|Year : 2018 | Volume
| Issue : 4 | Page : 166-170
Assessment of D-dimer and protein S in Egyptian patients with cirrhosis with and without ascites
Wesam A Ibrahim1, Nesma A Safwat2, Mohamed M.M Ibrahim1, Millimi A Djibrin1
1 Department of Internal Medicine and Gastroenterology, Ain Shams University, Cairo, Egypt
2 Department of Clinical Pathology, Ain Shams University, Cairo, Egypt
|Date of Submission||11-Jul-2018|
|Date of Acceptance||06-Aug-2018|
|Date of Web Publication||10-Apr-2019|
Nesma A Safwat
41 Mohammed Fareed Street, Heliopolis, 11757
Source of Support: None, Conflict of Interest: None
Background Liver cirrhosis is characterized by complex hemostatic defects, leading to both hemorrhagic and thrombotic complications. It is also associated with ascites. Being a derivative of plasma that accumulates in the abdominal cavity from transudative leakage out of cirrhotic liver and because ascites re-enters the systemic circulation, cirrhotic ascites may be a pathological fluid that contributes to hemostatic derangement in these patients. The aim of study was to measure plasma levels of d-dimer and protein S (PS) activity as hemostatic parameters in patients with cirrhosis of varying severity with and without ascites to evaluate the role of ascites as a contributor of coagulopathy associated with liver cirrhosis.
Patients and methods A total of 90 patients with cirrhosis with varying degree of severity owing to hepatitis C admitted to Ain Shams University hospitals from January 2017 to January 2018 were included in this study. Patients were categorized into two groups: group I included patients with cirrhosis complicated with ascites (n=38), and group II included patients with cirrhosis without ascites (n=52). The severity of liver disease was assessed according to the Child–Pugh classification. Plasma samples from each patient were analyzed for the level of d-dimer and PS activity.
Results Plasma d-dimer levels showed a significant increase in patients with ascites (2.04±0.38 mg/l) when compared with those without. However, PS activity was significantly decreased in presence of ascites (45.79±1.66%). These changes appeared to be significantly accompanied by the progression of liver dysfunction. Upon performing regression analysis (backward method), it was proved that ascites formation was a significant independent factor that increases d-dimer levels and deteriorates PS activity in patients with cirrhosis.
Conclusion Our results suggest that ascites contributes to the coagulopathy in decompensated liver disease, and the degree of coagulopathy was proportional to the severity of liver disease.
Keywords: ascites, D-dimer, liver cirrhosis, protein S
|How to cite this article:|
Ibrahim WA, Safwat NA, Ibrahim MM, Djibrin MA. Assessment of D-dimer and protein S in Egyptian patients with cirrhosis with and without ascites. Egypt J Haematol 2018;43:166-70
|How to cite this URL:|
Ibrahim WA, Safwat NA, Ibrahim MM, Djibrin MA. Assessment of D-dimer and protein S in Egyptian patients with cirrhosis with and without ascites. Egypt J Haematol [serial online] 2018 [cited 2019 Oct 23];43:166-70. Available from: http://www.ehj.eg.net/text.asp?2018/43/4/166/255871
| Introduction|| |
Liver cirrhosis is a severe hepatic parenchymal disease with potentially life-threatening complications. Patients with decompensated liver cirrhosis have significantly impaired synthetic functions. Many proteins involved in the coagulation process are synthesized in the liver. This has led to the widespread belief that decompensated liver cirrhosis is a prototype of hemorrhagic coagulopathy. Now it is realized that coagulation is a complex process involving the interaction of procoagulation, anticoagulation and the fibrinolytic system .
As both procoagulant and anticoagulant proteins are affected in liver disease, laboratory testing, which take into account the interplay between the various coagulant forces, can predict thrombosis and bleeding risk in patients with hepatic dysfunction .
The abnormalities of anticoagulant proteins are not well reflected in the current routine coagulation testing; however, they could theoretically provide an index of clotting potential . The plasma glycoprotein protein S (PS) is mainly formed by the liver and acts as an important cofactor for activated PC and enhances the PC-mediated inactivation of factor Va and factor VIIIa. Concentrations of PS decline with advanced hepatic dysfunction .
Cirrhosis is also considered to be a hyperfibrinolytic state. d-Dimer, a breakdown product of cross linked fibrin, is an accurate marker of fibrinolytic activity. d-Dimer levels increase with deteriorating liver function .
