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The impact of organ dysfunctions on mortality in patients with severe sepsis: A multicenter prospective observational study. J Crit Care 2018; 45:178-183. [DOI: 10.1016/j.jcrc.2018.03.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 02/08/2018] [Accepted: 03/02/2018] [Indexed: 12/29/2022]
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52
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Sokou R, Giallouros G, Konstantinidi A, Pantavou K, Nikolopoulos G, Bonovas S, Lytras T, Kyriakou E, Lambadaridis I, Gounaris A, Douramani P, Valsami S, Kapsimali V, Iacovidou N, Tsantes AE. Thromboelastometry for diagnosis of neonatal sepsis-associated coagulopathy: an observational study. Eur J Pediatr 2018; 177:355-362. [PMID: 29255948 DOI: 10.1007/s00431-017-3072-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 12/01/2017] [Accepted: 12/08/2017] [Indexed: 01/01/2023]
Abstract
UNLABELLED Our aim was to evaluate the potential role of standard extrinsically activated thromboelastometry (EXTEM) assay in the early detection of neonatal sepsis. We studied 91 hospitalized neonates categorized in two groups: group A included 35 neonates with confirmed sepsis, while group B included 56 neonates with suspected sepsis; 274 healthy neonates served as controls. Whenever sepsis was suspected, EXTEM assay was performed, Score for Neonatal Acute Physiology Perinatal Extension (SNAPPE) and Tοllner score were calculated, and clinical findings and laboratory results were recorded. Septic neonates had significantly prolonged clotting time (CT) and clot formation time (CFT), and reduced maximum clot firmness (MCF), compared to neonates with suspected sepsis (p values 0.001, 0.001, and 0.009, respectively) or healthy neonates (p values 0.001, 0.001, and 0.021, respectively). EXTEM parameters (CT, CFT, MCF) demonstrated a more intense hypocoagulable profile in septic neonates with hemorrhagic diathesis than those without (p values 0.021, 0.007, and 0.033, respectively). In septic neonates, CFT was correlated with platelet count, SNAPPE, Tollner score, and day of full enteral feeding (p values 0.01, 0.02, 0.05, and 0.03, respectively). CONCLUSIONS A ROTEM hypocoagulable profile at admission seems promising for the early detection of sepsis in neonates while the degree of hypocoagulation may be associated with sepsis severity. What is Known: • The early phase of septicemia might be difficult to be recognized in neonates. In adult septic patients, the diagnostic and prognostic role of thromboelastometry (ROTEM) have been extensively investigated. • Limited data are available on the role of ROTEM as an indicator of early neonatal sepsis. What is New: • ROTEM measurements indicate an early appearance of hypocoagulability in neonatal sepsis, while the degree of hypocoagulation might be associated with severity of sepsis. • ROTEM could be a useful tool in the early detection of sepsis in neonates.
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Affiliation(s)
- Rozeta Sokou
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikaia, Piraeus, Greece
| | | | | | | | | | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Humanitas Clinical and Research Center, Milan, Italy
| | - Theodore Lytras
- Hellenic Center for Disease Control and Prevention, Athens, Greece
| | - Elias Kyriakou
- Laboratory of Haematology and Blood Bank Unit, School of Medicine, "Attiko" University Hospital, National and Kapodistrian University of Athens, 1 Rimini Str, 12462, Athens, Greece
| | - Ioannis Lambadaridis
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikaia, Piraeus, Greece
| | - Antonis Gounaris
- Neonatal Intensive Care Unit, University Hospital of Larissa, Larissa, Greece
| | - Panagiota Douramani
- Laboratory of Haematology and Blood Bank Unit, School of Medicine, "Attiko" University Hospital, National and Kapodistrian University of Athens, 1 Rimini Str, 12462, Athens, Greece
| | - Serena Valsami
- Department of Blood Transfusion, Aretaieion Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Violetta Kapsimali
- Department of Microbiology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Nicoletta Iacovidou
- Neonatal Department, Aretaeio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Argirios E Tsantes
- Laboratory of Haematology and Blood Bank Unit, School of Medicine, "Attiko" University Hospital, National and Kapodistrian University of Athens, 1 Rimini Str, 12462, Athens, Greece.
