Preoperative Fibrinogen Levels Research Articles

The effect of perioperative sequential application of multiple doses of tranexamic acid on postoperative blood loss after PLIF: a prospective randomized controlled trial.

Tranexamic acid (TXA) has been utilized in spinal surgery to effectively reduce intraoperative blood loss (IBL) and allogeneic blood transfusion rates. However, the traditional TXA regimen might last the entire duration of hyperfibrinolysis caused by surgical trauma, resulting in its limited ability to reduce postoperative blood loss (PBL). Therefore, the aim of this study was to investigate the effectiveness of perioperative sequential administration of multiple doses of TXA in reducing PBL in patients who underwent posterior lumbar interbody fusion (PLIF). From October 2022 to June 2023, 231 patients who were diagnosed with lumbar degenerative disease and scheduled to undergo PLIF were prospectively enrolled in the present study. The patients were randomly divided into three groups. Moreover, all patients received an intravenous injection of TXA at a dose of 15mg/kg 15min before the surgical skin incision. Patients in Group A received a placebo of normal saline after surgery, while patients in Group B received three additional intravenous injections of TXA at a dose of 15mg/kg every 24h. Patients in Group C received three additional intravenous injections of TXA at a dose of 15mg/kg every 5h. The primary outcome measure was PBL. In addition, this study assessed total blood loss (TBL), IBL, routine blood parameters, liver and kidney function, coagulation parameters, fibrinolysis indexes, inflammatory indicators, drainage tube removal time (DRT), length of hospital stay (LOS), blood transfusion rate, and incidence of complications for all subjects. The PBL, TBL, DRT, and LOS of Group B and Group C were significantly lower than those of Group A ( P <0.05). The level of D-dimer (D-D) in Group C was significantly lower than that in Group A on the first day after the operation ( P =0.002), and that in Group B was significantly lower than that in Group A on the third day after the operation ( P =0.003). The interleukin-6 levels between the three groups from 1 to 5 days after the operation were in the order of Group A > Group B > Group C. No serious complications were observed in any patient. The results of multiple stepwise linear regression analysis revealed that PBL was positively correlated with incision length, IBL, smoking history, history of hypertension, preoperative fibrinogen degradation product level, and blood transfusion. It was negatively correlated with preoperative levels of fibrinogen, red blood cells, blood urea nitrogen, and age. Compared to female patients, male patients had an increased risk of PBL. Finally, the incidence of PBL was predicted. Sequential application of multiple doses of TXA during the perioperative period could safely and effectively reduce PBL and TBL, shorten DRT and LOS, reduce postoperative D-D generation, and reduce the postoperative inflammatory response. In addition, this study provided a novel prediction model for PBL in patients undergoing PLIF.

A retrospective study on the effect of Chinese patent medicine combined with conventional treatment on the survival outcomes of 313 patients with stage II-III NSCLC.

We aim to explore the effect of Chinese Patent Medicine (CPM), including Huisheng oral solution (HSOS) on the 4-year survival rate of patients with stage II and III non-small cell lung cancer, and assess the association between blood coagulation indicators and survival outcomes. 313 patients diagnosed with stage II and III NSCLC were collected during 2015-2016. Kaplan-Meier method and Cox proportional hazard model were applied to analyze the factors affecting the 4-year survival rate of patients. According to the effect of CPM, the medicine prescribed in this study could be classified into two types. The proportion of patients who received "Fuzheng Quyu" CPM for more than three months was higher than the proportion of patients who received other two types of CPM for more than three months. Medical records of 313 patients with NSCLC were analyzed. 4-year survival rate for patients received CPM more than 6 months and 3 months were higher than those received CPM less than 3 months (P = 0.028 and P = 0.021 respectively. In addition, 4-year survival rate for patients who received HSOS for more than 3 months was higher than those who received HSOS for less than 3 months (P = 0.041). Patients with elevated preoperative fibrinogen (FIB) level and those without surgery had an increased mortality risk (HR = 1.98, P < 0.01, and HR = 2.76, P < 0.01 respectively). The medium and long-term use of CPM/HSOS was positively associated with higher survival rate in NSCLC patients. Patients with high-level preoperative FIB level and those without surgery might have a poor prognosis in the following years.

Prediction of vascular complications in free flap reconstruction with machine learning.

