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Azer A, Kong K, Basta D, Modica SF, Gore A, Gorman E, Sutherland A, Tafesh Z, Horng H, Glass NE. Evaluation of coagulopathy in cirrhotic patients: A scoping review of the utility of viscoelastic testing. Am J Surg 2024; 227:34-43. [PMID: 37722936 DOI: 10.1016/j.amjsurg.2023.09.001] [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: 06/30/2023] [Revised: 08/17/2023] [Accepted: 09/01/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Cirrhosis causes significant coagulopathy. Traditional coagulation tests may not accurately measure coagulopathy in well-compensated patients with cirrhosis. Viscoelastic tests are functional tests that may better assess coagulopathy in cirrhotic patients. METHODS We searched PubMed, ScienceDirect, Google Scholar, and grey literature using terms meaning viscoelastic testing and cirrhosis. After reviewing over 500 titles and abstracts, 40 full-text papers met inclusion criteria. RESULTS Twenty-two papers found viscoelastic testing was a better indicator of baseline coagulation than traditional testing in cirrhosis. Nineteen additional papers evaluated the utility of peri-procedural viscoelastic testing and found they led to a reduction in blood product administration without increasing risk of hemorrhage, thrombotic events, or other complications. CONCLUSIONS The usage of viscoelastic testing in patients with cirrhosis allows for better assessment of coagulopathy, resulting in improved outcomes. Educating physicians to optimize care of this high-risk group is necessary to further improve their treatment.
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Affiliation(s)
| | | | | | | | - Amy Gore
- Rutgers New Jersey Medical School, USA
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2
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Lim HJ, Jang H, Lee N, Jeong E, Park Y, Jo Y, Kim J, Lee YE, Choi HJ, Kee SJ, Shin JH, Shin MG. Prediction of Mid-term Platelet Transfusion in Stable Trauma Patients Using Rotational Thromboelastometry. Ann Lab Med 2024; 44:74-81. [PMID: 37665288 PMCID: PMC10485857 DOI: 10.3343/alm.2024.44.1.74] [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: 02/13/2023] [Revised: 05/05/2023] [Accepted: 08/04/2023] [Indexed: 09/05/2023] Open
Abstract
Background Rotational thromboelastometry (ROTEM; TEM International GmbH, Munich, Germany) is a global coagulation test that guides evidence-based platelet transfusion in trauma patients. We evaluated ROTEM parameters for predicting mid-term (five days) platelet transfusion in trauma patients. Methods Maximum clot firmness and clot amplitudes after 5, 10, and 15 mins (A5, A10, and A15, respectively) of fibrin-specific ROTEM (FIBTEM) and extrinsically activated ROTEM (EXTEM) were retrospectively collected from 82 hospitalized, stable, non-bleeding trauma patients after successful initial resuscitation. Platelet-specific ROTEM (PLTEM) was calculated by subtracting FIBTEM from EXTEM. Platelet transfusions were reviewed for five days after ROTEM. Results The areas under the curve for FIBTEM, EXTEM, and PLTEM predicting platelet concentrate transfusion of >12 U at mid-term were 0.915-0.923, 0.878-0.896, and 0.551-0.735, respectively. FIBTEM and EXTEM parameters were comparable to those of fibrinogen, fibrin/fibrinogen degradation products, D-dimer, and antithrombin III. Strong correlations (r>0.7) were noted between platelet count and EXTEM (A5, A10, and A15) or PLTEM (A5), platelet function (per platelet count) and EXTEM (A10 and A15), and fibrinogen levels and all FIBTEM parameters. Conclusions FIBTEM and EXTEM can reliably predict mid-term platelet transfusion in trauma patients. FIBTEM, EXTEM, and PLTEM parameters correlate with conventional coagulation tests (platelets and fibrinogen).
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Affiliation(s)
- Ha Jin Lim
- Department of Laboratory Medicine, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Hyunseok Jang
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Naa Lee
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Euisung Jeong
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Yunchul Park
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Younggoun Jo
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Jungchul Kim
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Young Eun Lee
- Department of Laboratory Medicine, Chonnam National University Medical School and Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Hyun-Jung Choi
- Department of Laboratory Medicine, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Seung-Jung Kee
- Department of Laboratory Medicine, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Jong Hee Shin
- Department of Laboratory Medicine, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Myung Geun Shin
- Department of Laboratory Medicine, Chonnam National University Medical School and Chonnam National University Hwasun Hospital, Hwasun, Korea
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Li Z, Xu W, Wang L, Chai L, Ageno W, Romeiro FG, Li H, Qi X. Risk of Bleeding in Liver Cirrhosis Receiving Direct Oral Anticoagulants: A Systematic Review and Meta-analysis. Thromb Haemost 2023; 123:1072-1088. [PMID: 37336474 DOI: 10.1055/s-0043-1770100] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are effective for the management of thromboembolic disorders. However, bleeding remains a major concern in cirrhotic patients receiving DOACs. METHODS PubMed, EMBASE, and Cochrane Library databases were searched. The incidence of bleeding episodes in cirrhotic patients receiving DOACs was pooled. Odds ratios (ORs) were calculated to compare the incidence of bleeding episodes in cirrhotic patients who received DOACs versus those who received conventional anticoagulants and did not receive anticoagulants. RESULTS Twenty-nine studies were included. All bleeding, major bleeding, fatal bleeding, gastrointestinal bleeding, and intracranial hemorrhage episodes were observed in 310/2,469, 100/1,388, 2/611, 166/1,886, and 5/1,147 cirrhotic patients receiving DOACs, respectively. Their pooled incidences were 13, 6, 0, 8, and 0%, respectively. They became higher in subgroup analyses of studies with advanced age, a longer treatment duration, and Child-Turcotte-Pugh class C. Compared with conventional anticoagulants, DOACs were associated with lower incidences of all bleeding (OR = 0.71, 95% confidence interval [CI] = 0.52-0.98) and major bleeding (OR = 0.55, 95% CI = 0.37-0.83) in cirrhotic patients, but not those of fatal bleeding (OR = 0.21, 95% CI = 0.04-1.28), gastrointestinal bleeding (OR = 0.78, 95% CI = 0.52-1.17), or intracranial hemorrhage (OR = 0.36, 95% CI = 0.12-1.12). The incidences of all bleeding (OR = 1.04, 95% CI = 0.22-4.79) and major bleeding (OR = 0.96, 95% CI = 0.26-3.61) did not significantly differ between cirrhotic patients with portal vein thrombosis (PVT) who received DOACs and those who did not receive anticoagulants. CONCLUSION DOACs carry a low risk of bleeding in liver cirrhosis. Age, treatment duration, and Child-Turcotte-Pugh class may be associated with bleeding in cirrhotic patients receiving DOACs. The risk of bleeding is not increased by DOACs in cirrhotic patients with PVT.
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Affiliation(s)
- Zhe Li
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Wentao Xu
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Le Wang
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Lu Chai
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Fernando Gomes Romeiro
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University (UNESP), São Paulo, Brazil
| | - Hongyu Li
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
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Whitton TP, Healy WJ. Review of Thromboelastography (TEG): Medical and Surgical Applications. THERAPEUTIC ADVANCES IN PULMONARY AND CRITICAL CARE MEDICINE 2023; 18:29768675231208426. [PMID: 38107072 PMCID: PMC10725099 DOI: 10.1177/29768675231208426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 09/22/2023] [Indexed: 12/19/2023]
Abstract
Thromboelastography (TEG) is a laboratory assay utilized to evaluate hemostatic properties of blood, identify coagulopathy, and guide blood product administration. While the clinical use of TEG started in the care of surgical patients, the assay has now been incorporated more routinely in the care of the medical patient as well. In this review, we explore the evolution of TEG from the historical perspective of its inception to the current state of the art of the assay. The TEG procedure and its measurements are illustrated along with a table that summarizes recommendations from across the medical and surgical literature. After each section, we review salient learning points to provide the busy clinician with information that can be immediately integrated at the bedside. We conclude with a series of summary questions to check for comprehension and direct the reader to additional resources to improve their knowledge of TEG.
