Bo Wiinberg

Thromboelastographic Evaluation of Hemostatic Function in Dogs with Disseminated Intravascular Coagulation

BACKGROUND There is considerable variation in the coagulation profile of dogs with disseminated intravascular coagulation (DIC), making it difficult to assess overall hemostatic function. OBJECTIVES To characterize the overall hemostatic state in dogs with DIC, by use of tissue factor-activated thromboelastography (TF-TEG), and to determine whether there is an association between hemostasis and outcome. ANIMALS 50 dogs with DIC. METHODS Dogs admitted to the intensive care units, with an underlying disease known to predispose to DIC, were prospectively assessed with TF-TEG. Citrated blood samples were collected daily during hospitalization and an extended coagulation panel and TF-TEG were performed. Diagnosis of DIC was based on expert opinion. RESULTS Hemostatic dysfunction was observed on the TF-TEG profile in 33/50 of the dogs, of which 22/50 were hypercoagulable and 11/50 were hypocoagulable based on the TF-TEG G value alone. There were significant differences in k, alpha, and MA values (P < .0001) among hypo-, normo-, and hypercoagulable dogs. There was a significant difference in case fatality rate between hypo- (64%) and hypercoagulable (32%) dogs (relative risk = 2.38; P= .04). Dogs that died had significantly lower antithrombin activity (P= .03) and higher d-dimer concentration (P= .03) than survivors. CONCLUSIONS The most common overall hemostatic abnormality in dogs diagnosed with DIC was hypercoagulability, and there was significant difference in survival between hyper- and hypocoagulable dogs. The results suggest TF-TEG is valuable in the assessment of hemostatic function in dogs diagnosed with DIC.

Evaluation of human recombinant tissue factor-activated thromboelastography in 49 dogs with neoplasia.

BACKGROUND Abnormal routine coagulation assay results have been reported to be common in veterinary patients with neoplasia, but the overall hemostatic functional state, including hypercoagulability, has not been described. HYPOTHESIS The overall hemostatic functional state, including hypercoagulability, can be assessed in dogs with neoplasia by tissue factor (TF)-activated thromboelastography (TEG). ANIMALS Thirty-six dogs with malignant neoplasia and 13 dogs with benign neoplasia presented to the Small Animal Veterinary Teaching Hospital, The University of Copenhagen, Frederiksberg, Denmark. METHODS Prospective study evaluating the overall hemostatic functional state in dogs with neoplasia by a newly validated TF-activated TEG assay and routine coagulation parameters activated partial thromboplastin time (aPTT), prothrombin time (PT), platelet count, and D-dimer concentration. RESULTS Hemostatic dysfunction was observed in 28/49 (57%) dogs with neoplasia. Twenty-four were dogs with malignant neoplasia, the majority of which 18/36 (50%) were hypercoagulable, whereas 6/36 (17%) were hypocoagulable. All hypocoagulable dogs had metastatic disease. The proportion of dogs with altered hemostasis was significantly different between dogs with malignant and benign neoplasia. CONCLUSIONS AND CLINICAL IMPORTANCE TF-activated TEG detected hypercoagulable and hypocoagulable states in this population of dogs with neoplasia. The most common hemostatic abnormality in dogs with malignant neoplasia was hypercoagulability. These findings suggest that this novel hemostatic function test may be of value as a cage side method for the assessment of overall hemostatic function in dogs with cancer, including the detection of both hyper- and hypocoagulable states as well as mixed disorders.

Evaluation of the TEG ® platelet mapping™ assay in blood donors

BackgroundMonitoring of antiplatelet therapy in patients at cardiovascular risk is difficult because existing platelet function tests are too sophisticated for clinical routine. The whole blood TEG® Platelet Mapping™ assay measures clot strength as maximal amplitude (MA) and enables for quantification of platelet function, including the contribution of the adenosine diphosphate (ADP) and thromboxane A2 (TxA2) receptors to clot formation.MethodsIn 43 healthy blood donors, the analytical (CVa) and inter-individual variability (CVg) of the TEG® Platelet Mapping™ assay were determined together with platelet receptor inhibition in response to arachidonic acid (AA) and ADP.ResultsThe CVaof the assay for maximal platelet contribution to clot strength (MAThrombin) was 3.5%, for the fibrin contribution to clot strength (MAFibrin) 5.2%, for MAAA4.5% and for MAADPit was 6.6%. The MAThrombinCVgwas 2.8%, MAFibrin4.7%, MAAA6.6% and for MAADPit was 26.2%. Females had a higher MAThrombincompared to males (62.8 vs. 58.4 mm, p = 0.005). The platelet TxA2 receptor inhibition was 1.2% (range 0–10%) and lower than for the ADP receptor (18.6% (0–58%); p < 0.0001).ConclusionThe high variability in ADP receptor inhibition may explain both the differences in response to ADP receptor inhibitor therapy and why major bleeding sometimes develops during surgery in patients not treated with ADP receptor inhibitors. An analytical variation of ~5 % for the TEG® enables, however, for routine monitoring of the variability in ADP receptor inhibition and of antiplatelet therapy.