This study aims to explore the risk factors of vascular complications following free flap reconstruction and to develop a clinical auxiliary assessment tool for predicting vascular complications in patients undergoing free flap reconstruction leveraging machine learning methods. We reviewed the medical data of patients who underwent free flap reconstruction at the Affiliated Hospital of Zunyi Medical University retrospectively from January 1, 2019, to December 31, 2021. Statistical analysis was used to screen risk factors. A training data set was generated and augmented using the synthetic minority oversampling technique. Logistic regression, random forest and neural network, models were trained, using this dataset. The performance of these three predictive models was then evaluated and compared using a test set, with four metrics, area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, and specificity. A total of 570 patients who underwent free flap reconstruction were included in this study, 46 of whom developed postoperative vascular complications. Among the models tested, the neural network model exhibited superior performance on the test set, achieving an AUC of 0.828. Multivariate logistic regression analysis identified that preoperative hemoglobin levels, preoperative fibrinogen levels, operation duration, smoking history, the number of anastomoses, and peripheral vascular injury as statistically significant independent risk factors for vascular complications post-free flap reconstruction. The top five predictive factors in the neural network were fibrinogen content, operation duration, donor site, body mass index (BMI), and platelet count. Hemoglobin levels, fibrinogen levels, operation duration, smoking history, and anastomotic veins are independent risk factors for vascular complications following free flap reconstruction. These risk factors enhance the ability of machine learning models to predict the occurrence of vascular complications and identify high-risk patients. The neural network model outperformed the logistic regression and random forest models, suggesting its potential to aid clinicians in early identification of high-risk patients thereby mitigating patient suffering and improving prognosis.

New use of preoperative fibrinogen in ovarian cancer management.

Ovarian cancer (OC) is often diagnosed at an advanced stage due to the absence of specific symptoms in its early stages. And the prognosis greatly depends on when the disease is diagnosed. Thus, we conducted to evaluate the value of preoperative fibrinogen (Fib) levels for the diagnosis of OC in the hope of improving its diagnostic efficiency. A total of 126 ovarian tumor patients were retrospectively included in this study. Four candidate OC markers, including cancer antigen 125 (CA125), Fib, platelet (PLT) and homocysteine (Hcy) were employed to establish a diagnosis model for OC. The diagnostic performance of the model was evaluated using the area under the receiver operating characteristic curve (AUC) and Youden index. All included markers could be used for the diagnosis of OC. The AUCs of CA125, Fib, PLT and Hcy were 0.881, 0.825, 0.676 and 0.647, respectively. The new diagnosis model combining CA125 and Fib (CA125-Fib) had a higher AUC (0.924), Youden index (0.730), and best sensitivity (SN) (74.6%) and specificity (SP) (98.41%). CA125-Fib also had a high value in the diagnosis of stage I-II OC (AUC, Youden index, SN and SP: 0.853, 0.624, 81.48% and 80.95%). Fib could be used for OC diagnosis. In particular, the combination of Fib and CA125 could further improve the diagnostic efficiency. And the diagnostic value of PLT and Hcy was found to be poor.

FAR Ratio as Prognostic Biomarker in AMI.

Acute mesenteric ischemia (AMI) is a vascular emergency resulting from decreased blood flow caused by the occlusion of the mesenteric vessels, hypoperfusion, or vasospasm. This study aimed to investigate the prognostic value of the fibrinogen-to-albumin (FAR) ratio in patients with acute mesenteric ischemia. A total of 91 patients were enrolled in the study. Patients' demographics such as age and gender, pre- and postoperative hemoglobin, CRP, white blood cell (WBC), neutrophils, preoperative lymphocyte, alanine transaminase (ALT), aspartate transaminase (AST), thrombocytes, and postoperative D-dimer values were recorded. In addition, pre- and postoperative fibrinogen and albumin levels were recorded, and FAR was calculated. Patients were divided into two groups, survivors and non-survivors. The mean pre- and postoperative fibrinogen levels were statistically significantly higher in the non-survivor group than in the survivor group (p < 0.001). The mean pre- and postoperative albumin levels were significantly lower in the non-survivors than in the survivors (p = 0.059, p < 0.001; respectively). The mean pre- and postoperative FAR ratios were considerably higher in the non-survivor than in the survivor groups (p < 0.001). The change between pre- and postoperative fibrinogen, albumin, and FAR values was statistically significant between the non-survivors and the survivors (for all, p < 0.05). The preoperative and postoperative fibrinogen levels were significantly lower, and albumin levels were significantly higher in the survivor compared to the non-survivor patients with AMI. Furthermore, the preoperative and postoperative FAR ratio was significantly higher in the non-survivors. The FAR ratio may be a valuable prognostic biomarker for patients with AMI.

Plasma Fibrinogen as a Predictor of Perioperative-Blood-Component Transfusion in Major-Nontraumatic-Orthopedic-Surgery Patients: A Cohort Study.