Because advanced liver disease is associated with decline of PS concentrations and/or activity, exaggerated fibrinolysis as well as ascites and based on the fact that ascites is a plasma-derived fluid that contains coagulation-relevant proteins that re-enters the circulation , we conducted this work to test the hypothesis that cirrhotic ascites may be a pathological fluid that contribute to hemostatic derangement.
| Aim|| |
This study aimed to measure plasma levels of d-dimer and PS activity as hemostatic parameters in patients with cirrhosis of varying severity with and without ascites to evaluate the role of ascites as a contributor of coagulopathy associated with liver cirrhosis.
| Patients and methods|| |
This study was conducted on 90 patients with liver cirrhosis with varying degree of severity owing to hepatitis C, who were selected from the in-patient section of Internal Medicine Department, Ain Shams University Hospitals, during the period between January 2017 and January 2018. Their ages ranged from 24 to 74 years (mean 53.27±9.26 years). A total of 62 were males and 28 were females, with a male to female ratio of 2.2 : 1.Criteria for exclusion were hepatocellular carcinoma or other cancer and known hemostatic disorders other than cirrhosis. No patients were receiving blood transfusion, human albumin, antiaggregates or anticoagulants. The severity of liver disease was assessed according to the Child–Pugh classification . Patients were categorized into two groups: one group patients with cirrhosis complicated with ascites (n=38), and the other group included patients with cirrhosis without ascites (n=52).
All patients were asked to give an informed consent before participation in the study. The procedures applied in this study were approved by the Ethical Committee of Human Experimentation of Ain Shams University and are in accordance with the Helsinki Declaration of 1975.
Cirrhosis was diagnosed based on the history of liver disease; clinical presentations such as variceal haemorrhage, ascites, hepatic encephalopathy or spontaneous bacterial periotinitis; laboratory testing indicating decreased liver function; and imaging studies, which included abdominal ultrasound .
Three blood samples were taken from each patient: the first one is for complete blood picture using LH 750 (Bechman Coulter Inc., Fullerton, California, USA). The second one is to assess the coagulation state: prothrombin time (PT) and international normalization ratio (INR) using neoplastin CL plus supplied by Diagnostica Stago,Asnieres sur seine Marburg, France, in addition to estimation of d-dimer and PS levels. Plasma d-dimer was quantitatively estimated using immunoturbidimetric assay (innovence d-dimer; Siemens,Marburg,Germany), and functional activity of PS was determined by protein S Ac, Siemens. Both d-dimer and PS were tested using Siemens Coagulation analyzer. The third sample was used for liver function tests [total bilirubin, albumin, alanine transaminase (ALT), aspartate transaminase (AST) and alkaline phosphatase (ALP)]. Their analysis was done on AU 480 autoanalyser (Beckman Coulter Inc.).
Two milliliter of peripheral venous blood was collected in tubes containing EDTA (1.2 mg/ml) for complete blood count. Another 2 ml of peripheral venous blood was collected in Na citrate vacutainer for the performance of coagulation profile. For d-dimer and PS, re-centrifugation was done for 15 000g for 10 min, and plasma samples were frozen at −20°C until assay. Gel-activated vacutainers were used for serum separation of peripheral venous blood samples for determination of liver function tests.
Data were collected, revised, and entered into the statistical package for the social sciences (IBM SPSS) version 21(SPSS 21, IBM, Armonk, NY, United States of America). Qualitative data were presented as numbers and percentages whereas quantitative data were entered into Kolmogorov–Smirnov test of normality, and parametric distribution data were presented as mean, SD, and range. To compare parametric quantitative variables between the two groups, Student’s t-test was applied. For comparison of nonparametric quantitative variables between the two groups, Mann–Whitney test was used. The comparison between the two groups with qualitative data was done using χ2-test. A one-way analysis of variance was used when comparing between more than two means. Post-hoc test was used for multiple comparisons between different variables. The association between two variables among normally distributed data was done by Pearson correlation and by Spearman’s correlation among nonparametric data. Logistic regression analysis was employed to determine variables affected by the presence of ascites.
| Results|| |
Epidemiological, laboratory, and radiological findings of both studied groups are shown in [Table 1].
|Table 1 Epidemiological, laboratory and radiological finding of both studied groups|
Click here to view
D-Dimer level among studied groups
The mean d-dimer levels showed significant increase in patients with ascites when compared with patients without ([Table 1] and [Figure 1]). Then we correlated the plasma levels of d-dimer with the progression toward liver failure, which was reflected by Child–Pugh scores. As shown in [Table 2], d-dimer levels appeared to increase from Child–Pugh class A–C, and there was a significant increase between the two studied groups in each class (P<0.05).
