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PROGNOSTIC VALUE OF PLASMA D DIMER LEVELS IN PATIENTS WITH COMMUNITY ACQUIRED PNEUMONIA

PROGNOSTIC VALUE OF PLASMA D DIMER LEVELS IN PATIENTS WITH COMMUNITY ACQUIRED PNEUMONIA. Erkan Rodoplu 1 , Ahmet Ursavaş 1 , Hayrettin Göçmen 1 , Funda Coskun 1 , Esra Uzaslan 1 , R.Oktay Gözü 1 1 Department of Pulmonary Medicine, School of Medicine, University of Uludağ, Bursa, Turkey.

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PROGNOSTIC VALUE OF PLASMA D DIMER LEVELS IN PATIENTS WITH COMMUNITY ACQUIRED PNEUMONIA

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  1. PROGNOSTIC VALUE OF PLASMA D DIMER LEVELS IN PATIENTS WITH COMMUNITY ACQUIRED PNEUMONIA Erkan Rodoplu1, Ahmet Ursavaş1, Hayrettin Göçmen1, Funda Coskun1, Esra Uzaslan1, R.Oktay Gözü1 1Department of Pulmonary Medicine, School of Medicine, University of Uludağ, Bursa, Turkey

  2. Introduction • Mortality in community acquired pneumonia (CAP) • Outpatients 1-5% • Hospital 12% • Intensive care unit 40% Garibaldi RA. Am J Med 1985; 78: 32-7.

  3. Introduction • D-dimer result from the fibrin breakdown after fibrinolytic system activation • It is useful marker to demonstrate coagulation activity. Sie P. Haematologica 1995; 80: 57-60.

  4. Introduction • D-dimer levels can be elevated • Acute coronary syndrome • Peripheral vascular disease • Deep venous thrombosis, pulmonary embolism • Stroke • Pregnancy • Sickle cell anemia • Malignancy, dissemien intravascular coagulation • Surgery • Heart failure, chronic renal failure Chapman CS, et al. Clin Lab Haemotol 1990;12:37-42.

  5. Introduction • There was small number of investigation about relationship between CAP and D-dimer • Some studies suggested that intravascular and extravascular coagulation can be related acute and chronic lung injury Günther A, et al. Am J Respir Crit Care Med 2000; 161: 454-62.

  6. Aim • The aim of this study was to investigate • The relationship between plasma d-dimer levels and pneumonia severity index (PSİ) and • the prognostic value of plasma D-dimer levels in patients with CAP

  7. Materials and Methods • Inclusion criteria • From January-September 2006, in Uludag University Hospital, Pulmonary Medicine Depart. Prospectively included patients who had received a diagnosis of CAP or pulmonary embolism. • 64 patients who CAP • 45 patients who pulmonary embolism • 20 healty control subjects

  8. Materials and Methods • Exclusion criteria • Age < 18 • Malignancy • Coagulation and hemoragic disorders • Dissemine intravascular coagulation • Chronic renal failure, vasculit, sickle cell anemia • Pregnancy • Thromboembolic disease in CAP group

  9. All subjects Demographic data Physical examination Laboratory (leukocyts, haemoglobine, haemotocrit, glucose, sodium, potassium, ürea, creatinin, CRP, sedimentation) Chest x-ray in patients with CAP Lober multilober Materials and Methods

  10. Materials and Methods • D-dimer assay • D-dimer levels were measured using a latex buttressed turbidimetric method in pretreatment serum samples. • A value of > 375 μg/L was considered to be a positive D-dimer levels.

  11. Materials and Methods • Statistical Analysis • SPSS package for Windows, version 13.0 • Student’s t, Chi-Square, and Mann-Whitney tests • mean ± SD • p < 0.05

  12. Results • There were no significant differences in age and gender, between the two groups.

  13. Result Pulmonary embolism subjects 748.3±769.6 μg/L, p<0.05 CAP subjects 357.8±294.7 μg/L, p<0.05 Control group 149.7±99.6 μg/L

  14. Results • We seperated 5 group in CAP group according to PSİ (mild 1 5 severe) • D-dimer levels of 5 group • 1. group 195.7±88.3 μg/L • 2. group 310±185.2 μg/L • 3. group 210,9±100.5 μg/L • 4. group 433.6±397.9 μg/L • 5. group 416±182.7 μg/L The serum levels of D-dimer in thegroup 4-5 were significantly higher than those of the group 1 (p < 0.05)

  15. Results • Chest x-ray in CAP group • 33 patients lober • 31 patients multilober The plasma levels of D-dimer in the CAP who have multilober infiltration were significantly higher than those of the lober infiltration (p < 0.05)

  16. Results • There were 5 patients (7.8%) died in CAP group • 1 patient group 3, 1 patient group 4 and 3 patients group 5. • All who died had high serum D-dimer levels without 1 patients (group 3). • The plasma levels of D-dimer in died CAP patients significantly higher than alive CAP patients (p<0.05).

