Hemostatic Changes In Patients Research Articles

Blood Disorders in Patients with Obstructive Jaundice: A Literature Review

BACKGROUND: Mechanical jaundice is a pathological syndrome consisting in a violation of the outflow of hepatic bile through the bile ducts into the duodenum due to mechanical obstacles. The most common causes of mechanical jaundice are gallstone disease, malignant tumors, as well as cicatricial stricture of the bile duct or the large duodenal papilla of the duodenum. All this leads to the development of renal-hepatic insufficiency. Thrombohemorrhagic changes develop in the vascular bed, leading to the development of disseminated intravascular coagulation syndrome. Prevention and treatment of cholemic bleeding in case of mechanical jaundice remains one of the complex problems of hepatobiliary surgery. This article is an overview of the causes and pathophysiological changes affecting hemostasis in mechanical jaundice, as well as the main points of treatment of hemostasis disorders in patients with mechanical jaundice. AIM: This study aims to study the literature on homeostasis in patients with mechanical jaundice. SEARCH STRATEGY: To conduct a systematic search for scientific information and to achieve this goal, an analysis of scientific publications in evidence-based medicine databases (PubMed), using specialized search engines (Google Scholar) and in electronic scientific libraries (CyberLeninka, e-library) was carried out from 2005 to 2020. INCLUSION CRITERIA: Research of high methodological quality: Meta-analysis, systematic review and cohort studies, as well as publications with clearly formulated and statistically proven conclusions in English, Russian, and Kazakh. EXCLUSION CRITERIA: Summaries of reports, reports in the form of abstracts, and advertising articles. RESULTS: The mechanisms that affect hemostasis in obstructive jaundice can be considered from four perspectives: The first relates to Vitamin K deficiency in obstructive jaundice, the second describes the effect of ongoing fibrosis and cirrhosis of the liver on hemostasis, the third analyzes the relationship between infectious-septic mechanisms and the hemostasis system, their clinical significance in patients with obstructive jaundice, and the latter involves the analysis of specific factors that manifest obstructive jaundice and may themselves affect the blood coagulation system. CONCLUSION: Understanding the pathophysiology of hemostatic changes in patients with cholestasis and, more generally, liver disease is a clear way to accurate diagnosis and treatment. The combination of good knowledge with careful examination of each patient can lead to the most promising result.

The Hypercoagulable Profile of Patients with Bone Tumors: A Pilot Observational Study Using Rotational Thromboelastometry.

Introduction: A detailed evaluation of the malignancy-associated coagulopathy (MAC) in surgical patients with bone tumors may allow for more effective thromboprophylactic measures. The purpose of this study was to assess the perioperative hemostatic changes in patients with bone tumors, using rotational thromboelastometry (ROTEM). Methods: An observational study was performed, including 50 patients with bone tumors who underwent oncologic resection and 30 healthy controls, matched for age and gender. The preoperative and postoperative laboratory evaluation of coagulation in both groups included conventional coagulation tests and a ROTEM analysis. The results of the conventional coagulation tests and the ROTEM analysis were compared between the two groups. Results: The results of the conventional coagulation tests were comparable between the tumor patients and the healthy controls. However, compared to the healthy adults, the tumor patients had lower CT (p < 0.001) and CFT (p < 0.001) values suggesting a rapid induction of the coagulation cascade, elevated A10 (p < 0.001) and MCF (p < 0.001) values indicating a higher clot strength and platelet activation, and elevated LI60 (p < 0.001) values indicating hypofibrinolysis in patients with bone tumors. The multiple linear regression analysis (controlling for potential confounding factors) confirmed the independent association of bone tumors with these hemostatic changes. Conclusions: Our results support the advantageous use of a ROTEM in patients with bone tumors over conventional coagulation tests because the qualitative changes in the hemostatic profile of these patients that can be detected by a ROTEM analysis cannot be identified by conventional tests. The ROTEM results indicate that the hypercoagulable state in patients with bone tumors is caused by the malignancy-associated activation of the coagulation cascade, platelet activation, and hypofibrinolysis.

