Thrombin generation in cirrhosis

Aurélien Lebreton Hematology department, Clermont-Ferrand, France

alebreton@chu-clermontferrand.fr

Clermont-Ferrand

Introduction

Introduction

= +

Healthy Cirrhosis Alcohol

Liver diseases and haemostasis

Fibrinolysis

Primary hemostasis

Coagulation

Mechanical factors +++

Despite prolonged aPTT

and PT

Cirrhosis : a risk factor for VTE

Soogard et al, Am J Gastroenterol, 2009, 104:96 – 101

Etude danoise, cas (99 444 VTE+) contrôles (496 872)

Am J Gastroenterol, 2006, 101(7):1524-8 Prevalence of VTE in hospitalised cirrhotic

patients : 0.5%

Risk for DVT: OR = 2.0 (95% CI = 1.3 – 2.2, p < 0.0001) Risk for PE: OR = 1.7 (95% CI = 1.0 – 2.6, p = 0.033)

Thromb Haemost, 2017 Jan 5;117(1):139-148

Cirrhosis and haemostasis

Low plasminogen t-PA elevation Low A2-AP, FXIII & TAFI

Tissue Factor (TF)

Va Xa

VIIa

II Prothrombin

VIIIa

IIa Thrombin

IXa FXIa FXIIa

Extrinsic pathway PT

Intrinsic pathway aPTT

Fibrinogen

Coagulation in vitro

PL Ca++

PL Ca++

PL Ca++

Contact phase activator (silice, kaolin…)

Cirrhosis and routine coagulation assays

Tripodi et al, Hepatology, 2005, 41:553–558

o Prolonged routine coagulation assays (aPTT, PT) o Diminution of procoagulant factors (except FVIII)… and coagulation inhibitors

Coagulation in vivo

TF bearing cells TF

TF

TF bearing cells TF

Platelets

Activated Platelets

The goal of coagulation = to generate a thrombin burst !

Coagulation in vivo

Activated Platelets

Fibrinogen Fibrin monomers

Stable thrombus

II IIa

o Tissue Factor Pathway Inhibitor

o Antithrombin

o Protein C – Protein S

Inhibition of coagulation

Endothelial cells

Tripodi A and Mannucci PM, NEJM, 2011, 365:147-56

Thrombin generation assay

Thrombin generation assay

Tripodi A and Mannucci PM, NEJM, 2011, 365:147-56

+ TM

Thrombinogram

1 - Lag time (min) 2 - Peak height (nM) 3 - Time to peak (min) 4 - Endogenous thrombin potential (nM.min)

Thrombin (nM)

Time (min)

Tripodi A et al, Hepatology, 2005, 41:553–558 Δ Controls (n=30) o Patients (n=44)

• Patients with cirrhosis seem to have decreased TG

• No difference when adding TM in the system

• FII decrease is rebalanced by PC decrease and FVIII elevation

• Coagulation abnormalities probably do not play a key role in bleeding events

2005 2008 2009 2010 2011 2013 2014 2015 2016 2017

Tripodi A et al, Hepatology, 2006, 44:440-445

200xx 2005 2006 2007 2008 2009 2010 2011 2012 2013

• 60 controls, 71 patients

• Adjusted platelets rich plasma (PRP) to 100 G/l

• ETP PRP > ETP platelet poor plasma

Platelets are involved in the thrombin generation of cirrhotic patients in PRP

• 51 controls, 87 patients

• PRP, no adjustment

• ETP of unadjusted-PRP are lower than ETP adjusted-PRP

• The amount of generated thrombin is correlated to platelet number

> Platelet transfusion is justified only if severe thrombocytopenia or bleeding event are present (or

invasive procedure…) Tripodi A et al, Hepatology, 2006, 44:440-445

200xx 2005 2006 2007 2008 2009 2010 2011 2012 2013

Tripodi A et al, Gastroenterology, 2009, 137:2105–2111

• Controls (n= 131) • Cirrhotics (n=134)

2005 2008 2009 2010 2011 2013 2014 2015 2016 2017

• Ratio (ETP with TM / ETP without TM)

• Résistance to the action of TM

• Hypercoagulability is in relation with the severity of cirrhosis

(n= 134) (n= 131)

Tripodi A et al, Gastroenterology, 2009, 137:2105–2111

n=54 n=57 n=23

2005 2008 2009 2010 2011 2013 2014 2015 2016 2017

• FVIII/PC ratio (or FVIII/AT) is correlated to the hypercoagulable state Tripodi A et al, Gastroenterology, 2009, 137:2105–2111

n=54 n=57 n=23

n=54 n=57 n=23

2005 2008 2009 2010 2011 2013 2014 2015 2016 2017

Gatt et al, J Thromb Haemost, 2010, 8: 1994–2000

Tripodi et al, Hepatology, 2010, 52:249-255

1

1 2

2

2005 2008 2009 2010 2011 2013 2014 2015 2016 2017

Delahousse et al, Thromb Haemost, 2010, 104: 741–749

• 28 patients, comparison jugular vs portal blood • Significant differences between jugular vs portal blood for PC, PS, FVIII, F 1+2 and D-

dimers levels • Lower ETP and peak for cirrhotic vs controls, no difference jugular vs portal blood • Resistance to TM in jugular and portal blood

• In vitro addition of PC in 2 plasma normalises TG

Port. Port. Port.

