow State University, Moscow, Russia
| | - N A Mukhin
- M.V. Lomonosov Moscow State University, Moscow, Russia; I.M. Sechenov First Moscow State Medical University, Moscow, Russia
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6
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Hanafy AS, Alaa FA, Randa MH. Association of thrombogenic genes polymorphisms with hepatocellular carcinoma in HCV Egyptian patients. Gene 2016; 580:37-40. [PMID: 26768578 DOI: 10.1016/j.gene.2016.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 12/12/2015] [Accepted: 01/01/2016] [Indexed: 10/22/2022]
Abstract
The rate of development of fibrosis varies among HCV patients and affected by many variables. We aimed to investigate the association between mutations in Factor V, prothrombin gene and thrombospondin 1 polymorphisms with hepatic fibrosis progression rate and development of HCC in patients infected with HCV and if they are potential markers for early prediction of disease progression. A total of 280 HCV-infected patients (70 with mild fibrosis, 70 with advanced fibrosis, 70 cirrhotic patients and 70 HCC patients) and 100 healthy controls were included. Factor V Leiden G1691A, prothrombin G20210A and thrombospondin 1 mutations were analyzed by restriction fragment length polymorphism. We observed that there were no significant differences between Factor V Leiden (G1691A) or TPS-1 (A2210G) polymorphisms in the four patient subgroups and control group. In HCC patients, the frequencies of GA genotype were significantly increased compared with control subject. HCV patients carrying GA genotype were more likely to develop hepatocellular carcinoma (OR=5.4, 95% CI=1.09-27.05; P=0.026).We concluded that the risk of HCC was increased 5-fold in subjects carrying GA genotype of prothrombin G20210A gene. However, there was no evidence for a significant association between thrombogenic genes polymorphisms and progression of fibrosis in HCV Egyptian patients.
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Affiliation(s)
- Amr S Hanafy
- Internal Medicine Department, Faculty of Medicine, Hepatology Unit, Zagazig University, Zagazig, Egypt
| | - Farag A Alaa
- Internal Medicine Department, Faculty of Medicine, Hepatology Unit, Zagazig University, Zagazig, Egypt
| | - Mohamed H Randa
- Medical Biochemistry Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt.
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7
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Hugenholtz GCG, Northup PG, Porte RJ, Lisman T. Is there a rationale for treatment of chronic liver disease with antithrombotic therapy? Blood Rev 2014; 29:127-36. [PMID: 25468718 DOI: 10.1016/j.blre.2014.10.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 10/21/2014] [Accepted: 10/23/2014] [Indexed: 02/07/2023]
Abstract
Recent advances in the understanding of the coagulopathy in chronic liver disease have provided a strong support for anticoagulation as a new therapeutic paradigm for patients with cirrhosis. Laboratory studies indicate that the net effect of changes in hemostasis in many patients with chronic liver disease is a hypercoagulable status. In turn, clinical thrombosis is increasingly recognized as a complication of liver disease. When occurring within the liver, thrombosis may even progress the disease course. Exciting preliminary data regarding the potential of low-molecular-weight heparin to slow down the progression of liver disease indicate that this class of drugs may improve outcome without a major increase in bleeding risk. However, this new era for antithrombotic therapy in chronic liver disease is still hindered by a persistent false notion that patients with cirrhosis are "auto-anticoagulated" by their underlying liver disease. In addition, there is insufficient clinical evidence on safety and efficacy of anticoagulant therapy in cirrhosis and the studies conducted so far are limited by small sample sizes, uncontrolled treatment arms, or by their retrospective nature. Finally, a lack of knowledge on how or when to monitor antithrombotic treatment to optimize the risk-benefit ratio has restricted a widespread application of anticoagulant treatment in clinical management algorithms. Nonetheless, by systematically covering possibilities and pitfalls, this review highlights the potential of antithrombotic therapy to improve the quality of life and the clinical outcome of patients with chronic liver disease.