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Umemura Y, Yamakawa K, Hayakawa M, Kudo D, Fujimi S. Concomitant Versus Individual Administration of Antithrombin and Thrombomodulin for Sepsis-Induced Disseminated Intravascular Coagulation: A Nationwide Japanese Registry Study. Clin Appl Thromb Hemost 2018; 24:734-740. [PMID: 29471674 PMCID: PMC6714866 DOI: 10.1177/1076029618755948] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: Antithrombin and recombinant human thrombomodulin (rhTM) are individually reported to improve survival in sepsis-induced disseminated intravascular coagulation (DIC). However, continuing controversy exists as to which agent is superior and whether concomitant therapy is superior to individual administration. Methods: This post hoc analysis included adult patients with sepsis-induced DIC from a nationwide multicenter registry database in Japan. We categorized patients into 4 groups: patients who received (1) individual administration of antithrombin, (2) individual administration of rhTM, (3) both, and (4) neither. In-hospital mortality was compared between every 2 groups among the 4 groups by Cox proportional hazards model adjusted with propensity scores. Results: In total, 1432 patients with sepsis-induced DIC were included. Although both antithrombin and rhTM were associated better outcome compared with no anticoagulants, mortality benefits were similar between each individual anticoagulant. Similarly, no significant difference in mortality was detected between individual administrations and concomitant therapy. Conclusion: Antithrombin and rhTM might have comparable efficacy in reducing mortality in patients with sepsis; however, concomitant therapy appeared to offer no additional survival benefit.
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Affiliation(s)
- Yutaka Umemura
- 1 Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Yamadaoka, Suita, Osaka, Japan
| | - Kazuma Yamakawa
- 2 Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
| | - Mineji Hayakawa
- 3 Emergency and Critical Care Center, Hokkaido University Hospital, Kita-ku, Sapporo, Hokkaido, Japan
| | - Daisuke Kudo
- 4 Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai, Miyagi, Japan
| | - Satoshi Fujimi
- 2 Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
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Kudo D, Hayakawa M, Ono K, Yamakawa K. Impact of non-anticoagulant therapy on patients with sepsis-induced disseminated intravascular coagulation: A multicenter, case-control study. Thromb Res 2018; 163:22-29. [PMID: 29329022 DOI: 10.1016/j.thromres.2017.12.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 12/12/2017] [Accepted: 12/29/2017] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Anticoagulant therapy for patients with sepsis is not recommended in the latest Surviving Sepsis Campaign guidelines, and non-anticoagulant therapy is the global standard treatment approach at present. We aimed at elucidating the effect of non-anticoagulant therapy on patients with sepsis-induced disseminated intravascular coagulation (DIC), as evidence on this topic has remained inconclusive. MATERIALS AND METHODS Data from 3195 consecutive adult patients admitted to 42 intensive care units for the treatment of severe sepsis were retrospectively analyzed via propensity score analyses with and without multiple imputation. The primary outcome was in-hospital all-cause mortality. RESULTS Among 1784 patients with sepsis-induced DIC, 745 (41.8%) were not treated with anticoagulants. The inverse probability of treatment-weighted (with and without multiple imputation) and quintile-stratified propensity score analyses (without multiple imputation) indicated a significant association between non-anticoagulant therapy and higher in-hospital all-cause mortality (odds ratio [95% confidence interval]: 1.59 [1.19-2.12], 1.32 [1.02-1.81], and 1.32 [1.03-1.69], respectively). However, quintile-stratified propensity score analyses with multiple imputation and propensity score matching analysis with and without multiple imputation did not show this association. Survival duration was not significantly different between patients in the propensity score-matched non-anticoagulant therapy group and those in the anticoagulant therapy group (Cox regression analysis with and without multiple imputation: hazard ratio [95% confidence interval]: 1.26 [1.00-1.60] and 1.22 [0.93-1.59], respectively). CONCLUSIONS It remains controversial if non-anticoagulant therapy is harmful, equivalent, or beneficial compared with anticoagulant therapy in the treatment of patients with sepsis-induced DIC.
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Affiliation(s)
- Daisuke Kudo
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan.
| | - Mineji Hayakawa
- Emergency and Critical Care Center, Hokkaido University Hospital, 5 Kita8jonishi, Kita-ku, Sapporo 060-0808, Japan.
| | - Kota Ono
- Clinical Research and Medical Innovation Center, Hokkaido University Hospital, 5 Kita8jonishi, Kita-ku, Sapporo 060-0808, Japan.
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, 3-1-56 Bandaihigashi, Sumiyoshi-ku, Osaka 558-0056, Japan
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55
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Stephan F, Aarden LA, Zeerleder S. FSAP, a new player in inflammation? Hamostaseologie 2017; 32:51-5. [DOI: 10.5482/ha-1187] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Accepted: 11/04/2011] [Indexed: 12/11/2022] Open
Abstract
SummaryFactor VII-activating protease (FSAP) is a serine protease in plasma that has a role in coagulation and fibrinolysis. FVII could be activated by purified FSAP in a tissue factor independent manner and pro-urokinase has been demonstrated to be a substrate for purified FSAP in-vitro. However, the physiological role of FSAP in haemostasis remains unclear. More recently FSAP is suggested to be involved in inflammation. It modulates vascular permeability directly and indirectly by the generation of bradykinin. Furthermore, FSAP is activated by dead cells induced by the inflammatory response and subsequently removes nucleosomes from apoptotic cells. FSAP activation can be detected in sepsis patients as well. However, whether FSAP activation upon inflammation is beneficial or detrimental remains an open question.In this review the structure, activation mechanisms and the possible role of FSAP in inflammation are discussed.
