Unexplained Elevated D-dimer

Unexplained Elevated D-dimer
Jan 13, 2015 2:50pm

From Tony Tang: Dear George, recently we met a 1 year old child with serious hepatitis, the results of coagulation tests were as follows: PT : 26s, APTT : 56s, FIB: 1.07 g/L, TT : 23s, D-dimer: greater than 80 ug/mL FEU, FDP : greater than 360 ug/mL, AT-III: 54%, factor VIII: 212%, PLT count: 102 X 109/L (and increasing slowly) , LY30 of TEG : 0%, above results had been confirmed by repeat samples. There had no apparent signs of hemorrhage or thrombosis for the child, cryoprecipitate infusion seems to be invalid for increasing FIB level for several days. I wonder: 1. What's the cause of generating a lot of D-dimer, just a hyperfibrinolysis secondary to liver disease? Can DIC being excluded? 2. Why did the result of LY30 by TEG be inconsistent with D-dimer and FDP ? Thank you very much!

Hello, Tony, and thank you for sharing this provocative case. I have contacted members of our technical advisory board for their assistance. Except for liver enzymes and bilirubin, the clinical and laboratory findings for DIC and liver disease are similar, and in fact, DIC is a significant complication of liver disease. Consequently, the child's treatment should probably be designed to address DIC even when the diagnosis is uncertain, and in fact, the child's D-dimer and FDP levels seem to support the DIC diagnosis. The appearance of schistocytes in the peripheral blood film would also help confirm DIC. Before I can comment on the LY30 finding it would be interesting to know if the clotting parameters, especially the maximum amplitude (MA) were normal. It could be the LY 30 is normal only because the clot is inadequate to begin with. Let's watch for more comments. By the way, has your team tried the fibrinogen concentrate RiaSTAP?

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From Tony Tang: Dear George, recently we met a 1 year old child with serious hepatitis, the results of coagulation tests were as follows: PT : 26s, APTT : 56s, FIB: 1.07 g/L, TT : 23s, D-dimer: greater than 80 ug/mL FEU, FDP : greater than 360 ug/mL, AT-III: 54%, factor VIII: 212%, PLT count: 102 X 109/L (and increasing slowly) , LY30 of TEG : 0%, above results had been confirmed by repeat samples. There had no apparent signs of hemorrhage or thrombosis for the child, cryoprecipitate infusion seems to be invalid for increasing FIB level for several days. I wonder: 1. What's the cause of generating a lot of D-dimer, just a hyperfibrinolysis secondary to liver disease? Can DIC being excluded? 2. Why did the result of LY30 by TEG be inconsistent with D-dimer and FDP ? Thank you very much!

Hello, Tony, and thank you for sharing this provocative case. I have contacted members of our technical advisory board for their assistance. Except for liver enzymes and bilirubin, the clinical and laboratory findings for DIC and liver disease are similar, and in fact, DIC is a significant complication of liver disease. Consequently, the child's treatment should probably be designed to address DIC even when the diagnosis is uncertain, and in fact, the child's D-dimer and FDP levels seem to support the DIC diagnosis. The appearance of schistocytes in the peripheral blood film would also help confirm DIC. Before I can comment on the LY30 finding it would be interesting to know if the clotting parameters, especially the maximum amplitude (MA) were normal. It could be the LY 30 is normal only because the clot is inadequate to begin with. Let's watch for more comments. By the way, has your team tried the fibrinogen concentrate RiaSTAP?

By Dr. Ning Tang
Jan 15, 2015 10:25pm
Thanks for your suggestion, George, I agree with you that "the child's treatment should probably be designed to address DIC even when the diagnosis is uncertain," heparin had been used every day and got apparently a decrease of D-dimer level. Transfusion of FFP, PLT and human fibrinogen concentrate had been ordered besides cryoprecipitate, treatments might have interfered the interpretation of coagulation tests, however the FIB levels of the child remained to be around 1.0 g/L even after admission for two weeks and liver function has recovered, hence transfusion of FIB is continued now.
As regards TEG, MA of TEG was approximately normal, in fact we've met several cases with inconsistency between D-dimer and LY30, maybe the latter is not a sensitive marker for hyperfibrinolysis?

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