Abdel Galil M. Abdel Gader

Hypercoagulable states in patients with retinal venous occlusion

Background and purpose: The pathogenesis of thrombus formation in the retinal vein resulting in retinal vein occlusion is not well understood. This study was carried out to ascertain the role of hypercoagulable states in patients with retinal vein occlusion. Methods: Fifty seven consecutive patients with acute retinal vein occlusion (mean age 48 ± 11.5 years) were investigated for possible hypercoagulable states. Levels of antithrombin III (AT III), protein C (PC), Protein S (PS), factor XII, and fibrinogen as well as the presence of antiphospholipid antibodies (APAs) were investigated. The APAs and fibrinogen results obtained in these patients were compared to those of healthy controls. Results: We detected APAs in 15 out of 57 patients compared to 3 out of 74 controls (p = 0.0002). Fibrinogen levels were significantly higher in patients compared with the controls (p < 0; 0.001). Deficiencies in the naturally occurring anticoagulant proteins including AT III (4 out of 54 patients tested), PC (8 out of 42 patients tested), and PS (12 out of 56 patients tested) were detected. Seven patients out of 32 patients tested had reduced levels of factor XII. Subgroup analysis of the thrombophilic differences between patients who aged 45 years or less and older patients and patients with major trunk vein occlusion and patients with branch vein occlusion revealed no significant differences. Conclusion: Hypercoagulable states are common in patients with retinal vein occlusion and may contribute to the etiology of the disease.

Attitude to blood donation in Saudi Arabia.

Background and Objectives: The blood donor system in the Kingdom of Saudi Arabia depends on a combination of voluntary and involuntary donors. The aim of this study is to explore the attitudes, beliefs and motivations of Saudis toward blood donation. Materials and Methods: The study was conducted at the Donor Centers at King Khalid University Hospital (KKUH) Blood Bank and King Saud University Students Health Center, Riyadh. A self-administered questionnaire was distributed to donors (n = 517) and nondonors (n = 316), between February and June 2008. All were males. Results: Ninety-nine percent of the respondents showed positive attitude toward blood donations and its importance for patients care, and object the importation of blood from abroad. Blood donors: Ninety-one percent agree that that blood donation is a religious obligation, 91% think no compensation should be given, 63% will accept a token gift, 34% do not object to donating six times/year and 67% did not mind coming themselves to the donor center to give blood. Nondonors: Forty-six percent were not asked to give blood and those who were asked mentioned fear (5%) and lack of time (16%) as their main deterrents. Reasons for rejection as donors include underweight and age (71%) and health reasons (19%). Seventy-five percent objected to money compensation but 69% will accept token gifts and 92% will donate if a relative/friend needs blood. Conclusion: These results reflect an encouraging strong positive attitude toward blood donation. Further future planning with emphasis on educational/publicity programs and careful organization of donor recruitment campaigns could see the dream of total voluntary nonremunerated blood donations should not take long to be true.

Transfusion medicine in a developing country – Alloantibodies to red blood cells in multi-transfused patients in Saudi Arabia

BACKGROUND Multiple transfusions are frequently complicated by alloimmunization. This retrospective study aims to determine whether alloimmunization could be accounted for by racial differences between donors and recipients. MATERIALS AND METHODS The development of alloantibodies were determined in 68 multi-transfused patients (thalassaemia, n=38) and (sickle cell anemia, n=30). RESULTS The overall frequency of alloantibody formation in our patients is 22.06%. Thirteen patients received blood from the same ethnic group (Arab) and none developed antibodies, while of 47 patients who received multi-ethnic blood, 10 developed alloantibodies. CONCLUSIONS Alloantibodies formation can be reduced by limiting the transfusion of RBC, collected from donors of the same ethnic origin.

Haemostatic abnormalities in liver disease : could some haemostatic tests be useful as liver function tests?

