Changes in the hemostatic system indices of patients with chronic kidney failure under the influence of enterosorption and plasmapheresis

A total of 83 patients with chronic renal failure (CRF) at azotemia stage (S. I. Riabov's classification) complicating pyelonephritis were treated: 19 patients received symptomatic standard therapy (group 1), 29 patients received combined therapy with enterosorption (group 2), 35 patients received combined treatment with plasmapheresis (group 3). The efficacy of the treatments was controlled by platelet tests (platelet, coagulative hemostasis, fibrinolytic plasma activity) and parameters of kallikrein-kinin system. Treatment results in group 1 are characterized as poor: insignificant improvement of uremia, DIC syndrome against unchanged inhibition of kallikrein-kinin system. Group 2 patients achieved moderate response: uremia reduced to normal azotemia values, DIC syndrome and inhibition of kallikrein-kinin system reduced. Patients of group 3 got disappeared DIC syndrome and normal kallikrein-kinin system against high azotemia.     

Maintenance of remission in adult acute nonlymphoblastic leukemia using intermittent courses of cytosine arabinoside (NSC-63878) and 6-thioguanine (NSC-752)

In seven of 30 consecutive patients with the adult respiratory distress syndrome, disseminated intravascular coagulation (DIC) developed. Increasing respiratory dysfunction characterized by decreased effective static compliance and increased hypoxemia coincided with the development of DIC. Patients in whom DIC developed were characterized by a high incidence of bleeding, gangrene of the extremities, renal dysfunction, mortality and autopsy evidence of fibrin microthrombi in the lungs, kidney and skin. In 12 of 23 patients who did not meet the criteria for DIC, the platelet count decreased by at least 50 per cent of the initial values at some time during their illness. Fibrin microthrombi were found in the lungs in the majority of the patients subjected to autopsy. These data support the concept that depostion of platelet on damaged pulmonary capillary endothelium may be more common in the adult respiratory distress syndrome than the DIC syndrome.     

Comparative data on the use of a cryosupernatant and fresh-frozen plasma in the therapy of a protracted infectious-septic syndrome of disseminated intravascular coagulation

AIM: To compare therapeutic effectiveness of cryosupernatant plasma fraction (CSP) and fresh-frozen plasma (FFP) in long-term infectious-septic DIC syndrome arising in acute abscess and gangrene of the lung. MATERIALS AND METHODS: 106 and 131 patients with infectious-septic DIC syndrome were treated with CSP and FFP, respectively. The results of the treatment were compared clinically and hemotopogically. RESULTS: Clinical response to both treatments was evident from positive changes in XIIa-dependent fibrinolysis, lowering of fibrinogen level and enhanced activity of antithrombin III. CSP treatment brought about a decrease in the number of thromboses, lethal cases, unfavorable outcomes. CONCLUSION: The cryosupernatant can be used instead of fresh-frozen plasma in combined treatment of long-standing infectious-septic DIC syndrome.     

Original article (II): materials and methods

We experienced five patients with prostate cancer with disseminated intravascular coagulation syndrome (DIC) at the first presentation at Gunma University Hospital and affiliated institutions between 1991 and 1997. Their average age was 68 years, average DIC score at the first presentation was 10 and prostate specific antigen (PSA) level was more than 700 ng/ml. All of them had multiple bone metastases. The therapy for DIC and hormonal therapy for prostate cancer were simultaneously started at the first presentation before prostate needle biopsy, but all patients died. The average number of days from the start of DIC to death was 685 days. The patients initially showed a good response to therapy, but their conditions soon aggravated. The prognosis was extremely poor, but some proper therapies lead to the prognosis which was equal to that of prostate cancer in Stage D2 without DIC.     

Influence of hemosorption on hemostasis in patients with sepsis

The changes in the system of hemostasis were studied in 36 patients with sepsis managed with sorptive detoxication. The starting status of the system of hemostasis in patients with favorable outcome of the disease can be considered as the 2d stage of the disseminated intravascular coagulation (DIC), and in patients with the unfavorable outcome--as the 3d (hypocoagulative) stage. The sorptive detoxication provides the treatment of the DIC syndrome in favorable outcome, as well as further progression of the process in unfavorable outcome of sepsis. Conservative treatment provides stabilization of the hemostatic system and gives opportunity to perform delayed hemosorption with a positive clinical result.     