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Affiliation(s)
- Greg C G Hugenholtz
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Patrick G Northup
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, United States
| | - Robert J Porte
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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8
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Dik K, de Bruijne J, Takkenberg RB, Roelofs JJ, Tempelmans MJ, Dijkgraaf MGW, Gelderblom HC, Reesink HW, Meijers JCM, Jansen PL, Levi M. Factor XIII Val34Leu mutation accelerates the development of fibrosis in patients with chronic hepatitis B and C. Hepatol Res 2012; 42:668-76. [PMID: 22385348 DOI: 10.1111/j.1872-034x.2011.00963.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM There is considerable variation in liver fibrosis stage and progression to cirrhosis among patients with chronic hepatitis B (CHB) or C (CHC). Coagulation pathway activity due to genetic variations could influence the rate of fibrosis. We investigated thrombotic risk factors and their association with the extent and progression of fibrosis in CHB or CHC patients. METHODS In total, 194 patients with CHB (n = 88) or CHC (n = 106) were included. Data on demographic and laboratory findings were collected. Liver biopsies were evaluated according to the Ishak classification system. Fibrosis progression rate (FPR), defined as ratio of fibrosis score to duration of infection, was determined for 131 patients. Prevalence of factor V Leiden, prothrombin G20210A, plasminogen activator inhibitor type-1 (PAI-1) 4G/5G and factor XIIIA Val34Leu mutations was evaluated. RESULTS Heterozygosity for factor V Leiden, prothrombin G20210A, PAI-1 4G/5G and factor XIIIA Val34Leu mutations was present in 3.1%, 2.1%, 49% and 28% of the patients, respectively. Factor XIII Val34Leu mutation was a risk for enhanced FPR (odds ratio 4.7; P = 0.01). In patients with both factor XIII Val34Leu and PAI-1 4G/5G mutations the risk of an accelerated FPR was further increased (odds ratio 5.0; P = 0.02). Mutations of the other thrombotic genes were not significantly associated with fibrosis stage and FPR. CONCLUSION Our data show that factor XIII Val34Leu mutation alone or in combination with PAI-1 4G/5G mutation is a risk factor for an increased rate of liver fibrosis development in patients with CHB or CHC.
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Affiliation(s)
- Kathelijne Dik
- Department of Internal Medicine Department of Gastroenterology and Hepatology Department of Pathology Department of Experimental Immunology Clinical Research Unit Department of Vascular Medicine Department of Experimental Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands Department of Paediatrics, University of Oxford, Oxford, UK HIV Pathogenesis Program, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
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9
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Anstee QM, Dhar A, Thursz MR. The role of hypercoagulability in liver fibrogenesis. Clin Res Hepatol Gastroenterol 2011; 35:526-33. [PMID: 21570930 DOI: 10.1016/j.clinre.2011.03.011] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Accepted: 03/25/2011] [Indexed: 02/06/2023]
Abstract
The development of hepatic fibrosis on a background of chronic liver injury represents a complex disease trait modulated through the interaction of host genetic factors and environmental influences. Early observations that hepatic inflammation and cirrhosis are associated with the presence of microthrombi within the hepatic vasculature and fibrin/fibrinogen deposition were followed by epidemiological studies showing that carriage of the Factor V Leiden (FvL) mutation, protein C deficiency and increased expression of factor VIII are associated with accelerated progression to cirrhosis in a chronic hepatitis C infection. Additional data suggest that these factors may influence fibrogenesis in many forms of chronic liver disease and extra-hepatic fibrotic processes. Drawing evidence both from liver research and studies of fibrogenesis in other organ systems, two hypotheses may explain how activity of the coagulation cascade influences the rate of hepatic fibrogenesis: tissue ischaemia and parenchymal extinction and direct thrombin mediated stellate cell activation via PAR-1 cleavage. Drawing on preclinical and clinical studies we discuss the evidence for a role for coagulation cascade activity in hepatic fibrogenesis and explore the proposed pathogenic mechanisms that lead to stellate cell activation. The corollary of an association between hypercoagulation and increased fibrosis is that interference with the coagulation cascade may reduce hepatic fibrosis. We conclude this article by examining the implications for future therapeutic intervention.
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Affiliation(s)
- Quentin M Anstee
- Institute of Cellular Medicine, Newcastle University, The Medical School, 3rd Floor, William Leech Building, Framlington Place, Newcastle upon Tyne NE2 4HH, UK.