Hemostatic changes in patients undergoing hemodialysis: Differences between central venous catheters and arterio-venous fistulas.

Failure to mature the fistula in patients undergoing hemodialysis leads to prolonged use of the central venous catheter (CVC) and can compromise the patency of the catheter and the arteriovenous fistula (AVF) due to thrombus development. To evaluate hemostatic changes in patients undergoing hemodialysis with prolonged use of CVC or AVF. Cross-sectional study with a total of 200 adult participants who were divided into the following groups: I:control; II: patients who had 5-8 months of CVC insertion; III: patients who had 9-36 months of insertion; IV patients who had 5-8 months of AVF; and V: patients who had 9-36 months of AVF. Platelet activation was investigated by expressions of GPIIb/IIIa and p-selectin using flow cytometry. The Elisa-thrombomodulin (TM) test was used to compare groups III and V. The p-selectin percentage expression of group I was 15.30 (12.30-16.80), II 23.25 (20.75-30.55); and III 54.00 (44.75-59.29) were significant (p < 0.001). Groups I, IV, and V were also significant (p < 0.001). The median fluorescence for GPIIb/IIIa for groups I, II, and III were significant (p < 0.0001). As for the Elisa test, an increased absorbance of TM was verified in patients who used the CVC 4372 (3951-4733) compared with those patients who used the AVF 2162 (1932-2485) (p < 0.0001). It can be concluded that CVC patients had a larger platelet expression of GPIIb/IIIa and p-selectin than AVF patients. The high concentration of TM in CVC patients may suggest a greater stimulation of the intrinsic than extrinsic coagulation pathways.

Coagulation Profile in COVID-19 Patients and its Relation to Disease Severity and Overall Survival: A Single-Center Study.

Objectives: This study aims to investigate hemostatic changes in patients with coronavirus disease (COVID-19) and their relationship to disease severity and survival. Methods: This study included 284 patients with COVID-19 who attended the Security Forces Hospital, Makkah, Saudi Arabia between October 2020 and March 2021, and retrospectively reviewed their demographic, radiological, and laboratory findings. The coagulation profile was assayed at the time of diagnosis for platelet counts using an automated hematology analyzer; Sysmex XN2000 while international normalized ratio (INR), activated partial thromboplastin time (aPTT), fibrinogen, D-dimer, factor VIII, ristocetin cofactor (RiCoF), and von Willebrand factor antigen (VWF-Ag) were measured by Stago kits on a Stago automated coagulation analyzer (STA Compact Max®). Results: In this study, 32.3% of the cases had severe disease, while 8.8% of the cases died. D-dimer, factor VIII, and RiCoF were the only independent predictors of disease severity, with factor VIII and RiCoF having significantly higher areas under the curve (AUCs) than D-dimer (all p < 0.001). Furthermore, age, aPTT, and factor VIII were associated with an increased risk of mortality in multivariate Cox regression analysis, with factor VIII having a higher AUC of 0.98 than aPTT with an optimal cut-off value of >314 IU/dl in predicting mortality. Cases with factor VIII levels >314 IU/dl, compared to those with factor VIII levels <314 IU/dl, were associated with a significantly shorter mean overall survival time (20.08 vs. 31.35 days, p < 0.001), a lower survival rate (30.3% vs. 99.2%, p < 0.001), and a 16.62-fold increased mortality risk. Conclusion: RiCoF is a novel predictor of disease severity in COVID-19, while factor VIII is confirmed as a predictor of severity and mortality in COVID-19 patients and is associated with lower overall survival and increased mortality risk.