Purpura fulminans in pneumococcal sepsis: case report and review

Purpura fulminans is classically defined by ecchymotic skin lesions, fever, and hypotension. The majority of cases occur in association with bacterial sepsis, and disseminated intravascular coagulation (DIC) is usually present. Prompted by our experience with a patient with pneumococcal sepsis and purpura fulminans in whom hypotension was never observed, we evaluated the important parameters of sepsis in reports of this syndrome. 42 additional cases of pneumococcal bacteremia and purpura fulminans were identified. Hypotension was present in only 51%. Although DIC was present in 85% of patients, hypofibrinogenemia was documented in only 26%. By contrast, both hypotension and hypofibrinogenemia are present in the vast majority of patients described with purpura fulminans in association with meningococcal sepsis. These data confirm that hypotension is not a necessary feature of the syndrome of purpura fulminans associated with pneumococcal sepsis and suggest further that qualitative or quantitative differences exist in the DIC cascade of pneumococcal vs meningococcal sepsis.     

Morphological diagnosis of DIC syndrome. Shock liver

A total of 140 pathoanatomic conclusions and files collected by the author are analyzed. Morphological signs of the DIC syndrome were detected in 55% of patients who died. In 42% of lethal outcomes this syndrome was the final direct cause of death after such conditions as terminal stage of cancer, sepsis, extensive myocardial infarction, mechanical jaundice, uremia, bacteremia, etc. In 13% of autopsies fatal intravascular coagulation was a complication of the intervention or hemorrhage which was arrested before death. The DIC syndrome is diagnosed during autopsy due to a complex of peculiar changes in the viscera which are called "shock" in such cases. The signs of a shock liver are as follows: a characteristic red net pattern of the sliced surface and histological phenomena related to blocking of the sinusoidal bloodflow and lobular ischemia: abnormal hepatocyte complexes, fragmentation of liver bulks, and necrosis of the central lobules.     

The DIC syndrome as a complication of the surgical treatment of urolithiasis in urology patients

The authors discuss the causes of the DIC syndrome in urological patients operated on for urolithiasis. They enumerate the factors predisposing to the DIC syndrome and causing it. The predisposing factors are chronic renal insufficiency and metabolic disorders caused by azotemia, infectious inflammatory complications of urolithiasis, and intoxication. The causes of the disease are massive blood loss involving disorders of the hemodynamics and blood rheology, bacterial shock, and other stress conditions. A protocol for treating this complication and validation of pathogenetic therapy is offered.     

Disseminated intravascular coagulation. Objective criteria for diagnosis and management

Current concepts of the cause, pathophysiology, clinical and laboratory diagnosis, and management of fulminant and low-grade DIC have been presented. Considerable attention has been devoted to interrelationships within the hemostasis system. Only by clearly understanding these pathophysiological interrelationships can the clinician and laboratory scientist appreciate the divergent and wide spectrum of often confusing clinical and laboratory findings in patients with DIC. In this discussion, objective clinical and laboratory criteria for a diagnosis of DIC have been delineated, thus eradicating unnecessary confusion and empirical decisions regarding the diagnosis. Many therapeutic decisions to be made are controversial and will remain so until more is published about specific therapeutic modalities and survival patterns. Also, therapy must be highly individualized depending on the nature of DIC, age, cause of DIC, site and severity of hemorrhage or thrombosis, and hemodynamic and other clinical parameters. Also presented are clear criteria for severity of DIC and objective criteria for defining a response to therapy. Also, because it is often difficult for the individual physician to decide when to stop often extensive therapy, objective criteria whereby therapy may be stopped, as continuation is likely fruitless, have been presented as a guideline. Lastly, it should be appreciated that many syndromes that are often organ specific share common pathophysiology with DIC but are typically identified as an independent disease entity, such as hemolytic uremic syndrome, adult shock lung syndrome, eclampsia, and many other isolated organ-specific disorders.     