There is a trend towards increased perioperative bleeding in patients with plasma fibrinogen levels < 200 mg/dL-1. This study aimed to assess whether there is an association between preoperative fibrinogen levels and perioperative blood-product transfusion up to 48 h after major orthopedic surgery. This cohort study included 195 patients who underwent primary or revision hip arthroplasty for nontraumatic etiologies. Plasma fibrinogen, blood count, coagulation tests, and platelet count were measured preoperatively. A plasma fibrinogen level of 200 mg/dL-1 was the cutoff value used to predict blood transfusion. The mean (SD) plasma fibrinogen level was 325 (83) mg/dL-1. Only thirteen patients had levels < 200 mg/dL-1, and only one of them received a blood transfusion, with an absolute risk of 7.69% (1/13; 95%CI: 1.37-33.31%). Preoperative plasma fibrinogen levels were not associated with the need for blood transfusion (p = 0.745). The sensitivity and the positive predictive value of plasma fibrinogen < 200 mg/dL-1 as a predictor of blood transfusion were 4.17% (95%CI: 0.11-21.12%) and 7.69% (95%CI: 1.12-37.99%), respectively. Test accuracy was 82.05% (95%CI: 75.93-87.17%), but positive and negative likelihood ratios were poor. Therefore, preoperative plasma fibrinogen level in hip-arthroplasty patients was not associated with the need for blood-product transfusion.

Nomogram Based on Preoperative Fibrinogen and Systemic Immune-Inflammation Index Predicting Recurrence and Prognosis of Patients with Borrmann Type III Advanced Gastric Cancer.

The prognosis is known to differ significantly among advanced gastric cancer (AGC) with Borrmann type III. This study aimed to evaluate the prognosis of these patients more individually. We selected 542 AGC patients with Borrmann type III. We used the receiver operating characteristic curve to analyze the cutoff values of inflammation indexes, and used Kaplan-Meier and Log rank tests to analyze recurrence-free survival (RFS)and overall survival (OS). The independent risk factors for recurrence and prognosis were analyzed by Cox proportional hazards regression model. The nomogram models were constructed by R studio. Patients with high preoperative fibrinogen (F) and systemic immune-inflammation index (SII) levels had worse RFS and OS and higher risk of postoperative locoregional recurrence, hematogenous metastasis and lymph node metastasis. F and SII can combine with different clinicopathological features (all P<0.05) to construct nomograms to predict 5-year recurrence and prognosis, which both were superior to pTNM stage alone. The nomogram models based on F and SII can evaluate AGC with Borrmann type III postoperative recurrence and prognosis.

Risk factors for lymphorrhea and lymphocele after radical prostatectomy: a retrospective case-control study.

To investigate the risk factors for postoperative lymphorrhea or/and lymphocele (PLL) in patients undergoing radical prostatectomy (RP). The clinical data of 606 patients were retrospectively collected. The receiver operating characteristic (ROC) curve was utilized to identify the optimal cutoff value. Multivariable logistic regression analysis was used to screen the independent predictors of PLL. Univariate analysis showed that nine factors differed between the PLL and non-PLL group. Multivariable logistic regression analysis showed that low preoperative fibrinogen level, extraperitoneal surgery, robot-assisted laparoscopic radical prostatectomy (RALRP), and hypoalbuminemia were risk factors and the use of fibrin glue was a protective factor. Correlation analysis showed that the scope of LN dissection (LND) and number of lymph nodes (LNs) dissected were positively correlated with PLL in the extraperitoneal approach, but were not significantly correlated with PLL in the transperitoneal approach. The use of fibrin glue was negatively associated with PLL in the overall procedure and the extraperitoneal approach, but not significantly so in the transperitoneal approach. Comparison of LNs clearance between the two surgical approaches revealed that the extent of LND and number of LNs dissected in the extraperitoneal approach were less than in the transperitoneal approach. During RALRP, more attention should be paid to fully clotting the broken end of lymphatic vessels. The use of fibrin glue could reduce the probability of PLL. The extent of LND or number of LNs dissected were positively correlated with PLL in the extraperitoneal approach.

Risk factor prediction of severe postoperative acute kidney injury at stage 3 in patients with acute type A aortic dissection using thromboelastography.

