542 ble-blind trial. The
continuing improvement in these subsequent 12-wk open period were
parameters also impressive to the examiners and to both groups of patients. It is unlikely that the stable refractory disease of these chronic patients improved solely by chance. Proof of this point, however, will require a larger, longer term, fully controlled study. In addition to its apparent effectiveness, oral zinc sulphate was well tolerated. The emetic properties of this agent pose the only apparent problem in its use but can be circumvented by taking the medication with meals. Some foodstuffs interfere with zinc absorption, however, and it would therefore be desirable to establish and employ a zinc preparation which is more readily absorbed and can be taken by all subjects without gastrointestinal irritation. From our experience and that of others,22 23 however, virtually all patients can tolerate oral zinc sulphate for 3 to 6 months. Possible toxic effects of prolonged use must still be carefully sought. In this context, the further decline of depressed serum-histidine levels must especially be watched. This pilot study suggests that zinc supplementation may offer significant alleviation of many of the symptoms of active rheumatoid arthritis. Much additional work must be done, however, to confirm this observation, to determine the functions of zinc in both normal and diseased synovia, and to establish the appropriate place of oral zinc sulphate in the therapy of rheumatoid over a
arthritis. I thank Dr Robert
Levy
for his observations
on
four
patients;
Ms
J. Kempthorne and Dr J. Pizzorno for technical assistance; and Ms A. Ross, Dr M. Mannik, and Dr E. Swilley for review of the manuscript. This work was supported in part by grant AM-5602 from the National Institute of Arthritis, Metabolism, and Digestive Diseases and by an Arthritis Clinical Research Center grant from the Arthritis Foundation. A portion of this work was conducted through the Clinical Research Center facility supported, by National Institutes of Health grant RR-37.
CORRECTION OF ABNORMAL COAGULATION IN CHRONIC LIVER DISEASE BY COMBINED USE OF FRESH-FROZEN PLASMA AND PROTHROMBIN COMPLEX CONCENTRATES FRANCA FRANCHI P. M. MANNUCCI N. DIOGUARDI 3rd Department of Clinical Medicine, University of Milan and Hœmophilia and Thrombosis Centre Angelo Bianchi Bonomi,
Milan, Italy. The effect on abnormal coagulation tests Summary of infusions of fresh-frozen plasma (F.F.P.), prothrombin complex concentrates, and a combination of these treatments was compared in 30 patients with chronic liver disease undergoing needle biopsy. A single dose of F.F.P. (12 ml/kg body-weight) was found to be the least effective therapeutic regimen The concentrate containing factors II, IX, and x was also not adequate, but the additional administration of factor-VII concentrate corrected the prothrombin-time (P.T.) and ’Normotest’ (N.T.) in most patients. However, this regimen did not correct the prolonged kaolin activated partial thromboplastin-time (K.P.T.T.). The results of tests for exploring both the extrinsic (P.T. and N.T.) and intrinsic (K.P.T.T.) coagulation systems only became normal after the combined administration of a lower dose of F.F.P. (8 ml/kg body-weight) and of both concen trates (12 units/ml). There was no clinical or laboratory evidence of thrombotic complications. No patient developed acute hepatitis or hepatitis-B surface antigen in the twelve months after biopsy. These results indicate that prothrombin-complex concentrates in combination with F.F.P. may therefore be used to allow liver biopsy to be performed safely in patients presenting with severe coagulation defects. Introduction CHRONIC liver disease is often associated with
REFERENCES
