Coagulation Laboratory, Division of Hematology, University of Sao Paulo School of Medicine, Brazil.
Fondazione IRCCS Ca' Granda Ospedale Maggiore, Hemophilia and Thrombosis Center Angelo Bianchi Bonomi and Fondazione Luigi Villa, Milano, Italy.
J Hepatol. 2020 Jan;72(1):85-94. doi: 10.1016/j.jhep.2019.09.008. Epub 2019 Sep 16.
BACKGROUND & AIMS: The efficacy of fresh frozen plasma (FFP) transfusion in enhancing thrombin generation in patients with cirrhosis and impaired conventional coagulation tests has not been sufficiently explored. Thus, we aimed to assess the effect of FFP transfusion on thrombin generation in these patients.
Fifty-three consecutive patients receiving a standard dose of FFP to treat bleeding and/or before invasive procedures - if international normalized ratio (INR)/prothrombin time (PT) ratio were ≥1.5 - were prospectively enrolled. The primary endpoint was the amelioration of endogenous thrombin potential (ETP) with thrombomodulin (ETP-TM) after transfusion, which corresponds to the total amount of generated thrombin. INR/PT ratio and activated partial thromboplastin time (aPTT) were also assessed before and after transfusion.
FFP enhanced ETP-TM by 5.7%, from 973 (731-1,258) to 1,028 (885-1,343 nM × min; p = 0.019). Before transfusion, evidence of normal or high ETP-TM was found in 94% of patients, even in those with bacterial infections. Only 1 (1.9%) patient had ETP-TM values reverting to the normal range after transfusion. Notably, no patients with low ETP-TM had bleeding. The median decrease in ETP-TM was 8.3% and the mean was 12.8% in 18 (34%) patients after transfusion (from 1,225 [1,071-1,537] to 1,124 [812-1,370] nM × min; p ≤0.0001). Similar responses to FFP transfusion were observed in patients with compensated and acute decompensated cirrhosis, acute-on-chronic liver failure, infection or shock. FFP significantly ameliorated INR and aPTT values (p <0.0001), but in a minority of patients the values were reduced to less than the cut-off point of 1.5.
FFP transfusion enhanced thrombin generation and ameliorated conventional coagulation tests to normal values in a limited number of patients, and slightly decreased thrombin generation in 34% of cases.
Transfusion of fresh frozen plasma in patients with cirrhosis only slightly improves coagulation test values in a limited number of patients and even appears to worsen them in a third of cases. Transfusion for the purpose of preventing or treating bleeding events could cause inherent risks and costs without clear benefits.
在肝硬化和常规凝血检测异常的患者中，新鲜冷冻血浆（FFP）输注对增强凝血酶生成的疗效尚未得到充分探索。因此，我们旨在评估 FFP 输注对这些患者凝血酶生成的影响。
53 例连续患者因出血和/或侵入性操作前（INR/PT 比值≥1.5 时）接受标准剂量的 FFP 治疗，前瞻性入组。主要终点是输注后血栓调节蛋白（ETP-TM）改善的内源性凝血酶生成潜能（ETP），这对应于生成的凝血酶总量。在输注前后还评估了 INR/PT 比值和活化部分凝血活酶时间（aPTT）。
FFP 将 ETP-TM 提高了 5.7%，从 973（731-1258）增加到 1028（885-1343 nM×min；p=0.019）。在输注前，94%的患者有正常或高 ETP-TM 的证据，甚至在有细菌感染的患者中也是如此。仅有 1 例（1.9%）患者的 ETP-TM 值在输注后恢复到正常范围。值得注意的是，没有低 ETP-TM 值的患者发生出血。在 18 例（34%）患者中，输注后 ETP-TM 中位数降低 8.3%，平均降低 12.8%（从 1225[1071-1537]减少至 1124[812-1370]nM×min；p≤0.0001）。在代偿性和急性失代偿性肝硬化、急性肝衰竭伴慢性、感染或休克的患者中观察到类似的 FFP 输注反应。FFP 显著改善 INR 和 aPTT 值（p<0.0001），但少数患者的这些值降至 1.5 以下。
FFP 输注仅在少数患者中增强凝血酶生成并改善常规凝血检测值，在 34%的情况下轻度降低凝血酶生成。
肝硬化患者输注新鲜冷冻血浆仅在少数患者中略微改善凝血检测值，在三分之一的情况下甚至似乎会使凝血值恶化。为预防或治疗出血事件而输注可能会导致固有风险和成本，而没有明确的益处。
