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Disseminated Intravascular Coagulation (DIC) and Thrombosis The Critical Role of the LabPaul Riley PhD MBA Diagnostica Stago Inc

Learning Objectives

Describe the basic pathophysiology of DIC

Demonstrate a diagnostic and management approach for DIC

Compare markers of thrombin amp plasmin generation in DIC including D-Dimer fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs)

Correlate DIC theory and testing to specific clinical cases

DIC = Death is Coming

What is Hemostasis

Blood Circulation

ARTERIES

VEINS

Occurs through blood vessels

The heart pumps the blood

Arteries carry oxygenated blood away from the heart under high pressure

Veins carry de-oxygenated blood back to the heart under low pressure

Hemostasis

The mechanism that maintains blood fluidity

Keeps a balance between bleeding and clotting

2 major roles Stop bleeding by repairing holes in blood vessels Clean up the inside of blood vessels Removes temporary clot that stopped bleeding Sweeps off needless deposits that may cause blood flow

blockages

Bleeding =

Hemorrhage

Blood clot =

Thrombosis

Two Major Diseases Linked to Hemostatic Abnormalities

Physiology of Hemostasis

Wound Sealing

EFFRACbreak in vessel

FIBRINOLYSIS

clot destruction

PRIMARYHEMOSTASIS

PLASMATICCOAGULATION

strong clot

wound sealing blood flow plusmn stopped

The Three Steps of Hemostasis

Primary Hemostasis Interaction between vessel wall platelets and adhesive proteins platelet clot

Coagulation Consolidation of the platelet thrombus insoluble fibrin net

bull Coagulation factors and inhibitors

Fibrinolysis Clot lysis clot is digested

bull Fibrinolytic activators and inhibitors

Vessel Wall

Intact endothelium non thrombogenic Synthesis of vasodilators (prostacyclin) No reaction either with platelets or factors

Sub endotheliumTissue Endothelium

blood

When a vessel wall is damaged Exposure of the subendothelium Platelet adhesion Initiation of the mechanisms of coagulation and fibrinolysis

PlateletsFactors

Sub endotheliumTissue Endothelium

blood

Vessel Wall Damage

Aim is to clog the damaged vessel ( asymp bricks without cement )

Primary Hemostasis

Platelet Structure UnactivatedActivated

GpIb-IX-V

GpIIb-IIIa

α granules (raw materials)PF4 β-TG Fibrinogen VWF Factor V and PAI-1

dense granules (energy and glue)ATP ADP SerotoninCa2+ Mg2+ P

Hillman Robert S Ault Kenneth A Rinder Henry M Hematology in Clinical Practice 4th Edition McGraw-Hill New York NY 2005

Primary Hemostasis

2) activation2nd shape changeamp release

platelet at rest 1) adhesion1st shape change

3) aggregation(not reversible)

Vasoconstriction occurs first

Platelets then aggregate on the break in the vessel wall

Primary Hemostasis AssaysRoutine Platelet count PT APTT TT

Follow-up von Willebrand Factor Antigen determination Activity Factor VIII PFA-100 Platelet aggregation studies

SpecializedSend Out Activation markers (b-TG PF4 GPV) Specialized tests for platelet function

Aim is to strengthen the platelet plug

Coagulation

Coagulation is a balancebetween pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis

THROMBIN

Fibrinogen Fibrin

bull Triggering agentsbull pro-enzyme enzyme (serine-protease FIIa FVIIa FIXa FXa)bull Cofactors (FVa amp FVIIIa)

bull Serine-protease inhibitor Antithrombin (AT) bull Cofactorsinhibitors Protein C Sbull Tissue factor pathway inhibitor (TFPI)

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation Cascade Schematic

Coagulation factors

Historic name

Fibrinogen

Prothrombin

Proaccelerin

Proconvertin

Anti-hemophilic factor A

Anti-hemophilic factor B

Stuart factor

Rosenthal factor

Hageman factor

Fibrin Stabilizing Factor

Factor

I

II

V

VII

VIII

IX

X

XI

XII

XIII

Function

Substrate

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme = Zymogen activation Active Enzyme

Coagulation Assay Mechanisms

aPTT Based

PT Based

PT Based

Fibrin Under Microscope

Weisel JW Structure of fibrin impact on clot stability J Thromb Haemost 2007 5 Suppl 1 116-24

Low thrombin concentration

High thrombin concentration

Fibrin Formation

Soluble FibrinPolymer

ThrombinFibrinogen

FM+ fibrinopeptides A amp B

Stabilized Fibrin clot(not soluble)

ThrombinXIII XIIIa

(Digestion of Fibrin)

Fibrinolysis

Fibrinolysis Overview

Destroys fibrin fibers

Destroys the scab (dried wound)

Maintains vessel integrity

Fibrinolysis Overview

Fibrin =cement fibers

Plasmin

Plasmin digests fibrin

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Learning Objectives

Describe the basic pathophysiology of DIC

Demonstrate a diagnostic and management approach for DIC

Compare markers of thrombin amp plasmin generation in DIC including D-Dimer fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs)

Correlate DIC theory and testing to specific clinical cases

DIC = Death is Coming

What is Hemostasis

Blood Circulation

ARTERIES

VEINS

Occurs through blood vessels

The heart pumps the blood

Arteries carry oxygenated blood away from the heart under high pressure

Veins carry de-oxygenated blood back to the heart under low pressure

Hemostasis

The mechanism that maintains blood fluidity

Keeps a balance between bleeding and clotting

2 major roles Stop bleeding by repairing holes in blood vessels Clean up the inside of blood vessels Removes temporary clot that stopped bleeding Sweeps off needless deposits that may cause blood flow

blockages

Bleeding =

Hemorrhage

Blood clot =

Thrombosis

Two Major Diseases Linked to Hemostatic Abnormalities

Physiology of Hemostasis

Wound Sealing

EFFRACbreak in vessel

FIBRINOLYSIS

clot destruction

PRIMARYHEMOSTASIS

PLASMATICCOAGULATION

strong clot

wound sealing blood flow plusmn stopped

The Three Steps of Hemostasis

Primary Hemostasis Interaction between vessel wall platelets and adhesive proteins platelet clot

Coagulation Consolidation of the platelet thrombus insoluble fibrin net

bull Coagulation factors and inhibitors

Fibrinolysis Clot lysis clot is digested

bull Fibrinolytic activators and inhibitors

Vessel Wall

Intact endothelium non thrombogenic Synthesis of vasodilators (prostacyclin) No reaction either with platelets or factors

Sub endotheliumTissue Endothelium

blood

When a vessel wall is damaged Exposure of the subendothelium Platelet adhesion Initiation of the mechanisms of coagulation and fibrinolysis

PlateletsFactors

Sub endotheliumTissue Endothelium

blood

Vessel Wall Damage

Aim is to clog the damaged vessel ( asymp bricks without cement )

Primary Hemostasis

Platelet Structure UnactivatedActivated

GpIb-IX-V

GpIIb-IIIa

α granules (raw materials)PF4 β-TG Fibrinogen VWF Factor V and PAI-1

dense granules (energy and glue)ATP ADP SerotoninCa2+ Mg2+ P

Hillman Robert S Ault Kenneth A Rinder Henry M Hematology in Clinical Practice 4th Edition McGraw-Hill New York NY 2005

Primary Hemostasis

2) activation2nd shape changeamp release

platelet at rest 1) adhesion1st shape change

3) aggregation(not reversible)

Vasoconstriction occurs first

Platelets then aggregate on the break in the vessel wall

Primary Hemostasis AssaysRoutine Platelet count PT APTT TT

Follow-up von Willebrand Factor Antigen determination Activity Factor VIII PFA-100 Platelet aggregation studies

SpecializedSend Out Activation markers (b-TG PF4 GPV) Specialized tests for platelet function

Aim is to strengthen the platelet plug

Coagulation

Coagulation is a balancebetween pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis

THROMBIN

Fibrinogen Fibrin

bull Triggering agentsbull pro-enzyme enzyme (serine-protease FIIa FVIIa FIXa FXa)bull Cofactors (FVa amp FVIIIa)

bull Serine-protease inhibitor Antithrombin (AT) bull Cofactorsinhibitors Protein C Sbull Tissue factor pathway inhibitor (TFPI)

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation Cascade Schematic

Coagulation factors

Historic name

Fibrinogen

Prothrombin

Proaccelerin

Proconvertin

Anti-hemophilic factor A

Anti-hemophilic factor B

Stuart factor

Rosenthal factor

Hageman factor

Fibrin Stabilizing Factor

Factor

I

II

V

VII

VIII

IX

X

XI

XII

XIII

Function

Substrate

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme = Zymogen activation Active Enzyme

Coagulation Assay Mechanisms

aPTT Based

PT Based

PT Based

Fibrin Under Microscope

Weisel JW Structure of fibrin impact on clot stability J Thromb Haemost 2007 5 Suppl 1 116-24

Low thrombin concentration

High thrombin concentration

Fibrin Formation

Soluble FibrinPolymer

ThrombinFibrinogen

FM+ fibrinopeptides A amp B

Stabilized Fibrin clot(not soluble)

ThrombinXIII XIIIa

(Digestion of Fibrin)

Fibrinolysis

Fibrinolysis Overview

Destroys fibrin fibers

Destroys the scab (dried wound)

Maintains vessel integrity

Fibrinolysis Overview

Fibrin =cement fibers

Plasmin

Plasmin digests fibrin

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

DIC = Death is Coming

What is Hemostasis

Blood Circulation

ARTERIES

VEINS

Occurs through blood vessels

The heart pumps the blood

Arteries carry oxygenated blood away from the heart under high pressure

Veins carry de-oxygenated blood back to the heart under low pressure

Hemostasis

The mechanism that maintains blood fluidity

Keeps a balance between bleeding and clotting

2 major roles Stop bleeding by repairing holes in blood vessels Clean up the inside of blood vessels Removes temporary clot that stopped bleeding Sweeps off needless deposits that may cause blood flow

blockages

Bleeding =

Hemorrhage

Blood clot =

Thrombosis

Two Major Diseases Linked to Hemostatic Abnormalities

Physiology of Hemostasis

Wound Sealing

EFFRACbreak in vessel

FIBRINOLYSIS

clot destruction

PRIMARYHEMOSTASIS

PLASMATICCOAGULATION

strong clot

wound sealing blood flow plusmn stopped

The Three Steps of Hemostasis

Primary Hemostasis Interaction between vessel wall platelets and adhesive proteins platelet clot

Coagulation Consolidation of the platelet thrombus insoluble fibrin net

bull Coagulation factors and inhibitors

Fibrinolysis Clot lysis clot is digested

bull Fibrinolytic activators and inhibitors

Vessel Wall

Intact endothelium non thrombogenic Synthesis of vasodilators (prostacyclin) No reaction either with platelets or factors

Sub endotheliumTissue Endothelium

blood

When a vessel wall is damaged Exposure of the subendothelium Platelet adhesion Initiation of the mechanisms of coagulation and fibrinolysis

PlateletsFactors

Sub endotheliumTissue Endothelium

blood

Vessel Wall Damage

Aim is to clog the damaged vessel ( asymp bricks without cement )

Primary Hemostasis

Platelet Structure UnactivatedActivated

GpIb-IX-V

GpIIb-IIIa

α granules (raw materials)PF4 β-TG Fibrinogen VWF Factor V and PAI-1

dense granules (energy and glue)ATP ADP SerotoninCa2+ Mg2+ P

Hillman Robert S Ault Kenneth A Rinder Henry M Hematology in Clinical Practice 4th Edition McGraw-Hill New York NY 2005

Primary Hemostasis

2) activation2nd shape changeamp release

platelet at rest 1) adhesion1st shape change

3) aggregation(not reversible)

Vasoconstriction occurs first

Platelets then aggregate on the break in the vessel wall

Primary Hemostasis AssaysRoutine Platelet count PT APTT TT

Follow-up von Willebrand Factor Antigen determination Activity Factor VIII PFA-100 Platelet aggregation studies

SpecializedSend Out Activation markers (b-TG PF4 GPV) Specialized tests for platelet function

Aim is to strengthen the platelet plug

Coagulation

Coagulation is a balancebetween pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis

THROMBIN

Fibrinogen Fibrin

bull Triggering agentsbull pro-enzyme enzyme (serine-protease FIIa FVIIa FIXa FXa)bull Cofactors (FVa amp FVIIIa)

bull Serine-protease inhibitor Antithrombin (AT) bull Cofactorsinhibitors Protein C Sbull Tissue factor pathway inhibitor (TFPI)

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation Cascade Schematic

Coagulation factors

Historic name

Fibrinogen

Prothrombin

Proaccelerin

Proconvertin

Anti-hemophilic factor A

Anti-hemophilic factor B

Stuart factor

Rosenthal factor

Hageman factor

Fibrin Stabilizing Factor

Factor

I

II

V

VII

VIII

IX

X

XI

XII

XIII

Function

Substrate

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme = Zymogen activation Active Enzyme

Coagulation Assay Mechanisms

aPTT Based

PT Based

PT Based

Fibrin Under Microscope

Weisel JW Structure of fibrin impact on clot stability J Thromb Haemost 2007 5 Suppl 1 116-24

Low thrombin concentration

High thrombin concentration

Fibrin Formation

Soluble FibrinPolymer

ThrombinFibrinogen

FM+ fibrinopeptides A amp B

Stabilized Fibrin clot(not soluble)

ThrombinXIII XIIIa

(Digestion of Fibrin)

Fibrinolysis

Fibrinolysis Overview

Destroys fibrin fibers

Destroys the scab (dried wound)

Maintains vessel integrity

Fibrinolysis Overview

Fibrin =cement fibers

Plasmin

Plasmin digests fibrin

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

What is Hemostasis

Blood Circulation

ARTERIES

VEINS

Occurs through blood vessels

The heart pumps the blood

Arteries carry oxygenated blood away from the heart under high pressure

Veins carry de-oxygenated blood back to the heart under low pressure

Hemostasis

The mechanism that maintains blood fluidity

Keeps a balance between bleeding and clotting

2 major roles Stop bleeding by repairing holes in blood vessels Clean up the inside of blood vessels Removes temporary clot that stopped bleeding Sweeps off needless deposits that may cause blood flow

blockages

Bleeding =

Hemorrhage

Blood clot =

Thrombosis

Two Major Diseases Linked to Hemostatic Abnormalities

Physiology of Hemostasis

Wound Sealing

EFFRACbreak in vessel

FIBRINOLYSIS

clot destruction

PRIMARYHEMOSTASIS

PLASMATICCOAGULATION

strong clot

wound sealing blood flow plusmn stopped

The Three Steps of Hemostasis

Primary Hemostasis Interaction between vessel wall platelets and adhesive proteins platelet clot

Coagulation Consolidation of the platelet thrombus insoluble fibrin net

bull Coagulation factors and inhibitors

Fibrinolysis Clot lysis clot is digested

bull Fibrinolytic activators and inhibitors

Vessel Wall

Intact endothelium non thrombogenic Synthesis of vasodilators (prostacyclin) No reaction either with platelets or factors

Sub endotheliumTissue Endothelium

blood

When a vessel wall is damaged Exposure of the subendothelium Platelet adhesion Initiation of the mechanisms of coagulation and fibrinolysis

PlateletsFactors

Sub endotheliumTissue Endothelium

blood

Vessel Wall Damage

Aim is to clog the damaged vessel ( asymp bricks without cement )

Primary Hemostasis

Platelet Structure UnactivatedActivated

GpIb-IX-V

GpIIb-IIIa

α granules (raw materials)PF4 β-TG Fibrinogen VWF Factor V and PAI-1

dense granules (energy and glue)ATP ADP SerotoninCa2+ Mg2+ P

Hillman Robert S Ault Kenneth A Rinder Henry M Hematology in Clinical Practice 4th Edition McGraw-Hill New York NY 2005

Primary Hemostasis

2) activation2nd shape changeamp release

platelet at rest 1) adhesion1st shape change

3) aggregation(not reversible)

Vasoconstriction occurs first

Platelets then aggregate on the break in the vessel wall

Primary Hemostasis AssaysRoutine Platelet count PT APTT TT

Follow-up von Willebrand Factor Antigen determination Activity Factor VIII PFA-100 Platelet aggregation studies

SpecializedSend Out Activation markers (b-TG PF4 GPV) Specialized tests for platelet function

Aim is to strengthen the platelet plug

Coagulation

Coagulation is a balancebetween pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis

THROMBIN

Fibrinogen Fibrin

bull Triggering agentsbull pro-enzyme enzyme (serine-protease FIIa FVIIa FIXa FXa)bull Cofactors (FVa amp FVIIIa)

bull Serine-protease inhibitor Antithrombin (AT) bull Cofactorsinhibitors Protein C Sbull Tissue factor pathway inhibitor (TFPI)

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation Cascade Schematic

Coagulation factors

Historic name

Fibrinogen

Prothrombin

Proaccelerin

Proconvertin

Anti-hemophilic factor A

Anti-hemophilic factor B

Stuart factor

Rosenthal factor

Hageman factor

Fibrin Stabilizing Factor

Factor

I

II

V

VII

VIII

IX

X

XI

XII

XIII

Function

Substrate

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme = Zymogen activation Active Enzyme

Coagulation Assay Mechanisms

aPTT Based

PT Based

PT Based

Fibrin Under Microscope

Weisel JW Structure of fibrin impact on clot stability J Thromb Haemost 2007 5 Suppl 1 116-24

Low thrombin concentration

High thrombin concentration

Fibrin Formation

Soluble FibrinPolymer

ThrombinFibrinogen

FM+ fibrinopeptides A amp B

Stabilized Fibrin clot(not soluble)

ThrombinXIII XIIIa

(Digestion of Fibrin)

Fibrinolysis

Fibrinolysis Overview

Destroys fibrin fibers

Destroys the scab (dried wound)

Maintains vessel integrity

Fibrinolysis Overview

Fibrin =cement fibers

Plasmin

Plasmin digests fibrin

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Blood Circulation

ARTERIES

VEINS

Occurs through blood vessels

The heart pumps the blood

Arteries carry oxygenated blood away from the heart under high pressure

Veins carry de-oxygenated blood back to the heart under low pressure

Hemostasis

The mechanism that maintains blood fluidity

Keeps a balance between bleeding and clotting

2 major roles Stop bleeding by repairing holes in blood vessels Clean up the inside of blood vessels Removes temporary clot that stopped bleeding Sweeps off needless deposits that may cause blood flow

blockages

Bleeding =

Hemorrhage

Blood clot =

Thrombosis

Two Major Diseases Linked to Hemostatic Abnormalities

Physiology of Hemostasis

Wound Sealing

EFFRACbreak in vessel

FIBRINOLYSIS

clot destruction

PRIMARYHEMOSTASIS

PLASMATICCOAGULATION

strong clot

wound sealing blood flow plusmn stopped

The Three Steps of Hemostasis

Primary Hemostasis Interaction between vessel wall platelets and adhesive proteins platelet clot

Coagulation Consolidation of the platelet thrombus insoluble fibrin net

bull Coagulation factors and inhibitors

Fibrinolysis Clot lysis clot is digested

bull Fibrinolytic activators and inhibitors

Vessel Wall

Intact endothelium non thrombogenic Synthesis of vasodilators (prostacyclin) No reaction either with platelets or factors

Sub endotheliumTissue Endothelium

blood

When a vessel wall is damaged Exposure of the subendothelium Platelet adhesion Initiation of the mechanisms of coagulation and fibrinolysis

PlateletsFactors

Sub endotheliumTissue Endothelium

blood

Vessel Wall Damage

Aim is to clog the damaged vessel ( asymp bricks without cement )

Primary Hemostasis

Platelet Structure UnactivatedActivated

GpIb-IX-V

GpIIb-IIIa

α granules (raw materials)PF4 β-TG Fibrinogen VWF Factor V and PAI-1

dense granules (energy and glue)ATP ADP SerotoninCa2+ Mg2+ P

Hillman Robert S Ault Kenneth A Rinder Henry M Hematology in Clinical Practice 4th Edition McGraw-Hill New York NY 2005

Primary Hemostasis

2) activation2nd shape changeamp release

platelet at rest 1) adhesion1st shape change

3) aggregation(not reversible)

Vasoconstriction occurs first

Platelets then aggregate on the break in the vessel wall

Primary Hemostasis AssaysRoutine Platelet count PT APTT TT

Follow-up von Willebrand Factor Antigen determination Activity Factor VIII PFA-100 Platelet aggregation studies

SpecializedSend Out Activation markers (b-TG PF4 GPV) Specialized tests for platelet function

Aim is to strengthen the platelet plug

Coagulation

Coagulation is a balancebetween pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis

THROMBIN

Fibrinogen Fibrin

bull Triggering agentsbull pro-enzyme enzyme (serine-protease FIIa FVIIa FIXa FXa)bull Cofactors (FVa amp FVIIIa)

bull Serine-protease inhibitor Antithrombin (AT) bull Cofactorsinhibitors Protein C Sbull Tissue factor pathway inhibitor (TFPI)

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation Cascade Schematic

Coagulation factors

Historic name

Fibrinogen

Prothrombin

Proaccelerin

Proconvertin

Anti-hemophilic factor A

Anti-hemophilic factor B

Stuart factor

Rosenthal factor

Hageman factor

Fibrin Stabilizing Factor

Factor

I

II

V

VII

VIII

IX

X

XI

XII

XIII

Function

Substrate

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme = Zymogen activation Active Enzyme

Coagulation Assay Mechanisms

aPTT Based

PT Based

PT Based

Fibrin Under Microscope

Weisel JW Structure of fibrin impact on clot stability J Thromb Haemost 2007 5 Suppl 1 116-24

Low thrombin concentration

High thrombin concentration

Fibrin Formation

Soluble FibrinPolymer

ThrombinFibrinogen

FM+ fibrinopeptides A amp B

Stabilized Fibrin clot(not soluble)

ThrombinXIII XIIIa

(Digestion of Fibrin)

Fibrinolysis

Fibrinolysis Overview

Destroys fibrin fibers

Destroys the scab (dried wound)

Maintains vessel integrity

Fibrinolysis Overview

Fibrin =cement fibers

Plasmin

Plasmin digests fibrin

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Hemostasis

The mechanism that maintains blood fluidity

Keeps a balance between bleeding and clotting

2 major roles Stop bleeding by repairing holes in blood vessels Clean up the inside of blood vessels Removes temporary clot that stopped bleeding Sweeps off needless deposits that may cause blood flow

blockages

Bleeding =

Hemorrhage

Blood clot =

Thrombosis

Two Major Diseases Linked to Hemostatic Abnormalities

Physiology of Hemostasis

Wound Sealing

EFFRACbreak in vessel

FIBRINOLYSIS

clot destruction

PRIMARYHEMOSTASIS

PLASMATICCOAGULATION

strong clot

wound sealing blood flow plusmn stopped

The Three Steps of Hemostasis

Primary Hemostasis Interaction between vessel wall platelets and adhesive proteins platelet clot

Coagulation Consolidation of the platelet thrombus insoluble fibrin net

bull Coagulation factors and inhibitors

Fibrinolysis Clot lysis clot is digested

bull Fibrinolytic activators and inhibitors

Vessel Wall

Intact endothelium non thrombogenic Synthesis of vasodilators (prostacyclin) No reaction either with platelets or factors

Sub endotheliumTissue Endothelium

blood

When a vessel wall is damaged Exposure of the subendothelium Platelet adhesion Initiation of the mechanisms of coagulation and fibrinolysis

PlateletsFactors

Sub endotheliumTissue Endothelium

blood

Vessel Wall Damage

Aim is to clog the damaged vessel ( asymp bricks without cement )

Primary Hemostasis

Platelet Structure UnactivatedActivated

GpIb-IX-V

GpIIb-IIIa

α granules (raw materials)PF4 β-TG Fibrinogen VWF Factor V and PAI-1

dense granules (energy and glue)ATP ADP SerotoninCa2+ Mg2+ P

Hillman Robert S Ault Kenneth A Rinder Henry M Hematology in Clinical Practice 4th Edition McGraw-Hill New York NY 2005

Primary Hemostasis

2) activation2nd shape changeamp release

platelet at rest 1) adhesion1st shape change

3) aggregation(not reversible)

Vasoconstriction occurs first

Platelets then aggregate on the break in the vessel wall

Primary Hemostasis AssaysRoutine Platelet count PT APTT TT

Follow-up von Willebrand Factor Antigen determination Activity Factor VIII PFA-100 Platelet aggregation studies

SpecializedSend Out Activation markers (b-TG PF4 GPV) Specialized tests for platelet function

Aim is to strengthen the platelet plug

Coagulation

Coagulation is a balancebetween pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis

THROMBIN

Fibrinogen Fibrin

bull Triggering agentsbull pro-enzyme enzyme (serine-protease FIIa FVIIa FIXa FXa)bull Cofactors (FVa amp FVIIIa)

bull Serine-protease inhibitor Antithrombin (AT) bull Cofactorsinhibitors Protein C Sbull Tissue factor pathway inhibitor (TFPI)

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation Cascade Schematic

Coagulation factors

Historic name

Fibrinogen

Prothrombin

Proaccelerin

Proconvertin

Anti-hemophilic factor A

Anti-hemophilic factor B

Stuart factor

Rosenthal factor

Hageman factor

Fibrin Stabilizing Factor

Factor

I

II

V

VII

VIII

IX

X

XI

XII

XIII

Function

Substrate

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme = Zymogen activation Active Enzyme

Coagulation Assay Mechanisms

aPTT Based

PT Based

PT Based

Fibrin Under Microscope

Weisel JW Structure of fibrin impact on clot stability J Thromb Haemost 2007 5 Suppl 1 116-24

Low thrombin concentration

High thrombin concentration

Fibrin Formation

Soluble FibrinPolymer

ThrombinFibrinogen

FM+ fibrinopeptides A amp B

Stabilized Fibrin clot(not soluble)

ThrombinXIII XIIIa

(Digestion of Fibrin)

Fibrinolysis

Fibrinolysis Overview

Destroys fibrin fibers

Destroys the scab (dried wound)

Maintains vessel integrity

Fibrinolysis Overview

Fibrin =cement fibers

Plasmin

Plasmin digests fibrin

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Bleeding =

Hemorrhage

Blood clot =

Thrombosis

Two Major Diseases Linked to Hemostatic Abnormalities

Physiology of Hemostasis

Wound Sealing

EFFRACbreak in vessel

FIBRINOLYSIS

clot destruction

PRIMARYHEMOSTASIS

PLASMATICCOAGULATION

strong clot

wound sealing blood flow plusmn stopped

The Three Steps of Hemostasis

Primary Hemostasis Interaction between vessel wall platelets and adhesive proteins platelet clot

Coagulation Consolidation of the platelet thrombus insoluble fibrin net

bull Coagulation factors and inhibitors

Fibrinolysis Clot lysis clot is digested

bull Fibrinolytic activators and inhibitors

Vessel Wall

Intact endothelium non thrombogenic Synthesis of vasodilators (prostacyclin) No reaction either with platelets or factors

Sub endotheliumTissue Endothelium

blood

When a vessel wall is damaged Exposure of the subendothelium Platelet adhesion Initiation of the mechanisms of coagulation and fibrinolysis

PlateletsFactors

Sub endotheliumTissue Endothelium

blood

Vessel Wall Damage

Aim is to clog the damaged vessel ( asymp bricks without cement )

Primary Hemostasis

Platelet Structure UnactivatedActivated

GpIb-IX-V

GpIIb-IIIa

α granules (raw materials)PF4 β-TG Fibrinogen VWF Factor V and PAI-1

dense granules (energy and glue)ATP ADP SerotoninCa2+ Mg2+ P

Hillman Robert S Ault Kenneth A Rinder Henry M Hematology in Clinical Practice 4th Edition McGraw-Hill New York NY 2005

Primary Hemostasis

2) activation2nd shape changeamp release

platelet at rest 1) adhesion1st shape change

3) aggregation(not reversible)

Vasoconstriction occurs first

Platelets then aggregate on the break in the vessel wall

Primary Hemostasis AssaysRoutine Platelet count PT APTT TT

Follow-up von Willebrand Factor Antigen determination Activity Factor VIII PFA-100 Platelet aggregation studies

SpecializedSend Out Activation markers (b-TG PF4 GPV) Specialized tests for platelet function

Aim is to strengthen the platelet plug

Coagulation

Coagulation is a balancebetween pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis

THROMBIN

Fibrinogen Fibrin

bull Triggering agentsbull pro-enzyme enzyme (serine-protease FIIa FVIIa FIXa FXa)bull Cofactors (FVa amp FVIIIa)

bull Serine-protease inhibitor Antithrombin (AT) bull Cofactorsinhibitors Protein C Sbull Tissue factor pathway inhibitor (TFPI)

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation Cascade Schematic

Coagulation factors

Historic name

Fibrinogen

Prothrombin

Proaccelerin

Proconvertin

Anti-hemophilic factor A

Anti-hemophilic factor B

Stuart factor

Rosenthal factor

Hageman factor

Fibrin Stabilizing Factor

Factor

I

II

V

VII

VIII

IX

X

XI

XII

XIII

Function

Substrate

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme = Zymogen activation Active Enzyme

Coagulation Assay Mechanisms

aPTT Based

PT Based

PT Based

Fibrin Under Microscope

Weisel JW Structure of fibrin impact on clot stability J Thromb Haemost 2007 5 Suppl 1 116-24

Low thrombin concentration

High thrombin concentration

Fibrin Formation

Soluble FibrinPolymer

ThrombinFibrinogen

FM+ fibrinopeptides A amp B

Stabilized Fibrin clot(not soluble)

ThrombinXIII XIIIa

(Digestion of Fibrin)

Fibrinolysis

Fibrinolysis Overview

Destroys fibrin fibers

Destroys the scab (dried wound)

Maintains vessel integrity

Fibrinolysis Overview

Fibrin =cement fibers

Plasmin

Plasmin digests fibrin

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Physiology of Hemostasis

Wound Sealing

EFFRACbreak in vessel

FIBRINOLYSIS

clot destruction

PRIMARYHEMOSTASIS

PLASMATICCOAGULATION

strong clot

wound sealing blood flow plusmn stopped

The Three Steps of Hemostasis

Primary Hemostasis Interaction between vessel wall platelets and adhesive proteins platelet clot

