Coagulation factor concentrate in the treatment of the haemorrhagic diathesis of fulminant hepatic failure

Five Hub Genes Can Be The Potential DNA Methylation Biomarkers For Cholangiocarcinoma Using Bioinformatics Analysis

Background

Cholangiocarcinoma (CCA) is a subtype of highly malignant hepatic tumor, which has low 5-year survival rate and poor clinical outcome. Only a few patients can be detected early and accepted with the surgery. Most of CCA patients are diagnosed in advanced stage, and the treatments are limited. As for the inoperable, advanced CCA patients, chemotherapy is the main treatment, due to lacking molecular targets, therapeutic effect is limited.

Materials and methods

To explore potential therapeutic targets for CCA, we analyzed three microarray datasets derived from the Gene Expression Omnibus (GEO) database. Then, we used GEO2R tools of NCBI to discover the differentially expressed genes (DEGs) from the CCA and normal liver tumor microarrays (TMA). Subsequently, we used the Database for Annotation, Visualization and Integrated Discovery (DAVID GO) to perform the Gene Ontology function (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis. Then, we carried out the Cytoscape software to search for the hub genes downregulated in CCA and identify the protein–protein interaction (PPI) of these genes. Besides, we used the GEPIA tool to evaluate the differential expressions of hub genes in CCA patients. Then, we also used MEXPRESS database to detect the promoter methylation levels of hub genes in CCA and normal tissue samples. In addition, we evaluated the expression of these genes in CCA lines and normal bile tract cells after 5-AZA (DNA methyltransferase inhibitor) treatment.

Results

A total of 115 downregulated DEGs were identified. Among them, 10 hub genes with a high degree of connectivity were picked out. Among these 10 hub genes, F2, AHSG, ALDH8A1, SERPIND1 and AGXT showed higher DNA methylation levels of promoter in CCA compared with normal liver tissues. Therefore, these 5 genes may be the potential DNA methylation biomarkers and therapeutic targets in CCA.

Cryoprecipitate for the correction of coagulopathy associated with liver disease

In patients with liver disease at risk of pulmonary oedema, cryoprecipitate (small volume) might be a viable alternative to fresh frozen plasma (FFP, large volume) in the correction of coagulopathy. However, the efficacy of cryoprecipitate in these patients has not been tested. We evaluated the role of cryoprecipitate in the correction of the coagulopathy of liver disease. To establish initial evidence of efficacy, six consecutive patients with hepatic failure and coagulopathy received five units of cryoprecipitate. Then, using a crossover design, 11 consecutive patients were randomized to receive either four units of FFP or five units of cryoprecipitate. Pre and post infusion International Normalized Ratio (INR), activated Partial Thromboplastin Time (aPTT), fibrinogen D-dimers, Factors V and IX, and reptilase time were measured. In the first six patients, cryoprecipitate improved the INR, aPTT and fibrinogen concentration (P = 0.03). In the crossover study, FFP administration produced a greater improvement in INR (P = 0.007) and aPTT (P = 0.005) than cryoprecipitate. However, there were no differences in any of the other measured variables. One patient developed acute pulmonary oedema while receiving FFP. Cryoprecipitate improves the coagulopathy of liver disease. Four units of FFP are more efficacious than five units of cryoprecipitate. Cryoprecipitate may have a role in correction of the coagulopathy associated with liver disease where concerns about pulmonary oedema exist.

Hematologic management of gastrointestinal bleeding

The hematologic management of gastrointestinal (GI) bleeding requires evaluation of the underlying cause of bleeding, associated diseases that can exacerbate the bleeding, and identification of related and unrelated coagulation abnormalities. Erythrocyte transfusions are given to increase oxygen carrying capacity; however, there is limited information on the level of anemia that places a patient at increased risk of adverse events after a GI bleed and when patients should receive erythrocyte transfusion. Isolated thrombocytopenia is uncommon in patients with GI bleeding, and there is little evidence documenting the degree of thrombocytopenia associated with an increased risk of bleeding. Platelets are often administered when the count is 50,000 per cu/mL in a bleeding patient. The coagulopathy of liver disease is the most common abnormality seen in the setting of GI bleeding. Fresh-frozen plasma (FFP) should be given in a dose equivalent to the underlying abnormality and the common practice of administering 2 units of FFP is often insufficient in a bleeding patient.