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Matan M, King D, Peled E, Ackerman S, Bar-Lavi Y, Brenner B, Nadir Y. Heparanase level and procoagulant activity are reduced in severe sepsis. Eur J Haematol 2017; 100:182-188. [PMID: 29120525 DOI: 10.1111/ejh.12997] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND During severe sepsis, levels and activity of all coagulation proteins are reduced. Heparanase is implicated in angiogenesis and tumor progression. We previously demonstrated that heparanase also affected the hemostatic system. It forms a complex and increases the activity of the blood coagulation initiator tissue factor. AIM To evaluate heparanase levels and procoagulant activity as predictors of sepsis severity. MATERIALS AND METHODS Twenty-one patients with non-trauma, non-surgical sepsis admitted to the intensive care unit and 35 controls were recruited. Plasma samples were drawn from the study participants on days 1 and 7 following admission. RESULTS Heparanase levels and procoagulant activity on day 1 were significantly reduced in patients compared to controls (P < .0001, P < .0001, respectively). Day 1 heparanase procoagulant activity ≥350 ng/mL yielded a negative predictive value for severe sepsis of 89%. Additionally, heparanase procoagulant activity on day 7 correlated with the change in the APACHE score between days 1 and 7 (r = .66, P = .007). CONCLUSIONS Heparanase procoagulant activity decreases during sepsis and returns to normal levels as soon as the patient recovers. Hence, it can be potentially used to predict the risk of severe sepsis. These findings need to be further explored in large-scale studies.
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Affiliation(s)
- Moshe Matan
- Intensive Care Unit, Rambam Health Care Campus, The Bruce Rappaport Faculty of Medicine, The Technion, Haifa, Israel
| | - Daniel King
- Intensive Care Unit, Rambam Health Care Campus, The Bruce Rappaport Faculty of Medicine, The Technion, Haifa, Israel
| | - Eli Peled
- Department of Orthopedic B, Rambam Health Care Campus, The Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Shanny Ackerman
- Thrombosis and Hemostasis Unit, Rambam Health Care Campus, The Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Yaron Bar-Lavi
- Intensive Care Unit, Rambam Health Care Campus, The Bruce Rappaport Faculty of Medicine, The Technion, Haifa, Israel
| | - Benjamin Brenner
- Thrombosis and Hemostasis Unit, Rambam Health Care Campus, The Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Yona Nadir
- Thrombosis and Hemostasis Unit, Rambam Health Care Campus, The Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
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57
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Stephan F, Bulder I, Luken BM, Hazelzet J, Wuillemin WA, Zeerleder S. Complexes of factor VII-activating protease with plasminogen activator inhibitor-1 in human sepsis. Thromb Haemost 2017; 112:219-21. [DOI: 10.1160/th13-12-1062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 02/14/2014] [Indexed: 01/28/2023]
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58
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Screening itself for disseminated intravascular coagulation may reduce mortality in sepsis: A nationwide multicenter registry in Japan. Thromb Res 2017; 161:60-66. [PMID: 29202320 DOI: 10.1016/j.thromres.2017.11.023] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 11/13/2017] [Accepted: 11/24/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Screening of patients with sepsis for disseminated intravascular coagulation (DIC) has been recommended in several guidelines. However, DIC screening is still not widely accepted as an essential component of sepsis management, partly because of a lack of evidence that DIC screening has an effect on mortality. We investigated whether DIC screening was associated with a survival benefit in patients with sepsis. DESIGN Post hoc analysis of a nationwide multicenter retrospective cohort study. SETTING 42 intensive care units in Japan. PARTICIPANTS 2663 adult patients diagnosed as having severe sepsis: 1893 (71.1%) patients were considered candidates for and 770 (28.9%) patients were not considered candidates for International Society of Thrombosis and Hemostasis (ISTH) overt DIC screening on ICU day 1. MAIN OUTCOME MEASURES The primary outcome measure was all-cause in-hospital mortality. Patients were stratified according to whether DIC screening was performed at the time of ICU admission (day 1) to investigate the survival effect associated with DIC screening. We also evaluated survival benefit by classifying patients according to whether DIC screening was performed on day 1 and repeated on day 3. Effects of screening on mortality were assessed using Cox proportional hazards models adjusted by the inverse probability of treatment weighting (IPTW) method using propensity scoring. RESULTS After adjustment for imbalances, ISTH overt DIC screening on day 1 was associated with significantly lower mortality (IPTW-adjusted HR: 0.836; 95% confidence interval [CI]: 0.711-0.984), and this association became even stronger when ISTH overt DIC screening was repeated on day 3 (IPTW-adjusted HR: 0.727; 95% CI: 0.597-0.884). Besides, we observed an almost comparable effect on mortality associated with DIC screening using the Japanese Association for Acute Medicine criteria. CONCLUSION DIC screening was associated with a reduction in mortality in patients with sepsis. This association could be even stronger by repeating DIC screening.
