Clinical Application Of Thrombelastography

BackgroundThrombelastography(TEG)is a viscoelastic method for detecting thrombus,which is often used in trauma and large-scale surgery to guide blood transfusion treatment.However,the available data associated with conventional coagulation tests(CCT)and cirrhotic patient outcomes are slightly limited.AimsThe aim of this study was to investigate the association between TEG parameters and CCT parameters in hospitalized population,and to further explore the relationship between TEG parameters and cirrhosis,cirrhosis with portal vein thrombosis,and cirrhosis with gastrointestinal bleeding.Methods1.The correlation study included all hospitalized patients who were admitted to our hospital from October 2017 to January 2019 and underwent TEG regular cup examination.Data of TEG and CTT parameters were collected.Pearson or Spearman correlation analysis was used.Subgroup analysis was performed based on the use of anti-platelets and/or anti-coagulants.TEG parameters include: R,K,Angle,MA and LY30.CCT parameters include:(1)blood routine parameters: platelet count(PLT);(2)coagulation parameters: prothrombin time(PT),international normalized ratio(INR),activated partial thromboplastin time(APTT),thrombin time(TT)and fibrinogen(FIB);(3)fibrinolysis parameters: D-dimer and fibrin degradation products(FDP);(4)anticoagulation parameters: antithrombin III(ATIII),protein C(PC)and protein S(PS).2.The retrospective study included all hospitalized patients who were admitted to our hospital from October 2017 to January 2019 and underwent TEG regular cup examination.Data were collected from patients’ clinical data,laboratory tests and imaging examinations.Patients were assessed for cirrhosis,PVT,and gastrointestinal bleeding and were divided into cirrhosis and non-cirrhosis group,cirrhosis with and without PVT group,as well as cirrhosis with and without gastrointestinal bleeding group.Independent sample t-test or Mann-Whitney U-test were used for continuous data.Chi-square test or Fisher’s exact test were used for dichotomous variable data.The forward stepwise regression method was used for multivariate binary logistic regression analysis,and the odds ratio(OR)and 95% confidence interval(CI)were calculated.The receiver operating characteristic(ROC)curves were drawn and the sensitivity,specificity and area under curve(AUC)were calculated.Results1.A total of 288 inpatients were enrolled.Patients treated with and without antiplatelet and/or anti-coagulant drugs were 225 and 63,respectively.Regardless of the use of anti-platelet and/or anti-coagulant drugs:(1)Between TEG parameters: R is positively correlated with K,and negatively correlated with Angle;K is negatively correlated with Angle and MA;Angle is positively correlated with MA;LY30 is not correlated with R,K,Angle and MA.(2)Between TEG parameters and coagulation parameters and PLT: R is positively correlated with APTT,but not with PT and INR;K is positively correlated with PT,INR and APTT,and negatively correlated with FIB;Angle is negatively correlated with PT,and positively correlated with FIB and PLT;MA is negatively correlated with PT and INR,and positively correlated with FIB and PLT;LY30 is not correlated with FIB.(3)Between TEG parameters and fibrinolysis parameters: R,Angle and MA are not correlated with D-dimer and FDP;K and LY30 are not correlated with FDP;(4)Between TEG parameters and anticoagulation parameters: R and LY30 are not correlated with ATIII;K is negatively correlated with ATIII;both Angle and MA are positively correlated with ATIII.The use of anti-platelet and/or anti-coagulant drugs can lead to heterogeneity in the correlation between some parameters,including LY30 with PT,INR,APTT and D-dimer,TT with R,K and MA,APTT with Angle and MA,and PC with K and MA.2.(1)Comparison between cirrhosis and non-cirrhosis group.Thirty-seven patients with cirrhosis and 32 patients without cirrhosis were enrolled.Multivariate analysis showed that the levels of PLT(OR=0.980,95% CI [0.965-0.994],P=0.007)and AT III(OR=0.916,95% CI [0.841-0.999],P=0.048)were independently associated with cirrhosis development.The cut-off value,sensitivity,specificity and AUC of predicting cirrhosis were PLT(142x10^9/L,86.49%,74.19%,0.811 [95% CI=0.698-0.896]),ATIII(87%,75.68%,71.43%,0.749 [95% CI=0.626-0.848],respectively.(2)Comparison between PVT and non-PVT group in cirrhosis.Nine patients with PVT and 15 patients without PVT were enrolled.Multivariate analysis showed that the increased D-dimer level(OR=2.761,95% CI [1.174-6.489],P=0.020)was the only independent variable predicting the development of PVT in cirrhosis.The cut-off value,sensitivity,specificity and AUC of predicting PVT in cirrhosis were 2.12 mg/L,77.78%,93.33% and 0.904 [95% CI=0.713-0.985],respectively.(3)Comparison between gastrointestinal bleeding and non-gastrointestinal bleeding group in cirrhosis.Ten patients with gastrointestinal bleeding and 27 patients without gastrointestinal bleeding were enrolled.Multivariate analysis showed that increased HGB level(OR = 0.898,95% CI [0.829-0.972],P = 0.008)was the only protective factor for gastrointestinal bleeding in cirrhosis.The cut-off value,sensitivity,specificity and AUC of predicting gastrointestinal bleeding in cirrhosis were 97 g/L,90.00%,88.89% and 0.885 [95% CI = 0.737-0.966],respectively.Conclusions1.There is a correlation between the parameters of TEG and CCT,and the use of anti-platelet and/or anti-coagulant drugs may lead to heterogeneity in the correlation between some parameters.2.TEG parameters may not predict the development of PVT and gastrointestinal bleeding in cirrhosis.3.Increased levels of PLT and ATIII are protective factors for cirrhosis and are independently associated with the development of cirrhosis.4.Increased D-dimer level is the independent variable predicting the development of PVT in cirrhosis.5.Increased HGB level is protective factor for gastrointestinal bleeding in cirrhosis and is independently associated with the development of gastrointestinal bleeding in cirrhosis.