Niedermeier, W., Griggs, J. H. J. chron. Dis. 1971, 23, 527. Kennedy, A C., Fell, G. S., Rooney, P. J., Stevens, W. H., Dick, W. C., Buchanan, W. W. Scand. J. Rheum. 1975, 4, 243. 3. Gerber, D. A. J. clin. Invest. 1975, 55, 1164. 4. Hallman, P. S., Perrin, D. D., Watt, A. E. Biochem. J. 1971,121, 549. 5. Zukin, R. S., Hollis, D. P. J. biol. Chem. 1975, 250, 835. 6. Suso, F. A., Edwards, H. M., Jr. Nature, 1972, 236, 230. 7. Nielsen, F. H., Sunde, M. L., Hœkstra, W. G. J. Nutr. 1968, 94, 527. 8. Multicentre Trial Group: Andrews, F. M., Golding, D. N., Freeman, A. M., Golding, J. R., Day, A. T., Hill, A. G. S., Camp, A. V., Lewis-Fining, E., Lyle, W. H. Lancet, 1973, i, 275. 9. McCall, J. T., Goldstein, N, P., Randall, R. V., Gross, J. B. Am J. Med. Sci. 1967, 254, 13. 10. Chvapil, M., Ryan, J. N., Zukoski, C. F. Proc. Soc. exp. Biol. Med. 1972, 140, 642. 11. Nugteren, D. H., Beerthuis, R. K., Van Dorp, D. A. Rec Trav. chim. Pays-Bas Belg. 1966, 85, 405. 12. Yamamoto, K., Takahashi, M. Int. Archs. Allergy appl. Immun. 1975, 48, 1. 2.
653. 13. Karl, L., Chvapil, M., Zukoski, C. F. Proc. Soc. exp. Biol. Med. 1973, 142, 1123. 14. Lancet, 1973, i, 299. 15. Henkin, R. I. New Engl. J. Med. 1974, 291, 675. 16. Bennett, P. H., Burch, T. A. Bull. rheum. Dis. 1967, 17, 453. 17. Lee, P., Kennedy, A. C., Anderson, J., Buchanan, W. W. Qt. Jl Med. 1974,
43, 205. 18. Meret, S., Henkin, R. I. Clin. Chem. 1971, 17, 369. 19. Gerber, D. A. Analyt. Biochem. 1970, 34, 500. 20. Singer, J. M., Plotz, C. M.Am.J.Med. 1956, 21, 888. 21. Liddle, L., Seegmiller, J. E., Laster, L.J. lab. clin. Med. 1959, 54, 903. 22. Czerwinski, A. W., Clark, M. L., Serafetinides, E. A., Perrier, C., Huber, W. Clin. Pharmac. Ther. 1974, 15, 436. 23. Serjeant, G. R., Galloway, R. E., Gueri, M. C. Lancet, 1970, ii, 891.
an
acquired bleeding tendency. Although thrombocytopenia and hyperfibrinolysis may also be involved, defective synthesis by the hepatocyte of all the clotting proteins (except factor VIII) is thought to be an important causal factor.1 Hence biopsy, laparoscopy, and other surgical procedures are accompanied by a risk of haemorrhage unless the coagulation defect has been corrected. Fresh-frozen plasma (F.F.P.) which contains all the clotting factors, appears in principle to be the most useful therapeutic material. However, its use is limited by the large volumes which are usually needed; since these might aggravate the hypervolaemia often present in patients and lead to dangerous complications such as rupture of cesophageal varices or congestive heart-failure.
The availability of plasma derivatives containing in concentrated form clotting factors of the prothrombin complex (factors 11, VII, ix, and x) has prompted us to compare the effects of concentrates and of F.F.P., alone or in combination, on coagulation tests in patients with chronic liver disease undergoing liver biopsy.
Material and Methods Patients.-All patients requiring needle biopsy were screened for the presence of coagulation abnormalitiesby means of the following tests: prothrombin-time (P.T.) using
543
comparative thromboplastin ;2 kaolin-activated partial ’’1romboplastin-time (K.P.T.T.) ;3 ’Normotest’ (N.T.) for assesses tiver synthesis of coagulation factors n, VII, and X;4 and ;mplate bleeding-time.’ When the bleeding-time was longer ’1an -min (normal range 3-7 min) biopsy was not carried out :gardless of the results of clotting tests; patients in whom all use coagulation tests were simultaneously above the upper 3:;tlSh
- orma! limit (P.T.T. ratio of patient/control plasmas more than ; I! P,T. and N.T. ratio more than 1.25) and in whom the feeding-time was less than 7 min were admitted to the presmt trial. 30 patients were investigated, and the biopsy specimen showed evidence of cirrhosis in 8 and of chronic active "epaÜtÎs in 22.