Fulminant hepatic failure

FHF is an uncommon but devastating condition affecting otherwise healthy persons which causes significant morbidity and mortality. The etiologic factor is most commonly viral infection, with drugs and metabolic disorders being relatively less common causes. Hopefully, newer diagnostic techniques such as PCR will increase our understanding of the causes and pathogenesis of this disorder. Medical management at the present time must focus on anticipating, preventing, and rapidly identifying and treating complications that may affect every major organ system. Encouraging research continues on the clinical application of hepatotrophic drugs and artificial liver support systems, both as potentially definitive therapies and as maintenance for patients awaiting transplantation. Consultation with physicians at a transplant center should be sought early in the course of the patient's hospitalization when OLT is being considered. Liver transplantation has dramatically changed the outlook for patients with FHF, with current survival rates in the 55% to 75% range. The continuing challenge for the transplant team is to allocate available donor organs to those patients who would not otherwise survive, but also to provide OLT in a timely fashion to ensure the best chance of post-transplantation recovery. Newer techniques such as heterotopic liver transplantation, reduced-size organ transplantation, and the utilization of living related donors may further improve the survival of these patients.

Prothrombin complex concentrates for clinical use

Prothrombin complex concentrates prepared for clinical use are reviewed with emphasis on frequently observed adverse reactions such as viral hepatitis and thromboembolic complications. Preparation procedures and quality control are described briefly, and the use of these concentrates in the treatment of hemophilia A patients who develop factor VIII inhibitors is also described. The causes of and methods for the detection of potential thrombogenicity are discussed and suggestions which may result in a safer product are made.

The use of factor IX concentrates in man: a 9-year experience of Scottish concentrates in the South-East of Scotland

During the last 9 years, two factor IX concentrates produced in Scotland, PPSB and DEFIX, have been used for the treatment of haemophilia B and acquired coagulation disorders, including those due to liver disease, coumarin therapy, neonatal immaturity and post-operative bleeding. During the period of study 112 batches of DEFIX and 40 batches of PPSB were used in the Edinburgh and South-East Scotland Region. Data were analysed from 575 non-haemophilic patients, receiving 968 treatment episodes, as well as 24 haemophiliacs. Serial coagulation studies and analysis of retrospective data showed that both concentrates corrected the coagulation deficiencies in all the above patient groups; in no case was there any evidence of intravascular coagulation resulting from concentrate infusion.

A factor VII concentrate for therapeutic use

A concentrate of factor VII suitable for therapeutic use has been prepared from human plasma by a method forming part of a comprehensive scheme of large-scale plasma fractionation. Factor VIII was separated as cryoprecipitate and factors II, IX and X were adsorbed on DEAE-cellulose. Most of the factor VII remained in the supernatant. By batch adsorption on DEAE-Sepharose, followed by elution on a chromatographic column, factor VII was concentrated about 25-fold, and purified about 50-fold compared with original plasma, without the need for further dialysis or concentration steps. Data are presented from 10 batches, each from 80-120 kg plasma. Following doses of factor VII to six congenitally deficient patients, the mean rise in plasma factor VII was 95-100% of theoretical; the half-disappearance time was about 4 h. The treatment of four patients with acquired deficiency of factor VII is also described. No untoward side effects were observed.

Idiopathic fatty liver of pregnancy with maternal and fetal survival

A case of idiopathic fatty liver of pregnancy with survival of mother and child is reported. The management of this condition is essentially supportive; coagulation disturbances may require special attention. Maternal survival should be the major consideration and is favourably influenced by early delivery. Fetal monitoring aids obstetric management and may indirectly improve fetal survival. Evidence from the literature suggests that the condition does not usually recur in subsequent pregnancies.

Acute liver failure. Experience in a special unit

Acute liver failure involves disturbances of all major organ systems. The pathophysiology of these disturbances are reviewed and details of management for each system is discussed in clinical work in a special Liver Failure Unit is used to derive principles of treatment, and the use of extracorporeal charcoal haemoperfusion is outlined.