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Affiliation(s)
- TP Whitton
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - WJ Healy
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Medical College of Georgia at Augusta University, Augusta, GA, USA
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5
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Serag WM, Eysa BE. Diagnosis of portal vein thrombosis in cirrhotic patients with and without hepatocellular carcinoma. EGYPTIAN LIVER JOURNAL 2022. [DOI: 10.1186/s43066-022-00201-3] [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
The levels of Annexin A5 (Annexin V) were measured in patients with and without HCC who had liver cirrhosis. These patients were followed for 12 months to determine the incidence of PVT and to determine the role of Annexin V in the diagnosis of PVT. Our goal was to look at the value of Annexin A5, platelet count, spleen size, portal flow velocity, portal vein width, Fibrosis 4, and APRI score in these individuals to see if they might be used as PVT markers.
Methods
Between March 2017 and August 2018, ninety-one HCV patients with cirrhosis with and without HCC, as well as a control group of twenty healthy people, were included in this longitudinal study at the NHTMRI. The blood anxA5 level was determined using a commercial Hyphen BioMed immunoassay using Stat Fax 4700’s Microstrip Reader l.
Results
Cirrhotic patients with and without HCC who developed PVT had higher Annexin A5 scales (5.75 + 0.18), compared to cirrhotic patients who did not develop PVT (3.63 + 1.08 (P 0.001). PVT was 20% in all cirrhotic patients after a year, 15% in cirrhotic patients without HCC, and 25% in cirrhotic patients with HCC. Cirrhotic patients who had PVT throughout the follow-up period had greater AnxA5 serum levels than cirrhotic patients who did not develop PVT.
Conclusions
In all cirrhotic patients, AnxA5 level, platelet count, spleen size, portal flow velocity, portal vein diameter, and Fibrosis 4 score might be employed as markers for PVT development.
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He Y, Yao H, Ageno W, Méndez-Sánchez N, Guo X, Qi X. Review article: thromboelastography in liver diseases. Aliment Pharmacol Ther 2022; 56:580-591. [PMID: 35698893 DOI: 10.1111/apt.17080] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 05/16/2022] [Accepted: 05/29/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Patients with liver diseases have complicated haemostatic alternations, resulting in both bleeding and thromboembolic complications, which cannot be sufficiently evaluated by conventional coagulation tests (CCTs), such as platelet count or prothrombin time. Thromboelastography (TEG) is a whole blood viscoelastic test which globally reflects changes in the haemostatic system, and its utility in evaluating patients with liver disease is increasingly recognised. AIMS To review the current evidence and clinical significance of TEG in liver diseases. METHODS Literature regarding TEG and liver diseases was comprehensively searched. RESULTS TEG is associated closely with the severity and aetiology of liver disease, the course of infection and the risk of bleeding and death, but not the risk of portal venous system thrombosis. Additionally, TEG-guided transfusion protocols can significantly decrease the requirement for blood products compared to those guided by CCTs. CONCLUSION TEG can reflect the haemostatic status of liver diseases more comprehensively than CCTs. It has the potential to assess the severity of liver diseases, predict the risk of bleeding and death in patients with liver disease and guide blood product transfusion. Future studies should standardise the use of TEG for assessing disease severity and development of clinical events and guiding blood product transfusion in patients with liver diseases.
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Affiliation(s)
- Yanglan He
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China.,Postgraduate College, China Medical University, Shenyang, China
| | - Haijuan Yao
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Nahum Méndez-Sánchez
- Liver Research Unit Medica Sur Clinic & Foundation and Faculty of Medicine, National Autonomous University of Mexico, Mexico City, Mexico
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
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Zhang P, Wang H, Bao H, Wang N, Chen Z, Tu Q, Lin X, Li Y, Zheng Z, Chen Y, Ruan L, Zhuge Q. Non-invasive Liver Fibrosis Scores Are Associated With Recurrence of Postoperative Chronic Subdural Hematoma. Front Neurol 2022; 13:873124. [PMID: 35769370 PMCID: PMC9236226 DOI: 10.3389/fneur.2022.873124] [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: 02/10/2022] [Accepted: 04/29/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Although liver diseases have already been identified as a risk factor for increased recurrence and mortality in patients with chronic subdural hematoma (CSDH), the association between subclinical liver disease, specifically liver fibrosis (LF), and CSDH remains unknown. In the present study, we aimed to investigate the association between the LF scores and CSDH recurrence. Methods We retrospectively analyzed consecutive patients with CSDH who underwent burr-hole irrigation in the First Affiliated Hospital of Wenzhou Medical University between January 2015 and December 2018. The clinical data were collected, and the LF scores were calculated including aspartate aminotransferase–platelet ratio index (APRI), fibrosis-4 (FIB-4), and Forns index. Multivariable logistic regression analysis was applied to identify the association between the LF scores and CSDH recurrence, and Cox regression model and Fine–Gray competing risks model were performed to calculate hazard ratios (HRs) for CSDH recurrence based on time-to-event outcomes. The C-statistic, the integrated discrimination improvement (IDI), and the net reclassification improvement (NRI) evaluated the additive value of the LF scores to predict the recurrence of CSDH. Results A total of 419 patients with CSDH were included, hematoma recurrence was observed in 62 patients (14.80%) within 1 year after surgery. The LF scores were significantly higher in those who recurred, whereas the standard hepatic assays were mostly normal. The patients were assigned to groups of high and low LF scores based on the validated cut-offs; compared with the subjects with low scores, those with high score levels had significantly higher recurrence rates. After adjusting for potential confounders, the LF scores were independently associated with CSDH recurrence, multivariable-adjusted HRs (95% CI) for those with higher levels of APRI, FIB-4, and Forns score were 4.32 (1.37–13.60), 2.56 (1.20–5.43), and 2.02 (1.07–3.79) for the recurrence of CSDH, respectively. Moreover, adding the APRI to the conventional model improved the C-statistic from 0.731 to 0.763, with an NRI and IDI of 7.50 and 1.35%, respectively. Two further commonly-used LF score indices (FIB-4 score and Forns index) yielded comparable results. Conclusions The data from this study first indicated that the high LF scores were significantly associated with the recurrence of CSDH and that careful follow-up in these patients may be needed.
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Affiliation(s)
- Peng Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hua Wang
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Han Bao
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ning Wang
- Neurointerventional Department, Zhejiang Hospital, Hangzhou, China
| | - Zhen Chen
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Qi Tu
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiao Lin
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yun Li
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zezheng Zheng
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yu Chen
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Linhui Ruan
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- *Correspondence: Linhui Ruan
| | - Qichuan Zhuge
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Qichuan Zhuge
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A Liver Stiffness Measurement-Based Nomogram Predicts Variceal Rebleeding in Hepatitis B-Related Cirrhosis. DISEASE MARKERS 2022; 2022:4107877. [PMID: 35692881 PMCID: PMC9184154 DOI: 10.1155/2022/4107877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 04/03/2022] [Accepted: 04/11/2022] [Indexed: 11/17/2022]
Abstract
Background Cirrhosis esophageal variceal rebleeding is a major complication of chronic cirrhosis. The hepatic venous pressure gradient (HVPG) can predict the risk of rebleeding in patients with cirrhosis and has a good correlation with liver stiffness measurement (LSM). However, there are currently few studies based on liver stiffness to predict the risk of rebleeding in patients with liver cirrhosis. This study is aimed at exploring whether liver stiffness can predict rebleeding in patients with hepatitis B virus-related cirrhosis and developing an easy-to-use nomogram for predicting the risk of rebleeding in patients with liver cirrhosis undergoing secondary prevention. Methods A prospective analysis of 289 cirrhosis patients was performed. Univariate and multivariate analyses were used to identify independent prognostic factors to create a nomogram. The performance of the nomogram was evaluated by using a bootstrapped-concordance index and calibration plots. Results Use of a nonselective beta-blocker (NSBB) drug, LSM, hemoglobin, and platelet count were identified as factors that could predict rebleeding. We created a nomogram for rebleeding in cirrhosis by using these risk factors. The predictive ability of the nomogram was assessed by the C-index (0.772, 95% CI 0.732–0.822). The results of the calibration plots showed that the actual observation and prediction values obtained by the nomogram had good consistency. Conclusions LSM can predict the risk of rebleeding in patients with cirrhosis, while the nomogram is a conventional tool for doctors to facilitate a personalized prognostic evaluation.
