Measurment Of Fibrin Degrdation Products In Chronic Renal Failure Patients Using D-dimer Test

MEAS URM EN T O F FIBR IN DEG RDATI ON PR ODU CTS I N CH RONIC R EN AL FAI LU RE PATI EN TS USIN G D-DI MER TEST Submitted by: Mohammed Jomaa Ali Al-haj Faraj B.Sc. In Medical Laboratory Sciences UNIVERSITY OF SCIENCE AND TECHNOLOGY YEMEN ( 2001 ) A Thesis Submitted for Fulfillment of Master Degree IN Medical Laboratory Sciences ( Hematology ) Faculty of Medical Laboratory Sciences UNIVERSITY OF GEZIRA Main Supervisor: Prof. Ahmed Abdalla Mohamedani MBBS,D.C.P,F.R.C. Path. U.K. Co Supervisor: Dr. Mohammed Al-sabq MD, Medicine ( September 2006 )

It is disseminated intravascular coagulation with widespread deposition of fibrin and platelets within the microcirculation and consumption of .coagulation factors and platelets

Cont. Systemic activation of coagulation

Intravascular deposition of fibrin

Thrombosis of small and midsize vessels and organ failure

Depletion of platelets and coagulation factors

Bleeding

The mechanism of disseminated intravascular coagulation

Cont.

The clinical and laboratory features of acute disseminated intravascular coagulation differ from those of chronic disseminated intravascular .coagulation

Con.

:Laboratory findings * .

Prolonged prothrombin time, activated partial thromboplastin time and thrombin time

- Decreased fibrinogen levels. - Increased levels of fibrin degradation products and D-dimer tests. - Relative or absolute decrease of Platelet count. - Presence of schistocytes in peripheral smear.

Cont.

*Laboratory findings: - Modestly increased prothrombin time in some patients - Shortened or lengthened partial thromboplastin time. - Normal thrombin time in most patients. - High, normal or low platelet count. - Increased levels of fibrin degradation products and D-dimer.

Cont.

 The association of altered hemostasis and uraemia has long been recognized, as well as the fairly high morbidity associated with such events.  The pathogenesis of bleeding disorders is multifactorial and no single explanation.  The platelet count in ureamia is usually normal, but platelet function is impaired.

Cont.

 There was a previous belief that some dialyzable substances, found in increased concentration in the plasma of uremic patients, could play a role in the abnormal platelet function seen in chronic renal failure. Thrombotic and severe haemorrhagic complications are common in patients with end stage renal disease and contribute substantially to the morbidity and mortality in this populations.

Cont.

Disseminated intravascular coagulation (DIC) remains a clinical diagnosis supported by laboratory data.

Cont.

What is D-dimer ? D-dimer is a protein that is released into the circulation during the process of fibrin blood clot break down.

Cont.

 D- dimer tests are ordered, a long with other laboratory tests and imaging scan to help rule out, diagnosis and monitor disease and conditions that cause hypercoagulability.  One of the most common of these conditions is DVT and pulmonary embolism.

Cont.

 Measurements of D-dimer may also be ordered, along with other tests, to help diagnosing DIC (Disseminated intravascular coagulation).  D-dimer levels may be used to monitor the effectiveness of disseminated intravascular coagulation treatment.

Cont.

 There are many different D-dimer assays currently available on the market.  All of these assays rely on monoclonal antibodies.  The original assay is semi-quantitative and utilizes visual macroscopic latex agglutination (used in disseminated intravascular coagulation diagnosis).

Cont.

 The most sensitive quantitative D-dimer assay is based on the ELISA format.  The most practical quantitative assays are the latex-enhanced photometric assays that are turbidimetric or colorimetric.

Cont.

What are FDPs? Fibrin degradation products (FDPs), also known as fibrin spilt products, are present in blood when the thrombolytic enzyme plasmin cleaves fibrin or fibrinogen. This is a test that measures fibrin degradation products (which are produced when clots dissolve) in blood.

Cont.

 The measurement of FDPs provides a

direct indication of the activity of the fibrinolytic (clot dissolving) system.  When they are present in large amounts,

they indicate increased fibrinolysis, or clot breakdown.

To determine the level of D-dimer in chronic renal failure patients using a latex agglutination method.

Cont.

1. To evaluate the association between chronic renal failure and disseminated intravascular coagulation. 2. To evaluate the effect of dialysis on the level of D-dimer test, FDPs and others . 3. To evaluate performance of FDPs screening test. 4. To compare the performance of FDPs compared to D-dimer test.

Study area: This is study was conducted at Gezira hospital for renal diseases and surgery.

Study population: Patients diagnosed as chronic renal failure (CRF).

Study location: The study conducted in central laboratory at Gezira hospital for renal diseases and surgery.

Cont.