Abnormal fibrin polymerization in liver disease

Although there have been isolated reports of an acquired abnormal fibrinogen in patients with liver disease, its frequency and clinical significance is not known. In this study 121 consecutive patients with a wide spectrum of hepatic disorders were screened for abnormal fibrin polymerization. A simple colorimetric method using Reptilase was employed. Of 32 patients with proven cirrhosis, 16 (50%) showed abnormal fibrin polymerization. The incidence in decompensated alcoholic cirrhosis was particularly high. The abnormality was also detected in all patients with acute liver failure and seven of 15 with chronic active liver disease. Clinical improvement often correlated with its disappearance. Two patients with primary liver cell tumours demonstrated the abnormal polymerization. In patients with bleeding oesophageal varices the detection of abnormal fibrin polymerization was associated with a poor prognosis. None of the patients with surgical obstructive jaundice (26) or miscellaneous liver disorders (37) had abnormal fibrin polymerization. The occurrence of abnormal fibrin polymerization in liver disease is more frequent than previously suspected and usually signifies severe primary hepatocellular dysfunction. Evidence is presented to support the presence of a primary abnormality of fibrinogen as the cause of impaired fibrin monomer polymerization.

The use of fresh frozen plasma or a concentrate of factor IX as replacement therapy before liver biopsy

Thirty patients with various types of chronic liver disease and a prothrombin time prolonged for four or more seconds who required needle liver biopsy for diagnostic purposes were given either fresh frozen plasma or a concentrate of clotting factors as a prophylactic measure. The prothrombin time returned to within normal limits in seven of the 15 patients given the concentrate and in three of those receiving fresh frozen plasma. Levels of factors II, IX, and X showed increases of about 30% following concentrate administration; corresponding rises in the group given fresh frozen plasma were less. This was because of the smaller quantity of clotting factors administered with fresh frozen plasma and the increase in factor II and IX activity/kg body weight/unit of clotting factor injected was greater when fresh frozen plasma was used. In neither group was there clinical evidence of bleeding, but it was of interest that most of the clotting factor levels, except in factor II, before biopsy were above those normally required for haemostasis. No evidence of disseminated intravascular coagulation was found with the concentrate injection, and the most worrying finding was the appearance of HBAg some months later in three patients, two from the concentrate group and one from those given fresh frozen plasma. However, the conversion of these patients to HBAg positive may be unrelated to the clotting factor replacement therapy.

Early changes in coagulation following a paracetamol overdose and a controlled trial of fresh frozen plasma therapy

Early changes in coagulation were found in patients following a paracetamol overdose. Low levels of clotting factors II, V and VII were present within 24 hours of the overdose. As the levels of factor II correlated with plasma fibrinogen values at this time, it is possible that they were consumed in the process of intravascular coagulation, although this was not supported by the presence of raised titres of fibrin degradation products. The prothrombin time ratio was greater than 2-2 within 30 hours of ingestion of the overdose in all patients who eventually died, whereas it was less than this in those developing only moderate liver damage. The administration of fresh frozen plasma to patients did appear to reduce the maximum abnormality of the prothrombin time ratio, which was significantly less three days after the overdose in the group receiving fresh frozen plasma. However, the coagulation disturbance was of short duration, and the prothrombin time ratio had also returned to normal within one week of the overdose in the control patients, and the administration of fresh frozen plasma did not appear to reduce the morbidity or mortality in the treated patients.

Use of factor-VII-rich prothrombin complex concentrate in liver disease

A prothrombin complex concentrate rich in factor VII has been used in the management of the clotting defect in thirteen patients with liver disease. Adequate correction of coagulation was achieved immediately after infusion in all cases. Within 4 hours there was some deterioration and by 24 hours the results approximated to pre-fusion values. Liver biopsies were performed without haemorrhagic complication in the immediate post-infusion period. There was no evidence of induced intravascular coagulation. Since other prothrombin complex concentrates have proved disappointing, both in their failure to correct the clotting defect and in their production of disseminated intravascular coagulation, this factor-VII-rich concentrate may be the treatment of choice in patients with liver disease who require temporary correction of their coagulation defect.