Hemostatic system changes among diabetic foot ulcer patients

Background There are many reports about hemostatic changes in patients with diabetic foot ulcer (DFU). There are some reports about changes in the platelet morphology in patients with DFU. The goal of this research was to see whether platelet indices and hemostatic status might be used as predictors of DFU. Aim We aimed to assess the changes in the hemostatic system (hemostatic state and platelet indices) among patients with DFU. Patients and methods A total of 80 individuals were included in the study. They were divided into three groups: group 1 represented 20 diabetic patients without diabetic ulcer, group 2 represented 40 patients with known DFU, group 3 represented 20 normal healthy individuals. Laboratory investigations included fasting blood glucose level, kidney function tests (urea and creatinine), glycosylated hemoglobin, complete blood count including platelet count and platelet indices (platelet distribution width, mean platelet volume, plateletcrit, and platelet larger cell ratio), prothrombin time, international normalized ratio, activated partial thromboplastin time, and FVIII. Results Platelet indices (platelet distribution width, mean platelet volume, plateletcrit, and platelet larger cell ratio) were significantly greater in patients with DFU compared with other groups (P=0.0001), and FVIII was also significantly higher in patients with DFU compared with other groups (P=0.0001). Conclusion Diabetes is linked to a prothrombotic propensity as well as a hypercoagulable condition. Platelet indices indicate that patients with DFU have extra-reactive and aggregable platelets. Platelet indices could be used as an easy and cheap method for prediction and progression of DFU.

Hemostatic Changes in Patients with COVID-19: A Meta-Analysis with Meta-Regressions.

Background: Complications of coronavirus disease 2019 (COVID-19) include coagulopathy. We performed a meta-analysis on the association of COVID-19 severity with changes in hemostatic parameters. Methods: Data on prothrombin time (PT), activated partial thromboplastin time (aPTT), D-Dimer, platelets (PLT), or fibrinogen in severe versus mild COVID-19 patients, and/or in non-survivors to COVID-19 versus survivors were systematically searched. The standardized mean difference (SMD) was calculated. Results: Sixty studies comparing 5487 subjects with severe and 9670 subjects with mild COVID-19 documented higher PT (SMD: 0.41; 95%CI: 0.21, 0.60), D-Dimer (SMD: 0.67; 95%CI: 0.52, 0.82), and fibrinogen values (SMD: 1.84; 95%CI: 1.21, 2.47), with lower PLT count (SMD: −0.74; 95%CI: −1.01, −0.47) among severe patients. Twenty-five studies on 1511 COVID-19 non-survivors and 6287 survivors showed higher PT (SMD: 0.67; 95%CI: 0.39, 0.96) and D-Dimer values (SMD: 3.88; 95%CI: 2.70, 5.07), with lower PLT count (SMD: −0.60, 95%CI: −0.82, −0.38) among non-survivors. Regression models showed that C-reactive protein values were directly correlated with the difference in PT and fibrinogen. Conclusions: Significant hemostatic changes are associated with COVID-19 severity. Considering the risk of fatal complications with residual chronic disability and poor long-term outcomes, further studies should investigate the prognostic role of hemostatic parameters in COVID-19 patients.

Hemostatic changes in patients with chronic renal failure

Background: Renal disease results in significant disorder of hemostasis (bleeding diathesis orhypercoagulable state).Objectives: This study is to determine the changes in some hemostasis parameters in patients withchronic renal failure and identify the effect of dialysis on these changes.Patients and Methods: seventy five patients with end stage chronic renal failure were collected fromBaghdad hospital, a full detailed history and clinical examination were performed, 50 patients were onmaintenance weekly hemodialysis, and 25 patients were without dialysis.Result: Bleeding time was significantly higher in patients with chronic renal failure who didn’t needany type of dialysis, positive D-Dimer test. In some patients, Platelet count, prothrombin time, thrombintime, fibrinogene level, activated partial thromboplastin time; all did not reach significant level betweenboth groups of patients.Conclusion: hemostatic changes are not uncommon in patients with chronic renal failure, affecting thedifferent parameter hemostasis so it should be consider in the management of these patients.

