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Fierro-Angulo OM, González-Regueiro JA, Pereira-García A, Ruiz-Margáin A, Solis-Huerta F, Macías-Rodríguez RU. Hematological abnormalities in liver cirrhosis. World J Hepatol 2024; 16:1229-1244. [DOI: 10.4254/wjh.v16.i9.1229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 08/09/2024] [Accepted: 08/22/2024] [Indexed: 09/23/2024] Open
Abstract
Hematological abnormalities are common in cirrhosis and are associated with various pathophysiological mechanisms. Studies have documented a prevalence of thrombocytopenia, leukopenia, and anemia in patients with compensated cirrhosis of 77.9%, 23.5%, and 21.1%, respectively. These abnormalities carry significant clinical implications, including considerations for invasive procedures, infection risk, bleeding risk, and prognosis. Previously, cirrhosis was believed to predispose patients to bleeding due to alterations observed in classical coagulation tests such as prothrombin time, partial thromboplastin time, international normalized ratio, and thrombocytopenia. However, this understanding has evolved, and cirrhosis patients are now also acknowledged as being at a high risk for thrombotic events. Hemostasis in cirrhosis patients presents a complex phenotype, with procoagulant and anticoagulant abnormalities offsetting each other. This multifactorial phenomenon is inadequately reflected by routine laboratory tests. Thrombotic complications are more prevalent in decompensated cirrhosis and may correlate with disease severity. Bleeding is primarily associated with portal hypertension, endothelial dysfunction, mechanical vessel injury, disseminated intravascular coagulation, endotoxemia, and renal injury. This review comprehensively outlines hematologic index abnormalities, mechanisms of hemostasis, coagulation, and fibrinolysis abnormalities, limitations of laboratory testing, and clinical manifestations of bleeding and thrombosis in patients with liver cirrhosis.
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Affiliation(s)
- Oscar Manuel Fierro-Angulo
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico 14080, Mexico
| | - José Alberto González-Regueiro
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico 14080, Mexico
| | - Ariana Pereira-García
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico 14080, Mexico
| | - Astrid Ruiz-Margáin
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico 14080, Mexico
| | - Fernando Solis-Huerta
- Department of Hematology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico 14080, Mexico
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2
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Berg T, Aehling NF, Bruns T, Welker MW, Weismüller T, Trebicka J, Tacke F, Strnad P, Sterneck M, Settmacher U, Seehofer D, Schott E, Schnitzbauer AA, Schmidt HH, Schlitt HJ, Pratschke J, Pascher A, Neumann U, Manekeller S, Lammert F, Klein I, Kirchner G, Guba M, Glanemann M, Engelmann C, Canbay AE, Braun F, Berg CP, Bechstein WO, Becker T, Trautwein C. S2k-Leitlinie Lebertransplantation der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1397-1573. [PMID: 39250961 DOI: 10.1055/a-2255-7246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Affiliation(s)
- Thomas Berg
- Bereich Hepatologie, Medizinischen Klinik II, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Niklas F Aehling
- Bereich Hepatologie, Medizinischen Klinik II, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Tony Bruns
- Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Deutschland
| | - Martin-Walter Welker
- Medizinische Klinik I Gastroent., Hepat., Pneum., Endokrin. Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Tobias Weismüller
- Klinik für Innere Medizin - Gastroenterologie und Hepatologie, Vivantes Humboldt-Klinikum, Berlin, Deutschland
| | - Jonel Trebicka
- Medizinische Klinik B für Gastroenterologie und Hepatologie, Universitätsklinikum Münster, Münster, Deutschland
| | - Frank Tacke
- Charité - Universitätsmedizin Berlin, Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Campus Virchow-Klinikum (CVK) und Campus Charité Mitte (CCM), Berlin, Deutschland
| | - Pavel Strnad
- Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Deutschland
| | - Martina Sterneck
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Hamburg, Hamburg, Deutschland
| | - Utz Settmacher
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Jena, Deutschland
| | - Daniel Seehofer
- Klinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Eckart Schott
- Klinik für Innere Medizin II - Gastroenterologie, Hepatologie und Diabetolgie, Helios Klinikum Emil von Behring, Berlin, Deutschland
| | | | - Hartmut H Schmidt
- Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Essen, Essen, Deutschland
| | - Hans J Schlitt
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Johann Pratschke
- Chirurgische Klinik, Charité Campus Virchow-Klinikum - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Andreas Pascher
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Münster, Münster, Deutschland
| | - Ulf Neumann
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Essen, Deutschland
| | - Steffen Manekeller
- Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - Frank Lammert
- Medizinische Hochschule Hannover (MHH), Hannover, Deutschland
| | - Ingo Klein
- Chirurgische Klinik I, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Gabriele Kirchner
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg und Innere Medizin I, Caritaskrankenhaus St. Josef Regensburg, Regensburg, Deutschland
| | - Markus Guba
- Klinik für Allgemeine, Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Universitätsklinikum München, München, Deutschland
| | - Matthias Glanemann
- Klinik für Allgemeine, Viszeral-, Gefäß- und Kinderchirurgie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Cornelius Engelmann
- Charité - Universitätsmedizin Berlin, Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Campus Virchow-Klinikum (CVK) und Campus Charité Mitte (CCM), Berlin, Deutschland
| | - Ali E Canbay
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Deutschland
| | - Felix Braun
- Klinik für Allgemeine Chirurgie, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schlewswig-Holstein, Kiel, Deutschland
| | - Christoph P Berg
- Innere Medizin I Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - Wolf O Bechstein
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Thomas Becker
- Klinik für Allgemeine Chirurgie, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schlewswig-Holstein, Kiel, Deutschland
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Elhence A, Shalimar. Von Willebrand Factor as a Biomarker for Liver Disease - An Update. J Clin Exp Hepatol 2023; 13:1047-1060. [PMID: 37975050 PMCID: PMC10643510 DOI: 10.1016/j.jceh.2023.05.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 05/29/2023] [Indexed: 11/19/2023] Open
Abstract
The von Willebrand factor (vWF) is best known for its role in the hemostatic pathway, aiding platelet adhesion and aggregation, as well as circulating along with coagulation factor VIII, prolonging its half-life. However, vWF is more than a hemostatic protein and is a marker of endothelial dysfunction in patients with cirrhosis. The levels of vWF increase progressively as cirrhosis progresses. Despite its qualitative defects, it can support and carry out its hemostatic role and contribute to a pro-coagulant disbalance. Moreover, it has been shown to be a good noninvasive marker for predicting clinically significant portal hypertension (CSPH). The vWF has been shown to predict decompensation and mortality among cirrhosis patients independently of the stage of liver disease and severity of portal hypertension. Increased vWF levels in the setting of endothelial injury predict bacterial translocation and systemic inflammation. The vWF-to-thrombocyte ratio (VITRO) score adds to the diagnostic ability of vWF alone in detecting CSPH non-invasively. Not only have vWF levels been shown to help predict the risk of hepatocellular carcinoma (HCC) among cirrhosis patients, but they also predict the risk of complications post-resection for HCC and response to systemic therapies. vWF-induced portal microthrombi have been purported to contribute to the pathogenesis of acute liver failure progression as well as non-cirrhotic portal hypertension. The prospect of modulation of vWF levels using drugs such as non-selective beta-blockers, statins, anticoagulants, and non-absorbable antibiotics and its use as a predictive biomarker for the response to these drugs needs to be explored.
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Affiliation(s)
- Anshuman Elhence
- Department of Gastroenterology, National Cancer Institute- All India Institute of Medical Sciences, New Delhi, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
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Li F, Wang T, Liang J, Qian B, Tang F, Gao Y, Lv J. Albumin‑bilirubin grade and INR for the prediction of esophagogastric variceal rebleeding after endoscopic treatment in cirrhosis. Exp Ther Med 2023; 26:501. [PMID: 37822588 PMCID: PMC10562956 DOI: 10.3892/etm.2023.12200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 08/18/2023] [Indexed: 10/13/2023] Open
Abstract
Rebleeding following endoscopic treatment in patients with cirrhosis is a serious life-threatening complication. In the present study, a novel, reliable and non-invasive score for prediction of rebleeding following endoscopic therapy for esophagogastric variceal bleeding (EGVB) was developed. The present retrospective study recruited cirrhotic patients with EGVB (n=596) who underwent endoscopic therapy. Patients hospitalized from January 2015 to January 2020 were grouped into a training (n=437) cohort to develop the new score and those hospitalized from February 2020 to February 2022 were grouped into a validation (n=159) cohort to validate the score. The international normalized ratio (INR) and albumin-bilirubin (ALBI) grade were used to develop the INR-ALBI (IALBI) score to predict risk of rebleeding. In the training cohort, the prognostic performance of the IALBI score and other ALBI-associated scores (modified ALBI, platelet-ALBI and ALBI-fibrosis-4) at 1, 3 and 12 months was assessed using receiver operating characteristic (ROC) curve and Kaplan-Meier analysis. At each time point, most areas under the ROC curve of IALBI were higher than those of other ALBI-associated scores, particularly for prediction of early rebleeding. At 1 month, the rebleeding rates of patients with IALBI grade 2 and 3 were ~10.0- and 19.5-times higher than those of patients with grade 1, respectively. The negative predictive value (NPV) of IALBI for the training and validation cohort at 1 month was 100.0 and 97.8%, respectively. For viral and non-viral patients in the training cohort, IALBI showed good predictive ability and NPV for early rebleeding. The IALBI grading system successfully assessed rebleeding, particularly early rebleeding, in cirrhotic patients with EGVB following endoscopic therapy IALBI grade 1, predicted low risk of rebleeding and may not require endoscopic treatment again in the short-term.
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Affiliation(s)
- Fenghui Li
- Department of Gastroenterology and Hepatology, The Third Central Hospital of Tianjin, Tianjin Key Laboratory of Extra-Corporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin 300170, P.R. China
| | - Tao Wang
- Department of Gastroenterology and Hepatology, The Third Central Hospital of Tianjin, Tianjin Key Laboratory of Extra-Corporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin 300170, P.R. China
| | - Jing Liang
- Department of Gastroenterology and Hepatology, The Third Central Hospital of Tianjin, Tianjin Key Laboratory of Extra-Corporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin 300170, P.R. China
| | - Baoxin Qian
- Department of Gastroenterology and Hepatology, The Third Central Hospital of Tianjin, Tianjin Key Laboratory of Extra-Corporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin 300170, P.R. China
| | - Fei Tang
- Department of Gastroenterology and Hepatology, The Third Central Hospital of Tianjin, Tianjin Key Laboratory of Extra-Corporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin 300170, P.R. China
| | - Yanying Gao
- Department of Gastroenterology and Hepatology, The Third Central Hospital of Tianjin, Tianjin Key Laboratory of Extra-Corporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin 300170, P.R. China
| | - Jiayu Lv
- Department of Gastroenterology and Hepatology, The Third Central Hospital of Tianjin, Tianjin Key Laboratory of Extra-Corporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin 300170, P.R. China
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Guan C, Ma F, Chang S, Zhang J. Interpretable machine learning models for predicting venous thromboembolism in the intensive care unit: an analysis based on data from 207 centers. Crit Care 2023; 27:406. [PMID: 37875995 PMCID: PMC10598960 DOI: 10.1186/s13054-023-04683-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 10/11/2023] [Indexed: 10/26/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a severe complication in critically ill patients, often resulting in death and long-term disability and is one of the major contributors to the global burden of disease. This study aimed to construct an interpretable machine learning (ML) model for predicting VTE in critically ill patients based on clinical features and laboratory indicators. METHODS Data for this study were extracted from the eICU Collaborative Research Database (version 2.0). A stepwise logistic regression model was used to select the predictors that were eventually included in the model. The random forest, extreme gradient boosting (XGBoost) and support vector machine algorithms were used to construct the model using fivefold cross-validation. The area under curve (AUC), accuracy, no information rate, balanced accuracy, kappa, sensitivity, specificity, precision, and F1 score were used to assess the model's performance. In addition, the DALEX package was used to improve the interpretability of the final model. RESULTS This study ultimately included 109,044 patients, of which 1647 (1.5%) had VTE during ICU hospitalization. Among the three models, the Random Forest model (AUC: 0.9378; Accuracy: 0.9958; Kappa: 0.8371; Precision: 0.9095; F1 score: 0.8393; Sensitivity: 0.7791; Specificity: 0.9989) performed the best. CONCLUSION ML models can be a reliable tool for predicting VTE in critically ill patients. Among all the models we had constructed, the random forest model was the most effective model that helps the user identify patients at high risk of VTE early so that early intervention can be implemented to reduce the burden of VTE on the patients.
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Affiliation(s)
- Chengfu Guan
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Fuxin Ma
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Sijie Chang
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China.
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Saner FH, Scarlatescu E, Broering DC, Bezinover D. The Yin and the Yang of Hemostasis in End-Stage Liver Disease. J Clin Med 2023; 12:5759. [PMID: 37685826 PMCID: PMC10488973 DOI: 10.3390/jcm12175759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 09/10/2023] Open
Abstract
Patients with end-stage liver disease (ESLD) undergoing liver transplantation (LT) are prone to thromboses both while on the waiting list and in the perioperative period. This hypercoagulability is associated with significant endothelial dysfunction (ED) due to nitric oxide dysregulation. ED and increased thrombin generation are the main factors responsible for this hypercoagulability. Sepsis alone can significantly alter a patient's coagulation profile. In combination with ESLD, however, sepsis or septic shock are responsible for very complex changes. This makes both the assessment and management of coagulation in septic patients with ESLD very challenging. Viscoelastic testing (VET) is the preferred method of coagulation management in patients with cirrhosis because, as with standard laboratory testing, VET can assess the entire coagulation system including the interaction between both pro- and anticoagulants and platelets.
