Point-of-care coagulation monitors calibrated for the international normalized ratio for cirrhosis (INRliver) can help to implement the INRliver for the calculation of the MELD score

Tripodi, Armando; Chantarangkul, Veena; Primignani, Massimo; Dell’Era, Alessandra; Clerici, Marigrazia; Iannuzzi, Francesca; Aghemo, Alessio; Cazzaniga, M.; Salerno, Francesco; Mannucci, Pier Mannuccio

doi:10.1016/j.jhep.2009.04.014

Cited by 25 publications

(19 citation statements)

References 19 publications

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“…Since the implementation of the INR(liver) is complicated by practical restraints, an alternative could be to determine INR values meant to be used to calculate an MELD score exclusively using portable devices. Tripodi and coworkers recently showed that the INR(liver) also harmonizes the INR across different reagents using these portable point‐of‐care devices (12). The devices are widely used to monitor INR values in patients on VKAs, for example, in patients who monitor their INR at home (13).…”

Section: How Can We Deal With the Large Interlaboratory Variability Imentioning

confidence: 99%

The International Normalized Ratio (INR) in the MELD Score: Problems and Solutions

Porte

Lisman

Tripodi

et al. 2010

American Journal of Transplantation

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The Model for End-Stage Liver Disease (MELD) score is widely used to prioritize patients for liver transplantation. One of the pitfalls of the MELD score is the interlaboratory variability in all three components of the score (INR, bilirubin, creatinine). The interlaboratory variability in the INR has the largest impact on the MELD score, with a mean difference of around 5 MELD points in most studies. During the 3rd conference on Coagulopathy and Liver disease, a multidisciplinary group of scientists and physicians discussed possible solutions for the INR problem in the MELD score with the intention to provide a constructive contribution to the international debate on this issue. Here we will discuss possible solutions and highlight advantages and disadvantages.

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Section: How Can We Deal With the Large Interlaboratory Variability Imentioning

confidence: 99%

The International Normalized Ratio (INR) in the MELD Score: Problems and Solutions

Porte

Lisman

Tripodi

et al. 2010

American Journal of Transplantation

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“…Similarly, the MELD vka , but not the MELD liver , were significantly different. More recently, this alternative calibration has been successfully applied to point‐of care whole blood coagulation monitors (Tripodi et al , 2009). For the practical application of the alternative calibration, manufacturers of commercial thromboplastins and point‐of‐care coagulation monitors should ideally provide two ISI values, one valid for VKA and the other for cirrhosis.…”

Section: Use Of Pt and Aptt In Acquired Coagulopathiesmentioning

confidence: 99%

Acquired coagulation disorders: revisited using global coagulation/anticoagulation testing

2009

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SummaryAcquired coagulation defects are characterized by a decrease of both pro-and anti-coagulants. Because of this, we hypothesise that global tests, such as the prothrombin and partial thromboplastin times (PT and APTT), might be unsuitable for their investigation. Indeed, these tests are not good predictors of bleeding in acquired coagulopathies as they are in the congenital ones. This article discusses the possible reasons for this, using cirrhosis and the neonatal period as epitomes of acquired coagulation defects. Both display normal thrombin generation in the presence of thrombomodulin, in spite of prolonged PT and APTT. We surmise that, because of their design, the PT and APTT are responsive to thrombin generated as a function of pro-coagulants, but much less to thrombin inhibited by the anti-coagulants, especially protein C, which is activated to a limited extent in the absence of thrombomodulin. In conclusion, the PT and APTT can tell us whether or not a patient is deficient in one or more procoagulants, but not whether this deficiency is counterbalanced by a parallel deficiency of anti-coagulants. Thrombin generation assays are more suitable than PT and APTT for use in acquired coagulation defects.Keywords: bleeding disorders, coagulation factors, thrombin, liver disease, neonatal haematology.Tests for global coagulation, such as the prothrombin time (PT) and the activated partial thromboplastin time (APTT) are currently used to detect congenital deficiencies of pro-coagulant factors or as indexes of bleeding risk in clinical conditions characterized by acquired deficiencies of coagulation factors, such as chronic liver disease (cirrhosis), the neonatal period, disseminated intravascular coagulation (DIC) and others. It is, however, known that the PT is not as good at predicting bleeding in acquired as compared with congenital coagulopathies. This article aims to address the suitability of conventional global coagulation tests in assessing acquired coagulopathies using cirrhosis and the neonatal period as models. Use of PT and APTT in congenital coagulopathiesThe PT and APTT were designed many years ago for investigating the mechanisms of coagulation, as a guide to assess purification of coagulation factors from plasma and thereafter as laboratory tools to detect congenital deficiencies of coagulation factors (Tripodi, 2008). These tests and their modifications are still the simplest and most convenient laboratory methods to diagnose the most frequent congenital hemorrhagic coagulopathies, such as the haemophilias, factor VII deficiency and others. The rationale behind their use is that congenital deficiencies in any of the pro-coagulant factors ultimately translate into reduced thrombin generation and, therefore, into defective fibrinogen-to-fibrin conversion and prolonged coagulation times. However, as knowledge on the mechanisms of regulation of the haemostatic process improved, it became clear that in normal conditions pro-coagulants are counteracted in vivo by naturally-occurring anti-coagulants...

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“…This alternative system of calibration proved effective in minimizing between-thromboplastin MELD results. More recently, Sermon et al [7], confirmed these results, and Tripodi et al [8] extended this model of ISIliver calibration to portable coagulation monitors. Finally, a review article on this topic has been published in the Journal of Thrombosis and Haemostasis in 2009 [9] and official recommendations have been issued independently by the International Society on Thrombosis and Haemostasis [10] and by the American Journal of Transplantation [11].…”

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confidence: 81%

The validity of the INR system for patients with liver disease

Tripodi

2010

J Thromb Thrombolysis

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Point-of-care coagulation monitors calibrated for the international normalized ratio for cirrhosis (INRliver) can help to implement the INRliver for the calculation of the MELD score

Cited by 25 publications

References 19 publications

The International Normalized Ratio (INR) in the MELD Score: Problems and Solutions

The International Normalized Ratio (INR) in the MELD Score: Problems and Solutions

Acquired coagulation disorders: revisited using global coagulation/anticoagulation testing

The validity of the INR system for patients with liver disease

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