|Figure 1 D-Dimer levels in patients with cirrhosis with and without ascites.|
Click here to view
|Table 2 D-Dimer and protein S levels in the two studied groups according to Child–Pugh classification|
Click here to view
In all studied patients, d-dimer was negatively correlated with hemoglobin level, platelets count, serum albumin, PS activity, and hepatic span. However, it was positively correlated with AST and ALP levels, total and direct bilirubin, PT, INR, and splenic size ([Table 3]).
|Table 3 Correlation between D-dimer, laboratory data and radiological findings in all studied patients|
Click here to view
Protein S activity among the studied groups
Between the two groups of patients with liver cirrhosis with and without ascites, there was a significant decrease in PS activity ([Table 1] and [Figure 2]). In Child–Pugh class B and C, PS activity was significantly lower in the group with ascites (P<0.05; [Table 2]).
|Figure 2 Protein S activity in patients with cirrhosis with and without ascites.|
Click here to view
Regarding the relation between PS and studied parameters, a positive correlation between PS activity and hemoglobin level, platelets count, serum albumin, and hepatic size was reported. We also noticed a negative correlation with AST, ALP, total and direct bilirubin, PT, d-dimer level and INR ([Table 4]).
|Table 4 Correlation between protein S, laboratory data and radiological findings in all studied patients|
Click here to view
Effect of ascites on d-dimer and protein S activity
A regression analysis was constructed to evaluate the effect of ascites on the studied parameters. When d-dimer and PS activity were calculated in multivariate logistic regression analysis by backward (Wald) method, it was proved that ascites formation was a significant independent factor that increases d-dimer levels and deteriorates PS activity in patients with cirrhosis ([Table 5]).
|Table 5 Multivariate logistic regression analysis by backward method (Wald) for predictors of ascites:|
Click here to view
| Discussion|| |
Following the earlier observations that cirrhotic ascites contains plasma proteins that participate in coagulation and fibrinolysis, which is in continuous turnover with plasma , we conducted the current study in an attempt to test the hypothesis that ascites plays a role in hemostatic dysregulation state associated with liver cirrhosis.
Our results showed a significantly higher d-dimer levels in patients with cirrhosis decompensated with ascites compared with those without ascites. Likewise, Saray et al.  showed the same finding. This may be explained by the observation of increased d-dimer levels detected in ascetic fluid, suggesting that ascites reabsorption into systemic circulation contributes to hyperfibrinolytic state in patients with advanced liver disease . This hypothesis was underlined with the study of Saray et al.  who reported significant decrease of circulating d-dimer after ascites depletion. Moreover, in a previous study by Spadaro et al.  mean d-dimer levels in patients with cirrhosis with resolved ascites were not significantly different from those in patients who entered the study without ascites. Therefore, these findings and ours suggest a major role of ascites in the pathogenesis of the hyperfibrinolysis in patients with cirrhosis.
The underlying mechanism of hyperfibrinolysis in patients with cirrhosis with ascites is not yet clearly known . Some authors suggest the exchange of some coagulation and fibriolytic proteins between plasma and ascetic fluid . Violi et al.  proposed that hyperfibrinolysis in cirrhosis is a secondary phenomenon, related to the passage of gut-absorbed bacterial material into the systemic circulation, with a consequent activation of the clotting system in a sort of low-grade disseminated intravascular coagulation. On the basis of this finding, Piscaglia et al.  argue that the association between high plasma d-dimer and ascites might be owing only to more advanced liver disease with portal hypertension favoring bacterial translocation. This was evidenced by our findings that circulating d-dimer levels were dramatically higher in patients with ascites when stratified according to Child–Pugh scores.
Similarly, Gursoy et al.  noticed that d-dimer was found to be increased with increasing severity of hepatocyte damage, as it was the only parameter that differed significantly between Child A and B patients. Thus, it was considered as an important sign of decompensation in patients with cirrhosis.
Interestingly, an observation was reported by Agarwal et al. , which suggests that although ascites fluid has fibrinolytic activity, it does not cause systemic fibrinolysis in the absence of liver disease. If ascites leads to a systemic fibrinolytic state, it may happen in a situation in which compromised liver function is permissive.
PS, a vitamin K-dependent plasma glycoprotein, is mainly synthesized in the liver and has been proposed as a sensitive indicator of liver cell dysfunction . PS production and/or activity decreases in a higher proportion in patients with cirrhosis. Thus, a relatively hypercoagulable state can develop, and these patients can be at real risk for thromboembolic disease .
