medigraphic.com
Órgano Oficial de la Asociación Mexicana de Hepatología

2018, Number 6

<< Back Next >>

Ann Hepatol 2018; 17 (6)

Thromboelastography Parameters in Patients with Acute on Chronic Liver Failure

Sandeep-Goyal, Shekhar-Jadaun, Saurabh-Kedia, Kumar-Acharya S, Sharat-Varma, Baibaswata-Nayak, Bhaskar-Thakur, Shalimar

Language: English
References: 30
Page: 1042-1051
PDF size: 210.57 Kb.


ABSTRACT

Introduction and aim. Patients with acute on chronic liver failure (ACLF) have abnormal conventional coagulation tests- platelet count and international normalized ratio (INR). Thromboelastography (TEG) is a rapid, point-of-care assay, more comprehensive than platelet count and INR as it assesses for platelet adequacy(number and function), coagulation factors and clot retraction. The aim of the study was to evaluate the TEG parameters in patients with ACLF, chronic liver disease having acute decompensation (AD) and healthy subjects (HC). Material and methods. TEG parameters were assessed in patients with ACLF and AD within 24 h of admission. Consecutive patients were included in the study over 12 months. Healthy subjects were recruited as controls. Results. 179 patients were included- 68 ACLF, 53 AD and 58 HC. The mean values of INR in ACLF, AD and HC groups were 2.9 ± 1.4, 1.6 ± 0.4 and 1.1 ± 0.2; P ‹ 0.001. Among TEG parameters - maximum amplitude (MA) was low in ACLF and AD patients as compared with HC (53.8 ± 15, 58.3 ± 13.9 mm and 67.2 ± 12.1 mm, respectively; P ‹ 0.001). Lysis at 30 min (LY30) was high in ACLF patients, as compared to AD and HC (8.6 ± 14.1%, 5.0 ± 9.5% and 4.9 ± 9.8%, respectively; P = 0.060). There were no differences in r time, k time, and alpha angle between groups; normal in ›90% patients. There was no difference in TEG parameters between different ACLF grades, whereas CCTs were more deranged with increasing grades of ACLF. Conclusion. Despite abnormal conventional coagulation tests, TEG parameters in ACLF patients are essentially normal, except reduced maximum amplitude. Future studies are needed to explore the utility of TEG in clinical management of ACLF patients.


REFERENCES

  1. Moreau R, Jalan R, Gines P, Pavesi M, Angeli P, Cordoba J, Durand F, et al. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology 2013; 144: 1426-37.

  2. Shalimar, Kumar D, Vadiraja PK, Nayak B, Thakur B, Das P, Datta Gupta S, et al. Acute on chronic liver failure because of acute hepatic insults: Etiologies, course, extrahepatic organ failure and predictors of mortality. J Gastroenterol Hepatol 2016; 31: 856-4.

  3. Shi Y, Yang Y, Hu Y, Wu W, Yang Q, Zheng M, Zhang S, et al. Acute-on-chronic liver failure precipitated by hepatic injury is distinct from that precipitated by extrahepatic insults. Hepatology 2015; 62: 232-42.

  4. Shalimar, Saraswat V, Singh SP, Duseja A, Shukla A, Eapen CE, Kumar D, et al. Acute-on-chronic liver failure in India: The Indian National Association for Study of the Liver consortium experience. J Gastroenterol Hepatol 2016; 31: 1742-9.

  5. Tripodi A, Salerno F, Chantarangkul V, Clerici M, Cazzaniga M, Primignani M, Mannuccio Mannucci P, et al. Evidence of normal thrombin generation in cirrhosis despite abnormal conventional coagulation tests. Hepatology 2005; 41: 553-8.

  6. Søgaard KK, Horváth-Puhó E, Grønbaek H, Jepsen P, Vilstrup H, Sørensen HT. Risk of venous thromboembolism in patients with liver disease: a nationwide populationbased case-control study. Am J Gastroenterol 2009; 104: 96-101.

  7. Tripodi A, Primignani M, Chantarangkul V, Viscardi Y, Dell’Era A, Fabris FM, Mannucci PM. The coagulopathy of cirrhosis assessed by thromboelastometry and its correlation with conventional coagulation parameters. Thromb Res 2009; 124: 132-6.

  8. Stravitz RT. Potential applications of thromboelastography in patients with acute and chronic liver disease. Gastroenterol Hepatol 2012; 8: 513-20.

  9. Stravitz RT, Lisman T, Luketic VA, Sterling RK, Puri P, Fuchs M, Ibrahim A, et al. Minimal effects of acute liver injury/acute liver failure on hemostasis as assessed by thromboelastography. J Hepatol 2012; 56: 129-36.

  10. Shalimar, Kedia S, Gunjan D, Sonika U, Mahapatra SJ, Nayak B, Kaur H, et al. Acute Liver Failure Due to Hepatitis E Virus Infection Is Associated with Better Survival than Other Etiologies in Indian Patients. Dig Dis Sci 2017; 62: 1058-66.