Hemostatic changes in patients with chronic renal failure

Background: Renal disease results in significant disorder of hemostasis (bleeding diathesis orhypercoagulable state).Objectives: This study is to determine the changes in some hemostasis parameters in patients withchronic renal failure and identify the effect of dialysis on these changes.Patients and Methods: seventy five patients with end stage chronic renal failure were collected fromBaghdad hospital, a full detailed history and clinical examination were performed, 50 patients were onmaintenance weekly hemodialysis, and 25 patients were without dialysis.Result: Bleeding time was significantly higher in patients with chronic renal failure who didn’t needany type of dialysis, positive D-Dimer test. In some patients, Platelet count, prothrombin time, thrombintime, fibrinogene level, activated partial thromboplastin time; all did not reach significant level betweenboth groups of patients.Conclusion: hemostatic changes are not uncommon in patients with chronic renal failure, affecting thedifferent parameter hemostasis so it should be consider in the management of these patients.

Hemostatic changes in patients with peripheral artery disease before and after bypass surgery

To assess intrinsic coagulation pathway factors activity and hemostatic markers of endothelial dysfunction in patients with peripheral artery disease (PAD) before and after lower extremity bypass surgery. 80 patients with PAD Fontaine grade IIB-III were enrolled. 40 patients underwent open aorto-femoral-popliteal repair (group A) and 40 patients - medication (group B). Before and in 3 months after surgery peripheral venous blood samples were collected to assess the activity of factors VIII, IX, XI, von Willebrand factor (VWF), protein C (PrC), and metabolites of nitric oxide II (NO). Increased preoperative activity of VIII, IX, XI, and VWF factors compared with normal values was observed in group A. After 3 months there was an additional increase of VIII and VWF factors' activity. Activity of IX and XI factors remained increased on background of reduced level of NO metabolites. In group B increased activity of IX, XI, and VWF factors was revealed while levels of NO metabolites and PrC were normal. Thus, PAD is followed by prothrombotic state especially in patients after surgery. Surgical procedures are associated with more severe hypercoagulation.

Rheologic results and their correlation to hemostatic changes in patients with moderate and severe preeclampsia: An observational cross-sectional study

Previous study have shown an association between failure of physiological hemodilution during 2nd trimester and an increased risk for the development of subsequent pregnancy complications such as early birth, birth of a growth retarded newborn (IUGR), low fetal birth weight and preeclampsia. The latter complication in particular goes along with dramatic changes in the placental perfusion as well as systemic maternal blood flow. Severity of preeclampsia may be preceded by distinct impaired hemodilution and reflected by the results of rheological parameters. A subgroup analysis was performed in a community based retrospective study of 4,985 consecutively recorded singleton pregnant women of whom 423 had preeclampsia. Mean 2nd trimester hemoglobin levels and blood rheological results at the time of delivery were assessed and compared in women with moderate and severe preeclampsia. Mean 2nd trimester hemoglobin levels were calculated from the maternal records. Rheological variables included plasma viscosity (KSPV 1 Fresenius) and Red blood cell aggregation in stasis and under low shear conditions (MA1-Aggregometer; Myrenne). According to the definition of the German Society of Gynecology and Obstetrics (DGGG) 314 women had moderate preeclampsia (74.2%), while 109 had severe preeclampsia due to the presence of a blood pressure>170/110 mmHg (n=41; 9.7%), and/or IUGR<5th percentile (n=28; 6.6%), and/or HELLP-Syndrome (n=10; 2.4%), and/or proteinuria≥5 g/24 h (n=30; 7.1%). Age, BMI, smoking, and maternal weight were comparable in the groups, while gestational age at delivery as well as fetal outcome parameter were statistically significant unfavourable in patients with severe preeclampsia. Mean 2nd trimester hemoglobin level were statistically significantly higher in women who developed severe vs. moderate preeclampsia (m=12.75±0.99 g/dL vs. m=12.50±1.05 g/dL; p=0.033). However, in the ROC calculations a hemoglobin value of 12.05 g/dL revealed best sensitivity (78%) and specificity (33.8%) in women with subsequent diagnosis of severe preeclampsia, whereas sensitivity was 100% for a value>10.95 g/dL. There were no statistically significant differences for none of the rheological parameters at the time of delivery between groups of patient with moderate v.s severe preeclampsia. Severe preeclampsia and IUGR, however, was associated with statistically significantly higher RBC aggregation as compared to patients with moderate preeclampsia. Plasma viscosity was statistically significantly (p<0.05) correlated with Fibrinogen values (r=0.16), leukocyte-(r=0.11) and platelets-count (r=0.127), and hemoglobin/hematocrit values in particular (r=0.23/0.26). Although mean 2nd trimester hemoglobin concentration are higher in patients with subsequent development of severe preeclampsia, due to the low sensitivity and specificity of this parameter clinical use for identifying women at risk is of limited value. On the other hand, a hemoglobin value below 11.0 g/dL excluded the risk for severe preeclampsia to 100%. Blood rheological parameters at the time of delivery in the absence of IUGR are not markedly influenced by severity of preeclampsia.

