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The approval of revised diagnostic criteria for DIC from the Japanese Society on Thrombosis and Hemostasis

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Abstract

As proposed diagnostic criteria for DIC from the Japanese Society on Thrombosis and Hemostasis has been approved and revised, the contents and changes are informed.

Although disseminated intravascular coagulation (DIC) is a serious disease, there is no gold standard for its diagnosis, no single biomarker by which DIC can be clearly diagnosed, and no anticoagulants have been recommended for the treatment of DIC in worldwide [1]. We reviewed the diagnostic criteria for DIC including the newly proposed diagnostic criteria for DIC from the Japanese Society on Thrombosis and Hemostasis (JSTH) [2, 3]. Three diagnostic criteria for DIC have been established by the Japanese Ministry of Health and Welfare (JMHW) [4], the International Society of Thrombosis and Haemostasis [5] and the Japanese Association for Acute Medicine [6]. The three diagnostic criteria involve a scoring system based on the results of global coagulation tests (GCTs) such as the platelet count, prothrombin time (PT), fibrinogen and fibrin-related markers. Thus, there were no significant differences in the usefulness among three different diagnostic criteria for DIC [7].

For this reason, the JSTH proposed a provisional draft of the DIC diagnostic criteria, which used the classifications of “hematopoietic disorder type” which omitted the platelet count score, “infectious type” which omitted the fibrinogen score, and “basic type” based on the underlying pathology [2, 3]. An additional point was added to the GCTs scoring system if the platelet count decreased with time, and molecular markers and the antithrombin (AT) activity were added to the new criteria. To protect against misdiagnosis, 3 points were deducted if a patient had liver failure.

After the drafting of the proposed criteria [3], several evaluations were carried out to examine the issues associated with the diagnosis of the three types of DIC [8,9,10]. 1) What is the most useful combination for diagnosing DIC? The combination of GCTs, decreased platelet count, AT, increased soluble fibrin (SF), thrombin AT complex (TAT) or prothrombin complex F1 + 2 (F1 + 2) scores had the highest area under the curve (ARC) values and odds ratio in a analysis [8,9,10]. 2) Can this scoring system diagnose early-phase DIC? The JSTH diagnostic criteria could diagnose DIC several days before its onset (as defined by the JMHW criteria). 3) What score is appropriate for making a diagnosis of DIC? The ROC analysis revealed that a score of 4 points was an adequate cutoff value for hematopoietic disorder-type DIC {area under the curve (AUC) 0.979; sensitivity 97.2%; specificity 96.0%; positive predictive value (PPV) 95.4; negative predictive value (NPV) 97.6% and odd’s ratio 832} [8], while a score of 5 points (instead of the 6 points in the previous criteria) [2, 3] was suitable for the diagnosis of infectious-type DIC {AUC 0.984; sensitivity 93.7%; specificity 97.8%; positive predictive value (PPV) 98.3; negative predictive value (NPV) 91.7% and odd’s ratio 649} [9] and a score of 6 points was suitable for the diagnosis of basic-type DIC [10] {AUC 0.987; sensitivity 98.4%; specificity 94.8%; positive predictive value (PPV) 91.2; negative predictive value (NPV) 99.1% and odd’s ratio 1137}. 4) Can these diagnostic criteria predict a poor outcome? Although these diagnostic criteria can predict a poor outcome (odds ratio 2–3), there were no significant differences in the odds ratios of any of the combinations [8,9,10,11]. Thus, these diagnostic criteria have been approved as JSTH diagnostic criteria (Table 1) [12].

Table 1 JSTH’s DIC diagnostic criteria

In conclusion, the JSTH diagnostic criteria for DIC have been revised and approved: Infectious-type DIC is now diagnosed based on a score of 5 points instead of 6 points.

Abbreviations

ARC:

Area under the curve

AT:

AntithrombinSF

Soluble fibrin

DIC:

Disseminated intravascular coagulation

F1+2 :

Prothrombin fragment 1 + 2

GCTs:

Global coagulation tests

JMHW:

Japanese Ministry of Health and Welfare

JSTH:

Japanese Society on Thrombosis and Hemostasis

PT:

Prothrombin time

ROC:

Receiver operating characteristic curve

TAT:

Thrombin-antithrombin complex

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Acknowledgements

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Funding

Meeting expenses were funded by Japanese Society on Thrombosis and Hemostasis. This work was supported in part by a Grant-in-Aid from the Ministry of Education, Culture, Sports, Science and Technology of Japan.

Availability of data and materials

This review paper includes some of the material contained in a Japanese- language report that was published in Jpn J Thromb Hemost (Ref. [3, 12]).

Author information

HA, HT, TU, YE, KO, KK, SM and HW made substantial contributions to the conception of the manuscript, revised the manuscript critically for important intellectual content, provided final approval of the version to be submitted. All authors read and approved the final manuscript.

Correspondence to Hideo Wada.

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The authors declare that they have no competing interests with this article. They neither benefited from any source of funding nor sponsorship.

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Keywords

  • DIC
  • JSTH
  • Diagnostic criteria
  • Hemostatic molecular markers