Ascites is a plasma derivative that accumulates in the abdominal cavity from transudative leakage out of cirrhotic liver. An exchange of plasma proteins between peritoneal cavity and plasma has been demonstrated, and proteins have been detected in ascites in patients with cirrhosis, suggesting the existence of homeostatic mechanisms of control between the two compartments .
In the light of two previous observations, the significant decrease of PS activity in patients with cirrhosis decompensated with ascites could be explained. On evaluating PS activity among the two studied groups when they were divided according to Child–Pugh scores, we reported that PS activity was progressively decreased from A and B to C. A significant difference was obtained in the latter two classes. These results are in parallel with the findings of a prospective study published by Cong et al.  who concluded that there is a close relationship between the severity of cirrhosis and the hemostatic changes including increasing fibrinolytic activity and disturbance of the coagulation function.
Hyperfibrinolysis is one of the several conditions that are superimposed onto liver disease-related coagulopathy. On the contrary, the anticoagulant system that normally balances clotting is deranged in liver cirrhosis. Taken together these considerations with increases in factors produced in the endothelium of the blood vessels, such as factor VIII and von Willebrand factor, lead to a relative hypercoagulable state . These observations coupled with our results regarding the effect of ascites on d-dimer levels and PS activity suggest that ascites contributes to the coagulopathy in decompensated liver disease, and the degree of coagulopathy was proportional to the severity of liver disease. Patients with cirrhosis decompensated by ascites are at imminent risk of thromboembolism, thereby close monitoring to take preventive measures in time is mandatory.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Amarapurkar PD, Amarapurkar L. Management of coagulopathy in patients with decompensated liver cirrhosis. Int J Hepatol
Hodge A, Crispin P. Coagulopathy in liver disease: the whole is greater than the sum of its parts. J Gastroenterol Hepatol
Shah NNL, Caldwell SH. Assessing the risk of bleeding and clotting in cirrhosis. Clin Liver Dis
Zocco MA, Di Stasio E, De Cristofaro R, Novi M, Ainora ME, Ponziani F et al.
Thrombotic risk factors in patients with liver cirrhosis: correlation with MELD scoring system and portal vein thrombosis development. J Hepatol
Zhang D, Hao J, Yang N. Protein C and D-dimer are related to PVT in patients with liver cirrhosis. J Gasteroentrol Hepatol
Agarwal S, Joyner KA, Swaim MW. Ascites fluid as a possible origin for hyperfibrinolysis in advanced liver disease. Am J Gastroenterol
Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg
Schuppan D, Afdhal NH. Liver cirrhosis. Lancet
Saray A, Mesihovic R, Gornjakovic S, Vanis N, Mehmedovic A, Nahodovic K et al.
Association between high D-dimer plasma levels and ascites in patients with liver cirrhosis. Med Arch
Spadaro A, Tortorella V, Morace C, Fortiguerra A, Composto P, Bonfiglio C et al.
High circulating D-dimers are associated with ascites and hepatocellular carcinoma in liver cirrhosis. World J Gastroenterol
Toschi V, Rocchini GM, Motta A, Fiorini GF, Cimminiello C, Violi F et al.
The hyperfibrinolytic state of liver cirrhosis: possible pathogenic role of asites. Biomed Pharmacother
Violi F, Ferro D, Basili S, Saliola M, Quintarelli C, Alessandri C, Cordova C. Association between low grade disseminated intravascular coagulation and endotoxin in patients with liver cirrhosis. Gastroenterology
Piscaglia F, Donati G, Giannini R, Bolondi L. Liver cirrhosis, ascites, and hyperfibrinolysis. Am J Gastroenterol
Gursoy S, Baskol M, Yücesoy M. Importance of anticoagulant proteins in chronic liver disease. Turk J Gastroenterol
Zhang DL, Hao JY, Yang N. Value of D-dimer and protein S for diagnosis of portal vein thrombosis in patients with liver cirrhosis. J Int Med Res
Shen MC, Lin JS, Tsay W. Protein C and protein S deficiencies are the most important risk factors associated with thrombosis in chinese venous thrombophilic patients in Taiwan. Thromb Res
Cong YL, Wei YX, Zhang LW, Yin ZJ, Bai J. The relationship between hemostatic changes in liver cirrhosis patients with different degrees of liver lesions in reference to Child-Pugh scores. Zhonghua Gan Zang Bing Za Zhi
Caldwell SH. Management of coagulopathy in liver disease.Gastroenterol Hepatol
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]