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Acquired Coagulation Disorders. Dr Mohammed Saiem Al-dahr KAAU Faculty of Applied Medical Sciences. Acquired coagulation disorders. Objectives Following this lecture, the student will be able to Explain the classification of acquired disorder of haemostasis such as:

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Acquired Coagulation Disorders

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Acquired Coagulation Disorders

Dr Mohammed Saiem Al-dahr

KAAU

Faculty of Applied Medical Sciences

dr msaiem


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Acquired coagulation disorders

Objectives

  • Following this lecture, the student will be able to

  • Explain the classification of acquired disorder of haemostasis such as:

  • Hepatic disease, vitamin K deficiency, renal disease,

  • Explain the action of oral anticoagulants

  • Name the most common laboratory tests used to monitor oral anticoagulant therapy

  • List mechanisms and clinical conditions associated with DIC.

  • Define the three generalized clinical states of DIC

  • Laboratory abnormalities associated with DIC.

  • Identify therapies for treatment of DIC

dr msaiem


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Acquired coagulation disorders

  • The normal haemostasis is a normal balance carefully designed so that hemorrhage arrested and inappropriate thrombosis does not occur.

  • Acquired disorders of haemostasis occur with many, systemic diseases, drugs, physical states pregnancy and newborns.

  • Diagnosis depends on;

  • Careful history

  • Physical Examination

  • Properly directed lab tests.

dr msaiem


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Acquired coagulation disorders

  • The initial difficulty is to distinguish local bleeding e.g. peptic ulcer from systemic disease.

  • An initial series of screening tests are performed easily and rapidly;

  • Platelet count + Blood film

  • Bleeding time (BT)

  • Prothrombin Time (PT)

  • Partial Thromboplastin Time (PTT)

  • Thrombin Time (TT)

  • Assessment of Fibrinogen

dr msaiem


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Acquired coagulation disorders

  • If screening is suggestive, specific special investigations are performed to confirm, the diagnosis.

  • The acquired disorders of haemostasis that will be discussed here include the following;

  • Hepatic Disease

  • Vitamin K deficiency

  • Vitamin K Antagonists

  • Renal Disease

  • DIC

dr msaiem


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Acquired Coagulation Disorders

Hepatic Disease

  • The liver is the principal site of synthesis of pro-coagulant, fibrinolytic, and coagulation inhibitory proteins.

  • Liver disorders present two challenges:

    1-Decreased synthesis of coagulation, lysis and inhibitory proteins

    2-Impaired clearance of activated haemostatic components.

  • The type of disorder differs in neonates and adults.

dr msaiem


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Acquired coagulation disorders

  • Neonates display decreased levels of plasma contact factors secondary to hepatic immaturity.

  • They also lack sufficient levels of Plasminogen and anti-Thrombin III.

  • Neonates express a unique fetal fibrinogen that does not behave in the same manner as adult fibrinogen, and they have decreased of fibrinogen.

dr msaiem


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Acquired coagulation disorders

  • In adults, liver diseases, such as cirrhosis, hepatitis, and diseases that infiltrate liver tissue, such as neoplasm, affect the synthetic capacity of the liver.

  • Prolongation of the PT is considered a sign of worsening disease because of depression vitamin K-dependent factor synthesis, poor dietary intake or mal-absorption of vitamin K.

  • Fibrinolytic events and thrombocytopenia may accompany liver disease.

dr msaiem


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Acquired Coagulation Disorders

Laboratory Findings

  • Screening tests such as the PT, APTT, TT, bleeding Time, platelet count, fibrinogen levels, and FDP determinations are used to monitor haemostatic status in liver disease patients.

    Therapy

  • Infusion of fresh plasma may increase the circulating levels of pro-coagulants and minimize the hemorrhagic risk.

dr msaiem


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Acquired coagulation disorders

Vitamin K Deficiency

  • For coagulation factors (II, VII, IX, and X) to become active they have to bind Calcium. This is preceded by carboxylation which is mediated by Vitamin K

    Vitamin K

  • Is fat soluble vitamin, stored in the liver in small amounts so can be depleted in 2-3 days

  • Patients with depleted vitamin K or on K antagonists cannot carboxylate these coagulation factors.

dr msaiem


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Acquired coagulation disorders

  • Vitamin K is necessary co-factor for the conversion of terminal glutamic acid residues to gamma-carboxyglutamic acid on factors II, VII, IX, X, as well as on protein C & S

  • This conversion takes place in the hepatocyte and is necessary for proper function.

    Laboratory finding.

  • PT prolonged

  • PTT prolonged

  • Functional assays of vitamin K factors show low level

dr msaiem


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Acquired coagulation disorders

Vitamin K Antagonists

Oral anticoagulants

Mechanism of Action

  • All the vita K-dependent coagulation proteins, (F II, VII, IX, X, proteins S and C) are characterized in their structure by specific chain where some glutamic acid residues undergo a gamma-carboxylation.

  • This gamma-carboxylation is vitamin K-dependent.

  • The presence of carboxylated groups is necessary for the binding of Ca ions required for the formation of the various activation complexes during the activation of the coagulation.

dr msaiem


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Acquired coagulation disorders

dr msaiem


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Acquired coagulation disorders

  • The classic oral anticoagulant (Warfarin) presents a structural similarity with vitamin K

  • Therefore, these anticoagulant are able to inhibit theregeneration step of reduced vitamin K.

  • The inhibition of the reduced vitamin K by anticoagulants blocks the final synthesis step of these vitamin K dependent proteins.

dr msaiem


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Acquired coagulation disorders

Laboratory

  • The most common laboratory test to monitor oral anticoagulant therapy is the PT

  • It is sensitive to the decrease of factors II, VII, X.

  • PTdoes not reflect the effect of the drug on factor IX.

    To promote standardization of the PT for monitoring oral anticoagulant therapy,

  • HWO has developed an international reference thromboplastin from human brain tissue and has recommended that the PT ratio expressed as the International Normalized Ratio (INR).

  • INR value for a plasma depends on the international sensitivity index (ISI).

dr msaiem


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Acquired coagulation disorders

Renal Disease.

  • In acute and chronic renal diseases there is often bleeding tendency associated several haemostatic abnormalities.

  • Thrombocytopenia frequently develop in uremia

  • Vitamin K deficiency due to malnutrition, associated liver disease with factor V deficiency.

dr msaiem


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Acquired coagulation disorders

  • Isolated factors IX and XII deficiency were reported in nephrotic syndrome

  • excessive loss of these proteins in the urine.

  • Antithrombin III and plasminogen are also lost in nephrotic syndrome through increased urinary loss.

    Patients with renal disease commonly have:

  • A prolonged bleeding time (BT)

  • Prolonged PT and PTT

  • Low platelet count

  • Anemia

dr msaiem


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