Sample selection and size : Blood samples obtained from adult males and females (aged between 10 to 70 years). During the period from March 2005 to November 2005 as follows: -Control persons 60 samples with no clinical or Biochemical evidence of renal failure. -Patients with chronic renal failure 120 samples. -60 samples pre-dialysis. -60 samples post-dialysis. -The total numbers of samples was 180 samples.

Cont.

Study design: It was an observational prospective comparative case control study. :Data collection A questionnaire was designed to collect demographical and clinical data.

Using latex agglutination slide test for qualitative and semi-quantitative assay.

Cont.

Using qualitative and semi-quantitative determination of FDPs in plasma by latex agglutination method.

Cont.

Note: In addition to D-dimer & FDPS tests, we performed both PT & APTT tests.

Age Distribution : 30

27 25

20

17 15 13

Percent

10

3 0 10-20

age group

21-30

31-40

41-50

51-60

61-70

Cont. Sex distribution : Male 71.7% Female 28.3% In (17)

(I n (43

Cont. :Table

(1): Types and frequency of dialysis

Type of dialysis Peritoneal Dialysis

No of patients

Percent %

20

33.3

Haemodialysis

40

66.7

Total

60

100.0

Cont. Table (2): Duration of Haemodialysis: Duration / months

No. of patients

Patient %

1-6 7-12 13-18 19-24 25-30 31-36 37-42 43-48 Total

20 10 3 2 1 1 1 2 40

50.0 25.0 7.5 5.0 2.5 2.5 2.5 5.0 100.0

Cont. Table (3): Duration of Peritoneal dialysis:

No. of dialysis No. of patients 1 2 3 4 6 Total

6 8 4 1 1 20

Patient % 30.0 40.0 20.0 5.0 5.0 100.0

Cont.

Table (4): Result of D-dimer test pre peritoneal and haemodialysi

Type of dialysis Level of D-dimer

Frequency

Patient %

Peritoneal Dialysis

< 0.5 <0.5 > 1.0 <1.0 < 2.0 <2.0 <4.0 > 4.0 <8.0 Total

6 6 3 3 2 20

30.0 30.0 15.0 15.0 10.0 100.0

Haemodialysis

< 0.5 > 0.5 < 1.0 > 1.0 < 2.0 > 2 < 4.0 Total

12 23 3 2 40

30.0 57.5 7.5 5.0 100.0

Cont.

Table (5): Result of D-dimer test post peritoneal & haemodialysis

Type of dialysis

Level of Ddimer

Frequency

Patient %

Peritoneal Dialysis

< 0.5 > 0.5 < 1.0 > 1.0 < 2.0 > 2.0 < 4.0 > 4.0 < 8.0 Total

6 6 3 3 2 20

30.0 30.0 15.0 15.0 10.0 100.0

< 0.5 > 0.5 < 1.0 <1.0 < 2.0 Total

26 13 1 40

65.0 32.0 2.5 100.0

Haemodialysis

Cont. Table (6): Result of FDPS test pre peritoneal and haemodialysis:

Type of dialysis Peritoneal Dialysis

Haemodialysis

Level of FDPS

Frequency

Patient %

< 5.0 > 5.0 < 20 > 20 Total

5 4 11 20

25.0 100.0

< 5.0

17

42.5

<5.0 <20 > 20

14 9

35.0 22.5

Total

40

100.0

15.0 60.0

Cont. Table (7): Result of FDPS test post peritoneal and haemodialysis:

Type of dialysis

Patient %

Level of FDPS

Frequency

Peritoneal Dialysis

< 5.0 > 5.0 < 20 > 20 Total

5 3 12 20

25.0 15.0 60.0 100.0

Haemodialysis

< 5.0 > 5.0 < 20 > 20 Total

26 11 3 40

65.0 27.5 7.5 100.0

Cont. Table (8) T-test between pre PT and post PT in the types of dialysis:

Type of Dialysis

N

Mean Correlation

P value

Peritoneal Dialysis

Pre PT & post PT

20 20

16.6 16.2

0.98

0.189

Haemodialysis

Pre PT& Post PT

40 40

14.6 18.6

0.968

0.000

P value < 0.05 is* .significant

Cont.

Table (9) Test of significant between pre APTT and post APT according to type of dialysis :

Type of Dialysis

N

Mean

Correlation

P value

Peritoneal Dialysis

Pre PTT Post PTT

20 20

31.05 29.5

0.963 0.963

0.016

40

36.3

0.915

0.000

Haemodialysis

Pre PTT & Post PTT

40

42.9

P value < 0.05 is* .significant

Cont. Table (10) D-dimer and FDPs of Controls:

Test

N

Frequency

percent

D-dimer <0.5

60

60

100

FDPs <5.0

60

60

100

All controls (n=60 ) were normal for both D-dimer (<0.5µg/ml) & FDPs (<5.0µg/ml).