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Affiliation(s)
- Fuat H. Saner
- King Faisal Specialist Hospital & Research Center, Organ Transplant Center of Excellence, Riyadh 11564, Saudi Arabia;
| | - Ecaterina Scarlatescu
- Department of Anesthesia and Intensive Care Medicine III, Fundeni Clinical Institute, 022328 Bucharest, Romania;
- Anesthesia and Intensive Care Department, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
| | - Dieter Clemens Broering
- King Faisal Specialist Hospital & Research Center, Organ Transplant Center of Excellence, Riyadh 11564, Saudi Arabia;
| | - Dmitri Bezinover
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA;
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Franco MB, Jardim LL, de Carvalho BN, Basques F, Ribeiro DD, Pereira LS, Rezende SM. Deficiency of coagulation factors is associated with the bleeding diathesis of severe yellow fever. Ann Hematol 2023; 102:1939-1949. [PMID: 37226021 DOI: 10.1007/s00277-023-05262-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 05/03/2023] [Indexed: 05/26/2023]
Abstract
Yellow fever (YF) is an acute tropical infectious disease caused by an arbovirus and can manifest as a classic hemorrhagic fever. The mechanism of the bleeding diathesis in YF is not well understood. We assessed clinical and laboratory data (including a panel of coagulation tests) from 46 patients with moderate (M) and severe (S) YF admitted to a local hospital between January 2018 and April 2018. Among 46 patients, 34 had SYF of whom 12 (35%) patients died. A total of 21 (45%) patients developed some type of bleeding manifestation and 15 (32%) presented severe bleeding. Patients with SYF had more severe thrombocytopenia (p = 0.001); prolonged activated partial thromboplastin time (aPTT) and thrombin time (TT) (p = 0.03 and p = 0.005, respectively); reduced plasma levels of coagulation factor (F) II (p < 0.01), FIX (p = 0.01), and FX (p = 0.04); and D-dimer levels almost 10 times higher (p < 0.01) when compared with patients with MYF. Patients who died had more bleeding (p = 0.03), more major bleeding (p = 0.03), prolonged international normalized ratio (INR) and aPTT (p = 0.003 and p = 0.002, respectively), as well as lower activity of FII (p = 0.02), FV (p = 0.001), FVII (p = 0.005), FIX (p = 0.01), and protein C (p = 0.01) than the ones who survived. FVIII levels were either normal or increased in all patients studied. Our results suggest that the bleeding diathesis of SYF is associated with the deficiency of coagulation factors produced by the liver. Prolonged INR and aPTT and reduced FII, FV, FVII, FIX, and protein C were associated with death.
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Affiliation(s)
- Mariana Brandão Franco
- Faculty of Medicine, Universidade Federal de Minas Gerais, Avenida Alfredo Balena, 190, Room 255, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - Leticia Lemos Jardim
- Faculty of Medicine, Universidade Federal de Minas Gerais, Avenida Alfredo Balena, 190, Room 255, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | | | - Fernando Basques
- Hemocentro de Belo Horizonte, Fundação HEMOMINAS, Belo Horizonte, Minas Gerais, Brazil
| | - Daniel Dias Ribeiro
- Hematology Unit, University Hospital, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Leonardo Soares Pereira
- Hospital Eduardo de Menezes, Fundação Hospitalar Do Estado de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Suely Meireles Rezende
- Faculty of Medicine, Universidade Federal de Minas Gerais, Avenida Alfredo Balena, 190, Room 255, Belo Horizonte, Minas Gerais, 30130-100, Brazil.
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Lewis CS, Bari K, Xie C, Sherman KE, Vasse M, Van Dreden P, Bogdanov VY. Potential utility of a multi-component coagulation factor panel to calculate MELD scores and assess the risk of portal vein thrombosis in chronic liver disease. BMC Gastroenterol 2023; 23:65. [PMID: 36894870 PMCID: PMC9999630 DOI: 10.1186/s12876-023-02695-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 02/23/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Current quantitative approaches to assess chronic liver disease (CLD) severity have limitations. Further, portal vein thrombosis (PVT) pre-liver transplant (LT) is a major contributor to morbidity in CLD; the means of detecting and/or predicting PVT are limited. We sought to explore whether plasma coagulation factor activity levels can serve as a substitute for prothrombin time/international normalized ratio (PT/INR) in the Model for End-stage Liver Disease (MELD), and/or help assess the risk of PVT. METHODS Plasma activity levels of Factor V (FV), Factor VIII (FVIII), Protein C (PC), and Protein S (PS) and the concentrations of D-dimer, sP-selectin, and asTF were assessed in two cohorts of CLD patients (ambulatory, n = 42; LT, n = 43). RESULTS FV and PC activity levels strongly correlated with MELD scores, which enabled the development of a novel scoring system based on multiple linear regressions of the correlations of FV and PC activity with MELD-Na that substitutes PT/INR. Six-month and 1-year follow-up revealed that our novel approach was non-inferior to MELD-Na at predicting mortality. A significant inverse correlation between FVIII activity levels and PVT was found in the LT cohort (p = 0.010); FV and PS activity levels were in-trend (p = 0.069, p = 0.064). We developed a logistic regression-based compensation score to identify patients at risk of PVT. CONCLUSIONS We demonstrate that FV and PC activity levels may be used to replace PT/INR in MELD scoring. We also show the potential of using the combination of FV, FVIII, and PS activity levels to assess the risk of PVT in CLD.
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Affiliation(s)
- Clayton S Lewis
- Division of Hematology/Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, 3125 Eden Ave., Rm 1316, Cincinnati, OH, 45267, USA
| | - Khurram Bari
- Division of Digestive Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Changchun Xie
- Department of Environmental and Public Health Sciences, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kenneth E Sherman
- Division of Digestive Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Marc Vasse
- Department of Biology and UMR INSERM 1176, Foch Hospital, Suresnes, France
| | | | - Vladimir Y Bogdanov
- Division of Hematology/Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, 3125 Eden Ave., Rm 1316, Cincinnati, OH, 45267, USA.
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Sacco M, Tardugno M, Lancellotti S, Ferretti A, Ponziani FR, Riccardi L, Zocco MA, De Magistris A, Santopaolo F, Pompili M, De Cristofaro R. ADAMTS-13/von Willebrand factor ratio: A prognostic biomarker for portal vein thrombosis in compensated cirrhosis. A prospective observational study. Dig Liver Dis 2022; 54:1672-1680. [PMID: 35778228 DOI: 10.1016/j.dld.2022.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 05/13/2022] [Accepted: 06/07/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIMS In cirrhosis, decreased portal flow velocity, thrombophilia factors, and portal hypertension are considered risk factors for portal vein thrombosis (PVT). In cirrhosis, the transformation of the stellate cells causes a progressive decrease of ADAMTS-13, while VWF multimers secretion by endothelial cells is strongly enhanced. This imbalance leads to an accumulation of ultra-large VWF multimers that in sinusoidal circulation could favor PVT both in intra- and extra-hepatic branches, mostly in decompensated cirrhosis. This prospective study was aimed at identifying possible clinical, biochemical, and hemostatic factors predictive for non-tumoral PVT in a cohort of patients with compensated cirrhosis. METHODS Seventynine compensated cirrhosis patients were prospectively followed for 48 months, receiving a periodic Doppler-ultrasound liver examination associated with an extensive evaluation of clinical, biochemical, and hemostatic profile. RESULTS Five patients developed PVT (cumulative prevalence = 6.3%), occurring 4-36 months after enrollment. In logistic regression analysis, the ADAMTS-13/VWF:GpIbR ratio < 0.4 was the only independent variable significantly associated with PVT (OR 14.6, 95% C.I.:1.36-157.2, p = 0.027). A Cox-regression-analysis confirmed this finding (HR = 7.7, p = 0.027). CONCLUSIONS The ADAMTS-13/VWF ratio < 0.4 measured in compensated cirrhosis could be a reliable predictive biomarker for PVT development, paving the way to novel therapeutic strategies to prevent and treat PVT in this clinical setting.
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Affiliation(s)
- Monica Sacco
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica S. Cuore, Facoltà di Medicina e Chirurgia "Agostino Gemelli", Roma, Italy
| | - Maira Tardugno
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica S. Cuore, Facoltà di Medicina e Chirurgia "Agostino Gemelli", Roma, Italy
| | - Stefano Lancellotti
- Servizio Malattie Emorragiche e Trombotiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Roma, Italy
| | - Antonietta Ferretti
- Servizio Malattie Emorragiche e Trombotiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Roma, Italy
| | - Francesca Romana Ponziani
- Dipartimento di Scienze Mediche e Chirurgiche, Hepatology Service, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica S. Cuore, Roma, Italy
| | - Laura Riccardi
- Dipartimento di Scienze Mediche e Chirurgiche, Hepatology Service, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica S. Cuore, Roma, Italy
| | - Maria Assunta Zocco
- Dipartimento di Scienze Mediche e Chirurgiche, Hepatology Service, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica S. Cuore, Roma, Italy
| | - Antonio De Magistris
- Dipartimento di Scienze Mediche e Chirurgiche, Hepatology Service, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica S. Cuore, Roma, Italy
| | - Francesco Santopaolo
- Dipartimento di Scienze Mediche e Chirurgiche, Hepatology Service, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica S. Cuore, Roma, Italy
| | - Maurizio Pompili
- Dipartimento di Scienze Mediche e Chirurgiche, Hepatology Service, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica S. Cuore, Roma, Italy
| | - Raimondo De Cristofaro
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica S. Cuore, Facoltà di Medicina e Chirurgia "Agostino Gemelli", Roma, Italy; Servizio Malattie Emorragiche e Trombotiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Roma, Italy.
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10
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Saner FH, Hoyer DP, Hartmann M, Nowak KM, Bezinover D. The Edge of Unknown: Postoperative Critical Care in Liver Transplantation. J Clin Med 2022; 11:jcm11144036. [PMID: 35887797 PMCID: PMC9322367 DOI: 10.3390/jcm11144036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 06/29/2022] [Accepted: 07/07/2022] [Indexed: 02/04/2023] Open
Abstract
Perioperative care of patients undergoing liver transplantation (LT) is very complex. Metabolic derangements, hypothermia, coagulopathy and thromboses, severe infections, and graft dysfunction can affect outcomes. In this manuscript, we discuss several perioperative problems that can be encountered in LT recipients. The authors present the most up-to-date information regarding predicting and treating hemodynamic instability, coagulation monitoring and management, postoperative ventilation strategies and early extubation, management of infections, and ESLD-related pulmonary complications. In addition, early post-transplant allograft dysfunction will be discussed.
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Affiliation(s)
- Fuat H. Saner
- Department of General-, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, 45147 Essen, Germany; (D.P.H.); (K.M.N.)
- Correspondence: ; Fax: +49-201-723-1145
| | - Dieter P. Hoyer
- Department of General-, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, 45147 Essen, Germany; (D.P.H.); (K.M.N.)
| | - Matthias Hartmann
- Department of Anaesthesia and Critical Care, Medical Center University Duisburg-Essen, 45147 Essen, Germany;
| | - Knut M. Nowak
- Department of General-, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, 45147 Essen, Germany; (D.P.H.); (K.M.N.)
| | - Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Penn State Hershey Medical Center, Penn State College of Medicine, Hershey, PA 17033, USA;
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11
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Mak KM, Kee D, Cheng CP. A review of hepatic fibrosis-associated histopathology in aged cadavers. Anat Rec (Hoboken) 2022; 306:1031-1053. [PMID: 35446463 DOI: 10.1002/ar.24931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 11/08/2022]
Abstract
This article reviews hepatic fibrosis-associated histopathology of aged cadavers (mean age 82 years). A study of 68 livers identified steatosis in 35.5%, central vein fibrosis in 49.2%, perisinusoidal fibrosis in 63.2%, portal tract fibrosis in 47.7%, septa formation in 44.1%, bridging fibrosis in 30.8%, and cirrhosis in 4.4% of the samples as well as one hepatocellular carcinoma and six metastatic tumors. Other studies have revealed that collagens I, III, IV, V, and VI and fibronectin constitute the matrices of fibrous central veins, perisinusoidal space, portal tracts, and septa. Elastin is rich in portal tracts and fibrous septa but absent from the perisinusoidal space. Hepatic stellate cells are ubiquitous in the liver parenchyma while myofibroblasts localize in fibrotic foci. Factor VIII-related antigen expression signals sinusoidal to systemic vascular endothelium transformation while collagen IV and laminin codistribution indicates formation of perisinusoidal membranes. Their coincidence reflects focalized capillarization of sinusoids in the aged liver. In response to fibrogenesis, hepatic progenitor cells residing in the canal of Hering in the periportal parenchyma undergo expansion and migration deep into the lobule. Concomitantly, intermediate hepatocyte-like cells increase in advanced fibrosis stages, which is possibly related to hepatic regeneration. Metabolic zonation of glutamine synthetase expands from the perivenous to non-perivenous parenchyma in fibrosis progression but its expression is lost in cirrhosis, while cytochrome P-4502E1 expression is maintained in centrilobular and midlobular zones in fibrosis progression and expressed in cirrhosis. Hence, cadaveric livers provide a platform for further investigation of hepatic histopathologies associated with the aging liver.
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Affiliation(s)
- Ki M Mak
- Department of Medical Education, Center for Anatomy and Functional Morphology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Dustin Kee
- Department of Medical Education, Center for Anatomy and Functional Morphology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christopher P Cheng
- Department of Medical Education, Center for Anatomy and Functional Morphology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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12
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Premkumar M, Kulkarni AV, Kajal K, Divyaveer S. Principles, Interpretation, and Evidence-Based Role of Viscoelastic Point-of-Care Coagulation Assays in Cirrhosis and Liver Failure. J Clin Exp Hepatol 2022; 12:533-543. [PMID: 35535095 PMCID: PMC9077199 DOI: 10.1016/j.jceh.2021.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/02/2021] [Indexed: 12/12/2022] Open
Abstract
Background and Aims Standard coagulation tests such as prothrombin time, activated partial thromboplastin time, and international normalized ratio are determined by liver-synthesized coagulation factors. Despite an increased international normalized ratio, patients with cirrhosis are in a "rebalanced" state of hemostasis as the concomitant effect of reduced protein C, protein S, and thrombomodulin is not evaluated in standard coagulation tests. The cell-based model of hemostasis indicates additional mechanisms such as systemic inflammation, sepsis, and organ failures tip the delicate coagulation balance to an anticoagulant type in acute-on-chronic liver failure. In acute liver failure, thrombin generation and platelet function remain intact despite a marked prolongation in prothrombin time. We aimed to explain the principles, application, and utility of viscoelastic tests such as thromboelastography, rotational thromboelastometry, and Sonoclot. Methods We reviewed the available literature from MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trial with the search terms 'coagulation', 'cirrhosis', 'acute-on-chronic liver failure', 'thromboelastography', 'thromboelastometry' and 'sonoclot' for cross sectional studies, cohort studies and randomized trials. Results The point-of-care viscoelastic tests provide actionable targets for correcting the coagulation defect in a patient with bleeding and provide evidence-based algorithms for use in liver disease. A limitation of these tests is the inability to assess vessel injury and endothelial elements. Conclusion Global coagulation tests provide a comprehensive estimate of coagulation in vitro; however, their use has only been validated in the setting of liver transplantation. Newer guidelines for hemostatic resuscitation are now accepting these POC tests, but additional data are required to validate their use as standard of care.