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59
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Guo Y, Patil NK, Luan L, Bohannon JK, Sherwood ER. The biology of natural killer cells during sepsis. Immunology 2017; 153:190-202. [PMID: 29064085 DOI: 10.1111/imm.12854] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 10/09/2017] [Indexed: 12/11/2022] Open
Abstract
Natural killer (NK) cells are large granular lymphocytes largely recognized for their importance in tumour surveillance and the host response to viral infections. However, as the major innate lymphocyte population, NK cells also coordinate early responses to bacterial infections by amplifying the antimicrobial functions of myeloid cells, especially macrophages, by production of interferon-γ (IFN-γ). Alternatively, excessive NK cell activation and IFN-γ production can amplify the systemic inflammatory response during sepsis resulting in increased physiological dysfunction and organ injury. Our understanding of NK cell biology during bacterial infections and sepsis is mostly derived from studies performed in mice. Human studies have demonstrated a correlation between altered NK cell functions and outcomes during sepsis. However, mechanistic understanding of NK cell function during human sepsis is limited. In this review, we will review the current understanding of NK cell biology during sepsis and discuss the challenges associated with modulating NK cell function during sepsis for therapeutic benefit.
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Affiliation(s)
- Yin Guo
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Naeem K Patil
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Liming Luan
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Julia K Bohannon
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edward R Sherwood
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
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60
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Søgaard M, Skjøth F, Kjældgaard JN, Lip GYH, Larsen TB. Bleeding Complications in Anticoagulated Patients With Atrial Fibrillation and Sepsis: A Propensity-Weighted Cohort Study. J Am Heart Assoc 2017; 6:e007453. [PMID: 29122810 PMCID: PMC5721800 DOI: 10.1161/jaha.117.007453] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 10/05/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Sepsis may adversely affect bleeding risk in anticoagulated patients with atrial fibrillation (AF), but the impact of warfarin treatment in such patients is poorly described. This registry-based nationwide cohort study examined safety of oral anticoagulant treatment (OAC) in patients with preexisting AF who were hospitalized because of incident sepsis in the period 2000-2015. METHODS AND RESULTS We identified 3030 AF patients who were warfarin users at the time of sepsis diagnosis, and we used inverse probability of treatment weighting to compare the rates of bleeding, thromboembolic events, and death within 90 days after sepsis diagnosis with a comparable cohort of 55721 patients without warfarin treatment and known AF. Weighted 90-day bleeding rates were slightly higher among warfarin users compared with nonusers (0.14 versus 0.12 per 100 person-years), yielding a weighted hazard ratio of 1.19 (95% confidence interval, 1.00-1.41). Thromboembolic event rates during the 90-days after sepsis were marginally higher among warfarin users versus nonusers (0.04 versus 0.03; hazard ratio: 1.25, 95% confidence interval, 0.89-1.76), while the 90-day all-cause mortality was substantially lower among warfarin users (hazard ratio: 0.64, 95% confidence interval, 0.58-0.69). Various sensitivity analyses conducted to challenge the robustness these findings yielded results that were consistent with the main findings. CONCLUSIONS AF patients who are on warfarin therapy at sepsis diagnosis experienced an increase in bleeding rates within the 3 months following sepsis. Warfarin use was associated with lower mortality, despite virtually comparable thromboembolic event rates.