The liver plays a central role in haemostasis, being the site of synthesis of most of the clotting factors, coagulation inhibitors and fibrinolytic parameters, in addition to its clearance of activated clotting and fibrinolytic factors. Nonetheless, no haemostatic test(s) is included among the routine liver function tests and this study aims to probe this possibility. The liver disease group (n = 258) included acute hepatitis (n = 25), chronic viral hepatitis (n = 128), hepatitis B (HB) carriers (n = 25), liver cirrhosis (n = 67), and hepatocellular carcinoma (HCC) (n = 13). The prothrombin time was significantly prolonged in acute hepatitis, liver cirrhosis and HCC. However, the reptilase time was prolonged in all the groups except in HB carriers, while the thrombin time was prolonged only in the HCC group. Antithrombin III and protein C levels exhibited significant reduction in acute hepatitis, liver cirrhosis and HCC. On the other hand, protein S levels (total and free) were reduced significantly in all the patients groups, including HB carriers when compared with healthy controls. Derangement of haemostatic tests is a common feature in liver disease, being most significant in acute hepatitis, liver cirrhosis and hepatocellular carcinoma. The most sensitive markers of hepatocyte malfunction are protein S (total and free) and the reptilase time as they were abnormal, in the mildest liver affections, when other biochemical tests as well as other haemostatic tests were normal. Further studies are needed to see whether these two tests qualify for inclusion among the routine liver function tests.

The coagulopathy of liver disease: does vitamin K help?

Vitamin K is frequently administered in cirrhotic patients to correct their coagulopathy, but evidence for such practice is lacking. We aimed to assess whether vitamin K administration increases the levels of the vitamin K-dependent factor VII (FVII), protein C, and protein S in patients with different stages of liver dysfunction. Eighty-nine patients were recruited into four groups: group 1 [hepatitis B virus (HBV) inactive carriers, n = 23]; group 2 [chronic HBV and hepatitis C virus (HCV) hepatitis, n = 21]; group 3 (cirrhosis, n = 24); group 4 (hepatocellular carcinoma, n = 21); and a healthy control group (n = 39). A single dose of 10 mg of vitamin K1 was administered subcutaneously to all patients. Prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), fibrinogen, FVII, protein C, total and free protein S, and proteins induced by vitamin K absence (PIVKA)-II (des-gamma-carboxy prothrombin) were measured at baseline and 72 h after vitamin K administration. There was progressive increment in baseline PIVKA-II, and decrements in fibrinogen, FVII, protein C, and protein S across study groups (P < 0.0001). Compared to baseline, vitamin K administration did not affect the measured parameters, whereas TT showed no reduction in any of the groups. Protein C levels declined in group 2, whereas FVII, total and free protein S did not increase in any group, for all parameters. Vitamin K therapy does not cause significant improvements in the majority of coagulation parameters and hence does not seem to be routinely indicated in patients with liver disease.

Haemostatic and cytokine changes in gestational diabetes mellitus

Background. Limited data indicate the existence of a hypercoagulable state and the possible involvement of pro-inflammatory cytokines in the pathogenesis of gestational diabetes mellitus (GDM). Aim. To characterise the coagulation inhibitor and cytokine profiles in women with GDM. Methods. Two groups of women in the third trimester of pregnancy were studied: GDM (n = 150) and controls: women with normal pregnancy (n = 100); GDM in their first post-delivery day (n = 52). Laboratory assays. Plasma fibrinogen, antithrombin (AT), protein C, total and free protein S, interleukins-2, 6 and 8 (IL-2, 6, 8). Results. During pregnancy, the only significant alterations noted were higher levels of body mass index, fibrinogen and total protein S in women with GDM when compared to normal pregnancy. In the post-delivery group, there was further elevation in the levels of plasma fibrinogen and significant drop in the level of total protein S, protein C and AT. Significant elevation of IL-2 and IL-6 levels was recorded only in post-delivery group. Conclusion. In GDM, the only indicator of a tendency towards hypercoagulability is the higher fibrinogen levels as compared to normal pregnancy. This feature along with the higher body mass index and presumed associated insulin resistance suggests that GDM may be a mild form of the metabolic syndrome. The lack of significant change in the levels of pro-inflammatory cytokines do not support the existence of an inflammatory state in GDM.

Anterior ischaemic optic neuropathy associated with central retinal vein occlusion