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Key Words
- ACLF, acute-on-chronic liver failure
- ACT, activated clotting time
- ALF, acute liver failure
- CR, clot rate
- INR, international normalized ratio
- MA, maximum amplitude
- R, reaction time
- ROTEM
- ROTEM, rotational thromboelastometry
- SCT, standard coagulation tests
- TEG, thromboelastography
- VWF, von Willebrand factor
- aPTT, activated partial thromboplastin time
- cirrhosis
- coagulation
- sonoclot
- thromboelastography
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Affiliation(s)
- Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Anand V. Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Kamal Kajal
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Smita Divyaveer
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
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13
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El Shazli LB, Ragab DA, Abdelhady KA, Abdelaziz AW. Role of plasma von Willebrand factor antigen in prediction of esophageal varices in pediatric and adolescent patients with portal hypertension. EGYPTIAN LIVER JOURNAL 2021. [DOI: 10.1186/s43066-021-00159-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Ruptured esophageal varices (EVs) are a leading cause of death in Portal hypertension (PHT), it has been a big concern of research to screen EVs through non-invasive approaches. This study aimed to evaluate the role of plasma von Willebrand factor antigen (VWF-Ag) assay for early detection of EVs in patients with portal hypertension. This was a cross-sectional study, done on 47 portal hypertensive children and adolescents who were collected from the Pediatrics Hepatology Clinic, Children Hospital, Ain Shams University. All patients were subjected to comprehensive history taking, thorough clinical examination, routine investigations, abdominal ultrasound, upper GI endoscopy, and measurement of plasma VWF-Ag level. The patients were divided based on their endoscopic findings into two groups; a varices group which included 37 patients, and a non-varices group which included 10 patients.
Results
VWF-Ag rise significantly in patients with EVs, revealing a direct positive association with the degree of EVs.
Conclusion
The plasma VWF-Ag can be applied as a non-invasive evidence of the presence and grading of EVs.
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14
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Xu S, Guo X, Yang B, Romeiro FG, Primignani M, Méndez-Sánchez N, Yoshida EM, Mancuso A, Tacke F, Noronha Ferreira C, De Stefano V, Qi X. Evolution of Nonmalignant Portal Vein Thrombosis in Liver Cirrhosis: A Pictorial Review. Clin Transl Gastroenterol 2021; 12:e00409. [PMID: 34597281 PMCID: PMC8483868 DOI: 10.14309/ctg.0000000000000409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 08/22/2021] [Indexed: 02/07/2023] Open
Abstract
Portal vein thrombosis (PVT) is a common complication in liver cirrhosis, especially in advanced cirrhosis. It may be related to a higher risk of liver-related events and liver function deterioration. Imaging examinations can not only provide an accurate diagnosis of PVT, such as the extent of thrombus involvement and the degree of lumen occupied, but also identify the nature of thrombus (i.e., benign/malignant and acute/chronic). Evolution of PVT, mainly including development, recanalization, progression, stability, and recurrence, could also be assessed based on the imaging examinations. This article briefly reviews the pathophysiology, diagnosis, classification, and evolution of PVT with an emphasis on their computed tomography imaging features.
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Affiliation(s)
- Shixue Xu
- Liver Cirrhosis Study Group, Department of Gastroenterology, The General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, China
- Graduate School, China Medical University, Shenyang, China
| | - Xiaozhong Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, The General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, China
| | - Benqiang Yang
- Department of Radiology, The General Hospital of Northern Theater Command, Shenyang, China
| | - Fernando Gomes Romeiro
- Department of Internal Medicine, Botucatu Medical School, UNESP-Univ Estadual Paulista. Av. Prof. Mário Rubens Guimarães Montenegro, s/n Distrito de Rubião Jr, Botucatu, Brazil
| | - Massimo Primignani
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Division of Gastroenterology and Hepatology, Milan, Italy
| | - Nahum Méndez-Sánchez
- Liver Research Unit, Medica Sur Clinic and Foundation and Faculty of Medicine. National Autonomous University of Mexico, Mexico City, Mexico
| | - Eric M. Yoshida
- Division of Gastroenterology, University of British Columbia and Vancouver General Hospital, Vancouver, Canada
| | - Andrea Mancuso
- Medicina Interna 1, Azienda di Rilievo Nazionale ad Alta Specializzazione Civico, Di Cristina-Benfratelli, Palermo, Italy
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Carlos Noronha Ferreira
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria-Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Valerio De Stefano
- Dipartimento Di Diagnostica Per Immagini, Radioterapia Oncologica Ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, The General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, China
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15
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Hayakawa M, Sakata A, Hayakawa H, Matsumoto H, Hiramoto T, Kashiwakura Y, Baatartsogt N, Fukushima N, Sakata Y, Suzuki-Inoue K, Ohmori T. Characterization and visualization of murine coagulation factor VIII-producing cells in vivo. Sci Rep 2021; 11:14824. [PMID: 34290295 PMCID: PMC8295325 DOI: 10.1038/s41598-021-94307-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/09/2021] [Indexed: 11/22/2022] Open
Abstract
Coagulation factors are produced from hepatocytes, whereas production of coagulation factor VIII (FVIII) from primary tissues and cell species is still controversial. Here, we tried to characterize primary FVIII-producing organ and cell species using genetically engineered mice, in which enhanced green fluorescent protein (EGFP) was expressed instead of the F8 gene. EGFP-positive FVIII-producing cells existed only in thin sinusoidal layer of the liver and characterized as CD31high, CD146high, and lymphatic vascular endothelial hyaluronan receptor 1 (Lyve1)+. EGFP-positive cells can be clearly distinguished from lymphatic endothelial cells in the expression profile of the podoplanin− and C-type lectin-like receptor-2 (CLEC-2)+. In embryogenesis, EGFP-positive cells began to emerge at E14.5 and subsequently increased according to liver maturation. Furthermore, plasma FVIII could be abolished by crossing F8 conditional deficient mice with Lyve1-Cre mice. In conclusion, in mice, FVIII is only produced from endothelial cells exhibiting CD31high, CD146high, Lyve1+, CLEC-2+, and podoplanin− in liver sinusoidal endothelial cells.
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Affiliation(s)
- Morisada Hayakawa
- Department of Biochemistry, School of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan. .,Center for Gene Therapy Research, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan.
| | - Asuka Sakata
- Center for Molecular Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Hiroko Hayakawa
- Department of Biochemistry, School of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Hikari Matsumoto
- Department of Biochemistry, School of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Takafumi Hiramoto
- Department of Biochemistry, School of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Yuji Kashiwakura
- Department of Biochemistry, School of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Nemekhbayar Baatartsogt
- Department of Biochemistry, School of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Noriyoshi Fukushima
- Department of Pathology, School of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Yoichi Sakata
- Department of Biochemistry, School of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Katsue Suzuki-Inoue
- Department of Clinical and Laboratory Medicine, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 409-3898, Japan
| | - Tsukasa Ohmori
- Department of Biochemistry, School of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan. .,Center for Gene Therapy Research, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan.
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16
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McMurry HS, Jou J, Shatzel J. The hemostatic and thrombotic complications of liver disease. Eur J Haematol 2021; 107:383-392. [PMID: 34258797 DOI: 10.1111/ejh.13688] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 12/19/2022]
Abstract
Hepatic cirrhosis leads to numerous hematologic derangements resulting in a complex and tenuously rebalanced hemostatic milieu. The utility of common hematologic tests including the INR and aPTT in assessing hemostatic and thrombotic risk in patients with cirrhosis is limited, and consensus on transfusion thresholds and proper management of thrombotic complications continues to evolve. This review summarizes the pathophysiology of key derangements of hemostasis including those of platelets, von Willebrand factor, pro- and anticoagulation factors, and fibrin. Additionally, the pathogenesis, consequences, optimal management, and prevention of major thrombotic and bleeding complications in cirrhosis arte discussed.
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Affiliation(s)
- Hannah Stowe McMurry
- Divison of Internal Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Janice Jou
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, OR, USA
| | - Joseph Shatzel
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, USA.,Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
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17
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Groeneveld DJ, Poole LG, Luyendyk JP. Targeting von Willebrand factor in liver diseases: A novel therapeutic strategy? J Thromb Haemost 2021; 19:1390-1408. [PMID: 33774926 PMCID: PMC8582603 DOI: 10.1111/jth.15312] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/08/2021] [Accepted: 03/22/2021] [Indexed: 12/11/2022]
Abstract
Acute and chronic liver disease are associated with substantial alterations in the hemostatic system. Evidence from both experimental and clinical studies suggests that anticoagulants slow the progression of liver disease. Efficacy of those anticoagulant drugs is, in part, attributed to a reduction of microthrombi formation within the liver. Although anticoagulant drugs show promising results, bleeding risk associated with these drugs is an obvious drawback, particularly in patients with a complex coagulopathy driven by decreased liver function. Identifying therapies that reduce intrahepatic thrombosis with minimal bleeding risk would significantly advance the field. Among the hemostatic alterations observed in patients are substantially increased levels of the platelet-adhesive protein von Willebrand factor (VWF). In contrast, levels of A Disintegrin and Metalloproteinase with Thrombospondin motifs, the enzyme that regulates VWF activity, are significantly reduced in patients with liver disease. Highly elevated VWF levels are proposed to accelerate intrahepatic thrombus formation and thus be a driver of disease progression. Strong clinical evidence suggesting a link between liver disease and changes in VWF is now being matched by emerging mechanistic data showing a detrimental role for VWF in the progression of liver disease. This review focuses on clinical and experimental evidence supporting a connection between VWF function and the progression of acute and chronic liver diseases. Furthermore, with the recent anticipated approval of several novel therapies targeting VWF, we discuss potential strategies and benefits of targeting VWF as an innovative therapy for patients with liver disease.
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Affiliation(s)
- Dafna J Groeneveld
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, MI, USA
| | - Lauren G Poole
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, MI, USA
| | - James P Luyendyk
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, MI, USA
- Institute for Integrative Toxicology, Michigan State University, East Lansing, MI, USA
- Department of Pharmacology & Toxicology, Michigan State University, East Lansing, MI, USA
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18
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Pradhan-Sundd T, Gudapati S, Kaminski TW, Ragni MV. Exploring the Complex Role of Coagulation Factor VIII in Chronic Liver Disease. Cell Mol Gastroenterol Hepatol 2021; 12:1061-1072. [PMID: 33705963 PMCID: PMC8342958 DOI: 10.1016/j.jcmgh.2021.02.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/25/2021] [Accepted: 02/25/2021] [Indexed: 12/22/2022]
Abstract
Chronic liver disease is one of the leading causes of death in the United States. Coagulopathy is often a sequela of chronic liver disease, however, the role and regulation of coagulation components in chronic liver injury remain poorly understood. Clinical and experimental evidence indicate that misexpression of the procoagulant factor VIII (FVIII) is associated with chronic liver disease. Nevertheless, the molecular mechanism of FVIII-induced chronic liver injury progression remains unknown. This review provides evidence supporting a pathologic role for FVIII in the development of chronic liver disease using both experimental and clinical models.
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Affiliation(s)
- Tirthadipa Pradhan-Sundd
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, Pittsburgh, Pennsylvania; Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Shweta Gudapati
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, Pittsburgh, Pennsylvania
| | - Tomasz W Kaminski
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, Pittsburgh, Pennsylvania
| | - Margaret V Ragni
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, Pittsburgh, Pennsylvania; Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Hemophilia Center of Western Pennsylvania, Pittsburgh, Pennsylvania
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19
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Kim A, Niu B, Woreta T, Chen PH. Clinical Considerations of Coagulopathy in Acute Liver Failure. J Clin Transl Hepatol 2020; 8:407-413. [PMID: 33447524 PMCID: PMC7782116 DOI: 10.14218/jcth.2020.00058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 08/08/2020] [Accepted: 08/31/2020] [Indexed: 12/12/2022] Open
Abstract
Acute liver failure (ALF) is the rapid onset of severe liver dysfunction, defined by the presence of hepatic encephalopathy and impaired synthetic function (international normalized ratio of ≥1.5) in the absence of underlying liver disease. The elevated international normalized ratio value in ALF is often misinterpreted as an increased hemorrhagic tendency, which can lead to inappropriate, prophylactic transfusions of blood products. However, global assessments of coagulopathy via viscoelastic tests or thrombin generation assay suggest a reestablished hemostatic, or even hypercoagulable, status in patients with ALF. Although the current versions of global assays are not perfect, they can provide more nuanced insights into the hemostatic system in ALF than the conventional measures of coagulopathy.
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Affiliation(s)
- Ahyoung Kim
- Division of Gastroenterology & Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bolin Niu
- Division of Gastroenterology & Hepatology, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Tinsay Woreta
- Division of Gastroenterology & Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Po-Hung Chen
- Division of Gastroenterology & Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Correspondence to: Po-Hung Chen, Division of Gastroenterology & Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite 429, Baltimore, MD 21287, USA. Tel: +1-410-614-3530, Fax: +1-410-550-7861, E-mail:
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20
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Spinosa M, Stine JG. Nonalcoholic Fatty Liver Disease-Evidence for a Thrombophilic State? Curr Pharm Des 2020; 26:1036-1044. [PMID: 32003679 DOI: 10.2174/1381612826666200131101553] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 12/16/2019] [Indexed: 02/06/2023]
Abstract
Nonalcoholic fatty liver disease is the leading cause of liver disease worldwide. It has expansive extrahepatic morbidity and mortality including increased rates of both cardiovascular disease and venous thromboembolism. Derangements in primary, secondary and tertiary hemostasis are found in nonalcoholic fatty liver disease independent of those ascribed to end-stage liver disease. The abnormalities across all stages of hemostasis explain the increased rates of clinically relevant thrombotic events, including pulmonary embolism, deep vein thrombosis and portal vein thrombosis, which on an epidemiologic basis appears to be independent of obesity and other traditional venous thromboembolic risk factors. However, given the complex interaction between obesity, body composition and nonalcoholic fatty liver disease and the potential for exercise to benefit all three, more research is needed to further define the role of each in contributing to the prohemostatic state of nonalcoholic fatty liver disease in order to improve patient oriented outcomes.