Coagulation Consolidation of the platelet thrombus insoluble fibrin net

bull Coagulation factors and inhibitors

Fibrinolysis Clot lysis clot is digested

bull Fibrinolytic activators and inhibitors

Vessel Wall

Intact endothelium non thrombogenic Synthesis of vasodilators (prostacyclin) No reaction either with platelets or factors

Sub endotheliumTissue Endothelium

blood

When a vessel wall is damaged Exposure of the subendothelium Platelet adhesion Initiation of the mechanisms of coagulation and fibrinolysis

PlateletsFactors

Sub endotheliumTissue Endothelium

blood

Vessel Wall Damage

Aim is to clog the damaged vessel ( asymp bricks without cement )

Primary Hemostasis

Platelet Structure UnactivatedActivated

GpIb-IX-V

GpIIb-IIIa

α granules (raw materials)PF4 β-TG Fibrinogen VWF Factor V and PAI-1

dense granules (energy and glue)ATP ADP SerotoninCa2+ Mg2+ P

Hillman Robert S Ault Kenneth A Rinder Henry M Hematology in Clinical Practice 4th Edition McGraw-Hill New York NY 2005

Primary Hemostasis

2) activation2nd shape changeamp release

platelet at rest 1) adhesion1st shape change

3) aggregation(not reversible)

Vasoconstriction occurs first

Platelets then aggregate on the break in the vessel wall

Primary Hemostasis AssaysRoutine Platelet count PT APTT TT

Follow-up von Willebrand Factor Antigen determination Activity Factor VIII PFA-100 Platelet aggregation studies

SpecializedSend Out Activation markers (b-TG PF4 GPV) Specialized tests for platelet function

Aim is to strengthen the platelet plug

Coagulation

Coagulation is a balancebetween pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis

THROMBIN

Fibrinogen Fibrin

bull Triggering agentsbull pro-enzyme enzyme (serine-protease FIIa FVIIa FIXa FXa)bull Cofactors (FVa amp FVIIIa)

bull Serine-protease inhibitor Antithrombin (AT) bull Cofactorsinhibitors Protein C Sbull Tissue factor pathway inhibitor (TFPI)

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation Cascade Schematic

Coagulation factors

Historic name

Fibrinogen

Prothrombin

Proaccelerin

Proconvertin

Anti-hemophilic factor A

Anti-hemophilic factor B

Stuart factor

Rosenthal factor

Hageman factor

Fibrin Stabilizing Factor

Factor

I

II

V

VII

VIII

IX

X

XI

XII

XIII

Function

Substrate

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme = Zymogen activation Active Enzyme

Coagulation Assay Mechanisms

aPTT Based

PT Based

PT Based

Fibrin Under Microscope

Weisel JW Structure of fibrin impact on clot stability J Thromb Haemost 2007 5 Suppl 1 116-24

Low thrombin concentration

High thrombin concentration

Fibrin Formation

Soluble FibrinPolymer

ThrombinFibrinogen

FM+ fibrinopeptides A amp B

Stabilized Fibrin clot(not soluble)

ThrombinXIII XIIIa

(Digestion of Fibrin)

Fibrinolysis

Fibrinolysis Overview

Destroys fibrin fibers

Destroys the scab (dried wound)

Maintains vessel integrity

Fibrinolysis Overview

Fibrin =cement fibers

Plasmin

Plasmin digests fibrin

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Wound Sealing

EFFRACbreak in vessel

FIBRINOLYSIS

clot destruction

PRIMARYHEMOSTASIS

PLASMATICCOAGULATION

strong clot

wound sealing blood flow plusmn stopped

The Three Steps of Hemostasis

Primary Hemostasis Interaction between vessel wall platelets and adhesive proteins platelet clot

Coagulation Consolidation of the platelet thrombus insoluble fibrin net

bull Coagulation factors and inhibitors

Fibrinolysis Clot lysis clot is digested

bull Fibrinolytic activators and inhibitors

Vessel Wall

Intact endothelium non thrombogenic Synthesis of vasodilators (prostacyclin) No reaction either with platelets or factors

Sub endotheliumTissue Endothelium

blood

When a vessel wall is damaged Exposure of the subendothelium Platelet adhesion Initiation of the mechanisms of coagulation and fibrinolysis

PlateletsFactors

Sub endotheliumTissue Endothelium

blood

Vessel Wall Damage

Aim is to clog the damaged vessel ( asymp bricks without cement )

Primary Hemostasis

Platelet Structure UnactivatedActivated

GpIb-IX-V

GpIIb-IIIa

α granules (raw materials)PF4 β-TG Fibrinogen VWF Factor V and PAI-1

dense granules (energy and glue)ATP ADP SerotoninCa2+ Mg2+ P

Hillman Robert S Ault Kenneth A Rinder Henry M Hematology in Clinical Practice 4th Edition McGraw-Hill New York NY 2005

Primary Hemostasis

2) activation2nd shape changeamp release

platelet at rest 1) adhesion1st shape change

3) aggregation(not reversible)

Vasoconstriction occurs first

Platelets then aggregate on the break in the vessel wall

Primary Hemostasis AssaysRoutine Platelet count PT APTT TT

Follow-up von Willebrand Factor Antigen determination Activity Factor VIII PFA-100 Platelet aggregation studies

SpecializedSend Out Activation markers (b-TG PF4 GPV) Specialized tests for platelet function

Aim is to strengthen the platelet plug

Coagulation

Coagulation is a balancebetween pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis

THROMBIN

Fibrinogen Fibrin

bull Triggering agentsbull pro-enzyme enzyme (serine-protease FIIa FVIIa FIXa FXa)bull Cofactors (FVa amp FVIIIa)

bull Serine-protease inhibitor Antithrombin (AT) bull Cofactorsinhibitors Protein C Sbull Tissue factor pathway inhibitor (TFPI)

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation Cascade Schematic

Coagulation factors

Historic name

Fibrinogen

Prothrombin

Proaccelerin

Proconvertin

Anti-hemophilic factor A

Anti-hemophilic factor B

Stuart factor

Rosenthal factor

Hageman factor

Fibrin Stabilizing Factor

Factor

I

II

V

VII

VIII

IX

X

XI

XII

XIII

Function

Substrate

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme = Zymogen activation Active Enzyme

Coagulation Assay Mechanisms

aPTT Based

PT Based

PT Based

Fibrin Under Microscope

Weisel JW Structure of fibrin impact on clot stability J Thromb Haemost 2007 5 Suppl 1 116-24

Low thrombin concentration

High thrombin concentration

Fibrin Formation

Soluble FibrinPolymer

ThrombinFibrinogen

FM+ fibrinopeptides A amp B

Stabilized Fibrin clot(not soluble)

ThrombinXIII XIIIa

(Digestion of Fibrin)

Fibrinolysis

Fibrinolysis Overview

Destroys fibrin fibers

Destroys the scab (dried wound)

Maintains vessel integrity

Fibrinolysis Overview

Fibrin =cement fibers

Plasmin

Plasmin digests fibrin

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

The Three Steps of Hemostasis

Primary Hemostasis Interaction between vessel wall platelets and adhesive proteins platelet clot

Coagulation Consolidation of the platelet thrombus insoluble fibrin net

bull Coagulation factors and inhibitors

Fibrinolysis Clot lysis clot is digested

bull Fibrinolytic activators and inhibitors

Vessel Wall

Intact endothelium non thrombogenic Synthesis of vasodilators (prostacyclin) No reaction either with platelets or factors

Sub endotheliumTissue Endothelium

blood

When a vessel wall is damaged Exposure of the subendothelium Platelet adhesion Initiation of the mechanisms of coagulation and fibrinolysis

PlateletsFactors

Sub endotheliumTissue Endothelium

blood

Vessel Wall Damage

Aim is to clog the damaged vessel ( asymp bricks without cement )

Primary Hemostasis

Platelet Structure UnactivatedActivated

GpIb-IX-V

GpIIb-IIIa

α granules (raw materials)PF4 β-TG Fibrinogen VWF Factor V and PAI-1

dense granules (energy and glue)ATP ADP SerotoninCa2+ Mg2+ P

Hillman Robert S Ault Kenneth A Rinder Henry M Hematology in Clinical Practice 4th Edition McGraw-Hill New York NY 2005

Primary Hemostasis

2) activation2nd shape changeamp release

platelet at rest 1) adhesion1st shape change

3) aggregation(not reversible)

Vasoconstriction occurs first

Platelets then aggregate on the break in the vessel wall

Primary Hemostasis AssaysRoutine Platelet count PT APTT TT

Follow-up von Willebrand Factor Antigen determination Activity Factor VIII PFA-100 Platelet aggregation studies

SpecializedSend Out Activation markers (b-TG PF4 GPV) Specialized tests for platelet function

Aim is to strengthen the platelet plug

Coagulation

Coagulation is a balancebetween pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis

THROMBIN

Fibrinogen Fibrin

bull Triggering agentsbull pro-enzyme enzyme (serine-protease FIIa FVIIa FIXa FXa)bull Cofactors (FVa amp FVIIIa)

bull Serine-protease inhibitor Antithrombin (AT) bull Cofactorsinhibitors Protein C Sbull Tissue factor pathway inhibitor (TFPI)

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation Cascade Schematic

Coagulation factors

Historic name

Fibrinogen

Prothrombin

Proaccelerin

Proconvertin

Anti-hemophilic factor A

Anti-hemophilic factor B

Stuart factor

Rosenthal factor

Hageman factor

Fibrin Stabilizing Factor

Factor

I

II

V

VII

VIII

IX

X

XI

XII

XIII

Function

Substrate

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme = Zymogen activation Active Enzyme

Coagulation Assay Mechanisms

aPTT Based

PT Based

PT Based

Fibrin Under Microscope

Weisel JW Structure of fibrin impact on clot stability J Thromb Haemost 2007 5 Suppl 1 116-24

Low thrombin concentration

High thrombin concentration

Fibrin Formation

Soluble FibrinPolymer

ThrombinFibrinogen

FM+ fibrinopeptides A amp B

Stabilized Fibrin clot(not soluble)

ThrombinXIII XIIIa

(Digestion of Fibrin)

Fibrinolysis

Fibrinolysis Overview

Destroys fibrin fibers

Destroys the scab (dried wound)

Maintains vessel integrity

Fibrinolysis Overview

Fibrin =cement fibers

Plasmin

Plasmin digests fibrin

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Vessel Wall

Intact endothelium non thrombogenic Synthesis of vasodilators (prostacyclin) No reaction either with platelets or factors

Sub endotheliumTissue Endothelium

blood

When a vessel wall is damaged Exposure of the subendothelium Platelet adhesion Initiation of the mechanisms of coagulation and fibrinolysis

PlateletsFactors

Sub endotheliumTissue Endothelium

blood

Vessel Wall Damage

Aim is to clog the damaged vessel ( asymp bricks without cement )

Primary Hemostasis

Platelet Structure UnactivatedActivated

GpIb-IX-V

GpIIb-IIIa

α granules (raw materials)PF4 β-TG Fibrinogen VWF Factor V and PAI-1

dense granules (energy and glue)ATP ADP SerotoninCa2+ Mg2+ P

Hillman Robert S Ault Kenneth A Rinder Henry M Hematology in Clinical Practice 4th Edition McGraw-Hill New York NY 2005

Primary Hemostasis

2) activation2nd shape changeamp release

platelet at rest 1) adhesion1st shape change

3) aggregation(not reversible)

Vasoconstriction occurs first

Platelets then aggregate on the break in the vessel wall

Primary Hemostasis AssaysRoutine Platelet count PT APTT TT

Follow-up von Willebrand Factor Antigen determination Activity Factor VIII PFA-100 Platelet aggregation studies

SpecializedSend Out Activation markers (b-TG PF4 GPV) Specialized tests for platelet function

Aim is to strengthen the platelet plug

Coagulation

Coagulation is a balancebetween pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis

THROMBIN

Fibrinogen Fibrin

bull Triggering agentsbull pro-enzyme enzyme (serine-protease FIIa FVIIa FIXa FXa)bull Cofactors (FVa amp FVIIIa)

bull Serine-protease inhibitor Antithrombin (AT) bull Cofactorsinhibitors Protein C Sbull Tissue factor pathway inhibitor (TFPI)

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation Cascade Schematic

Coagulation factors

Historic name

Fibrinogen

Prothrombin

Proaccelerin

Proconvertin

Anti-hemophilic factor A

Anti-hemophilic factor B

Stuart factor

Rosenthal factor

Hageman factor

Fibrin Stabilizing Factor

Factor

I

II

V

VII

VIII

IX

X

XI

XII

XIII

Function

Substrate

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme = Zymogen activation Active Enzyme

Coagulation Assay Mechanisms

aPTT Based

PT Based

PT Based

Fibrin Under Microscope

Weisel JW Structure of fibrin impact on clot stability J Thromb Haemost 2007 5 Suppl 1 116-24

Low thrombin concentration

High thrombin concentration

Fibrin Formation

Soluble FibrinPolymer

ThrombinFibrinogen

FM+ fibrinopeptides A amp B

Stabilized Fibrin clot(not soluble)

ThrombinXIII XIIIa

(Digestion of Fibrin)

Fibrinolysis

Fibrinolysis Overview

Destroys fibrin fibers

Destroys the scab (dried wound)

Maintains vessel integrity

Fibrinolysis Overview

Fibrin =cement fibers

Plasmin

Plasmin digests fibrin

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

When a vessel wall is damaged Exposure of the subendothelium Platelet adhesion Initiation of the mechanisms of coagulation and fibrinolysis

PlateletsFactors

Sub endotheliumTissue Endothelium

blood

Vessel Wall Damage

Aim is to clog the damaged vessel ( asymp bricks without cement )

Primary Hemostasis

Platelet Structure UnactivatedActivated

GpIb-IX-V

GpIIb-IIIa

α granules (raw materials)PF4 β-TG Fibrinogen VWF Factor V and PAI-1

dense granules (energy and glue)ATP ADP SerotoninCa2+ Mg2+ P

Hillman Robert S Ault Kenneth A Rinder Henry M Hematology in Clinical Practice 4th Edition McGraw-Hill New York NY 2005

Primary Hemostasis

2) activation2nd shape changeamp release

platelet at rest 1) adhesion1st shape change

3) aggregation(not reversible)

Vasoconstriction occurs first

Platelets then aggregate on the break in the vessel wall

Primary Hemostasis AssaysRoutine Platelet count PT APTT TT

Follow-up von Willebrand Factor Antigen determination Activity Factor VIII PFA-100 Platelet aggregation studies

SpecializedSend Out Activation markers (b-TG PF4 GPV) Specialized tests for platelet function

Aim is to strengthen the platelet plug

Coagulation

Coagulation is a balancebetween pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis

THROMBIN

Fibrinogen Fibrin

bull Triggering agentsbull pro-enzyme enzyme (serine-protease FIIa FVIIa FIXa FXa)bull Cofactors (FVa amp FVIIIa)

bull Serine-protease inhibitor Antithrombin (AT) bull Cofactorsinhibitors Protein C Sbull Tissue factor pathway inhibitor (TFPI)

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation Cascade Schematic

Coagulation factors

Historic name

Fibrinogen

Prothrombin

Proaccelerin

Proconvertin

Anti-hemophilic factor A

Anti-hemophilic factor B

Stuart factor

Rosenthal factor

Hageman factor

Fibrin Stabilizing Factor

Factor

I

II

V

VII

VIII

IX

X

XI

XII

XIII

Function

Substrate

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme = Zymogen activation Active Enzyme

Coagulation Assay Mechanisms

aPTT Based

PT Based

PT Based

Fibrin Under Microscope

Weisel JW Structure of fibrin impact on clot stability J Thromb Haemost 2007 5 Suppl 1 116-24

Low thrombin concentration

High thrombin concentration

Fibrin Formation

Soluble FibrinPolymer

ThrombinFibrinogen

FM+ fibrinopeptides A amp B

Stabilized Fibrin clot(not soluble)

ThrombinXIII XIIIa

(Digestion of Fibrin)

Fibrinolysis

Fibrinolysis Overview

Destroys fibrin fibers

Destroys the scab (dried wound)

Maintains vessel integrity

Fibrinolysis Overview

Fibrin =cement fibers

Plasmin

Plasmin digests fibrin

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Aim is to clog the damaged vessel ( asymp bricks without cement )

Primary Hemostasis

Platelet Structure UnactivatedActivated

GpIb-IX-V

GpIIb-IIIa

α granules (raw materials)PF4 β-TG Fibrinogen VWF Factor V and PAI-1

dense granules (energy and glue)ATP ADP SerotoninCa2+ Mg2+ P

Hillman Robert S Ault Kenneth A Rinder Henry M Hematology in Clinical Practice 4th Edition McGraw-Hill New York NY 2005

Primary Hemostasis

2) activation2nd shape changeamp release

platelet at rest 1) adhesion1st shape change

3) aggregation(not reversible)

Vasoconstriction occurs first

Platelets then aggregate on the break in the vessel wall

Primary Hemostasis AssaysRoutine Platelet count PT APTT TT

Follow-up von Willebrand Factor Antigen determination Activity Factor VIII PFA-100 Platelet aggregation studies

SpecializedSend Out Activation markers (b-TG PF4 GPV) Specialized tests for platelet function

Aim is to strengthen the platelet plug

Coagulation

Coagulation is a balancebetween pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis

THROMBIN

Fibrinogen Fibrin

bull Triggering agentsbull pro-enzyme enzyme (serine-protease FIIa FVIIa FIXa FXa)bull Cofactors (FVa amp FVIIIa)

bull Serine-protease inhibitor Antithrombin (AT) bull Cofactorsinhibitors Protein C Sbull Tissue factor pathway inhibitor (TFPI)

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation Cascade Schematic

Coagulation factors

Historic name

Fibrinogen

Prothrombin

Proaccelerin

Proconvertin

Anti-hemophilic factor A

Anti-hemophilic factor B

Stuart factor

Rosenthal factor

Hageman factor

Fibrin Stabilizing Factor

Factor

I

II

V

VII

VIII

IX

X

XI

XII

XIII

Function

Substrate

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme = Zymogen activation Active Enzyme

Coagulation Assay Mechanisms

aPTT Based

PT Based

PT Based

Fibrin Under Microscope

Weisel JW Structure of fibrin impact on clot stability J Thromb Haemost 2007 5 Suppl 1 116-24

Low thrombin concentration

High thrombin concentration

Fibrin Formation

Soluble FibrinPolymer

ThrombinFibrinogen

FM+ fibrinopeptides A amp B

Stabilized Fibrin clot(not soluble)

ThrombinXIII XIIIa

(Digestion of Fibrin)

Fibrinolysis

Fibrinolysis Overview

Destroys fibrin fibers

Destroys the scab (dried wound)

Maintains vessel integrity

Fibrinolysis Overview

Fibrin =cement fibers

Plasmin

Plasmin digests fibrin

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Platelet Structure UnactivatedActivated

GpIb-IX-V

GpIIb-IIIa

α granules (raw materials)PF4 β-TG Fibrinogen VWF Factor V and PAI-1

dense granules (energy and glue)ATP ADP SerotoninCa2+ Mg2+ P

Hillman Robert S Ault Kenneth A Rinder Henry M Hematology in Clinical Practice 4th Edition McGraw-Hill New York NY 2005

Primary Hemostasis

2) activation2nd shape changeamp release

platelet at rest 1) adhesion1st shape change

3) aggregation(not reversible)

Vasoconstriction occurs first

Platelets then aggregate on the break in the vessel wall

Primary Hemostasis AssaysRoutine Platelet count PT APTT TT

Follow-up von Willebrand Factor Antigen determination Activity Factor VIII PFA-100 Platelet aggregation studies

SpecializedSend Out Activation markers (b-TG PF4 GPV) Specialized tests for platelet function

Aim is to strengthen the platelet plug

Coagulation

Coagulation is a balancebetween pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis

THROMBIN

Fibrinogen Fibrin

bull Triggering agentsbull pro-enzyme enzyme (serine-protease FIIa FVIIa FIXa FXa)bull Cofactors (FVa amp FVIIIa)

bull Serine-protease inhibitor Antithrombin (AT) bull Cofactorsinhibitors Protein C Sbull Tissue factor pathway inhibitor (TFPI)

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation Cascade Schematic

Coagulation factors

Historic name

Fibrinogen

Prothrombin

Proaccelerin

Proconvertin

Anti-hemophilic factor A

Anti-hemophilic factor B

Stuart factor

Rosenthal factor

Hageman factor

Fibrin Stabilizing Factor

Factor

I

II

V

VII

VIII

IX

X

XI

XII

XIII

Function

Substrate

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme = Zymogen activation Active Enzyme

Coagulation Assay Mechanisms

aPTT Based

PT Based

PT Based

Fibrin Under Microscope

Weisel JW Structure of fibrin impact on clot stability J Thromb Haemost 2007 5 Suppl 1 116-24

Low thrombin concentration

High thrombin concentration

Fibrin Formation

Soluble FibrinPolymer

ThrombinFibrinogen

FM+ fibrinopeptides A amp B

Stabilized Fibrin clot(not soluble)

ThrombinXIII XIIIa

(Digestion of Fibrin)

Fibrinolysis

Fibrinolysis Overview

Destroys fibrin fibers

Destroys the scab (dried wound)

Maintains vessel integrity

Fibrinolysis Overview

Fibrin =cement fibers

Plasmin

Plasmin digests fibrin

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Primary Hemostasis

2) activation2nd shape changeamp release

platelet at rest 1) adhesion1st shape change

3) aggregation(not reversible)

Vasoconstriction occurs first

Platelets then aggregate on the break in the vessel wall

Primary Hemostasis AssaysRoutine Platelet count PT APTT TT

Follow-up von Willebrand Factor Antigen determination Activity Factor VIII PFA-100 Platelet aggregation studies

SpecializedSend Out Activation markers (b-TG PF4 GPV) Specialized tests for platelet function

Aim is to strengthen the platelet plug

Coagulation

Coagulation is a balancebetween pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis

THROMBIN

Fibrinogen Fibrin

bull Triggering agentsbull pro-enzyme enzyme (serine-protease FIIa FVIIa FIXa FXa)bull Cofactors (FVa amp FVIIIa)

bull Serine-protease inhibitor Antithrombin (AT) bull Cofactorsinhibitors Protein C Sbull Tissue factor pathway inhibitor (TFPI)

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation Cascade Schematic

Coagulation factors

Historic name

Fibrinogen

Prothrombin

Proaccelerin

Proconvertin

Anti-hemophilic factor A

Anti-hemophilic factor B

Stuart factor

Rosenthal factor

Hageman factor

Fibrin Stabilizing Factor

Factor

I

II

V

VII

VIII

IX

X

XI

XII

XIII

Function

Substrate

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme = Zymogen activation Active Enzyme

Coagulation Assay Mechanisms

aPTT Based

PT Based

PT Based

Fibrin Under Microscope

Weisel JW Structure of fibrin impact on clot stability J Thromb Haemost 2007 5 Suppl 1 116-24

Low thrombin concentration

High thrombin concentration

Fibrin Formation

Soluble FibrinPolymer

ThrombinFibrinogen

FM+ fibrinopeptides A amp B

Stabilized Fibrin clot(not soluble)

ThrombinXIII XIIIa

(Digestion of Fibrin)

Fibrinolysis

Fibrinolysis Overview

Destroys fibrin fibers

Destroys the scab (dried wound)

Maintains vessel integrity

Fibrinolysis Overview

Fibrin =cement fibers

Plasmin

Plasmin digests fibrin

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Primary Hemostasis AssaysRoutine Platelet count PT APTT TT

Follow-up von Willebrand Factor Antigen determination Activity Factor VIII PFA-100 Platelet aggregation studies

SpecializedSend Out Activation markers (b-TG PF4 GPV) Specialized tests for platelet function

Aim is to strengthen the platelet plug

Coagulation

Coagulation is a balancebetween pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis

THROMBIN

Fibrinogen Fibrin

bull Triggering agentsbull pro-enzyme enzyme (serine-protease FIIa FVIIa FIXa FXa)bull Cofactors (FVa amp FVIIIa)

bull Serine-protease inhibitor Antithrombin (AT) bull Cofactorsinhibitors Protein C Sbull Tissue factor pathway inhibitor (TFPI)

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation Cascade Schematic

Coagulation factors

Historic name

Fibrinogen

Prothrombin

Proaccelerin

Proconvertin

Anti-hemophilic factor A

Anti-hemophilic factor B

Stuart factor

Rosenthal factor

Hageman factor

Fibrin Stabilizing Factor

Factor

I

II

V

VII

VIII

IX

X

XI

XII

XIII

Function

Substrate

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme = Zymogen activation Active Enzyme

Coagulation Assay Mechanisms

aPTT Based

PT Based

PT Based

Fibrin Under Microscope

Weisel JW Structure of fibrin impact on clot stability J Thromb Haemost 2007 5 Suppl 1 116-24

Low thrombin concentration

High thrombin concentration

Fibrin Formation

Soluble FibrinPolymer

ThrombinFibrinogen

FM+ fibrinopeptides A amp B

Stabilized Fibrin clot(not soluble)

ThrombinXIII XIIIa

(Digestion of Fibrin)

Fibrinolysis

Fibrinolysis Overview

Destroys fibrin fibers

Destroys the scab (dried wound)

Maintains vessel integrity

Fibrinolysis Overview

Fibrin =cement fibers

Plasmin

Plasmin digests fibrin

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Aim is to strengthen the platelet plug

Coagulation

Coagulation is a balancebetween pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis

THROMBIN

Fibrinogen Fibrin

bull Triggering agentsbull pro-enzyme enzyme (serine-protease FIIa FVIIa FIXa FXa)bull Cofactors (FVa amp FVIIIa)

bull Serine-protease inhibitor Antithrombin (AT) bull Cofactorsinhibitors Protein C Sbull Tissue factor pathway inhibitor (TFPI)

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation Cascade Schematic

Coagulation factors

Historic name

Fibrinogen

Prothrombin

Proaccelerin

Proconvertin

Anti-hemophilic factor A

Anti-hemophilic factor B

Stuart factor

Rosenthal factor

Hageman factor

Fibrin Stabilizing Factor

Factor

I

II

V

VII

VIII

IX

X

XI

XII

XIII

Function

Substrate

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme = Zymogen activation Active Enzyme

Coagulation Assay Mechanisms

aPTT Based

PT Based

PT Based

Fibrin Under Microscope

Weisel JW Structure of fibrin impact on clot stability J Thromb Haemost 2007 5 Suppl 1 116-24

Low thrombin concentration

High thrombin concentration

Fibrin Formation

Soluble FibrinPolymer

ThrombinFibrinogen

FM+ fibrinopeptides A amp B

Stabilized Fibrin clot(not soluble)

ThrombinXIII XIIIa

(Digestion of Fibrin)

Fibrinolysis

Fibrinolysis Overview

Destroys fibrin fibers

Destroys the scab (dried wound)

Maintains vessel integrity

Fibrinolysis Overview

Fibrin =cement fibers

Plasmin

Plasmin digests fibrin

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Coagulation is a balancebetween pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis

THROMBIN

Fibrinogen Fibrin

bull Triggering agentsbull pro-enzyme enzyme (serine-protease FIIa FVIIa FIXa FXa)bull Cofactors (FVa amp FVIIIa)

bull Serine-protease inhibitor Antithrombin (AT) bull Cofactorsinhibitors Protein C Sbull Tissue factor pathway inhibitor (TFPI)

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation Cascade Schematic

Coagulation factors

Historic name

Fibrinogen

Prothrombin

Proaccelerin

Proconvertin

Anti-hemophilic factor A

Anti-hemophilic factor B

Stuart factor

Rosenthal factor

Hageman factor

Fibrin Stabilizing Factor

Factor

I

II

V

VII

VIII

IX

X

XI

XII

XIII

Function

Substrate

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme = Zymogen activation Active Enzyme

Coagulation Assay Mechanisms

aPTT Based

PT Based

PT Based

Fibrin Under Microscope

Weisel JW Structure of fibrin impact on clot stability J Thromb Haemost 2007 5 Suppl 1 116-24

Low thrombin concentration

High thrombin concentration

Fibrin Formation

Soluble FibrinPolymer

ThrombinFibrinogen

FM+ fibrinopeptides A amp B

Stabilized Fibrin clot(not soluble)

ThrombinXIII XIIIa

(Digestion of Fibrin)

Fibrinolysis

Fibrinolysis Overview

Destroys fibrin fibers

Destroys the scab (dried wound)

Maintains vessel integrity

Fibrinolysis Overview

Fibrin =cement fibers

Plasmin

Plasmin digests fibrin

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation Cascade Schematic

Coagulation factors

Historic name

Fibrinogen

Prothrombin

Proaccelerin

Proconvertin

Anti-hemophilic factor A

Anti-hemophilic factor B

Stuart factor

Rosenthal factor

Hageman factor

Fibrin Stabilizing Factor

Factor

I

II

V

VII

VIII

IX

X

XI

XII

XIII

Function

Substrate

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme = Zymogen activation Active Enzyme

Coagulation Assay Mechanisms

aPTT Based

PT Based

PT Based

Fibrin Under Microscope

Weisel JW Structure of fibrin impact on clot stability J Thromb Haemost 2007 5 Suppl 1 116-24

Low thrombin concentration

High thrombin concentration

Fibrin Formation

Soluble FibrinPolymer

ThrombinFibrinogen

FM+ fibrinopeptides A amp B

Stabilized Fibrin clot(not soluble)

ThrombinXIII XIIIa

(Digestion of Fibrin)

Fibrinolysis

Fibrinolysis Overview

Destroys fibrin fibers

Destroys the scab (dried wound)

Maintains vessel integrity

Fibrinolysis Overview

Fibrin =cement fibers

Plasmin

Plasmin digests fibrin

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Coagulation factors

Historic name

Fibrinogen

Prothrombin

Proaccelerin

Proconvertin

Anti-hemophilic factor A

Anti-hemophilic factor B

Stuart factor

Rosenthal factor

Hageman factor

Fibrin Stabilizing Factor

Factor

I

II

V

VII

VIII

IX

X

XI

XII

XIII

Function

Substrate

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-cofactor

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme

Pro-enzyme = Zymogen activation Active Enzyme

Coagulation Assay Mechanisms

aPTT Based

PT Based

PT Based

Fibrin Under Microscope

Weisel JW Structure of fibrin impact on clot stability J Thromb Haemost 2007 5 Suppl 1 116-24