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10
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Tripodi A, Anstee QM, Sogaard KK, Primignani M, Valla DC. Hypercoagulability in cirrhosis: causes and consequences. J Thromb Haemost 2011; 9:1713-23. [PMID: 21729237 DOI: 10.1111/j.1538-7836.2011.04429.x] [Citation(s) in RCA: 185] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Decreased levels of most coagulation factors and thrombocytopenia are the main haemostatic abnormalities of cirrhosis. As a consequence, this condition was, until recently, considered as the prototype acquired coagulopathy responsible for bleeding. However, recent evidence suggests that it should, rather, be regarded as a condition associated with normal or even increased thrombin generation. The bleeding events that occur in these patients should, therefore, be explained by the superimposed conditions that frequently occur in this setting. Due to elevated levels of factor VIII (procoagulant driver) in combination with decreased protein C (anticoagulant driver), which are typically found in patients with cirrhosis, a procoagulant imbalance, defined as a partial resistance to the in vitro anticoagulant action of thrombomodulin, can be demonstrated. Whether this in vitro hypercoagulability is truly representative of what occurs in vivo remains to be established. However, the hypothesis that it may have clinical consequences is attractive and deserves attention. The possible consequences that we discuss herein include whether (i) cirrhosis is a condition associated with increased risk of venous thromboembolism or portal vein thrombosis; (ii) the hypercoagulability associated with cirrhosis has any other role outside coagulation (i.e. progression of liver fibrosis); and (iii) anticoagulation should be used in cirrhosis. Although apparently provocative, considering anticoagulation as a therapeutic option in patients with cirrhosis is now supported by a rationale of increasing strength. There may be subgroups of patients who benefit from anticoagulation to treat or prevent thrombosis and to slow hepatic fibrosis. Clinical studies are warranted to explore these therapeutic options.
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Affiliation(s)
- A Tripodi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Department of Internal Medicine, IRCCS Cà Granda Ospedale Maggiore Policlinico Foundation and Università degli Studi di Milan, Milan, Italy.
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11
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Viral cirrhosis: an overview of haemostatic alterations and clinical consequences. Mediterr J Hematol Infect Dis 2009; 1:e2009033. [PMID: 21415961 PMCID: PMC3033129 DOI: 10.4084/mjhid.2009.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2009] [Accepted: 12/27/2009] [Indexed: 12/13/2022] Open
Abstract
Viral hepatitis is a major health problem worldwide, the principal cause of cirrhosis and hepatocarcinoma. Once cirrhosis occurs, the consequences of liver dysfunction and portal hypertension become evident and, sometimes, life threatening for patients. Among the various complications of liver cirrhosis, the alteration of haemostatic balance is often a hard challenge for the clinician, since it is capable to predispose both to bleeding or thrombosis. In this review, we analyze the principal aspects of procoagulant, anticoagulant and fibrinolytic capacity of cirrhotic patients, which appears to be variably altered in all these aspects, not only in the direction of a tendency to bleeding. Laboratory investigations, at present, may provide only a partial representation of this condition, because of the impossibility to obtain a test capable to furnish a global overview of the haemostatic system and to reproduce in vivo conditions. Furthermore, we describe the pathophysiological mechanisms underlying bleeding manifestations and thrombosis development in cirrhotic patients, which should be considered not only as obvious consequences of the advanced liver disease but, rather, as the result of a complex interaction between inherited and acquired factors.
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12
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Anstee QM, Wright M, Goldin R, Thursz MR. Parenchymal extinction: coagulation and hepatic fibrogenesis. Clin Liver Dis 2009; 13:117-126. [PMID: 19150316 DOI: 10.1016/j.cld.2008.09.013] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Observations that hepatic inflammation and cirrhosis are associated with the presence of thrombi within the hepatic microvasculature and fibrin-fibrinogen deposition have led to epidemiologic studies showing that carriage of the factor V Leiden mutation, protein C deficiency, and increased expression of factor VIII are associated with rapid progression to cirrhosis in a chronic hepatitis C virus. Additional data suggest that this process may extend more broadly to progression in many forms of chronic liver disease. This article discusses the evidence for a role for coagulation cascade activity in hepatic fibrogenesis and explores the proposed pathogenic mechanisms including the downstream events of thrombin activation. Interference with either the generation of thrombin or its downstream activity may reduce hepatic fibrosis. Also examined are the implications for future therapeutic intervention.
