MEASURMENT OF FIBRIN DEGRDATION PRODUCTS IN CHRONIC RENAL FAILURE PATIENTS USING D-DIMER TEST

Submitted by: Mohammed Jomaa Ali Al-haj Faraj

B.Sc. In Medical Laboratory Sciences

UNIVERSITY OF SCIENCE AND TECHNOLOGY

YEMEN ( 2001 )

A Thesis

Submitted for Fulfillment of Master Degree

IN

Medical Laboratory Sciences ( Hematology )

Faculty of Medical Laboratory Sciences

UNIVERSITY OF GEZIRA

Main Supervisor: Prof. Ahmed Abdalla Mohamedani

MBBS,D.C.P,F.R.C. Path. U.K.

Co Supervisor: Dr. Mohammed Al-sabq

MD, Medicine

( September 2006 )

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

The mechanism of disseminated intravascular coagulation

Intravascular deposition of

fibrin

Depletion of platelets and coagulation

factors

Systemic activation of coagulation

Thrombosis of small and

midsize vessels and organ failure

Bleeding

Cont.

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

Cont.

*Laboratory findings:

- Prolonged prothrombin time, activated partial thromboplastin time and thrombin time.

- Decreased fibrinogen levels.

- Increased levels of fibrin degradation products and D-dimer tests. - Relative or absolute decrease of Platelet count.

- Presence of schistocytes in peripheral smear.

Con.

*Laboratory findings:- Modestly increased prothrombin time in some patients- Shortened or lengthened partial thromboplastin time.- Normal thrombin time in most patients.

- High, normal or low platelet count.

- Increased levels of fibrin degradation products and D-dimer.

Cont.

The association of altered hemostasis and uraemia has long been recognized, as well as the fairly high morbidity associated with such events. The pathogenesis of bleeding disorders is multifactorial and no single explanation.

The platelet count in ureamia is usually normal, but platelet function is impaired.

Cont.

Thrombotic and severe haemorrhagic complications are common in patients with end stage

renal disease and contribute substantially to the morbidity and mortality in this populations.

There was a previous belief that some dialyzable substances, found in increased concentration in the plasma of uremic patients, could play a role in the

abnormal platelet function seen in chronic renal failure.

Cont.

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

Cont.

What is D-dimer ?

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

Cont.

D- dimer tests are ordered, a long with other laboratory tests and imaging scan to help rule out, diagnosis and monitor disease and conditions that cause hypercoagulability.

One of the most common of these conditions is DVT and pulmonary embolism.

Cont.

Measurements of D-dimer may also be ordered, along with other tests, to help diagnosing DIC (Disseminated intravascular coagulation).

D-dimer levels may be used to monitor the effectiveness of disseminated intravascular coagulation treatment.

Cont.

There are many different D-dimer assays currently available on the market.

All of these assays rely on monoclonal antibodies.

The original assay is semi-quantitative and utilizes visual macroscopic latex agglutination (used in disseminated intravascular coagulation diagnosis).

Cont.

The most sensitive quantitative D-dimer assay is based on the ELISA format.

The most practical quantitative assays are the latex-enhanced photometric assays that are turbidimetric or colorimetric.

Cont.

What are FDPs?

Fibrin degradation products (FDPs), also known as fibrin spilt products, are present in blood when the thrombolytic enzyme plasmin cleaves fibrin or fibrinogen.

This is a test that measures fibrin degradation products (which are produced when clots dissolve) in blood.

Cont.

The measurement of FDPs provides a direct indication of the activity of the fibrinolytic (clot dissolving) system.

When they are present in large amounts, they indicate increased fibrinolysis, or clot breakdown.

Cont.

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

1. To evaluate the association between chronic renal failure and disseminated intravascular coagulation.

2. To evaluate the effect of dialysis on the level of D-dimer test, FDPs and others .3. To evaluate performance of FDPs screening test.

4. To compare the performance of FDPs compared to D-dimer test.

Cont.

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

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

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

Sample selection and size : Blood samples obtained from adult males and females (aged between 10 to 70 years). During the period from March 2005 to November 2005 as follows:

-Control persons 60 samples with no clinical or Biochemical evidence of renal failure.-Patients with chronic renal failure 120 samples.-60 samples pre-dialysis.-60 samples post-dialysis.-The total numbers of samples was 180 samples.

Cont.

Data collection:A questionnaire was designed to collect demographical and clinical data.

Study design:It was an observational prospective comparative

case control study.

Cont.

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

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

Cont.

Note:

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

Cont.

age group

61-7051-6041-5031-4021-3010-20

Pe

rce

nt

30

20

10

0

13

17

25

15

27

3

Age Distribution :

Sex distribution :

Female 28.3%

Male 71.7%

In (17)

In (43)

Cont.

Table (1): Types and frequency of dialysis:

Type of dialysis

No of patientsPercent %

PeritonealDialysis

Haemodialysis

Total

20

40

60

33.3

66.7

100.0

Cont.

Table (2): Duration of Haemodialysis:

Duration / months

No. of patientsPatient %

1-67-12

13-1819-2425-3031-3637-4243-48Total

2010 3 2 1 1 1 2

40

50.025.07.55.02.52.52.55.0

100.0

Cont.

Table (3): Duration of Peritoneal dialysis:

No. of dialysisNo. of patientsPatient %

12346

Total

68411

20

30.040.020.0 5.0 5.0

100.0

Cont.