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Affiliation(s)
- Margaret Spinosa
- Department of Medicine, Pennsylvania State University Milton S. Hershey Medical Center, PA 17033, United States
| | - Jonathan G Stine
- Division of Gastroenterology & Hepatology, Department of Medicine, Pennsylvania State University Milton S. Hershey Medical Center, United States.,Department of Public Health Sciences, Pennsylvania State University Milton S. Hershey Medical Center, PA 17033, United States
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21
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Chang JC. Disseminated intravascular coagulation: new identity as endotheliopathy-associated vascular microthrombotic disease based on in vivo hemostasis and endothelial molecular pathogenesis. Thromb J 2020; 18:25. [PMID: 33061857 PMCID: PMC7553785 DOI: 10.1186/s12959-020-00231-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/27/2020] [Indexed: 12/12/2022] Open
Abstract
Disseminated intravascular coagulation (DIC) can be correctly redefined as disseminated intravascular microthrombosis based on "two-path unifying theory" of in vivo hemostasis. "DIC" is a form of vascular microthrombotic disease characterized by "microthrombi" composed of platelets and unusually large von Willebrand factor multimers (ULVWF). Microthrombotic disease includes not only "DIC", but also microthrombosis occurring in thrombotic thrombocytopenic purpura (TTP), TTP-like syndrome, and focal, multifocal and localized microthrombosis. Being a hemostatic disease, microthrombotic disease occurs as a result of lone activation of ULVWF path via partial in vivo hemostasis. In endothelial injury associated with critical illnesses such as sepsis, the vascular damage is limited to the endothelial cell and activates ULVWF path. In contrast, in intravascular traumatic injury, the local damage may extend from the endothelial cell to subendothelial tissue and sometimes beyond, and activates both ULVWF and tissue factor (TF) paths. When endotheliopathy triggers exocytosis of ULVWF and recruits platelets, ULVWF path is activated and promotes microthrombogenesis to produce microthrombi composed of microthrombi strings, but when localized vascular damage causes endothelial and subendothelial tissue damage, both ULVWF and TF paths are activated and promote macrothrombogenesis to produce macrothrombus made of complete "blood clots". Currently, "DIC" concept is ascribed to activated TF path leading to fibrin clots. Instead, it should be correctly redefined as microthrombosis caused by activation of ULVWF path, leading to endotheliopathy-associated microthrombosis. The correct term for acute "DIC" is disseminated microthrombosis-associated hepatic coagulopathy, and that for chronic "DIC" is disseminated microthrombosis without hepatic coagulopathy. TTP-like syndrome is hematologic phenotype of endotheliopathy-associated microthrombosis. This correct concept of "DIC" is identified from novel theory of "in vivo hemostasis", which now can solve every mystery associated with "DIC" and other associated thrombotic disorders. Thus, sepsis-associated coagulopathy is not "DIC", but is endotheliopathy-associated vascular microthrombotic disease.
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Affiliation(s)
- Jae C. Chang
- Department of Medicine, University of California School of Medicine, Irvine, CA 92603 USA
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22
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Becatti M, Mannucci A, Argento FR, Gitto S, Vizzutti F, Marra F, Taddei N, Fiorillo C, Laffi G. Super-Resolution Microscopy Reveals an Altered Fibrin Network in Cirrhosis: The Key Role of Oxidative Stress in Fibrinogen Structural Modifications. Antioxidants (Basel) 2020; 9:antiox9080737. [PMID: 32806658 PMCID: PMC7464401 DOI: 10.3390/antiox9080737] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/07/2020] [Accepted: 08/10/2020] [Indexed: 02/06/2023] Open
Abstract
Cirrhotic patients show a reduced synthesis of both pro- and anti-coagulant factors. Recent reports indicate that they are characterized by a higher risk of thrombotic rather than hemorrhagic complications, but the mechanisms conferring this risk are not fully elucidated. Oxidative-mediated fibrinogen modifications may explain, at least in part, a prothrombotic profile. The aim of the present pilot study was to investigate the alterations in fibrinogen structure and function in patients with cirrhosis of various severity and to correlate these findings with the mechanisms of thrombus formation. We assessed in plasma specific oxidative stress markers and measured oxidative modifications, functional and structural parameters in purified fibrinogen fractions obtained from cirrhotic patients and control subjects. We enrolled 15 cirrhotic patients (5 patients belonging to each of the three Child-Turcotte-Pugh classes) and 20 age- and sex-matched healthy controls. Plasma redox status, fibrinogen oxidative modifications, thrombin-catalyzed fibrin polymerization and fibrin resistance to plasmin-induced lysis were significantly altered in cirrhotic patients and were associated to disease severity. Importantly, clot structure obtained by stimulated emission depletion (STED) super-resolution microscopy indicated modifications in fiber diameter and in clot porosity in cirrhotic patients. Fibrin fiber diameter significantly decreased in cirrhotic patients when compared to controls, and this difference became more marked with disease progression. In parallel, fibrin pore size progressively decreased along with disease severity. In cirrhotic patients, fibrinogen clot analysis and oxidative-dependent changes reveal novel structural and functional fibrinogen modifications which may favor thrombotic complications in cirrhosis.
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Affiliation(s)
- Matteo Becatti
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Viale Morgagni 50, 50134 Florence, Italy; (A.M.); (F.R.A.); (N.T.); (C.F.)
- Correspondence: ; Tel.: +39-0552751261
| | - Amanda Mannucci
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Viale Morgagni 50, 50134 Florence, Italy; (A.M.); (F.R.A.); (N.T.); (C.F.)
| | - Flavia Rita Argento
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Viale Morgagni 50, 50134 Florence, Italy; (A.M.); (F.R.A.); (N.T.); (C.F.)
| | - Stefano Gitto
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134 Florence, Italy; (S.G.); (F.V.); (F.M.); (G.L.)
| | - Francesco Vizzutti
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134 Florence, Italy; (S.G.); (F.V.); (F.M.); (G.L.)
| | - Fabio Marra
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134 Florence, Italy; (S.G.); (F.V.); (F.M.); (G.L.)
| | - Niccolò Taddei
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Viale Morgagni 50, 50134 Florence, Italy; (A.M.); (F.R.A.); (N.T.); (C.F.)
| | - Claudia Fiorillo
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Viale Morgagni 50, 50134 Florence, Italy; (A.M.); (F.R.A.); (N.T.); (C.F.)
| | - Giacomo Laffi
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134 Florence, Italy; (S.G.); (F.V.); (F.M.); (G.L.)
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23
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Morrow GB, Beavis J, Harper S, Baker P, Desborough MJR, Curry N, Stanworth SJ, Laffan MA. Coagulation status of critically ill patients with and without liver disease assessed using a novel thrombin generation analyzer. J Thromb Haemost 2020; 18:1576-1585. [PMID: 32196929 DOI: 10.1111/jth.14802] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/13/2020] [Accepted: 03/16/2020] [Indexed: 12/11/2022]
Abstract
The liver synthesizes the majority of pro- and anti-coagulant and fibrinolytic proteins, and during liver dysfunction synthesis of these proteins is reduced. The end point of conventional hemostatic tests, such as the prothrombin time (PT), occurs when only 5% of thrombin generation (TG) has taken place and is not sensitive to the effects of natural anti-coagulants. The aim of this study was to determine whether TG in the presence of thrombomodulin (TM) provides more useful information about coagulation potential, in comparison to the PT. Analysis was performed on ST Genesia, a novel TG analyzer from Diagnostica Stago. TG was measured using STG-Thromboscreen, a reagent containing an intermediate concentration of human tissue factor (TF) ± rabbit TM to account for anti-coagulant protein C (PC) activity. Platelet-poor plasma (PPP) samples were from the Intensive Care Study of Coagulopathy-2 (ISOC-2), which recruited patients admitted to critical care with a prolonged PT (3 seconds above the reference range). Despite a prolonged PT, 48.0% and 60.7% of patients in the liver and non-liver groups had TG parameters within the normal range. Addition of TM reduced TG by 34.5% and 41.8% in the liver and non-liver groups, respectively. Interestingly, fresh frozen plasma (FFP) transfusion had no impact on TG. Measurement of TG with addition of TM provides a more informative assessment of coagulation capacity and indicates that hemostasis is balanced in patients with liver disease during critical illness, despite conventional tests suggesting that bleeding risk is increased.
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Affiliation(s)
- Gael B Morrow
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - James Beavis
- Oxford Haemophilia and Thrombosis Centre, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sarah Harper
- Oxford Haemophilia and Thrombosis Centre, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Peter Baker
- Oxford Haemophilia and Thrombosis Centre, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Nicola Curry
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Oxford Haemophilia and Thrombosis Centre, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Simon J Stanworth
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Transfusion Medicine, NHS Blood and Transplant, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mike A Laffan
- Oxford Haemophilia and Thrombosis Centre, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Centre for Haematology, Imperial College London, London, UK
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24
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Khoury T, Massarwa M, Hazou W, Daher S, Hakimian D, Benson AA, Ashqar T, Mahamid M, Yaari S. Acute Portal Vein Thrombosis Predicts Concomitant Diagnosis of Hepatocellular Carcinoma in Cirrhotic Patients. J Gastrointest Cancer 2020; 50:759-762. [PMID: 30043228 DOI: 10.1007/s12029-018-0149-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE Portal vein thrombosis (PVT) is a common condition in cirrhotic patients and mostly attributed to portal hypertension. The objective of our study was to examine the association of PVT with hepatocellular carcinoma (HCC) in cirrhotic patients. METHODS A retrospective study was performed to identify cirrhotic patients with thrombosis of the portal system. Clinical and laboratory characteristics were collected and analyzed. RESULTS Thirty-nine patients were identified. Twenty-four out of 39 patients with PVT did not develop HCC (group A) after follow-up time of 38.5 months from the diagnosis of PVT. Eight patients (20.5%) were diagnosed with HCC within two weeks following diagnosis of PVT (group B). Seven patients (17.9%) were diagnosed with tumor thrombus (group C) at time of PVT diagnosis. The average age was 53.5, 66.5, and 69 years for groups A, B, and C respectively. Most patients (75 and 87.5% for groups B and C respectively) diagnosed with PVT and HCC were males. The most common cause of cirrhosis in groups B and C was chronic hepatitis B virus infection (HBV) in 62.5% and 50% respectively. The most common clinical presentation of PVT in group A was abdominal pain in 55.5% compared to new/worsening ascites in 43% and 37.5% for groups B and C respectively. The platelet count in groups B and C was higher as compared to that in group A (126 and 125 vs. 107 thousand, P = NS). CONCLUSION In 38.4% of cases, new diagnosis of PVT was associated with concomitant diagnosis of HCC. Identifiable risk factors were chronic HBV infection and higher platelet count.
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Affiliation(s)
- Tawfik Khoury
- Institute of Gastroenterology and Liver Diseases, Department of Internal Medicine, Hebrew University-Hadassah Medical Center, P.O.B. 12000, IL-91120, Jerusalem, Israel. .,The Liver Unit, Institute of Gastroenterology and Liver Diseases, Division of Internal Medicine, Hebrew University-Hadassah Medical Center, P.O.B. 12000, IL-91120, Jerusalem, Israel.
| | - Muhammad Massarwa
- Institute of Gastroenterology and Liver Diseases, Department of Internal Medicine, Hebrew University-Hadassah Medical Center, P.O.B. 12000, IL-91120, Jerusalem, Israel.,The Liver Unit, Institute of Gastroenterology and Liver Diseases, Division of Internal Medicine, Hebrew University-Hadassah Medical Center, P.O.B. 12000, IL-91120, Jerusalem, Israel
| | - Wadi Hazou
- Institute of Gastroenterology and Liver Diseases, Department of Internal Medicine, Hebrew University-Hadassah Medical Center, P.O.B. 12000, IL-91120, Jerusalem, Israel.,The Liver Unit, Institute of Gastroenterology and Liver Diseases, Hebrew University-Hadassah Medical Center, P.O.B. 12000, IL-91120, Jerusalem, Israel
| | - Saleh Daher
- Institute of Gastroenterology and Liver Diseases, Department of Internal Medicine, Hebrew University-Hadassah Medical Center, P.O.B. 12000, IL-91120, Jerusalem, Israel.,The Liver Unit, Institute of Gastroenterology and Liver Diseases, Division of Internal Medicine, Hebrew University-Hadassah Medical Center, P.O.B. 12000, IL-91120, Jerusalem, Israel
| | - David Hakimian
- Institute of Gastroenterology and Liver Diseases, Department of Internal Medicine, Hebrew University-Hadassah Medical Center, P.O.B. 12000, IL-91120, Jerusalem, Israel.,The Liver Unit, Institute of Gastroenterology and Liver Diseases, Division of Internal Medicine, Hebrew University-Hadassah Medical Center, P.O.B. 12000, IL-91120, Jerusalem, Israel
| | - Ariel A Benson
- Institute of Gastroenterology and Liver Diseases, Department of Internal Medicine, Hebrew University-Hadassah Medical Center, P.O.B. 12000, IL-91120, Jerusalem, Israel.,Institute of Gastroenterology and Liver Diseases, Hebrew University-Hadassah Medical Center, P.O.B. 12000, IL-91120, Jerusalem, Israel
| | - Toni Ashqar
- Institute of Gastroenterology and Liver Diseases, Department of Internal Medicine, Hebrew University-Hadassah Medical Center, P.O.B. 12000, IL-91120, Jerusalem, Israel
| | - Mahmud Mahamid
- Gastroenterology and Endoscopy United, The Nazareth Hospital, EMMS, Nazareth, Israel
| | - Shaul Yaari
- Institute of Gastroenterology and Liver Diseases, Department of Internal Medicine, Hebrew University-Hadassah Medical Center, P.O.B. 12000, IL-91120, Jerusalem, Israel
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25
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Groeneveld D, Cline-Fedewa H, Baker KS, Williams KJ, Roth RA, Mittermeier K, Lisman T, Palumbo JS, Luyendyk JP. Von Willebrand factor delays liver repair after acetaminophen-induced acute liver injury in mice. J Hepatol 2020; 72:146-155. [PMID: 31606553 PMCID: PMC6941657 DOI: 10.1016/j.jhep.2019.09.030] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 09/05/2019] [Accepted: 09/08/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIM Acetaminophen (APAP)-induced acute liver failure is associated with substantial alterations in the hemostatic system. In mice, platelets accumulate in the liver after APAP overdose and appear to promote liver injury. Interestingly, patients with acute liver injury have highly elevated levels of the platelet-adhesive protein von Willebrand factor (VWF), but a mechanistic connection between VWF and progression of liver injury has not been established. We tested the hypothesis that VWF contributes directly to experimental APAP-induced acute liver injury. METHODS Wild-type mice and VWF-deficient (Vwf-/-) mice were given a hepatotoxic dose of APAP (300 mg/kg, i.p.) or vehicle (saline). VWF plasma levels were measured by ELISA, and liver necrosis or hepatocyte proliferation was measured by immunohistochemistry. Platelet and VWF deposition were measured by immunofluorescence. RESULTS In wild-type mice, VWF plasma levels, high molecular weight (HMW) VWF multimers, and VWF activity decreased 24 h after APAP challenge. These changes coupled to robust hepatic VWF and platelet deposition, although VWF deficiency had minimal effect on peak hepatic platelet accumulation or liver injury. VWF plasma levels were elevated 48 h after APAP challenge, but with relative reductions in HMW multimers and VWF activity. Whereas hepatic platelet aggregates persisted in livers of APAP-challenged wild-type mice, platelets were nearly absent in Vwf-/- mice 48 h after APAP challenge. The absence of platelet aggregates was linked to dramatically accelerated repair of the injured liver. Complementing observations in Vwf-/- mice, blocking VWF or the platelet integrin αIIbβ3 during development of injury significantly reduced hepatic platelet aggregation and accelerated liver repair in APAP-challenged wild-type mice. CONCLUSION These studies are the first to suggest a mechanistic link between VWF, hepatic platelet accumulation, and liver repair. Targeting VWF might provide a novel therapeutic approach to improve repair of the APAP-injured liver. LAY SUMMARY Patients with acute liver injury due to acetaminophen overdose have highly elevated levels of the platelet-adhesive protein von Willebrand factor. It is not known whether von Willebrand factor plays a direct role in the progression of acute liver injury. We discovered that von Willebrand factor delays repair of the acetaminophen-injured liver in mice and that targeting von Willebrand factor, even in mice with established liver injury, accelerates liver repair.