Low thrombin concentration

High thrombin concentration

Fibrin Formation

Soluble FibrinPolymer

ThrombinFibrinogen

FM+ fibrinopeptides A amp B

Stabilized Fibrin clot(not soluble)

ThrombinXIII XIIIa

(Digestion of Fibrin)

Fibrinolysis

Fibrinolysis Overview

Destroys fibrin fibers

Destroys the scab (dried wound)

Maintains vessel integrity

Fibrinolysis Overview

Fibrin =cement fibers

Plasmin

Plasmin digests fibrin

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Coagulation Assay Mechanisms

aPTT Based

PT Based

PT Based

Fibrin Under Microscope

Weisel JW Structure of fibrin impact on clot stability J Thromb Haemost 2007 5 Suppl 1 116-24

Low thrombin concentration

High thrombin concentration

Fibrin Formation

Soluble FibrinPolymer

ThrombinFibrinogen

FM+ fibrinopeptides A amp B

Stabilized Fibrin clot(not soluble)

ThrombinXIII XIIIa

(Digestion of Fibrin)

Fibrinolysis

Fibrinolysis Overview

Destroys fibrin fibers

Destroys the scab (dried wound)

Maintains vessel integrity

Fibrinolysis Overview

Fibrin =cement fibers

Plasmin

Plasmin digests fibrin

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Fibrin Under Microscope

Weisel JW Structure of fibrin impact on clot stability J Thromb Haemost 2007 5 Suppl 1 116-24

Low thrombin concentration

High thrombin concentration

Fibrin Formation

Soluble FibrinPolymer

ThrombinFibrinogen

FM+ fibrinopeptides A amp B

Stabilized Fibrin clot(not soluble)

ThrombinXIII XIIIa

(Digestion of Fibrin)

Fibrinolysis

Fibrinolysis Overview

Destroys fibrin fibers

Destroys the scab (dried wound)

Maintains vessel integrity

Fibrinolysis Overview

Fibrin =cement fibers

Plasmin

Plasmin digests fibrin

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Fibrin Formation

Soluble FibrinPolymer

ThrombinFibrinogen

FM+ fibrinopeptides A amp B

Stabilized Fibrin clot(not soluble)

ThrombinXIII XIIIa

(Digestion of Fibrin)

Fibrinolysis

Fibrinolysis Overview

Destroys fibrin fibers

Destroys the scab (dried wound)

Maintains vessel integrity

Fibrinolysis Overview

Fibrin =cement fibers

Plasmin

Plasmin digests fibrin

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

(Digestion of Fibrin)

Fibrinolysis

Fibrinolysis Overview

Destroys fibrin fibers

Destroys the scab (dried wound)

Maintains vessel integrity

Fibrinolysis Overview

Fibrin =cement fibers

Plasmin

Plasmin digests fibrin

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Fibrinolysis Overview

Destroys fibrin fibers

Destroys the scab (dried wound)

Maintains vessel integrity

Fibrinolysis Overview

Fibrin =cement fibers

Plasmin

Plasmin digests fibrin

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Fibrinolysis Overview

Fibrin =cement fibers

Plasmin

Plasmin digests fibrin

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

t-PA

Pro Urokinase

Urokinase

PAI-1PAI-1

Plasminogen Plasmin

1st Step

2nd Step

Fibrinolysis Cascade

t-PA tissue-type plasminogen activator PAI-1 Plasminogen activator inhibitor 1 PK Prekallikrein FDP Fibrinogen degradation products AP Antiplasmin = a2AP alpha 2 Antiplasmin a2MG alpha 2 Macroglobulin

Extrinsic pathway(endothelia l cells)

Intrinsic pathway(plasma)

Fibrin clot

D-dimerFibrin degradation products

Fibrin

TAFIa

APAntiplasmin(amp a2-MG)

PK Kallikrein

XII

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Fibrinolysis Releases D-dimers

D-dimer presence fibrin has been formed and digested in patients body

Normal D-dimer level no thrombosis occurred in the patient

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Basic Pathophysiology of DIC

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Disseminated Intravascular Coagulation (DIC)

Massive activation of coagulation leading to clots forming in multiple locations around the bodyRapid consumption of clotting factors leading to bleedingParadoxical condition leading to both clotting and bleedingA confusing disorder from both diagnostic and therapeutic standpoints Many unrelated diseases can trigger DIC Lack of uniformity in clinical manifestation Lack of uniformity in the laboratory diagnosis Lack of uniformity or consensus on management

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Clinical Manifestations of DICOrgan Ischemic Hemorrhagic

Skin Pupura Fulminans Petechiae

Gangrene Echymoses

Acral cyanosis Oozing

CNS Deliriumcoma Intracranial

Infarcts Bleeding

Renal OliguriaAzotemia Hematuria

Cortical Necrosis

Cardiovascular Myocardial dysfunction

Pulmonary DyspneaHypoxia Hemorrhagic lung

Infarct

Gastrointestinal Ulcers infarcts Massive hemorrhage

Endocrine Adrenal infarcts

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Purpura Fulminans with DIC Due to Meningococcal Sepsis

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Clinical Conditions Associated With DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Frequency of DIC in Selected Disease States

Disease Frequency

Gram-negative sepsis 30-50

Severe trauma and systemic inflammation 50-70

Metastasized tumors 15

Abruptio placentaamniotic fluid embolism 50

Severe preeclampsia 7

Giant hemangioma 25

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Masao Nakagawa Modified from a research report on the incidence of disseminated intravascular coagulation (DIC) and underlying diseases in Japan Ministry of Health Labour and Welfare Research report published in Fiscal Year 1998 57-64 199 httpwwwrecomodulincomendicindexhtml Accessed Apr 21 2017

Underlying Diseases in DIC Patients

In a Japanese survey from 1997 on incidence of DIC and underlying diseases in 652 divisions and departments of university hospitals DIC occurred in 2193 patients with the number of patient with infections (including sepsis) and hematologic tumors (including leukemia) accounted for 28 and 23 respectively

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Epidemiology of DIC

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Impact of DIC Status on Mortality - 1

Okamoto K Wada H Hatada T Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Frequency and hemostatic abnormalities in pre-DIC patients Thromb Res 2010 126 74-8

Patients with positivity of DIC tend to have worse mortality outcomes compared to negative patients or those with pre-DIC

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Impact of DIC Status on Mortality - 2

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Patients with positivity of either Overt or Non-Overt DIC tend to have worse mortality outcomes compared to negative patients

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Impact of Age on Mortality in DIC Patients

Wada H Hatada T Okamoto K Uchiyama T Kawasugi K Mayumi T et al Japanese Society of Thrombosis HemostasisDIC subcommittee Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC Am J Hematol 2010 85 691-4

Older patients with DIC (black bars) generally tend to have worse outcomes compared to non-DIC patients (grey bars)

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Pathophysiology of DIC

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Pathogenesis of DIC in Sepsis

Allen KS Sawheny E Kinasewitzet GT Anticoagulant modulation of inflammation in severe sepsis World J Crit Care Med 2015 4 105-15

Bacteria in sepsis infections cause release of TF from immune cells leading to coagulation activation and proinflammatory cytokines cause endothelial cell activation impairing the anticoagulation and fibrinolysis process resulting in DIC

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Host Response in Severe Sepsis

Exaggerated inflammation as a result of the host response to sepsis is collateral tissue damage and cell death further resulting in release of danger molecules continuing the inflammatory process in a downward spiral

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Organ Failure in Severe Sepsis

Sepsis associated with microvascular thrombosis as a result of TF mediated coagulation activation results in release of neutrophil extracellular traps (NETs) tissue hypoperfusion and mitochondrial damage resulting in a downward spiral leading to organ failure

Angus DC van der Poll T Severe Sepsis and Septic Shock N Engl J Med 2013 369 840-51

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Mechanism of DIC in Organ Failure

Underlying condition(sepsis trauma)

Cytokines

TF-mediatedactivation of coagulation

Depression of inhibitory systems

Reducesfibrinolysis

Fibrin deposition

Organ failure

Inadequate fibrin removal

Fibrinformation

Note impaired fibrinolysis in relation to the clinical need not in absolute value (FDPs are )

Levi M de Jonge E van der Poll T ten Cate H Disseminated intravascular coagulation ThrombHaemost 1999 82 695-705

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Interaction of Inflammation and Coagulation in Sepsis

Binding of TF thrombin and other activation coagulation factors to PARs and fibrin to TLRs on inflammatory cells results in inflammation through release of proinflammatory cytokines and chemokines

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Mechanism of Multiple Organ Failure in DIC

Wheeler AP Bernard GR Treating Patients with Severe Sepsis N Engl J Med 1999 340207-14

Inflammatory activation and microvascular thrombosis contributes to multiple organ failure in DIC

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

lipopolysaccharides

cytokines

coagulation activation

mononuclear cell

tissue factor

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Diverse and Opposing Effects of Thrombin

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Coagulation and Fibrinolysis in DIC

Soluble fibrin Polymer

XIIIa

D-Dimer

E

Fibrin clot

Fibrin Degradation Products

Fibrinogen Thrombin

Fibrinogen Degradation

Products

D E

Plasmin

DFM + fibrinopeptides

Soluble FM ComplexesPre-throm

boticPost-throm

botic

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis Semin Thromb Hemost 2008 34 33-8

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Mechanism of DIC

THROMBOSIS

Fibrin

Blood activationEndothelial lysisTF expression

BLEEDING

FDPs

D-Dimer

Plasmin

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Pathophysiology of DIC

1st step abnormal activation of coagulation Injury of vessel wall cells venous stasis release of large quantities of

thromboplastin influx of activated cells (monocytes macrophages)

Results in an intravascular deposition of fibrin

Morbidity from disseminated microthrombosis in small and midsize vessels leading to multiple organ failure

Second step Consumption and depletion of coagulation factors inhibitors (Protein C

Protein S AT) and platelets Local fibrinolytic response

bull Local plasmin generation dissolves the thrombusbull Disseminated overwhelming fibrinolytic response leading to production of

FDP and D-Dimer

Bleeding

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Pathophysiology of DIC - Mechanism

Systemic activation of coagulation

Intravasculardepositionof fibrin

Thrombosis of small and midsize vessels

and organ failure

Depletion of platelets and

coagulation factors

Bleeding

Levi M Ten Cate H Disseminated intravascular coagulation N Engl J Med 1999 341 586-92

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Pathophysiology of DIC ndash 2 Types of Clinical pictures

Chronic = non - overt DICMay be unrecognized clinically

Acute = overt DIClife threatening bleedingor multiple organ failure

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Sub-Acute and Non-Overt DIC Clinical Findings

Compensated non-overt DIC Steady low level or intermittent activation

bull Compensated by increased production of coagulation components and platelets

Few or no clinical signs or multiple microvascular thrombosis sometimes not clinically obvious

Risk of decompensation leading to overt DIC

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Pathophysiology of Overt DIC

Massive activation of coagulation and fibrinolysis

Does not allow for compensatory efforts

Rapid depletion of coagulation factors inhibitors and platelets

Thrombosis multiple organ failures

Bleeding complications and shock

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Physiopathology of DIC ndash Overt DIC Findings

Thrombin generation

Thrombosis

Renal liver respiratory failures coma skin necrosis gangrene venous thromboembolism hypotension edema

Cytokine and kinin generation (shock)bull Tachycardia hypotension edema

Plasmin generationHemorrhage

bull Spontaneous bruising petechiae intracranial gastrointestinal and respiratory tract bleeding persistent bleeding at venipuncture sites at surgical wounds

bull Tachycardia hypotension edema

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Pathogenesis Pathways in DIC

Cytokines

TF-mediated dysfunctional impairedthrombin anticoagulant fibrinolysisgeneration mechanism due to PAI-1 deficiency

fibrin inadequateformation fibrin removal

Fibrin deposition

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Inflammation

Coagulation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Stago Celebrates Lab Week 2017

NA

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Stago 247 Educational Webinar Sites

wwwstago-edvantagecomUS based KOLsPACE accredited ndash all 1 hourAccessible from mobile devicesVirtual exhibit hall

wwwstagowebinarscomMostly European KOLs30 ndash 45 min including 15 min discussion

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Stago Educational Apps

HaemoscoreClinical scoring algorithmsApple and AndroidTablet or phone

iHemostasisCoagulation diagramsCase studiesApple amp AndroidTablet only

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

BREAK

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Diagnostic and Management Approach for DIC

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Diagnosis of DIC

Clinical diagnosis is obvious in cases of overt DIC

Laboratory tests are necessary To makeconfirm the diagnosis To assess stage of the patient To assess the treatment efficacy

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Lab Diagnosis of DIC ndash Markers of Factor Consumption

Routinescreening assays PT APTT Platelets Fibrinogen Thrombin time

Other coagulation assays Factor assays AntithrombinGeneration of Thrombin FMFSPsGeneration of Plasmin D-dimer FDPs

Important to recognize simultaneous formation of thrombin and plasmin

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Lab Diagnosis of DIC ndash Screening Tests

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 16 312 683-687Schmaier AH Laboratory evaluation of hemostatic and thrombotic disorders In Hoffman R Benz EJ Jr Shattil SJ et al eds Hoffman Hematology Basic Principles and Practice 5th ed Philadelphia Pa Churchill Livingstone Elsevier 2008chap 122

Platelet count usually decreasedPT abnormal in 70 of cases (short half-life of FVII)APTT abnormal in 50 of casesThrombin time usually prolonged in overt DIC normal in non-overt DIC and no relation with syndrome severityFibrinogen low in lt 50 of cases sensitivity 22 specificity 87 overall predictive value 64 Normal fibrinogen level should not exclude DIC diagnosis (acute phase reactant initial high

fibrinogen level) repeat testing assesses progression

Screening tests not clinically specific or sensitive for DIC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Laboratory Changes in Overt DIC

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

DIC Diagnostic Practices Over Time

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

British Journal of Haematology Overt DIC Score

Levi M Toh CH Thachil J Watson HG Guidelines for the diagnosis and management of disseminatedintravascular coagulation British Journal of Haematology 145 24ndash33

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

ISTH Step by Step DIC Algorithm

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Soundar EP Jariwala P Nguyen TC Eldin KW Teruya J Evaluation of the International Society on Thrombosis and Haemostasis and institutional diagnostic criteria of disseminated intravascular coagulation in pediatric patients Am J Clin Pathol 2013 139 812-6

US Based Validation of ISTH DIC Score

When retrospectively comparing the ISTH score to a locally derived score in 2136 DIC panels from 130 pediatric patients the ISTH score had a higher AUC

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Differential Diagnosis in DIC

aHUS atypical hemolytic uremic syndrome

HUS hemolytic uremic syndrome

HIT heparin-induced thrombocytopenia

ITP immune thrombocytopenic purpura

TTP thrombotic thrombocytopenic purpura

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

DIC and MAHA

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

lt 3 schistocytes per high-power field considered normal gt 10 schistocytesapparent per high-power field (picture taken with oil emersion lens at x 100)

When RBCs pass through compromised vasoconstricted vessles result is microangiopathichemolytic anemia (MAHA) overt DIC is therefore a thrombotic MAHA because there is thrombocytopenia in addition to schistocyteformation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

DIC Management Goals

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Identify and correct the underlying causeMicroclots preventing blood flow in organs may strongly impair the biosynthesis of new coagulation factors inhibitors fibrinolysis proteins leading to severe deficienciesCorrect consumption and restore anticoagulation pathway with blood components Fresh frozen plasma (preferred) Coagulation factor concentrates fibrinogen andor cryoprecipitate Antithrombin Platelet concentrates Monitor coagulation markers for correction

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

DIC Management and Treatment

Baglin T Disseminated intravascular coagulation diagnosis and treatment BMJ 1996 312 683-7

Stop activation process Thrombin and plasmin inhibitors Unfractionaed heparin (UFH) amp low molecular weight heparin (LMWH)

requires adequate AT levels typically low dose Monitor with anti-Xa activity no APTT (if UFH)

Longer term once the patient stabilizes oral anticoagulantsOther supportive treatment Vitamin K for critically ill patients with acquired vitamin K deficiency Oxygen to correct hypoxia

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

DIC Management Strategies

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Anticoagulant Factor Concentrate Treatment

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Anticoagulant factor concentrates (eg AT TFPI TM aPC) target sepsis with DIC before DIC emergence leads to deterioration of physiological responses maintaining homeostasis

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Anticoagulant Factor Concentrate Treatment Trials

Gando S Levi M Toh CH Disseminated intravascular coagulation Nat Rev Dis Primers 2016 2 16037

Recombinant aPC AT and TFPI have been attempted for treatment of DIC in large clinical trials with mostly failures recombinant TM trials have shown promise

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Markers of Thrombin amp Plasmin Generation in DIC

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

D-Dimer sensitive test for DIC but not specific Elevated D-Dimer Thrombin + Plasmin activity Negative D-Dimer low probability for DIC

Cut-off value

Fibrin monomers (FM aka soluble fibrin monomers SFM) and fibrin degradation products (FDPs aka fibrin split products FSPs) Manual FDPFSP detects both fibrin and fibrinogen

degradation products Sensitive assay typically with cutoff adapted for DIC

D-dimer FDPs and DIC

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

D-Dimer and FDPs in DICDetects both fibrin and fibrinogen degradation productsSensitive cut-off adapted to DIC

Yu M Nardella A Pechet L Screening tests of disseminated intravascular coagulation guidelines for rapid and specific laboratory diagnosis Crit Care Med 2000 28 1777-80

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Follow Up of DIC State of Disease

Dhainaut JF Shorr AF Macias WL Kollef MJ Levi M Reinhart K et al Dynamic evolution of coagulopathyin the first day of severe sepsis relationship with mortality and organ failure Crit Care Med 2005 33 341-8

Coagulopathy continuing or worsening during the first day of severe sepsis (followed by PT AT and D-dimer) was associated with development of organ failure and 28 day mortaility

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

FMD-Dimer in DIC Major Differences

onset of thrombosis

days

Wada H Sakuragawa N Are fibrin-related markers useful for the diagnosis of thrombosis SeminThromb Hemost 2008 34 33-8

FM may be predictive Appear 0-3 days after the onset of thrombosis typically prethrombotic Short half-life (6 - 8 hrs)

D-Dimer (a specific FDP) well-established DIC Appear 2-10 days after the onset of thrombosis typically postthrombotic Longer half-life (4 - 11 hrs)

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

of Abnormal Results in Patients with Confirmed and Suspected DIC

0

20

40

60

80

100

94 85 90N = 62

Woodhams BJ Esteve F Migaud-Fressart M Wold M Grimaux M D-dimer levels in samples from patients with disseminated intravascular coagulation (DIC) or suspected DIC using 3 different assay procedures Fibrinolysis amp Proteolysis 2000 14 Suppl 1 32

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Positivity of Test Results ISTH Score and Disease State

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

Red bar positive for 2 points of DIC score

Pink bar positive for 1-2 points of DIC score

HT hematopoietic tumor

IF infection

SC solid cancer

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Markers in Patients with or without DIC

Wada H Matsumoto T Hatada T Diagnostic criteria and laboratory tests for disseminated intravascular coagulation Expert Rev Hematol 2012 5 643-52

HT hematopoietic tumorIF infectionSC solid cancer

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Comparing an Automated FM vs Manual FSP Test

Westerlund E Woodhams BJ Eintrei J Soumlderblom L Antovic JP The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory Int J Lab Hematol 2013 35 666-71

Automated (Stago) vs Manual (Stago) Automated (Mitsubishi) vs Manual (Stago)

Automated (Mitsubishi) vs Automated (Stago)

In a study of ED patients automated FM assays exhibit much better inter-assayagreement compared to automated FM vs a manual FSP assay from Stago

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Non-Overt to Non-DIC patients FM far outperforms D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing DIC positive to Non-Overt DIC patients D-dimer outperforms FM on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

In comparing Overt to Non-DIC patients FM is more comparable to D-dimer on the ROC

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Diagnostic Performance of FM and D-dimer in DIC

Singh N Prasad Pati H Tyagi S Datt Upadhyay A Saxena R Evaluation of the Diagnostic Performanceof Fibrin Monomer in Comparison to D-Dimer in Patients With Overt and Nonovert DisseminatedIntravascular Coagulation Clin Appl ThrombHemost 2015 1-6

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

No DIC Non Overt DIC Overt DIC No DIC Non Overt DIC Overt DIC

Levels of D-dimer and FM generally rise going from no DIC to non-overt to overt DIC

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Diagnostic Performance of FM and D-dimer in DIC

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

Non Overt DIC Overt DIC

AUC in the ROC was higher for D-dimer (dashed line) in Non-overt but higher for FM (solidline) in Overt DIC

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Trends in Markers of DIC for Different Patients

Toh JMH Ken-Drorb G Downeyd C Abram ST The clinical utility of fibrin-related biomarkers in sepsisBlood Coagulation and Fibrinolysis 2013 2400ndash00

Sepsis patients have much higher levels of FDP FM and D-dimer compared to normal and systemic inflammatory response syndrome (SIRS) patients

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Trends in Markers of DIC for Different Patients

Park KJ Kwon EH Kim HJ Kim SH Evaluation of the diagnostic performance of fibrin monomer in disseminated intravascular coagulation Korean J Lab Med 2011 31 143-7

FDP FM and D-dimer all increase for patients with survival outcomes compared to thosewith death outcomes

28 day outcome survival

28 day outcome death

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Determination of Cutoffs of FM and D-dimer in DIC

Hatada T Wada H Kawasugi K Okamoto K Uchiyama T Kushimoto S et al Japanese Society of Thrombosis HemostasisDIC subcommittee Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC Clin Appl Thromb Hemost 2012 18 495-500

Analysis of D-dimer FDP and FM in DIC patients and classifying by outcome enablescutoff values to be determined in concordance with ISTH guidelines

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

DIC Case Studies

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Case Study 1 - Presentation

18 year old male presented to the ED after 3 weeks of nosebleeds and increasing levels of severe fatigue No medical history born at term all developmental milestones achieved No family history of bleeding or thrombosis No medications denies recreational drugsalcohol Physical exam finds blood clots in both nostrils and petechial hemorrhages in mouth and lower extremities Bleeding subsided but lab results were monitored closely during hospitalization while blood products were administered

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Case Study 1 ndash Lab ResultsTEST RESULT REFERENCE RANGE

WBC count 77 KμL 423 ndash 907 x KμL

RBC count 17 MμL 137 ndash 175 x MμL

Hemoglobin 67 gdL 137 ndash 175 gdL

Hematocrit 195 401 ndash 510

MCV 95 fL 790 ndash 922 fL

MPV 12 fL 94 ndash 124 fL

Platelet count 9 KμL 161 ndash 347 KμL

Metamyelocytes promyelocytes myelocytes myeloblasts all elevated above normal level of 0

Lymphocytes monocytes eosinophils basophils all below normal range

PT 47 sec (corrected on mixing study) 116 ndash 152 sec

APTT 75 sec (corrected on mixing study) 253 ndash 373 sec

Fibrinogen lt 76 mgdL 177 ndash 466 mgdL

D-dimer 900 μgmL FEU 0 ndash 050 μgmL FEU

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Case Study 1 ndash Microscopy

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

Arrow shows giant platelets in this peripheral smear Promyelocytes apparent

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

Case Study 1 ndash Diagnosis and TherapyProfound anemia significant reticulocytosis and increased mean corpuscular volume (MCV) decreased platelets with increased mean platelet volume (MPV) numerous promyelocytes High D-dimer with PTAPTT correcting on mixing study along with low fibrinogen indicate disseminated intravascular coagulation (DIC) secondary to acute myelogenous leukemia (AML) most likely acute promyelocytic leukemia (APL)

DIC due to TF release by APL blasts

Molecular studies of PML-retinoic acid receptor-alpha (RARA) gene fusion was positive occurs in gt95 of APL cases

Transfusions to replace factors along with platelets and RBCs during APL treatment

Fisher VR Scott MK Tremblay CA Beaulieu GP Ward DC Byrne KM Disseminated Intravascular Coagulation Laboratory Support for Management and Treatment Lab Med 2013 Spring Supplement e10-e14

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

20-year-old male college student presenting to EDGeneral malaise hypotension (9060 mmHg) high-grade fever purplish discoloration on his body pain in both legs vomiting and diarrhea on the preceding dayFacial discoloration developed rapidly during the time from when he left house to the time he arrived at the emergency roomBlood cultures started

Case Study 2 ndash Presentation

TEST RESULT REFERENCE RANGEPlatelet count 67 x 109L 150-400 x 109L

PT 30 sec 113 ndash 146 sec

APTT 75 sec 25 ndash 34 sec

D-dimer 078 microgml FEU lt050 microgml FEU

Fibrinogen 92 mgdl 150-400 mgdl

pH 728 738 to 742

PaO2 570 mmHg 80-100 mmHg

WBC 33 times 103mm3 40-11 times 103mm3

ALT 111 IUL 0ndash34 IUL

AST 61 IUL 0ndash34 IUL

BUN 303 mgdL 08-13 mgdL

Case Study 2 ndash Lab Results

Pneumococcal infectionWaterhouse-Friderichsen Syndrome with DICProvide antibiotics with supportive measures

Case Study 2 ndash Diagnosis

60-year-old male 4 day history of bleeding from the gums diffuse spontaneous ecchymoses mild fatigue and bone pain6-month history of pain localized to his right thigh with extension to the posterior part of his right legPast medical history included atrial fibrillation hypercholesterolemia and hypertension all well controlled with medicationNo history of smoking moderate alcohol consumption until 1 year prior

Case Study 3 ndash Presentation

Pneumococcal infectionWaterhouse-Friderichsen Syndrome with DICProvide antibiotics with supportive measures

Case Study 2 ndash Diagnosis

60-year-old male 4 day history of bleeding from the gums diffuse spontaneous ecchymoses mild fatigue and bone pain6-month history of pain localized to his right thigh with extension to the posterior part of his right legPast medical history included atrial fibrillation hypercholesterolemia and hypertension all well controlled with medicationNo history of smoking moderate alcohol consumption until 1 year prior

Case Study 3 ndash Presentation

60-year-old male 4 day history of bleeding from the gums diffuse spontaneous ecchymoses mild fatigue and bone pain6-month history of pain localized to his right thigh with extension to the posterior part of his right legPast medical history included atrial fibrillation hypercholesterolemia and hypertension all well controlled with medicationNo history of smoking moderate alcohol consumption until 1 year prior

Case Study 3 ndash Presentation

TEST RESULT REFERENCE RANGEPlatelet count 107 x 109L 150-400 x 109L

PT 228 sec 113 ndash 146 sec

APTT 45 sec 25 ndash 34 sec

D-dimer 080 microgml FEU lt050 microgmL FEU

Fibrinogen 82 mgdL 150-400 mgdL

FV Normal 70-120

FVII Normal 55-170

FVIII Normal 60-150

Protein C Normal 70-130

Hb 134 gdL 14-16 gdL

WBC 81 times 103mm3 40-11 times 103mm3

ALT 32 IUL 0ndash34 IUL

AST 28 IUL 0ndash34 IUL

BUN 09 mgdL 08-13 mgdL

Case Study 3 ndash Lab Results

Acute promyelocytic leukemia with DICTransfusions to replace platelets and RBCs during APL treatment

Case Study 3 ndash Diagnosis and Therapy

Critical care transport arranged for 48 year old male admitted to the local hospital 3 days prior with weakness and hypotension Four days prior insect bite while hiking large hematoma on left armNo prior medical history no drug allergies no current medicationsUpon arrival patient is awake and alert in moderate respiratory distress oozing blood from both vascular access sites nose and urinary catheter skin is cool and mildly jaundicedVital signs heart rate 110 beats per minute blood pressure 9244 slightly labored respiratory rate 22 breaths per minute pulse oximetry 91

Case Study 4 ndash Presentation

TEST RESULT REFERENCE RANGEPlatelet count 70 x 109L 150-400 x 109L

PT 28 sec 113 ndash 146 sec

APTT 71 sec 25 ndash 34 sec

D-dimer 31 microgmL FEU lt050 microgml FEU

Fibrinogen 92 mgdL 150-400 mgdl

FV Normal 70-120

FVII Normal 55-170

FVIII Normal 60-150

Protein C Normal 70-130

Hb 158 gdL 14-16 gdL

WBC 71 times 103mm3 40-11 times 103mm3

ALT 60 IUL 0ndash34 IUL

AST 47 IUL 0ndash34 IUL

BUN 38 mgdL 08-13 mgdL

Case Study 4 ndash Lab Results

Lyme disease with DICProvide antibiotics with supportive measures

Case Study 4 ndash Diagnosis

55-year-old man 10 following months after thoracic endovascular aortic repair (TEVAR) multiple ecchymoses diffusely distributed in his torso along with upper and lower extremitiesChronic type B aortic dissection and descending thoracic aortic aneurysmPersistent retrograde flow in false lumen with stable aneurysm diameterFalse lumen embolized with multiple Amplatzer plugs which promoted false lumen thrombosis

Case Study 5 ndash Presentation

Mendes BC Oderich GS Erben Y Reed NR Pruthi RK False Lumen Embolization to Treat Disseminated Intravascular Coagulation After Thoracic Endovascular Aortic Repair of Type B Aortic Dissection Journal of Endovascular Therapy 2015 22 938ndash41

Case Study 5 ndash Lab Results and Time Course

Mendes BC Oderich GS Erben Y Reed NR Pruthi RK False Lumen Embolization to Treat Disseminated Intravascular Coagulation After Thoracic Endovascular Aortic Repair of Type B Aortic Dissection Journal of Endovascular Therapy 2015 22 938ndash41

TEST RESULT REFERENCE RANGE

Platelet count 33 x 109L 150-450 x 109L

PT 215 sec 103 ndash 128 sec

APTT 44 sec 26 ndash 36 sec

D-dimer 20 microgmL FEU lt025 microgml FEU

Fibrinogen 34 mgdL 200-375 mgdl

FII FV FVIII Low Not reported (NR)

