Diagnosis and management of coagulation derangements in patients with acute leukemia: is there a potential role for thromboelastography?

Background: Acute leukemia (AL) is characterized by a complex spectrum of coagulopathy ranging from a high bleeding risk to thrombotic risk, varying according to disease phases and treatments. To date platelet count and conventional coagulation tests (CCTs) have been unable to predict thrombotic and hemorrhagic risk in AL. Objectives: Thromboelastography (TEG) is a global haemostatic test that measures the viscoelastic properties of the clot, thus providing information on the entire process of blood coagulation. The primary aim of this study was to assess with TEG the coagulation balance in patients with AL, from diagnosis to the end of first cycle of chemotherapy (CHT). Methods: Assessment of CCTs and TEG were made at the following time points: 1) Diagnosis of AL (T0); 2) during the first cycle of CHT (T1); 3) during myelosuppression T2 (PLT < 30x109/L, absolute neutrophil count < 1000/mmc); 4) At the end of the first cycle of CHT (T3). Patients were followed-up for bleeding and thrombotic episodes daily up to the time of hospital discharge or death. Results: Forty consecutive patients were included. Comparing TEG results, we found that the most clinically significant changes emerged during CHT, including the myelosuppression phase, and after CHT. TEG identifies a hypocoagulable state on CHT, exacerbated during myelosuppression, and a hypercoagulable state after CHT. When CCTs and TEG results were compared based on the type of complications (thrombosis or hemorrhages), no differences were found at each analyzed time point.Conclusions: Cumulative, our findings showed the capacity of TEG revealing complex and dynamic abnormalities in patients with AL according to course of disease and treatment, respect coagulation test. Further studies will investigate the role of TEG in defining hemostatic profile and in individualizing the approach to transfusion and anticoagulant therapy/prophylaxis in patients with AL.