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Affiliation(s)
- Mette Søgaard
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Flemming Skjøth
- Unit of Clinical Biostatistics, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Jette Nordstrøm Kjældgaard
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Gregory Y H Lip
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
- City Hospital, University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom
| | - Torben Bjerregaard Larsen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
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Haworth JA, Mears RG, Jenkinson HF, Kerrigan SW, Nobbs AH. Oral hygiene as a risk factor in infective endocarditis. ACTA ACUST UNITED AC 2017. [DOI: 10.12968/denu.2017.44.9.877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jennifer A Haworth
- Academic Clinical Lecturer, Bristol Dental School, University of Bristol, Lower Maudlin Street, BS1 2LY, Bristol, UK
| | - Richard G Mears
- General Dental Practitioner, Combe Road Dental Practice, 6 Combe Road, Portishead, BS20 6BJ and Clinical Teaching Fellow, Restorative Dentistry, Bristol Dental School, University of Bristol, Lower Maudlin Street, BS1 2LY, Bristol, UK
| | - Howard F Jenkinson
- Professor of Oral Microbiology, Bristol Dental School, University of Bristol, Lower Maudlin Street, BS1 2LY, Bristol, UK
| | - Steve W Kerrigan
- Senior Lecturer in Pharmacology, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin 2, Ireland
| | - Angela H Nobbs
- Senior Lecturer in Oral Microbiology, Bristol Dental School, University of Bristol, Lower Maudlin Street, BS1 2LY, Bristol, UK
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Lukas P, Durila M, Jonas J, Vymazal T. Evaluation of Thromboelastometry in Sepsis in Correlation With Bleeding During Invasive Procedures. Clin Appl Thromb Hemost 2017; 24:993-997. [PMID: 28950719 PMCID: PMC6714732 DOI: 10.1177/1076029617731624] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Prolongation of prothrombin time (PT) is often encountered in patients with sepsis. On the other hand, thromboelastometry as a global coagulation test might yield normal results. The aim of our study was to evaluate whether prolonged PT in the presence of normal thromboelastometry parameters is associated with severe bleeding in patients with sepsis undergoing invasive procedures. In patients with sepsis undergoing low-risk bleeding invasive procedures (central venous catheter placement, dialysis catheter insertion, drain insertion, and so on) or high-risk bleeding invasive procedures (surgical tracheostomy, surgical laparotomy, thoracotomy, and so on), coagulation was assessed by thromboelastometry using EXTEM test (test for evaluation of the extrinsic pathway of coagulation, contains activator of extrinsic pathway) and with PT. For period of years 2013 to 2016, we assessed occurrence of severe bleeding during those procedures and 24 hours later in patients with prolonged PT and normal thromboelastometry results. This retrospective study was performed at Department of Anaesthesiology and Intensive Care Medicine of Motol University Hospital in Prague. Data from 76 patients with sepsis were analyzed. Median value of international normalized ratio (INR) was 1.59 (min—1.3 and max—2.56), and median value of prothrombin ratio (PR) was 1.5 (min—1.23 and max—2.55) with normal thromboelastometry finding. Despite prolonged INR/PR, no severe bleeding was observed during invasive procedures. Our data show that sepsis may be accompanied by normal thromboelastometry results, despite prolonged values of PT, and invasive procedures were performed without severe bleeding. This approach to coagulation assessment in sepsis may reduce administration of fresh frozen plasma to the patients. The study was registered at Clinical Trials.gov with assigned number NCT02971111.
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Affiliation(s)
- Pavel Lukas
- 1 Second Faculty of Medicine, Department of Anaesthesiology and Intensive Care Medicine, Charles University, Motol University Hospital, Prague, Czech Republic, Europe
| | - Miroslav Durila
- 1 Second Faculty of Medicine, Department of Anaesthesiology and Intensive Care Medicine, Charles University, Motol University Hospital, Prague, Czech Republic, Europe
| | - Jakub Jonas
- 1 Second Faculty of Medicine, Department of Anaesthesiology and Intensive Care Medicine, Charles University, Motol University Hospital, Prague, Czech Republic, Europe
| | - Tomas Vymazal
- 1 Second Faculty of Medicine, Department of Anaesthesiology and Intensive Care Medicine, Charles University, Motol University Hospital, Prague, Czech Republic, Europe
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63
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Kell DB, Pretorius E. To What Extent Are the Terminal Stages of Sepsis, Septic Shock, Systemic Inflammatory Response Syndrome, and Multiple Organ Dysfunction Syndrome Actually Driven by a Prion/Amyloid Form of Fibrin? Semin Thromb Hemost 2017; 44:224-238. [PMID: 28778104 PMCID: PMC6193370 DOI: 10.1055/s-0037-1604108] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A well-established development of increasing disease severity leads from sepsis through systemic inflammatory response syndrome, septic shock, multiple organ dysfunction syndrome, and cellular and organismal death. Less commonly discussed are the equally well-established coagulopathies that accompany this. We argue that a lipopolysaccharide-initiated (often disseminated intravascular) coagulation is accompanied by a proteolysis of fibrinogen such that formed fibrin is both inflammatory and resistant to fibrinolysis. In particular, we argue that the form of fibrin generated is amyloid in nature because much of its normal α-helical content is transformed to β-sheets, as occurs with other proteins in established amyloidogenic and prion diseases. We hypothesize that these processes of amyloidogenic clotting and the attendant coagulopathies play a role in the passage along the aforementioned pathways to organismal death, and that their inhibition would be of significant therapeutic value, a claim for which there is considerable emerging evidence.