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9
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Nguyen G, Lejeune M, Crichi B, Frere C. Hemostasis testing in patients with liver dysfunction: Advantages and caveats. World J Gastroenterol 2021; 27:7285-7298. [PMID: 34876789 PMCID: PMC8611202 DOI: 10.3748/wjg.v27.i42.7285] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/08/2021] [Accepted: 10/20/2021] [Indexed: 02/06/2023] Open
Abstract
Due to concomitant changes in pro- and anti-coagulant mechanisms, patients with liver dysfunction have a “rebalanced hemostasis”, which can easily be tipped toward either a hypo- or a hypercoagulable phenotype. Clinicians are often faced with the question whether patients with chronic liver disease undergoing invasive procedures or surgery and those having active bleeding require correction of the hemostasis abnormalities. Conventional coagulation screening tests, such as the prothrombin time/international normalized ratio and the activated partial thromboplastin time have been demonstrated to have numerous limitations in these patients and do not predict the risk of bleeding prior to high-risk procedures. The introduction of global coagulation assays, such as viscoelastic testing (VET), has been an important step forward in the assessment of the overall hemostasis profile. A growing body of evidence now suggests that the use of VET might be of significant clinical utility to prevent unnecessary infusion of blood products and to improve outcomes in numerous settings. The present review discusses the advantages and caveats of both conventional and global coagulation assays to assess the risk of bleeding in patients with chronic liver disease as well as the current role of transfusion and hemostatic agents to prevent or manage bleeding.
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Affiliation(s)
- Guillaume Nguyen
- Department of Hematology, Trousseau Hospital, Assistance Publique Hôpitaux de Paris, Paris 75012, France
| | - Manon Lejeune
- Department of Hematology, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Paris 75013, France
| | - Benjamin Crichi
- Department of Internal Medicine, Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris, Paris 75010, France
| | - Corinne Frere
- Department of Hematology, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Paris 75013, France
- Inserm UMRS_1166, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris 75013, France
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10
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Sripongpun P, Pongpaibul A, Charatcharoenwitthaya P. Value and risk of percutaneous liver biopsy in patients with cirrhosis and clinical suspicion of autoimmune hepatitis. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000701. [PMID: 34362759 PMCID: PMC8351491 DOI: 10.1136/bmjgast-2021-000701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/20/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE The decision regarding whether to perform a liver biopsy in patients with cirrhosis and clinically suspected autoimmune hepatitis (AIH) remains a challenge. This study aimed to assess the utility and complications of percutaneous liver biopsy in cirrhosis for differentiating AIH from other liver conditions. METHODS A clinicopathological database of patients undergoing percutaneous liver biopsies for suspected AIH (unexplained hepatitis with elevated γ-globulin and autoantibody seropositivity) was reviewed to identify patients presenting with cirrhosis. Biopsy slides were reviewed by an experienced hepatopathologist who was blinded to clinical data. RESULTS In 207 patients who underwent liver biopsy for suspected AIH, 59 patients (mean age: 59.0±12.0 years, 83.1% female) had clinically diagnosis of cirrhosis. Mean Child-Turcotte-Pugh score was 6.6±1.6, and 44% of patients had a Child-Turcotte-Pugh score≥7. According to the revised International AIH Group (IAIHG) criteria, histology assessment combined with clinical information facilitated a diagnosis of AIH or overlap syndrome of AIH and primary biliary cholangitis (PBC) in 81.4% of cases. Liver biopsy identified other aetiologies, including PBC (n=2), non-alcoholic steatohepatitis (n=6) and cryptogenic cirrhosis (n=3). A reliable diagnosis of AIH could be made using histological category of the simplified criteria in 69.2% and 81.8% of cases using IAIHG scores before biopsy of <10 and 10-15, respectively. Three patients with cirrhosis (5.1%) experienced bleeding following biopsy, but none of 148 patients with non-cirrhosis had bleeding complication (p=0.022). CONCLUSION Liver biopsy provides important diagnostic information for the management of patients with cirrhosis and suspected AIH, but the procedure is associated with significant risk.
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Affiliation(s)
- Pimsiri Sripongpun
- Medicine, Mahidol University Faculty of Medicine Siriraj Hospital, Bangkok, Thailand.,Medicine, Faculty of Medicine Prince of Songkla University, Hat Yai, Songkla, Thailand
| | - Ananya Pongpaibul
- Pathology, Mahidol University Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
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11
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Ding JN, Zhao WF. Mechanism, diagnosis, and treatment of portal vein thrombosis in cirrhosis. Shijie Huaren Xiaohua Zazhi 2021; 29:670-676. [DOI: 10.11569/wcjd.v29.i12.670] [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] [Indexed: 02/06/2023] Open
Abstract
Portal vein thrombosis (PVT) is one of the common complications of cirrhosis. Its formation is influenced by many factors, such as liver function grade, blood coagulation state, portal vein pressure, and blood flow velocity. The treatment of patients with PVT is more difficult than that of patients without PVT, and the prognosis is poor. However, the presence of PVT is usually asymptomatic, thus early detection and intervention are important. Currently, there are different views on the mechanism of PVT. This review will discuss the mechanism of PVT and summarize its pathogenesis, diagnosis, and treatment, with an aim to provide evidence for clinical practice.
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Affiliation(s)
- Jing-Nuo Ding
- Department of Infectious Diseases, The First Affiliated Hospital of Soochow University, Suzhou 215000, JiangSu Province, China
| | - Wei-Feng Zhao
- Department of Infectious Diseases, The First Affiliated Hospital of Soochow University, Suzhou 215000, JiangSu Province, China
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12
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Lu M, Blaine KP, Cullinane A, Hall C, Dulau-Florea A, Sun J, Chenwi HF, Graninger GM, Harper B, Thompson K, Krack J, Barnett CF, Brusca SB, Elinoff JM, Solomon MA. Pulmonary arterial hypertension patients display normal kinetics of clot formation using thrombelastography. Pulm Circ 2021; 11:20458940211022204. [PMID: 34249330 PMCID: PMC8237222 DOI: 10.1177/20458940211022204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 05/16/2021] [Indexed: 11/15/2022] Open
Abstract
Pulmonary arterial hypertension is characterized by endothelial dysfunction and
microthrombi formation. The role of anticoagulation remains controversial, with
studies demonstrating inconsistent effects on pulmonary arterial hypertension
mortality. Clinical anticoagulation practices are currently heterogeneous,
reflecting physician preference. This study uses thrombelastography and
hematology markers to evaluate whether clot formation and fibrinolysis are
abnormal in pulmonary arterial hypertension patients. Venous blood was collected
from healthy volunteers (n = 20) and patients with pulmonary
arterial hypertension (n = 20) on stable medical therapy for
thrombelastography analysis. Individual thrombelastography parameters and a
calculated coagulation index were used for comparison. In addition, hematologic
markers, including fibrinogen, factor VIII activity, von Willebrand factor
activity, von Willebrand factor antigen, and alpha2-antiplasmin, were measured
in pulmonary arterial hypertension patients and compared to healthy volunteers.
Between group differences were analyzed using t tests and linear mixed models,
accounting for repeated measures when applicable. Although the degree of
fibrinolysis (LY30) was significantly lower in pulmonary arterial hypertension
patients compared to healthy volunteers (0.3% ± 0.6 versus
1.3% ± 1.1, p = 0.04), all values were within the normal
reference range (0–8%). All other thrombelastography parameters were not
significantly different between pulmonary arterial hypertension patients and
healthy volunteers (p ≥ 0.15 for all). Similarly,
alpha2-antiplasmin activity levels were higher in pulmonary arterial
hypertension patients compared to healthy volunteers (103.7% ± 13.6
versus 82.6% ± 9.5, p < 0.0001), but
all individual values were within the normal range (75–132%). There were no
other significant differences in hematologic markers between pulmonary arterial
hypertension patients and healthy volunteers (p ≥ 0.07 for
all). Sub-group analysis comparing thrombelastography results in patients
treated with or without prostacyclin pathway targeted therapies were also
non-significant. In conclusion, treated pulmonary arterial hypertension patients
do not demonstrate abnormal clotting kinetics or fibrinolysis by
thrombelastography.
