Sarah Bos

22 CHAPTER 2 Given the paucity of clinical and laboratory data on the hemostatic status of cirrhosis of specific etiologies, we performed in depth hemostatic profiling of a large cohort of patients which we stratified according to etiology of disease. Better insight in etiology-specific hemostatic changes may facilitate prevention and/or treatment of bleeding and thrombotic events, and may lead to a more personalized approach to hemostatic management of the cirrhotic patient. Patients and methods Patients One hundred and nine adult patients with cirrhosis were enrolled from the outpatient hepatology clinic of the University Medical Center Groningen, The Netherlands. In addition, 44 healthy volunteers were included to determine reference values for the various tests performed. Inclusion criteria for the patient group consisted of an age of 18 years or older, and a diagnosis of cirrhosis. The diagnosis of cirrhosis had to be confirmed via fibroscan suggestive for F4 cirrhosis, histology compatible with severe fibrosis (Metavir F4) or via imaging. Historical clinical diagnoses were used to define the etiology. Exclusion criteria were the presence of malignancy, a known hereditary bleeding disorder or current use of antithrombotic drugs. Additional exclusion criteria for the control group included the presence of auto-immune disease or known liver function abnormalities. The study protocol was approved by the local medical ethical committee (METC 2016/400) and informed consent was obtained from each subject before inclusion in the study. Plasma samples Plasma samples for analyses were taken by venipuncture and collected into 3.2% citrate tubes. The blood was processed to platelet-poor plasma (PPP) by double centrifugation at 2000 g and 10,000 g respectively for 10 min. Plasma was stored at -80 ◦ C until use. Pooled normal plasma, which was used to calibrate some of the tests, was a generous gift fromDr. J.C. Meijers (Sanquin and Academic Medical Center Amsterdam, Amsterdam, The Netherlands) and consisted of > 200 healthy individuals. Thrombin generation assay The thrombin generation assay (TGA) was performed in platelet-poor plasma (PPP) with the fluorimetric method described by Hemker, Calibrated Automated Thrombography® (CAT).(18) Coagulation was activated using commercially available reagents containing recombinant tissue factor (TF, final concentration 5 pM), phospholipids (final concentration 4 µM), in the presence of soluble thrombomodulin (TM, the concentration of which is not revealed by the