Thromboelastography results on citrated whole blood from clinically healthy cats depend on modes of activation.

BackgroundDuring the last decade, thromboelastography (TEG) has gained increasing acceptance as a diagnostic test in veterinary medicine for evaluation of haemostasis in dogs, however the use of TEG in cats has to date only been described in one previous study and a few abstracts. The objective of the present study was to evaluate and compare three different TEG assays in healthy cats, in order to establish which assay may be best suited for TEG analyses in cats.Methods90 TEG analyses were performed on citrated whole blood samples from 15 clinically healthy cats using assays without activator (native) or with human recombinant tissue factor (TF) or kaolin as activators. Results for reaction time (R), clotting time (K), angle (α), maximum amplitude (MA) and clot lysis (LY30; LY60) were recorded.ResultsCoefficients of variation (CVs) were highest in the native assay and comparable in TF and kaolin activated assays. Significant differences were observed between native and kaolin assays for all measured parameters, between kaolin and TF for all measured parameters except LY60 and between native and TF assays for R and K.ConclusionThe results indicate that TEG is a reproducible method for evaluation of haemostasis in clinically healthy cats. However, the three assays cannot be used interchangeably and the kaolin- and TF activated assays have the lowest analytical variation indicating that using an activator may be superior for performing TEG in cats.

Serial assessment of the coagulation status of dogs with immune-mediated haemolytic anaemia using thromboelastography.

This study investigated the coagulation status of dogs with immune-mediated haemolytic anaemia (IMHA) over time. Thirty animals with primary IMHA were blood sampled on three occasions over a 5 day period and assays performed included prothrombin time, activated partial thromboplastin time, D-dimer and fibrinogen concentration, antithrombin activity and recalcified unactivated thromboelastography (TEG). Based on TEG, dogs with IMHA were significantly hypercoagulable vs. controls (P<0.001) and over the 5 day period, 3/4 of the TEG parameters reflected increased clotting kinetics (P ≤ 0.02). The 30 day survival of these patients was 80% and, at hospital admission, the TEG maximum amplitude (MA) was significantly higher in survivors than non-survivors (P=0.015). Each unit increase in MA was associated with an increased odds of 30 day survival of 1.13 (95%; CI 1.02-1.25). Based on TEG, most dogs with IMHA were hypercoagulable on admission and their clotting kinetics increased with time. Relative hypocoagulability identified by TEG at initial assessment was found to be a negative prognostic indicator.

Thromboelastography in Veterinary Medicine

Thromboelastography (TEG) has been used in experimental animal studies since the early 1960s and in a routine clinical setting for the past decade. From the data currently available, it is clear that both the scope and limitations of TEG in animals resemble those observed in humans. TEG has been used to diagnose hypercoagulability in animals with disseminated intravascular coagulation, various types of cancer, and critical illness. Its ability to detect and monitor animals with various types of coagulopathies has been well established, both clinically and in experimental studies. TEG is often used in animals to monitor the effect of different pro- and anticoagulant drugs and often performs better at this task than conventional coagulation assays. TEG is already well established in veterinary medicine, and with the rapid dissemination of the technique currently taking place, we can expect to see a wide variety of interesting animal data published in the near future.

Use of Serum Concentrations of Interleukin-18 and Monocyte Chemoattractant Protein-1 as Prognostic Indicators in Primary Immune-Mediated Hemolytic Anemia in Dogs