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Affiliation(s)
- Mengyun Lu
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Kevin P Blaine
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA.,Department of Anesthesiology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Ann Cullinane
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Courtney Hall
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Alina Dulau-Florea
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Junfeng Sun
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Herman F Chenwi
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Grace M Graninger
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Bonnie Harper
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Keshia Thompson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Janell Krack
- Pharmacy Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Christopher F Barnett
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC, USA
| | - Samuel B Brusca
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Jason M Elinoff
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Michael A Solomon
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA.,Cardiology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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13
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He Y, Yuan S, Guo X, Yi F, Xu X, An Y, Xu S, Ageno W, Qi X. Association of thromboelastography profile with severity of liver cirrhosis and portal venous system thrombosis. BMC Gastroenterol 2021. [PMID: 34098892 DOI: : 10.1186/s12876-021-01832-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND AIM Hemostasis profile is often complicated in liver cirrhosis. Thromboelastography is a global viscoelastic test recommended by the current practice guideline and consensus. This cross-sectional study aimed to evaluate the association of thromboelastography profile with severity of liver cirrhosis and presence of portal venous system thrombosis (PVST). METHODS Overall, 116 and 50 cirrhotic patients were included in the Shenyang and Xi'an cohorts, respectively. Thromboelastography parameters were compared between cirrhotic patients with Child-Pugh class A and B/C, those with and without decompensated events, and those with and without PVST. Hypercoagulability would be considered if at least two of the following thromboelastography parameters were met: shortened reactive time (R), shortened coagulation time (K), increased angle, and increased maximum amplitude (MA). RESULTS In the Shenyang cohort, 16 patients had shortened R, of whom seven (43.75%) had prolonged K and 11 (68.75%) decreased MA. In the Xi'an cohort, 24 patients had shortened R, of whom seven (29.17%) had prolonged K and 15 (62.50%) decreased MA. In the Shenyang cohort, the prevalence of hypercoagulability was not significantly different between cirrhotic patients with Child-Pugh class A and B/C (3.85% vs. 6.25%, P = 0.873), those with and without decompensated events (5.49% vs. 4.00%, P = 1.000), and those with and without PVST (4.17% vs. 5.88%, P = 1.000), which were similar to the results obtained in the Xi'an cohort. CONCLUSION There is a high rate of discordance between R and other thromboelastography parameters. In addition, hypercoagulability may not be related to more advanced stage of liver cirrhosis or presence of PVST.
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Affiliation(s)
- Yanglan He
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning Province, China
- Postgraduate College, China Medical University, Shenyang, 110122, China
| | - Shanshan Yuan
- Department of Gastroenterology, Xi'an Central Hospital, Xi'an, 710003, China
| | - Xiaozhong Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning Province, China
| | - Fangfang Yi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning Province, China
| | - Xiangbo Xu
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning Province, China
| | - Yang An
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning Province, China
| | - Shixue Xu
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning Province, China
- Postgraduate College, China Medical University, Shenyang, 110122, China
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning Province, China.
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14
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He Y, Yuan S, Guo X, Yi F, Xu X, An Y, Xu S, Ageno W, Qi X. Association of thromboelastography profile with severity of liver cirrhosis and portal venous system thrombosis. BMC Gastroenterol 2021; 21:253. [PMID: 34098892 PMCID: PMC8185912 DOI: 10.1186/s12876-021-01832-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 05/25/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND AIM Hemostasis profile is often complicated in liver cirrhosis. Thromboelastography is a global viscoelastic test recommended by the current practice guideline and consensus. This cross-sectional study aimed to evaluate the association of thromboelastography profile with severity of liver cirrhosis and presence of portal venous system thrombosis (PVST). METHODS Overall, 116 and 50 cirrhotic patients were included in the Shenyang and Xi'an cohorts, respectively. Thromboelastography parameters were compared between cirrhotic patients with Child-Pugh class A and B/C, those with and without decompensated events, and those with and without PVST. Hypercoagulability would be considered if at least two of the following thromboelastography parameters were met: shortened reactive time (R), shortened coagulation time (K), increased angle, and increased maximum amplitude (MA). RESULTS In the Shenyang cohort, 16 patients had shortened R, of whom seven (43.75%) had prolonged K and 11 (68.75%) decreased MA. In the Xi'an cohort, 24 patients had shortened R, of whom seven (29.17%) had prolonged K and 15 (62.50%) decreased MA. In the Shenyang cohort, the prevalence of hypercoagulability was not significantly different between cirrhotic patients with Child-Pugh class A and B/C (3.85% vs. 6.25%, P = 0.873), those with and without decompensated events (5.49% vs. 4.00%, P = 1.000), and those with and without PVST (4.17% vs. 5.88%, P = 1.000), which were similar to the results obtained in the Xi'an cohort. CONCLUSION There is a high rate of discordance between R and other thromboelastography parameters. In addition, hypercoagulability may not be related to more advanced stage of liver cirrhosis or presence of PVST.
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Affiliation(s)
- Yanglan He
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840 Liaoning Province China
- grid.412449.e0000 0000 9678 1884Postgraduate College, China Medical University, Shenyang, 110122 China
| | - Shanshan Yuan
- grid.478124.cDepartment of Gastroenterology, Xi’an Central Hospital, Xi’an, 710003 China
| | - Xiaozhong Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840 Liaoning Province China
| | - Fangfang Yi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840 Liaoning Province China
| | - Xiangbo Xu
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840 Liaoning Province China
| | - Yang An
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840 Liaoning Province China
| | - Shixue Xu
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840 Liaoning Province China
- grid.412449.e0000 0000 9678 1884Postgraduate College, China Medical University, Shenyang, 110122 China
| | - Walter Ageno
- grid.18147.3b0000000121724807Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840 Liaoning Province China
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15
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Thrombocytopenia and Hemostatic Changes in Acute and Chronic Liver Disease: Pathophysiology, Clinical and Laboratory Features, and Management. J Clin Med 2021; 10:jcm10071530. [PMID: 33917431 PMCID: PMC8038677 DOI: 10.3390/jcm10071530] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/22/2021] [Accepted: 03/24/2021] [Indexed: 12/12/2022] Open
Abstract
Thrombocytopenia, defined as a platelet count <150,000/μL, is the most common complication of advanced liver disease or cirrhosis with an incidence of up to 75%. A decrease in platelet count can be the first presenting sign and tends to be proportionally related to the severity of hepatic failure. The pathophysiology of thrombocytopenia in liver disease is multifactorial, including (i) splenomegaly and subsequently increased splenic sequestration of circulating platelets, (ii) reduced hepatic synthesis of thrombopoietin with missing stimulation both of megakaryocytopoiesis and thrombocytopoiesis, resulting in diminished platelet production and release from the bone marrow, and (iii) increased platelet destruction or consumption. Among these pathologies, the decrease in thrombopoietin synthesis has been identified as a central mechanism. Two newly licensed oral thrombopoietin mimetics/receptor agonists, avatrombopag and lusutrombopag, are now available for targeted treatment of thrombocytopenia in patients with advanced liver disease, who are undergoing invasive procedures. This review summarizes recent advances in the understanding of defective but at low level rebalanced hemostasis in stable cirrhosis, discusses clinical consequences and persistent controversial issues related to the inherent bleeding risk, and is focused on a risk-adapted management of thrombocytopenia in patients with chronic liver disease, including a restrictive transfusion regimen.
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16
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Topical Issues in Diagnosis of Coagulopathies and Prevention of Thromboembolic Complications of Atrial Fibrillation in Patients with Liver Cirrhosis. Fam Med 2021. [DOI: 10.30841/2307-5112.5-6.2020.225448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Nowadays the comorbid pathology of liver cirrhosis and atrial fibrillation has been widely discussed and reported in the literature in the light of recent findings from the study of the effectiveness and safety of anticoagulants in this category of patients. The review is devoted to summarizing the existing data on the comorbid course of these diseases from the point of view of the impact of bleeding and thrombosis on the quality of life and mortality of patients and the possibility of using new methods of diagnosis and prevention of these complications.