Purpose To report the unusual association between non-arteritic anterior ischaemic optic neuropathy (NAION) and non-ischaemic central retinal vein occlusion (CRVO) in two patients.Methods Case reports are presented.Results Non-ischaemic CRVO was manifested by dilated, tortuous retinal veins with flameshape retinal haemorrhages. Fluorescein angiography showed prolonged arteriovenous transit time and normal retinal capillary perfusion without macular oedema. The presence of colour vision abnormalities, relative afferent pupillary defects, pale disc swelling and visual field deficits indicated that the visual loss was attributable entirely to NAION. Laboratory investigations disclosed impaired fibrinolytic function in case 1 and the presence of antiphospholipid antibodies in case 2.Conclusions Compression of the central retinal vein by the swollen optic nerve could have predisposed to CRVO. The presence of thrombophilic abnormalities may have contributed to the concomitant occlusion of posterior ciliary arteries and central retinal vein. Ischaemic optic neuropathy needs to be considered in patients with CRVO when the visual acuity is not consistent with the retinal pathology.Purpose To report the unusual association between non-arteritic anterior ischaemic optic neuropathy (NAION) and non-ischaemic central retinal vein occlusion (CRVO) in two patients.Methods Case reports are presented.Results Non-ischaemic CRVO was manifested by dilated, tortuous retinal veins with flameshape retinal haemorrhages. Fluorescein angiography showed prolonged arteriovenous transit time and normal retinal capillary perfusion without macular oedema. The presence of colour vision abnormalities, relative afferent pupillary defects, pale disc swelling and visual field deficits indicated that the visual loss was attributable entirely to NAION. Laboratory investigations disclosed impaired fibrinolytic function in case 1 and the presence of antiphospholipid antibodies in case 2.Conclusions Compression of the central retinal vein by the swollen optic nerve could have predisposed to CRVO. The presence of thrombophilic abnormalities may have contributed to the concomitant occlusion of posterior ciliary arteries and central retinal vein. Ischaemic optic neuropathy needs to be considered in patients with CRVO when the visual acuity is not consistent with the retinal pathology.

Natural anticoagulants can be useful predictors of severity in chronic liver disease.

Protein S (PS), protein C (PC), and antithrombin (AT) are produced by the liver, and their levels were previously shown to be reduced in chronic as well as acute liver disease. The aim of this study was to determine whether measurement of PS, PC, and AT levels in patients would be as good as the commonly used clinical and histological parameters of liver disease in discriminating early and advanced hepatocyte dysfunction. A total of 154 patients were recruited and categorized into five groups: hepatitis B inactive carriers in group 1 (n = 29), nonalcoholic steatohepatitis patients in group 2 (n = 30), chronic hepatitis B patients with elevated liver enzymes in group 3 (n = 29), chronic hepatitis C patients with elevated liver enzymes in group 4 (n = 30), liver cirrhosis patients in group 5 (n = 36). There were significant differences between groups in the levels of PC (P = 0.0001), total PS (P = 0.0001), and free PS (P = 0.0001) and AT (P = 0.0001). These parameters were least affected in the control group, then groups 1 and 2, followed by groups 3 and 4, and most affected in group 5. No differences in these tests were detected between groups 1 and 2 and between groups 3 and 4. Univariate and multivariate analyses showed that free PS was the only predictor of significant inflammation (P = 0.0001), and AT (P = 0.001) and PC (P = 0.003) were the most important factors associated with advanced fibrosis. Both PS and PC are sensitive markers of liver disease, but PS is a sensitive marker of liver inflammation, whereas PC may be a more sensitive marker for liver fibrosis.

IgA antiphospholipid and adrenal insufficiency: Is there a link?

We present two females with antiphospholipid antibody (APA) syndrome who came with adrenal insufficiency (Addisons disease), recurrent abortions and extensive deep vein thrombosis (DVT). Both cases were positive for lupus anticoagulant (LA), global antiphospholipid test (APA), and IgG, IgA, IgM APA antibodies. Seventeen other cases with documented lupus anticoagulant and various clinical associations were tested for APA IgG, IgA, IgM. Only two were positive for IgA as well as IgG and IgM APA. Thirty volunteer blood donors (24 males and 6 females, aged 19-35 years) were taken as a control group. One person was moderately positive for LA and showed low positivity for IgG APA. These data suggest that the presence of IgA APA may signify a severe disease. Further studies are needed to confirm this observation.

Camel milk ameliorates the coagulopathy in streptozotocin diabetic rat model

This study investigated the effect of camel milk (CM) on blood coagulation in streptozotocin (STZ) – induced diabetic rats. Rats were split into four groups: controls, healthy rats treated with CM, STZ-induced diabetic rats and diabetic rats treated with CM. The untreated diabetic animals showed marked hyperglycemia, significant hypofibrinogenemia and inhibition of platelet aggregation. CM treatment ameliorated hyperglycemia, blocked fibrinogen consumption and restored platelet aggregation. This antithrombotic action of CM offers further beneficial effects in addition to its known hypoglycemic action in diabetes. The responsible antithrombotic component(s) is a potential nutraceutical that needs further studies.