Jug. Jug. Jug.

2005 2008 2009 2010 2011 2013 2014 2015 2016 2017

Lisman et al, J Hepatol, 2010, 52: 355–361

2005 2008 2009 2010 2011 2013 2014 2015 2016 2017

• 10 patients undergoing liver transplantation • Follow-up of TG up to D10

• ETP significantly decreased before surgery

• Velocity index, peak (with and without TM)

significantly higher after surgery

• No correlation with PT nor aPTT

• Resistance to TM before and after surgery

• Correction of PC levels after liver transplantation

• Correction of AT & PS after liver transplantation

• Persistant elevation of FVIII after transplantation

These data reinforce the hypothesis that hemostatic system of cirrhotic patients is competent, including during liver transplantation, without needs of systematic

transfusions Lisman et al, J Hepatol, 2010, 52: 355–361

2005 2008 2009 2010 2011 2013 2014 2015 2016 2017

Tripodi et al, Liver International, 2012, 33: 362–367

• 26 cirrhotic patients with thrombocytopenia (< 50 G/l)

• Prophylactic platelet transfusion before variceal ligation

• Limited elevation of platelet number (< 100 G/l)

• Limited impact on thrombin generation

• No impact on thromboelastometry

2005 2008 2009 2010 2012 2013 2014 2015 2016 2017

Senzolo et al, J Thromb Haemost, 2012, 10: 1823–9

n=10 n=10 n=10 n=10 n=10

• ETP ratio with/without LMWH

• Increased sensibility to LMWH in relation with the severity

• Same response in the presence of TM

> Authors recommend to used TG assay to monitor the treatment by LMWH in

patients with cirrhosis

2005 2008 2009 2010 2012 2013 2014 2015 2016 2017

Tripodi et al, J Hepatol, 2013, 59: 265–270

• The correction of PC levels improves in a dose dependent manner the sensibility to TM

• Good correlation between ETP ratio and PC levels

2005 2008 2009 2010 2011 2013 2014 2015 2016 2017

Tripodi et al, J Hepatol, 2013, 59: 265–270

• The correction of PC levels improves in a dose dependent manner the sensibility to Protac

• Good correlation between PICI and PC levels

2005 2008 2009 2010 2011 2013 2014 2015 2016 2017

Lebreton A et al, J Gastroenterol Hepatol. 2016, Epub

• Identical sensibility to aPC (no significant difference between all ETP) between controls and patients (despite PS deficiency)

2005 2008 2009 2010 2011 2013 2014 2015 2016 2017

Plasma hypercoagulability in the presence of thrombomodulin but not of activated protein C in patients with cirrhosis

ETP with aPC ETP with TM

Impact of acquired PC deficiency / high FVIII

PC PC FVIII

FVIII

Thrombin generation assays (TF : 5 pM, PL : 4 µM) with TM (4 µM)

N = 48 N = 88 N = 43

+ + + Purified PC

(Adjusted amounts to reach 80 – 120 %)

Inhibitory ant-FVIII mAb (ESH8) (Adjusted amounts to

reach 80 – 120 %)

Simultaneous normalisation of PC and

FVIII

PC < 70% FVIII > 150% FVIII > 150% PC < 70%

Normalisation of PC on TGA+TM

Sinegre T. et al, under review

• Correction of PC alone is not sufficient to normalise TGA with TM

Sinegre T. et al, under review

Normalisation of FVIII on TGA+TM

• Correction of FVIII alone is not sufficient to normalise TGA with TM

Sinegre T. et al, under review Only a simultaneous normalisation of PC and FVIII restore sensitivity to TM

Simultaneous normalisation of PC & FVIII

TGA and cirrhosis : conclusion

• Cirrhotic patients are exposed to thrombotic events despite prolonged routine coagulation assays : they are not « naturally anticoagulated »

• Thrombin generation assays in the presence of thrombomodulin revealed a hypercoagulable state

• The main determinants of the low sensitivity to the action of TM are the acquired PC deficiency and acquired FVIII elevation

• Recently, a study demonstrate that fibrin clot structure of cirrhotic patients is also procoagulant

• Clinical validation of the use of thrombin generation assays is lacking

• Retrospective study

• Resistance to TM is an independant risk factor for de novo portal vein thrombosis

• Resistance to TM is associated to a worse prognosis of liver transplantation

Liver Int, 2016, 36(9):1322-30

2005 2008 2009 2010 2011 2013 2014 2015 2016 2017

Cirrhosis and hemostasis

A fragile equilibrium…

Healthy Cirrhosis

Thank you for your attention !