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Affiliation(s)
- Douglas B Kell
- School of Chemistry, The University of Manchester, Manchester, United Kingdom.,Manchester Institute of Biotechnology, The University of Manchester, Manchester, United Kingdom.,Centre for Synthetic Biology of Fine and Speciality Chemicals, The University of Manchester, Manchester, United Kingdom
| | - Etheresia Pretorius
- Department of Physiological Sciences, Stellenbosch University, Matieland, South Africa
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64
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Novel Function of Isoamylamine Improves Survival in Endotoxemic Mice by Ameliorating Coagulopathy and Attenuating MMP-9 Expression Through p-ERK/p-p38 Signaling at Early Stage. Shock 2017; 47:772-779. [DOI: 10.1097/shk.0000000000000786] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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65
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Crochemore T, Nunes Dias Campos F, Menezes Souza Pessoa C, Lima Rocha L, Zanella do Amaral Campos PP, Corrêa TD. Thromboelastometry-guided blood transfusion in septic shock complicated with disseminated intravascular coagulation: a case report. Clin Case Rep 2017; 5:701-706. [PMID: 28469879 PMCID: PMC5412820 DOI: 10.1002/ccr3.912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 02/22/2017] [Accepted: 02/25/2017] [Indexed: 11/11/2022] Open
Abstract
Approximately 25–50% of septic patients develop disseminated intravascular coagulation. The thromboelastometry evaluates whole blood clot formation and dissolution in real time and has been considered for management of bleeding in diverse clinical conditions. We present a case of thromboelastometry‐guided bleeding management of a septic shock patient with overt disseminated intravascular coagulation (DIC).
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Affiliation(s)
- Tomaz Crochemore
- Intensive Care Unit; Hospital Israelita Albert Einstein; São Paulo SP Brazil
| | | | | | - Leonardo Lima Rocha
- Intensive Care Unit; Hospital Israelita Albert Einstein; São Paulo SP Brazil
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Nakamura M, Takeuchi T, Shirakawa K, Furusako S. Anti-human CD14 monoclonal antibody improves survival following sepsis induced by endotoxin, but not following polymicrobial infection. Eur J Pharmacol 2017; 806:18-24. [PMID: 28322834 DOI: 10.1016/j.ejphar.2017.03.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 02/28/2017] [Accepted: 03/15/2017] [Indexed: 12/15/2022]
Abstract
Cluster of differentiation 14 (CD14), a pattern recognition receptor expressed on myeloid cells and a critical component of the innate immune system, mediates local and systemic host responses to gram-negative bacterial products, including lipopolysaccharide (LPS). Therefore, CD14 is an attractive target for development of sepsis therapies, and several monoclonal anti-CD14 antibodies have been reported. In this study, we prepared an anti-human CD14 monoclonal antibody, F1024-1-3, which suppressed LPS-induced upregulation of pro-inflammatory cytokines and an adhesion molecule in human peripheral mononuclear cells and human vascular endothelial cells. Half-maximal inhibitory concentrations in these assays ranged from 0.1 to 1μg/ml. In rabbits, intravenous administration (3mg/kg) as well as in vitro exposure of F1024-1-3 suppressed LPS-induced cytokine production in whole blood. In endotoxemia models generated by three sequential injections of LPS, intravenous administration of F1024-1-3 at 0.3-3mg/kg sharply reduced pro-inflammatory responses in a dose-dependent manner and moderately attenuated pro-coagulant responses; at 1mg/kg, the protein protected rabbits from lethality even when administered 2h after the initial LPS injection. However, F1024-1-3 (10mg/kg) given 2h post-surgery did not prevent death of rabbits in a cecal ligation and puncture model. Thus, suppression of CD14-mediated activation of leukocytes and endothelial cells alone may not be clinically efficacious for the treatment of severe sepsis and septic shock.
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Affiliation(s)
- Masaki Nakamura
- Discovery Research, Mochida Pharmaceutical Co., Ltd., Shizuoka, Japan.