Fine particulate organic material in the Los Angeles Basin-I: assessment of the high-volume Brigham Young University organic sampling system, BIG BOSS

BACKGROUND AND OBJECTIVE: Acute generalized, widespread bleeding is often related to disseminated intravascular coagulation (DIC), a pathologic process which complicates the clinical course of many diseases and is characterized by huge amounts of thrombin and plasmin within the circulation. The final result is the consumption of platelets, coagulation factors and inhibitors, as well as secondary hyperfibrinolysis, all leading to diffuse hemorrhage and microthromboses. This review article examines the present attitudes to the diagnosis and treatment of overt DIC in clinical practice, emphasizing the importance of an accurate differential diagnosis from some other processes characterized by acute generalized, widespread bleeding. INFORMATION SOURCES: The authors have been working in this field, both at experimental and clinical levels, contributing original papers for many years. In addition, material examined in this review includes articles published in journals covered by MedLine, recent reviews in journals with high impact factor and in relevant books on hemostasis and thrombosis. STATE OF ART AND PERSPECTIVES: DIC is an intermediary mechanism of disease which complicates the clinical course of many well-known disorders. Although the systemic hemorrhagic syndrome is the predominant clinical manifestation, massive intravascular thrombosis frequently occurs contributing to ischemia and associated organ damage, making the mortality rate of this condition high. Current concepts on the pathophysiology, laboratory diagnosis and management of DIC are presented. Complex pathophysiological interrelations make the diagnosis of the etiology of the DIC difficult in clinical practice, although simple tests are useful for identification of patients with the process. Laboratory diagnosis of DIC is mainly based on screening assays, which allow a rapid diagnosis, whereas some other highly sensitive but more complex assays are not always available to routine clinical laboratories. The management of DIC is based on the treatment of the underlying disease, supportive and replacement therapies and the control of the coagulation mechanisms. Although some advances have been achieved, management decisions are still controversial, so that therapy should be highly individualized depending on the nature of the DIC and severity of clinical symptoms. Many syndromes sharing common findings with DIC, such as primary hyperfibrinolysis or thrombotic thrombocytopenic purpura, should be excluded. Finally, new therapeutic approaches to the management of this potentially catastrophic syndrome are required.     

Fibrinogen metabolism and disseminated intravascular coagulation in dengue hemorrhagic fever

In 29 patients with dengue hemorrhagic fever (DHF), 12 with grade 2 and 17 with grades 3 and 4, fibrinogen metabolism was studied by using 125I-fibrinogen; 11 of these patients were studied during shock. Hemostatic studies were also performed to search for evidence of disseminated intravascular coagulation (DIC). Increased intravascular coagulation, as judged by rapid T1/2 of 125I-fibrinogen, as well as evidence of DIC by hemostatic patients with DHF grade 2 had rapid T1/2 and only 17% had DIC. Of the 11 patients studied during shock, 91% had both rapid T1/2 and evidence of DIC, whereas 63% of the 18 patients without shock had rapid T1/2 and only 11% of this latter group had DIC. A correlation between the increased fibrinogen consumption as judged by rapid T1/2 of 125I-fibrinogen, DIC, clinical severity, and shock was demonstrated. The role of DIC in the pathogenesis of DHF is discussed, and heparin is suggested for patients with prolonged shock and severe acidosis when DIC becomes clinically apparent.     

Prevalence of cervical Chlamydia trachomatis infection in a female population seeking contraception counseling

To analyze the outcome of systemic lupus erythematosus (SLE) associated with acute disseminated intravascular coagulation (DIC) and also to clarify the clinical factor(s) contributing to the outcome, we retrospectively investigated 120 SLE patients treated between 1981 and 1991. Eight of these patients (6.7%) developed acute DIC; four recovered and the other four died within 2 weeks of onset. Infection preceded acute DIC in all these patients. Acute DIC associated with atypical pneumonia was always fatal, while the patients with pharyngitis or urinary tract infection survived when they were treated adequately. Comparison of the dead and surviving groups revealed that the activity of SLE before the onset of DIC, the severity of DIC, and the treatment given for DIC and the coexistent infection were not significantly related to a fatal outcome. However, severe infection such as atypical pneumonia in patients with secondary immunodeficiency was likely to be fatal irrespective of the presence of DIC.     