Replacement therapy trial.-After obtaining informed ,ent, 21 consecutive patients were randomly allocated by ’;m of sealed
envelopes
to treatment
with either
con-
a
sys-
F.F.P.
(10
clients) or concentrates (11 patients). F.F.P. (12 ml/kg bodyheight) was administered by continuous intravenous infusion :’or 45-60 min; citrated blood-samples for coagulation studies
obtained before and 15 min after’the infusion. ’Prothromplex’ (Immuno, Vienna) containing 25 units/ml each of factors II, ix, and x dissolved in 20 ml of distilled water, was administered by rapid intravenous injection at a dose of 25 units/kg body-weight; 15 min after the injection, factor vn ;oncentrate (Immuno, Vienna) was given at the same dose. Blood-samples were obtained before and 15 min after the administration of prothromplex and again 15 min after the ini iusion of factor-vn concentrate. In these patients, post-infusion studies were also done at 1 and 4 hours. After completion 01’ the controlled trial, 9 additional patients were treated with a combination of the two regimens. F.F.P. administration (8 mt/kg) was followed by the combined administration of prothromplex (12 units/kg body-weight) and factor-vn concentrate 12units/kg). Blood-coagulation studies were carried out on samples obtained before treatment, 15 min after the administration of F.F.P. and prothrombin complex concentrates, and 1 and 4 hours after infusion started. Methods.-Concentrations of factors 11, v, VII, and x were determined by standard one-stage methods;6 and factor VIII and factor ix as described by Wilson et all Fibrinogen was estimated by a thrombin-time method. and fibrinogen-degrawere
Fig. l-Effect of F.F.P. (12 m)/kg) on coagulation screening tetts. Tests were carried out before and 15 min after infusion. Dotted lines indicate upper limit of normal values.
those
tests
that depend on the extrinsic system of 11 patients).
(P.T.
and
N.T., 4 Prothrombin-complex concentrates (fig. 2).-In 6 out of 11 patients correction of P.T. and N.T. was not achieved in the samples obtained after the administration of prothromplex. However, the subsequent treatout
ment
lowed
with factor VII concentrate was invariably folby the complete correction of P.T. and N.T.; also
dation products by the staphylococcal clumping technique9 which used a commercial kit (Boehringer). ’Thrombotest’10 to assess blood coagulability) was carried out according to the
manufacturer’s instructions; the plasma concentrations of the low molecular weight 1X2-globulin inhibitor"known as antithrombin in and Xa inhibitor (anti-Xa) were studied by both mmunochemical 12 and biological13 assays. Serum samples were tested for hepatitis-B surface (HBsiAg) antigen by solid-
phase radioimmunoassay (R.I.A.).14 Statistical analysis.-Values were logarithmically transformed before evaluation by means of Student’s t test for paired data. ’
Results
of the patients was there any clinical or evidence of bleeding. Signs of thromboembolMoratory ism or other side-effects related to the use of concenrates were not observed. 4 patients treated with F.F.P. experienced mild febrile or allergic reactions which were :nanaged with prednisolone (40 mg intravenously). Sub;equently, this drug was injected prophylactically into all patients treated with F.F.P. Freshjrozen plasma.-Although the abnormal of coagulation screening tests were improved in ,:most every instance, normal values were usually Mined only in those patients whose pre-infusion slues were closest to the upper limit of the normal range fig. 1). F.F.P. was slightly more effective in cor’::nng K.P.T.T. (5 out of 11 patients) than it was in In
Fig. 2-Effect of prothrombin-complex screening tests.