FVII FIX FX vWF Normal NR

Improvement in Pltand Fib after false lumen embolization with multiple endovascular plugs(arrows)

DIC secondary to large type Ib endoleakUFH infusion cryoprecipitate partial improvement in platelet count and fibrinogenRare case of DIC following TEVAR (A) 3D CT reconstruction (B) Illustration demonstrating chronic type B aortic

dissection with associated aneurysmal dilatation of the descending thoracic aorta patient treated with TEVAR

(C) Completion angiogram demonstrated patent supra-aortic vessels and thoracic stent-graft no evidence of an antegrade endoleak but persistent distal type Ib endoleak (black arrow) into false lumen

(D) Illustration demonstrating repair

Case Study 5 ndash Diagnosis and Treatment

Mendes BC Oderich GS Erben Y Reed NR Pruthi RK False Lumen Embolization to Treat Disseminated Intravascular Coagulation After Thoracic Endovascular Aortic Repair of Type B Aortic Dissection Journal of Endovascular Therapy 2015 22 938ndash41

29 year old female 50 kg hematuria and epistaxis pregnant 37 weeks no prior prenatal check ups hematuria 10 days priorOn examination blood pressure 200160 started on α-methyldopaShe developed profuse epistaxis controlled after bilateral nasal packinNo history of blurring of vision or epigastric pain denied history of prior abnormal bleeding episodes ingestion of any medication except α-methyldopaExamination revealed pallor and pedal edema controlled with three 5 mg boluses of intravenous labetalolTrachea was electively intubated under midazolam sedation for protection of airway and patient placed on ventilation with oxygen supplementationBaby was monitored using cardiotocography and Doppler ultrasonography

Case Study 6 ndash Presentation

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

Case Study 6 ndash Lab Results

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

TEST RESULT REFERENCE RANGEPlatelet count 109 x 109L 150-400 x 109L

PT 63 sec gt control 113 ndash 146 sec

INR 658 1 ndash 125

APTT 80 sec gt control 25 ndash 34 sec

D-dimer gt200 microgmL DDU 02 microgmL DDU

Urine exam Proteinuria and hematuria 150-400 mgdl

Albumin 28 gdL NR

Hb 58 gdL NR

LDH 1196 UL NR

SGPT 144 IU NR

SGOT 88 IU NR

Bilirubin 32 mgdL NR

DIC complicating hemolysis elevated liver enzymes and low platelets (HELLP) syndrome in preeclampsia was made and C section plannedIntraoperative blood loss replaced with FFP packed red blood cells (RBC) hexastarch and crystalloidsBaby delivered successfullyPostop vaginal bleeding treated with intravenous TXA platelets and FFPPatient remained haemodynamically stable and disharged on the 10th

day postop

Case Study 6 ndash Diagnosis and Treatment

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

HELLP syndrome complicates 02 ndash06 of all pregnancies 4ndash12 of cases with severe preeclampsia and 30ndash50 of eclamptic gravidasMaternal and neonatal mortality 2ndash24 and 3ndash39 respectively HELLP syndrome may progress to DIC in 15ndash38 of patientsPatients with HELLP syndrome are at increased risk of abruptio placentae pulmonary edema ruptured liver hematoma acute renal failure cerebrovascular accident and multiorgan failure

Case Study 6 ndash Discussion

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

44-year-old man with history of hepatitis C cirrhosis and chronic kidney disease presents to ED for altered mental status and ammonia level gt 500 mM (RR 11-51 mM)Patient was given lactulose however his mental status worsened to require intubationVital signs on admission to ICU on Oct 23 BP 12084 heart rate 107 beatsmin respiratory rate 18min temperature 978 degF

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 23 patient started on vancomycin piperacillintazobactam and fluids because of concern for sepsis associated with systemic inflammatory response syndrome (SIRS) and multiorgan failure as well as laboratory values showing a high WBC count and elevated lactate of 8 mM (RR 05-16mmolL)Vital signs worsened over next 24 hours became hypotensive requiring treatment with norepinephrine and 6 L of normal saline on Oct 24Renal function continued to decline received continuous renal replacement therapy on Oct 25

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Case Study 7 ndash Lab Results vs Time

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Lab values from Oct 25 consistent with DIC given packed RBCs FFP cryo plts and vit K to treat peritoneal bleeding which stopped by Oct 26Over next few days continued to require norepinephrine but eventually vital signs and laboratory values stabilizedDuring next few days improvement was apparent but found to have multiple infections including vancomycin-resistant enterococcus (VRE) along with Stenotrophomonas maltophilia peritoneal fluid growing Acinetobacter and urinalysis growing Candida glabrata

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 29 started on daptomycin linezolid trimethoprimsulfamethoxazole and fluconazole vancomycin and piperacillintazobactam were discontinuedHemodynamically stable taken off pressors and extubated on Nov 1In process of transfer from ICU became obtunded and hypotensive onFFP cryo platelets and packed RBCs were ordered but patient went into cardiac arrest and passed away

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

DIC Take Home Messages

Heterogeneous rapidly fatal syndromeEtiology sepsis tumors injuries or obstetric complicationsSimultaneous activation of coagulation and fibrinolysis Consumption of factors anticoagulant proteins fibrinogen and plateletsDiagnosis not with a single test panel including activation markers Screening coags platelets FMFS and D-dimer 1st consideration treat the critical symptoms and underlying issue 2nd consideration compensation for the consumption and sometimes anticoagulation

Monitor efficacy of therapy Activation markers (D-Dimer FMFSP) Normalization of coagulation markers

DIC

Thank you Questions

• Disseminated Intravascular Coagulation (DIC) and Thrombosis The Critical Role of the Lab
• Learning Objectives
• Slide Number 3
• Slide Number 4
• Slide Number 5
• Slide Number 6
• Slide Number 7
• Slide Number 8
• Wound Sealing
• The Three Steps of Hemostasis
• Vessel Wall
• Slide Number 12
• Slide Number 13
• Platelet Structure UnactivatedActivated
• Primary Hemostasis
• Primary Hemostasis Assays
• Slide Number 17
• Coagulation is a balance between pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis
• Slide Number 19
• Coagulation factors
• Coagulation Assay Mechanisms
• Slide Number 22
• Fibrin Formation
• Slide Number 24
• Fibrinolysis Overview
• Fibrinolysis Overview
• Slide Number 27
• Fibrinolysis Releases D-dimers
• Basic Pathophysiology of DIC
• Disseminated Intravascular Coagulation (DIC)
• Purpura Fulminans with DIC Due to Meningococcal Sepsis
• Clinical Conditions Associated With DIC
• Frequency of DIC in Selected Disease States
• Underlying Diseases in DIC Patients
• Slide Number 36
• Slide Number 37
• Slide Number 38
• Slide Number 39
• Pathophysiology of DIC
• Pathogenesis of DIC in Sepsis
• Host Response in Severe Sepsis
• Organ Failure in Severe Sepsis
• Mechanism of DIC in Organ Failure
• Interaction of Inflammation and Coagulation in Sepsis
• Slide Number 47
• Diverse and Opposing Effects of Thrombin
• Coagulation and Fibrinolysis in DIC
• Mechanism of DIC
• Pathophysiology of DIC
• Pathophysiology of DIC - Mechanism
• Pathophysiology of DIC ndash 2 Types of Clinical pictures
• Sub-Acute and Non-Overt DIC Clinical Findings
• Pathophysiology of Overt DIC
• Physiopathology of DIC ndash Overt DIC Findings
• Slide Number 57
• Slide Number 58
• Slide Number 59
• Slide Number 60
• Slide Number 61
• BREAK
• Diagnostic and Management Approach for DIC
• Diagnosis of DIC
• Lab Diagnosis of DIC ndash Markers of Factor Consumption
• Lab Diagnosis of DIC ndash Screening Tests
• Slide Number 67
• Slide Number 68
• British Journal of Haematology Overt DIC Score
• Slide Number 70
• Slide Number 71
• Slide Number 72
• Slide Number 73
• DIC Management Goals
• DIC Management and Treatment
• DIC Management Strategies
• Anticoagulant Factor Concentrate Treatment
• Anticoagulant Factor Concentrate Treatment Trials
• Markers of Thrombin amp Plasmin Generation in DIC
• D-dimer FDPs and DIC
• D-Dimer and FDPs in DIC
• Follow Up of DIC State of Disease
• FMD-Dimer in DIC Major Differences
• of Abnormal Results in Patients with Confirmed and Suspected DIC
• Slide Number 85
• Slide Number 86
• Comparing an Automated FM vs Manual FSP Test
• Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Slide Number 98
• Slide Number 99
• DIC Case Studies
• Case Study 1 - Presentation
• Case Study 1 ndash Lab Results
• Case Study 1 ndash Microscopy
• Case Study 1 ndash Diagnosis and Therapy
• Slide Number 105
• Slide Number 106
• Slide Number 107
• Slide Number 108
• Slide Number 109
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Slide Number 113
• Slide Number 114
• Slide Number 115
• Slide Number 116
• Slide Number 117
• Slide Number 118
• Slide Number 119
• Slide Number 120
• Slide Number 121
• Slide Number 122
• Slide Number 123
• Slide Number 124
• Slide Number 125
• DIC Take Home Messages
• Slide Number 127
• Slide Number 128

Acute promyelocytic leukemia with DICTransfusions to replace platelets and RBCs during APL treatment

Case Study 3 ndash Diagnosis and Therapy

Critical care transport arranged for 48 year old male admitted to the local hospital 3 days prior with weakness and hypotension Four days prior insect bite while hiking large hematoma on left armNo prior medical history no drug allergies no current medicationsUpon arrival patient is awake and alert in moderate respiratory distress oozing blood from both vascular access sites nose and urinary catheter skin is cool and mildly jaundicedVital signs heart rate 110 beats per minute blood pressure 9244 slightly labored respiratory rate 22 breaths per minute pulse oximetry 91

Case Study 4 ndash Presentation

TEST RESULT REFERENCE RANGEPlatelet count 70 x 109L 150-400 x 109L

PT 28 sec 113 ndash 146 sec

APTT 71 sec 25 ndash 34 sec

D-dimer 31 microgmL FEU lt050 microgml FEU

Fibrinogen 92 mgdL 150-400 mgdl

FV Normal 70-120

FVII Normal 55-170

FVIII Normal 60-150

Protein C Normal 70-130

Hb 158 gdL 14-16 gdL

WBC 71 times 103mm3 40-11 times 103mm3

ALT 60 IUL 0ndash34 IUL

AST 47 IUL 0ndash34 IUL

BUN 38 mgdL 08-13 mgdL

Case Study 4 ndash Lab Results

Lyme disease with DICProvide antibiotics with supportive measures

Case Study 4 ndash Diagnosis

55-year-old man 10 following months after thoracic endovascular aortic repair (TEVAR) multiple ecchymoses diffusely distributed in his torso along with upper and lower extremitiesChronic type B aortic dissection and descending thoracic aortic aneurysmPersistent retrograde flow in false lumen with stable aneurysm diameterFalse lumen embolized with multiple Amplatzer plugs which promoted false lumen thrombosis

Case Study 5 ndash Presentation

Mendes BC Oderich GS Erben Y Reed NR Pruthi RK False Lumen Embolization to Treat Disseminated Intravascular Coagulation After Thoracic Endovascular Aortic Repair of Type B Aortic Dissection Journal of Endovascular Therapy 2015 22 938ndash41

Case Study 5 ndash Lab Results and Time Course

Mendes BC Oderich GS Erben Y Reed NR Pruthi RK False Lumen Embolization to Treat Disseminated Intravascular Coagulation After Thoracic Endovascular Aortic Repair of Type B Aortic Dissection Journal of Endovascular Therapy 2015 22 938ndash41

TEST RESULT REFERENCE RANGE

Platelet count 33 x 109L 150-450 x 109L

PT 215 sec 103 ndash 128 sec

APTT 44 sec 26 ndash 36 sec

D-dimer 20 microgmL FEU lt025 microgml FEU

Fibrinogen 34 mgdL 200-375 mgdl

FII FV FVIII Low Not reported (NR)

FVII FIX FX vWF Normal NR

Improvement in Pltand Fib after false lumen embolization with multiple endovascular plugs(arrows)

DIC secondary to large type Ib endoleakUFH infusion cryoprecipitate partial improvement in platelet count and fibrinogenRare case of DIC following TEVAR (A) 3D CT reconstruction (B) Illustration demonstrating chronic type B aortic

dissection with associated aneurysmal dilatation of the descending thoracic aorta patient treated with TEVAR

(C) Completion angiogram demonstrated patent supra-aortic vessels and thoracic stent-graft no evidence of an antegrade endoleak but persistent distal type Ib endoleak (black arrow) into false lumen

(D) Illustration demonstrating repair

Case Study 5 ndash Diagnosis and Treatment

Mendes BC Oderich GS Erben Y Reed NR Pruthi RK False Lumen Embolization to Treat Disseminated Intravascular Coagulation After Thoracic Endovascular Aortic Repair of Type B Aortic Dissection Journal of Endovascular Therapy 2015 22 938ndash41

29 year old female 50 kg hematuria and epistaxis pregnant 37 weeks no prior prenatal check ups hematuria 10 days priorOn examination blood pressure 200160 started on α-methyldopaShe developed profuse epistaxis controlled after bilateral nasal packinNo history of blurring of vision or epigastric pain denied history of prior abnormal bleeding episodes ingestion of any medication except α-methyldopaExamination revealed pallor and pedal edema controlled with three 5 mg boluses of intravenous labetalolTrachea was electively intubated under midazolam sedation for protection of airway and patient placed on ventilation with oxygen supplementationBaby was monitored using cardiotocography and Doppler ultrasonography

Case Study 6 ndash Presentation

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

Case Study 6 ndash Lab Results

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

TEST RESULT REFERENCE RANGEPlatelet count 109 x 109L 150-400 x 109L

PT 63 sec gt control 113 ndash 146 sec

INR 658 1 ndash 125

APTT 80 sec gt control 25 ndash 34 sec

D-dimer gt200 microgmL DDU 02 microgmL DDU

Urine exam Proteinuria and hematuria 150-400 mgdl

Albumin 28 gdL NR

Hb 58 gdL NR

LDH 1196 UL NR

SGPT 144 IU NR

SGOT 88 IU NR

Bilirubin 32 mgdL NR

DIC complicating hemolysis elevated liver enzymes and low platelets (HELLP) syndrome in preeclampsia was made and C section plannedIntraoperative blood loss replaced with FFP packed red blood cells (RBC) hexastarch and crystalloidsBaby delivered successfullyPostop vaginal bleeding treated with intravenous TXA platelets and FFPPatient remained haemodynamically stable and disharged on the 10th

day postop

Case Study 6 ndash Diagnosis and Treatment

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

HELLP syndrome complicates 02 ndash06 of all pregnancies 4ndash12 of cases with severe preeclampsia and 30ndash50 of eclamptic gravidasMaternal and neonatal mortality 2ndash24 and 3ndash39 respectively HELLP syndrome may progress to DIC in 15ndash38 of patientsPatients with HELLP syndrome are at increased risk of abruptio placentae pulmonary edema ruptured liver hematoma acute renal failure cerebrovascular accident and multiorgan failure

Case Study 6 ndash Discussion

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

44-year-old man with history of hepatitis C cirrhosis and chronic kidney disease presents to ED for altered mental status and ammonia level gt 500 mM (RR 11-51 mM)Patient was given lactulose however his mental status worsened to require intubationVital signs on admission to ICU on Oct 23 BP 12084 heart rate 107 beatsmin respiratory rate 18min temperature 978 degF

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 23 patient started on vancomycin piperacillintazobactam and fluids because of concern for sepsis associated with systemic inflammatory response syndrome (SIRS) and multiorgan failure as well as laboratory values showing a high WBC count and elevated lactate of 8 mM (RR 05-16mmolL)Vital signs worsened over next 24 hours became hypotensive requiring treatment with norepinephrine and 6 L of normal saline on Oct 24Renal function continued to decline received continuous renal replacement therapy on Oct 25

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Case Study 7 ndash Lab Results vs Time

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Lab values from Oct 25 consistent with DIC given packed RBCs FFP cryo plts and vit K to treat peritoneal bleeding which stopped by Oct 26Over next few days continued to require norepinephrine but eventually vital signs and laboratory values stabilizedDuring next few days improvement was apparent but found to have multiple infections including vancomycin-resistant enterococcus (VRE) along with Stenotrophomonas maltophilia peritoneal fluid growing Acinetobacter and urinalysis growing Candida glabrata

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 29 started on daptomycin linezolid trimethoprimsulfamethoxazole and fluconazole vancomycin and piperacillintazobactam were discontinuedHemodynamically stable taken off pressors and extubated on Nov 1In process of transfer from ICU became obtunded and hypotensive onFFP cryo platelets and packed RBCs were ordered but patient went into cardiac arrest and passed away

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

DIC Take Home Messages

Heterogeneous rapidly fatal syndromeEtiology sepsis tumors injuries or obstetric complicationsSimultaneous activation of coagulation and fibrinolysis Consumption of factors anticoagulant proteins fibrinogen and plateletsDiagnosis not with a single test panel including activation markers Screening coags platelets FMFS and D-dimer 1st consideration treat the critical symptoms and underlying issue 2nd consideration compensation for the consumption and sometimes anticoagulation

Monitor efficacy of therapy Activation markers (D-Dimer FMFSP) Normalization of coagulation markers

DIC

Thank you Questions

• Disseminated Intravascular Coagulation (DIC) and Thrombosis The Critical Role of the Lab
• Learning Objectives
• Slide Number 3
• Slide Number 4
• Slide Number 5
• Slide Number 6
• Slide Number 7
• Slide Number 8
• Wound Sealing
• The Three Steps of Hemostasis
• Vessel Wall
• Slide Number 12
• Slide Number 13
• Platelet Structure UnactivatedActivated
• Primary Hemostasis
• Primary Hemostasis Assays
• Slide Number 17
• Coagulation is a balance between pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis
• Slide Number 19
• Coagulation factors
• Coagulation Assay Mechanisms
• Slide Number 22
• Fibrin Formation
• Slide Number 24
• Fibrinolysis Overview
• Fibrinolysis Overview
• Slide Number 27
• Fibrinolysis Releases D-dimers
• Basic Pathophysiology of DIC
• Disseminated Intravascular Coagulation (DIC)
• Purpura Fulminans with DIC Due to Meningococcal Sepsis
• Clinical Conditions Associated With DIC
• Frequency of DIC in Selected Disease States
• Underlying Diseases in DIC Patients
• Slide Number 36
• Slide Number 37
• Slide Number 38
• Slide Number 39
• Pathophysiology of DIC
• Pathogenesis of DIC in Sepsis
• Host Response in Severe Sepsis
• Organ Failure in Severe Sepsis
• Mechanism of DIC in Organ Failure
• Interaction of Inflammation and Coagulation in Sepsis
• Slide Number 47
• Diverse and Opposing Effects of Thrombin
• Coagulation and Fibrinolysis in DIC
• Mechanism of DIC
• Pathophysiology of DIC
• Pathophysiology of DIC - Mechanism
• Pathophysiology of DIC ndash 2 Types of Clinical pictures
• Sub-Acute and Non-Overt DIC Clinical Findings
• Pathophysiology of Overt DIC
• Physiopathology of DIC ndash Overt DIC Findings
• Slide Number 57
• Slide Number 58
• Slide Number 59
• Slide Number 60
• Slide Number 61
• BREAK
• Diagnostic and Management Approach for DIC
• Diagnosis of DIC
• Lab Diagnosis of DIC ndash Markers of Factor Consumption
• Lab Diagnosis of DIC ndash Screening Tests
• Slide Number 67
• Slide Number 68
• British Journal of Haematology Overt DIC Score
• Slide Number 70
• Slide Number 71
• Slide Number 72
• Slide Number 73
• DIC Management Goals
• DIC Management and Treatment
• DIC Management Strategies
• Anticoagulant Factor Concentrate Treatment
• Anticoagulant Factor Concentrate Treatment Trials
• Markers of Thrombin amp Plasmin Generation in DIC
• D-dimer FDPs and DIC
• D-Dimer and FDPs in DIC
• Follow Up of DIC State of Disease
• FMD-Dimer in DIC Major Differences
• of Abnormal Results in Patients with Confirmed and Suspected DIC
• Slide Number 85
• Slide Number 86
• Comparing an Automated FM vs Manual FSP Test
• Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Slide Number 98
• Slide Number 99
• DIC Case Studies
• Case Study 1 - Presentation
• Case Study 1 ndash Lab Results
• Case Study 1 ndash Microscopy
• Case Study 1 ndash Diagnosis and Therapy
• Slide Number 105
• Slide Number 106
• Slide Number 107
• Slide Number 108
• Slide Number 109
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Slide Number 113
• Slide Number 114
• Slide Number 115
• Slide Number 116
• Slide Number 117
• Slide Number 118
• Slide Number 119
• Slide Number 120
• Slide Number 121
• Slide Number 122
• Slide Number 123
• Slide Number 124
• Slide Number 125
• DIC Take Home Messages
• Slide Number 127
• Slide Number 128

Critical care transport arranged for 48 year old male admitted to the local hospital 3 days prior with weakness and hypotension Four days prior insect bite while hiking large hematoma on left armNo prior medical history no drug allergies no current medicationsUpon arrival patient is awake and alert in moderate respiratory distress oozing blood from both vascular access sites nose and urinary catheter skin is cool and mildly jaundicedVital signs heart rate 110 beats per minute blood pressure 9244 slightly labored respiratory rate 22 breaths per minute pulse oximetry 91

Case Study 4 ndash Presentation

TEST RESULT REFERENCE RANGEPlatelet count 70 x 109L 150-400 x 109L

PT 28 sec 113 ndash 146 sec

APTT 71 sec 25 ndash 34 sec

D-dimer 31 microgmL FEU lt050 microgml FEU

Fibrinogen 92 mgdL 150-400 mgdl

FV Normal 70-120

FVII Normal 55-170

FVIII Normal 60-150

Protein C Normal 70-130

Hb 158 gdL 14-16 gdL

WBC 71 times 103mm3 40-11 times 103mm3

ALT 60 IUL 0ndash34 IUL

AST 47 IUL 0ndash34 IUL

BUN 38 mgdL 08-13 mgdL

Case Study 4 ndash Lab Results

Lyme disease with DICProvide antibiotics with supportive measures

Case Study 4 ndash Diagnosis

55-year-old man 10 following months after thoracic endovascular aortic repair (TEVAR) multiple ecchymoses diffusely distributed in his torso along with upper and lower extremitiesChronic type B aortic dissection and descending thoracic aortic aneurysmPersistent retrograde flow in false lumen with stable aneurysm diameterFalse lumen embolized with multiple Amplatzer plugs which promoted false lumen thrombosis

Case Study 5 ndash Presentation

Mendes BC Oderich GS Erben Y Reed NR Pruthi RK False Lumen Embolization to Treat Disseminated Intravascular Coagulation After Thoracic Endovascular Aortic Repair of Type B Aortic Dissection Journal of Endovascular Therapy 2015 22 938ndash41

Case Study 5 ndash Lab Results and Time Course

Mendes BC Oderich GS Erben Y Reed NR Pruthi RK False Lumen Embolization to Treat Disseminated Intravascular Coagulation After Thoracic Endovascular Aortic Repair of Type B Aortic Dissection Journal of Endovascular Therapy 2015 22 938ndash41

TEST RESULT REFERENCE RANGE

Platelet count 33 x 109L 150-450 x 109L

PT 215 sec 103 ndash 128 sec

APTT 44 sec 26 ndash 36 sec

D-dimer 20 microgmL FEU lt025 microgml FEU

Fibrinogen 34 mgdL 200-375 mgdl

FII FV FVIII Low Not reported (NR)

FVII FIX FX vWF Normal NR

Improvement in Pltand Fib after false lumen embolization with multiple endovascular plugs(arrows)

DIC secondary to large type Ib endoleakUFH infusion cryoprecipitate partial improvement in platelet count and fibrinogenRare case of DIC following TEVAR (A) 3D CT reconstruction (B) Illustration demonstrating chronic type B aortic

dissection with associated aneurysmal dilatation of the descending thoracic aorta patient treated with TEVAR

(C) Completion angiogram demonstrated patent supra-aortic vessels and thoracic stent-graft no evidence of an antegrade endoleak but persistent distal type Ib endoleak (black arrow) into false lumen

(D) Illustration demonstrating repair

Case Study 5 ndash Diagnosis and Treatment

Mendes BC Oderich GS Erben Y Reed NR Pruthi RK False Lumen Embolization to Treat Disseminated Intravascular Coagulation After Thoracic Endovascular Aortic Repair of Type B Aortic Dissection Journal of Endovascular Therapy 2015 22 938ndash41

29 year old female 50 kg hematuria and epistaxis pregnant 37 weeks no prior prenatal check ups hematuria 10 days priorOn examination blood pressure 200160 started on α-methyldopaShe developed profuse epistaxis controlled after bilateral nasal packinNo history of blurring of vision or epigastric pain denied history of prior abnormal bleeding episodes ingestion of any medication except α-methyldopaExamination revealed pallor and pedal edema controlled with three 5 mg boluses of intravenous labetalolTrachea was electively intubated under midazolam sedation for protection of airway and patient placed on ventilation with oxygen supplementationBaby was monitored using cardiotocography and Doppler ultrasonography

Case Study 6 ndash Presentation

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

Case Study 6 ndash Lab Results

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

TEST RESULT REFERENCE RANGEPlatelet count 109 x 109L 150-400 x 109L

PT 63 sec gt control 113 ndash 146 sec

INR 658 1 ndash 125

APTT 80 sec gt control 25 ndash 34 sec

D-dimer gt200 microgmL DDU 02 microgmL DDU

Urine exam Proteinuria and hematuria 150-400 mgdl

Albumin 28 gdL NR

Hb 58 gdL NR

LDH 1196 UL NR

SGPT 144 IU NR

SGOT 88 IU NR

Bilirubin 32 mgdL NR

DIC complicating hemolysis elevated liver enzymes and low platelets (HELLP) syndrome in preeclampsia was made and C section plannedIntraoperative blood loss replaced with FFP packed red blood cells (RBC) hexastarch and crystalloidsBaby delivered successfullyPostop vaginal bleeding treated with intravenous TXA platelets and FFPPatient remained haemodynamically stable and disharged on the 10th

day postop

Case Study 6 ndash Diagnosis and Treatment

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

HELLP syndrome complicates 02 ndash06 of all pregnancies 4ndash12 of cases with severe preeclampsia and 30ndash50 of eclamptic gravidasMaternal and neonatal mortality 2ndash24 and 3ndash39 respectively HELLP syndrome may progress to DIC in 15ndash38 of patientsPatients with HELLP syndrome are at increased risk of abruptio placentae pulmonary edema ruptured liver hematoma acute renal failure cerebrovascular accident and multiorgan failure

Case Study 6 ndash Discussion

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

44-year-old man with history of hepatitis C cirrhosis and chronic kidney disease presents to ED for altered mental status and ammonia level gt 500 mM (RR 11-51 mM)Patient was given lactulose however his mental status worsened to require intubationVital signs on admission to ICU on Oct 23 BP 12084 heart rate 107 beatsmin respiratory rate 18min temperature 978 degF

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 23 patient started on vancomycin piperacillintazobactam and fluids because of concern for sepsis associated with systemic inflammatory response syndrome (SIRS) and multiorgan failure as well as laboratory values showing a high WBC count and elevated lactate of 8 mM (RR 05-16mmolL)Vital signs worsened over next 24 hours became hypotensive requiring treatment with norepinephrine and 6 L of normal saline on Oct 24Renal function continued to decline received continuous renal replacement therapy on Oct 25

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Case Study 7 ndash Lab Results vs Time

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Lab values from Oct 25 consistent with DIC given packed RBCs FFP cryo plts and vit K to treat peritoneal bleeding which stopped by Oct 26Over next few days continued to require norepinephrine but eventually vital signs and laboratory values stabilizedDuring next few days improvement was apparent but found to have multiple infections including vancomycin-resistant enterococcus (VRE) along with Stenotrophomonas maltophilia peritoneal fluid growing Acinetobacter and urinalysis growing Candida glabrata

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 29 started on daptomycin linezolid trimethoprimsulfamethoxazole and fluconazole vancomycin and piperacillintazobactam were discontinuedHemodynamically stable taken off pressors and extubated on Nov 1In process of transfer from ICU became obtunded and hypotensive onFFP cryo platelets and packed RBCs were ordered but patient went into cardiac arrest and passed away

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

DIC Take Home Messages

Heterogeneous rapidly fatal syndromeEtiology sepsis tumors injuries or obstetric complicationsSimultaneous activation of coagulation and fibrinolysis Consumption of factors anticoagulant proteins fibrinogen and plateletsDiagnosis not with a single test panel including activation markers Screening coags platelets FMFS and D-dimer 1st consideration treat the critical symptoms and underlying issue 2nd consideration compensation for the consumption and sometimes anticoagulation

Monitor efficacy of therapy Activation markers (D-Dimer FMFSP) Normalization of coagulation markers