  17. Discussion • D-dimer is useful marker to demonstrate fibrinolytic activity • Vascular congestion can be cause fibrin deposit in alveols in patients with pneumonia • D-dimer levels can be elevated due to intraalveolar fibrin breakdown after fibrinolytic system activation. Kubzik L. Robbins Pathologic Basis Of Disease. 6 ed. WB. Saunders, 1999: 697-755. The plasma levels of D-dimer in the pneumonia were significantly higher than those of the control group (p < 0.05)

  18. Discussion • Levi et al. • D-dimer level in patients with severe pneumonia • Not related to CRP, leukocyte count and bacteriemi • Correlated to presence of pleural effusion, intensity of pulmonary involvement in radiologic assesment Levi M, et al. Crit Care Med 2003; 31: 238-42.

  19. Discussion • Querol-Ribelles et al. • Elevated D-dimer levels were associated with radiologic pneumonia extension. • There were no significant relationhip between D-dimer levels and microorganism, antibiotics Querol-Ribelles JM, et al. Chest 2004, 124; 4:1087-1092. There were significant relationhip between D-dimer levels radiologic pneumonia extension

  20. Discussion • Shilon Y et al. • Sixty-eight patients admitted with CAP were included • Mean D-dimer levels of patients for whom hospitalization is recommended (PSI IV-V) were significantly higher than D-dimer levels of patients for whom hospitalization is not recommended (PSI I-III) • D-dimer levels were positively correlated with the APACHE II score, the PSI and the length of hospital stay Shilon Y, et al. Blood Coagulation and Fibrinolysis 2003; 14:745-748.

  21. Discussion • Güneysel et al. • CAP Guideline they divided the patients into two groups [severe (n= 14) and non-severe (n= 37) CAP] • Patients with non-severe CAP and those with severe CAP group both showed an increase in plasma levels of D-dimer compared to control group. • They also found that the severe CAP group had increased in plasma levels of D-d compared to the non-severe CAP group. Güneysel Ö, ve ark. Tüberkülöz ve Toraks Dergisi 2004; 52 (4): 341-347.

  22. Discussion • Some studies suggested that • Plasma D-dimer plasma levels could be useful for predicting mortality in patients with CAP. • Kollef et al. • The hospital mortality rate was significantly greater among D-dimer level elevated patients compared with D-dimer level normaly patients. Kollef MH Crit Care Med 1998; 26: 1054-60. We detected 7.8% hospital mortality in patients with CAP. There were significantly relationship between mortality and D-dimer level .

  23. Discussion • Pulmonary embolism must to take into consideration in differtial diagnosis of CAP • CAP can be similar pulmonary embolism • Symtoms, physical examination, biochemical test • Chest x-ray • Differential diagnosis between CAP and pulmonary embolism may be difficult due to these similar clinical characteristics.

  24. Discussion • Raimondi et al. • D-dimer levels in pulmonary embolism significantly higher than coronary artery disease, cerebrovascular disease, and romatologic disease. • D-dimer levels higher than normal limit in CAP • There were not significantly difference between CAP nad pulmonary embolism Raimondi P, et al. Thromb Res 1993; 69: 125-30.

  25. Discussion • Castro et al. • Plasma D-dimer levels were significantly higher in PE in relation to controls. • DD levels were also higher in patients diagnosed with community-acquired pneumonia in relation to controls • but lower than those obtained in high probability PE. Castro DJ, et al. Respiration 2001; 68: 371-5. In our study, serum D-dimer level in pulmonary embolism significantly higher than CAP. In addition both two group serum D-dimer level significantly higher control group.

  26. Conclusion • Elevated D-dimer level may be predict clinical outcome and high mortality

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