Fibridysis(l993) 7. Suppl2 : 20-22 0 1993 h.gman mup UK Ltd

Clinical Evaluation Coagulation (DIC)

of D-dimer Testing in Disseminated Intravascular

K. Fukutake, K. Kuroso, N. Isogai, K. Shinozawa

INTRODUCTION

Disseminated intravascular coagulation (DIC) develops against a background of both medical and surgical disor- ders; indeed as a consequence of disease processes in which blood coagulation mechanisms are excessively ac- tivated. Once DIC develops severe hemorrhage and/or organ failure may be precipitated, these complications posing a direct threat to the life of the patient. Acconl- ingly, DIC is of major concern to all clinicians. To im- prove the prognosis of DIC, the earliest possible diagnosis and initiation of appropriate therapy are vital. Measurement of fibrin/fibrinogen degradation products (PDP) has been demonstrated in numerous reports to be a useful clinical test parameter for the diagnosis of DIC.‘-4 Recently, a measurement method that specifi- cally detects the FDP D-dimer structure and which shows that cross-linked fibrin has been formed in vivo, has been developed.5’6 This test has made it possible to demonstrate that Iibrinolysis is occurring secondary to activation of the coagulation system. In addition, by means of this D-dimer testing it has become possible to

Table 1 D-dimer assays which are available in Japan

Assay Method Manufacturer

A Latex agglutination test Agen B Latex agglutination test Stag0

C Latex agglutination test Iatmn D Enzyme immunoassay Agen E Enzyme immunoassay stag0 F Enzyme immunoassay OrOganon Teknika G Enzyme immunoassay Authors I Latex photometric immunoassay Dia-Iatmn .I Whole blood assay Agen

K. E’ukutake, K. Kuroso, N. Isogai, K. Shinozawa, Department of Clinical Pathology, Tokyo Medical College Hospital, 6-7-l Nishishinjuku, Shinjuku-ku, Tokyo 160, Japan (Tel 81-3-3342-6111 Ext 5851, Fax 8 l-3-3340-5448). Correspondence to Dr K. Fukutake.

diagnose accurately DIC at an early stage and to follow precisely the course of therapy.

Some D-dimer Assays Currently in Use

In Japan at present, methods available to measure D- dimer include enzyme immunoassay? latex agglutina- tion test,7 latex photometric immunoassay,’ and whole blood assay’ (Table 1). These methods range from simple to precise and, depending on the features of indi- vidual methods, differences are found in reactivity ac- cording possibly to the degree of fibrin degradation.

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Fig. 1 D-dimer values in plasma of patients with DIC using various assays shown in Table 1. Normal values in each assay are expressed as bars.

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Fibrinolysis 21

Values of D-dimer in Patients with DIC

Differences are found in the reactivity to degradation products among the individual testing methods shown in Table 1 and the results in DIC cases using these methods are shown in Figure 1. Using alI the assays cited in Table 1, considerable elevations in D-dimer were ob- served in all clinically diagnosed DIC plasmas. As com- pared to the normal range, illustrated by the bars in the lower portion, high values were obtained with each of the testing methods, with the choice of testing method not affecting the clinical significance of the results.‘* However, the clinical usefulness of individual testing methods will require further study.

Fibrinolysis and Fibrinogenolysis in Patients with DIC

By measuring separately fibrin degradation products (FbDP) and fibrinogen degradation products (FgDP), using the Organon Teknika Reagents (denoted F in Table l), it has been surmised that once fibrinolysis begins in vivo the fibrin and fibrinogen present in the surronnding area am degraded together. In DIC, FgDP and FbDP are both markedly increased, and when the ratio of the two is compared as the FgDP/FbDP ratio (g/b) it is seen that in normal persons FgDP are somewhat predominant, with the g/b ratio showing high values. In DIC patients the situation is reversed, with FbDP predominating and the g/b ratio lower (Fig. 2). Changes in the g/b ratio dur-

platelet Fibrinogen CX104/pl) (mg/dll

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Fig. 2 Fluctuations of FgDP, FbDP and total degradation products (J’DP) levels and g/b ratio on pre- and posttreatment of heparin in patients with improved DIC.

ing the therapeutic conrse of patients with DIC are illus- trated= As successful treatment of the DIC proceeds the g/b ratio approaches the value of normal subjects. Ac-

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Wg. 3 Fluctuations of FDP by a variety of procedures (lower figure) and other parameten (Platelets and fibrinogen, top fiw) in au acute DIC case. DD-Latex (Agen) is a latex agglutination test for Ddimer, DD-EIA (Age@ is an enzyme immunoassay for Ddimer, FDP-E (Dia-Iatrcn) is a latex photometric immunoassay for E fraction and FDP-L (Teikoku Zoki) is a latex agglutination test based on an anti-fibrinogen polyclonal antibody.