DIC

Thank you Questions

• Disseminated Intravascular Coagulation (DIC) and Thrombosis The Critical Role of the Lab
• Learning Objectives
• Slide Number 3
• Slide Number 4
• Slide Number 5
• Slide Number 6
• Slide Number 7
• Slide Number 8
• Wound Sealing
• The Three Steps of Hemostasis
• Vessel Wall
• Slide Number 12
• Slide Number 13
• Platelet Structure UnactivatedActivated
• Primary Hemostasis
• Primary Hemostasis Assays
• Slide Number 17
• Coagulation is a balance between pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis
• Slide Number 19
• Coagulation factors
• Coagulation Assay Mechanisms
• Slide Number 22
• Fibrin Formation
• Slide Number 24
• Fibrinolysis Overview
• Fibrinolysis Overview
• Slide Number 27
• Fibrinolysis Releases D-dimers
• Basic Pathophysiology of DIC
• Disseminated Intravascular Coagulation (DIC)
• Purpura Fulminans with DIC Due to Meningococcal Sepsis
• Clinical Conditions Associated With DIC
• Frequency of DIC in Selected Disease States
• Underlying Diseases in DIC Patients
• Slide Number 36
• Slide Number 37
• Slide Number 38
• Slide Number 39
• Pathophysiology of DIC
• Pathogenesis of DIC in Sepsis
• Host Response in Severe Sepsis
• Organ Failure in Severe Sepsis
• Mechanism of DIC in Organ Failure
• Interaction of Inflammation and Coagulation in Sepsis
• Slide Number 47
• Diverse and Opposing Effects of Thrombin
• Coagulation and Fibrinolysis in DIC
• Mechanism of DIC
• Pathophysiology of DIC
• Pathophysiology of DIC - Mechanism
• Pathophysiology of DIC ndash 2 Types of Clinical pictures
• Sub-Acute and Non-Overt DIC Clinical Findings
• Pathophysiology of Overt DIC
• Physiopathology of DIC ndash Overt DIC Findings
• Slide Number 57
• Slide Number 58
• Slide Number 59
• Slide Number 60
• Slide Number 61
• BREAK
• Diagnostic and Management Approach for DIC
• Diagnosis of DIC
• Lab Diagnosis of DIC ndash Markers of Factor Consumption
• Lab Diagnosis of DIC ndash Screening Tests
• Slide Number 67
• Slide Number 68
• British Journal of Haematology Overt DIC Score
• Slide Number 70
• Slide Number 71
• Slide Number 72
• Slide Number 73
• DIC Management Goals
• DIC Management and Treatment
• DIC Management Strategies
• Anticoagulant Factor Concentrate Treatment
• Anticoagulant Factor Concentrate Treatment Trials
• Markers of Thrombin amp Plasmin Generation in DIC
• D-dimer FDPs and DIC
• D-Dimer and FDPs in DIC
• Follow Up of DIC State of Disease
• FMD-Dimer in DIC Major Differences
• of Abnormal Results in Patients with Confirmed and Suspected DIC
• Slide Number 85
• Slide Number 86
• Comparing an Automated FM vs Manual FSP Test
• Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Slide Number 98
• Slide Number 99
• DIC Case Studies
• Case Study 1 - Presentation
• Case Study 1 ndash Lab Results
• Case Study 1 ndash Microscopy
• Case Study 1 ndash Diagnosis and Therapy
• Slide Number 105
• Slide Number 106
• Slide Number 107
• Slide Number 108
• Slide Number 109
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Slide Number 113
• Slide Number 114
• Slide Number 115
• Slide Number 116
• Slide Number 117
• Slide Number 118
• Slide Number 119
• Slide Number 120
• Slide Number 121
• Slide Number 122
• Slide Number 123
• Slide Number 124
• Slide Number 125
• DIC Take Home Messages
• Slide Number 127
• Slide Number 128

TEST RESULT REFERENCE RANGEPlatelet count 70 x 109L 150-400 x 109L

PT 28 sec 113 ndash 146 sec

APTT 71 sec 25 ndash 34 sec

D-dimer 31 microgmL FEU lt050 microgml FEU

Fibrinogen 92 mgdL 150-400 mgdl

FV Normal 70-120

FVII Normal 55-170

FVIII Normal 60-150

Protein C Normal 70-130

Hb 158 gdL 14-16 gdL

WBC 71 times 103mm3 40-11 times 103mm3

ALT 60 IUL 0ndash34 IUL

AST 47 IUL 0ndash34 IUL

BUN 38 mgdL 08-13 mgdL

Case Study 4 ndash Lab Results

Lyme disease with DICProvide antibiotics with supportive measures

Case Study 4 ndash Diagnosis

55-year-old man 10 following months after thoracic endovascular aortic repair (TEVAR) multiple ecchymoses diffusely distributed in his torso along with upper and lower extremitiesChronic type B aortic dissection and descending thoracic aortic aneurysmPersistent retrograde flow in false lumen with stable aneurysm diameterFalse lumen embolized with multiple Amplatzer plugs which promoted false lumen thrombosis

Case Study 5 ndash Presentation

Mendes BC Oderich GS Erben Y Reed NR Pruthi RK False Lumen Embolization to Treat Disseminated Intravascular Coagulation After Thoracic Endovascular Aortic Repair of Type B Aortic Dissection Journal of Endovascular Therapy 2015 22 938ndash41

Case Study 5 ndash Lab Results and Time Course

Mendes BC Oderich GS Erben Y Reed NR Pruthi RK False Lumen Embolization to Treat Disseminated Intravascular Coagulation After Thoracic Endovascular Aortic Repair of Type B Aortic Dissection Journal of Endovascular Therapy 2015 22 938ndash41

TEST RESULT REFERENCE RANGE

Platelet count 33 x 109L 150-450 x 109L

PT 215 sec 103 ndash 128 sec

APTT 44 sec 26 ndash 36 sec

D-dimer 20 microgmL FEU lt025 microgml FEU

Fibrinogen 34 mgdL 200-375 mgdl

FII FV FVIII Low Not reported (NR)

FVII FIX FX vWF Normal NR

Improvement in Pltand Fib after false lumen embolization with multiple endovascular plugs(arrows)

DIC secondary to large type Ib endoleakUFH infusion cryoprecipitate partial improvement in platelet count and fibrinogenRare case of DIC following TEVAR (A) 3D CT reconstruction (B) Illustration demonstrating chronic type B aortic

dissection with associated aneurysmal dilatation of the descending thoracic aorta patient treated with TEVAR

(C) Completion angiogram demonstrated patent supra-aortic vessels and thoracic stent-graft no evidence of an antegrade endoleak but persistent distal type Ib endoleak (black arrow) into false lumen

(D) Illustration demonstrating repair

Case Study 5 ndash Diagnosis and Treatment

Mendes BC Oderich GS Erben Y Reed NR Pruthi RK False Lumen Embolization to Treat Disseminated Intravascular Coagulation After Thoracic Endovascular Aortic Repair of Type B Aortic Dissection Journal of Endovascular Therapy 2015 22 938ndash41

29 year old female 50 kg hematuria and epistaxis pregnant 37 weeks no prior prenatal check ups hematuria 10 days priorOn examination blood pressure 200160 started on α-methyldopaShe developed profuse epistaxis controlled after bilateral nasal packinNo history of blurring of vision or epigastric pain denied history of prior abnormal bleeding episodes ingestion of any medication except α-methyldopaExamination revealed pallor and pedal edema controlled with three 5 mg boluses of intravenous labetalolTrachea was electively intubated under midazolam sedation for protection of airway and patient placed on ventilation with oxygen supplementationBaby was monitored using cardiotocography and Doppler ultrasonography

Case Study 6 ndash Presentation

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

Case Study 6 ndash Lab Results

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

TEST RESULT REFERENCE RANGEPlatelet count 109 x 109L 150-400 x 109L

PT 63 sec gt control 113 ndash 146 sec

INR 658 1 ndash 125

APTT 80 sec gt control 25 ndash 34 sec

D-dimer gt200 microgmL DDU 02 microgmL DDU

Urine exam Proteinuria and hematuria 150-400 mgdl

Albumin 28 gdL NR

Hb 58 gdL NR

LDH 1196 UL NR

SGPT 144 IU NR

SGOT 88 IU NR

Bilirubin 32 mgdL NR

DIC complicating hemolysis elevated liver enzymes and low platelets (HELLP) syndrome in preeclampsia was made and C section plannedIntraoperative blood loss replaced with FFP packed red blood cells (RBC) hexastarch and crystalloidsBaby delivered successfullyPostop vaginal bleeding treated with intravenous TXA platelets and FFPPatient remained haemodynamically stable and disharged on the 10th

day postop

Case Study 6 ndash Diagnosis and Treatment

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

HELLP syndrome complicates 02 ndash06 of all pregnancies 4ndash12 of cases with severe preeclampsia and 30ndash50 of eclamptic gravidasMaternal and neonatal mortality 2ndash24 and 3ndash39 respectively HELLP syndrome may progress to DIC in 15ndash38 of patientsPatients with HELLP syndrome are at increased risk of abruptio placentae pulmonary edema ruptured liver hematoma acute renal failure cerebrovascular accident and multiorgan failure

Case Study 6 ndash Discussion

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

44-year-old man with history of hepatitis C cirrhosis and chronic kidney disease presents to ED for altered mental status and ammonia level gt 500 mM (RR 11-51 mM)Patient was given lactulose however his mental status worsened to require intubationVital signs on admission to ICU on Oct 23 BP 12084 heart rate 107 beatsmin respiratory rate 18min temperature 978 degF

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 23 patient started on vancomycin piperacillintazobactam and fluids because of concern for sepsis associated with systemic inflammatory response syndrome (SIRS) and multiorgan failure as well as laboratory values showing a high WBC count and elevated lactate of 8 mM (RR 05-16mmolL)Vital signs worsened over next 24 hours became hypotensive requiring treatment with norepinephrine and 6 L of normal saline on Oct 24Renal function continued to decline received continuous renal replacement therapy on Oct 25

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Case Study 7 ndash Lab Results vs Time

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Lab values from Oct 25 consistent with DIC given packed RBCs FFP cryo plts and vit K to treat peritoneal bleeding which stopped by Oct 26Over next few days continued to require norepinephrine but eventually vital signs and laboratory values stabilizedDuring next few days improvement was apparent but found to have multiple infections including vancomycin-resistant enterococcus (VRE) along with Stenotrophomonas maltophilia peritoneal fluid growing Acinetobacter and urinalysis growing Candida glabrata

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 29 started on daptomycin linezolid trimethoprimsulfamethoxazole and fluconazole vancomycin and piperacillintazobactam were discontinuedHemodynamically stable taken off pressors and extubated on Nov 1In process of transfer from ICU became obtunded and hypotensive onFFP cryo platelets and packed RBCs were ordered but patient went into cardiac arrest and passed away

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

DIC Take Home Messages

Heterogeneous rapidly fatal syndromeEtiology sepsis tumors injuries or obstetric complicationsSimultaneous activation of coagulation and fibrinolysis Consumption of factors anticoagulant proteins fibrinogen and plateletsDiagnosis not with a single test panel including activation markers Screening coags platelets FMFS and D-dimer 1st consideration treat the critical symptoms and underlying issue 2nd consideration compensation for the consumption and sometimes anticoagulation

Monitor efficacy of therapy Activation markers (D-Dimer FMFSP) Normalization of coagulation markers

DIC

Thank you Questions

• Disseminated Intravascular Coagulation (DIC) and Thrombosis The Critical Role of the Lab
• Learning Objectives
• Slide Number 3
• Slide Number 4
• Slide Number 5
• Slide Number 6
• Slide Number 7
• Slide Number 8
• Wound Sealing
• The Three Steps of Hemostasis
• Vessel Wall
• Slide Number 12
• Slide Number 13
• Platelet Structure UnactivatedActivated
• Primary Hemostasis
• Primary Hemostasis Assays
• Slide Number 17
• Coagulation is a balance between pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis
• Slide Number 19
• Coagulation factors
• Coagulation Assay Mechanisms
• Slide Number 22
• Fibrin Formation
• Slide Number 24
• Fibrinolysis Overview
• Fibrinolysis Overview
• Slide Number 27
• Fibrinolysis Releases D-dimers
• Basic Pathophysiology of DIC
• Disseminated Intravascular Coagulation (DIC)
• Purpura Fulminans with DIC Due to Meningococcal Sepsis
• Clinical Conditions Associated With DIC
• Frequency of DIC in Selected Disease States
• Underlying Diseases in DIC Patients
• Slide Number 36
• Slide Number 37
• Slide Number 38
• Slide Number 39
• Pathophysiology of DIC
• Pathogenesis of DIC in Sepsis
• Host Response in Severe Sepsis
• Organ Failure in Severe Sepsis
• Mechanism of DIC in Organ Failure
• Interaction of Inflammation and Coagulation in Sepsis
• Slide Number 47
• Diverse and Opposing Effects of Thrombin
• Coagulation and Fibrinolysis in DIC
• Mechanism of DIC
• Pathophysiology of DIC
• Pathophysiology of DIC - Mechanism
• Pathophysiology of DIC ndash 2 Types of Clinical pictures
• Sub-Acute and Non-Overt DIC Clinical Findings
• Pathophysiology of Overt DIC
• Physiopathology of DIC ndash Overt DIC Findings
• Slide Number 57
• Slide Number 58
• Slide Number 59
• Slide Number 60
• Slide Number 61
• BREAK
• Diagnostic and Management Approach for DIC
• Diagnosis of DIC
• Lab Diagnosis of DIC ndash Markers of Factor Consumption
• Lab Diagnosis of DIC ndash Screening Tests
• Slide Number 67
• Slide Number 68
• British Journal of Haematology Overt DIC Score
• Slide Number 70
• Slide Number 71
• Slide Number 72
• Slide Number 73
• DIC Management Goals
• DIC Management and Treatment
• DIC Management Strategies
• Anticoagulant Factor Concentrate Treatment
• Anticoagulant Factor Concentrate Treatment Trials
• Markers of Thrombin amp Plasmin Generation in DIC
• D-dimer FDPs and DIC
• D-Dimer and FDPs in DIC
• Follow Up of DIC State of Disease
• FMD-Dimer in DIC Major Differences
• of Abnormal Results in Patients with Confirmed and Suspected DIC
• Slide Number 85
• Slide Number 86
• Comparing an Automated FM vs Manual FSP Test
• Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Slide Number 98
• Slide Number 99
• DIC Case Studies
• Case Study 1 - Presentation
• Case Study 1 ndash Lab Results
• Case Study 1 ndash Microscopy
• Case Study 1 ndash Diagnosis and Therapy
• Slide Number 105
• Slide Number 106
• Slide Number 107
• Slide Number 108
• Slide Number 109
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Slide Number 113
• Slide Number 114
• Slide Number 115
• Slide Number 116
• Slide Number 117
• Slide Number 118
• Slide Number 119
• Slide Number 120
• Slide Number 121
• Slide Number 122
• Slide Number 123
• Slide Number 124
• Slide Number 125
• DIC Take Home Messages
• Slide Number 127
• Slide Number 128

Lyme disease with DICProvide antibiotics with supportive measures

Case Study 4 ndash Diagnosis

55-year-old man 10 following months after thoracic endovascular aortic repair (TEVAR) multiple ecchymoses diffusely distributed in his torso along with upper and lower extremitiesChronic type B aortic dissection and descending thoracic aortic aneurysmPersistent retrograde flow in false lumen with stable aneurysm diameterFalse lumen embolized with multiple Amplatzer plugs which promoted false lumen thrombosis

Case Study 5 ndash Presentation

Mendes BC Oderich GS Erben Y Reed NR Pruthi RK False Lumen Embolization to Treat Disseminated Intravascular Coagulation After Thoracic Endovascular Aortic Repair of Type B Aortic Dissection Journal of Endovascular Therapy 2015 22 938ndash41

Case Study 5 ndash Lab Results and Time Course

Mendes BC Oderich GS Erben Y Reed NR Pruthi RK False Lumen Embolization to Treat Disseminated Intravascular Coagulation After Thoracic Endovascular Aortic Repair of Type B Aortic Dissection Journal of Endovascular Therapy 2015 22 938ndash41

TEST RESULT REFERENCE RANGE

Platelet count 33 x 109L 150-450 x 109L

PT 215 sec 103 ndash 128 sec

APTT 44 sec 26 ndash 36 sec

D-dimer 20 microgmL FEU lt025 microgml FEU

Fibrinogen 34 mgdL 200-375 mgdl

FII FV FVIII Low Not reported (NR)

FVII FIX FX vWF Normal NR

Improvement in Pltand Fib after false lumen embolization with multiple endovascular plugs(arrows)

DIC secondary to large type Ib endoleakUFH infusion cryoprecipitate partial improvement in platelet count and fibrinogenRare case of DIC following TEVAR (A) 3D CT reconstruction (B) Illustration demonstrating chronic type B aortic

dissection with associated aneurysmal dilatation of the descending thoracic aorta patient treated with TEVAR

(C) Completion angiogram demonstrated patent supra-aortic vessels and thoracic stent-graft no evidence of an antegrade endoleak but persistent distal type Ib endoleak (black arrow) into false lumen

(D) Illustration demonstrating repair

Case Study 5 ndash Diagnosis and Treatment

Mendes BC Oderich GS Erben Y Reed NR Pruthi RK False Lumen Embolization to Treat Disseminated Intravascular Coagulation After Thoracic Endovascular Aortic Repair of Type B Aortic Dissection Journal of Endovascular Therapy 2015 22 938ndash41

29 year old female 50 kg hematuria and epistaxis pregnant 37 weeks no prior prenatal check ups hematuria 10 days priorOn examination blood pressure 200160 started on α-methyldopaShe developed profuse epistaxis controlled after bilateral nasal packinNo history of blurring of vision or epigastric pain denied history of prior abnormal bleeding episodes ingestion of any medication except α-methyldopaExamination revealed pallor and pedal edema controlled with three 5 mg boluses of intravenous labetalolTrachea was electively intubated under midazolam sedation for protection of airway and patient placed on ventilation with oxygen supplementationBaby was monitored using cardiotocography and Doppler ultrasonography

Case Study 6 ndash Presentation

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

Case Study 6 ndash Lab Results

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

TEST RESULT REFERENCE RANGEPlatelet count 109 x 109L 150-400 x 109L

PT 63 sec gt control 113 ndash 146 sec

INR 658 1 ndash 125

APTT 80 sec gt control 25 ndash 34 sec

D-dimer gt200 microgmL DDU 02 microgmL DDU

Urine exam Proteinuria and hematuria 150-400 mgdl

Albumin 28 gdL NR

Hb 58 gdL NR

LDH 1196 UL NR

SGPT 144 IU NR

SGOT 88 IU NR

Bilirubin 32 mgdL NR

DIC complicating hemolysis elevated liver enzymes and low platelets (HELLP) syndrome in preeclampsia was made and C section plannedIntraoperative blood loss replaced with FFP packed red blood cells (RBC) hexastarch and crystalloidsBaby delivered successfullyPostop vaginal bleeding treated with intravenous TXA platelets and FFPPatient remained haemodynamically stable and disharged on the 10th

day postop

Case Study 6 ndash Diagnosis and Treatment

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

HELLP syndrome complicates 02 ndash06 of all pregnancies 4ndash12 of cases with severe preeclampsia and 30ndash50 of eclamptic gravidasMaternal and neonatal mortality 2ndash24 and 3ndash39 respectively HELLP syndrome may progress to DIC in 15ndash38 of patientsPatients with HELLP syndrome are at increased risk of abruptio placentae pulmonary edema ruptured liver hematoma acute renal failure cerebrovascular accident and multiorgan failure

Case Study 6 ndash Discussion

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

44-year-old man with history of hepatitis C cirrhosis and chronic kidney disease presents to ED for altered mental status and ammonia level gt 500 mM (RR 11-51 mM)Patient was given lactulose however his mental status worsened to require intubationVital signs on admission to ICU on Oct 23 BP 12084 heart rate 107 beatsmin respiratory rate 18min temperature 978 degF

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 23 patient started on vancomycin piperacillintazobactam and fluids because of concern for sepsis associated with systemic inflammatory response syndrome (SIRS) and multiorgan failure as well as laboratory values showing a high WBC count and elevated lactate of 8 mM (RR 05-16mmolL)Vital signs worsened over next 24 hours became hypotensive requiring treatment with norepinephrine and 6 L of normal saline on Oct 24Renal function continued to decline received continuous renal replacement therapy on Oct 25

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Case Study 7 ndash Lab Results vs Time

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Lab values from Oct 25 consistent with DIC given packed RBCs FFP cryo plts and vit K to treat peritoneal bleeding which stopped by Oct 26Over next few days continued to require norepinephrine but eventually vital signs and laboratory values stabilizedDuring next few days improvement was apparent but found to have multiple infections including vancomycin-resistant enterococcus (VRE) along with Stenotrophomonas maltophilia peritoneal fluid growing Acinetobacter and urinalysis growing Candida glabrata

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 29 started on daptomycin linezolid trimethoprimsulfamethoxazole and fluconazole vancomycin and piperacillintazobactam were discontinuedHemodynamically stable taken off pressors and extubated on Nov 1In process of transfer from ICU became obtunded and hypotensive onFFP cryo platelets and packed RBCs were ordered but patient went into cardiac arrest and passed away

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

DIC Take Home Messages

Heterogeneous rapidly fatal syndromeEtiology sepsis tumors injuries or obstetric complicationsSimultaneous activation of coagulation and fibrinolysis Consumption of factors anticoagulant proteins fibrinogen and plateletsDiagnosis not with a single test panel including activation markers Screening coags platelets FMFS and D-dimer 1st consideration treat the critical symptoms and underlying issue 2nd consideration compensation for the consumption and sometimes anticoagulation

Monitor efficacy of therapy Activation markers (D-Dimer FMFSP) Normalization of coagulation markers

DIC

Thank you Questions

• Disseminated Intravascular Coagulation (DIC) and Thrombosis The Critical Role of the Lab
• Learning Objectives
• Slide Number 3
• Slide Number 4
• Slide Number 5
• Slide Number 6
• Slide Number 7
• Slide Number 8
• Wound Sealing
• The Three Steps of Hemostasis
• Vessel Wall
• Slide Number 12
• Slide Number 13
• Platelet Structure UnactivatedActivated
• Primary Hemostasis
• Primary Hemostasis Assays
• Slide Number 17
• Coagulation is a balance between pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis
• Slide Number 19
• Coagulation factors
• Coagulation Assay Mechanisms
• Slide Number 22
• Fibrin Formation
• Slide Number 24
• Fibrinolysis Overview
• Fibrinolysis Overview
• Slide Number 27
• Fibrinolysis Releases D-dimers
• Basic Pathophysiology of DIC
• Disseminated Intravascular Coagulation (DIC)
• Purpura Fulminans with DIC Due to Meningococcal Sepsis
• Clinical Conditions Associated With DIC
• Frequency of DIC in Selected Disease States
• Underlying Diseases in DIC Patients
• Slide Number 36
• Slide Number 37
• Slide Number 38
• Slide Number 39
• Pathophysiology of DIC
• Pathogenesis of DIC in Sepsis
• Host Response in Severe Sepsis
• Organ Failure in Severe Sepsis
• Mechanism of DIC in Organ Failure
• Interaction of Inflammation and Coagulation in Sepsis
• Slide Number 47
• Diverse and Opposing Effects of Thrombin
• Coagulation and Fibrinolysis in DIC
• Mechanism of DIC
• Pathophysiology of DIC
• Pathophysiology of DIC - Mechanism
• Pathophysiology of DIC ndash 2 Types of Clinical pictures
• Sub-Acute and Non-Overt DIC Clinical Findings
• Pathophysiology of Overt DIC
• Physiopathology of DIC ndash Overt DIC Findings
• Slide Number 57
• Slide Number 58
• Slide Number 59
• Slide Number 60
• Slide Number 61
• BREAK
• Diagnostic and Management Approach for DIC
• Diagnosis of DIC
• Lab Diagnosis of DIC ndash Markers of Factor Consumption
• Lab Diagnosis of DIC ndash Screening Tests
• Slide Number 67
• Slide Number 68
• British Journal of Haematology Overt DIC Score
• Slide Number 70
• Slide Number 71
• Slide Number 72
• Slide Number 73
• DIC Management Goals
• DIC Management and Treatment
• DIC Management Strategies
• Anticoagulant Factor Concentrate Treatment
• Anticoagulant Factor Concentrate Treatment Trials
• Markers of Thrombin amp Plasmin Generation in DIC
• D-dimer FDPs and DIC
• D-Dimer and FDPs in DIC
• Follow Up of DIC State of Disease
• FMD-Dimer in DIC Major Differences
• of Abnormal Results in Patients with Confirmed and Suspected DIC
• Slide Number 85
• Slide Number 86
• Comparing an Automated FM vs Manual FSP Test
• Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Slide Number 98
• Slide Number 99
• DIC Case Studies
• Case Study 1 - Presentation
• Case Study 1 ndash Lab Results
• Case Study 1 ndash Microscopy
• Case Study 1 ndash Diagnosis and Therapy
• Slide Number 105
• Slide Number 106
• Slide Number 107
• Slide Number 108
• Slide Number 109
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Slide Number 113
• Slide Number 114
• Slide Number 115
• Slide Number 116
• Slide Number 117
• Slide Number 118
• Slide Number 119
• Slide Number 120
• Slide Number 121
• Slide Number 122
• Slide Number 123
• Slide Number 124
• Slide Number 125
• DIC Take Home Messages
• Slide Number 127
• Slide Number 128

55-year-old man 10 following months after thoracic endovascular aortic repair (TEVAR) multiple ecchymoses diffusely distributed in his torso along with upper and lower extremitiesChronic type B aortic dissection and descending thoracic aortic aneurysmPersistent retrograde flow in false lumen with stable aneurysm diameterFalse lumen embolized with multiple Amplatzer plugs which promoted false lumen thrombosis

Case Study 5 ndash Presentation

Mendes BC Oderich GS Erben Y Reed NR Pruthi RK False Lumen Embolization to Treat Disseminated Intravascular Coagulation After Thoracic Endovascular Aortic Repair of Type B Aortic Dissection Journal of Endovascular Therapy 2015 22 938ndash41

Case Study 5 ndash Lab Results and Time Course

Mendes BC Oderich GS Erben Y Reed NR Pruthi RK False Lumen Embolization to Treat Disseminated Intravascular Coagulation After Thoracic Endovascular Aortic Repair of Type B Aortic Dissection Journal of Endovascular Therapy 2015 22 938ndash41

TEST RESULT REFERENCE RANGE

Platelet count 33 x 109L 150-450 x 109L

PT 215 sec 103 ndash 128 sec

APTT 44 sec 26 ndash 36 sec

D-dimer 20 microgmL FEU lt025 microgml FEU

Fibrinogen 34 mgdL 200-375 mgdl

FII FV FVIII Low Not reported (NR)

FVII FIX FX vWF Normal NR

Improvement in Pltand Fib after false lumen embolization with multiple endovascular plugs(arrows)

DIC secondary to large type Ib endoleakUFH infusion cryoprecipitate partial improvement in platelet count and fibrinogenRare case of DIC following TEVAR (A) 3D CT reconstruction (B) Illustration demonstrating chronic type B aortic

dissection with associated aneurysmal dilatation of the descending thoracic aorta patient treated with TEVAR

(C) Completion angiogram demonstrated patent supra-aortic vessels and thoracic stent-graft no evidence of an antegrade endoleak but persistent distal type Ib endoleak (black arrow) into false lumen

(D) Illustration demonstrating repair

Case Study 5 ndash Diagnosis and Treatment

Mendes BC Oderich GS Erben Y Reed NR Pruthi RK False Lumen Embolization to Treat Disseminated Intravascular Coagulation After Thoracic Endovascular Aortic Repair of Type B Aortic Dissection Journal of Endovascular Therapy 2015 22 938ndash41

29 year old female 50 kg hematuria and epistaxis pregnant 37 weeks no prior prenatal check ups hematuria 10 days priorOn examination blood pressure 200160 started on α-methyldopaShe developed profuse epistaxis controlled after bilateral nasal packinNo history of blurring of vision or epigastric pain denied history of prior abnormal bleeding episodes ingestion of any medication except α-methyldopaExamination revealed pallor and pedal edema controlled with three 5 mg boluses of intravenous labetalolTrachea was electively intubated under midazolam sedation for protection of airway and patient placed on ventilation with oxygen supplementationBaby was monitored using cardiotocography and Doppler ultrasonography

Case Study 6 ndash Presentation

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

Case Study 6 ndash Lab Results

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

TEST RESULT REFERENCE RANGEPlatelet count 109 x 109L 150-400 x 109L

PT 63 sec gt control 113 ndash 146 sec

INR 658 1 ndash 125

APTT 80 sec gt control 25 ndash 34 sec

D-dimer gt200 microgmL DDU 02 microgmL DDU

Urine exam Proteinuria and hematuria 150-400 mgdl

Albumin 28 gdL NR

Hb 58 gdL NR

LDH 1196 UL NR

SGPT 144 IU NR

SGOT 88 IU NR

Bilirubin 32 mgdL NR

DIC complicating hemolysis elevated liver enzymes and low platelets (HELLP) syndrome in preeclampsia was made and C section plannedIntraoperative blood loss replaced with FFP packed red blood cells (RBC) hexastarch and crystalloidsBaby delivered successfullyPostop vaginal bleeding treated with intravenous TXA platelets and FFPPatient remained haemodynamically stable and disharged on the 10th

day postop

Case Study 6 ndash Diagnosis and Treatment

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

HELLP syndrome complicates 02 ndash06 of all pregnancies 4ndash12 of cases with severe preeclampsia and 30ndash50 of eclamptic gravidasMaternal and neonatal mortality 2ndash24 and 3ndash39 respectively HELLP syndrome may progress to DIC in 15ndash38 of patientsPatients with HELLP syndrome are at increased risk of abruptio placentae pulmonary edema ruptured liver hematoma acute renal failure cerebrovascular accident and multiorgan failure

Case Study 6 ndash Discussion

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

44-year-old man with history of hepatitis C cirrhosis and chronic kidney disease presents to ED for altered mental status and ammonia level gt 500 mM (RR 11-51 mM)Patient was given lactulose however his mental status worsened to require intubationVital signs on admission to ICU on Oct 23 BP 12084 heart rate 107 beatsmin respiratory rate 18min temperature 978 degF

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 23 patient started on vancomycin piperacillintazobactam and fluids because of concern for sepsis associated with systemic inflammatory response syndrome (SIRS) and multiorgan failure as well as laboratory values showing a high WBC count and elevated lactate of 8 mM (RR 05-16mmolL)Vital signs worsened over next 24 hours became hypotensive requiring treatment with norepinephrine and 6 L of normal saline on Oct 24Renal function continued to decline received continuous renal replacement therapy on Oct 25

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Case Study 7 ndash Lab Results vs Time

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Lab values from Oct 25 consistent with DIC given packed RBCs FFP cryo plts and vit K to treat peritoneal bleeding which stopped by Oct 26Over next few days continued to require norepinephrine but eventually vital signs and laboratory values stabilizedDuring next few days improvement was apparent but found to have multiple infections including vancomycin-resistant enterococcus (VRE) along with Stenotrophomonas maltophilia peritoneal fluid growing Acinetobacter and urinalysis growing Candida glabrata