The purpose of the review is to focus the attention of physicians and researches on the relevance and prevalence of comorbid course of liver cirrhosis and atrial fibrillation, their complications, and discuss the benefits and possibilities of applying global methods of hemostasis assessment and anticoagulants in clinical practice.
This article examines the main pathophysiological aspects of «rebalanced hemostasis» theory in liver coagulopathies, its effect on the onset of bleeding and thrombotic events, and considering the clinical benefit of the use of anticoagulants. The disadvantages of traditional coagulation assessment tests compared to the benefits of thromboelastometry (ROTEM) and thromboelastography (TEG), general fulfilling principles and evaluation of their indicators are discussed. Existing research findings on the safety and efficacy of warfarin and direct oral anticoagulants in patients with liver cirrhosis and atrial fibrillation compared with no treatment are highlighted.
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17
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Mpaili E, Tsilimigras DI, Moris D, Sigala F, Frank SM, Hartmann J, Pawlik TM. Utility of viscoelastic coagulation testing in liver surgery: a systematic review. HPB (Oxford) 2021; 23:331-343. [PMID: 33229277 DOI: 10.1016/j.hpb.2020.10.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 09/30/2020] [Accepted: 10/01/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The objective of the current study was to summarize and evaluate all published evidence regarding viscoelastic testing in the field of liver surgery. METHODS A systematic search of the literature was performed using Medline/PubMed, Scopus, Cochrane Library Central, Google Scholar, and clinicaltrials.gov databases. The following keywords were used:"Thromboelastography", "Thromboelastometry", "Viscoelastic tests OR testing", "Sonoclot Devices", "Point-of-care tests OR testing", "Coagulation OR Haemostasis OR Hemostasis", "Liver OR Hepatic Surgery", "Cirrhosis." RESULTS A total of 12 studies analyzing 348 patients who underwent viscoelastic testing of coagulation during liver surgery for benign or malignant diseases were included; 7 (58.3%) studies reported on the use of thromboelastography (TEG), and 5 (41.7%) reported on rotational thromboelastometry (ROTEM). Viscoelastic testing (TEG and ROTEM) identified normo-, hyper- and hypo-coagulable status in 77% (n = 268/348), 18.4% (n = 64/348), and 4.6% (n = 16/348) of patients, respectively. In contrast, conventional coagulation tests indicated normo-coagulability in 111 patients (34.2% out of 325) and hypo-coagulability in 214 (65.8% out of 325) patients following liver resection. No patient (0% out of 291) experienced postoperative hemorrhage, whereas 5.8% (n = 17/291) experienced postoperative thromboembolic events. CONCLUSIONS Global viscoelastic testing may be a reasonable adjunct to conventional coagulation testing to provide a more robust assessment of the coagulation status of patients undergoing liver surgery.
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Affiliation(s)
- Eustratia Mpaili
- Department of Surgery, Laikon University Hospital, University of Athens, Athens, Greece
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Fragiska Sigala
- First Department of Surgery, Hippocration Hospital, University of Athens, Athens, Greece
| | - Steven M Frank
- Johns Hopkins Health System Blood Management Program, Armstrong Institute for Patient Safety and Quality, Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | | | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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18
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Li C, Zhou H, Feng Y, Zhao Y, Wang J, Chen Z, Yin S. Coagulation States in Patients With Sudden Sensorineural Hearing Loss Evaluated by Thromboelastography. Otolaryngol Head Neck Surg 2020; 164:1280-1286. [PMID: 33138704 DOI: 10.1177/0194599820965240] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE The state of coagulation is controversial in patients with sudden sensorineural hearing loss (SSNHL). We used thromboelastography (TEG) to explore the relationships between blood coagulation parameters and SSNHL pathogenesis and recovery. STUDY DESIGN Prospective study. SETTING Affiliated Sixth People's Hospital, Shanghai Jiao Tong University. METHODS A total of 104 newly diagnosed patients with SSNHL and 29 matched healthy controls were recruited. Hearing assessments, TEG, and conventional coagulation tests (CCTs) were performed, followed by standard treatments and follow-up. RESULTS The TEG parameters of patients with SSNHL were in the normal range, but the group exhibited a significantly prolonged kinetic time (K; P = .004) and a smaller angle (P = .003) as compared with the controls. After grouping the patients with SSNHL according to audiograms and comparing them in pairs, we found that the differences were significant only when controls were compared with patients with low-frequency SSNHL (K, P = .023; angle, P = .04) and flat-type SSNHL (K, P = .017; angle, P = .014). Logistic regression analysis showed that neither TEG nor CCT parameters significantly affected hearing improvement after SSNHL treatment. CONCLUSIONS Although the K value and angle were significantly increased and significantly reduced, respectively, in the test group as compared with the control group, the state of coagulation in patients with SSNHL was still within the normal range. No CCT or TEG coagulation parameters (except the angle) differed significantly among patients in each group according to hearing recovery status, which suggested that the coagulation status does not determine the prognosis of patients with SSNHL.
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Affiliation(s)
- Chunyan Li
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Xuhui District, Shanghai, China.,Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
| | - Huiqun Zhou
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Xuhui District, Shanghai, China.,Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
| | - Yanmei Feng
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Xuhui District, Shanghai, China.,Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
| | - Yan Zhao
- Jinshan Branch of Shanghai Sixth People's Hospital, Shanghai, China.,Shanghai Jinshan District Central Hospital, Shanghai, China.,Shanghai Jinshan Hospital of Traditional Chinese Medicine, Shanghai, China
| | - Jingjing Wang
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Xuhui District, Shanghai, China.,Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
| | - Zhengnong Chen
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Xuhui District, Shanghai, China.,Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
| | - Shankai Yin
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Xuhui District, Shanghai, China.,Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
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19
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Tyler PD, Yang LM, Snider SB, Lerner AB, Aird WC, Shapiro NI. New Uses for Thromboelastography and Other Forms of Viscoelastic Monitoring in the Emergency Department: A Narrative Review. Ann Emerg Med 2020; 77:357-366. [PMID: 32988649 DOI: 10.1016/j.annemergmed.2020.07.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 07/10/2020] [Accepted: 07/14/2020] [Indexed: 12/17/2022]
Abstract
Patients frequently visit the emergency department with conditions that place them at risk of worse outcomes when accompanied by coagulopathy. Routine tests of coagulation-prothrombin time, partial thromboplastin time, platelets, and fibrinogen-have shortcomings that limit their use in providing emergency care. One alternative is to investigate coagulation disturbance with viscoelastic monitoring (VEM), a coagulation test that measures the timing and strength of blood clot development in real time. VEM is widely used and studied in cardiac surgery, liver transplant surgery, anesthesia, and trauma. In this article, we review the technique of VEM and the biologic rationale of using it in addition to routine tests of coagulation in emergency clinical situations. Then, we review the evidence (or lack thereof) for using VEM in the diagnosis and treatment of specific conditions. Finally, we describe the limitations of the test and future directions for clinical use and research in emergency medicine.