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Affiliation(s)
- Quentin M Anstee
- Department of Academic Medicine, St Mary+s Hospital Campus, Imperial College London, 10th Floor, QEQM Building, Praed Street, London W2 1PG, UK.
| | - Mark Wright
- Department of Hepatology, Southampton General Hospital, Southampton, UK
| | - Robert Goldin
- Department of Histopathology, St Mary's Hospital Campus, Imperial College London, 10th Floor, QEQM Building, Praed Street, London W2 1PG, UK
| | - Mark R Thursz
- Department of Academic Medicine, St Mary+s Hospital Campus, Imperial College London, 10th Floor, QEQM Building, Praed Street, London W2 1PG, UK
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13
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Abstract
The coagulopathy of liver disease is complex and often unpredictable. Despite clear evidence of an increased tendency for bleeding in patients who have cirrhosis, many circumstances also promote local and systemic hypercoagulable states. The consequences of hypercoagulability include the obvious morbidity and mortality of portal vein thrombosis, deep vein thrombosis, and pulmonary embolism, but possibly also include other end-organ syndromes, such as portopulmonary hypertension, hepatorenal syndrome, and spontaneous bacterial peritonitis. A more subtle contribution also could be responsible for progression of early fibrosis to decompensated cirrhosis. Future research is needed to elucidate specific mechanistic pathways that might lead to local hypercoagulation and the clinical interventions that might prevent morbidity and mortality related to hypercoagulation in patients who have cirrhosis.
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Affiliation(s)
- Patrick G Northup
- Division of Gastroenterology and Hepatology, University of Virginia Health System, JPA and Lee Streets, MSB 2142, Charlottesville VA 22908-0708, USA.
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14
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Anstee QM, Goldin RD, Wright M, Martinelli A, Cox R, Thursz MR. Coagulation status modulates murine hepatic fibrogenesis: implications for the development of novel therapies. J Thromb Haemost 2008; 6:1336-43. [PMID: 18485088 DOI: 10.1111/j.1538-7836.2008.03015.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND There is strong evidence demonstrating that coagulation system activation contributes to wound healing and promotes organ fibrosis. Several epidemiological studies have now shown that prothrombotic status, including carriage of the factor (F)V Leiden mutation, is associated with rapid progression of hepatic fibrosis. OBJECTIVES To assess the effect of a procoagulant state on progression of hepatic fibrosis in a controlled environment and to test whether anticoagulation could attenuate fibrogenesis. METHODS We investigated the effects of coagulation status on liver fibrosis development in a mouse model of chronic toxic liver injury. Prothrombotic FV Leiden mutant mice, C57BL/6 control animals and anticoagulated mice were studied after chronic exposure to carbon tetrachloride. RESULTS Carriage of the FV Leiden mutation caused a significant increase in hepatic fibrosis. Anticoagulation with warfarin significantly reduced fibrosis progression in wild-type mice but was less effective against the profibrotic FV Leiden mutation. Changes in the fibrosis scores were mirrored by changes in liver hydroxyproline content and hepatic stellate cell activation detected by alpha-smooth muscle actin expression. CONCLUSIONS These results demonstrate that coagulation status has a strong influence on hepatic fibrogenesis. It is likely that thrombin signaling through the proteinase-activated receptor 1 (PAR(1)) receptor expressed on hepatic stellate cells is responsible for this relationship. These results represent the first reported use of anticoagulation to slow hepatic fibrogenesis and suggest a potential novel anti-fibrotic therapeutic approach for the future.
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Affiliation(s)
- Q M Anstee
- Faculty of Medicine, Imperial College, London, UK.
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Missiha SB, Ostrowski M, Heathcote EJ. Disease progression in chronic hepatitis C: modifiable and nonmodifiable factors. Gastroenterology 2008; 134:1699-714. [PMID: 18471548 DOI: 10.1053/j.gastro.2008.02.069] [Citation(s) in RCA: 159] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2007] [Revised: 02/15/2008] [Accepted: 02/21/2008] [Indexed: 12/13/2022]
Abstract
The hepatic complications of chronic hepatitis C (CHC) usually occur only after progression to cirrhosis has taken place. Progression to cirrhosis, however, is extremely variable and depends on a broad set of host and viral factors that modify the rate at which fibrosis develops in a given individual. Despite their inherent limitations, studies of the natural history of CHC have identified several nonmodifiable factors associated with disease progression. These include age at acquisition of infection, sex, and race. More recent reports suggest important roles for host genetic polymorphisms and viral factors. Of greater immediate relevance to patients and their clinicians are the potentially modifiable factors, which include excessive alcohol consumption; smoking (tobacco and marijuana); insulin resistance; and coinfection with hepatitis B virus, human immunodeficiency virus type 1, or schistosomiasis. Unfortunately, to date, there are no reliable predictive models that can accurately estimate the risk of CHC disease progression.
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Affiliation(s)
- Sharif B Missiha
- Division of Gastroenterology, University Health Network, University of Toronto, Toronto, Ontario, Canada
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