Perioperative blood transfusions and postoperative drainage volume not only are the commonly recognized risk factors for acute kidney injury (AKI) but also are indirect indicators of coagulopathy in patients with acute type A aortic dissection (ATAAD). However, standard laboratory tests fail to accurately reflect and assess the overall coagulopathy profile in patients with ATAAD. Thus, this study aimed to explore the association between the hemostatic system and severe postoperative AKI (stage 3) in patients with ATAAD using thromboelastography (TEG). We selected 106 consecutive patients with ATAAD who underwent emergency aortic surgery at Beijing Anzhen Hospital. All participants were categorized into the stage 3 and non-stage 3 groups. The hemostatic system was evaluated using routine laboratory tests and TEG preoperatively. We undertook univariate and multivariate stepwise logistic regression analyses to determine the potential risk factors for severe postoperative AKI (stage 3), with a special investigation on the association between hemostatic system biomarkers and severe postoperative AKI (stage 3). The receiver operating characteristic (ROC) curves were generated to assess the predictive ability of hemostatic system biomarkers for severe postoperative AKI (stage 3). A total of 25 (23.6%) patients developed severe postoperative AKI (stage 3), including 21 patients (19.8%) who required continuous renal replacement therapy (RRT). Multivariate logistic regression analysis demonstrated that the preoperative fibrinogen level (OR, 2.02; 95% CI, 1.03 to 3.00; p = 0.04), platelet function (MA level) (OR, 1.23; 95% CI, 1.09 to 1.39; p = 0.001), and cardiopulmonary bypass (CPB) time (OR, 1.01; 95% CI, 1.00 to 1.02; p = 0.02) were independently associated with severe postoperative AKI (stage 3). The cutoff values of preoperative fibrinogen and platelet function (MA level) for predicting severe postoperative AKI (stage 3) were determined to be 2.56 g/L and 60.7 mm in the ROC curve [area under the curve (AUC): 0.824 and 0.829; p < 0.001]. The preoperative fibrinogen level and platelet function (measured by the MA level) were identified as potential predictive factors for developing severe postoperative AKI (stage 3) in patients with ATAAD. Thromboelastography could be considered a potentially valuable tool for real-time monitoring and rapid assessment of the hemostatic system to improve postoperative outcomes in patients.

Low preoperative serum fibrinogen level is associated with postoperative acute kidney injury in patients with in acute aortic dissection

ObjectiveAcute kidney injury (AKI) after cardiac surgery is associated with serious complication and high risk of mortality. The relationship between hemostatic system and the prognosis of patients with acute type A aortic dissection (ATAAD) has not been evaluated. The purpose of this study was to investigate the association between preoperative serum fibrinogen level and risk of postoperative AKI in patients with ATAAD.MethodsA total of 172 consecutive patients undergoing urgent aortic arch surgery for ATAAD between April 2020 and December 2021 were identified from Beijing Anzhen Hospital aortic surgery database. The primary outcome was postoperative AKI as defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria. The univariate and multivariate logistic regression analysis were done to assess the independent predictors of risk for postoperative AKI. Receiver operating characteristic (ROC) curve was generated to evaluate the predictive probabilities of risk factors for AKI.ResultsIn our study, 51.2% (88/172) patients developed postoperative AKI. Multivariate logistic regression analysis identified low preoperative serum fibrinogen level (OR, 1.492; 95% CI, 1.023 to 2.476; p = 0.021) and increased body mass index (BMI) (OR, 1.153; 95% CI, 1.003 to 1.327; p = 0.046) as independent predictors of postoperative AKI in patients with ATAAD. A mixed effect analysis of variance modeling revealed that obese patients with low preoperative serum fibrinogen level had higher incidence of postoperative AKI (p = 0.04). The ROC curve indicated that low preoperative serum fibrinogen level was a significant predictor of AKI [area under the curve (AUC), 0.771; p < 0.001].ConclusionsLow preoperative serum fibrinogen level and obesity were associated with the risk of postoperative AKI in patients with ATAAD. These data suggested that low preoperative serum fibrinogen level was preferred marker for predicting the postoperative AKI, especially in obese patients with ATAAD.

Risk factors for hypercoagulability after laparoscopic hepatic haemangioma resection.

Laparoscopic hepatectomy with a small incision, light abdominal wall trauma and rapid postoperative recovery has been widely used in the surgical treatment of benign liver diseases. However, the occurrence of complications, such as deep-vein thrombosis, associated with laparoscopic techniques has raised concerns. This study aimed to investigate the factors influencing the development of a hypercoagulable state in patients following laparoscopic hepatic haemangioma resection. Between 2017 and 2019, 78 patients to be treated by laparoscopic hepatic haemangioma resection were selected prospectively for the study. The differences in relevant clinical factors between patients with and without blood hypercoagulability at 24 h after surgery were compared, and the factors influencing the development of blood hypercoagulability after surgery were analysed. The study included 78 patients, split into the hypercoagulable group (n = 27) and nonhypercoagulable group (n = 51). Compared with patients who did not develop blood hypercoagulability, patients who did had significantly higher preoperative levels of fibrinogen (Fib), D-dimer (D-Di), fibrinogen degradation products (FDP), platelet count (PLT), low-density lipoprotein cholesterol (LDL-C) and history of hyperlipidaemia whereas high-density lipoprotein cholesterol (HDL-C) levels were significantly lower (P < 0.05.) in hypercoagulable group. Univariate and multifactorial logistic regression analyses showed that a history of hyperlipidaemia, Fib ≥3.83 g/L, D-Di ≥9.12 μg/ml, FDP ≥14.64 μg/ml, PLT ≥292 × 109/L, HDL-C ≥1.25 mmol/L and LDL-C ≥2.03 mmol/L was the most common independent risk factors for the development of a hypercoagulable state of blood in patients after laparoscopic hepatic haemangioma resection (P < 0.05). For patients undergoing laparoscopic hepatic haemangioma resection, attention should be paid to the development of a hypercoagulable state in those with the risk factors described in this study.

