The Diagnosis Of Disseminated Intravascular Coagulation Caused By Hematologic Disease

Part1Sample bank establishment and plasma factors screeningObjectivesThere is no "gold standard" for the diagnosis of disseminated intravascular coagulation (DIC), the diagnosis of DIC is highly dependent on laboratory tests. As a result, we aimed to establish a large sample bank involving plasma samples from consecutive hematologic disease patients. Simultaneously, we record every patient’s clinical data.Then,we carry out a series of coagulation screening tests, to explore the characteristics of patients suspected with DIC caused by hematologic disease. It is convenient for the later researches to explore valuable laboratory indicators and their reasonable cut-off values for the diagnosis of hematologic disease complicated with DIC, and compare the three different diagnostic criteria for hematologic disease complicated with DIC. If possible, to improve the Chinese diagnostic criteria for DIC.MethodsOne hundred and sixty consecutive hematologic disease patients suspected with DIC were recruited between December2012and August2013at Department and Institute of Hematology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology.Every patient’s corresponding clinical data was recorded. All plasma samples were carried out DIC screening tests, including platelet count (PLT), activated partial thromboplastin time (APTT), prothrombin time (PT), PT international standardization ratio (PT-INR), fibrinogen (FIB), fibrin/fibrinogen degradation products (FDP), D-dimer (D-D), thrombin time (TT), toluidine blue correct experimental (ATT), antithrombin III compounds (ATA), FⅧ:C. To evaluate each sample everyday by the International Society On Thrombosis And Haemostasis(ISTH) scoring system for overt DIC, Japanese Ministry of Health And Welfare(JMHW) scoring system for overt DIC and the DIC diagnosis expert consensus in China in2012, respectively.ResultsFive hundred and seventy-nine plasma samples of one hundred and sixty consecutive hematologic disease patients suspected with DIC were recruited.The results showed that78cases were diagnosed as DIC (+), and82cases were diagnosed as DIC (-) by the ISTH criteria, if considered the FDP or D-D as fibrin-related markers. However, if considered the FDP as fibrin-related markers only,45cases were diagnosed as DIC (+), and115cases were diagnosed as DIC (-) by the ISTH criteria.57cases were diagnosed as DIC (+), and103cases were diagnosed as DIC (-) by the JMHW criteria.43cases were diagnosed as DIC (+), and117cases were diagnosed as DIC (-) by the Chinese criteria. The positive rate of each indicator is different in three different criteria.ConclusionsFor the diagnosis of disseminated intravascular coagulation in hematologic disease patients, the results of three kinds of different diagnostic criteria are different. It is necessary to further evaluate three kinds of diagnostic criteria. In addition, the diagnostic value of each indicator in DIC screening tests is not confirmed. It is also necessary to be further evaluated. Part2Comparison of diagnostic criteria for disseminated intravascular coagulation in hematologic disease patientsObjectivesTo prospectively evaluate the three different diagnostic criteria for disseminated intravascular coagulation in hematologic disease patients:the International Society on Thrombosis and Haemostasis (ISTH)(ISTH criteria), the Japanese Ministry Health and Welfare (JMHW criteria) and China expert consensus of the diagnosis of DIC in2012(Chinese criteria). And explore the diagnostic value of some indicators included in the DIC screening tests for the diagnosis of DIC in hematologic disease patients.MethodsOne hundred and sixty consecutive hematologic disease patients suspected with DIC were included in this study. All of them received the DIC screening tests. We investigated the28-day mortality of three different diagnostic criteria. To evaluate their diagnostic value and difference by comparing their sensitivity and specificity for death. We also investigated the abnormalities of mean values of PLT、FDP、D-D、PT-INR and PT between DIC diagnostic scores, and explore the relationship between the indicators and the three different diagnostic criteria, respectively.ResultsThe sensitivity of Chinese criteria, ISTH criteria, JMHW criteria was26.9%(43/160),48.8%(78/160),35.6%(57/160),respectively. The28-day mortality of DIC (+) groups in three different diagnostic criteria was32.6%(14/43)、37.8%(17/45)、31.6%(18/57), respectively. The sensitivity for death of them was56.0%、68.0%、72.0%,respectively. The