Outcome of disseminated intravascular coagulation in relation to the score when treatment was begun. Mie DIC Study Group

We examined 395 patients with disseminated intravascular coagulation (DIC) divided into two groups: non-leukemic and leukemic. In 58% of the patients as a whole, treatment of DIC resulted in complete or partial remission, while exacerbation and death occurred in 31%. The efficacy of DIC treatment in the non-leukemic group was less than that in the leukemic group, indicating that the outcome of DIC depended, in part, on the underlying disease. We examined hemostatic indicators in relation to DIC score: prothrombin time (PT) ratio, FDP, platelet count, and fibrinogen levels were found to be important indicators for the diagnosis of DIC, but not for Pre-DIC. Plasma levels of fibrin-D-dimer, thrombin-antithrombin complex (TAT), and plasmin-plasmin inhibitor complex (PPIC) were significantly increased in pre-DIC. The efficacy of treatment in relation to the DIC score when the treatment was begun showed that greater efficacy was achieved in pre-DIC than in DIC patients. The outcome was poorer with increasing DIC score, suggesting that early diagnosis and early treatment are important. On examining the relationship between outcome and hemostatic indicators, we found that the PT ratio and the levels of antithrombin, plasminogen, PPIC, the PPIC/TAT ratio, and thrombomodulin were related to outcome, suggesting that very high consumption of blood coagulation factors, liver dysfunction, hypofibrinolysis, or organ failure caused a poor outcome. Although the outcome in DIC patients may not depend substantially on plasma levels of TAT and fibrin-D-dimer, we can use these indicators to treat DIC patients at an early stage.     

A flexible lingual clasp as an esthetic alternative: a clinical report

Disseminated intravascular coagulation (DIC) and thrombocytopenia are well-known complications of sepsis, but the relationship between these coagulation abnormalities and outcome have not been well documented. We studied the incidence of thrombocytopenia and DIC in our Medical Intensive Care Unit, and evaluated their usefulness as prognostic risk factors for mortality. Platelet count was not found to be an independent risk factor associated with overall mortality in the 107 patients studied. In the sub-group of 53 patients with sepsis, 22 (42%) developed DIC, 31 (58%) developed thrombocytopenia (< 150,000 x 10(9)/L) and 27 (51%) died. Thrombocytopenia was associated with presence of DIC (p = 0.003), but not with the type of infecting organism. The platelet count in non-survivors (mean +/- sem, 97 +/- 18 x 10(9)/L) was significantly lower than survivors (194 +/- 27 x 10(9)/L, p < 0.005). Multiple regression analysis showed that thrombocytopenia was a risk factor for mortality, independent of the APACHE II score. The presence of DIC surprisingly was not an independent risk factor. We conclude that DIC and thrombocytopenia are common in our adult Medical Intensive Care patients with sepsis, but only the latter is a prognostic factor in addition to the APACHE II score. The incidence of DIC in our patients (mainly Chinese) seems to be more than that of 10 to 20% reported in other series of Caucasian patients. We would, therefore, like to emphasise the importance of platelet count as an prognostic risk factor in sepsis.     

Transient fetal cerebral dysfunction after road traffic accident. A case report

BACKGROUND: The relationship of Haemolysis, Elevated Liver Enzymes and Low Platelets (HELLP) syndrome with maternal and perinatal health and its presentation in Pakistani population is not known. PURPOSE: To determine the mode of presentation along with maternal and perinatal outcome of patients with HELLP syndrome. METHODS: Case records of patients with severe hypertension in pregnancy who delivered between January 1, 1989 and December 31, 1994 at The Aga Khan University Hospital, Karachi. Out of 120 cases of severe pre-eclampsia/eclampsia, there were 36 cases of HELLP syndrome (Group-A). These were then compared with cases without HELLP syndrome (Group B) for their mode of presentation along with maternal and perinatal morbidity and mortality. RESULTS: The overall incidence of HELLP syndrome was 0.4%. In the antepartum factors; unbooked status (66% vs 30%; p < 0.05), diastolic B.P. > 120 mmHg (61% vs 16%; p < 0.05) DIC (13% vs 2%; p = 0.03), seizures (40% vs 16%, p = 0.01) and ARF (11% vs 1%, p = 0.07) were significantly raised. In the intrapartum factors there were no significant differences between the two groups in mode of delivery and complications of delivery. Neonatal outcomes did not differ significantly in the two groups. CONCLUSIONS: Women with severe hypertension in pregnancy manifesting with HELLP syndrome show a significantly greater frequency of developing DIC, seizures and acute renal failure. Therefore, their care necessitates intensive monitoring to preclude development of these complications.     