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Affiliation(s)
- Dafna Groeneveld
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, MI, USA
| | - Holly Cline-Fedewa
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, MI, USA
| | - Kevin S Baker
- Institute for Integrative Toxicology, Michigan State University, East Lansing, MI, USA; Department of Pharmacology & Toxicology, Michigan State University, East Lansing, MI, USA
| | - Kurt J Williams
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, MI, USA
| | - Robert A Roth
- Institute for Integrative Toxicology, Michigan State University, East Lansing, MI, USA; Department of Pharmacology & Toxicology, Michigan State University, East Lansing, MI, USA
| | - Karen Mittermeier
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ton Lisman
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Joseph S Palumbo
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - James P Luyendyk
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, MI, USA; Institute for Integrative Toxicology, Michigan State University, East Lansing, MI, USA; Department of Pharmacology & Toxicology, Michigan State University, East Lansing, MI, USA.
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26
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Batyrova AS, Vasilieva EM, Bakanov MI, Surkov AN. [Biomarkers of angiogenesis and endothelial dysfunction in children and adolescents with chronic viral hepatitis.]. Klin Lab Diagn 2019; 64:588-593. [PMID: 31742950 DOI: 10.18821/0869-2084-2019-64-10-588-593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 10/01/2019] [Indexed: 11/17/2022]
Abstract
At some works, it has been shown there are signs of damage and endothelium dysfunction in patients with chronic viral hepatitis (CVH) and liver cirrhosis of viral etiology the severity of these conditions depends on the severity of the pathological process. Evaluation of the role of angiogenic factors and endothelial dysfunction in persistent of CVH in children and adolescents. 35 patients were examined: of which 11 with chronic hepatitis B (CHB) and 24 with chronic hepatitis C (CHC). The reference group consisted of 120 practically healthy persons of the corresponding age and sex. VEGF-A, angiotensin (ANG), soluble receptors of VEGF-A (sVEGF-R1 и sVEGF-R2) and trombomodulin (TM) have been investigated in serum by enzyme immunoassay using special kits (BCM Diagnostics, USA). Other endothelial dysfunction markers as von Willebrand factor (vWf) was determined in blood plasma by immunoturbidimetry (Siemens, Germany), plasminogen (PLG) was investigated due to extended coagulation. In children with CVH, regardless of etiology, the concentration of VEGF-A was significantly lower, and sVEGF-R2, sVEGF-R1 and TM was higher than in children without liver disease (p <0.001, p <0.05, p <0.01, p <0.001, respectively). The concentration of TM and the level of PLG activity in patients with CHC were slightly higher than in CHB. Decreased level of VEGF-A and increased expression of its soluble receptors indicate enhanced inhibition of angiogenesis in CVH, which may indicate the pathogenetic role of this phenomenon in the development of liver damage in CHC.
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Affiliation(s)
- A S Batyrova
- FSAI «National Medical Research Center for Childrens Health» of the Ministry of Health of the Russian Federation, 119991, Moscow, Russia
| | - E M Vasilieva
- FSAI «National Medical Research Center for Childrens Health» of the Ministry of Health of the Russian Federation, 119991, Moscow, Russia
| | - M I Bakanov
- FSAI «National Medical Research Center for Childrens Health» of the Ministry of Health of the Russian Federation, 119991, Moscow, Russia
| | - A N Surkov
- FSAI «National Medical Research Center for Childrens Health» of the Ministry of Health of the Russian Federation, 119991, Moscow, Russia
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27
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Shahramian I, Tabrizian K, Delaramnasab M, Khosravi Bonjar A, Dehghani SM, Sargazi-Aval O, Bazi A. A Review on Clinical, Pathophysiological, and Diagnostic Hematological Features in Children With Liver Cirrhosis. INTERNATIONAL JOURNAL OF BASIC SCIENCE IN MEDICINE 2019. [DOI: 10.15171/ijbsm.2019.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Appropriate diagnostic and therapeutic measures for liver cirrhosis is critical, particularly in children. In the present review, a comprehensive approach was provided toward hematological parameters in pediatric liver cirrhosis. The literature search included MeSH terms "liver cirrhosis" and "hepatic cirrhosis" and databases such as PubMed, Web of Science, Scopus, and Google Scholar were searched up until December 2017. Hematologic changes in the liver cirrhosis mainly encompassed anemia and coagulopathies. In addition, bleeding diathesis was considered as the most clinical complication in these patients. In addition to reduced coagulation factors, hyperfibrinolysis is a common feature in childhood cirrhosis and may be an important contributor to the risk of bleeding. Based on the results, children with liver cirrhosis also demonstrated a procoagulant state at laboratory and clinical levels. This may be partly due to a reduction in coagulation inhibitors such as anti-thrombin, C1 inhibitor, and α1-antitrypsin in children with cirrhosis. The portal vein thrombosis and portal hypertension are considered as the most clinical presentations of the hypercoagulable state. Further, children with liver cirrhosis complicated with portal hypertension usually show leukopenia, anemia, and thrombocytopenia due to hypersplenism. Although the etiology of childhood and adult cirrhosis may be different, their hematological compilations and clinicopathological features are somehow similar.
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Affiliation(s)
- Iraj Shahramian
- Pediatric Digestive and Hepatic Diseases Research Center, Zabol University of Medical Sciences, Zabol, Iran
| | - Kaveh Tabrizian
- Department of Pharmacology, Zabol University of Medical Sciences, Zabol, Iran
| | - Mojtaba Delaramnasab
- Faculty of Allied Medical Sciences, Zabol University of Medical Sciences, Zabol, Iran
| | - Ali Khosravi Bonjar
- Faculty of Allied Medical Sciences, Zabol University of Medical Sciences, Zabol, Iran
| | - Seyed Mohsen Dehghani
- Shiraz Organ Transplantation Center, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Ali Bazi
- Faculty of Allied Medical Sciences, Zabol University of Medical Sciences, Zabol, Iran
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28
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Zou Z, Yan X, Li C, Li X, Ma X, Zhang C, Ju S, Tian J, Qi X. von Willebrand factor as a biomarker of clinically significant portal hypertension and severe portal hypertension: a systematic review and meta-analysis. BMJ Open 2019; 9:e025656. [PMID: 31473610 PMCID: PMC6720471 DOI: 10.1136/bmjopen-2018-025656] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE This meta-analysis was performed to investigate the correlation between von Willebrand factor (vWF) antigen and hepatic venous pressure gradient (HVPG) and to evaluate the diagnostic performance of vWF to detect clinically significant portal hypertension (CSPH) and severe portal hypertension (SPH). DESIGN Systematic review and meta-analysis. METHODS MEDLINE, EMBASE, Web of Science and the Cochrane Library were screened up to 5 April 2018. Studies related to the diagnostic performance of vWF to detect CSPH and/or SPH with HVPG as the reference standard were included. Study quality was assessed by using the Quality Assessment of Diagnostic Accuracy Studies scale. Two authors independently used a standardised form to extract data. OUTCOMES The primary outcome was the correlation coefficient between vWF and HVPG. The secondary outcome was the diagnostic performance of vWF to detect CSPH or SPH. RESULTS A total of six articles involving 994 patients were included in this study. Five of the included articles were used to stratify the results for the correlation coefficient, three for the diagnostic performance of CSPH and two for SPH. The pooled correlation coefficient based on the random effects model was 0.54 (95% CI 0.35 to 0.69), thus suggesting a moderate correlation between vWF and HVPG. The pooled sensitivity, specificity and area under the curve of vWF for CSPH detection were 82% (95% CI 78 to 86), 76% (95% CI 68 to 83) and 0.87 (95% CI 0.80 to 0.94), respectively. Regarding the ability of vWF to detect SPH, the pooled sensitivity and specificity were 86% (95% CI 80 to 90) and 75% (95% CI 66 to 83), respectively. These results supported the satisfactory diagnostic performance of vWF for CSPH and SPH detection. CONCLUSIONS vWF, as a novel biomarker, has a moderate correlation with HVPG and shows a satisfactory performance for the diagnosis of CSPH and SPH in patients with cirrhosis.
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Affiliation(s)
- Ziyuan Zou
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
- The First School of Clinical Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xinwen Yan
- The First School of Clinical Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Cheng Li
- Guangdong Traditional Medical and Sports Injury Rehabilitation Research Institute, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Xiaofeng Li
- Second Department of General Surgery, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Xiaofen Ma
- Department of Medical Imaging, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Chunqing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Shenghong Ju
- Department of Radiology, Zhongda Hospital, Medical School of Southeast University, Nanjing, China
| | - Junzhang Tian
- Department of Medical Imaging, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Xiaolong Qi
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
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29
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Tsuchiya S, Matsumoto Y, Doman T, Fujiya T, Sugisawa J, Suda A, Sato K, Ikeda S, Shindo T, Kikuchi Y, Hao K, Takahashi J, Hatta W, Koike T, Masamune A, Saiki Y, Horiuchi H, Shimokawa H. Disappearance of Angiodysplasia Following Transcatheter Aortic Valve Implantation in a Patient with Heyde's Syndrome: A Case Report and Review of the Literature. J Atheroscler Thromb 2019; 27:271-277. [PMID: 31378751 PMCID: PMC7113142 DOI: 10.5551/jat.49239] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
An 83-year-old woman with severe aortic stenosis was admitted to our hospital due to heart failure with refractory anemia requiring blood transfusions. She had repetitive bleeding episodes from endoscopically proven angiodysplasia in the stomach. Moreover, she repeatedly underwent endoscopic argon plasma coagulation for hemostasis. Importantly, she had a deficiency of the high-molecular-weight (HMW) multimers of von Willebrand factor (VWF), and she was diagnosed with Heyde's syndrome.After she underwent transcatheter aortic valve implantation (TAVI), aortic valve area and mean left ventricular aorta pressure gradient improved. Notably, endoscopy showed cessation of bleeding at 10 days after TAVI and the disappearance of angiodysplasia at 4 months after TAVI. Even at 2 years after TAVI, follow-up endoscopy showed remaining free of angiodysplasia in the stomach. She experienced no episodes of anemia since TAVI procedure. Additionally, analysis of HMW multimers demonstrated immediate and lasting recovery after TAVI.Recovery of HMW multimers of VWF with cessation of gastrointestinal bleeding following aortic valve replacement has been previously reported in a patient diagnosed with Heyde's syndrome. To the best our knowledge, this is the first case to demonstrate that angiodysplasia disappears after TAVI for a long term with endoscopic images in a patient with Heyde's syndrome. Here, we summarized case reports of patients with Heyde's syndrome that required aortic valve intervention. Cessation of gastrointestinal bleeding and anemia after aortic valve intervention for severe aortic stenosis may be attributed not only to recovery of HMW multimers of VWF but also to the disappearance of angiodysplasia.
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Affiliation(s)
- Satoshi Tsuchiya
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Yasuharu Matsumoto
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Tsuyoshi Doman
- Department of Molecular and Cellular Biology, Institute of Development, Aging, and Cancer, Tohoku University
| | - Taku Fujiya
- Department of Gastroenterology, Tohoku University Graduate School of Medicine
| | - Jun Sugisawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Akira Suda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Koichi Sato
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Shohei Ikeda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Tomohiko Shindo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Yoku Kikuchi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Kiyotaka Hao
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Waku Hatta
- Department of Gastroenterology, Tohoku University Graduate School of Medicine
| | - Tomoyuki Koike
- Department of Gastroenterology, Tohoku University Graduate School of Medicine
| | - Atsushi Masamune
- Department of Gastroenterology, Tohoku University Graduate School of Medicine
| | - Yoshikatsu Saiki
- Department of Cardiovascular Surgery, Tohoku University Graduate school of Medicine
| | - Hisanori Horiuchi
- Department of Molecular and Cellular Biology, Institute of Development, Aging, and Cancer, Tohoku University
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
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Puchkova LV, Broggini M, Polishchuk EV, Ilyechova EY, Polishchuk RS. Silver Ions as a Tool for Understanding Different Aspects of Copper Metabolism. Nutrients 2019; 11:E1364. [PMID: 31213024 PMCID: PMC6627586 DOI: 10.3390/nu11061364] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/08/2019] [Accepted: 06/12/2019] [Indexed: 12/11/2022] Open
Abstract
In humans, copper is an important micronutrient because it is a cofactor of ubiquitous and brain-specific cuproenzymes, as well as a secondary messenger. Failure of the mechanisms supporting copper balance leads to the development of neurodegenerative, oncological, and other severe disorders, whose treatment requires a detailed understanding of copper metabolism. In the body, bioavailable copper exists in two stable oxidation states, Cu(I) and Cu(II), both of which are highly toxic. The toxicity of copper ions is usually overcome by coordinating them with a wide range of ligands. These include the active cuproenzyme centers, copper-binding protein motifs to ensure the safe delivery of copper to its physiological location, and participants in the Cu(I) ↔ Cu(II) redox cycle, in which cellular copper is stored. The use of modern experimental approaches has allowed the overall picture of copper turnover in the cells and the organism to be clarified. However, many aspects of this process remain poorly understood. Some of them can be found out using abiogenic silver ions (Ag(I)), which are isoelectronic to Cu(I). This review covers the physicochemical principles of the ability of Ag(I) to substitute for copper ions in transport proteins and cuproenzyme active sites, the effectiveness of using Ag(I) to study copper routes in the cells and the body, and the limitations associated with Ag(I) remaining stable in only one oxidation state. The use of Ag(I) to restrict copper transport to tumors and the consequences of large-scale use of silver nanoparticles for human health are also discussed.
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Affiliation(s)
- Ludmila V Puchkova
- Laboratory of Trace elements metabolism, ITMO University, Kronverksky av., 49, St.-Petersburg 197101, Russia.
- Department of Molecular Genetics, Research Institute of Experimental Medicine, Acad. Pavlov str., 12, St.-Petersburg 197376, Russia.
- Department of Biophysics, Peter the Great St. Petersburg Polytechnic University, Politekhnicheskaya str., 29, St.-Petersburg 195251, Russia.
| | - Massimo Broggini
- Laboratory of Trace elements metabolism, ITMO University, Kronverksky av., 49, St.-Petersburg 197101, Russia.
- Laboratory of molecular pharmacology, Istituto di Ricerche Farmacologiche "Mario Negri" IRCCS, Via La Masa, 19, Milan 20156, Italy.
| | - Elena V Polishchuk
- Laboratory of Trace elements metabolism, ITMO University, Kronverksky av., 49, St.-Petersburg 197101, Russia.