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 29 started on daptomycin linezolid trimethoprimsulfamethoxazole and fluconazole vancomycin and piperacillintazobactam were discontinuedHemodynamically stable taken off pressors and extubated on Nov 1In process of transfer from ICU became obtunded and hypotensive onFFP cryo platelets and packed RBCs were ordered but patient went into cardiac arrest and passed away

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

DIC Take Home Messages

Heterogeneous rapidly fatal syndromeEtiology sepsis tumors injuries or obstetric complicationsSimultaneous activation of coagulation and fibrinolysis Consumption of factors anticoagulant proteins fibrinogen and plateletsDiagnosis not with a single test panel including activation markers Screening coags platelets FMFS and D-dimer 1st consideration treat the critical symptoms and underlying issue 2nd consideration compensation for the consumption and sometimes anticoagulation

Monitor efficacy of therapy Activation markers (D-Dimer FMFSP) Normalization of coagulation markers

DIC

Thank you Questions

• Disseminated Intravascular Coagulation (DIC) and Thrombosis The Critical Role of the Lab
• Learning Objectives
• Slide Number 3
• Slide Number 4
• Slide Number 5
• Slide Number 6
• Slide Number 7
• Slide Number 8
• Wound Sealing
• The Three Steps of Hemostasis
• Vessel Wall
• Slide Number 12
• Slide Number 13
• Platelet Structure UnactivatedActivated
• Primary Hemostasis
• Primary Hemostasis Assays
• Slide Number 17
• Coagulation is a balance between pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis
• Slide Number 19
• Coagulation factors
• Coagulation Assay Mechanisms
• Slide Number 22
• Fibrin Formation
• Slide Number 24
• Fibrinolysis Overview
• Fibrinolysis Overview
• Slide Number 27
• Fibrinolysis Releases D-dimers
• Basic Pathophysiology of DIC
• Disseminated Intravascular Coagulation (DIC)
• Purpura Fulminans with DIC Due to Meningococcal Sepsis
• Clinical Conditions Associated With DIC
• Frequency of DIC in Selected Disease States
• Underlying Diseases in DIC Patients
• Slide Number 36
• Slide Number 37
• Slide Number 38
• Slide Number 39
• Pathophysiology of DIC
• Pathogenesis of DIC in Sepsis
• Host Response in Severe Sepsis
• Organ Failure in Severe Sepsis
• Mechanism of DIC in Organ Failure
• Interaction of Inflammation and Coagulation in Sepsis
• Slide Number 47
• Diverse and Opposing Effects of Thrombin
• Coagulation and Fibrinolysis in DIC
• Mechanism of DIC
• Pathophysiology of DIC
• Pathophysiology of DIC - Mechanism
• Pathophysiology of DIC ndash 2 Types of Clinical pictures
• Sub-Acute and Non-Overt DIC Clinical Findings
• Pathophysiology of Overt DIC
• Physiopathology of DIC ndash Overt DIC Findings
• Slide Number 57
• Slide Number 58
• Slide Number 59
• Slide Number 60
• Slide Number 61
• BREAK
• Diagnostic and Management Approach for DIC
• Diagnosis of DIC
• Lab Diagnosis of DIC ndash Markers of Factor Consumption
• Lab Diagnosis of DIC ndash Screening Tests
• Slide Number 67
• Slide Number 68
• British Journal of Haematology Overt DIC Score
• Slide Number 70
• Slide Number 71
• Slide Number 72
• Slide Number 73
• DIC Management Goals
• DIC Management and Treatment
• DIC Management Strategies
• Anticoagulant Factor Concentrate Treatment
• Anticoagulant Factor Concentrate Treatment Trials
• Markers of Thrombin amp Plasmin Generation in DIC
• D-dimer FDPs and DIC
• D-Dimer and FDPs in DIC
• Follow Up of DIC State of Disease
• FMD-Dimer in DIC Major Differences
• of Abnormal Results in Patients with Confirmed and Suspected DIC
• Slide Number 85
• Slide Number 86
• Comparing an Automated FM vs Manual FSP Test
• Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Slide Number 98
• Slide Number 99
• DIC Case Studies
• Case Study 1 - Presentation
• Case Study 1 ndash Lab Results
• Case Study 1 ndash Microscopy
• Case Study 1 ndash Diagnosis and Therapy
• Slide Number 105
• Slide Number 106
• Slide Number 107
• Slide Number 108
• Slide Number 109
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Slide Number 113
• Slide Number 114
• Slide Number 115
• Slide Number 116
• Slide Number 117
• Slide Number 118
• Slide Number 119
• Slide Number 120
• Slide Number 121
• Slide Number 122
• Slide Number 123
• Slide Number 124
• Slide Number 125
• DIC Take Home Messages
• Slide Number 127
• Slide Number 128

Case Study 5 ndash Lab Results and Time Course

Mendes BC Oderich GS Erben Y Reed NR Pruthi RK False Lumen Embolization to Treat Disseminated Intravascular Coagulation After Thoracic Endovascular Aortic Repair of Type B Aortic Dissection Journal of Endovascular Therapy 2015 22 938ndash41

TEST RESULT REFERENCE RANGE

Platelet count 33 x 109L 150-450 x 109L

PT 215 sec 103 ndash 128 sec

APTT 44 sec 26 ndash 36 sec

D-dimer 20 microgmL FEU lt025 microgml FEU

Fibrinogen 34 mgdL 200-375 mgdl

FII FV FVIII Low Not reported (NR)

FVII FIX FX vWF Normal NR

Improvement in Pltand Fib after false lumen embolization with multiple endovascular plugs(arrows)

DIC secondary to large type Ib endoleakUFH infusion cryoprecipitate partial improvement in platelet count and fibrinogenRare case of DIC following TEVAR (A) 3D CT reconstruction (B) Illustration demonstrating chronic type B aortic

dissection with associated aneurysmal dilatation of the descending thoracic aorta patient treated with TEVAR

(C) Completion angiogram demonstrated patent supra-aortic vessels and thoracic stent-graft no evidence of an antegrade endoleak but persistent distal type Ib endoleak (black arrow) into false lumen

(D) Illustration demonstrating repair

Case Study 5 ndash Diagnosis and Treatment

Mendes BC Oderich GS Erben Y Reed NR Pruthi RK False Lumen Embolization to Treat Disseminated Intravascular Coagulation After Thoracic Endovascular Aortic Repair of Type B Aortic Dissection Journal of Endovascular Therapy 2015 22 938ndash41

29 year old female 50 kg hematuria and epistaxis pregnant 37 weeks no prior prenatal check ups hematuria 10 days priorOn examination blood pressure 200160 started on α-methyldopaShe developed profuse epistaxis controlled after bilateral nasal packinNo history of blurring of vision or epigastric pain denied history of prior abnormal bleeding episodes ingestion of any medication except α-methyldopaExamination revealed pallor and pedal edema controlled with three 5 mg boluses of intravenous labetalolTrachea was electively intubated under midazolam sedation for protection of airway and patient placed on ventilation with oxygen supplementationBaby was monitored using cardiotocography and Doppler ultrasonography

Case Study 6 ndash Presentation

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

Case Study 6 ndash Lab Results

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

TEST RESULT REFERENCE RANGEPlatelet count 109 x 109L 150-400 x 109L

PT 63 sec gt control 113 ndash 146 sec

INR 658 1 ndash 125

APTT 80 sec gt control 25 ndash 34 sec

D-dimer gt200 microgmL DDU 02 microgmL DDU

Urine exam Proteinuria and hematuria 150-400 mgdl

Albumin 28 gdL NR

Hb 58 gdL NR

LDH 1196 UL NR

SGPT 144 IU NR

SGOT 88 IU NR

Bilirubin 32 mgdL NR

DIC complicating hemolysis elevated liver enzymes and low platelets (HELLP) syndrome in preeclampsia was made and C section plannedIntraoperative blood loss replaced with FFP packed red blood cells (RBC) hexastarch and crystalloidsBaby delivered successfullyPostop vaginal bleeding treated with intravenous TXA platelets and FFPPatient remained haemodynamically stable and disharged on the 10th

day postop

Case Study 6 ndash Diagnosis and Treatment

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

HELLP syndrome complicates 02 ndash06 of all pregnancies 4ndash12 of cases with severe preeclampsia and 30ndash50 of eclamptic gravidasMaternal and neonatal mortality 2ndash24 and 3ndash39 respectively HELLP syndrome may progress to DIC in 15ndash38 of patientsPatients with HELLP syndrome are at increased risk of abruptio placentae pulmonary edema ruptured liver hematoma acute renal failure cerebrovascular accident and multiorgan failure

Case Study 6 ndash Discussion

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

44-year-old man with history of hepatitis C cirrhosis and chronic kidney disease presents to ED for altered mental status and ammonia level gt 500 mM (RR 11-51 mM)Patient was given lactulose however his mental status worsened to require intubationVital signs on admission to ICU on Oct 23 BP 12084 heart rate 107 beatsmin respiratory rate 18min temperature 978 degF

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 23 patient started on vancomycin piperacillintazobactam and fluids because of concern for sepsis associated with systemic inflammatory response syndrome (SIRS) and multiorgan failure as well as laboratory values showing a high WBC count and elevated lactate of 8 mM (RR 05-16mmolL)Vital signs worsened over next 24 hours became hypotensive requiring treatment with norepinephrine and 6 L of normal saline on Oct 24Renal function continued to decline received continuous renal replacement therapy on Oct 25

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Case Study 7 ndash Lab Results vs Time

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Lab values from Oct 25 consistent with DIC given packed RBCs FFP cryo plts and vit K to treat peritoneal bleeding which stopped by Oct 26Over next few days continued to require norepinephrine but eventually vital signs and laboratory values stabilizedDuring next few days improvement was apparent but found to have multiple infections including vancomycin-resistant enterococcus (VRE) along with Stenotrophomonas maltophilia peritoneal fluid growing Acinetobacter and urinalysis growing Candida glabrata

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 29 started on daptomycin linezolid trimethoprimsulfamethoxazole and fluconazole vancomycin and piperacillintazobactam were discontinuedHemodynamically stable taken off pressors and extubated on Nov 1In process of transfer from ICU became obtunded and hypotensive onFFP cryo platelets and packed RBCs were ordered but patient went into cardiac arrest and passed away

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

DIC Take Home Messages

Heterogeneous rapidly fatal syndromeEtiology sepsis tumors injuries or obstetric complicationsSimultaneous activation of coagulation and fibrinolysis Consumption of factors anticoagulant proteins fibrinogen and plateletsDiagnosis not with a single test panel including activation markers Screening coags platelets FMFS and D-dimer 1st consideration treat the critical symptoms and underlying issue 2nd consideration compensation for the consumption and sometimes anticoagulation

Monitor efficacy of therapy Activation markers (D-Dimer FMFSP) Normalization of coagulation markers

DIC

Thank you Questions

• Disseminated Intravascular Coagulation (DIC) and Thrombosis The Critical Role of the Lab
• Learning Objectives
• Slide Number 3
• Slide Number 4
• Slide Number 5
• Slide Number 6
• Slide Number 7
• Slide Number 8
• Wound Sealing
• The Three Steps of Hemostasis
• Vessel Wall
• Slide Number 12
• Slide Number 13
• Platelet Structure UnactivatedActivated
• Primary Hemostasis
• Primary Hemostasis Assays
• Slide Number 17
• Coagulation is a balance between pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis
• Slide Number 19
• Coagulation factors
• Coagulation Assay Mechanisms
• Slide Number 22
• Fibrin Formation
• Slide Number 24
• Fibrinolysis Overview
• Fibrinolysis Overview
• Slide Number 27
• Fibrinolysis Releases D-dimers
• Basic Pathophysiology of DIC
• Disseminated Intravascular Coagulation (DIC)
• Purpura Fulminans with DIC Due to Meningococcal Sepsis
• Clinical Conditions Associated With DIC
• Frequency of DIC in Selected Disease States
• Underlying Diseases in DIC Patients
• Slide Number 36
• Slide Number 37
• Slide Number 38
• Slide Number 39
• Pathophysiology of DIC
• Pathogenesis of DIC in Sepsis
• Host Response in Severe Sepsis
• Organ Failure in Severe Sepsis
• Mechanism of DIC in Organ Failure
• Interaction of Inflammation and Coagulation in Sepsis
• Slide Number 47
• Diverse and Opposing Effects of Thrombin
• Coagulation and Fibrinolysis in DIC
• Mechanism of DIC
• Pathophysiology of DIC
• Pathophysiology of DIC - Mechanism
• Pathophysiology of DIC ndash 2 Types of Clinical pictures
• Sub-Acute and Non-Overt DIC Clinical Findings
• Pathophysiology of Overt DIC
• Physiopathology of DIC ndash Overt DIC Findings
• Slide Number 57
• Slide Number 58
• Slide Number 59
• Slide Number 60
• Slide Number 61
• BREAK
• Diagnostic and Management Approach for DIC
• Diagnosis of DIC
• Lab Diagnosis of DIC ndash Markers of Factor Consumption
• Lab Diagnosis of DIC ndash Screening Tests
• Slide Number 67
• Slide Number 68
• British Journal of Haematology Overt DIC Score
• Slide Number 70
• Slide Number 71
• Slide Number 72
• Slide Number 73
• DIC Management Goals
• DIC Management and Treatment
• DIC Management Strategies
• Anticoagulant Factor Concentrate Treatment
• Anticoagulant Factor Concentrate Treatment Trials
• Markers of Thrombin amp Plasmin Generation in DIC
• D-dimer FDPs and DIC
• D-Dimer and FDPs in DIC
• Follow Up of DIC State of Disease
• FMD-Dimer in DIC Major Differences
• of Abnormal Results in Patients with Confirmed and Suspected DIC
• Slide Number 85
• Slide Number 86
• Comparing an Automated FM vs Manual FSP Test
• Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Slide Number 98
• Slide Number 99
• DIC Case Studies
• Case Study 1 - Presentation
• Case Study 1 ndash Lab Results
• Case Study 1 ndash Microscopy
• Case Study 1 ndash Diagnosis and Therapy
• Slide Number 105
• Slide Number 106
• Slide Number 107
• Slide Number 108
• Slide Number 109
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Slide Number 113
• Slide Number 114
• Slide Number 115
• Slide Number 116
• Slide Number 117
• Slide Number 118
• Slide Number 119
• Slide Number 120
• Slide Number 121
• Slide Number 122
• Slide Number 123
• Slide Number 124
• Slide Number 125
• DIC Take Home Messages
• Slide Number 127
• Slide Number 128

DIC secondary to large type Ib endoleakUFH infusion cryoprecipitate partial improvement in platelet count and fibrinogenRare case of DIC following TEVAR (A) 3D CT reconstruction (B) Illustration demonstrating chronic type B aortic

dissection with associated aneurysmal dilatation of the descending thoracic aorta patient treated with TEVAR

(C) Completion angiogram demonstrated patent supra-aortic vessels and thoracic stent-graft no evidence of an antegrade endoleak but persistent distal type Ib endoleak (black arrow) into false lumen

(D) Illustration demonstrating repair

Case Study 5 ndash Diagnosis and Treatment

Mendes BC Oderich GS Erben Y Reed NR Pruthi RK False Lumen Embolization to Treat Disseminated Intravascular Coagulation After Thoracic Endovascular Aortic Repair of Type B Aortic Dissection Journal of Endovascular Therapy 2015 22 938ndash41

29 year old female 50 kg hematuria and epistaxis pregnant 37 weeks no prior prenatal check ups hematuria 10 days priorOn examination blood pressure 200160 started on α-methyldopaShe developed profuse epistaxis controlled after bilateral nasal packinNo history of blurring of vision or epigastric pain denied history of prior abnormal bleeding episodes ingestion of any medication except α-methyldopaExamination revealed pallor and pedal edema controlled with three 5 mg boluses of intravenous labetalolTrachea was electively intubated under midazolam sedation for protection of airway and patient placed on ventilation with oxygen supplementationBaby was monitored using cardiotocography and Doppler ultrasonography

Case Study 6 ndash Presentation

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

Case Study 6 ndash Lab Results

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

TEST RESULT REFERENCE RANGEPlatelet count 109 x 109L 150-400 x 109L

PT 63 sec gt control 113 ndash 146 sec

INR 658 1 ndash 125

APTT 80 sec gt control 25 ndash 34 sec

D-dimer gt200 microgmL DDU 02 microgmL DDU

Urine exam Proteinuria and hematuria 150-400 mgdl

Albumin 28 gdL NR

Hb 58 gdL NR

LDH 1196 UL NR

SGPT 144 IU NR

SGOT 88 IU NR

Bilirubin 32 mgdL NR

DIC complicating hemolysis elevated liver enzymes and low platelets (HELLP) syndrome in preeclampsia was made and C section plannedIntraoperative blood loss replaced with FFP packed red blood cells (RBC) hexastarch and crystalloidsBaby delivered successfullyPostop vaginal bleeding treated with intravenous TXA platelets and FFPPatient remained haemodynamically stable and disharged on the 10th

day postop

Case Study 6 ndash Diagnosis and Treatment

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

HELLP syndrome complicates 02 ndash06 of all pregnancies 4ndash12 of cases with severe preeclampsia and 30ndash50 of eclamptic gravidasMaternal and neonatal mortality 2ndash24 and 3ndash39 respectively HELLP syndrome may progress to DIC in 15ndash38 of patientsPatients with HELLP syndrome are at increased risk of abruptio placentae pulmonary edema ruptured liver hematoma acute renal failure cerebrovascular accident and multiorgan failure

Case Study 6 ndash Discussion

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

44-year-old man with history of hepatitis C cirrhosis and chronic kidney disease presents to ED for altered mental status and ammonia level gt 500 mM (RR 11-51 mM)Patient was given lactulose however his mental status worsened to require intubationVital signs on admission to ICU on Oct 23 BP 12084 heart rate 107 beatsmin respiratory rate 18min temperature 978 degF

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 23 patient started on vancomycin piperacillintazobactam and fluids because of concern for sepsis associated with systemic inflammatory response syndrome (SIRS) and multiorgan failure as well as laboratory values showing a high WBC count and elevated lactate of 8 mM (RR 05-16mmolL)Vital signs worsened over next 24 hours became hypotensive requiring treatment with norepinephrine and 6 L of normal saline on Oct 24Renal function continued to decline received continuous renal replacement therapy on Oct 25

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Case Study 7 ndash Lab Results vs Time

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Lab values from Oct 25 consistent with DIC given packed RBCs FFP cryo plts and vit K to treat peritoneal bleeding which stopped by Oct 26Over next few days continued to require norepinephrine but eventually vital signs and laboratory values stabilizedDuring next few days improvement was apparent but found to have multiple infections including vancomycin-resistant enterococcus (VRE) along with Stenotrophomonas maltophilia peritoneal fluid growing Acinetobacter and urinalysis growing Candida glabrata

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 29 started on daptomycin linezolid trimethoprimsulfamethoxazole and fluconazole vancomycin and piperacillintazobactam were discontinuedHemodynamically stable taken off pressors and extubated on Nov 1In process of transfer from ICU became obtunded and hypotensive onFFP cryo platelets and packed RBCs were ordered but patient went into cardiac arrest and passed away

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

DIC Take Home Messages

Heterogeneous rapidly fatal syndromeEtiology sepsis tumors injuries or obstetric complicationsSimultaneous activation of coagulation and fibrinolysis Consumption of factors anticoagulant proteins fibrinogen and plateletsDiagnosis not with a single test panel including activation markers Screening coags platelets FMFS and D-dimer 1st consideration treat the critical symptoms and underlying issue 2nd consideration compensation for the consumption and sometimes anticoagulation

Monitor efficacy of therapy Activation markers (D-Dimer FMFSP) Normalization of coagulation markers

DIC

Thank you Questions

• Disseminated Intravascular Coagulation (DIC) and Thrombosis The Critical Role of the Lab
• Learning Objectives
• Slide Number 3
• Slide Number 4
• Slide Number 5
• Slide Number 6
• Slide Number 7
• Slide Number 8
• Wound Sealing
• The Three Steps of Hemostasis
• Vessel Wall
• Slide Number 12
• Slide Number 13
• Platelet Structure UnactivatedActivated
• Primary Hemostasis
• Primary Hemostasis Assays
• Slide Number 17
• Coagulation is a balance between pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis
• Slide Number 19
• Coagulation factors
• Coagulation Assay Mechanisms
• Slide Number 22
• Fibrin Formation
• Slide Number 24
• Fibrinolysis Overview
• Fibrinolysis Overview
• Slide Number 27
• Fibrinolysis Releases D-dimers
• Basic Pathophysiology of DIC
• Disseminated Intravascular Coagulation (DIC)
• Purpura Fulminans with DIC Due to Meningococcal Sepsis
• Clinical Conditions Associated With DIC
• Frequency of DIC in Selected Disease States
• Underlying Diseases in DIC Patients
• Slide Number 36
• Slide Number 37
• Slide Number 38
• Slide Number 39
• Pathophysiology of DIC
• Pathogenesis of DIC in Sepsis
• Host Response in Severe Sepsis
• Organ Failure in Severe Sepsis
• Mechanism of DIC in Organ Failure
• Interaction of Inflammation and Coagulation in Sepsis
• Slide Number 47
• Diverse and Opposing Effects of Thrombin
• Coagulation and Fibrinolysis in DIC
• Mechanism of DIC
• Pathophysiology of DIC
• Pathophysiology of DIC - Mechanism
• Pathophysiology of DIC ndash 2 Types of Clinical pictures
• Sub-Acute and Non-Overt DIC Clinical Findings
• Pathophysiology of Overt DIC
• Physiopathology of DIC ndash Overt DIC Findings
• Slide Number 57
• Slide Number 58
• Slide Number 59
• Slide Number 60
• Slide Number 61
• BREAK
• Diagnostic and Management Approach for DIC
• Diagnosis of DIC
• Lab Diagnosis of DIC ndash Markers of Factor Consumption
• Lab Diagnosis of DIC ndash Screening Tests
• Slide Number 67
• Slide Number 68
• British Journal of Haematology Overt DIC Score
• Slide Number 70
• Slide Number 71
• Slide Number 72
• Slide Number 73
• DIC Management Goals
• DIC Management and Treatment
• DIC Management Strategies
• Anticoagulant Factor Concentrate Treatment
• Anticoagulant Factor Concentrate Treatment Trials
• Markers of Thrombin amp Plasmin Generation in DIC
• D-dimer FDPs and DIC
• D-Dimer and FDPs in DIC
• Follow Up of DIC State of Disease
• FMD-Dimer in DIC Major Differences
• of Abnormal Results in Patients with Confirmed and Suspected DIC
• Slide Number 85
• Slide Number 86
• Comparing an Automated FM vs Manual FSP Test
• Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Slide Number 98
• Slide Number 99
• DIC Case Studies
• Case Study 1 - Presentation
• Case Study 1 ndash Lab Results
• Case Study 1 ndash Microscopy
• Case Study 1 ndash Diagnosis and Therapy
• Slide Number 105
• Slide Number 106
• Slide Number 107
• Slide Number 108
• Slide Number 109
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Slide Number 113
• Slide Number 114
• Slide Number 115
• Slide Number 116
• Slide Number 117
• Slide Number 118
• Slide Number 119
• Slide Number 120
• Slide Number 121
• Slide Number 122
• Slide Number 123
• Slide Number 124
• Slide Number 125
• DIC Take Home Messages
• Slide Number 127
• Slide Number 128

29 year old female 50 kg hematuria and epistaxis pregnant 37 weeks no prior prenatal check ups hematuria 10 days priorOn examination blood pressure 200160 started on α-methyldopaShe developed profuse epistaxis controlled after bilateral nasal packinNo history of blurring of vision or epigastric pain denied history of prior abnormal bleeding episodes ingestion of any medication except α-methyldopaExamination revealed pallor and pedal edema controlled with three 5 mg boluses of intravenous labetalolTrachea was electively intubated under midazolam sedation for protection of airway and patient placed on ventilation with oxygen supplementationBaby was monitored using cardiotocography and Doppler ultrasonography

Case Study 6 ndash Presentation

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

Case Study 6 ndash Lab Results

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

TEST RESULT REFERENCE RANGEPlatelet count 109 x 109L 150-400 x 109L

PT 63 sec gt control 113 ndash 146 sec

INR 658 1 ndash 125

APTT 80 sec gt control 25 ndash 34 sec

D-dimer gt200 microgmL DDU 02 microgmL DDU

Urine exam Proteinuria and hematuria 150-400 mgdl

Albumin 28 gdL NR

Hb 58 gdL NR

LDH 1196 UL NR

SGPT 144 IU NR

SGOT 88 IU NR

Bilirubin 32 mgdL NR

DIC complicating hemolysis elevated liver enzymes and low platelets (HELLP) syndrome in preeclampsia was made and C section plannedIntraoperative blood loss replaced with FFP packed red blood cells (RBC) hexastarch and crystalloidsBaby delivered successfullyPostop vaginal bleeding treated with intravenous TXA platelets and FFPPatient remained haemodynamically stable and disharged on the 10th

day postop

Case Study 6 ndash Diagnosis and Treatment

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

HELLP syndrome complicates 02 ndash06 of all pregnancies 4ndash12 of cases with severe preeclampsia and 30ndash50 of eclamptic gravidasMaternal and neonatal mortality 2ndash24 and 3ndash39 respectively HELLP syndrome may progress to DIC in 15ndash38 of patientsPatients with HELLP syndrome are at increased risk of abruptio placentae pulmonary edema ruptured liver hematoma acute renal failure cerebrovascular accident and multiorgan failure

Case Study 6 ndash Discussion

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

44-year-old man with history of hepatitis C cirrhosis and chronic kidney disease presents to ED for altered mental status and ammonia level gt 500 mM (RR 11-51 mM)Patient was given lactulose however his mental status worsened to require intubationVital signs on admission to ICU on Oct 23 BP 12084 heart rate 107 beatsmin respiratory rate 18min temperature 978 degF

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 23 patient started on vancomycin piperacillintazobactam and fluids because of concern for sepsis associated with systemic inflammatory response syndrome (SIRS) and multiorgan failure as well as laboratory values showing a high WBC count and elevated lactate of 8 mM (RR 05-16mmolL)Vital signs worsened over next 24 hours became hypotensive requiring treatment with norepinephrine and 6 L of normal saline on Oct 24Renal function continued to decline received continuous renal replacement therapy on Oct 25

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Case Study 7 ndash Lab Results vs Time

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Lab values from Oct 25 consistent with DIC given packed RBCs FFP cryo plts and vit K to treat peritoneal bleeding which stopped by Oct 26Over next few days continued to require norepinephrine but eventually vital signs and laboratory values stabilizedDuring next few days improvement was apparent but found to have multiple infections including vancomycin-resistant enterococcus (VRE) along with Stenotrophomonas maltophilia peritoneal fluid growing Acinetobacter and urinalysis growing Candida glabrata

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 29 started on daptomycin linezolid trimethoprimsulfamethoxazole and fluconazole vancomycin and piperacillintazobactam were discontinuedHemodynamically stable taken off pressors and extubated on Nov 1In process of transfer from ICU became obtunded and hypotensive onFFP cryo platelets and packed RBCs were ordered but patient went into cardiac arrest and passed away

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

DIC Take Home Messages

Heterogeneous rapidly fatal syndromeEtiology sepsis tumors injuries or obstetric complicationsSimultaneous activation of coagulation and fibrinolysis Consumption of factors anticoagulant proteins fibrinogen and plateletsDiagnosis not with a single test panel including activation markers Screening coags platelets FMFS and D-dimer 1st consideration treat the critical symptoms and underlying issue 2nd consideration compensation for the consumption and sometimes anticoagulation

Monitor efficacy of therapy Activation markers (D-Dimer FMFSP) Normalization of coagulation markers

DIC

Thank you Questions

• Disseminated Intravascular Coagulation (DIC) and Thrombosis The Critical Role of the Lab
• Learning Objectives
• Slide Number 3
• Slide Number 4
• Slide Number 5
• Slide Number 6
• Slide Number 7
• Slide Number 8
• Wound Sealing
• The Three Steps of Hemostasis
• Vessel Wall
• Slide Number 12
• Slide Number 13
• Platelet Structure UnactivatedActivated
• Primary Hemostasis
• Primary Hemostasis Assays
• Slide Number 17
• Coagulation is a balance between pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis
• Slide Number 19
• Coagulation factors
• Coagulation Assay Mechanisms
• Slide Number 22
• Fibrin Formation
• Slide Number 24
• Fibrinolysis Overview
• Fibrinolysis Overview
• Slide Number 27
• Fibrinolysis Releases D-dimers
• Basic Pathophysiology of DIC
• Disseminated Intravascular Coagulation (DIC)
• Purpura Fulminans with DIC Due to Meningococcal Sepsis
• Clinical Conditions Associated With DIC
• Frequency of DIC in Selected Disease States
• Underlying Diseases in DIC Patients
• Slide Number 36
• Slide Number 37
• Slide Number 38
• Slide Number 39
• Pathophysiology of DIC
• Pathogenesis of DIC in Sepsis
• Host Response in Severe Sepsis
• Organ Failure in Severe Sepsis
• Mechanism of DIC in Organ Failure
• Interaction of Inflammation and Coagulation in Sepsis
• Slide Number 47
• Diverse and Opposing Effects of Thrombin
• Coagulation and Fibrinolysis in DIC
• Mechanism of DIC
• Pathophysiology of DIC
• Pathophysiology of DIC - Mechanism
• Pathophysiology of DIC ndash 2 Types of Clinical pictures
• Sub-Acute and Non-Overt DIC Clinical Findings
• Pathophysiology of Overt DIC
• Physiopathology of DIC ndash Overt DIC Findings
• Slide Number 57
• Slide Number 58
• Slide Number 59
• Slide Number 60
• Slide Number 61
• BREAK
• Diagnostic and Management Approach for DIC
• Diagnosis of DIC
• Lab Diagnosis of DIC ndash Markers of Factor Consumption
• Lab Diagnosis of DIC ndash Screening Tests
• Slide Number 67
• Slide Number 68
• British Journal of Haematology Overt DIC Score
• Slide Number 70
• Slide Number 71
• Slide Number 72
• Slide Number 73
• DIC Management Goals
• DIC Management and Treatment
• DIC Management Strategies
• Anticoagulant Factor Concentrate Treatment
• Anticoagulant Factor Concentrate Treatment Trials
• Markers of Thrombin amp Plasmin Generation in DIC
• D-dimer FDPs and DIC
• D-Dimer and FDPs in DIC
• Follow Up of DIC State of Disease
• FMD-Dimer in DIC Major Differences
• of Abnormal Results in Patients with Confirmed and Suspected DIC
• Slide Number 85
• Slide Number 86
• Comparing an Automated FM vs Manual FSP Test
• Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Slide Number 98
• Slide Number 99
• DIC Case Studies
• Case Study 1 - Presentation
• Case Study 1 ndash Lab Results
• Case Study 1 ndash Microscopy
• Case Study 1 ndash Diagnosis and Therapy
• Slide Number 105
• Slide Number 106
• Slide Number 107
• Slide Number 108
• Slide Number 109
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Slide Number 113
• Slide Number 114
• Slide Number 115
• Slide Number 116
• Slide Number 117
• Slide Number 118
• Slide Number 119
• Slide Number 120
• Slide Number 121
• Slide Number 122
• Slide Number 123
• Slide Number 124
• Slide Number 125
• DIC Take Home Messages
• Slide Number 127
• Slide Number 128