 D-dimer is a blood test performed in the medical laboratory to diagnose I.V. thrombosis. When clots are formed at the wrong time and place as a result of underlying disease, D-dimer becomes available marker because its presence indicates the occurrence of unwanted thrombotic events.  In this study the majority of the cases (38.3%) were 50 years and above. At this age we expect co-morbid conditions, which warrant a timely multidisciplinary approach towards the management of chronic renal failure.

Cont.

 There are gross clinical problems regarding those patients with high D-dimer and/or FDPs. There might be also some subclinical problems. This may have an effect on the morbidity and mortality of these patients. We observed that those with high D-dimer and/or FDPs bled more at the site of veinipuncture.  Elevated baseline levels of D-dimer and FDPs test in chronic renal failure.

Cont.

 Plasma level of D-dimer and FDPs were significantly elevated in patients before peritoneal dialysis and haemodialysis but both (D-dimer and FDPs) showed normal or decreased level after haemodialysis (may be due to heparin intake because the heparin can decrease D-dimer and possibly generate a falsely low value), and no changes occurred after peritoneal dialysis because the .patients usually are not given heparin

Cont.

 Matsui E. and etal. results on fibrinolaysis in End Stage Renal Disease have shown decreased fibrinolytic activity in uraemia. Tomura S. and etal. have documented hyperfibrinolaysis of coagulation activation, which seems to be secondary to fibrin deposition. Our results show activation of the fibrinolytic system, as evidenced by raised levels of D-dimer.  Comparing the levels of D-dimer with FDPs different results were obtained.

Cont.

 The D-dimer test is more accurate and sensitive compared to FDPs test. It is important to remember that high concentration of FDPs are not specific for disseminated intravascular coagulation, as they may occur after surgery, in patients with haematomas and liver or renal failure`. So, when in doubt, a D-dimr test is useful, as it is specific for fibrin degradation and thus indicates that thrombosis has occurred before fibrinolysis, thereby distinguishing disseminated intravascular coagulation from primary fibrinolysis.

Cont.

 Looking at the prothrombin time (PT) and activated partial thromboplastin time (APTT) of our study patients, they showed increased PT and APTT in 7 out of 40 haemodialysis cases and 6 out of 20 peritoneal dialysis cases.  Most studies found that PT and APTT were normal before haemodialysis and peritoneal dialysis, but both showed significant prolongation after haemodialysis and no changes occurred after peritoneal dialysis. This prolongation may be due to heparin therapy because heparin can contribute to an increase in PT and APTT.

Cont.

 The results of PT & APTT are agreement with Enaam Hussein results (In Khartoum), who studied a group of 30 patients (20 patients on haemodialysis and 10 on peritoneal dialysis) she found that PT and APTT were normal before haemodialysis and peritoneal dialysis, but both showed significant prolongation after haemodialysis and no changes after peritoneal dialysis .  Seven of out 60 patients (haemodialysis and peritoneal dialysis patients) had classical laboratory findings of DIC i.e. elevation of D-dimer, FDPs, PT and APTT.

Cont.

 Whether these results may contribute to and add more complications to renal failure patients needs to be investigated further as they may be suffering from some degree of disseminated intravascular coagulation.

 In this study the levels of D-dimer and FDPS tests were increased in chronic renal failure patients (peritoneal dialysis and haemodialysis patients).  Both D-dimer and FDPS tests showed normal and decreased level after haemodialysis (may be due to heparin therapy), and no changes occurred after peritoneal dialysis.

Cont.

 The D-dimer test is more accurate and sensitive compared to FDPS test .The D-dimer test is a confirmatory test for diagnosis disseminated intravascular coagulation.  PT and APTT tests were normal before haemodialysis and peritoneal dialysis, but both showed prolongation after haemodialysis (may be due to heparin therapy) and no changes occurred after peritoneal dislysis, but some patients had abnormal PT and APTT before and after dialysis.

1. Further studies are suggested to explain more the relationship between chronic renal failure and disseminated intravascular coagulation. 2. The use of D-dimer test is recommended to confirm diagnosis of disseminated intravascular coagulation. 3. Periodical coagulation profile test in chronic renal failure patients are advisable.

My deep and sincere gratitude to my supervisor prof. Ahmed Abdalla Mohamedani, professor of pathology, Dean Faculty of Medical Laboratory Science, University of Gezira, and to my Co-Supervisor Dr. Mohammad Al-Sabq, Director General of Gezira Hospital for Renal Diseases and surgery. My thanks are due to all the staff of the central laboratory in the Gezira Hospital for Renal Diseases and surgery for their help and cooperation. My thanks are also due to Dr. Ameer Hasabo,

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