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Affiliation(s)
- Patrick D Tyler
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
| | - Lauren M Yang
- Department of Medicine, Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Samuel B Snider
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Adam B Lerner
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - William C Aird
- Department of Medicine, Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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20
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Janko N, Majeed A, Kemp W, Roberts SK. Viscoelastic Tests as Point-of-Care Tests in the Assessment and Management of Bleeding and Thrombosis in Liver Disease. Semin Thromb Hemost 2020; 46:704-715. [PMID: 32932542 DOI: 10.1055/s-0040-1715475] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Viscoelastic point-of-care (VET POC) tests provide a global assessment of hemostasis and have an increasing role in the management of bleeding and blood component delivery across several clinical settings. VET POC tests have a rapid turnaround time, provide a better overall picture of hemostasis, predict bleeding more accurately than conventional coagulation tests, and reduce blood component usage and health care costs. Despite commonly having abnormal conventional coagulation tests, most patients with chronic liver disease have a "rebalanced" hemostasis. However, this hemostatic balance is delicate and these patients are predisposed to both bleeding and thromboembolic events. Over recent years, VET POC tests have been increasingly studied for their potential as better functional tests of hemostasis in liver disease patients. This review provides a background on the most common VET POC tests (thromboelastography and rotational thromboelastometry) and discusses the current evidence for these tests in the prediction and management of bleeding and thrombosis in patients with chronic liver disease, and in liver resection and transplant. With the recent publication of several randomized controlled trials, there is growing evidence that VET POC tests may be used to improve bleeding risk assessment and reduce blood product use in liver disease patients outside of the transplant setting. However, consensus is still lacking regarding the VET POC tests' thresholds that should be used to trigger blood product transfusion. VET POC tests also show promise in predicting thrombosis in patients with liver disease, but further research is needed before they can be used to guide anticoagulant therapy.
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Affiliation(s)
- Natasha Janko
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Ammar Majeed
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - William Kemp
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Stuart K Roberts
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
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21
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Thromboelastography Better Reflects Hemostatic Abnormalities in Cirrhotics Compared With the International Normalized Ratio. J Clin Gastroenterol 2020; 54:741-746. [PMID: 31764489 PMCID: PMC7234893 DOI: 10.1097/mcg.0000000000001285] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
GOAL The goal of this study was to describe potential key differences in thromboelastography (TEG) variables in hospitalized cirrhotics compared with a healthy population, identify patterns of hematologic disturbance with disease progression, and assess the value of traditional tests such as international normalized ratio (INR) and platelet count to determine coagulopathy in cirrhotics. BACKGROUND TEG, a functional assay of coagulation, has emerged as a useful tool for predicting bleeding risk in cirrhosis. STUDY Hospitalized cirrhotics who received a TEG before any blood products between January 2017 and February 2018 at a liver transplant center were included. Reaction time (r-time), coagulation time (k-time), angle-rate of clot polymerization (α) and maximum clot strength (maximum amplitude) were measured with kaolin-activated citrated blood TEG assays. RESULTS A total of 106 cirrhotic patients (Child-Turcotte-Pugh A, B, C; n=25, 25, 56) were identified for comparison against data from 53 healthy controls. TEG parameters in cirrhotics were statistically different from controls. Mean INR and platelet count for all cirrhotics were largely outside the normal reference range, contrary to TEG parameters which demonstrated parameters mostly within the normal reference ranges. The r-time, k-time, and α values in the cirrhotics progressively increased and maximum amplitude values progressively decreased as the liver disease progressed. Regression analysis showed no significant correlations between INR and r-time across any Child-Turcotte-Pugh class (r=0.01, 0.18, 0.23; P=0.95, 0.39, 0.08, respectively). CONCLUSIONS Although cirrhotics had TEG parameters within normal ranges, there was a propensity for decreased clot formation as liver function worsened. Importantly, the INR did not correlate with TEG parameters in cirrhotic patients, and given the precarious hemostatic balance in these patients, a TEG may be a better predictor of bleeding risk.
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Seeßle J, Löhr J, Kirchner M, Michaelis J, Merle U. Rotational thrombelastometry (ROTEM) improves hemostasis assessment compared to conventional coagulation test in ACLF and Non-ACLF patients. BMC Gastroenterol 2020; 20:271. [PMID: 32807080 PMCID: PMC7433140 DOI: 10.1186/s12876-020-01413-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 08/07/2020] [Indexed: 12/11/2022] Open
Abstract
Background Patients with liver cirrhosis typically exhibit abnormal coagulation parameters in conventional coagulation tests (CCTs). Rotational thromboelastometry (ROTEM) is a holistic blood coagulation assay. This method provides an insight into the global hemostatic capabilities and has been suggested to provide a better overview of the coagulation system in liver cirrhosis. Methods The goal of this study was to examine hemostasis in patients with stable liver cirrhosis (Non-ACLF) and in acute-on-chronic liver failure (ACLF) by CCT and ROTEM including agreement of both tests and the prospective assessment of test performance based on clinical outcomes in ACLF patients. Therefore, ACLF patients were additionally subgrouped by bleeding events. Fifty-five Non-ACLF patients and twenty-two patients with ACLF were analysed in this prospective cohort study. Results Coagulation parameters analysed by CCT were outside the normal range in Non-ACLF and ACLF patients, but were significantly more aberrant in ACLF patients. Non-ACLF patients analysed by ROTEM revealed parameters largely within the normal limits, while significantly more ROTEM parameters in ACLF patients were affected. Maximum clot firmness (MCF) was significantly divergent between both patient groups and correlated well with levels of fibrinogen and platelet count. Using Cohen’s Kappa coefficient κ, the strength of agreement between CCT and ROTEM analyses was determined to be fair for Non-ACLF patients and moderate for ACLF patients. Bleeding events occurred significantly more often in ACLF group with significantly reduced A10 and MCF. Conclusions For assessing hemostasis in Non-ACLF and ACLF patients the underlying dataset shows advantages of ROTEM over CCT. A10 and MCF represent suitable prognostic parameters in predicting bleeding events in ACLF group.
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Affiliation(s)
- Jessica Seeßle
- Department of Gastroenterology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Jan Löhr
- Department of Gastroenterology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Marietta Kirchner
- Institute of Medical Biometry and Informatics, University Hospital Heidelberg, Heidelberg, Germany
| | - Josefin Michaelis
- Department of Gastroenterology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Uta Merle
- Department of Gastroenterology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
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Kakar N, Daniel G, Fellman C, de Laforcade A, Webster CR. Thromboelastography in cats with cholestatic liver disease. J Feline Med Surg 2020; 23:160-167. [PMID: 32672497 DOI: 10.1177/1098612x20939828] [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: 12/22/2022]
Abstract
OBJECTIVES While thromboelastography (TEG) has helped define a complex state of hemostasis in dogs and humans with hepatobiliary disease, it has not been explored in cats with cholestatic liver disease (CLD). The objective of this study was to describe TEG parameters in cats with CLD and to compare these parameters with conventional plasma-based coagulation tests, white blood cell (WBC) count and biochemical indicators of liver disease grade and severity. METHODS Eighteen cats with CLD, defined by a serum bilirubin ⩾3 mg/dl and a greater than two-fold increase in serum alanine aminotransferase (ALT) and/or alkaline phosphatase (ALP) activity, were prospectively enrolled. All cats received vitamin K1 subcutaneously for 24-36 h prior to acquisition of blood for kaolin-activated TEG analysis, prothrombin time (PT) and activated partial thromboplastin time (aPTT). Patient total solids, packed cell volume, platelet count, WBC count, and serum liver enzymes and bilirubin were extracted from the medical record and correlated with coagulation test results. RESULTS TEG global clot strength (TEG G) values defined 9/18 (50%), 5/18 (28%) and 4/18 (22%) cats as hypercoagulable, normocoagulable or hypocoagulable, respectively. TEG G was significantly negatively correlated with PT, aPTT and serum ALP activity and positively correlated with total solids. Five cats (5/18, 28%) were hyperfibrinolytic with clot lysis at 60 mins (LY 60) >15.3%. LY 60 was significantly positively correlated with PT. CONCLUSIONS AND RELEVANCE By TEG analysis, cholestatic cats replete with vitamin K1 display a variety of coagulation profiles. Indications of synthetic failure (prolonged PT and aPTT) were associated with hypocoagulable and hyperfibrinolytic TEG parameters. High disease activity (serum ALP) was associated with a hypocoagulable state.