Hemostatic evaluation of a patient with haloperidol-induced neuroleptic malignant syndrome associated with disseminated intravascular coagulation

A 94-year-old man who had been admitted to our hospital for the treatment of senile dementia and restless behavior exhibited consciousness disturbances, acute respiratory failure, high fever, and thrombocytopenia the day after receiving haloperidol as prescribed by a psychiatrist. On the fourth day following administration of haloperidol, acute renal failure with rhabdomyolysis and disseminated intravascular coagulation (DIC) developed in the patient, who was accordingly given a diagnosis of haloperidol-induced neuroleptic malignant syndrome (NMS) associated with DIC. He was then given heparin and antithrombin III, and his DIC symptoms improved soon thereafter. Elevated plasma levels of tissue factor and tumor necrosis factor-alpha (TNF-alpha) were sustained during this therapy course. Other cytokines, including interleukin IL-1 beta, IL-2 and IL-6, were not elevated. There are activation of extrinsic coagulation and an elevated level of TNF-alpha during acute renal failure and rhabdomyolysis associated with NMS, which is thought to trigger the onset of DIC.     

Activation of coagulation and fibrinolysis in patients with abdominal true aortic aneurysm associated with disseminated intravascular coagulation

Two cases of abdominal true aortic aneurysm (AAA) associated with disseminated intravascular coagulation (DIC) were reported. Case 1 was an 81-year-old male who was admitted because of hematoma on the left leg and in whom was found by MRI an aortic aneurysm of 14 cm in diameter. Coagulation studies indicated DIC by revealing thrombocytopenia, hypofibrinogenemia and increased level of FDP. DIC was well controlled by surgical repair of the aneurysm after the administration of a small dose of heparin. Case 2 was a 60-year-old male who was admitted because of lumbago and hematoemesis and in whom was found by CT and echography an aortic aneurysm of 5.5 cm in diameter. Coagulation studies indicated DIC by revealing thrombocytopenia and an increased level of FDP. On the 2nd hospital day, he suddenly died due to the rupture of the aortic aneurysm. In most of 9 cases with AAA without DIC, plasma levels of thrombin-antithrombin III complex, plasmin-alpha 2 plasmin inhibitor complex and FDP-D dimer were also elevated. These findings indicate that the coagulation and fibrinolysis systems were generally activated in patients with AAA, and that DIC tends to occur in patients with a giant aortic aneurysm or an impending ruptured aneurysm.     

Antithrombin III in various conditions in internal medicine

In a group of 993 patients with serious medical diseases an important deficiency of antithrombin III was found in patients with hepatic insufficiency, pulmonary embolism and with disseminated intravascular coagulation. Acquired antithrombin III deficiency in these conditions develops when the antithrombin production in the liver is low and also in patients with shock syndrome and disseminated intravascular coagulation. Assessment of antithrombin III is of diagnostic and prognostic value in thrombotic and prethrombotic conditions and its results is decisive for adequate substitution. Adequate AT III substitution without concurrent heparin administration in patients with septicaemia and manifestations of DIC improves the prognosis of patients with an increased endothelial resistance.     

Training staff to provide a continence helpline

We report here the operative findings, the incidence of successful laparoscopic treatment, and the perioperative complications in patients with nonvisualized gallbladder on drip infusion cholangiography (DIC). Eighty-five patients with a nonvisualized gallbladder on DIC were entered into the study. None of the patients had a minimal adhesive gallbladder; 51 to 85 patients (60.0%) had moderate adhesive gallbladders, and 34 (40.0%) had severely adhesive ones. The rate of successful laparoscopic treatment, including laparoscopy-assisted abdominal surgery, was 97.6% (83 of 85 patients). Perioperative complications occurred in only three patients (3.5%), and there were no deaths related to the operation. Thus, when patients with a nonvisualized gallbladder on DIC undergo laparoscopic cholecystectomy, meticulous procedures must be carried out; however, as the rate of successful laparoscopic treatment is high, cholecystectomy under laparoscopy is feasible for experienced surgeons.     

Preparation for upper gastrointestinal endoscopy: opportunity or inconvenience?

A 59-year-old man, who manifested lower back pain, was admitted with sepsis and disseminated intravascular coagulation (DIC). A computed tomographic scan showed a slight thickening of the abdominal aortic wall. A blood examination revealed pancytopenia. Myelodysplastic syndrome was diagnosed after bone marrow aspiration and a chromosome analysis. Sepsis due to a Staphylococcus aureus infection and DIC subsided after medical treatment; however, an aortobifemoral bypass was performed upon the detection of a localized rupture of a mycotic abdominal aortic aneurysm 1 month later. The patient is still alive 2 years after operation despite the presence of a hematological disorder.