Nomograms Based on Fibrinogen, Albumin, Neutrophil-Lymphocyte Ratio, and Carbohydrate Antigen 125 for Predicting Endometrial Cancer Prognosis.

Background: This study aimed to determine the prognostic value of the preoperative levels of fibrinogen, albumin (ALB), neutrophil-lymphocyte ratio (NLR), and carbohydrate antigen 125 (CA125) in endometrial cancer and to establish nomograms for predicting patient survival. Methods: Patients with endometrial cancer (n = 1483) who underwent surgery were included in this study, and their preoperative fibrinogen, ALB, NLR, and CA125 levels and clinicopathological characteristics were collected. Patients were randomized into a training cohort (70%, n = 1038) and an external validation cohort (30%, n = 445). The Cox regression analysis was performed using the data for the patients in the training cohort to identify independent prognostic factors; nomograms for predicting prognosis were established and validated. Results: High fibrinogen (≥3.185 g/L), NLR (≥2.521 g/L), and CA125 (≥35 U/mL) levels and low ALB (&lt;4.185 g/L) levels were independently associated with poor progression-free survival (PFS) and poor overall survival (OS) in patients with endometrial cancer. Prognostic prediction model nomograms were developed and validated based on these results. Calibration curves and C-indexes underscored the good predictive power of the nomograms, and both the net reclassification index (NRI) and integrated discrimination improvement (IDI) values of the prognostic prediction model nomograms were improved. Conclusions: Nomograms that are developed based on preoperative fibrinogen, ALB, NLR, and CA125 levels accurately predict PFS and OS in patients with endometrial cancer.

The Prognostic Value of Preoperative Fibrinogen in Patients with Radical Cholecystectomy

Background and Aims. There is currently a lack of suitable hematological markers as a complement to pathological factors in predicting the prognosis of patients with gallbladder cancer. The study aimed to investigate the clinical value of preoperative fibrinogen levels in assessing the prognosis of patients with gallbladder cancer after radical surgery. Methods. The study retrospectively analyzed 260 gallbladder cancer patients who underwent radical resection. Time-dependent receiver operating characteristic (ROC) curves were used to calculate the optimal cut-off values of carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9), and fibrinogen. Besides, univariate and multivariate analyses of disease-free survival (DFS) and overall survival (OS) were performed to determine independent markers in peripheral blood. Then, subgroup analyses of fibrinogen in different degrees of differentiation, age, gender, and BMI were performed by log-rank test. Result. The cut-off values of fibrinogen, CEA, and CA19-9 were set at 2.97 g/L, 2.17 ng/mL, and 41.1 U/mL, respectively. The results showed that the preoperative fibrinogen level was associated with tumor size, degree of differentiation, TNM stage, and CA19-9 levels. Multivariate analyses indicated that advanced TNM stage, excessive fibrinogen, CEA, and CA19-9 levels were independent risk factors for postoperative DFS. And gallbladder neck tumors, poor differentiation, cancer nodules, advanced TNM stage, excessive fibrinogen, and CEA levels were independent adverse factors for postoperative OS. Notably, the preoperative excessive fibrinogen was an independent adverse factor for both DFS ( p = 0.044 , HR = 1.629 , 95% CI = 1.014 − 2.618 ) and OS ( p = 0.006 , HR = 2.328 , 95% CI = 1.272 − 4.261 ) in patients with gallbladder cancer. The subgroup analyses further indicated that patients with high-level of fibrinogen had both poorer DFS ( p = 0.002 ) and OS ( p = 0.005 ) than patients with poorly-differentiated gallbladder cancer. And for well-differentiated gallbladder cancer, patients with high fibrinogen levels had poorer OS ( p = 0.004 ), but no significant difference in DFS ( p = 0.062 ). Besides, fibrinogen was more significant in GBC patients with higher BMI (&gt;22.62) or older age (&gt;60 yrs) and was not affected by gender. Conclusion. Elevated preoperative fibrinogen level was independently associated with poor postoperative DFS and OS in patients with gallbladder cancer, especially for poor differentiation.