BACKGROUND The cytokine response in immune-mediated hemolytic anemia (IMHA) is poorly characterized and correlation with outcome is unknown. HYPOTHESIS/OBJECTIVES To determine if cytokine activity is correlated with outcome in dogs with IMHA. ANIMALS Twenty dogs with primary IMHA and 6 control dogs. METHODS Prospective study on dogs with IMHA with blood sampling at admission. Serum activity of interleukin-2 (IL-2), IL-4, IL-6, IL-7, IL-8, IL-10, IL-15, IL-18, monocyte chemoattractant protein-1 (MCP-1), granulocyte-macrophage colony stimulating factor (GM-CSF), interferon-inducible protein-10, interferon-gamma, and keratinocyte chemoattractant (KC) was assessed. RESULTS Thirty-day case fatality rate was 25% (5/20 dogs). Increased concentrations (median [range]) of IL-2 (45.5 ng/L [0;830] versus 0 ng/L [0;46.8]), IL-10 (8.2 ng/L [0;60.6] versus 0 ng/L [0;88.2]), KC (1.7 μg/L [0.3;4.7] versus 0.5 μg/L [0.2;1.1]), and MCP-1 (162 ng/L [97.6;438] versus 124 ng/L [90.2;168]) were observed in dogs with IMHA compared with controls. The cytokine profile was indicative of a mixture of pro- and anti-inflammatory cytokines of various cellular origins. Cytokines/chemokines strongly associated with macrophage/monocyte activation and recruitment were significantly increased in nonsurvivors compared with survivors; IL-15 (179 ng/L [48.0;570] versus 21.3 ng/L [0;193]), IL-18 (199 ng/L [58.7;915] versus 37.4 ng/L [0;128]), GM-CSF (134 ng/L [70.0;863] versus 57.6 ng/L [0;164]), and MCP-1 (219 ng/L [135;438] versus 159 ng/L [97.6;274]), respectively. Logistic regression suggested increased IL-18 and MCP-1 concentrations were independently associated with mortality in this population (P<.05, Walds type 3). CONCLUSIONS AND CLINICAL IMPORTANCE A mixed cytokine response is present in dogs with IMHA and mediators of macrophage activation and recruitment might serve as prognostic indicators.

Partnership on Rotational ViscoElastic Test Standardization (PROVETS): Evidence‐based guidelines on rotational viscoelastic assays in veterinary medicine

Objective To systematically examine the evidence relating to the performance of rotational viscoelastic testing in companion animals, to develop assay guidelines, and to identify knowledge gaps. Design Multiple questions were considered within 5 parent domains, specifically system comparability, sample handling, assay activation and test protocol, definitions and data reporting, and nonstandard assays. Standardized, systematic evaluation of the literature was performed. Relevant articles were categorized according to level of evidence and assessed for quality. Consensus was developed regarding conclusions for application of concepts to clinical practice. Setting Academic and referral veterinary medical centers. Results Databases searched included Medline, Commonwealth Agricultural Bureaux abstracts, and Google Scholar. Worksheets were prepared evaluating 28 questions across the 5 domains and generating 84 assay guidelines. Conclusions Evidence-based guidelines for the performance of thromboelastography in companion animals were generated through this process. Some of these guidelines are well supported while others will benefit from additional evidence. Many knowledge gaps were identified and future work should be directed to address these gaps and to objectively evaluate the impact of these guidelines on assay comparability within and between centers.OBJECTIVE To systematically examine the evidence relating to the performance of rotational viscoelastic testing in companion animals, to develop assay guidelines, and to identify knowledge gaps. DESIGN Multiple questions were considered within 5 parent domains, specifically system comparability, sample handling, assay activation and test protocol, definitions and data reporting, and nonstandard assays. Standardized, systematic evaluation of the literature was performed. Relevant articles were categorized according to level of evidence and assessed for quality. Consensus was developed regarding conclusions for application of concepts to clinical practice. SETTING Academic and referral veterinary medical centers. RESULTS Databases searched included Medline, Commonwealth Agricultural Bureaux abstracts, and Google Scholar. Worksheets were prepared evaluating 28 questions across the 5 domains and generating 84 assay guidelines. CONCLUSIONS Evidence-based guidelines for the performance of thromboelastography in companion animals were generated through this process. Some of these guidelines are well supported while others will benefit from additional evidence. Many knowledge gaps were identified and future work should be directed to address these gaps and to objectively evaluate the impact of these guidelines on assay comparability within and between centers.

Development of a model based scoring system for diagnosis of canine disseminated intravascular coagulation with independent assessment of sensitivity and specificity

