Thromboelastographic Evaluation of Dogs with Acute Liver Disease

Abstract

Background: Given the liver's pivotal role in hemostasis and fibrinolysis, the coagulopathy accompanying hepatic disease is complex.Hypothesis/Objectives: To prospectively evaluate kaolin-activated thromboelastography (TEG) in dogs with acute liver disease (ALD) and compare with plasma-based coagulation tests.Animals: Twenty-one dogs with a diagnosis of ALD based on recent onset of clinical signs accompanied by increases in serum bilirubin concentration and alanine aminotransferase activity.Methods: Clinical presentation, CBC, serum biochemistry, platelet count, prothrombin time (PT), activated partial thromboplastin time (aPTT), and TEG analysis were evaluated in 21 dogs with a subset also having fibrinogen, antithrombin (AT) activity, protein C (PC) activity, d-dimers, and von Willebrand's factor (vWF) activity analyzed. A PT >1.5 times the upper limit of normal defined acute liver failure (ALF).Results: Dogs with ALD had mean increases in R, K, LY30, PT, aPTT, and vWF activity, and decreases in angle, maximal amplitude (MA), G, AT activity, and PC activity. The TEG results defined dogs as hypocoagulable (11/21), normocoagulable (8/21), or hypercoagulable (2/21). Increases in LY30 defined 8/21 dogs as hyperfibrinolytic. Hypocoagulable and hyperfibrinolytic dogs had lower fibrinogen and PC activity than dogs without these abnormalities. Overall, ALF dogs had greater increases in K and LY30, and decreases in MA, G, and PC activity than dogs with less severe hepatic impairment. Results for MA and LY30 were positively correlated with serum bilirubin concentration and white blood cell count, and negatively correlated with serum cholesterol concentration.Conclusions and Clinical Importance: ALD dogs have a range of coagulation abnormalities that trend toward hypocoagulability and hyperfibrinolysis as functional impairment occurs.

ACVIM consensus statement on the diagnosis and treatment of chronic hepatitis in dogs

“…At this time, the value of TEG in predicting coagulation status in dogs with CH is unknown. Plasma fibrinogen concentrations seemingly reflect TEG indices of clot strength in dogs with liver disease . As such, plasma fibrinogen concentration is recommended for bleeding risk assessment in CH …”

A review of hyperfibrinolysis in cats and dogs

“…, Kelley et al . ). Haemorrhage can occur due to thrombocytopenia, thrombocytopathia, decreased concentrations of procoagulant factors (factors I, II, V, VII, XIII), dysfibrinogenaemia and hypofibrinogenaemia (Willis et al .…”

“…Dogs with acute liver disease trend towards hypocoagulability and hyperfibrinolysis as functional impairment occurs (Kelley et al . ). Hyperfibrinolysis can occur due to decreased hepatic production of antifibrinolytic proteins such as alpha 2‐antiplasmin (Williams ).…”

“…The liver is an essential organ in coagulation because it is the primary source of most coagulation factors and fibrinolytic proteins, and it is also responsible for their clearance (Mammen 1992, Kavanagh et al 2011. Coagulation changes associated with liver disease are dynamic and multifactorial -both haemorrhage and thrombosis are reported (Mammen 1992, Rogers et al 2008, Kavanagh et al 2011, Dircks et al 2012, Respess et al 2012, Kelley et al 2015. Haemorrhage can occur due to thrombocytopenia, thrombocytopathia, decreased concentrations of procoagulant factors (factors I, II, V, VII, XIII), dysfibrinogenaemia and hypofibrinogenaemia (Willis et al 1989, Dunayer & Gwaltney-Brant 2006, Botsch et al 2009, Poldervaart et al 2009, Prins et al 2010.…”

“…Dysfunction of the fibrinolytic system is also reported in people and dogs with liver disease and may result in hypofibrinolysis or hyperfibrinolysis, and the latter can produce a consumptive coagulopathy (Pernambuco et al 1993, Kelley et al 2015, Leebeek & Rijken 2015. Hypocoagulation and hyperfibrinolysis is documented in people and veterinary patients with liver disease and is associated with disease severity (Kelley et al 2015, Fry et al 2017. Dogs with acute liver disease trend towards hypocoagulability and hyperfibrinolysis as functional impairment occurs (Kelley et al 2015).…”