The Supply Side of Coagulation: Fibrinogen and Bleeding in Liver Disease and Transplantation.

In this issue of Transplantation, Carrier et al1 describe a study that assesses the effect of preoperative fibrinogen levels on perioperative bleeding and outcomes. In 613 patients with end-stage liver disease who underwent liver transplantation between 2008 and 2019, preoperative low fibrinogen levels were associated with more blood loss but not worse 1-y survival in univariate and multivariate statistical models. This effect was most prominent when fibrinogen levels were below 3 g/L before surgery. In any model of coagulation, fibrinogen is the substrate required to create an effective clot and provide hemostasis. Like most components of hemostasis, fibrinogen is synthesized by the liver and reduced in severe liver disease. Additionally, and maybe more commonly‚ dysfibrinogenemia occurs in liver disease resulting in defects of the fibrinogen structure with undetermined effects on hemostasis.2 The coagulation abnormalities associated with liver disease result in dysbalanced hemostasis that can cause impaired clot formation or excessive thrombosis. Conventional coagulation tests cannot detect this dysbalanced hemostasis‚ as they measure only (a part of) the procoagulant side of hemostasis. Viscoelastic testing, now routinely used in many transplant centers‚ may provide a better assessment of all aspects of clot formation by creating a visual representation of changes in the viscosity of blood when a clot forms. Viscoelastic testing can guide transfusion management in many clinical scenarios‚ including liver transplantation‚ but possibly, more importantly, allows us to identify patients who are hypercoagulable even when the conventional coagulation tests are abnormally high. The results of Carrier et al suggest that low preoperative fibrinogen levels may be an indicator that a patient is at risk for increased intraoperative bleeding. This may be particularly useful if perioperative viscoelastic testing is not used or available as with the study center. This risk of bleeding increased when fibrinogen levels were below 3 g/L before surgery, a level that is far higher than what has traditionally been considered a concerning threshold. Most experts and societies, for example, the review on perioperative coagulation management in liver transplant recipients by Bezinover et al here in Transplantation in 2018,3 recommend fibrinogen concentrate and/or cryoprecipitate transfusion for fibrinogen levels below 1.5 to 2 g/L. Although raising new questions, the present study does not provide enough evidence to change this recommendation at this time. An association with bleeding (even in a multivariate model) does not necessarily mean that replacing fibrinogen with levels over 3 g/L will reduce the risk of bleeding. The assumption is that fibrinogen levels that are below 3 g/L before surgery may decrease more during transplantation to a level that actually impairs hemostasis. Excessive transfusion of cryoprecipitate (and, to a lesser degree, fibrinogen concentrates) is not without risk and may increase the risk of thromboembolic complications.4 The results by Carrier et al are raising new questions about fibrinogen thresholds and may provide the impetus for future (prospective) studies but should not necessarily change our current management. The Centre Hospitalier de L’Universite de Montreal (CHUM) has demonstrated for many years with great success what can be achieved with a concerted effort to reduce blood transfusion5: More than 70% of the patients in the present study did not receive any red blood cell transfusion at all! The center undertakes a number of interventions to achieve these remarkable results. For example, over 50% of the patients in this study underwent phlebotomy at the beginning of surgery. I am not aware of any other center that implemented such a vigorous and successful program to reduce blood transplantation. Unfortunately, this also limits the generalizability of the present study (and reduces the statistical power of the study). Furthermore, because viscoelastic testing was not used in this study, we do not know if lower preoperative fibrinogen levels result in deficient fibrinogen contribution to clot strength later during surgery (assessed, for example, using fibrinogen assays such as FIBTEM with rotational thromboelastometry, ROTEM). In summary, Carrier et al provide important insight into the role of fibrinogen in achieving hemostasis during and good outcomes after liver transplantation. Their data encourage us to check for fibrinogen levels whenever we measure conventional or viscoelastic coagulation tests and design future randomized trials of fibrinogen replacement in liver transplantation.

Preoperative Fibrinogen Level and Bleeding in Liver Transplantation for End-stage Liver Disease: A Cohort Study.