Intact thrombin generation and decreased fibrinolytic capacity in patients with acute liver injury or acute liver failure

It has been well established that hemostatic potential in patients with chronic liver disease is in a rebalanced status due to a concomitant decrease in pro- and antihemostatic drivers. The hemostatic changes in patients with acute liver injury/failure (ALI/ALF) are similar but not identical to the changes in patients with chronic liver disease and have not been studied in great detail. To assess thrombin generation and fibrinolytic potential in patients with ALI/ALF. We performed thrombin generation tests and clot lysis assays in platelet-poor plasma from 50 patients with ALI/ALF. Results were compared with values obtained in plasma from 40 healthy volunteers. The thrombin generation capacity of plasma from patients with ALI/ALF sampled on the day of admission to hospital was indistinguishable from that of healthy controls, provided thrombomodulin was added to the test mixture. Fibrinolytic capacity was profoundly impaired in patients with ALI/ALF on admission (no lysis in 73.5% of patients, compared with 2.5% of the healthy controls), which was associated with decreased levels of the plasminogen and increased levels of plasminogen activator inhibitor type 1. The intact thrombin generating capacity and the hypofibrinolytic status persisted during the first week of admission. Patients with ALI/ALF have a normal thrombin generating capacity and a decreased capacity to remove fibrin clots. These results contrast with routine laboratory tests such as the PT/INR, which are by definition prolonged in patients with ALI/ALF and suggest a bleeding tendency.

Subclinical central nervous system involvement and thrombophilic status in young thalassemia intermedia patients of Greek origin

Beta thalassemia is known to be characterized by a hypercoagulable state, with prothrombotic factors present and thrombotic event development in a number of patients. The aim of the present study was to evaluate subclinical involvement of the central nervous system (CNS) in young patients with thalassemia intermedia, the use of nonimaging, noninvasive laboratory methods for detecting relevant abnormalities, and the frequency and possible correlation of coagulation abnormalities with CNS lesions. In this cross-sectional study, 24 young patients with thalassemia intermedia were evaluated (mean age 12 ± 4.6 years, range 4.5-20 years). Patients underwent neurological examination, inherited and acquired coagulation defect testing, as well as neurophysiologic and neuroimaging evaluation. Patients aged 6-16 also had intelligence scores measured. With regards to coagulation, a decrease in antithrombin III (ATIII), protein C and protein S activity was found in 4.1, 54.16 and 45.8% of patients, respectively. Increased D-dimers, as well as thrombin-antithrombin complex (TAT) and prothrombin fragment (F1 + 2) values were found in 12.5, 62.5 and 8.33% of patients, respectively. Heterozygosity and homozygosity for the methylenetetrahydrofolate reductase mutation was found in 45.8 and 12.5% of patients, whereas heterozygosity for factor V Leiden and G20210FII was found in 8.33 and 12.5% of patients, respectively, with increased prevalence compared to Greek population. Neuroimaging evaluation was normal in all patients. Neurophysiologic evaluation revealed abnormal findings in 33.3% of patients on electroencephalogram (EEG), 16% on brain auditory-evoked potentials (BAEPs) and 4.12% on somatosensory evoked potentials (SEPs). Visual-evoked potentials (VEPs) were normal in all patients. A statistically significant difference was found between low protein C values, as well as high platelet counts, with abnormal EEG findings (P = 0.004 and P = 0.039, respectively). Transcranial Doppler (TCD) measurements revealed increased peak systolic velocities in anterior and posterior cerebral arteries and in basilar artery in 57, 38 and 41% of patients, respectively, as compared to healthy population values. On the contrary, decreased mean velocities were found both on middle cerebral artery and pars terminalis of internal carotid examination in 28.5% of patients. Patients with pathological findings on TCD study had lower hematocrit (P = 0.049) and younger age (P = 0.001) than patients with normal measurements. With regards to intelligence scores, mean intelligence quotient (IQ) was 100 ± 19.1, with 11.7% of patients demonstrating IQ below 85. The study results confirm the early presence of hemostatic changes in patients with thalassemia intermedia. Additionally, they demonstrate subclinical CNS involvement starting at childhood. For such involvement detection, in addition to neuroimaging, neurophysiological and neuropsychological evaluation is warranted.