Case Study 6 ndash Lab Results

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

TEST RESULT REFERENCE RANGEPlatelet count 109 x 109L 150-400 x 109L

PT 63 sec gt control 113 ndash 146 sec

INR 658 1 ndash 125

APTT 80 sec gt control 25 ndash 34 sec

D-dimer gt200 microgmL DDU 02 microgmL DDU

Urine exam Proteinuria and hematuria 150-400 mgdl

Albumin 28 gdL NR

Hb 58 gdL NR

LDH 1196 UL NR

SGPT 144 IU NR

SGOT 88 IU NR

Bilirubin 32 mgdL NR

DIC complicating hemolysis elevated liver enzymes and low platelets (HELLP) syndrome in preeclampsia was made and C section plannedIntraoperative blood loss replaced with FFP packed red blood cells (RBC) hexastarch and crystalloidsBaby delivered successfullyPostop vaginal bleeding treated with intravenous TXA platelets and FFPPatient remained haemodynamically stable and disharged on the 10th

day postop

Case Study 6 ndash Diagnosis and Treatment

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

HELLP syndrome complicates 02 ndash06 of all pregnancies 4ndash12 of cases with severe preeclampsia and 30ndash50 of eclamptic gravidasMaternal and neonatal mortality 2ndash24 and 3ndash39 respectively HELLP syndrome may progress to DIC in 15ndash38 of patientsPatients with HELLP syndrome are at increased risk of abruptio placentae pulmonary edema ruptured liver hematoma acute renal failure cerebrovascular accident and multiorgan failure

Case Study 6 ndash Discussion

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

44-year-old man with history of hepatitis C cirrhosis and chronic kidney disease presents to ED for altered mental status and ammonia level gt 500 mM (RR 11-51 mM)Patient was given lactulose however his mental status worsened to require intubationVital signs on admission to ICU on Oct 23 BP 12084 heart rate 107 beatsmin respiratory rate 18min temperature 978 degF

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 23 patient started on vancomycin piperacillintazobactam and fluids because of concern for sepsis associated with systemic inflammatory response syndrome (SIRS) and multiorgan failure as well as laboratory values showing a high WBC count and elevated lactate of 8 mM (RR 05-16mmolL)Vital signs worsened over next 24 hours became hypotensive requiring treatment with norepinephrine and 6 L of normal saline on Oct 24Renal function continued to decline received continuous renal replacement therapy on Oct 25

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Case Study 7 ndash Lab Results vs Time

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Lab values from Oct 25 consistent with DIC given packed RBCs FFP cryo plts and vit K to treat peritoneal bleeding which stopped by Oct 26Over next few days continued to require norepinephrine but eventually vital signs and laboratory values stabilizedDuring next few days improvement was apparent but found to have multiple infections including vancomycin-resistant enterococcus (VRE) along with Stenotrophomonas maltophilia peritoneal fluid growing Acinetobacter and urinalysis growing Candida glabrata

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 29 started on daptomycin linezolid trimethoprimsulfamethoxazole and fluconazole vancomycin and piperacillintazobactam were discontinuedHemodynamically stable taken off pressors and extubated on Nov 1In process of transfer from ICU became obtunded and hypotensive onFFP cryo platelets and packed RBCs were ordered but patient went into cardiac arrest and passed away

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

DIC Take Home Messages

Heterogeneous rapidly fatal syndromeEtiology sepsis tumors injuries or obstetric complicationsSimultaneous activation of coagulation and fibrinolysis Consumption of factors anticoagulant proteins fibrinogen and plateletsDiagnosis not with a single test panel including activation markers Screening coags platelets FMFS and D-dimer 1st consideration treat the critical symptoms and underlying issue 2nd consideration compensation for the consumption and sometimes anticoagulation

Monitor efficacy of therapy Activation markers (D-Dimer FMFSP) Normalization of coagulation markers

DIC

Thank you Questions

• Disseminated Intravascular Coagulation (DIC) and Thrombosis The Critical Role of the Lab
• Learning Objectives
• Slide Number 3
• Slide Number 4
• Slide Number 5
• Slide Number 6
• Slide Number 7
• Slide Number 8
• Wound Sealing
• The Three Steps of Hemostasis
• Vessel Wall
• Slide Number 12
• Slide Number 13
• Platelet Structure UnactivatedActivated
• Primary Hemostasis
• Primary Hemostasis Assays
• Slide Number 17
• Coagulation is a balance between pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis
• Slide Number 19
• Coagulation factors
• Coagulation Assay Mechanisms
• Slide Number 22
• Fibrin Formation
• Slide Number 24
• Fibrinolysis Overview
• Fibrinolysis Overview
• Slide Number 27
• Fibrinolysis Releases D-dimers
• Basic Pathophysiology of DIC
• Disseminated Intravascular Coagulation (DIC)
• Purpura Fulminans with DIC Due to Meningococcal Sepsis
• Clinical Conditions Associated With DIC
• Frequency of DIC in Selected Disease States
• Underlying Diseases in DIC Patients
• Slide Number 36
• Slide Number 37
• Slide Number 38
• Slide Number 39
• Pathophysiology of DIC
• Pathogenesis of DIC in Sepsis
• Host Response in Severe Sepsis
• Organ Failure in Severe Sepsis
• Mechanism of DIC in Organ Failure
• Interaction of Inflammation and Coagulation in Sepsis
• Slide Number 47
• Diverse and Opposing Effects of Thrombin
• Coagulation and Fibrinolysis in DIC
• Mechanism of DIC
• Pathophysiology of DIC
• Pathophysiology of DIC - Mechanism
• Pathophysiology of DIC ndash 2 Types of Clinical pictures
• Sub-Acute and Non-Overt DIC Clinical Findings
• Pathophysiology of Overt DIC
• Physiopathology of DIC ndash Overt DIC Findings
• Slide Number 57
• Slide Number 58
• Slide Number 59
• Slide Number 60
• Slide Number 61
• BREAK
• Diagnostic and Management Approach for DIC
• Diagnosis of DIC
• Lab Diagnosis of DIC ndash Markers of Factor Consumption
• Lab Diagnosis of DIC ndash Screening Tests
• Slide Number 67
• Slide Number 68
• British Journal of Haematology Overt DIC Score
• Slide Number 70
• Slide Number 71
• Slide Number 72
• Slide Number 73
• DIC Management Goals
• DIC Management and Treatment
• DIC Management Strategies
• Anticoagulant Factor Concentrate Treatment
• Anticoagulant Factor Concentrate Treatment Trials
• Markers of Thrombin amp Plasmin Generation in DIC
• D-dimer FDPs and DIC
• D-Dimer and FDPs in DIC
• Follow Up of DIC State of Disease
• FMD-Dimer in DIC Major Differences
• of Abnormal Results in Patients with Confirmed and Suspected DIC
• Slide Number 85
• Slide Number 86
• Comparing an Automated FM vs Manual FSP Test
• Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Slide Number 98
• Slide Number 99
• DIC Case Studies
• Case Study 1 - Presentation
• Case Study 1 ndash Lab Results
• Case Study 1 ndash Microscopy
• Case Study 1 ndash Diagnosis and Therapy
• Slide Number 105
• Slide Number 106
• Slide Number 107
• Slide Number 108
• Slide Number 109
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Slide Number 113
• Slide Number 114
• Slide Number 115
• Slide Number 116
• Slide Number 117
• Slide Number 118
• Slide Number 119
• Slide Number 120
• Slide Number 121
• Slide Number 122
• Slide Number 123
• Slide Number 124
• Slide Number 125
• DIC Take Home Messages
• Slide Number 127
• Slide Number 128

DIC complicating hemolysis elevated liver enzymes and low platelets (HELLP) syndrome in preeclampsia was made and C section plannedIntraoperative blood loss replaced with FFP packed red blood cells (RBC) hexastarch and crystalloidsBaby delivered successfullyPostop vaginal bleeding treated with intravenous TXA platelets and FFPPatient remained haemodynamically stable and disharged on the 10th

day postop

Case Study 6 ndash Diagnosis and Treatment

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

HELLP syndrome complicates 02 ndash06 of all pregnancies 4ndash12 of cases with severe preeclampsia and 30ndash50 of eclamptic gravidasMaternal and neonatal mortality 2ndash24 and 3ndash39 respectively HELLP syndrome may progress to DIC in 15ndash38 of patientsPatients with HELLP syndrome are at increased risk of abruptio placentae pulmonary edema ruptured liver hematoma acute renal failure cerebrovascular accident and multiorgan failure

Case Study 6 ndash Discussion

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

44-year-old man with history of hepatitis C cirrhosis and chronic kidney disease presents to ED for altered mental status and ammonia level gt 500 mM (RR 11-51 mM)Patient was given lactulose however his mental status worsened to require intubationVital signs on admission to ICU on Oct 23 BP 12084 heart rate 107 beatsmin respiratory rate 18min temperature 978 degF

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 23 patient started on vancomycin piperacillintazobactam and fluids because of concern for sepsis associated with systemic inflammatory response syndrome (SIRS) and multiorgan failure as well as laboratory values showing a high WBC count and elevated lactate of 8 mM (RR 05-16mmolL)Vital signs worsened over next 24 hours became hypotensive requiring treatment with norepinephrine and 6 L of normal saline on Oct 24Renal function continued to decline received continuous renal replacement therapy on Oct 25

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Case Study 7 ndash Lab Results vs Time

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Lab values from Oct 25 consistent with DIC given packed RBCs FFP cryo plts and vit K to treat peritoneal bleeding which stopped by Oct 26Over next few days continued to require norepinephrine but eventually vital signs and laboratory values stabilizedDuring next few days improvement was apparent but found to have multiple infections including vancomycin-resistant enterococcus (VRE) along with Stenotrophomonas maltophilia peritoneal fluid growing Acinetobacter and urinalysis growing Candida glabrata

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 29 started on daptomycin linezolid trimethoprimsulfamethoxazole and fluconazole vancomycin and piperacillintazobactam were discontinuedHemodynamically stable taken off pressors and extubated on Nov 1In process of transfer from ICU became obtunded and hypotensive onFFP cryo platelets and packed RBCs were ordered but patient went into cardiac arrest and passed away

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

DIC Take Home Messages

Heterogeneous rapidly fatal syndromeEtiology sepsis tumors injuries or obstetric complicationsSimultaneous activation of coagulation and fibrinolysis Consumption of factors anticoagulant proteins fibrinogen and plateletsDiagnosis not with a single test panel including activation markers Screening coags platelets FMFS and D-dimer 1st consideration treat the critical symptoms and underlying issue 2nd consideration compensation for the consumption and sometimes anticoagulation

Monitor efficacy of therapy Activation markers (D-Dimer FMFSP) Normalization of coagulation markers

DIC

Thank you Questions

• Disseminated Intravascular Coagulation (DIC) and Thrombosis The Critical Role of the Lab
• Learning Objectives
• Slide Number 3
• Slide Number 4
• Slide Number 5
• Slide Number 6
• Slide Number 7
• Slide Number 8
• Wound Sealing
• The Three Steps of Hemostasis
• Vessel Wall
• Slide Number 12
• Slide Number 13
• Platelet Structure UnactivatedActivated
• Primary Hemostasis
• Primary Hemostasis Assays
• Slide Number 17
• Coagulation is a balance between pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis
• Slide Number 19
• Coagulation factors
• Coagulation Assay Mechanisms
• Slide Number 22
• Fibrin Formation
• Slide Number 24
• Fibrinolysis Overview
• Fibrinolysis Overview
• Slide Number 27
• Fibrinolysis Releases D-dimers
• Basic Pathophysiology of DIC
• Disseminated Intravascular Coagulation (DIC)
• Purpura Fulminans with DIC Due to Meningococcal Sepsis
• Clinical Conditions Associated With DIC
• Frequency of DIC in Selected Disease States
• Underlying Diseases in DIC Patients
• Slide Number 36
• Slide Number 37
• Slide Number 38
• Slide Number 39
• Pathophysiology of DIC
• Pathogenesis of DIC in Sepsis
• Host Response in Severe Sepsis
• Organ Failure in Severe Sepsis
• Mechanism of DIC in Organ Failure
• Interaction of Inflammation and Coagulation in Sepsis
• Slide Number 47
• Diverse and Opposing Effects of Thrombin
• Coagulation and Fibrinolysis in DIC
• Mechanism of DIC
• Pathophysiology of DIC
• Pathophysiology of DIC - Mechanism
• Pathophysiology of DIC ndash 2 Types of Clinical pictures
• Sub-Acute and Non-Overt DIC Clinical Findings
• Pathophysiology of Overt DIC
• Physiopathology of DIC ndash Overt DIC Findings
• Slide Number 57
• Slide Number 58
• Slide Number 59
• Slide Number 60
• Slide Number 61
• BREAK
• Diagnostic and Management Approach for DIC
• Diagnosis of DIC
• Lab Diagnosis of DIC ndash Markers of Factor Consumption
• Lab Diagnosis of DIC ndash Screening Tests
• Slide Number 67
• Slide Number 68
• British Journal of Haematology Overt DIC Score
• Slide Number 70
• Slide Number 71
• Slide Number 72
• Slide Number 73
• DIC Management Goals
• DIC Management and Treatment
• DIC Management Strategies
• Anticoagulant Factor Concentrate Treatment
• Anticoagulant Factor Concentrate Treatment Trials
• Markers of Thrombin amp Plasmin Generation in DIC
• D-dimer FDPs and DIC
• D-Dimer and FDPs in DIC
• Follow Up of DIC State of Disease
• FMD-Dimer in DIC Major Differences
• of Abnormal Results in Patients with Confirmed and Suspected DIC
• Slide Number 85
• Slide Number 86
• Comparing an Automated FM vs Manual FSP Test
• Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Slide Number 98
• Slide Number 99
• DIC Case Studies
• Case Study 1 - Presentation
• Case Study 1 ndash Lab Results
• Case Study 1 ndash Microscopy
• Case Study 1 ndash Diagnosis and Therapy
• Slide Number 105
• Slide Number 106
• Slide Number 107
• Slide Number 108
• Slide Number 109
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Slide Number 113
• Slide Number 114
• Slide Number 115
• Slide Number 116
• Slide Number 117
• Slide Number 118
• Slide Number 119
• Slide Number 120
• Slide Number 121
• Slide Number 122
• Slide Number 123
• Slide Number 124
• Slide Number 125
• DIC Take Home Messages
• Slide Number 127
• Slide Number 128

HELLP syndrome complicates 02 ndash06 of all pregnancies 4ndash12 of cases with severe preeclampsia and 30ndash50 of eclamptic gravidasMaternal and neonatal mortality 2ndash24 and 3ndash39 respectively HELLP syndrome may progress to DIC in 15ndash38 of patientsPatients with HELLP syndrome are at increased risk of abruptio placentae pulmonary edema ruptured liver hematoma acute renal failure cerebrovascular accident and multiorgan failure

Case Study 6 ndash Discussion

Garg R Nath MP Bhalla AP Kuma A Unusual association of diseasessymptoms Disseminated intravascular coagulation complicating HELLP syndrome perioperative management BMJ Case Rep 2009 2009 bcr1020081027

44-year-old man with history of hepatitis C cirrhosis and chronic kidney disease presents to ED for altered mental status and ammonia level gt 500 mM (RR 11-51 mM)Patient was given lactulose however his mental status worsened to require intubationVital signs on admission to ICU on Oct 23 BP 12084 heart rate 107 beatsmin respiratory rate 18min temperature 978 degF

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 23 patient started on vancomycin piperacillintazobactam and fluids because of concern for sepsis associated with systemic inflammatory response syndrome (SIRS) and multiorgan failure as well as laboratory values showing a high WBC count and elevated lactate of 8 mM (RR 05-16mmolL)Vital signs worsened over next 24 hours became hypotensive requiring treatment with norepinephrine and 6 L of normal saline on Oct 24Renal function continued to decline received continuous renal replacement therapy on Oct 25

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Case Study 7 ndash Lab Results vs Time

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Lab values from Oct 25 consistent with DIC given packed RBCs FFP cryo plts and vit K to treat peritoneal bleeding which stopped by Oct 26Over next few days continued to require norepinephrine but eventually vital signs and laboratory values stabilizedDuring next few days improvement was apparent but found to have multiple infections including vancomycin-resistant enterococcus (VRE) along with Stenotrophomonas maltophilia peritoneal fluid growing Acinetobacter and urinalysis growing Candida glabrata

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 29 started on daptomycin linezolid trimethoprimsulfamethoxazole and fluconazole vancomycin and piperacillintazobactam were discontinuedHemodynamically stable taken off pressors and extubated on Nov 1In process of transfer from ICU became obtunded and hypotensive onFFP cryo platelets and packed RBCs were ordered but patient went into cardiac arrest and passed away

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

DIC Take Home Messages

Heterogeneous rapidly fatal syndromeEtiology sepsis tumors injuries or obstetric complicationsSimultaneous activation of coagulation and fibrinolysis Consumption of factors anticoagulant proteins fibrinogen and plateletsDiagnosis not with a single test panel including activation markers Screening coags platelets FMFS and D-dimer 1st consideration treat the critical symptoms and underlying issue 2nd consideration compensation for the consumption and sometimes anticoagulation

Monitor efficacy of therapy Activation markers (D-Dimer FMFSP) Normalization of coagulation markers

DIC

Thank you Questions

• Disseminated Intravascular Coagulation (DIC) and Thrombosis The Critical Role of the Lab
• Learning Objectives
• Slide Number 3
• Slide Number 4
• Slide Number 5
• Slide Number 6
• Slide Number 7
• Slide Number 8
• Wound Sealing
• The Three Steps of Hemostasis
• Vessel Wall
• Slide Number 12
• Slide Number 13
• Platelet Structure UnactivatedActivated
• Primary Hemostasis
• Primary Hemostasis Assays
• Slide Number 17
• Coagulation is a balance between pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis
• Slide Number 19
• Coagulation factors
• Coagulation Assay Mechanisms
• Slide Number 22
• Fibrin Formation
• Slide Number 24
• Fibrinolysis Overview
• Fibrinolysis Overview
• Slide Number 27
• Fibrinolysis Releases D-dimers
• Basic Pathophysiology of DIC
• Disseminated Intravascular Coagulation (DIC)
• Purpura Fulminans with DIC Due to Meningococcal Sepsis
• Clinical Conditions Associated With DIC
• Frequency of DIC in Selected Disease States
• Underlying Diseases in DIC Patients
• Slide Number 36
• Slide Number 37
• Slide Number 38
• Slide Number 39
• Pathophysiology of DIC
• Pathogenesis of DIC in Sepsis
• Host Response in Severe Sepsis
• Organ Failure in Severe Sepsis
• Mechanism of DIC in Organ Failure
• Interaction of Inflammation and Coagulation in Sepsis
• Slide Number 47
• Diverse and Opposing Effects of Thrombin
• Coagulation and Fibrinolysis in DIC
• Mechanism of DIC
• Pathophysiology of DIC
• Pathophysiology of DIC - Mechanism
• Pathophysiology of DIC ndash 2 Types of Clinical pictures
• Sub-Acute and Non-Overt DIC Clinical Findings
• Pathophysiology of Overt DIC
• Physiopathology of DIC ndash Overt DIC Findings
• Slide Number 57
• Slide Number 58
• Slide Number 59
• Slide Number 60
• Slide Number 61
• BREAK
• Diagnostic and Management Approach for DIC
• Diagnosis of DIC
• Lab Diagnosis of DIC ndash Markers of Factor Consumption
• Lab Diagnosis of DIC ndash Screening Tests
• Slide Number 67
• Slide Number 68
• British Journal of Haematology Overt DIC Score
• Slide Number 70
• Slide Number 71
• Slide Number 72
• Slide Number 73
• DIC Management Goals
• DIC Management and Treatment
• DIC Management Strategies
• Anticoagulant Factor Concentrate Treatment
• Anticoagulant Factor Concentrate Treatment Trials
• Markers of Thrombin amp Plasmin Generation in DIC
• D-dimer FDPs and DIC
• D-Dimer and FDPs in DIC
• Follow Up of DIC State of Disease
• FMD-Dimer in DIC Major Differences
• of Abnormal Results in Patients with Confirmed and Suspected DIC
• Slide Number 85
• Slide Number 86
• Comparing an Automated FM vs Manual FSP Test
• Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Slide Number 98
• Slide Number 99
• DIC Case Studies
• Case Study 1 - Presentation
• Case Study 1 ndash Lab Results
• Case Study 1 ndash Microscopy
• Case Study 1 ndash Diagnosis and Therapy
• Slide Number 105
• Slide Number 106
• Slide Number 107
• Slide Number 108
• Slide Number 109
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Slide Number 113
• Slide Number 114
• Slide Number 115
• Slide Number 116
• Slide Number 117
• Slide Number 118
• Slide Number 119
• Slide Number 120
• Slide Number 121
• Slide Number 122
• Slide Number 123
• Slide Number 124
• Slide Number 125
• DIC Take Home Messages
• Slide Number 127
• Slide Number 128

44-year-old man with history of hepatitis C cirrhosis and chronic kidney disease presents to ED for altered mental status and ammonia level gt 500 mM (RR 11-51 mM)Patient was given lactulose however his mental status worsened to require intubationVital signs on admission to ICU on Oct 23 BP 12084 heart rate 107 beatsmin respiratory rate 18min temperature 978 degF

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 23 patient started on vancomycin piperacillintazobactam and fluids because of concern for sepsis associated with systemic inflammatory response syndrome (SIRS) and multiorgan failure as well as laboratory values showing a high WBC count and elevated lactate of 8 mM (RR 05-16mmolL)Vital signs worsened over next 24 hours became hypotensive requiring treatment with norepinephrine and 6 L of normal saline on Oct 24Renal function continued to decline received continuous renal replacement therapy on Oct 25

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Case Study 7 ndash Lab Results vs Time

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Lab values from Oct 25 consistent with DIC given packed RBCs FFP cryo plts and vit K to treat peritoneal bleeding which stopped by Oct 26Over next few days continued to require norepinephrine but eventually vital signs and laboratory values stabilizedDuring next few days improvement was apparent but found to have multiple infections including vancomycin-resistant enterococcus (VRE) along with Stenotrophomonas maltophilia peritoneal fluid growing Acinetobacter and urinalysis growing Candida glabrata

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 29 started on daptomycin linezolid trimethoprimsulfamethoxazole and fluconazole vancomycin and piperacillintazobactam were discontinuedHemodynamically stable taken off pressors and extubated on Nov 1In process of transfer from ICU became obtunded and hypotensive onFFP cryo platelets and packed RBCs were ordered but patient went into cardiac arrest and passed away

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

DIC Take Home Messages

Heterogeneous rapidly fatal syndromeEtiology sepsis tumors injuries or obstetric complicationsSimultaneous activation of coagulation and fibrinolysis Consumption of factors anticoagulant proteins fibrinogen and plateletsDiagnosis not with a single test panel including activation markers Screening coags platelets FMFS and D-dimer 1st consideration treat the critical symptoms and underlying issue 2nd consideration compensation for the consumption and sometimes anticoagulation

Monitor efficacy of therapy Activation markers (D-Dimer FMFSP) Normalization of coagulation markers

DIC

Thank you Questions

• Disseminated Intravascular Coagulation (DIC) and Thrombosis The Critical Role of the Lab
• Learning Objectives
• Slide Number 3
• Slide Number 4
• Slide Number 5
• Slide Number 6
• Slide Number 7
• Slide Number 8
• Wound Sealing
• The Three Steps of Hemostasis
• Vessel Wall
• Slide Number 12
• Slide Number 13
• Platelet Structure UnactivatedActivated
• Primary Hemostasis
• Primary Hemostasis Assays
• Slide Number 17
• Coagulation is a balance between pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis
• Slide Number 19
• Coagulation factors
• Coagulation Assay Mechanisms
• Slide Number 22
• Fibrin Formation
• Slide Number 24
• Fibrinolysis Overview
• Fibrinolysis Overview
• Slide Number 27
• Fibrinolysis Releases D-dimers
• Basic Pathophysiology of DIC
• Disseminated Intravascular Coagulation (DIC)
• Purpura Fulminans with DIC Due to Meningococcal Sepsis
• Clinical Conditions Associated With DIC
• Frequency of DIC in Selected Disease States
• Underlying Diseases in DIC Patients
• Slide Number 36
• Slide Number 37
• Slide Number 38
• Slide Number 39
• Pathophysiology of DIC
• Pathogenesis of DIC in Sepsis
• Host Response in Severe Sepsis
• Organ Failure in Severe Sepsis
• Mechanism of DIC in Organ Failure
• Interaction of Inflammation and Coagulation in Sepsis
• Slide Number 47
• Diverse and Opposing Effects of Thrombin
• Coagulation and Fibrinolysis in DIC
• Mechanism of DIC
• Pathophysiology of DIC
• Pathophysiology of DIC - Mechanism
• Pathophysiology of DIC ndash 2 Types of Clinical pictures
• Sub-Acute and Non-Overt DIC Clinical Findings
• Pathophysiology of Overt DIC
• Physiopathology of DIC ndash Overt DIC Findings
• Slide Number 57
• Slide Number 58
• Slide Number 59
• Slide Number 60
• Slide Number 61
• BREAK
• Diagnostic and Management Approach for DIC
• Diagnosis of DIC
• Lab Diagnosis of DIC ndash Markers of Factor Consumption
• Lab Diagnosis of DIC ndash Screening Tests
• Slide Number 67
• Slide Number 68
• British Journal of Haematology Overt DIC Score
• Slide Number 70
• Slide Number 71
• Slide Number 72
• Slide Number 73
• DIC Management Goals
• DIC Management and Treatment
• DIC Management Strategies
• Anticoagulant Factor Concentrate Treatment
• Anticoagulant Factor Concentrate Treatment Trials
• Markers of Thrombin amp Plasmin Generation in DIC
• D-dimer FDPs and DIC
• D-Dimer and FDPs in DIC
• Follow Up of DIC State of Disease
• FMD-Dimer in DIC Major Differences
• of Abnormal Results in Patients with Confirmed and Suspected DIC
• Slide Number 85
• Slide Number 86
• Comparing an Automated FM vs Manual FSP Test
• Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Slide Number 98
• Slide Number 99
• DIC Case Studies
• Case Study 1 - Presentation
• Case Study 1 ndash Lab Results
• Case Study 1 ndash Microscopy
• Case Study 1 ndash Diagnosis and Therapy
• Slide Number 105
• Slide Number 106
• Slide Number 107
• Slide Number 108
• Slide Number 109
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Slide Number 113
• Slide Number 114
• Slide Number 115
• Slide Number 116
• Slide Number 117
• Slide Number 118
• Slide Number 119
• Slide Number 120
• Slide Number 121
• Slide Number 122
• Slide Number 123
• Slide Number 124
• Slide Number 125
• DIC Take Home Messages
• Slide Number 127
• Slide Number 128

On Oct 23 patient started on vancomycin piperacillintazobactam and fluids because of concern for sepsis associated with systemic inflammatory response syndrome (SIRS) and multiorgan failure as well as laboratory values showing a high WBC count and elevated lactate of 8 mM (RR 05-16mmolL)Vital signs worsened over next 24 hours became hypotensive requiring treatment with norepinephrine and 6 L of normal saline on Oct 24Renal function continued to decline received continuous renal replacement therapy on Oct 25

Case Study 7 ndash Presentation

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Case Study 7 ndash Lab Results vs Time

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Lab values from Oct 25 consistent with DIC given packed RBCs FFP cryo plts and vit K to treat peritoneal bleeding which stopped by Oct 26Over next few days continued to require norepinephrine but eventually vital signs and laboratory values stabilizedDuring next few days improvement was apparent but found to have multiple infections including vancomycin-resistant enterococcus (VRE) along with Stenotrophomonas maltophilia peritoneal fluid growing Acinetobacter and urinalysis growing Candida glabrata

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 29 started on daptomycin linezolid trimethoprimsulfamethoxazole and fluconazole vancomycin and piperacillintazobactam were discontinuedHemodynamically stable taken off pressors and extubated on Nov 1In process of transfer from ICU became obtunded and hypotensive onFFP cryo platelets and packed RBCs were ordered but patient went into cardiac arrest and passed away

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

DIC Take Home Messages

Heterogeneous rapidly fatal syndromeEtiology sepsis tumors injuries or obstetric complicationsSimultaneous activation of coagulation and fibrinolysis Consumption of factors anticoagulant proteins fibrinogen and plateletsDiagnosis not with a single test panel including activation markers Screening coags platelets FMFS and D-dimer 1st consideration treat the critical symptoms and underlying issue 2nd consideration compensation for the consumption and sometimes anticoagulation

Monitor efficacy of therapy Activation markers (D-Dimer FMFSP) Normalization of coagulation markers