A template for a scoring system for disseminated intravascular coagulation (DIC) in humans has been proposed by the International Society on Thrombosis and Haemostasis (ISTH). The objective of this study was to develop and validate a similar objective scoring system based on generally available coagulation tests for the diagnosis of DIC in dogs. To develop the scoring system, 100 dogs consecutively admitted to an intensive care unit (ICU) with diseases predisposing for DIC were enrolled prospectively (group A). The validation involved 50 dogs consecutively diagnosed with diseases predisposing for DIC, admitted to a different ICU (group B). Citrated blood samples were collected daily during hospitalisation and diagnosis of DIC was based on the expert evaluation of an extended coagulation panel. A multiple logistic regression model was developed in group A for DIC diagnosis. The integrity and diagnostic accuracy of the model was subsequently evaluated in a separate prospective study at a different ICU (group B) and was carried out according to The Standards for Reporting of Diagnostic Accuracy (STARD) criteria. Thirty-seven dogs were excluded from group A and four from group B due to missing data. Based on expert opinion, 23/63 dogs (37%) had DIC. The final multiple logistic regression model was based on activated partial thromboplastin time, prothrombin time, D-Dimer and fibrinogen. The model had a diagnostic sensitivity and specificity of 90.9% and 90.0%, respectively. The diagnostic accuracy of the model was sustained by prospective evaluation in group B (sensitivity 83.3%, specificity 77.3%). Based on commonly used, plasma-based coagulation assays, it was possible to design an objective diagnostic scoring system for canine DIC with a high sensitivity and specificity.

Evaluation of platelet aggregometry in dogs using the Multiplate platelet analyzer: impact of anticoagulant choice and assay duration

Objective To investigate the performance of the Multiplate platelet function analyzer with regards to: (1) the use of 3 different anticoagulants (ie, citrate, hirudin, and heparin) and (2) the evaluation of optimal assay time. Design Prospective observational in vitro study. Setting University veterinary teaching hospital. Animals Twenty clinically healthy dogs and 3 ill dogs. Interventions None. Measurements and Main Results A total of 184 analyses were performed with duplicate measurements in each test cell and results are reported as mean of the 2 measurements. Analyses were performed on blood samples from 20 dogs collected in citrate, hirudin, or heparin. A total of 4 analyses were performed on every blood sample using adenosine diphosphate, collagen, and arachidonic acid as agonists as well as a control with 0.9% sodium chloride (buffer). Aggregation in hirudin samples was significantly increased compared with heparin at all analysis times except at 6 minutes when using ADP as agonist; however, hirudin samples also demonstrated significant aggregation in the buffer control, compared to both citrate and heparin. Citrated samples yielded significantly lower aggregation compared with both hirudin- and heparin-stabilized samples at 6 and 12 minutes when ADP and collagen were used as agonists, and at most analysis times with arachidonic acid. The assay performed best at shorter analyses times, whereas longer analyses times yielded larger variation in data. Conclusions There was a good aggregation response and acceptable analytical variation in both heparin- and hirudin-anticoagulated samples with all tested agonist at the concentrations recommended by the manufacturer. The results suggest that heparin may be superior as anticoagulant for Multiplate analyses in dogs and that short analyses times are preferable. Spontaneous platelet autoaggregation in hirudin samples warrants careful evaluation of results using this anticoagulant, especially at longer test times. The use of citrate is discouraged for Multiplate analyses in dogs due to a weak aggregation response.OBJECTIVE To investigate the performance of the Multiplate platelet function analyzer with regards to: (1) the use of 3 different anticoagulants (ie, citrate, hirudin, and heparin) and (2) the evaluation of optimal assay time. DESIGN Prospective observational in vitro study. SETTING University veterinary teaching hospital. ANIMALS Twenty clinically healthy dogs and 3 ill dogs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 184 analyses were performed with duplicate measurements in each test cell and results are reported as mean of the 2 measurements. Analyses were performed on blood samples from 20 dogs collected in citrate, hirudin, or heparin. A total of 4 analyses were performed on every blood sample using adenosine diphosphate, collagen, and arachidonic acid as agonists as well as a control with 0.9% sodium chloride (buffer). Aggregation in hirudin samples was significantly increased compared with heparin at all analysis times except at 6 minutes when using ADP as agonist; however, hirudin samples also demonstrated significant aggregation in the buffer control, compared to both citrate and heparin. Citrated samples yielded significantly lower aggregation compared with both hirudin- and heparin-stabilized samples at 6 and 12 minutes when ADP and collagen were used as agonists, and at most analysis times with arachidonic acid. The assay performed best at shorter analyses times, whereas longer analyses times yielded larger variation in data. CONCLUSIONS There was a good aggregation response and acceptable analytical variation in both heparin- and hirudin-anticoagulated samples with all tested agonist at the concentrations recommended by the manufacturer. The results suggest that heparin may be superior as anticoagulant for Multiplate analyses in dogs and that short analyses times are preferable. Spontaneous platelet autoaggregation in hirudin samples warrants careful evaluation of results using this anticoagulant, especially at longer test times. The use of citrate is discouraged for Multiplate analyses in dogs due to a weak aggregation response.