Microcirculatory and Hemostatic Changes in Patients after Endoprosthetic Hip Joint Replacement

Objective: to estimate the values of microcirculation, hemostasis, and fibrinolysis in patients after hip joint replacement. Subjects and methods. Thirty-two patients were examined after total endoprosthetic hip joint replacement (TEHJR). Microcirculation was explored by laser Doppler flowmetry (LDF). The level of ADAMTS-13 and its inhibitor and the concentrations of tissue factor pathway inhibitor (TFPI), tissue plasminogen activator (t-PA), and tissue plasminogen activator inhibitor-1 (PAI-1) were measured in the patients’ plasma by enzyme immunoassay. Results. Analysis of LDF measurements of the operated limb showed a 1.3-fold reduction in the value of microcirculation as compared with the intact limb in the patients in the early postoperative period after TEHJR. There were 1.3- and 1.4-fold increases in neurogenic and myogenic tones, respectively. The shunting ratio was 15% higher in the operated versus intact limb. The content of ADAMTS-13 was increased by 1.4-fold in the blood of the operated limp. As compared with the control group, the blood level of TFPI in the operated and intact limbs was elevated by 1.8 and 1.6 times, respectively. As compared with the controls, the patients after hip joint replacement displayed 1.9- and 1.6-fold decreases in the blood concentration of t-PA and PAI-1, respectively. Conclusion. In the patients after hip joint replacement, the value of microcirculation was lower, neurogenic and myogenic tones were higher, as well as there were increases in the levels of ADAMTS-13 and TFPI in the blood flowing from the operated limb as compared with the intact one. The plasma content of t-PA and PAI-1 became lower in the post-TEHJR patients than that in the control group. Key words: endoprosthetic hip joint replacement, microcirculation, hemostasis.

Purpura fulminans in a newborn infant with galactosemia

An 11-day-old neonate presented with purpura fulminans and was subsequently diagnosed with galactosemia. Neonatal purpura fulminans occurs predominantly in patients suffering from inherited protein C deficiency or disseminated intravascular coagulation associated with septicemia. Hemostatic changes in patients with liver disease may result in bleeding or, rarely, thrombosis. We suppose that in the present patient, deficiency of protein C, secondary to liver disease, was responsible for the development of purpura fulminans. Treatment consisted of blood and blood products and galactose-free formula. The patient recovered with residual mild psychomotor retardation and the lesions with minimal scarring. In conclusion, galactosemia also should be kept in mind as an uncommon cause of purpura fulminans in newborn infants.

Perioperative Hemostatic Features in Patients with Acute Coronary Syndrome and Chronic Coronary Heart Disease

Objecive: to study and compare the time course of hemostatic changes in patients with acute coronary syndrome (ACS) and chronic coronary heart disease (CCHD) undergoing surgical myocardial revascularization. Subjects and methods. Eleven hemostatic parameters were determined at 3 study stages (before, within 24 hours after surgery and before hospital discharge) in 20 patients with CCHD and 23 with ACS. Results: The study demonstrated that there was a preponderance of a higher blood tendency to intravascular thrombogenesis in all the patients at all the stages of the study; however, the degree of disorders and the cases of their occurrence in the CCHD and ACS groups varied. Conclusion: There was an increased blood tendency to coagulation in all the patients despite the therapy performed. In the CCHD group, hemostatic disorders were, as before, more pronounced than those in the ACS group. These facts suggest that the reserve functional capacities of the hemostatic system become normal only a significant amount of time after elimination of thrombogenic change-causing agents.

