Antihaemophilic factor A (F VIII) and serum fibrin-fibrinogen degradation products in hepatic cirrhosis

Relation of simple clotting tests to clotting factor levels in liver disease

The prothrombin time with Manchester and ox thromboplastins, the 'P & P' test of Owren and Aas, the partial thromboplastin time, the thrombin time and assays for factors II, V, VII, VIII:C, IX and X were performed by one observer in 18 patients with liver disease and 27 normal subjects; the prothrombin time and partial thromboplastin time were also carried out on another 28 similar patients by various observers. Routine liver function tests were measured in all patients. The prothrombin time with Manchester thromboplastin was well correlated with other clotting tests, and performing the other tests did not add to the information. Discriminant function analysis confirmed that clotting tests did not distinguish between different types of liver disease. Correlations between clotting tests and liver function tests reflected liver cell damage but were also influenced by acute phase reactions.

Quantification of thrombelastographic changes after blood component transfusion in patients with liver disease in the intensive care unit

Thrombelastography (TEG) can be used to monitor hemostasis and guide transfusion therapy during orthotopic liver transplantation. However, data are limited regarding the type and quantity of blood components necessary for TEG-guided blood component transfusion in coagulopathic critically ill patients with liver disease. We evaluated changes in four thrombelastogram variables (reaction time, thrombin constant time, alpha angle, and maximum amplitude) in whole blood samples after 74 separate blood component transfusions in 60 critically ill patients with a coagulopathy and liver disease. Only platelets significantly improved TEG variables in patients who received a single type of blood component. Each unit of platelets decreased the reaction and thrombin constant time by 0.43 (P < 0.05) and 0.82 (P < 0.005) min, respectively, increased the alpha angle by 1.5 degrees (P < 0.005), and the maximum amplitude by 1.4 mm (P < 0.005). In patients who received multiple blood components, cryoprecipitate decreased the thrombin constant time by 0.56 min/U (P < 0.05), and each unit of platelets decreased the thrombin constant time by 0.39 min (P < 0.005), and increased the alpha angle and maximum amplitude by 0.63 degrees (P < 0.05) and 0.99 mm (P < 0.005), respectively. We conclude that platelet transfusions, alone or in combination with other blood components, are most effective for improving abnormal TEG variables in coagulopathic critically ill patients with liver disease.

Activation of the fibrinolytic system in patients with fulminant liver failure

Abnormalities of blood coagulation and fibrinolysis are a major part of fulminant liver failure. In this study, the key components of the fibrinolytic system were determined in 42 patients with this condition. Admission levels of plasma plasminogen activity were low (9.1% of normal), as to a lesser extent were the activities of its inhibitors alpha 2-antiplasmin (20.5% of normal) and C1 inhibitor (64% of normal). Tissue plasminogen activator activity was found at normal levels, whereas the level of its fast inhibitor, plasminogen activator inhibitor-1, was greatly increased compared with that of controls (24.3 U/ml and 7.4 U/ml, respectively), indicating a shift toward inhibition of fibrinolysis in these patients. Thrombin-antithrombin complex levels in plasma were significantly increased in fulminant liver failure compared with those in controls (33.5 micrograms/L vs. 2.5 micrograms/L, p < 0.001), indicating activation of coagulation in these patients. High plasma levels of D-dimer, a fragment of cross-linked fibrin, were also found (1,510 micrograms/L vs. 33 micrograms/L in controls, p < 0.001); this finding correlated with the increased level of thrombin-antithrombin complex (r = 0.61, p < 0.001), consistent with activation of fibrinolysis resulting from intravascular coagulation. In conclusion, there are gross abnormalities of the fibrinolytic system in fulminant liver failure, but because inhibitory activity appears to be present in adequate quantities, this limits the incidence of bleeding due to fibrinolysis.

Studies on hemorrhagic tendency in cirrhosis of the liver

Recently it has been paid attention whether the liver diseases might induce the disseminated intravascular coagulation (DIC) or not, although it has well known that liver cirrhosis contribute to the hemorrhagic diathesis. In this paper, we studied on the hemorrhagic tendency and hemostatic tests in the patients with liver cirrhosis in order to clarify the coagulation and fibrinolytic activity. We can conclude that the hemorrhagic diathesis occurs due to the complex of decreases in platelet number, platelet functions, clotting factors, and increased fibrinolytic activity. The increased fibrinolytic activity may be primary and the frequency of clinically important DIC is quite low.

Abnormal factor VIII in chronic renal failure

Factor VIII procoagulant activity (VIII-C), related antigen (VIII-AG), and von Willebrand factor (VIII-vWf) were measured in 38 patients with chronic renal failure (CRF), in 19 patients with normal renal function from a general medical ward, and in 17 normal subjects. Wide variation in the levels of factor VIII (FVIII) functions were found in the group of CRF patients. There was no correlation between the levels of the three individual activities of FVIII in renal disease. The levels of the three functions were elevated in the patient controls and no significant differences were found between the two groups of patients, although both groups were significantly different from the normal subjects. Increased electrophoretic mobility (EM) was detected in 22 of the 38 patients with CRF (58%) compared to seven of the 19 patients controls (37%). These studies suggest caution in interpretation of changes in FVIII status in patients with other clinical disorders, such as liver disease.