- Telethon Institute of Genetics and Medicine, Via Campi Flegrei 34, Pozzuoli (NA) 80078, Italy.
| | - Ekaterina Y Ilyechova
- Laboratory of Trace elements metabolism, ITMO University, Kronverksky av., 49, St.-Petersburg 197101, Russia.
| | - Roman S Polishchuk
- Telethon Institute of Genetics and Medicine, Via Campi Flegrei 34, Pozzuoli (NA) 80078, Italy.
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Zhuang M, Xin G, Wei Z, Li S, Xing Z, Ji C, Du J, Niu H, Huang W. Dihydrodiosgenin inhibits endothelial cell-derived factor VIII and platelet-mediated hepatocellular carcinoma metastasis. Cancer Manag Res 2019; 11:4871-4882. [PMID: 31239763 PMCID: PMC6554527 DOI: 10.2147/cmar.s202225] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 04/20/2019] [Indexed: 02/05/2023] Open
Abstract
Background: Our previous studies have demonstrated that diosgenin and diosgenin derivatives exhibit excellent antithrombotic activity via regulating platelet function and coagulation factor level. Platelets and blood coagulation system are highly associated with tumor hematogenous metastasis. Therefore, the purpose of this study was to evaluate whether dihydrodiosgenin (dydio) mediated-platelet inhibition or coagulation factor level modulation is involved in hepatocellular carcinoma cell (HCC) metastasis. Methods: Cell viability was examined by MTT and colony formation assays. Platelet aggregation text and morphology were used to assess dydio's role on tumor cell-induced platelet activation (TCIPA). Scratch assay, adhesion assay and Western blot were used to evaluate dydio's role on platelet-mediated metastasis. Western blot and fluorescence detection were performed to clarify dydio's role on endothelial cell (EC) function. The mice lung metastasis model was constructed to investigated dydio's function on coagulation factor and platelet-mediated metastasis. Results: This study found that pretreatment with dydio caused a significant inhibition of TCIPA. Platelets exposed to dydio significantly inhibited their adhesion to tumor cells, meanwhile, releasates of platelets that pretreated with dydio led to diminished cancer cell proliferation and migration along with the increase of epithelial markers E-cadherin and loss of mesenchymal phenotype. Additionally, ECs pretreated with dydio suppressed factor VIII (FVIII) level which in turn restrained the activation of platelets and the adhesion of cancer cells or platelets to ECs. Interestingly, our study demonstrated that FVIII could promote HCC proliferation. In vivo study revealed that mice intragastrical (i.g.) administration with dydio significantly inhibited the lung metastasis of hepal-6 cells which is highly correlated with the altered platelet function and coagulation level. Conclusion: Taken together, these results demonstrated that dydio altered platelet function and coagulation FVIII level, resulting in decreased metastatic potential of HCC. Thus, our study reveals that dydio exerts novel mechanisms of antitumor action beside its direct antitumor activity.
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Affiliation(s)
- Manjiao Zhuang
- Laboratory of Ethnopharmacology, West China School of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Guang Xin
- Laboratory of Ethnopharmacology, West China School of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Zeliang Wei
- Laboratory of Ethnopharmacology, West China School of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Shiyi Li
- Laboratory of Ethnopharmacology, West China School of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Zhihua Xing
- Laboratory of Ethnopharmacology, West China School of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Chengjie Ji
- Laboratory of Ethnopharmacology, West China School of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
- Department of Laboratory Medicine, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, Sichuan, People's Republic of China
| | - Junrong Du
- Laboratory of Ethnopharmacology, West China School of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Hai Niu
- Laboratory of Ethnopharmacology, West China School of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
- College of Mathematics, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Wen Huang
- Laboratory of Ethnopharmacology, West China School of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
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Abstract
PURPOSE OF REVIEW This article aims to review the latest literature on prophylactic and therapeutic anticoagulation and the safety profile of anticoagulants in patients with cirrhosis. RECENT FINDINGS The understanding of hematological hemostasis is cirrhotic patients has changed drastically in recent years. Although in the past, cirrhotic patients were often considered to be 'auto-anticoagulated' and at higher risk of bleeding, recent studies have demonstrated that there may be a rebalance in procoagulation and anticoagulation factors in patients with cirrhosis. This, and clinical experience, suggest that cirrhotic patients are at risk of development of venous thrombosis, pulmonary embolism and ischemic strokes and as such, the best management approaches in these patients remains controversial. The bulk of the data suggest that patients with cirrhosis who are at risk for thrombotic or embolic complications should be anticoagulated. However, it is imperative that they be closely monitored. SUMMARY The medical literature on anticoagulation in patients with liver cirrhosis is conflicting and limited to small sample observational studies. However, most studies suggest that in patients with early stages of liver cirrhosis and no history of varices, anticoagulation appears to be well tolerated.
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Rogalski P, Rogalska-Plonska M, Wroblewski E, Kostecka-Roslen I, Dabrowska M, Swidnicka-Siergiejko A, Wasielica-Berger J, Cydzik M, Hirnle T, Flisiak R, Dabrowski A. Laboratory evidence for hypercoagulability in cirrhotic patients with history of variceal bleeding. Thromb Res 2019; 178:41-46. [PMID: 30959281 DOI: 10.1016/j.thromres.2019.03.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 03/01/2019] [Accepted: 03/31/2019] [Indexed: 12/18/2022]
Abstract
AIM We aimed to assess the relationship between procoagulant imbalance and the occurrence of variceal bleeding in patients with liver cirrhosis. METHODS We compared the results of chromogenic assay for the functional evaluation of the Protein C anticoagulant pathway (ThromboPath®), thromboelastometry and the levels of factor VII, VIII, and antithrombin in two groups of cirrhotic patients: Group 1 (n = 25) - patients with moderate or large esophageal or gastric varices, who had never experienced acute gastrointestinal bleeding and Group 2 (n = 24) - patients with a history of variceal bleeding. RESULTS Despite the differences in MELD score and the results of basic laboratory tests indicating more severe cirrhosis and suggesting a greater risk of bleeding in Group 2, the results of thromboelastometry did not differ significantly between groups. The ThromboPath® test results [ThP B: 67.8 ± 13.4 versus 59.09 ± 12.4%, p = 0.023] and factor VII level [69.04 ± 24.16 vs 53.54 ± 25.06, p = 0.032] confirmed greater plasma procoagulant activity in Group 1 compared to Group 2. However, there were no statistically significant differences in thrombin generation after activation of the protein C. Plasma of patients in Group 2 was more resistant to anticoagulation with protein C compared to Group 1 (PICI%: 65.58 ± 7.24 versus 55.64 ± 13.07%, p = 0.001). CONCLUSION The results of our study confirm the lack of influence of coagulation disorders on the occurrence of variceal bleeding. Moreover, the results of ThromboPath® assay indicate hypercoagulability in patients with a history of variceal bleeding and more severe liver cirrhosis, compared to patients who have never bled.
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Affiliation(s)
- Pawel Rogalski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej - Curie 24a, 15-276 Bialystok, Poland.
| | - Magdalena Rogalska-Plonska
- Department of Infectious Diseases and Hepatology, Medical University of Bialystok, M. Sklodowskiej - Curie 24a, 15-276 Bialystok, Poland
| | - Eugeniusz Wroblewski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej - Curie 24a, 15-276 Bialystok, Poland
| | - Ines Kostecka-Roslen
- Department of Hematological Diagnostics, Medical University of Bialystok, M. Sklodowskiej - Curie 24a, 15-276 Bialystok, Poland
| | - Milena Dabrowska
- Department of Hematological Diagnostics, Medical University of Bialystok, M. Sklodowskiej - Curie 24a, 15-276 Bialystok, Poland
| | - Agnieszka Swidnicka-Siergiejko
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej - Curie 24a, 15-276 Bialystok, Poland
| | - Justyna Wasielica-Berger
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej - Curie 24a, 15-276 Bialystok, Poland
| | - Mariusz Cydzik
- Department of Cardiosurgery, Medical University of Bialystok, M. Sklodowskiej - Curie 24a, 15-276 Bialystok, Poland
| | - Tomasz Hirnle
- Department of Cardiosurgery, Medical University of Bialystok, M. Sklodowskiej - Curie 24a, 15-276 Bialystok, Poland
| | - Robert Flisiak
- Department of Infectious Diseases and Hepatology, Medical University of Bialystok, M. Sklodowskiej - Curie 24a, 15-276 Bialystok, Poland
| | - Andrzej Dabrowski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej - Curie 24a, 15-276 Bialystok, Poland
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Premkumar M, Saxena P, Rangegowda D, Baweja S, Mirza R, Jain P, Bhatia P, Kumar G, Bihari C, Kalal C, Vyas T, Choudhury A, Sarin SK. Coagulation failure is associated with bleeding events and clinical outcome during systemic inflammatory response and sepsis in acute-on-chronic liver failure: An observational cohort study. Liver Int 2019; 39:694-704. [PMID: 30589495 DOI: 10.1111/liv.14034] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 12/12/2018] [Accepted: 12/12/2018] [Indexed: 02/13/2023]
Abstract
BACKGROUND Patients with acute-on-chronic liver failure (ACLF) have coagulation failure in the setting of systemic inflammatory syndrome (SIRS), sepsis and extra-hepatic organ failures. METHODS Consecutive ACLF patients without sepsis at baseline were assessed at days 0, 3 and 7 with thromboelastography (TEG) and specific assays (Factor VIII, von Willebrand factor [vWF], protein C and antithrombin III [ATIII]) and followed for development of sepsis, bleeding and outcome. RESULTS Of 243 patients, 114 (63% ethanol related; mean age 44.3 ± 11.7 years; 90% male) were recruited. SIRS was noted in 39 (34.2%), 45 (39.5%) and 46 (40%) patients at days 0, 3 and 7 and sepsis in 28 (24%) and 52 (56.1%) patients at days 3 and 7 respectively. The 28- and 90-day survivals were 62% and 51% respectively. A hypocoagulable TEG at baseline was a predictor of bleeding (hazard ratio [HR] 2.1; CI 1.6-4.9; P = 0.050) and mortality (HR 1.9; CI 1.3-7.9; P = 0.043). ACLF patients had increased Factor VIII, vWF, tissue factor levels and tissue plasminogen activator (tPA) activity with reduced protein C and ATIII. Coagulation parameters like Coagulation Index (HR 2.1; CI 1.1-4.5; P = 0.044),clot lysis (HR 3.2; CI 1.9-3.4; P = 0.033), low protein C < 30% (HR 2.1; CI 1.5-2.8; P = 0.017), ATIII (HR 1.4; CI 1.7-3.1; P = 0.052) and tPA (HR 1.5; CI 1.1-2.4; P = 0.052) were predictors of mortality at day 28. Protein C activity <30% (HR 1.3; CI 1.0-2.9; P = 0.042) and tPA >20 ng/mL (HR 1.2; CI 1.1-2.1; P = 0.040) predicted mortality when adjusted for age, gender and baseline MELD. CONCLUSIONS Dynamic coagulation derangements, measured by TEG, determine the likelihood of bleeding and mortality in ACLF.
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Affiliation(s)
- Madhumita Premkumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Priyanka Saxena
- Department of Hematology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Devaraja Rangegowda
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Sukriti Baweja
- Department of Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Roshni Mirza
- Department of Hematology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Priyanka Jain
- Department of Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Puja Bhatia
- Department of Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Chhagan Bihari
- Department of Hematology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Chetan Kalal
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Tanmay Vyas
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ashok Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Bezinover D, Deacutis MF, Dalal PG, Moores RP, Stine JG, Wang M, Reeder E, Hollenbeak CS, Saner FH, Riley TR, Janicki PK. Perioperative thrombotic complications associated with pediatric liver transplantation: a UNOS database evaluation. HPB (Oxford) 2019; 21:370-378. [PMID: 30266497 PMCID: PMC7480188 DOI: 10.1016/j.hpb.2018.08.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 08/31/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND This retrospective UNOS database evaluation analyzes the prevalence of preoperative portal vein thromboses (PVT), and postoperative thromboses leading to graft failure in pediatric patients undergoing liver transplantation (LT). METHODS The evaluation was performed in three age groups: I (0-5), II (6-11), III (12-18) years old. Factors predictive of pre- and postoperative thromboses were analyzed. RESULTS Between 2000 and 2015, 8982 pediatric LT were performed in the US. Of those, 390 patients had preoperative PVT (4.3%), and 396 (4.4%) had postoperative thromboses. The prevalence of both types of thromboses was less in Group III than in the other two groups (3.20% vs 4.65%, p = 0.007 and 1.73% vs. 5.13%, p < 0.001, respectively). The prevalence of postoperative thromboses was significantly higher in Group I than in the other two groups (5.49% vs. 2.51%, p < 0.001). Preoperative PVT was independently associated with postoperative thromboses (OR = 1.7, p = 0.02). Children less than 5 years of age were more likely to develop postoperative thromboses leading to graft failure (OR = 2.9, p < 0.001). CONCLUSION Younger children undergoing LT are prone to pre-and postoperative thrombotic complications. Preoperative PVT at the time of transplantation was independently associated with postoperative thromboses. Perioperative antithrombotic therapy should be considered in pediatric patients undergoing LT.
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Affiliation(s)
- Dmitri Bezinover
- Departments of Anesthesiology and Perioperative Medicine, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey
| | - Molly F. Deacutis
- Departments of Anesthesiology and Perioperative Medicine, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey
| | - Priti G. Dalal
- Departments of Anesthesiology and Perioperative Medicine, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey
| | - Robert P. Moores
- Department of Anesthesiology, School of Medicine, Washington University in St Louis, St Louis
| | - Jonathan G. Stine
- Department of Medicine, Division of Hepatology, Penn State Milton S. Hershey Medical Center
| | - Ming Wang
- Department of Public Health Science, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, USA
| | - Ethan Reeder
- Departments of Anesthesiology and Perioperative Medicine, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey
| | - Christopher S. Hollenbeak
- Department of Public Health Science, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, USA
| | - Fuat H. Saner
- Department of General, Visceral and Transplant Surgery, Essen University Medical Center, Essen, Germany
| | - Thomas R. Riley
- Department of Medicine, Division of Hepatology, Penn State Milton S. Hershey Medical Center
| | - Piotr K. Janicki
- Departments of Anesthesiology and Perioperative Medicine, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey
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Ibrahim EH, Marzouk SA, Zeid AE, Lashen SA, Taher TM. Role of the von Willebrand factor and the VITRO score as predictors for variceal bleeding in patients with hepatitis C-related cirrhosis. Eur J Gastroenterol Hepatol 2019; 31:241-247. [PMID: 30281535 DOI: 10.1097/meg.0000000000001272] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Noninvasive methods have been established to detect clinically significant portal hypertension in liver cirrhosis with variable limitations. The von Willebrand factor (vEF) has been found to increase in liver cirrhosis. AIM The aim of this study was to explore the vEF and VITRO (von Willebrand factor antigen/platelet ratio) score in the prediction of variceal bleeding in patients with portal hypertension. MATERIALS AND METHODS Fifty patients with hepatitis C-related liver cirrhosis (25 patients with variceal bleeding and 25 without variceal bleeding) as well as 80 healthy controls were included. Laboratory investigations and upper gastrointestinal endoscopy were performed in all patients. Serum vEF was measured in the patient and the control group. The VITRO score was calculated. RESULTS The mean levels of the vEF antigen and the VITRO score were higher in patients with variceal bleeding compared with patients without variceal bleeding and controls (P<0.001). At levels of at least 100.1 ng/ml and at least 0.732, the vEF and the VITRO score could predict variceal bleeding with a sensitivity and a specificity of 92 and 99.9% for the vEF and 80 and 68% for the VITRO score (area under the curve=0.982 and 0.843), respectively. Levels of vEF were correlated positively with esophageal varices grade. CONCLUSION Serum vEF level and the VITRO score are potential noninvasive biomarkers for the prediction and risk stratification of variceal bleeding in hepatitis C-related liver cirrhosis.