Investigation of Hemostatic Changes in Patients with Sepsis

It is known that severe infection and inflammation lead to hemostatic abnormalities. Recently, much attention is focused on the mechanisms of infection or inflammation and on how it plays a central role in effecting the coagulation system. Disseminated intravascular coagulation in particular, is a common phenomenon in patients with sepsis, but the clinical implications of this condition are not clear. Therefore we attempted to evaluate the changes of the coagulation system in patients with sepsis and studied the factors that lead to such changes. One hundred one patients diagnosed with sepsis were enrolled in this study. The patients were clinically evaluated for underlying disease and data for inflammatory status and coagulative changes were evaluated retrospectively. The WBC count increased in 76% and decreased in 6% of sepsis patients in comparison to the reference interval. The platelet count decreased in 65.3%. Changes in coagulative tests such as prothrombin time, activated partial thromboplastin time, antithrombin III, and D-dimer were observed in 70.4%, 52.7%, 87.2% and 100% of the patients, respectively. Correlation between ESR and fibrinogen was the highest in relation to the other coagulation factors. CRP also showed the highest correlation with fibrinogen in contrast to the other coagulation factors. This study confirmed the clear activation of coagulation in patients with sepsis. Of the evaluated factors involved in coagulation and fibrinolysis, fibrinogen showed the highest correlation to indices representing the inflammatory state. However further studies on the anticoagulant pathway are necessary in elucidating this matter.

Coagulation, Fibrinolytic System Activation and Endothelial Dysfunction in Patients With Mitral Stenosis and Sinus Rhythm

Anticoagulation treatment can prevent systemic embolism in patients with mitral stenosis (MS) and atrial fibrillation (AF), but this treatment is under debate if patients are in sinus rhythm. The authors aimed to determine the hemostatic changes in patients with MS and sinus rhythm. Forty-six patients (28 in sinus rhythm and 18 in AF) with mitral stenosis were enrolled in this study. They studied systemic venous fibrinogen, D-dimer, antithrombin-III, tissue plasminogen activator (tPA), plasminogen activator inhibitor-I (PAI-I), von Willebrand factor (vWF), and platelet factor 4 (PF 4) in these patients. The patients were first classified according to their rhythm as sinusal and AF, and then according to the presence of left atrial spontaneous echo contrast (LASEC). Fibrinogen, D-dimer, antithrombin-III, vWF, and PF 4 levels were significantly greater in patients with MS and sinus rhythm or atrial fibrillation compared to the control group (p < 0.05). Whether the rhythm was sinus or AF, fibrinogen, D-dimer, antithrombin-III, vWF, and PF 4 levels were significantly higher in patients with LASEC than in the control group (p < 0.05). Only PF 4 was higher in the AF group than in those with sinus rhythm (p < 0.05). As to plasminogen activator and PAI-I levels, only tissue plasminogen activator levels were found to be higher in the AF group than in those with sinus rhythm and the control group (p < 0.05). In patients with mitral stenosis and sinus rhythm, if LASEC is present, coagulation activation, platelet activation, and endothelial dysfunction are similar in patients with AF, and anticoagulation should be considered in these patients.

Thromboelastometry in Patients Receiving Platelet Transfusion after Chemotherapy.