| | - Takashi Takeuchi
- Discovery Research, Mochida Pharmaceutical Co., Ltd., Shizuoka, Japan
| | - Kamon Shirakawa
- Discovery Research, Mochida Pharmaceutical Co., Ltd., Shizuoka, Japan
| | - Shoji Furusako
- Discovery Research, Mochida Pharmaceutical Co., Ltd., Shizuoka, Japan
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Nakamura M, Takeuchi T, Kawahara T, Hirose J, Nakayama K, Hosaka Y, Furusako S. Simultaneous targeting of CD14 and factor XIa by a fusion protein consisting of an anti-CD14 antibody and the modified second domain of bikunin improves survival in rabbit sepsis models. Eur J Pharmacol 2017; 802:60-68. [PMID: 28249709 DOI: 10.1016/j.ejphar.2017.02.045] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 02/05/2017] [Accepted: 02/24/2017] [Indexed: 02/03/2023]
Abstract
Severe sepsis is a complex, multifactorial, and rapidly progressing disease characterized by excessive inflammation and coagulation following bacterial infection. To simultaneously suppress pro-inflammatory and pro-coagulant responses, we genetically engineered a novel fusion protein (MR1007) consisting of an anti-CD14 antibody and the modified second domain of bikunin, and evaluated the potential of MR1007 as an anti-sepsis agent. Suppressive effects of MR1007 on lipopolysaccharide (LPS)-induced inflammatory responses were assessed using peripheral blood mononuclear cells or endothelial cells. Its inhibitory activity against the coagulation factor XIa was assessed using a purified enzyme and a chromogenic substrate. Anticoagulant activity was assessed using human or rabbit plasma. Anti-inflammatory and anti-coagulant effects and/or survival benefits were evaluated in an endotoxemia model and a cecal ligation and puncture model. MR1007 inhibited LPS-induced cytokine production in peripheral blood mononuclear cells and endothelial cells, inhibited factor XIa, and exhibited anticoagulant activity. In an endotoxemia model, 0.3-3mg/kg MR1007 suppressed pro-inflammatory and pro-coagulant responses in a dose-dependent manner; at a dose of 3mg/kg, the protein improved survival even when administered 8h after the LPS injection. In addition, 10mg/kg MR1007 administered 2h post cecal ligation and puncture improved survival. However, MR1007 administered at doses up to 30mg/kg did not increase ear bleeding time or bacterial counts in the cecal ligation and puncture model. Thus, simultaneous targeting of CD14 and factor XIa improves survival in the rabbit endotoxemia and sepsis models and represents a promising approach for the treatment of severe sepsis.
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Affiliation(s)
- Masaki Nakamura
- Discovery Research, Mochida Pharmaceutical Co., Ltd., 722 Jimba-aza-Uenohara, Gotemba, Shizuoka 412-8524, Japan.
| | - Takashi Takeuchi
- Discovery Research, Mochida Pharmaceutical Co., Ltd., 722 Jimba-aza-Uenohara, Gotemba, Shizuoka 412-8524, Japan
| | - Tetsushi Kawahara
- Discovery Research, Mochida Pharmaceutical Co., Ltd., 722 Jimba-aza-Uenohara, Gotemba, Shizuoka 412-8524, Japan
| | - Jiro Hirose
- Discovery Research, Mochida Pharmaceutical Co., Ltd., 722 Jimba-aza-Uenohara, Gotemba, Shizuoka 412-8524, Japan
| | - Kazuyuki Nakayama
- Discovery Research, Mochida Pharmaceutical Co., Ltd., 722 Jimba-aza-Uenohara, Gotemba, Shizuoka 412-8524, Japan
| | - Yoshitaka Hosaka
- Discovery Research, Mochida Pharmaceutical Co., Ltd., 722 Jimba-aza-Uenohara, Gotemba, Shizuoka 412-8524, Japan
| | - Shoji Furusako
- Discovery Research, Mochida Pharmaceutical Co., Ltd., 722 Jimba-aza-Uenohara, Gotemba, Shizuoka 412-8524, Japan
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Abstract
Extracellular histones promote platelet aggregation and thrombosis; this is followed by induction of coagulation disorder, which results in exhaustion of coagulation factors. Complement component 5 (C5) is known to be associated with platelet aggregation and coagulation system activation. To date, the pathological mechanism underlying liver injury has remained unclear. Here, we investigated whether C5 promotes liver injury associated with histone-induced lethal thrombosis. C5-sufficient and C5-deficient mice received single tail vein injections of purified, unfractionated histones obtained from calf thymus (45–75 μg/g). Subsequently, the mice were monitored for survival for up to 72 h. Based on the survival data, the 45 μg/g dose was used for analysis of blood cell count, liver function, blood coagulation ability, and promotion of platelet aggregation and platelet/leukocyte aggregate (PLA) production by extracellular histones. C5-deficient mice were protected from lethal thrombosis and had milder thrombocytopenia, consumptive coagulopathy, and liver injury with embolism and lower PLA production than C5-sufficient mice. These results indicate that C5 is associated with coagulation disorders, PLA production, and embolism-induced liver injury. In conclusion, C5 promotes liver injury associated with histone-induced lethal thrombosis.