Type of dialysisLevel of D-dimer

FrequencyPatient %

PeritonealDialysis

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

Total

66332

20

30.030.015.015.010.0

100.0

Haemodialysis

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

Total

122332

40

30.057.57.55.0

100.0

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

Cont.

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

Type of dialysis

Level of D-dimer

FrequencyPatient %

PeritonealDialysis

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

Total

66332

20

30.030.015.015.010.0

100.0

Haemodialysis

< 0.5> 0.5 < 1.0<1.0 < 2.0

Total

26131

40

65.032.02.5

100.0

Cont.

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

Type of dialysisLevel of FDPS

FrequencyPatient %

PeritonealDialysis

< 5.0> 5.0 < 20

> 20Total

54

1120

25.015.060.0

100.0

Haemodialysis

< 5.0<5.0 <20

> 20

Total

17149

40

42.535.022.5

100.0

Cont.

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

Type of dialysisLevel of FDPSFrequencyPatient %

PeritonealDialysis

< 5.0> 5.0 < 20

> 20Total

53

1220

25.0 15.0 60.0 100.0

Haemodialysis

< 5.0> 5.0 < 20

> 20Total

26113

40

65.027.57.5

100.0

Cont.

Type of DialysisNMeanCorrelationP value

Peritoneal Dialysis

Pre PT & post

PT

2020

16.616.2

0.980.189

HaemodialysisPre PT& Post PT

4040

14.618.6

0.9680.000

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

*P value < 0.05 is significant.

Cont.

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

Type of DialysisNMeanCorrelationP value

Peritoneal Dialysis

Pre PTTPost PTT

2020

31.0529.5

0.9630.963

0.016

HaemodialysisPre PTT

& Post PTT

40

40

36.3

42.9

0.9150.000

*P value < 0.05 is significant.

Cont.

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

TestNFrequencypercent

D-dimer <0.5

6060100

FDPs <5.06060100

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

Cont.

D-dimer is a blood test performed in the medical laboratory to diagnose I.V. thrombosis. When clots are formed at the wrong time and place as a result of underlying disease, D-dimer becomes available marker because its presence indicates the occurrence of unwanted thrombotic events.

In this study the majority of the cases (38.3%) were 50 years and above. At this age we expect co-morbid conditions, which warrant a timely multidisciplinary approach towards the management of chronic renal failure.

Elevated baseline levels of D-dimer and FDPs test in chronic renal failure.

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

Cont.

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

Cont.

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

Comparing the levels of D-dimer with FDPs different results were obtained.

Cont.

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

Cont.

Looking at the prothrombin time (PT) and activated partial thromboplastin time (APTT) of our study patients, they showed increased PT and APTT in 7 out of 40 haemodialysis cases and 6 out of 20 peritoneal dialysis cases.

Most studies found that PT and APTT were normal before haemodialysis and peritoneal dialysis, but both showed significant prolongation after haemodialysis and no changes occurred after peritoneal dialysis. This prolongation may be due to heparin therapy because heparin can contribute to an increase in PT and APTT.

Cont.

Seven of out 60 patients (haemodialysis and peritoneal dialysis patients) had classical laboratory findings of DIC i.e. elevation of D-dimer, FDPs, PT and APTT.

The results of PT & APTT are agreement with Enaam Hussein results (In Khartoum), who studied a group of 30 patients (20 patients on haemodialysis and 10 on peritoneal dialysis) she found that PT and APTT were normal before haemodialysis and peritoneal dialysis, but both showed significant prolongation after haemodialysis and no changes after peritoneal dialysis .

Cont.

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

Cont.

In this study the levels of D-dimer and FDPS tests were increased in chronic renal failure patients (peritoneal dialysis and haemodialysis patients).

Both D-dimer and FDPS tests showed normal and decreased level after haemodialysis (may be due to heparin therapy), and no changes occurred after peritoneal dialysis.

The D-dimer test is more accurate and sensitive compared to FDPS test .The D-dimer test is a confirmatory test for diagnosis disseminated intravascular coagulation.

PT and APTT tests were normal before haemodialysis and peritoneal dialysis, but both showed prolongation after haemodialysis (may be due to heparin therapy) and no changes occurred after peritoneal dislysis, but some patients had abnormal PT and APTT before and after dialysis.

Cont.

2. The use of D-dimer test is recommended to confirm diagnosis of disseminated intravascular coagulation.

1. Further studies are suggested to explain more the relationship between chronic renal failure and disseminated intravascular coagulation.

3. Periodical coagulation profile test in chronic renal failure patients are advisable.

My deep and sincere gratitude to my supervisor prof. Ahmed Abdalla Mohamedani, professor of pathology, Dean Faculty of Medical Laboratory Science, University of Gezira, and to my Co-Supervisor Dr. Mohammad Al-Sabq, Director General of Gezira Hospital for Renal Diseases and surgery. My thanks are due to all the staff of the central laboratory in the Gezira Hospital for Renal Diseases and surgery for their help and cooperation.My thanks are also due to Dr. Ameer Hasabo, medical director of Gezira Hospital for Renal Diseases and surgery for his kind cooperation during this study. Especial thanks to Molecular Biology Department in Institute of Nuclear Medicine, Molicular biology & Oncology (I N M O). Thanks are due to Fathia Mohmmad & Mohammad Husin for typing the manuscript. My thanks are extended to all those who helped me and were not mentioned in this acknowledgment.

ThaThanksnks