DIC

Thank you Questions

• Disseminated Intravascular Coagulation (DIC) and Thrombosis The Critical Role of the Lab
• Learning Objectives
• Slide Number 3
• Slide Number 4
• Slide Number 5
• Slide Number 6
• Slide Number 7
• Slide Number 8
• Wound Sealing
• The Three Steps of Hemostasis
• Vessel Wall
• Slide Number 12
• Slide Number 13
• Platelet Structure UnactivatedActivated
• Primary Hemostasis
• Primary Hemostasis Assays
• Slide Number 17
• Coagulation is a balance between pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis
• Slide Number 19
• Coagulation factors
• Coagulation Assay Mechanisms
• Slide Number 22
• Fibrin Formation
• Slide Number 24
• Fibrinolysis Overview
• Fibrinolysis Overview
• Slide Number 27
• Fibrinolysis Releases D-dimers
• Basic Pathophysiology of DIC
• Disseminated Intravascular Coagulation (DIC)
• Purpura Fulminans with DIC Due to Meningococcal Sepsis
• Clinical Conditions Associated With DIC
• Frequency of DIC in Selected Disease States
• Underlying Diseases in DIC Patients
• Slide Number 36
• Slide Number 37
• Slide Number 38
• Slide Number 39
• Pathophysiology of DIC
• Pathogenesis of DIC in Sepsis
• Host Response in Severe Sepsis
• Organ Failure in Severe Sepsis
• Mechanism of DIC in Organ Failure
• Interaction of Inflammation and Coagulation in Sepsis
• Slide Number 47
• Diverse and Opposing Effects of Thrombin
• Coagulation and Fibrinolysis in DIC
• Mechanism of DIC
• Pathophysiology of DIC
• Pathophysiology of DIC - Mechanism
• Pathophysiology of DIC ndash 2 Types of Clinical pictures
• Sub-Acute and Non-Overt DIC Clinical Findings
• Pathophysiology of Overt DIC
• Physiopathology of DIC ndash Overt DIC Findings
• Slide Number 57
• Slide Number 58
• Slide Number 59
• Slide Number 60
• Slide Number 61
• BREAK
• Diagnostic and Management Approach for DIC
• Diagnosis of DIC
• Lab Diagnosis of DIC ndash Markers of Factor Consumption
• Lab Diagnosis of DIC ndash Screening Tests
• Slide Number 67
• Slide Number 68
• British Journal of Haematology Overt DIC Score
• Slide Number 70
• Slide Number 71
• Slide Number 72
• Slide Number 73
• DIC Management Goals
• DIC Management and Treatment
• DIC Management Strategies
• Anticoagulant Factor Concentrate Treatment
• Anticoagulant Factor Concentrate Treatment Trials
• Markers of Thrombin amp Plasmin Generation in DIC
• D-dimer FDPs and DIC
• D-Dimer and FDPs in DIC
• Follow Up of DIC State of Disease
• FMD-Dimer in DIC Major Differences
• of Abnormal Results in Patients with Confirmed and Suspected DIC
• Slide Number 85
• Slide Number 86
• Comparing an Automated FM vs Manual FSP Test
• Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Slide Number 98
• Slide Number 99
• DIC Case Studies
• Case Study 1 - Presentation
• Case Study 1 ndash Lab Results
• Case Study 1 ndash Microscopy
• Case Study 1 ndash Diagnosis and Therapy
• Slide Number 105
• Slide Number 106
• Slide Number 107
• Slide Number 108
• Slide Number 109
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Slide Number 113
• Slide Number 114
• Slide Number 115
• Slide Number 116
• Slide Number 117
• Slide Number 118
• Slide Number 119
• Slide Number 120
• Slide Number 121
• Slide Number 122
• Slide Number 123
• Slide Number 124
• Slide Number 125
• DIC Take Home Messages
• Slide Number 127
• Slide Number 128

Case Study 7 ndash Lab Results vs Time

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

Lab values from Oct 25 consistent with DIC given packed RBCs FFP cryo plts and vit K to treat peritoneal bleeding which stopped by Oct 26Over next few days continued to require norepinephrine but eventually vital signs and laboratory values stabilizedDuring next few days improvement was apparent but found to have multiple infections including vancomycin-resistant enterococcus (VRE) along with Stenotrophomonas maltophilia peritoneal fluid growing Acinetobacter and urinalysis growing Candida glabrata

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 29 started on daptomycin linezolid trimethoprimsulfamethoxazole and fluconazole vancomycin and piperacillintazobactam were discontinuedHemodynamically stable taken off pressors and extubated on Nov 1In process of transfer from ICU became obtunded and hypotensive onFFP cryo platelets and packed RBCs were ordered but patient went into cardiac arrest and passed away

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

DIC Take Home Messages

Heterogeneous rapidly fatal syndromeEtiology sepsis tumors injuries or obstetric complicationsSimultaneous activation of coagulation and fibrinolysis Consumption of factors anticoagulant proteins fibrinogen and plateletsDiagnosis not with a single test panel including activation markers Screening coags platelets FMFS and D-dimer 1st consideration treat the critical symptoms and underlying issue 2nd consideration compensation for the consumption and sometimes anticoagulation

Monitor efficacy of therapy Activation markers (D-Dimer FMFSP) Normalization of coagulation markers

DIC

Thank you Questions

• Disseminated Intravascular Coagulation (DIC) and Thrombosis The Critical Role of the Lab
• Learning Objectives
• Slide Number 3
• Slide Number 4
• Slide Number 5
• Slide Number 6
• Slide Number 7
• Slide Number 8
• Wound Sealing
• The Three Steps of Hemostasis
• Vessel Wall
• Slide Number 12
• Slide Number 13
• Platelet Structure UnactivatedActivated
• Primary Hemostasis
• Primary Hemostasis Assays
• Slide Number 17
• Coagulation is a balance between pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis
• Slide Number 19
• Coagulation factors
• Coagulation Assay Mechanisms
• Slide Number 22
• Fibrin Formation
• Slide Number 24
• Fibrinolysis Overview
• Fibrinolysis Overview
• Slide Number 27
• Fibrinolysis Releases D-dimers
• Basic Pathophysiology of DIC
• Disseminated Intravascular Coagulation (DIC)
• Purpura Fulminans with DIC Due to Meningococcal Sepsis
• Clinical Conditions Associated With DIC
• Frequency of DIC in Selected Disease States
• Underlying Diseases in DIC Patients
• Slide Number 36
• Slide Number 37
• Slide Number 38
• Slide Number 39
• Pathophysiology of DIC
• Pathogenesis of DIC in Sepsis
• Host Response in Severe Sepsis
• Organ Failure in Severe Sepsis
• Mechanism of DIC in Organ Failure
• Interaction of Inflammation and Coagulation in Sepsis
• Slide Number 47
• Diverse and Opposing Effects of Thrombin
• Coagulation and Fibrinolysis in DIC
• Mechanism of DIC
• Pathophysiology of DIC
• Pathophysiology of DIC - Mechanism
• Pathophysiology of DIC ndash 2 Types of Clinical pictures
• Sub-Acute and Non-Overt DIC Clinical Findings
• Pathophysiology of Overt DIC
• Physiopathology of DIC ndash Overt DIC Findings
• Slide Number 57
• Slide Number 58
• Slide Number 59
• Slide Number 60
• Slide Number 61
• BREAK
• Diagnostic and Management Approach for DIC
• Diagnosis of DIC
• Lab Diagnosis of DIC ndash Markers of Factor Consumption
• Lab Diagnosis of DIC ndash Screening Tests
• Slide Number 67
• Slide Number 68
• British Journal of Haematology Overt DIC Score
• Slide Number 70
• Slide Number 71
• Slide Number 72
• Slide Number 73
• DIC Management Goals
• DIC Management and Treatment
• DIC Management Strategies
• Anticoagulant Factor Concentrate Treatment
• Anticoagulant Factor Concentrate Treatment Trials
• Markers of Thrombin amp Plasmin Generation in DIC
• D-dimer FDPs and DIC
• D-Dimer and FDPs in DIC
• Follow Up of DIC State of Disease
• FMD-Dimer in DIC Major Differences
• of Abnormal Results in Patients with Confirmed and Suspected DIC
• Slide Number 85
• Slide Number 86
• Comparing an Automated FM vs Manual FSP Test
• Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Slide Number 98
• Slide Number 99
• DIC Case Studies
• Case Study 1 - Presentation
• Case Study 1 ndash Lab Results
• Case Study 1 ndash Microscopy
• Case Study 1 ndash Diagnosis and Therapy
• Slide Number 105
• Slide Number 106
• Slide Number 107
• Slide Number 108
• Slide Number 109
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Slide Number 113
• Slide Number 114
• Slide Number 115
• Slide Number 116
• Slide Number 117
• Slide Number 118
• Slide Number 119
• Slide Number 120
• Slide Number 121
• Slide Number 122
• Slide Number 123
• Slide Number 124
• Slide Number 125
• DIC Take Home Messages
• Slide Number 127
• Slide Number 128

Lab values from Oct 25 consistent with DIC given packed RBCs FFP cryo plts and vit K to treat peritoneal bleeding which stopped by Oct 26Over next few days continued to require norepinephrine but eventually vital signs and laboratory values stabilizedDuring next few days improvement was apparent but found to have multiple infections including vancomycin-resistant enterococcus (VRE) along with Stenotrophomonas maltophilia peritoneal fluid growing Acinetobacter and urinalysis growing Candida glabrata

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

On Oct 29 started on daptomycin linezolid trimethoprimsulfamethoxazole and fluconazole vancomycin and piperacillintazobactam were discontinuedHemodynamically stable taken off pressors and extubated on Nov 1In process of transfer from ICU became obtunded and hypotensive onFFP cryo platelets and packed RBCs were ordered but patient went into cardiac arrest and passed away

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

DIC Take Home Messages

Heterogeneous rapidly fatal syndromeEtiology sepsis tumors injuries or obstetric complicationsSimultaneous activation of coagulation and fibrinolysis Consumption of factors anticoagulant proteins fibrinogen and plateletsDiagnosis not with a single test panel including activation markers Screening coags platelets FMFS and D-dimer 1st consideration treat the critical symptoms and underlying issue 2nd consideration compensation for the consumption and sometimes anticoagulation

Monitor efficacy of therapy Activation markers (D-Dimer FMFSP) Normalization of coagulation markers

DIC

Thank you Questions

• Disseminated Intravascular Coagulation (DIC) and Thrombosis The Critical Role of the Lab
• Learning Objectives
• Slide Number 3
• Slide Number 4
• Slide Number 5
• Slide Number 6
• Slide Number 7
• Slide Number 8
• Wound Sealing
• The Three Steps of Hemostasis
• Vessel Wall
• Slide Number 12
• Slide Number 13
• Platelet Structure UnactivatedActivated
• Primary Hemostasis
• Primary Hemostasis Assays
• Slide Number 17
• Coagulation is a balance between pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis
• Slide Number 19
• Coagulation factors
• Coagulation Assay Mechanisms
• Slide Number 22
• Fibrin Formation
• Slide Number 24
• Fibrinolysis Overview
• Fibrinolysis Overview
• Slide Number 27
• Fibrinolysis Releases D-dimers
• Basic Pathophysiology of DIC
• Disseminated Intravascular Coagulation (DIC)
• Purpura Fulminans with DIC Due to Meningococcal Sepsis
• Clinical Conditions Associated With DIC
• Frequency of DIC in Selected Disease States
• Underlying Diseases in DIC Patients
• Slide Number 36
• Slide Number 37
• Slide Number 38
• Slide Number 39
• Pathophysiology of DIC
• Pathogenesis of DIC in Sepsis
• Host Response in Severe Sepsis
• Organ Failure in Severe Sepsis
• Mechanism of DIC in Organ Failure
• Interaction of Inflammation and Coagulation in Sepsis
• Slide Number 47
• Diverse and Opposing Effects of Thrombin
• Coagulation and Fibrinolysis in DIC
• Mechanism of DIC
• Pathophysiology of DIC
• Pathophysiology of DIC - Mechanism
• Pathophysiology of DIC ndash 2 Types of Clinical pictures
• Sub-Acute and Non-Overt DIC Clinical Findings
• Pathophysiology of Overt DIC
• Physiopathology of DIC ndash Overt DIC Findings
• Slide Number 57
• Slide Number 58
• Slide Number 59
• Slide Number 60
• Slide Number 61
• BREAK
• Diagnostic and Management Approach for DIC
• Diagnosis of DIC
• Lab Diagnosis of DIC ndash Markers of Factor Consumption
• Lab Diagnosis of DIC ndash Screening Tests
• Slide Number 67
• Slide Number 68
• British Journal of Haematology Overt DIC Score
• Slide Number 70
• Slide Number 71
• Slide Number 72
• Slide Number 73
• DIC Management Goals
• DIC Management and Treatment
• DIC Management Strategies
• Anticoagulant Factor Concentrate Treatment
• Anticoagulant Factor Concentrate Treatment Trials
• Markers of Thrombin amp Plasmin Generation in DIC
• D-dimer FDPs and DIC
• D-Dimer and FDPs in DIC
• Follow Up of DIC State of Disease
• FMD-Dimer in DIC Major Differences
• of Abnormal Results in Patients with Confirmed and Suspected DIC
• Slide Number 85
• Slide Number 86
• Comparing an Automated FM vs Manual FSP Test
• Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Slide Number 98
• Slide Number 99
• DIC Case Studies
• Case Study 1 - Presentation
• Case Study 1 ndash Lab Results
• Case Study 1 ndash Microscopy
• Case Study 1 ndash Diagnosis and Therapy
• Slide Number 105
• Slide Number 106
• Slide Number 107
• Slide Number 108
• Slide Number 109
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Slide Number 113
• Slide Number 114
• Slide Number 115
• Slide Number 116
• Slide Number 117
• Slide Number 118
• Slide Number 119
• Slide Number 120
• Slide Number 121
• Slide Number 122
• Slide Number 123
• Slide Number 124
• Slide Number 125
• DIC Take Home Messages
• Slide Number 127
• Slide Number 128

On Oct 29 started on daptomycin linezolid trimethoprimsulfamethoxazole and fluconazole vancomycin and piperacillintazobactam were discontinuedHemodynamically stable taken off pressors and extubated on Nov 1In process of transfer from ICU became obtunded and hypotensive onFFP cryo platelets and packed RBCs were ordered but patient went into cardiac arrest and passed away

Case Study 7 ndash Diagnosis and Treatment

Boral BM Williams DJ Boral LI Disseminated Intravascular Coagulation Am J Clin Pathol 2016 146 670-80

DIC Take Home Messages

Heterogeneous rapidly fatal syndromeEtiology sepsis tumors injuries or obstetric complicationsSimultaneous activation of coagulation and fibrinolysis Consumption of factors anticoagulant proteins fibrinogen and plateletsDiagnosis not with a single test panel including activation markers Screening coags platelets FMFS and D-dimer 1st consideration treat the critical symptoms and underlying issue 2nd consideration compensation for the consumption and sometimes anticoagulation

Monitor efficacy of therapy Activation markers (D-Dimer FMFSP) Normalization of coagulation markers

DIC

Thank you Questions

• Disseminated Intravascular Coagulation (DIC) and Thrombosis The Critical Role of the Lab
• Learning Objectives
• Slide Number 3
• Slide Number 4
• Slide Number 5
• Slide Number 6
• Slide Number 7
• Slide Number 8
• Wound Sealing
• The Three Steps of Hemostasis
• Vessel Wall
• Slide Number 12
• Slide Number 13
• Platelet Structure UnactivatedActivated
• Primary Hemostasis
• Primary Hemostasis Assays
• Slide Number 17
• Coagulation is a balance between pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis
• Slide Number 19
• Coagulation factors
• Coagulation Assay Mechanisms
• Slide Number 22
• Fibrin Formation
• Slide Number 24
• Fibrinolysis Overview
• Fibrinolysis Overview
• Slide Number 27
• Fibrinolysis Releases D-dimers
• Basic Pathophysiology of DIC
• Disseminated Intravascular Coagulation (DIC)
• Purpura Fulminans with DIC Due to Meningococcal Sepsis
• Clinical Conditions Associated With DIC
• Frequency of DIC in Selected Disease States
• Underlying Diseases in DIC Patients
• Slide Number 36
• Slide Number 37
• Slide Number 38
• Slide Number 39
• Pathophysiology of DIC
• Pathogenesis of DIC in Sepsis
• Host Response in Severe Sepsis
• Organ Failure in Severe Sepsis
• Mechanism of DIC in Organ Failure
• Interaction of Inflammation and Coagulation in Sepsis
• Slide Number 47
• Diverse and Opposing Effects of Thrombin
• Coagulation and Fibrinolysis in DIC
• Mechanism of DIC
• Pathophysiology of DIC
• Pathophysiology of DIC - Mechanism
• Pathophysiology of DIC ndash 2 Types of Clinical pictures
• Sub-Acute and Non-Overt DIC Clinical Findings
• Pathophysiology of Overt DIC
• Physiopathology of DIC ndash Overt DIC Findings
• Slide Number 57
• Slide Number 58
• Slide Number 59
• Slide Number 60
• Slide Number 61
• BREAK
• Diagnostic and Management Approach for DIC
• Diagnosis of DIC
• Lab Diagnosis of DIC ndash Markers of Factor Consumption
• Lab Diagnosis of DIC ndash Screening Tests
• Slide Number 67
• Slide Number 68
• British Journal of Haematology Overt DIC Score
• Slide Number 70
• Slide Number 71
• Slide Number 72
• Slide Number 73
• DIC Management Goals
• DIC Management and Treatment
• DIC Management Strategies
• Anticoagulant Factor Concentrate Treatment
• Anticoagulant Factor Concentrate Treatment Trials
• Markers of Thrombin amp Plasmin Generation in DIC
• D-dimer FDPs and DIC
• D-Dimer and FDPs in DIC
• Follow Up of DIC State of Disease
• FMD-Dimer in DIC Major Differences
• of Abnormal Results in Patients with Confirmed and Suspected DIC
• Slide Number 85
• Slide Number 86
• Comparing an Automated FM vs Manual FSP Test
• Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Slide Number 98
• Slide Number 99
• DIC Case Studies
• Case Study 1 - Presentation
• Case Study 1 ndash Lab Results
• Case Study 1 ndash Microscopy
• Case Study 1 ndash Diagnosis and Therapy
• Slide Number 105
• Slide Number 106
• Slide Number 107
• Slide Number 108
• Slide Number 109
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Slide Number 113
• Slide Number 114
• Slide Number 115
• Slide Number 116
• Slide Number 117
• Slide Number 118
• Slide Number 119
• Slide Number 120
• Slide Number 121
• Slide Number 122
• Slide Number 123
• Slide Number 124
• Slide Number 125
• DIC Take Home Messages
• Slide Number 127
• Slide Number 128

DIC Take Home Messages

Heterogeneous rapidly fatal syndromeEtiology sepsis tumors injuries or obstetric complicationsSimultaneous activation of coagulation and fibrinolysis Consumption of factors anticoagulant proteins fibrinogen and plateletsDiagnosis not with a single test panel including activation markers Screening coags platelets FMFS and D-dimer 1st consideration treat the critical symptoms and underlying issue 2nd consideration compensation for the consumption and sometimes anticoagulation

Monitor efficacy of therapy Activation markers (D-Dimer FMFSP) Normalization of coagulation markers

DIC

Thank you Questions

• Disseminated Intravascular Coagulation (DIC) and Thrombosis The Critical Role of the Lab
• Learning Objectives
• Slide Number 3
• Slide Number 4
• Slide Number 5
• Slide Number 6
• Slide Number 7
• Slide Number 8
• Wound Sealing
• The Three Steps of Hemostasis
• Vessel Wall
• Slide Number 12
• Slide Number 13
• Platelet Structure UnactivatedActivated
• Primary Hemostasis
• Primary Hemostasis Assays
• Slide Number 17
• Coagulation is a balance between pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis
• Slide Number 19
• Coagulation factors
• Coagulation Assay Mechanisms
• Slide Number 22
• Fibrin Formation
• Slide Number 24
• Fibrinolysis Overview
• Fibrinolysis Overview
• Slide Number 27
• Fibrinolysis Releases D-dimers
• Basic Pathophysiology of DIC
• Disseminated Intravascular Coagulation (DIC)
• Purpura Fulminans with DIC Due to Meningococcal Sepsis
• Clinical Conditions Associated With DIC
• Frequency of DIC in Selected Disease States
• Underlying Diseases in DIC Patients
• Slide Number 36
• Slide Number 37
• Slide Number 38
• Slide Number 39
• Pathophysiology of DIC
• Pathogenesis of DIC in Sepsis
• Host Response in Severe Sepsis
• Organ Failure in Severe Sepsis
• Mechanism of DIC in Organ Failure
• Interaction of Inflammation and Coagulation in Sepsis
• Slide Number 47
• Diverse and Opposing Effects of Thrombin
• Coagulation and Fibrinolysis in DIC
• Mechanism of DIC
• Pathophysiology of DIC
• Pathophysiology of DIC - Mechanism
• Pathophysiology of DIC ndash 2 Types of Clinical pictures
• Sub-Acute and Non-Overt DIC Clinical Findings
• Pathophysiology of Overt DIC
• Physiopathology of DIC ndash Overt DIC Findings
• Slide Number 57
• Slide Number 58
• Slide Number 59
• Slide Number 60
• Slide Number 61
• BREAK
• Diagnostic and Management Approach for DIC
• Diagnosis of DIC
• Lab Diagnosis of DIC ndash Markers of Factor Consumption
• Lab Diagnosis of DIC ndash Screening Tests
• Slide Number 67
• Slide Number 68
• British Journal of Haematology Overt DIC Score
• Slide Number 70
• Slide Number 71
• Slide Number 72
• Slide Number 73
• DIC Management Goals
• DIC Management and Treatment
• DIC Management Strategies
• Anticoagulant Factor Concentrate Treatment
• Anticoagulant Factor Concentrate Treatment Trials
• Markers of Thrombin amp Plasmin Generation in DIC
• D-dimer FDPs and DIC
• D-Dimer and FDPs in DIC
• Follow Up of DIC State of Disease
• FMD-Dimer in DIC Major Differences
• of Abnormal Results in Patients with Confirmed and Suspected DIC
• Slide Number 85
• Slide Number 86
• Comparing an Automated FM vs Manual FSP Test
• Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Slide Number 98
• Slide Number 99
• DIC Case Studies
• Case Study 1 - Presentation
• Case Study 1 ndash Lab Results
• Case Study 1 ndash Microscopy
• Case Study 1 ndash Diagnosis and Therapy
• Slide Number 105
• Slide Number 106
• Slide Number 107
• Slide Number 108
• Slide Number 109
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Slide Number 113
• Slide Number 114
• Slide Number 115
• Slide Number 116
• Slide Number 117
• Slide Number 118
• Slide Number 119
• Slide Number 120
• Slide Number 121
• Slide Number 122
• Slide Number 123
• Slide Number 124
• Slide Number 125
• DIC Take Home Messages
• Slide Number 127
• Slide Number 128

DIC

Thank you Questions

• Disseminated Intravascular Coagulation (DIC) and Thrombosis The Critical Role of the Lab
• Learning Objectives
• Slide Number 3
• Slide Number 4
• Slide Number 5
• Slide Number 6
• Slide Number 7
• Slide Number 8
• Wound Sealing
• The Three Steps of Hemostasis
• Vessel Wall
• Slide Number 12
• Slide Number 13
• Platelet Structure UnactivatedActivated
• Primary Hemostasis
• Primary Hemostasis Assays
• Slide Number 17
• Coagulation is a balance between pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis
• Slide Number 19
• Coagulation factors
• Coagulation Assay Mechanisms
• Slide Number 22
• Fibrin Formation
• Slide Number 24
• Fibrinolysis Overview
• Fibrinolysis Overview
• Slide Number 27
• Fibrinolysis Releases D-dimers
• Basic Pathophysiology of DIC
• Disseminated Intravascular Coagulation (DIC)
• Purpura Fulminans with DIC Due to Meningococcal Sepsis
• Clinical Conditions Associated With DIC
• Frequency of DIC in Selected Disease States
• Underlying Diseases in DIC Patients
• Slide Number 36
• Slide Number 37
• Slide Number 38
• Slide Number 39
• Pathophysiology of DIC
• Pathogenesis of DIC in Sepsis
• Host Response in Severe Sepsis
• Organ Failure in Severe Sepsis
• Mechanism of DIC in Organ Failure
• Interaction of Inflammation and Coagulation in Sepsis
• Slide Number 47
• Diverse and Opposing Effects of Thrombin
• Coagulation and Fibrinolysis in DIC
• Mechanism of DIC
• Pathophysiology of DIC
• Pathophysiology of DIC - Mechanism
• Pathophysiology of DIC ndash 2 Types of Clinical pictures
• Sub-Acute and Non-Overt DIC Clinical Findings
• Pathophysiology of Overt DIC
• Physiopathology of DIC ndash Overt DIC Findings
• Slide Number 57
• Slide Number 58
• Slide Number 59
• Slide Number 60
• Slide Number 61
• BREAK
• Diagnostic and Management Approach for DIC
• Diagnosis of DIC
• Lab Diagnosis of DIC ndash Markers of Factor Consumption
• Lab Diagnosis of DIC ndash Screening Tests
• Slide Number 67
• Slide Number 68
• British Journal of Haematology Overt DIC Score
• Slide Number 70
• Slide Number 71
• Slide Number 72
• Slide Number 73
• DIC Management Goals
• DIC Management and Treatment
• DIC Management Strategies
• Anticoagulant Factor Concentrate Treatment
• Anticoagulant Factor Concentrate Treatment Trials
• Markers of Thrombin amp Plasmin Generation in DIC
• D-dimer FDPs and DIC
• D-Dimer and FDPs in DIC
• Follow Up of DIC State of Disease
• FMD-Dimer in DIC Major Differences
• of Abnormal Results in Patients with Confirmed and Suspected DIC
• Slide Number 85
• Slide Number 86
• Comparing an Automated FM vs Manual FSP Test
• Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Slide Number 98
• Slide Number 99
• DIC Case Studies
• Case Study 1 - Presentation
• Case Study 1 ndash Lab Results
• Case Study 1 ndash Microscopy
• Case Study 1 ndash Diagnosis and Therapy
• Slide Number 105
• Slide Number 106
• Slide Number 107
• Slide Number 108
• Slide Number 109
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Slide Number 113
• Slide Number 114
• Slide Number 115
• Slide Number 116
• Slide Number 117
• Slide Number 118
• Slide Number 119
• Slide Number 120
• Slide Number 121
• Slide Number 122
• Slide Number 123
• Slide Number 124
• Slide Number 125
• DIC Take Home Messages
• Slide Number 127
• Slide Number 128

Thank you Questions

• Disseminated Intravascular Coagulation (DIC) and Thrombosis The Critical Role of the Lab
• Learning Objectives
• Slide Number 3
• Slide Number 4
• Slide Number 5
• Slide Number 6
• Slide Number 7
• Slide Number 8
• Wound Sealing
• The Three Steps of Hemostasis
• Vessel Wall
• Slide Number 12
• Slide Number 13
• Platelet Structure UnactivatedActivated
• Primary Hemostasis
• Primary Hemostasis Assays
• Slide Number 17
• Coagulation is a balance between pro- amp anti-coagulant mechanisms bleed amp clot hemorrhage amp thrombosis
• Slide Number 19
• Coagulation factors
• Coagulation Assay Mechanisms
• Slide Number 22
• Fibrin Formation
• Slide Number 24
• Fibrinolysis Overview
• Fibrinolysis Overview
• Slide Number 27
• Fibrinolysis Releases D-dimers
• Basic Pathophysiology of DIC
• Disseminated Intravascular Coagulation (DIC)
• Purpura Fulminans with DIC Due to Meningococcal Sepsis
• Clinical Conditions Associated With DIC
• Frequency of DIC in Selected Disease States
• Underlying Diseases in DIC Patients
• Slide Number 36
• Slide Number 37
• Slide Number 38
• Slide Number 39
• Pathophysiology of DIC
• Pathogenesis of DIC in Sepsis
• Host Response in Severe Sepsis
• Organ Failure in Severe Sepsis
• Mechanism of DIC in Organ Failure
• Interaction of Inflammation and Coagulation in Sepsis
• Slide Number 47
• Diverse and Opposing Effects of Thrombin
• Coagulation and Fibrinolysis in DIC
• Mechanism of DIC
• Pathophysiology of DIC
• Pathophysiology of DIC - Mechanism
• Pathophysiology of DIC ndash 2 Types of Clinical pictures
• Sub-Acute and Non-Overt DIC Clinical Findings
• Pathophysiology of Overt DIC
• Physiopathology of DIC ndash Overt DIC Findings
• Slide Number 57
• Slide Number 58
• Slide Number 59
• Slide Number 60
• Slide Number 61
• BREAK
• Diagnostic and Management Approach for DIC
• Diagnosis of DIC
• Lab Diagnosis of DIC ndash Markers of Factor Consumption
• Lab Diagnosis of DIC ndash Screening Tests
• Slide Number 67
• Slide Number 68
• British Journal of Haematology Overt DIC Score
• Slide Number 70
• Slide Number 71
• Slide Number 72
• Slide Number 73
• DIC Management Goals
• DIC Management and Treatment
• DIC Management Strategies
• Anticoagulant Factor Concentrate Treatment
• Anticoagulant Factor Concentrate Treatment Trials
• Markers of Thrombin amp Plasmin Generation in DIC
• D-dimer FDPs and DIC
• D-Dimer and FDPs in DIC
• Follow Up of DIC State of Disease
• FMD-Dimer in DIC Major Differences
• of Abnormal Results in Patients with Confirmed and Suspected DIC
• Slide Number 85
• Slide Number 86
• Comparing an Automated FM vs Manual FSP Test
• Baseline Characteristics in Study of Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Diagnostic Performance of FM and D-dimer in DIC
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Slide Number 98
• Slide Number 99
• DIC Case Studies
• Case Study 1 - Presentation
• Case Study 1 ndash Lab Results
• Case Study 1 ndash Microscopy
• Case Study 1 ndash Diagnosis and Therapy
• Slide Number 105
• Slide Number 106
• Slide Number 107
• Slide Number 108
• Slide Number 109
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Slide Number 113
• Slide Number 114
• Slide Number 115
• Slide Number 116
• Slide Number 117
• Slide Number 118
• Slide Number 119
• Slide Number 120
• Slide Number 121
• Slide Number 122
• Slide Number 123
• Slide Number 124
• Slide Number 125
• DIC Take Home Messages
• Slide Number 127
• Slide Number 128