A critical evaluation of cryoprecipitate for replacement of fibrinogen
Summary (2 min read)
Introduction
- In patients without pre-existing haemostatic disorders, coagulation defects that occur during surgery and/or massive haemorrhage are caused by loss, consumption and dilution of coagulation factors, collectively referred to as ‘dilutional coagulopathy’.
- Some types of surgery disturb haemostasis in other ways: during cardiopulmonary bypass (CPB), interactions with the extracorporeal circuit activates the coagulation and fibrinolytic systems, resulting in platelet dysfunction, which is exacerbated by parallel induction of an inflammatory enzymatic cascade (Dietrich 2000).
- Fibrinogen plays an important role in the coagulation process and clot stabilisation via its cleavage by thrombin to form fibrin polymers capable of binding factor XIII (Velik-Salchner, et al 2007), with consequent crosslinkage to form a robust fibrin network.
- Alternatively, pasteurised human fibrinogen concentrates are available.
- As initially stated almost a decade ago (Bevan 1999), the use of cryoprecipitate in the treatment of perioperative bleeding represents a double standard since it is contraindicated for the treatment of haemophilia, in preference for recombinant and pathogen-reduced plasma-fractionated products when available, on safety grounds.
Perioperative bleeding
- Initially, whole blood was used in the management of perioperative bleeding, but this evolved to the use of blood components including red blood cells, FFP, cryoprecipitate and platelets.
- Other ongoing developments include haemoglobin- or perfluorocarbon-based artificial oxygen carriers (Henkel-Honke and Oleck 2007).
- During the era of whole-blood transfusion, thrombocytopenia was the first haemostatic abnormality observed during blood loss.
- A further indication of the importance of fibrinogen comes from the observation that patients with high fibrinogen levels experience fewer bleeding complications than those with low levels (Blome, et al 2005, Fries, et al 2005, Pothula, et al 2004, Ucar, et al 2007a).
- Based on this work, some current guidelines recommend transfusing fibrinogen concentrate in massive bleeding.
Current sources of fibrinogen
- Today’s therapeutic options for supplementing plasma fibrinogen are FFP, cryoprecipitate and fibrinogen concentrate.
- Other potential complications associated with the use of FFP include volume overload and transfusion-related acute lung injury (Stanworth 2007).
- In afibrinogenaemia, homozygous or double heterozygous inheritance of lesions in the FGA, FGB or FGG genes encoding the paired Aα, Bβ and γ chains that form the hexameric fibrinogen molecule result in profound quantitative deficiency of fibrinogen (plasma concentration <0.1 g/L).
- In terms of safety, cryoprecipitate retains, to a degree, the statistically low risk of pathogen transmission entailed by its single-donor origin.
- For all these reasons, appropriately treated fibrinogen concentrate, if available, offers clear advantages over cryoprecipitate as therapy for inherited deficiencies and disorders of fibrinogen.
Efficacy
- This is even more the case for cryoprecipitate (Danes, et al 2008), with no published studies specifically addressing the efficacy of cryoprecipitate in the management of perioperative bleeding.
- In an observational study of 69 patients suffering from various forms of acquired severe hypofibrinogenaemia, most (62%) had consumptive hypofibrinogenaemia (Danes, et al 2008).
- Furthermore, there was an association between plasma fibrinogen concentrations after treatment and 7-day patient survival.
- This may reflect differences between the two study populations including underlying clinical conditions and proportion of paediatric patients.
- There are no published studies comparing the efficacy of fibrinogen concentrate with cryoprecipitate.
Safety
- In the past, nearly all patients with haemophilia who received factor VIII concentrates were exposed to transfusion-transmitted viruses, due to factor VIII being unable to withstand heating at 60°C during the standard pasteurisation process.
- By 2002, four transplant-associated cases and 23 transfusion-transmitted symptomatic cases of WNV had been identified.
- The use of methylene blue for viral inactivation of plasma was first described in 1991.
- The authors proposed compensation for low fibrinogen content as the most plausible explanation for this increase.
- Cryoprecipitate is not subject to the same postmarketing surveillance as fibrinogen concentrate, but has been associated with thrombotic events (Nizzi, et al 2002).
Cost and availability
- Fibrinogen concentrate is often perceived as much more expensive than cryoprecipitate.
- The true cost of cryoprecipitate may not be seen by operating theatre staff.
Conclusions
- There is evidence that effective fibrinogen supplementation in patients with perioperative bleeding can: reduce blood loss, lower the requirement for transfusion of other blood components such as FFP and platelet concentrates, restore coagulation, and improve survival.
- Where cryoprecipitate is still used, replacement with fibrinogen concentrate would offer improvements in efficacy and safety, bringing the standard of treatment for surgical patients in line with that offered to haemophilia patients.
- Additional improvements to perioperative bleeding management may be attained by the introduction of more rapid and reliable tests for monitoring fibrinogen levels, and by clarification of the level of fibrinogen at which therapy should be initiated.
- In congenital fibrinogen deficiencies, the argument for using current pathogenreduced fibrinogen concentrates as replacement therapy, in preference to cryoprecipitate, is very strong, although the current unlicensed status of this product in the UK is a significant impediment.
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Citations
20 citations
Cites background from "A critical evaluation of cryoprecip..."
...It is important in this respect that being fibrinogen the main component present in the cryoprecipitates, two recent opinion articles have raised the question on whether commercially available fibrinogen concentrate could be a more useful alternative to the cryoprecipitate.(26,27) Moreover, in this sense, a recent retrospective study compared the use of fibrinogen concentrate in acquired hypofibrinogenemia with noninactivated cryoprecipitate....
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20 citations
Cites background from "A critical evaluation of cryoprecip..."
...Some authors argue that in situations where cryoprecipitate is indicated, replacement with FC offers advantages from the point of view of efficacy and safety [47]....
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19 citations
Cites background from "A critical evaluation of cryoprecip..."
...Supraphysiologic levels of procoagulants in cryoprecipitate may lead to thromboembolic complications.(23) In the setting of endothelial dysfunction, cryoprecipitate may contribute to the development of thromboembolic events....
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19 citations
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References
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"A critical evaluation of cryoprecip..." refers background in this paper
...However, in the modern era of intravenous fluids and red cell concentrates, fibrinogen deficiency was the first defect observed (Hiippala et al, 1995)....
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617 citations
"A critical evaluation of cryoprecip..." refers background in this paper
...Thus, the threshold level for treatment may be substantially higher than the ‘historical’ 1 g/l, particularly in patients suffering from postpartum bleeding [4 g/l; (Charbit et al, 2007)] or excessive blood loss during cardiac surgery [3Æ8 g/l; (Karlsson et al, 2008)]....
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...In postpartum bleeding, low levels of fibrinogen are associated with severe bleeding, with a positive predictive value of 100% (Charbit et al, 2007)....
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...In a study of postpartum haemorrhage (PPH), fibrinogen concentrations less than 2 g/l had a 100% positive predictive value for severe PPH (Charbit et al, 2007)....
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402 citations
"A critical evaluation of cryoprecip..." refers background in this paper
...Cryoprecipitate contains a higher concentration of fibrinogen than FFP, typically around 15 g/l (Stinger et al, 2008)....
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