  11. Riegler JL, Lake JR. Fulminant hepatic failure. Med Clin North Am 1993; 77: 1057-83.

  12. Jalan R, Saliba F, Pavesi M, Amoros A, Moreau R, Ginès P, et al. Development and validation of a prognostic score to predict mortality in patients with acute-on-chronic liver failure. J Hepatol 2014; 61: 1038-47.

  13. Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PC. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 2000; 31: 864-71.

  14. Biggins SW, Kim WR, Terrault NA, Saab S, Balan V, Schiano T, Benson J, et al. Evidence-based incorporation of serum sodium concentration into MELD. Gastroenterology 2006; 130: 1652-60.

  15. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med 1985; 13: 818-29.

  16. O’Shea RS, Dasarathy S, McCullough AJ, Practice Guideline Committee of the American Association for the Study of Liver Diseases, Practice Parameters Committee of the American College of Gastroenterology. Alcoholic liver disease. Hepatology 2010; 51: 307-28.

  17. Shalimar, Kedia S, Mahapatra SJ, Nayak B, Gunjan D, Thakur B, Acharya SK, et al. Severity and Outcome of Acute-on- Chronic Liver Failure is Dependent on the Etiology of Acute Hepatic Insults: Analysis of 368 Patients. J Clin Gastroenterol 2017; 51: 734-41.

  18. Subramanian A, Albert V, Saxena R, Agrawal D, Pandey RM. Establishing a normal reference range for thromboelastography in North Indian healthy volunteers. Indian J Pathol Microbiol 2014; 57: 43-50.

  19. Fisher C, Patel VC, Stoy SH, Singanayagam A, Adelmeijer J, Wendon J, Shawcross DL, et al. Balanced haemostasis with both hypo- and hyper-coagulable features in critically ill patients with acute-on-chronic-liver failure. J Crit Care 2018; 43: 54-60.

  20. Lisman T, Kleiss S, Patel VC, Fisher C, Adelmeijer J, Bos S, Singanayagam A, et al. In vitro efficacy of pro- and anticoagulant strategies in compensated and acutely ill patients with cirrhosis. Liver Int 2018. doi:10.1111/liv.13882 [Epub ahead of print].

  21. Lisman T, Bongers TN, Adelmeijer J, Janssen HLA, de Maat MPM, de Groot PG, Leebeek FW, et al. Elevated levels of von Willebrand Factor in cirrhosis support platelet adhesion despite reduced functional capacity. Hepatology 2006; 44: 53-61.

  22. Tripodi A, Primignani M, Chantarangkul V, Dell’Era A, Clerici M, de Franchis R, Colombo M, et al. An imbalance of pro- vs anti-coagulation factors in plasma from patients with cirrhosis. Gastroenterology 2009; 137: 2105-11.

  23. Muciño-Bermejo J, Carrillo-Esper R, Uribe M, Méndez- Sánchez N. Coagulation abnormalities in the cirrhotic patient. Ann Hepatol 2013; 12: 713-24.

  24. Royston D, von Kier S. Reduced haemostatic factor transfusion using heparinase-modified thrombelastography during cardiopulmonary bypass. Br J Anaesth 2001; 86: 575-8.

  25. Wang S-C, Shieh J-F, Chang K-Y, Chu Y-C, Liu C-S, Loong C-C, Chan KH, et al. Thromboelastography-guided transfusion decreases intraoperative blood transfusion during orthotopic liver transplantation: randomized clinical trial. Transplant Proc 2010; 42: 2590-3.

  26. De Pietri L, Bianchini M, Montalti R, De Maria N, Di Maira T, Begliomini B, Gerunda GE, et al. Thrombelastography-guided blood product use before invasive procedures in cirrhosis with severe coagulopathy: A randomized, controlled trial. Hepatology 2016; 63: 566-73.

  27. De Pietri L, Bianchini M, Rompianesi G, Bertellini E, Begliomini B. Thromboelastographic reference ranges for a cirrhotic patient population undergoing liver transplantation. World J Transplant 2016; 6: 583-93.

  28. Chau TN, Chan YW, Patch D, Tokunaga S, Greenslade L, Burroughs AK. Thrombelastographic changes and early rebleeding in cirrhotic patients with variceal bleeding. Gut 1998; 43: 267-71.

  29. Darlington A, Ferreiro JL, Ueno M, Suzuki Y, Desai B, Capranzano P, Capodanno D, et al. Haemostatic profiles assessed by thromboelastography in patients with end-stage renal disease. Thromb Haemost 2011; 106: 67-74.

  30. Papatheodoridis GV, Patch D, Webster GJ, Brooker J, Barnes E, Burroughs AK. Infection and hemostasis in decompensated cirrhosis: a prospective study using thrombelastography. Hepatology 1999; 29: 1085-90.




2020     |     www.medigraphic.com