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Affiliation(s)
| | - Salah A Marzouk
- Department of Clinical and Chemical Pathology, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Ahmed E Zeid
- Department of Internal Medicine, Hepatobiliary Unit
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Russo FP, Zanetto A, Campello E, Bulato C, Shalaby S, Spiezia L, Gavasso S, Franceschet E, Radu C, Senzolo M, Burra P, Lisman T, Simioni P. Reversal of hypercoagulability in patients with HCV-related cirrhosis after treatment with direct-acting antivirals. Liver Int 2018; 38:2210-2218. [PMID: 29738632 DOI: 10.1111/liv.13873] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 04/20/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS The long-term impact of sustained virological response (SVR) after direct-acting antivirals (DAAs) on the hypercoagulability associated with HCV cirrhosis is unknown. We longitudinally evaluated the effect of DAAs treatment on cirrhotic coagulopathy. METHODS Pro- and anticoagulant factor levels and thrombin generation were assessed in patients with HCV-related cirrhosis at baseline, end of therapy (EOT), at 12, 24 and 48 weeks (W) after EOT. RESULTS Fifty-eight patients were enrolled (86% Child's A). SVR was 100%. Median factor VIII activity significantly decreased at EOT, 12 weeks and 24 weeks compared with baseline, whereas protein C significantly increased at 24 weeks and 48 weeks. Cirrhotic patients showed a slight but sustained increase in endogenous thrombin potential (ETP) with a statistically significant difference at EOT, 12 weeks, 24 weeks and 48 weeks compared with baseline. Conversely, thrombomodulin-modified ETP was elevated before treatment and decreased over time to normal levels at 24 weeks and 48 weeks. The ETP ratio decreased slowly at EOT and 12 weeks, and was significantly decreased at 24 weeks and 48 weeks compared with baseline (P < .001 for both comparisons), being not statistically different from ETP ratio measured in healthy controls. Child's B patients showed a significantly higher ETP ratio compared to Child's A at baseline and did not show any significant improvement in ETP ratio through 12 weeks. Two Child's B patients developed PVT with an incidence rate of 1.1% p-yrs (95%CI, 0.18 to 3.58). CONCLUSIONS DAAs therapy in HCV-related cirrhotic patients is associated with significant changes in thrombin generation suggesting a reversal of hypercoagulability particularly in Child's A patients.
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Affiliation(s)
- Francesco Paolo Russo
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Elena Campello
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padua University Hospital, Padua, Italy
| | - Cristiana Bulato
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padua University Hospital, Padua, Italy
| | - Sarah Shalaby
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Luca Spiezia
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padua University Hospital, Padua, Italy
| | - Sabrina Gavasso
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padua University Hospital, Padua, Italy
| | - Enrica Franceschet
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Claudia Radu
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padua University Hospital, Padua, Italy
| | - Marco Senzolo
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Patrizia Burra
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Ton Lisman
- Section of Hepatobiliary Surgery and Liver Transplantation, Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Paolo Simioni
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padua University Hospital, Padua, Italy
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Hypercoagulability in End-stage Liver Disease: Review of Epidemiology, Etiology, and Management. Transplant Direct 2018; 4:e403. [PMID: 30534594 PMCID: PMC6233657 DOI: 10.1097/txd.0000000000000843] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 09/23/2018] [Indexed: 12/14/2022] Open
Abstract
In this review, we analyze the epidemiology of thromboses related to end-stage liver disease (ESLD), discuss causes of hypercoagulability, describe susceptible populations, and critically evaluate proposed prophylaxis and treatment of thromboses. Classically, ESLD has been regarded as a model for coagulopathy, and patients were deemed to be at high risk for bleeding complications. Patients with ESLD are not auto-anticoagulated, and they do not have a lower risk of portal vein thrombosis, intracardiac thrombus formation, pulmonary embolism or hepatic artery thrombosis. Though the cause of hypercoagulability is multifactorial, endothelial dysfunction likely plays a central role for all patients with ESLD. Some subpopulations, such as patients with nonalcoholic steatohepatitis and autoimmune conditions, are at increased risk of thrombotic events as are patients of Hispanic ethnicity. The science behind prophylaxis of different types of clotting and treatment of thromboses is developing rapidly. A number of medications, including low molecular weight heparin, unfractionated heparin, aspirin, vitamin K antagonists, and direct oral anticoagulants can be used, but clear guidelines are lacking. Acute intraoperative clotting can be associated with high mortality. Routine use of transesophageal echocardiography can be helpful in early recognition and treatment of intraoperative thrombosis. Heparin should be reserved for cases of intracardiac thrombus/pulmonary embolism without hemodynamic instability. In unstable patients, low dose of recombinant tissue plasminogen activator can be used. In this new era of heightened awareness of thrombotic events in ESLD patients, prospective randomized trials are urgently needed to best guide clinical practice.
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Ghadimi K, Levy JH, Welsby IJ. Perioperative management of the bleeding patient. Br J Anaesth 2018; 117:iii18-iii30. [PMID: 27940453 DOI: 10.1093/bja/aew358] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Perioperative bleeding remains a major complication during and after surgery, resulting in increased morbidity and mortality. The principal causes of non-vascular sources of haemostatic perioperative bleeding are a preexisting undetected bleeding disorder, the nature of the operation itself, or acquired coagulation abnormalities secondary to haemorrhage, haemodilution, or haemostatic factor consumption. In the bleeding patient, standard therapeutic approaches include allogeneic blood product administration, concomitant pharmacologic agents, and increasing application of purified and recombinant haemostatic factors. Multiple haemostatic changes occur perioperatively after trauma and complex surgical procedures including cardiac surgery and liver transplantation. Novel strategies for both prophylaxis and therapy of perioperative bleeding include tranexamic acid, desmopressin, fibrinogen and prothrombin complex concentrates. Point-of-care patient testing using thromboelastography, rotational thromboelastometry, and platelet function assays has allowed for more detailed assessment of specific targeted therapy for haemostasis. Strategic multimodal management is needed to improve management, reduce allogeneic blood product administration, and minimize associated risks related to transfusion.
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Affiliation(s)
- K Ghadimi
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - J H Levy
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - I J Welsby
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
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40
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Sinegre T, Duron C, Lecompte T, Pereira B, Massoulier S, Lamblin G, Abergel A, Lebreton A. Increased factor VIII plays a significant role in plasma hypercoagulability phenotype of patients with cirrhosis. J Thromb Haemost 2018; 16:1132-1140. [PMID: 29577605 DOI: 10.1111/jth.14011] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Indexed: 12/14/2022]
Abstract
Essentials The role of increased factor VIII in cirrhosis-induced hypercoagulability has never been demonstrated. Factor VIII and protein C effects were characterized by thrombin generation with thrombomodulin. Factor VIII elevation plays a significant role in cirrhosis-induced plasma hypercoagulability. Only protein C and factor VIII normalization led to thrombin generation similar to controls. SUMMARY Background In cirrhosis, thrombin generation (TG) studied in the presence of thrombomodulin (TM) indicates plasma hypercoagulability. Although the role of protein C (PC) deficiency has been investigated, the influence of an increase in the factor VIII level has never been addressed. Objectives We investigated the roles of high FVIII and low PC levels in increased TG in the presence of TM. Methods Blood samples were prospectively collected from 35 healthy controls and 93 patients with cirrhosis (Child-Turcotte-Pugh [CTP]-A, n = 61; CTP-B, n = 19; and CTP-C, n = 13) and FVIII levels > 150% (n = 48) and/or PC levels < 70% (n = 88). TG was performed with tissue factor (5 pm), phospholipids, and TM (4 nm). FVIII and PC levels were normalized by adding an inhibitory anti-FVIII antibody and exogenous PC, respectively. Results The endogenous thrombin potential (ETP) in the presence of TM was higher in patients than in controls. After FVIII normalization, the ETP (median) decreased from 929 nm min to 621 nm min (CTP-A), 1122 nm min to 1082 nm min (CTP-B), and 1221 nm min to 1143 nm min (CTP-C); after PC normalization, it decreased from 776 nm min to 566 nm min (CTP-A), 1120 nm min to 790 nm min (CTP-B), and 995 nm min to 790 nm min (CTP-C). The ETP was reduced by 17% and 30%, respectively, but normal TG was not restored. When both FVIII and PC levels were normalized, the ETP decreased from 929 nm min to 340 nm min (CTP-A), 1122 nm min to 506 nm min (CTP-B), and 1226 nm min to 586 nm min (CTP-C), becoming similar to control levels. Conclusion Cirrhosis-induced plasma hypercoagulability, as demonstrated in these experimental conditions, can be partly explained by opposite changes in two factors: PC level (decrease) and FVIII level (increase).
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Affiliation(s)
- T Sinegre
- Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, INRA, UMR 1019, Clermont-Ferrand, France
| | - C Duron
- Service d'Hépato-Gastro-Entérologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, CNRS, UMR 6284, Clermont-Ferrand, France
| | - T Lecompte
- Hôpitaux Universitaires de Genève, Unité d'hémostase, Département des spécialités de médecine, Geneva, Switzerland
- Université de Genève, GpG, Geneva, Switzerland
| | - B Pereira
- CHU Clermont-Ferrand, Unité de Biostatistiques (Direction de la recherche clinique et de l'innovation), Clermont-Ferrand, France
| | - S Massoulier
- Service d'Hépato-Gastro-Entérologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - G Lamblin
- Service d'Hépato-Gastro-Entérologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - A Abergel
- Service d'Hépato-Gastro-Entérologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, CNRS, UMR 6284, Clermont-Ferrand, France
| | - A Lebreton
- Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, INRA, UMR 1019, Clermont-Ferrand, France
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42
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Rutkowsky JM, Lee LL, Puchowicz M, Golub MS, Befroy DE, Wilson DW, Anderson S, Cline G, Bini J, Borkowski K, Knotts TA, Rutledge JC. Reduced cognitive function, increased blood-brain-barrier transport and inflammatory responses, and altered brain metabolites in LDLr -/-and C57BL/6 mice fed a western diet. PLoS One 2018; 13:e0191909. [PMID: 29444171 PMCID: PMC5812615 DOI: 10.1371/journal.pone.0191909] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 01/12/2018] [Indexed: 12/20/2022] Open
Abstract
Recent work suggests that diet affects brain metabolism thereby impacting cognitive function. Our objective was to determine if a western diet altered brain metabolism, increased blood-brain barrier (BBB) transport and inflammation, and induced cognitive impairment in C57BL/6 (WT) mice and low-density lipoprotein receptor null (LDLr -/-) mice, a model of hyperlipidemia and cognitive decline. We show that a western diet and LDLr -/- moderately influence cognitive processes as assessed by Y-maze and radial arm water maze. Also, western diet significantly increased BBB transport, as well as microvessel factor VIII in LDLr -/- and microglia IBA1 staining in WT, both indicators of activation and neuroinflammation. Interestingly, LDLr -/- mice had a significant increase in 18F- fluorodeoxyglucose uptake irrespective of diet and brain 1H-magnetic resonance spectroscopy showed increased lactate and lipid moieties. Metabolic assessments of whole mouse brain by GC/MS and LC/MS/MS showed that a western diet altered brain TCA cycle and β-oxidation intermediates, levels of amino acids, and complex lipid levels and elevated proinflammatory lipid mediators. Our study reveals that the western diet has multiple impacts on brain metabolism, physiology, and altered cognitive function that likely manifest via multiple cellular pathways.
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Affiliation(s)
- Jennifer M. Rutkowsky
- Department of Molecular Biosciences, School of Veterinary Medicine, University of California, Davis, California, United States of America
- * E-mail:
| | - Linda L. Lee
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of California, Davis, California, United States of America
| | - Michelle Puchowicz
- Department of Nutrition, School of Medicine, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Mari S. Golub
- Department of Environmental Toxicology, University of California, Davis, California, United States of America
| | - Douglas E. Befroy
- Magnetic Resonance Research Center, Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Dennis W. Wilson
- Department of Pathology, Microbiology, and Immunology, School of Veterinary Medicine, University of California, Davis, California, United States of America
| | - Steven Anderson
- Department of Physiology and Membrane Biology, University of California, Davis, California, United States of America
| | - Gary Cline
- Department of Endocrinology, Yale University, New Haven, Connecticut, United States of America
| | - Jason Bini
- Yale PET Center, Department of Diagnostic Radiology, Yale University, New Haven, Connecticut, United States of America
| | - Kamil Borkowski
- West Coast Metabolomics Center, Genome Center, University of California, Davis, California, United States of America
| | - Trina A. Knotts
- Department of Molecular Biosciences, School of Veterinary Medicine, University of California, Davis, California, United States of America
| | - John C. Rutledge
- Department of Molecular Biosciences, School of Veterinary Medicine, University of California, Davis, California, United States of America
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Forkin KT, Colquhoun DA, Nemergut EC, Huffmyer JL. The Coagulation Profile of End-Stage Liver Disease and Considerations for Intraoperative Management. Anesth Analg 2018; 126:46-61. [PMID: 28795966 DOI: 10.1213/ane.0000000000002394] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The coagulopathy of end-stage liver disease results from a complex derangement in both anticoagulant and procoagulant processes. With even minor insults, cirrhotic patients experience either inappropriate bleeding or clotting, or even both simultaneously. The various phases of liver transplantation along with fluid and blood product administration may contribute to additional disturbances in coagulation. Thus, anesthetic management of patients undergoing liver transplantation to improve hemostasis and avoid inappropriate thrombosis in the perioperative environment can be challenging. To add to this challenge, traditional laboratory tests of coagulation are difficult to interpret in patients with end-stage liver disease. Viscoelastic coagulation tests such as thromboelastography (Haemonetics Corporation, Braintree, MA) and rotational thromboelastometry (TEM International, Munich, Germany) have helped to reduce transfusion of allogeneic blood products, especially fresh frozen plasma, but have also lead to the increased use of fibrinogen-containing products. In general, advancements in surgical techniques and anesthetic management have led to significant reduction in blood transfusion requirements during liver transplantation. Targeted transfusion protocols and pharmacologic prevention of fibrinolysis may further aid in the management of the complex coagulopathy of end-stage liver disease.