Liver transplantation is a high-risk surgery associated with important perioperative bleeding and transfusion needs. Uncertainties remain on the association between preoperative fibrinogen level and bleeding in this population. We conducted a cohort study that included all consecutive adult patients undergoing a liver transplantation for end-stage liver disease in 1 center. We analyzed the association between the preoperative fibrinogen level and bleeding-related outcomes. Our primary outcome was intraoperative blood loss, and our secondary outcomes were estimated perioperative blood loss, intraoperative and perioperative red blood cell transfusions, reinterventions for bleeding and 1-y graft and patient survival. We estimated linear regression models and marginal risk models adjusted for all important potential confounders. We used restricted cubic splines to explore potential nonlinear associations and reported dose-response curves. We included 613 patients. We observed that a lower fibrinogen level was associated with a higher intraoperative blood loss, a higher estimated perioperative blood loss and a higher risk of intraoperative and perioperative red blood cell transfusions (nonlinear effects). Based on an exploratory analysis of the dose-response curves, these effects were observed below a threshold value of 3 g/L for these outcomes. We did not observe any association between preoperative fibrinogen level and reinterventions, 1-y graft survival or 1-y patient survival. This study suggests that a lower fibrinogen level is associated with bleeding in liver transplantation. The present results may help improving the selection of patients for further studies on preoperative fibrinogen administration in liver transplant recipients with end-stage liver disease.

Hemostatic Markers as Predictors of Massive Blood Transfusion in Orthotopic Liver Transplantation

The aim of this study was to determine which standard preoperative laboratory results correlate to intraoperative transfusion requirement during orthotopic liver transplantation (OLT). We retrospectively analyzed data from 305 adult patients who underwent OLT between 2009 and 2013 using laboratory results: International Normalization Ratio, platelet count, fibrinogen, and hemoglobin and total blood transfusion requirements (group L ≤ 1 L, group M > 1 L). All statistical analyses were conducted using the Statistical Package for Social Sciences software (IBM Corp. Released 2012. IBM SPSS for Windows, Version 21.0; IBM Corp., Armonk, NY, United States). We found a positive correlation with hemoglobin and fibrinogen using multivariate analysis (P < .001). The receiver operating characteristic analysis in favor of total blood replacement > 1 L has shown a correlation with fibrinogen (cut-off value of 2.3 g/L, sensitivity of 85.8%, and specificity of 37.4%) and hemoglobin (cut-off 111 g/L, sensitivity of 69.9%, and specificity of 71.6%). This study has confirmed that preoperative fibrinogen and hemoglobin level, but not International Normalization Ratio and platelet count, are indicators of potential massive perioperative blood loss during OLT and that within our patient cohort a cut-off fibrinogen value of 2.3 g/L and Hb level of 110g/L can predict a blood replacement of >1 L.

Preoperative fibrinogen level and postcardiac surgery morbidity and mortality rates.

High preoperative fibrinogen levels are associated with reduced bleeding rates after cardiac surgery. Fibrinogen is directly involved in inflammatory processes and is a cardiovascular risk factors. Whether high fibrinogen levels before cardiac surgery are a risk factor for mortality or morbidity remains unclear. This study aimed to examine the association between preoperative fibrinogen levels and mortality and morbidity rates after cardiac surgery. This is a single-center retrospective study. Patients (n = 1628) were divided into high (HFGr) and normal (NFGr) fibrinogen level groups, based on the cutoff value of 3.3 g/L, derived from the receiver operating characteristic (ROC) curve analysis. The primary outcome was the 30-day mortality rate. The rates of postoperative complications, including postoperative bleeding and transfusion rates, were examined. Between-group comparisons were performed with the Mann-Whitney U test and Chi-squared test, as suitable. Model discriminative power was examined with the area under the ROC curve. The HFGr and NFGr included 1103 and 525 patients, respectively. Mortality rate was higher in the HFGr than in the NFGr (2.7% vs. 1.1%, P = 0.04). The 12-h bleeding volume (280 mL [195-400] vs. 305 mL [225-435], P = 0.0003) and 24-h bleeding volume values (400 mL [300-550] vs. 450 mL [340-620], P &lt; 0.0001) were lower in the HFGr than in the NFGr. However, the rate of red blood cell transfusion during hospitalization was higher in the HFGr than in the NFGr (21.7% vs. 5.9%, P = 0.0103). Major complications were more frequent in the HFGr than in the NFGr. High fibrinogen levels were associated with reduced postoperative bleeding volume and increased mortality and morbidity rates.

Perioperative Hidden Blood Loss in Lumbar Disk Herniation Patients With Percutaneous Endoscopic Transforaminal Discectomy and Influencing Factors.

