title: Hemostasis in patients with acute kidney injury secondary to acute liver failure.
abstract: Acute kidney injury (AKI) occurs in over half of patients with acute liver failure. Despite prolonged prothrombin times and thrombocytopenia, continuous renal replacement therapy circuits frequently develop clots during patient treatment. Here we assessed factors contributing to this by measuring coagulation parameters (standard coagulation tests, pro- and anticoagulant factors, thromboelastography, and thrombin generation) in 20 consecutive patients with acute liver failure; mean age 42 years. Within 48 h, 10 had developed stage 3 AKI and 9 required continuous renal replacement therapy, of whom 2 had frequent circuit clots. The patients with stage 3 AKI were found to have significantly lower platelet counts and levels of factor V and the natural anticoagulants antithrombin, Protein C and Protein S, but increased extrinsic pathway activation and von Willebrand factor levels. Tissue factor levels were greater in those with stage 3 AKI, as was microparticle activity. Although patients with acute liver failure and advanced AKI requiring continuous renal replacement therapy have an even more marked thrombocytopenia and more prolonged extrinsic pathway activation, this was not associated with increased bleeding. Thus, more frequent circuit clots during continuous renal replacement therapy appear to be due to a combination of increased tissue factor and microparticle release, endothelial activation, and reduction in natural anticoagulants.
authors.affiliation: Intensive Care Unit, Royal Free Hospital, London, UK.
authors.forename: Banwari
authors.initials: B
authors.lastname: Agarwal
authors.forename: Alex
authors.initials: A
authors.lastname: Gatt
authors.forename: Anne
authors.initials: A
authors.lastname: Riddell
authors.forename: Gavin
authors.initials: G
authors.lastname: Wright
authors.forename: Pratima
authors.initials: P
authors.lastname: Chowdary
authors.forename: Rajiv
authors.initials: R
authors.lastname: Jalan
authors.forename: Andrew K
authors.initials: AK
authors.lastname: Burroughs
authors.forename: Andrew
authors.initials: A
authors.lastname: Davenport
mesh_terms: D058186:Acute Kidney Injury / Q000097:blood* / Q000209:etiology* / Q000628:therapy; D000328:Adult; D000704:Analysis of Variance; D015415:Biomarkers / Q000097:blood; D001777:Blood Coagulation; D001779:Blood Coagulation Factors / Q000032:analysis; D001780:Blood Coagulation Tests; D016009:Chi-Square Distribution; D005260:Female; D006487:Hemostasis; D006801:Humans; D017114:Liver Failure, Acute / Q000097:blood* / Q000150:complications*; D008297:Male; D008875:Middle Aged; D010976:Platelet Count; D011237:Predictive Value of Tests; D017582:Renal Replacement Therapy / Q000009:adverse effects; D012307:Risk Factors; D012720:Severity of Illness Index; D013917:Thrombin / Q000032:analysis; D013921:Thrombocytopenia / Q000097:blood / Q000209:etiology; D013927:Thrombosis / Q000097:blood / Q000209:etiology; D013997:Time Factors
chemical_list: D015415:Biomarkers; D001779:Blood Coagulation Factors; D013917:Thrombin