concentrates
on
coagulation
Tests were carried out (a) before and 15 minutes after infusion of prothromplex (25 units/kg) and (b) again 15 min after the subsequent administration of factor vn concentrate (25 units/kg). Dotted lines in-
dicate upper limit of normal values.
none
the thrombotest became unusually short. K.P.T.T. was hardly modified by the combination of the two concentrates, and remained outside the normal limits in most patients (9 out of 11). F.F.P. plus concentrates (fig. 3).-In all patients the combined administration of reduced doses of plasma (8 ml/kg) and of the two concentrates (12 units/kg) was followed by a complete return to normal of the P.T. and normotest. K.P.T.T. remained abnormal in only 1 patient who had had the most pronounced defect before replacement therapy. The shortening of thrombotest was usually less pronounced than that produced by the administration of higher doses of prothromplex and factor ’
vii concentrate.
544
Fig.
3-Effect of F.F.P. and prothrombin concentrates
on
coagulation
screening tests. Tests were carried out (a) before and 15 min after infusion of F.F.P. (8 ml/kg), and (b) again 15 min after the combined administration of prothromplex (12 units/kg) and factor-vn concentrate (12 units/kg). Dotted lines indicate upper limit of normal values.
Hepatitis-B surface antigen-was detected before rereplacement therapy in 6 patients with chronic active hepatitis. All 6 were persistently positive during follow-up period which ranged from six to twelve months, whereas the other patients remained negative. No patients developed acute hepatitis in this period. Changes of other coagulation indices (table).-Preinfusion plasma concentrations of clotting factors n, v, vn, IX, and x were usually reduced. There was a moderate increase in these factors after the administration of F.F.P. (12 units/ml). As expected, factors n, ix, and x were markedly increased after prothromplex (25 units/kg body-weight); also factor vn concentrations, which were hardly modified by this treatment, were markedly increased by the subsequent administration of
factor vn concentrate (25 units/ml). Treatment w)it; combination of plasma (8 ml/kg body-weight) and pr;. thromplex and factor vu concentrate at reduced dosa4 (12 units/kg body-weight) was followed by a signifkarr increase in plasma concentrations of factors II, v, vn.;;"" and x. None of the 3 treatments produced signinearr changes in factor viu, platelet-count, fibrinogen, or F.D.P. The pre-infusion values of antithrombin m an’ Xa) as determined by both the immunochemical and biological assays were often reduced; they increased signifr cantly after F.F.P. and changed slightly after protbrom plex. However, administration of factor-vn concentrate r. was followed by a significant increase in antithrombin as measured by biological assay (possibly due to potentiation of the inhibitor by small amounts of heparin in the concentrate). A significant increase in antithrombin III, as measured by both the biological and immunochemical assays, was also observed after treatment with a combination of F.F.P. and prothrombin-complex concentrates.
Discussion
patients with chronic liver disease and thrombocvtopenia, platelet transfusion is usually followed by prolonged splenic and hepatic sequestration. Therefore, since the liver is highly vascularised and local measures to prevent bleeding at the site of injury are not possible after needle biopsy, we suggest that this procedure In
should not be carried out in presence of defective primary haemostasis as expressed by the prolongation ofthe bleeding-time. Biopsy, however, is not contraindicated by a coagulation defect, because it can be corrected by replacement therapy. Although the critical concentrations of clotting factors required for normal hxmostasis in patients with chronic liver disease are not known, the experience gained in the management of surgical proced-
CHANGES IN COAGULATION INDICES AFTER TREATMENT WITH F.F.P., PROTHROMBIN COMPLEX CONCENTRATES AND F.F.P. PLUS CONCENTRATES & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; . & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; , & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; &m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & md a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m d a s h ; & m da s h ; & m d a s h ; & m d a s h ; & m d a s h ;
Values
are
expressed as geometric means, and figures in parentheses are 95% confidence limits. Statistical evaluation was carried out by means of Student’s1 tt";,’
paired data. *p