22 Clinical Evaluation of Ddimer Testing in DIC

coxdingly, since the values for Ddimer (e.g. FbDP) show major fluctuations, it is considered that measuring D-dimer allows the disease process of DIC to be sensi- tively assessed.”

A Typical Case of DIC

The measurement of FDP by a variety of procedures (latex and FIA D-dime& FDP-E, FDP-L) and other par- ameters [platelet count, fibrin monomer (FM test), fibri- nogen] in an acute DIC case are shown in Figure 3. The patient was a 64-year-old man with gastric cancer with metastasis to the bones and the kidney. On the fifth day a marked decrease in the platelet count and an increase in FDP by all assay procedures were noted. DIC was di- agnosed and therapy initiated. The initial therapy con- sisted of heparin, 10 000 U per day but, as little improvement in the clinical data was apparent, fi-om the seventh day fresh frozen plasma (FFP) was also adminis- tered. This combined treatment resulted in an increase in the platelet count and decrease in FDP, and the patient was relieved from a state of DIC. This case demon- strates that the changes in D-dimer (or appropriate FDP assay) were a mirror image of platelet levels, while D- dimer closely reflected the course of DIC. The pro- nounced elevation of the fibrinogen level from the fourth day is currently inexplicable,

CONCLUDING REMARKS

DIC syndrome develops in a variety of morbid condi- tions encompassing both internal medicine and surgery, in which the blood coagulation system is overactivated. DIC is feared by all clinicians, because it can cause bleeding and organ failure, and is frequently fatal. Early diagnosis and appropriate treatment are important for improving the prognosis of DIC.

FDP have been identified as useful items in the clinical diagnosis of DIC. In recent years, a method of detecting specifically the D-dimer structure in the plasma FDP fraction has been developed. It has become possible to show the in vivo formation of cross-linked fibrin and to demonstrate fibrinolysis secondary to activation of the coagulation system. D-dimer structures

are present in blood in a variety of structural guises, i.e. from very large breakdown products to the smallest DD/E fraction.

The determination of D-dimer levels is useful for the early diagnosis of DIC. When a patient suddenly develops what appears to be DIC, the latex agglutination reaction and whole blood agglutination reaction tests for D-dimer are convenient because they can be carried out urgently. For determining the treatment course, an automated method allowing quantitative determination is recommended.

REFERENCES

1. Ikematsu S, Hada M, Kuroso K, Arai M. DIG: An application of new laboratoty tests. Rinsho Ketsueki 1986; 27: 1983-1991.

2. Kutoso K. Development of a new assay method of DD/E complex and its antigenic degradation during fibrinolytic process. J Tokyo Medical College 1986; 44: 860-871.

3. Bick R L. Baker W F. Diagnostic efficacy of the D-dimer assay in disseminated intravascular coagulation (DIC). Thtomb Res 1992; 65: 785-790.

4. Can J M, McKinley M, McDonagh J. Diagnosis of disseminated intravascular coagulation. Role of D-dimer. Am J CIin Path01 1989; 91: 280-287.

5. Rylatt D B, Blake A S, Cottis L E, et al. An immunoassay for human D-dimer using monoclonal antibodies. Thromb Res 1983; 3 1: 767-778.

6. Nieuwenhuixen W. New strategies in the determination of fibrin and tibrin(ogen) derivatives by monoclonal antibodies. Blood 1988; 57: 285291.

7. Elms M J, Bunce I H. Bundesen P G et al. Rapid detection of cross-linked fibrin degradation products in plasma using monoclonal antibody coated latex particles. Am J CIin Path 1986; 85: 360-364.

8. Shinozawa K, Sato T, Kumso K, Fukutake K, Fujimaki M. Fully automated analysis of D-dimer associated products in plasma and serum using latex photometric immunoassay. Kiki-Shiyaku 1990, 13: 1209-1214.

9. Kumso K, Isogai N, Koike K, Fukutake K, Fujimaki M. Evaluation of novel assay for the detection of crosslinked fibrin degradation products in whole blood by the agglutination of the red blood cells. Jpn J Clin Path01 1992.40: 1281-1286.

10. Ikematsu S, Kumso K. Comparative evaluation of D-dimer assays. Jpn J Clin Path01 1989; Suppl81: 189-197.

11. Isogai N. Yamagishi T, Kaku M et al. Differentiation between fibrin degradation products and fibrinogen degradation products by using newly developed ELISAs. Jpn J Clin Path01 1991; 39: 753-757.