This was a retrospective study. This study aimed to evaluate hidden blood loss (HBL) and its influencing factors in lumbar disk herniation (LDH) patients treated with percutaneous endoscopic transforaminal discectomy (PETD). PETD is a minimally invasive spine surgery and is widely used to treat LDH. It is generally believed that there is less bleeding during PETD. However, HBL during the perioperative period is always ignored. From January 2018 to March 2021, 74 LDH patients treated with PETD was selected. The patient's sex, age, height, weight, previous medical history (hypertension and diabetes) and other basic information were recorded. The preoperative fibrinogen (FIB) level, activated partial thromboplastin time and prothrombin time were recoded. The hemoglobin, hematocrit, and platelet immediately after admission and the next day postoperative were recorded. The surgical time, intraoperative blood loss, intervertebral disk degeneration grade and soft tissue thickness of the PETD approach were recorded. The total blood loss was calculated according to the Gross formula, and then HBL was calculated based on total blood loss and visible blood loss (VBL). The influencing factors were analyzed by single factor correlation analysis and multivariate linear regression analysis. Among the 74 patients, there were 34 males (20-68 y old) and 40 females (26-75 y old). The mean amount of VBL was (85.04±26.53) mL and HBL was (341.04±191.15) mL. There were statistically significant differences between HBL and VBL (P=0.000). Multiple linear regression analysis showed that sex (P=0.000), disk degeneration grade (P=0.000), preoperative FIB level (P=0.022) and preoperative platelet (P=0.026) were independent risk factors that contributed to HBL, but age (P=0.870), BMI (P=0.480), hypertension (P=0.867), diabetes (P=0.284), soft tissue thickness (P=0.701), preoperative prothrombin time (P=0.248) and preoperative activated partial thromboplastin time (P=0.521) were not. There was a large amount of HBL during the perioperative period of PETD in patients with LDH. Sex, disk degeneration grade, preoperative FIB level and preoperative platelet are the independent risk factors of HBL in the perioperative period of PETD. More attention should be paid to the patients with risk factors to ensure perioperative safety.

The clinical significance of preoperative serum fibrinogen levels and platelet counts in patients with gallbladder carcinoma

BackgroundGallbladder carcinoma (GBC) was the most common malignancy of biliary tract. Patients with malignancies frequently present with activated coagulation pathways, which might potentially related to tumor progression and prognosis. The purpose of the study was to investigate the clinical significance of preoperative serum fibrinogen levels and platelet counts in GBC patients.Methods The preoperative fasting serum fibrinogen levels and platelet counts of 58 patients with GBC were measured by AUV2700 automatic biochemical analyzer, as well as 60 patients with cholesterol polyps and 60 healthy volunteers. Kaplan–Meier survival analysis was applied to show the correction between fibrinogen levels and outcome after surgery.ResultsThe fibrinogen levels of patients with GBC were significantly higher than healthy gallbladder and cholesterol polyp of gallbladder (p < 0.001 and p < 0.001, respectively). In GBC, fibrinogen levels were associated with tumor depth (p = 0.001), lymph node metastasis (p = 0.002), distant metastasis (p < 0.001) and Tumor Node Metastasis (TNM) stage (p < 0.001). The levels in TNM stage IV disease were significantly higher than stage III or stage I + II disease (p = 0.048 and p < 0.001, respectively), and in TNM stage III disease were significantly higher than stage I + II disease (p = 0.002). Furthermore, the overall survival was better in low fibrinogen level group than in high fibrinogen level group (p < 0.001). However, thrombocytosis was not significantly associated with overall survivals (p > 0.05) in multivariate analysis.ConclusionsThe preoperative serum fibrinogen levels and platelet counts might be reliable biomarkers for the occurance of disease, tumor depth, lymph node metastasis, distant metastasis and advanced TNM stage in patients with GBC. The serum fibrinogen levels might be a prognostic factor to predict outcome for GBC patients suffering from surgery treatment. Anticoagulation therapy might be considered to control cancer progression in future studies.

Preoperative serum fibrinogen as a valuable predictor in the nomogram predicting overall survival of postoperative patients with gallbladder cancer.

Coagulation and fibrinolysis activation are frequently observed in cancer patients, and the tumors in these cases are thought to be associated with a higher risk of invasion, metastasis and worse long-term outcome. The specific aim of this study was to develop an effective prognostic nomogram to help make individualized estimates for patients with resected gallbladder cancer (GBC). Patients with resected GBC who were diagnosed between 2006 and 2014 at Xinhua Hospital were selected. Model performance was measured by c-index and calibration curve. The results were further validated using bootstrap and a cohort of 38 patients from a branch hospital who underwent surgery from 2006 to 2014. Backward stepwise selection and Lasso were applied respectively to select predictors. T stage, N stage, and preoperative serum fibrinogen were included in the final model. Predictions correlated well with observed 1- and 3-year survival. The c-index for predicting survival was 0.74 (95% confidence interval, 0.70-0.78), which was statistically higher than that of the AJCC 7th system and Nevin system (P=0.04, 0.04, respectively). In the validation cohort, the nomogram performed better than the other two staging systems (c-index: 0.71 vs. 0.67 and 0.67). The validated nomogram is a practical tool for predicting the overall survival (OS) of postoperative GBC patients. Preoperative serum fibrinogen levels were associated with tumor progression and may be an independent predictor for GBC patients.