specificity for death of them was78.5%、79.3%、71.1%,respectively. By the three different diagnostic criteria, there was statistically significant differences (p<0.01) among the abnormalities of the mean values of various indicators like PLT, FDP, D-D, PT-INR and PT. By ISTH and JMHW criteria, there was statistically significant difference (p<0.01) between DIC (+) group and DIC (-) group for the mean value of FIB. However, by Chinese criteria, there was no statistically significant difference (p=0.07) between DIC (+) group and DIC (-) group for the mean value of FIB. The abnormalities of the mean values of various indicators are described as following:PLT is26.14G/L,28.92G/L,37.25G/L,respectively; FIB is3.24g/L,3.25g/L,2.57g/L,respectively; FDP is24.65ug/ml,36.95ug/ml,48.34ug/ml,respectively; D-D is8.29ug/ml,7.76ug/ml,9.71ug/ml,respectively; PT-INR is1.37,1.39,1.51,respectively; PT is16.9s,17.03s,18.04s,respectively.ConclusionsThe sensitivity of JMHW criteria is the highest among the three different diagnostic criteria, but the specificity of ISTH criteria is the highest. The diagnostic accuracy of all the three kinds of diagnostic criteria need to be improved. It is necessary to design studies with larger samples to explore the suitable cut-off values of various indicators, to explore new indicators with higher diagnosis value. Finally, we will propose new diagnostic criteria which will be more suitable for the diagnosis of DIC caused by hematologic disease. Part3Evaluation of indicators in disseminated intravascular coagulation screening testsObjectivesTo evaluate value of indicators in disseminated intravascular coagulation screening tests. To observe the characteristics of indicators in hematologic disease patients suspected with disseminated intravascular coagulation. To explore the possible indicators and their optimal cut-off values can improve the efficiency of the diagnosis of DIC in hematologic disease patients.MethodsOne hundred and sixty consecutive hematologic disease patients suspected with DIC were recruited between December2012and August2013at Department and Institute of Hematology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology.Every patient’s corresponding clinical data was recorded. All plasma samples were carried out DIC screening tests, including platelet count (PLT), activated partial thromboplastin time (APTT), prothrombin time (PT), PT international standardization ratio (PT-INR), fibrinogen (FIB), fibrin/fibrinogen degradation products (FDP), D-dimer (D-D), thrombin time (TT), toluidine blue correct experimental (ATT), antithrombin HI compounds (ATA), FⅧ:C. Evaluation the positive rate, sensitivity, specificity and odds ratio of all the indicators.Then draw the receiver-operating characteristics (Receiver operating characteristic, ROC) curve of each indicator and calculate the area under the curve (AUC).ResultsFive hundred and seventy-nine plasma samples of one hundred and sixty consecutive hematologic disease patients suspected with DIC were recruited.The results showed that57 cases were diagnosed as DIC (+), and103cases were diagnosed as DIC (-) by the JMHW criteria, PLT, APTT, FIB and D-D are all with good sensitivity, but the specificity of them are poor, especially D-D and PLT. The sensitivity and specificity of the PT and PT-INR are both relatively high, so the diagnostic value are relatively high. The positive rate of TT and ATT are only19.3%and19.3%,respectively. The results of ROC curve showed that the AUC of PT, PT-INR, FIB, FDP and D-D were0.822,0.824,0.757,0.933and0.897, respectively. There were statistically significant difference(P<0.001). However, the AUC of the PLT and APTT were0.594and0.501, respectively. There was no statistically significant difference(P>0.05). The suitable cut-off values of PT, PT-INR, FIB, FDP, D-D are15.5s,1.18,4g/L,10μg/ml and3μg/ml, respectively. The corresponding sensitivity and specificity are72%and80%,70%and73%,81%and60%,93%and83%,84%and82%,respectively.ConclusionsPT, PT-INR, FIB, FDP and D-D are all with high value for the diagnosis of disseminated intravascular coagulation in hematologic disease patients. The diagnostic value of the PLT and APTT are very limited. Appropriate indicators combining tests will be helpful for the diagnosis of disseminated intravascular coagulation. Our study puts forward the suitable indicators combining tests for the diagnosis of disseminated intravascular coagulation in hematologic disease patients, and also present their optimal cut-off value. But the results should be further confirmed by prospective studies with larger samples.