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Affiliation(s)
- Neketa Kakar
- Small Animal Internal Medicine, Cummings School of Veterinary Medicine at Tufts University, Grafton, MA, USA
| | - Gideon Daniel
- Friendship Hospital for Small Animals, Washington, DC, USA
| | - Claire Fellman
- Department of Clinical Sciences, Cummings School of Veterinary Medicine at Tufts University, Grafton, MA, USA
| | - Armelle de Laforcade
- Department of Clinical Sciences, Cummings School of Veterinary Medicine at Tufts University, Grafton, MA, USA
| | - Cynthia Rl Webster
- Department of Clinical Sciences, Cummings School of Veterinary Medicine at Tufts University, Grafton, MA, USA
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Zhu Z, Yu Y, Ke Y, Deng D, Zheng G, Hua X, Gao G. Thromboelastography maximum amplitude predicts short-term mortality in patients with hepatitis B virus-related acute-on-chronic liver failure. Exp Ther Med 2020; 20:2657-2664. [PMID: 32765759 PMCID: PMC7401745 DOI: 10.3892/etm.2020.8990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 05/29/2020] [Indexed: 12/13/2022] Open
Abstract
Patients with hepatitis B virus (HBV)-related acute-on-chronic liver failure (ACLF) exhibit complex hemostatic defects. Thromboelastography (TEG) can be used to reveal global hemostasis in patients with liver disease; however, little is known about the association between TEG and the outcome of patients with HBV-related ACLF. The present study aimed to investigate the value of TEG for predicting 90 day mortality in patients with HBV-related ACLF. A total of 51 patients with HBV-related ACLF, 26 patients with chronic hepatitis B (CHB) and 26 healthy controls (HC) were enrolled in the present study. TEG, standard coagulation tests, routine blood tests, biochemical markers and demographic variables were recorded and assessed for prognostic value. The results indicated that a prolonged reaction and kinetics (K) time, a shortened α angle and a decreased maximum amplitude (MA) and coagulation index (CI) were observed in patients with HBV-related ACLF, compared with CHB and HC subjects. Patients with HBV-related ACLF in the mortality group exhibited a decrease in α angle, MA, lysis at 30 min, CI, fibrinogen and platelet count, and an increase in K time, international normalized ratio (INR) and the model for end-stage liver disease (MELD) score in comparison with the survival group. MA and INR were two independent predictors of 90 day mortality in patients with HBV-related ACLF, with hazard ratios of 0.918 (95% CI, 0.867-0.971; P=0.003) and 3.141 (95% CI, 1.843-5.354; P<0.001) respectively. When predicting 90 day mortality, MA + INR exhibited the highest area under the receiver operating characteristic curve, followed by INR, MELD score and MA. Patients with ACLF and MA ≤51.5 mm exhibited a poorer outcome than those with MA >51.5 mm, as revealed via the Kaplan-Meier analysis. In summary, the findings of the present study suggested that TEG MA was associated with 90 day mortality in patients with HBV-related ACLF, and a combination of MA and INR was superior to MA, INR and MELD score in terms of prognostic value.
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Affiliation(s)
- Zhe Zhu
- Department of Blood Transfusion, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315010, P.R. China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315010, P.R. China
| | - Yong Yu
- Department of Blood Transfusion, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315010, P.R. China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315010, P.R. China
| | - Yefang Ke
- Department of Clinical Laboratory, Ningbo Women and Children's Hospital, Ningbo, Zhejiang 315012, P.R. China
| | - Danfei Deng
- Department of Blood Transfusion, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315010, P.R. China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315010, P.R. China
| | - Guodong Zheng
- Department of Blood Transfusion, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315010, P.R. China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315010, P.R. China
| | - Xin Hua
- Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315010, P.R. China.,Department of Clinical Laboratory, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315010, P.R. China
| | - Guosheng Gao
- Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315010, P.R. China.,Department of Clinical Laboratory, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315010, P.R. China
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25
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Vuyyuru SK, Singh AD, Gamanagatti SR, Rout G, Gunjan D, Shalimar. A Randomized Control Trial of Thromboelastography-Guided Transfusion in Cirrhosis for High-Risk Invasive Liver-Related Procedures. Dig Dis Sci 2020; 65:2104-2111. [PMID: 31720889 DOI: 10.1007/s10620-019-05939-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 11/05/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Hemostasis in cirrhosis is dynamic and balanced. Thromboelastography (TEG) assesses global coagulation status. We aimed to assess whether TEG-guided blood product transfusions result in lower blood product requirements in patients with cirrhosis undergoing invasive liver-related procedures as compared to the conventional standard of care (SOC). METHODS In this open-label, randomized controlled trial, cirrhosis patients with coagulopathy, undergoing invasive liver-related procedures, were randomized to either TEG-guided blood product transfusion or SOC. The primary outcome was difference in the amount of fresh frozen plasma (FFP) and platelet units transfused between the two groups. The secondary outcome was procedure-related bleeding complications within 5 days and any complications until 28 days. RESULTS From November 2017 till June 2019, 58 patients were recruited (29: TEG and 29: SOC). Most common procedures performed were percutaneous liver biopsy (n = 48), followed by transjugular intrahepatic portosystemic shunt (n = 2), percutaneous acetic acid injection (n = 2), and transarterial chemoembolization (n = 2). There were no differences in baseline demographics, hemostatic profile, and types of procedures between the two groups. Only nine patients in TEG group received transfusions compared to all patients in SOC (31% vs 100%; P < 0.001). In TEG group, six (20.7%) received FFP (P = 0.753 vs. SOC), two (6.9%) received platelets (P < 0.001 vs. SOC), and 1(3.4%) patient received both FFP and platelet (P ≥ 0.999 vs. SOC) transfusion. None of the patients in either group developed procedure-related bleeding complications until 5 days post-procedure. The complication rates at 28-day follow-up were similar between the groups. CONCLUSION TEG-guided blood product transfusion strategy reduces blood product transfusion without increased risk of bleeding in cirrhotic patients undergoing invasive liver-related procedures (CTRI/2017/12/010822).
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Affiliation(s)
- Sudheer K Vuyyuru
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Achintya D Singh
- Department of Internal Medicine, All India Institute of Medical Sciences, New Delhi, India.,Departments of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | | | - Gyanranjan Rout
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
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26
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Gilbert BW, Bissell BD, Santiago RD, Rech MA. Tracing the Lines: A Review of Viscoelastography for Emergency Medicine Clinicians. J Emerg Med 2020; 59:201-215. [PMID: 32418869 DOI: 10.1016/j.jemermed.2020.04.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 03/25/2020] [Accepted: 04/08/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Viscoelastography (VE) is an established method to identify coagulopathies in various disease processes. Clinical decisions can be made with real-time tracings and quantitative values at the bedside. Thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®) have been utilized in several disease states with clinical varying success. OBJECTIVES This review will summarize the literature and provide recommendations pertaining to major disease processes where VE may be beneficial, including trauma, anticoagulation reversal, liver disease, acute ischemic stroke, and acquired brain injuries. DISCUSSION VE has a role in many emergency medicine patients encountered by clinicians. Reduced mortality, decreased blood product utilization, and prognostication ability makes VE an intriguing tool that can be utilized by providers to improve patient care. CONCLUSION This review serves as a way for emergency medicine clinicians to utilize VE in their practice and provides an insightful literature overview.
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Affiliation(s)
- Brian W Gilbert
- Department of Emergency Medicine, Wesley Medical Center, Wichita, Kansas
| | - Brittany D Bissell
- Medical Intensive Care Unit, University of Kentucky Healthcare, Lexington, Kentucky
| | - Ruben D Santiago
- Department of Emergency Medicine, Jackson Memorial Hospital, Miami, Florida
| | - Megan A Rech
- Department of Emergency Medicine, Loyola University Medical Center, Maywood, Illinois
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27
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Primary Hemostasis in Chronic Liver Disease and Cirrhosis: What Did We Learn over the Past Decade? Int J Mol Sci 2020; 21:ijms21093294. [PMID: 32384725 PMCID: PMC7247544 DOI: 10.3390/ijms21093294] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/21/2020] [Accepted: 05/03/2020] [Indexed: 02/07/2023] Open
Abstract
Changes in primary hemostasis have been described in patients with chronic liver disease (CLD) and cirrhosis and are still subject to ongoing debate. Thrombocytopenia is common and multifactorial. Numerous studies also reported platelet dysfunction. In spite of these changes, primary hemostasis seems to be balanced. Patients with CLD and cirrhosis can suffer from both hemorrhagic and thrombotic complications. Variceal bleeding is the major hemorrhagic complication and is mainly determined by high portal pressure. Non portal hypertension-related bleeding due to hemostatic failure is uncommon. Thrombocytopenia can complicate management of invasive procedures in CLD patients. Recently, oral thrombopoietin agonists have been approved to raise platelets before invasive procedures. In this review we aim to bundle literature, published over the past decade, discussing primary hemostasis in CLD and cirrhosis including (1) platelet count and the role of thrombopoietin (TPO) agonists, (2) platelet function tests and markers of platelet activation, (3) von Willebrand factor and (4) global hemostasis tests.