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Affiliation(s)
- Katherine T Forkin
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | | | - Edward C Nemergut
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia.,Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Julie L Huffmyer
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
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44
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Blaine KP, Sakai T. Viscoelastic Monitoring to Guide Hemostatic Resuscitation in Liver Transplantation Surgery. Semin Cardiothorac Vasc Anesth 2017; 22:150-163. [PMID: 29099334 DOI: 10.1177/1089253217739121] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Coagulopathic bleeding must be anticipated during liver transplantation (LT) surgery. Patients with end-stage liver disease (ESLD) often present with disease-related hematologic disturbances, including the loss of hepatic procoagulant and anticoagulant clotting factors and thrombocytopenia. Transplantation surgery itself presents additional hemostatic changes, including hyperfibrinolysis. Viscoelastic monitoring (VEM) is often used to provide targeted, personalized hemostatic therapies for complex bleeding states including cardiac surgery and major trauma. The use in these coagulopathic conditions led to its application to LT, although the mechanisms of coagulopathy in these patients are quite different. While VEM is often used during transplant surgeries in Europe and North America, evidence supporting its use is limited to a few small clinical studies. The theoretical and clinical applications of the standard and specialized VEM assays are discussed in the setting of LT and ESLD.
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Affiliation(s)
- Kevin P Blaine
- 1 Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Tetsuro Sakai
- 2 University of Pittsburgh Medical Center Health System, Pittsburgh, PA, USA
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45
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Monereo Muñoz M, Aguilera García SG, de la Barreda Heusser R, González Arnay E, García Hernández S, González Reimers E. Cryptogenetic liver cirrhosis and prothrombotic mutations - A mere association? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 108:588-91. [PMID: 26785615 DOI: 10.17235/reed.2016.3871/2015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Thrombin activation and microthrombosis of intrahepatic portal venules is a common feature in liver cirrhosis, due in part to relative protein C deficiency and altered coagulation-anticoagulation-fibrinolysis balance. Extension of this microthrombotic process to larger portal vessels explains the increased incidence of portal vein thrombosis in liver cirrhosis. Thrombin not only leads to thrombosis, but also activates liver stellate cells and promotes fibrogenesis. Also, ischemia associated with thrombosis up-regulates the expression and secretion of growth factors involved in fibrogenesis. The coincidence in a given patient of prothrombotic mutations, such as factor V Leiden or PAI-1 polymorphisms, can accelerate the fibrogenetic process. We hereby present two cases of liver cirrhosis in which etiologic evaluation was negative except for the finding of a factor V Leiden mutation in one case and the 4G/5G PAI polymorphism in the second case. These observations support the hypothesis that these mutations may be involved in the etiology of some cases of cirrhosis, or, at least, accelerate the evolution of the disease. It is therefore convenient to search for the presence of prothrombotic mutations in patients with cryptogenetic cirrhosis.
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Affiliation(s)
| | | | | | | | | | - Emilio González Reimers
- Medicina Interna, Dermatología y Psiquiatría, Hospital Universitario de Canarias. Universidad de, España
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46
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Carnevale R, Raparelli V, Nocella C, Bartimoccia S, Novo M, Severino A, De Falco E, Cammisotto V, Pasquale C, Crescioli C, Scavalli AS, Riggio O, Basili S, Violi F. Gut-derived endotoxin stimulates factor VIII secretion from endothelial cells. Implications for hypercoagulability in cirrhosis. J Hepatol 2017; 67:950-956. [PMID: 28716745 DOI: 10.1016/j.jhep.2017.07.002] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 07/05/2017] [Accepted: 07/07/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Patients with cirrhosis display enhanced blood levels of factor VIII, which may result in harmful activation of the clotting system; however, the underlying mechanism is unknown. METHODS We performed a cross-sectional study in patients with cirrhosis (n=61) and matched controls (n=61) comparing blood levels of factor VIII, von Willebrand factor (vWf), lipopolysaccharide (LPS) and positivity for Escherichia coli DNA. Furthermore, we performed an in vitro study to investigate if LPS, in a concentration range similar to that found in the peripheral circulation of cirrhotic patients, was able to elicit factor VIII secretion from human umbilical vein endothelial cells (HUVEC). RESULTS Patients with cirrhosis displayed higher serum levels of LPS (55.8 [42.2-79.9] vs. 23.0 [7.0-34.0]pg/ml, p<0.001), factor VIII (172.0 [130.0-278.0] vs. 39.0 [26.0-47.0]U/dl, p<0.0001), vWf (265.0 [185.0-366.0] vs. 57.0 [48.0-65.0]U/dl, p<0.001) and positivity for Escherichia coli DNA (88% vs. 3%, p<0.001, n=34) compared to controls. Serum LPS correlated significantly with factor VIII (r=0.80, p<0.001) and vWf (r=0.63, p<0.001). Only LPS (beta-coefficient=0.70, p<0.0001) independently predicted factor VIII levels. The in vitro study showed that LPS provoked factor VIII and vWf release from HUVEC via formation and secretion of Weibel-Palade bodies, a phenomenon blunted by pre-treating HUVEC with an inhibitor of Toll-like receptor 4. CONCLUSIONS The study provides the first evidence that LPS derived from gut microbiota increases the systemic levels of factor VIII via stimulating its release by endothelial cells. Lay summary: Cirrhosis is associated with thrombosis in portal and systemic circulation. Enhanced levels of factor VIII have been suggested to play a role but the underlying mechanism is still unclear. Here we show that patients with cirrhosis display a concomitant increase of factor VIII and lipopolysaccharide (LPS) from Escherichia coli and suggest that LPS contributes to the release of factor VIII from endothelial cells.
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Affiliation(s)
- Roberto Carnevale
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Valeria Raparelli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Cristina Nocella
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Simona Bartimoccia
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Marta Novo
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Anna Severino
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Elena De Falco
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Vittoria Cammisotto
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Chiara Pasquale
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension, Sapienza-University of Rome, Rome, Italy
| | - Clara Crescioli
- Department of Movement, Human and Health Sciences, Section of Health Sciences, "Foro Italico" University of Rome, Rome, Italy
| | - Antonio Sili Scavalli
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Oliviero Riggio
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension, Sapienza-University of Rome, Rome, Italy
| | - Stefania Basili
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Francesco Violi
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy.
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Tripodi A, D'Ambrosio R, Padovan L, Tosetti G, Aghemo A, Primignani M, Chantarangkul V, Peyvandi F, Colombo M. Evaluation of coagulation during treatment with directly acting antivirals in patients with hepatitis C virus related cirrhosis. Liver Int 2017; 37:1295-1303. [PMID: 28129465 DOI: 10.1111/liv.13374] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 01/20/2017] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS The effect of direct-acting-antivirals (DAA) on coagulation of hepatitis-C-virus (HCV)-related cirrhosis is unknown. METHODS We investigated 28 patients on DAA treatment and performed prothrombin-time, thrombin generation with and without thrombomodulin, whole-blood thromboelastometry, as well as the individual procoagulants (II, VIII, XIII, von Willebrand) and anticoagulants, antithrombin and protein-C. RESULTS Patients had undetectable HCV-RNA at the end-of- treatment and at 12-weeks after end-of-treatment (sustained virological response). Transaminases were significantly decreased at both end-of-treatment and at 12-weeks. Prothrombin-time declined at 12-weeks, but did not reach statistical significance. Factor-II, protein-C and antithrombin increased significantly at end-of-treatment (P<.001) and persisted at 12-weeks. Factor-VIII decreased at end-of-treatment and to a greater extent at 12-weeks when reached statistical significance (P<.05). Factor-VIII/protein-C ratio decreased sharply, reached statistical significance at end-of-treatment (P<.01) and persisted at 12-weeks. Von-Willebrand decreased at end-of-treatment and reached statistical significance at 12-weeks (P<.001). Endogenous-thrombin-potential without thrombomodulin increased significantly at end-of-treatment (P<.01) and persisted at 12-weeks. No changes were observed after addition of thrombomodulin. Endogenous-thrombin-potential ratio (with/without thrombomodulin) decreased and reached statistical significance at 12-weeks (P<.05). Thromboelastometry clotting time decreased sharply, reached statistical significance at end-of treatment (P<.001) and persisted at 12-weeks. CONCLUSIONS Treatment with DAAs in HCV-related cirrhosis results in improvement of the individual pro- and anticoagulants. It can be hypothesised that the net effect does not substantially modify their balance (as shown by the unchanged thrombin generation in the presence of thrombomodulin) but makes it more stable and less amenable to be perturbed as presumably occurs before treatment when there is a partial deficiency for both.
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Affiliation(s)
- Armando Tripodi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milano, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milano, Italy.,IRCCS Cà Granda Maggiore Hospital Foundation, Milano, Italy
| | - Roberta D'Ambrosio
- IRCCS Cà Granda Maggiore Hospital Foundation, Milano, Italy.,Division of Gastroenterology and Hepatology, Milano, Italy
| | - Lidia Padovan
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milano, Italy.,IRCCS Cà Granda Maggiore Hospital Foundation, Milano, Italy
| | - Giulia Tosetti
- IRCCS Cà Granda Maggiore Hospital Foundation, Milano, Italy.,Division of Gastroenterology and Hepatology, Milano, Italy
| | - Alessio Aghemo
- IRCCS Cà Granda Maggiore Hospital Foundation, Milano, Italy.,Division of Gastroenterology and Hepatology, Milano, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
| | - Massimo Primignani
- IRCCS Cà Granda Maggiore Hospital Foundation, Milano, Italy.,Division of Gastroenterology and Hepatology, Milano, Italy
| | | | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milano, Italy.,IRCCS Cà Granda Maggiore Hospital Foundation, Milano, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
| | - Massimo Colombo
- IRCCS Cà Granda Maggiore Hospital Foundation, Milano, Italy.,Division of Gastroenterology and Hepatology, Milano, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy.,Humanitas Clinical and Research Center, Milano, Italy
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48
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Saxena P, Bihari C, Mirza R, Bhadoria AS, Sarin SK. The imbalance of procoagulant and anticoagulant factors in patients with chronic liver diseases in North India. Blood Res 2017; 52:143-145. [PMID: 28698855 PMCID: PMC5503896 DOI: 10.5045/br.2017.52.2.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 09/23/2016] [Accepted: 11/18/2016] [Indexed: 11/17/2022] Open
Affiliation(s)
- Priyanka Saxena
- Department of Pathology, Maulana Azad Medical College, New Delhi, India
| | - Chhagan Bihari
- Department of Pathology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Roshni Mirza
- Department of Hematology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ajeet Singh Bhadoria
- Department of Clinical Epidemiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Abstract
Acute and chronic liver failure are associated with numerous alterations in different features of the coagulation system. Consequently, there is widespread confusion regarding the potential for both bleeding and thrombosis in patients with liver disease. The risk of bleeding is related to the hemodynamic changes in portal pressures and venous congestion whereas the thrombotic risk stems from changes in the coagulation system. Antithrombotic prophylaxis and treatment of patients with hemorrhage and thrombosis requires careful assessment, interpretation of laboratory workup, and attention to coexistent morbidities. A framework for the management of these conditions is presented for clinicians.
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Affiliation(s)
- Michael G Allison
- Critical Care Medicine, St. Agnes Hospital, 900 South Caton Avenue, Box 062, Baltimore, MD 21229, USA.
| | - Carl B Shanholtz
- Medical Intensive Care Unit, Division of Pulmonary and Critical Care, University of Maryland School of Medicine, 110 South Paca Street, 2nd Floor, Baltimore, MD 21201, USA
| | - Ashutosh Sachdeva
- Interventional Pulmonary Program, Division of Pulmonary and Critical Care, University of Maryland School of Medicine, 110 South Paca Street, 2nd Floor, Baltimore, MD 21201, USA
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50
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Joshi N, Kopec AK, Ray JL, Cline-Fedewa H, Groeneveld DJ, Lisman T, Luyendyk JP. Von Willebrand factor deficiency reduces liver fibrosis in mice. Toxicol Appl Pharmacol 2017; 328:54-59. [PMID: 28527913 DOI: 10.1016/j.taap.2017.05.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 05/09/2017] [Accepted: 05/16/2017] [Indexed: 02/07/2023]
Abstract
Liver diseases are associated with complex changes in the hemostatic system and elevated levels of the platelet-adhesive protein Von Willebrand factor (VWF) are reported in patients with acute and chronic liver damage. Although elevated levels of VWF are associated with fibrosis in the general population, the role of VWF in acute and chronic liver injury has not been examined in depth in experimental settings. We tested the hypothesis that VWF deficiency inhibits experimental liver injury and fibrosis. Wild-type (WT) and VWF-deficient mice were challenged with carbon tetrachloride (CCl4) and the impact of VWF deficiency on acute liver injury and chronic liver fibrosis was determined. VWF deficiency did not significantly affect acute CCl4-induced hepatocellular necrosis in mice. Chronic CCl4 challenge, twice weekly for 6weeks, significantly increased hepatic stellate cell activation and collagen deposition in livers of WT mice. Interestingly, hepatic induction of several profibrogenic and stellate cell activation genes was attenuated in VWF-deficient mice. Moreover, birefringent sirius red staining (indicating type I and III collagens) and type I collagen immunofluorescence indicated a reduction in hepatic collagen deposition in CCl4-exposed VWF-deficient mice compared to CCl4-exposed WT mice. The results indicate that VWF deficiency attenuates chronic CCl4-induced liver fibrosis without affecting acute hepatocellular necrosis. The results are the first to demonstrate that VWF deficiency reduces the progression of liver fibrosis, suggesting a mechanistic role of elevated plasma VWF levels in cirrhosis.
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Affiliation(s)
- Nikita Joshi
- Department of Pharmacology & Toxicology, Michigan State University, United States; Institute for Integrative Toxicology, Michigan State University, East Lansing, MI, United States
| | - Anna K Kopec
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, United States; Institute for Integrative Toxicology, Michigan State University, East Lansing, MI, United States
| | - Jessica L Ray
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, United States
| | - Holly Cline-Fedewa
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, United States
| | - Dafna J Groeneveld
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - James P Luyendyk
- Department of Pharmacology & Toxicology, Michigan State University, United States; Department of Pathobiology & Diagnostic Investigation, Michigan State University, United States; Institute for Integrative Toxicology, Michigan State University, East Lansing, MI, United States.
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