Prophylactic platelet transfusion is frequently administered to reduce the risk of hemorrhage in patients undergoing chemotherapy for leukemia or cancer. A platelet count of 10 or 20x109 L−1 is often used as an occasion for platelet transfusion. In clinical studies, the bleeding risk was similar using either threshold (Rebulla, NEJM 1997; 337:1870, Wand, Blood 1998; 91:3601). Moreover, serious bleeding events were not related to the patients' platelet count. Thromboelastometry with ROTEM® Whole-Blood Coagulation Analyzer (Pentapharm, Munich, Germany) is a method that may provide a better estimate of the risk of hemorrhage because it also depends on platelet function and plasma coagulation. We therefore performed a pilot study in 13 adult patients receiving prophylactic platelet transfusion after chemotherapy for leukemia or lymphoma. ROTEM® was performed using an ellagic acid based activating reagent (in-TEM®, Pentapharm). Clotting profiles were evaluated using the following thromboelastometric measures: clotting time (CT), clot formation time (CFT), and maximum clot firmness (MCF). The median platelet count before transfusion was 9x109 L−1 (range 1 to 20). CT was within the normal range in all patients (median 168 s, range 125–212, reference range 100–240). In contrast, a prolonged CFT (median 139 s, range 51–4526, reference range 30–110) and reduced MCF (median 34 mm, range 19–54, reference range 50–72) was recorded. Correlation between platelet count and CFT (R=−0.41, Spearman) or MCF (R=+0.48) was weak and not statistically significant. 15 min after platelet transfusion, there was an increase in platelet count (median 39x109 L−1, range 23–48) and a substantial improvement of CFT (median 99 s, range 44–332) and MCF (median 49 mm, range 40–64). Changes in thromboelastometric measures were due to platelet transfusion as the addition of cytochalasin D (fib-TEM®, Pentapharm) resulted in identical profiles before and after transfusion. Changes in platelet count correlated with changes in MCF (R=+0.73, P<0.01), but not CFT (R=−0.40, P=0.17). Comparing patients who had a maximum of one mild bleeding symptom (n=9) with patients who experienced one severe or at least two mild bleeding symptoms (n=4), there was no difference in platelet counts (median 10 vs. 9x109 L−1, p=0.77). In contrast, there was a trend towards a shorter CFT (median 111 vs. 388 s, P=0.09) and higher MCF (median 39 vs. 29.5 mm, P=0.09) in the group of non-bleeding patients. In summary, ROTEM® seems to be a sensitive method to detect hemostatic changes in patients with severe thrombocytopenia receiving platelet transfusion and to identify thrombocytopenic patients with an increased bleeding risk. Therefore, further studies to evaluate ROTEM® as a means to estimate the bleeding risk in thrombocytopenic patients are warranted.

Thrombin activatable fibrinolysis inhibitor and hemostatic changes in patients with type I diabetes mellitus with and without microvascular complications.

We investigated thrombin activatable fibrinolysis inhibitor (TAFI) and its influence on fibrinolysis by measuring pro-TAFI activity and total TAFI antigen in 38 patients with type I diabetes mellitus (18 with and 20 without microvascular complications), as well as in 20 healthy controls. The pro-TAFI levels in the two groups of patients did not differ from those in the control group. Total TAFI antigen [i.e. pro-TAFI, TAFI and inactive carboxypeptidase U (TAFIi)] tended to decrease in both the patient groups (59.7 +/- 7.2 and 73.4 +/- 8.9% with and without microvascular complications, respectively) compared with controls (91.9 +/- 12.2%) (P = 0.12). We also assessed the overall hemostatic potential (OHP) in plasma, the clot lysis time and the overall fibrinolytic potential. The OHP was significantly higher in patients with complications compared with controls (8.9 +/- 0.9 versus 6.7 +/- 0.4; P < 0.05) and also higher in the diabetics without complications (7.8 +/- 0.6), although the latter difference did not reach statistical significance. Levels of clot lysis time and overall fibrinolytic potential were similar in the two groups of patients and the controls. The increased OHP in plasma from diabetic patients with microvascular complications indicates an imbalance of the hemostatic system towards a prothrombotic state. No signs of impaired fibrinolysis were observed in patients with diabetes. Using the OHP method for estimation of overall hemostasis, it seems that TAFI does not influence either fibrinolysis or the increased thrombotic potential observed in patients with type I diabetes mellitus.

Hemostatic Changes in Patients Receiving Hydroxyethyl Starch: The Influence of ABO Blood Group

Hemostatic Changes in Patients Receiving Hydroxyethyl Starch: The Influence of ABO Blood Group