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28
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Parikh NS, Kamel H, Navi BB, Iadecola C, Merkler AE, Jesudian A, Dawson J, Falcone GJ, Sheth KN, Roh DJ, Elkind MS, Hanley DF, Ziai WC, Murthy SB. Liver Fibrosis Indices and Outcomes After Primary Intracerebral Hemorrhage. Stroke 2020; 51:830-837. [PMID: 31906832 PMCID: PMC7048169 DOI: 10.1161/strokeaha.119.028161] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background and Purpose- Cirrhosis-clinically overt, advanced liver disease-is associated with an increased risk of hemorrhagic stroke and poor stroke outcomes. We sought to investigate whether subclinical liver disease, specifically liver fibrosis, is associated with clinical and radiological outcomes in patients with primary intracerebral hemorrhage. Methods- We performed a retrospective cohort study using data from the Virtual International Stroke Trials Archive-Intracerebral Hemorrhage. We included adult patients with primary intracerebral hemorrhage presenting within 6 hours of symptom onset. We calculated 3 validated fibrosis indices-Aspartate Aminotransferase-Platelet Ratio Index, Fibrosis-4 score, and Nonalcoholic Fatty Liver Disease Fibrosis Score-and modeled them as continuous exposure variables. Primary outcomes were admission hematoma volume and hematoma expansion. Secondary outcomes were mortality, and the composite of major disability or death, at 90 days. We used linear and logistic regression models adjusted for previously established risk factors. Results- Among 432 patients with intracerebral hemorrhage, the mean Aspartate Aminotransferase-Platelet Ratio Index, Fibrosis-4, and Nonalcoholic Fatty Liver Disease Fibrosis Score values on admission reflected intermediate probabilities of fibrosis, whereas standard hepatic assays and coagulation parameters were largely normal. After adjusting for potential confounders, Aspartate Aminotransferase-Platelet Ratio Index was associated with hematoma volume (β, 0.20 [95% CI, 0.04-0.36]), hematoma expansion (odds ratio, 1.6 [95% CI, 1.1-2.3]), and mortality (odds ratio, 1.8 [95% CI, 1.1-2.7]). Fibrosis-4 was also associated with hematoma volume (β, 0.27 [95% CI, 0.07-0.47]), hematoma expansion (odds ratio, 1.9 [95% CI, 1.2-3.0]), and mortality (odds ratio, 2.0 [95% CI, 1.1-3.6]). Nonalcoholic Fatty Liver Disease Fibrosis Score was not associated with any outcome. Indices were not associated with the composite of major disability or death. Conclusions- In patients with largely normal liver chemistries, 2 liver fibrosis indices were associated with admission hematoma volume, hematoma expansion, and mortality after intracerebral hemorrhage.
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Affiliation(s)
- Neal S. Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Babak B. Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Costantino Iadecola
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Alexander E. Merkler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Arun Jesudian
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY
| | - Jesse Dawson
- Department of Cerebrovascular Medicine, University of Glasgow, United Kingdom
| | - Guido J. Falcone
- Department of Neurology, Division of Neurocritical Care & Emergency Neurology, Yale University, New Haven, CT
| | - Kevin N. Sheth
- Department of Neurology, Division of Neurocritical Care & Emergency Neurology, Yale University, New Haven, CT
| | - David J. Roh
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Mitchell S.V. Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Daniel F. Hanley
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Wendy C. Ziai
- Department of Neurology, Neurosurgery and Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Santosh B. Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
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30
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Veronese LR, Miller M, Spearman WC. Thromboelastography in mild, chronic liver disease: challenging conventional coagulation tests preceding liver biopsy. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2018. [DOI: 10.1080/22201181.2018.1510234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- LR Veronese
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - M Miller
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - WC Spearman
- Division of Hepatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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31
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Álvarez Román MT, Fernández Bello I, Jiménez-Yuste V, Martín Salces M, Arias-Salgado EG, Rivas Pollmar MI, Justo Sanz R, Butta NV. Immune thrombocytopenia - in defence of the platelet count. Response to Hill. Br J Haematol 2018; 182:130-131. [DOI: 10.1111/bjh.14730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
| | | | - Víctor Jiménez-Yuste
- Hematology and Hemotherapy Unit; University Hospital La Paz-IdiPaz; Madrid Spain
- Universidad Autónoma de Madrid; Madrid Spain
| | - Mónica Martín Salces
- Hematology and Hemotherapy Unit; University Hospital La Paz-IdiPaz; Madrid Spain
| | | | | | - Raúl Justo Sanz
- Hematology and Hemotherapy Unit; University Hospital La Paz-IdiPaz; Madrid Spain
| | - Nora V. Butta
- Hematology and Hemotherapy Unit; University Hospital La Paz-IdiPaz; Madrid Spain
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Abstract
Long thought to be hypocoagulable, new evidence suggests cirrhosis patients have "rebalanced" coagulation in the setting of decreased synthesis of both pro- and anti-coagulant factors. Traditional testing like PT/INR reflects only the decreased synthesis of pro-coagulant factors and thus does not correspond to bleeding or clotting risk in this population. In this review, we discuss the use of viscoelastic testing (VET), an assay of global hemostasis in cirrhosis patients. We describe the technique and interpretation of commercially available VET and assess the application of VET in both transplant and non-transplant cirrhosis populations. VET largely correlates well with traditional testing including platelet count and fibrinogen level, however, is potentially less accurate in patients with low fibrinogen levels. VET may be useful in identifying patients at higher risk of hypercoagulable complications post-transplant and reflects changes in hemostasis in decompensated patients. While VET has been associated with decreased transfusión support in multiple studies, the lack of bleeding in patients who avoided prophylactic transfusion suggests a "rescue" rather than prophylactic approach to transfusion may be ideal and further studies with a "rescue" arm are needed. Additional prospective studies of VET should include clinically relevant endpoints of bleeding and thrombosis.
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Affiliation(s)
- Jessica P E Davis
- University of Virginia, Charlottesville, Virginia, USA. Center for the Study of Coagulation in Liver Disease
| | - Patrick G Northup
- University of Virginia, Charlottesville, Virginia, USA. Center for the Study of Coagulation in Liver Disease
| | - Stephen H Caldwell
- University of Virginia, Charlottesville, Virginia, USA. Center for the Study of Coagulation in Liver Disease
| | - Nicolas M Intagliata
- Center for the Study of Coagulation in Liver Disease University of Virginia, Charlottesville, Virginia, USA
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Abstract
PURPOSE OF REVIEW Previous perceptions of cirrhosis as a hypocoagulable state have resulted in empirical blood product transfusions prior to invasive procedures. We evaluate procedure-related bleeding risks in patients with cirrhosis, assess the utility of conventional and newer global coagulation tests, and explore evidence surrounding prophylactic transfusion strategies. RECENT FINDINGS Recent literature supports the concept of a rebalanced, albeit fragile, haemostasis equilibrium in cirrhosis, with a potential hypercoagulable tendency in stable patients. Standard coagulation tests provide a poor reflection of bleeding risks and yet are relied upon for transfusion thresholds. Consequently, a sizeable proportion of patients receive unnecessary blood products. The role of viscoelastic tests to guide transfusions requires further evaluation. In stable cirrhotic patients, procedure-related bleeding rates appear low. Prophylactic transfusion strategies based on arbitrary thresholds lack evidence of clinical benefit. There is a pressing need for point-of-care coagulation tests that represent the complex coagulopathy of cirrhosis and well-powered randomised controlled trials to develop evidence-based pre-procedure transfusion guidelines.
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