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Zaragoza JJ, Espinoza-Villafuerte MV. Current approach to disseminated intravascular coagulation related to sepsis - organ failure type. World J Hematol 2017; 6:11-16. [DOI: 10.5315/wjh.v6.i1.11] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 11/18/2016] [Accepted: 12/19/2016] [Indexed: 02/05/2023] Open
Abstract
Disseminated intravascular coagulation (DIC) is a syndrome characterized by the systemic activation of blood clotting, which generates large amount of intravascular thrombin and fibrin. Various diseases may cause acceleration of the clotting cascade, inactivate the endogenous anticoagulants and modify fibrinolysis, having thus the formation of micro thrombi in the systemic circulation. The abnormalities in the hemostatic system in patients with DIC result from the sum of pathways that generate both hypercoagulability and augmented fibrinolysis. When the hypercoagulability state prevails, the main manifestation is organic failure. This subtype of DIC is often referred as “organ impairment” type, frequently seen in patients suffering from severe sepsis. To identify the underlying infection, early initiation of culture-based antimicrobial treatment, and to resolve any infection source promptly are keystone actions of DIC related to sepsis prevention and treatment. These should be combined with specific treatment related to each DIC subtype. In the context of septic shock, DIC is associated to increased severity, greater number and seriousness of organ failures, more frequent side-effects from treatment itself, and worse outcomes. Therefore, we ought to review the information available in the literature about approach and management of DIC in severe sepsis.
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Boeddha NP, Driessen GJ, Cnossen MH, Hazelzet JA, Emonts M. Circadian Variation of Plasminogen-Activator-Inhibitor-1 Levels in Children with Meningococcal Sepsis. PLoS One 2016; 11:e0167004. [PMID: 27893784 PMCID: PMC5125643 DOI: 10.1371/journal.pone.0167004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 11/07/2016] [Indexed: 11/18/2022] Open
Abstract
Objective To study whether the circadian variation of plasminogen-activator-inhibitor-1 (PAI-1) levels, with high morning levels, is associated with poor outcome of children with meningococcal sepsis presenting in the morning hours. Design Retrospective analysis of prospectively collected clinical and laboratory data. Setting Single center study at Erasmus MC-Sophia Children’s Hospital, Rotterdam, the Netherlands. Subjects 184 patients aged 3 weeks to 18 years with meningococcal sepsis. In 36 of these children, PAI-1 levels at admission to the PICU were measured in plasma by ELISA. Interventions None. Measurements and main results Circadian variation was studied by dividing one day in blocks of 6 hours. Patients admitted between 6:00 am and 12:00 am had increased illness severity scores and higher PAI-1 levels (n = 9, median 6912 ng/mL, IQR 5808–15600) compared to patients admitted at night (P = 0.019, n = 9, median 3546 ng/mL, IQR 1668–6118) or in the afternoon (P = 0.007, n = 7, median 4224 ng/mL, IQR 1804–5790). In 184 patients, analysis of circadian variation in relation to outcome showed more deaths, amputations and need for skin grafts in patients admitted to the PICU between 6:00 am and 12:00 am than patients admitted during the rest of the day (P = 0.009). Conclusions Circadian variation of PAI-1 levels is present in children with meningococcal sepsis and is associated with illness severity, with a peak level in the morning. Whether circadian variation is an independent risk factor for morbidity and mortality in meningococcal sepsis needs to be explored in future studies.
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Affiliation(s)
- Navin P. Boeddha
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Pediatrics, Division of Pediatric Infectious Diseases & Immunology, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Gertjan J. Driessen
- Department of Pediatrics, Division of Pediatric Infectious Diseases & Immunology, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marjon H. Cnossen
- Department of Pediatrics, Division of Pediatric Hematology, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jan A. Hazelzet
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- * E-mail:
| | - Marieke Emonts
- Paediatric Infectious Diseases and Immunology Department, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
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Scarlatescu E, Tomescu D, Arama SS. Sepsis-Associated Coagulopathy. ACTA ACUST UNITED AC 2016; 2:156-163. [PMID: 29967855 DOI: 10.1515/jccm-2016-0024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 09/29/2016] [Indexed: 11/15/2022]
Abstract
Systemic inflammatory activation in sepsis often leads to coagulation activation, but the relationship is bilateral, as coagulation also modulates the inflammatory response. This close associate has significant consequences for the pathogenesis of microvascular thrombosis and organ dysfunction in sepsis. While coagulation activation can be beneficial for immune defense, it can also be detrimental once it becomes widespread and uncontrolled. The knowledge of the pathophysiologic mechanisms involved in the interaction between infection and coagulation may lead to the better timing for the administration of targeted antithrombotic therapies in septic patients. This brief review highlights the pathophysiologic pathways leading to the prothrombotic state in sepsis and the mechanisms that play a role in the interaction between infection and coagulation.
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Affiliation(s)
- Ecaterina Scarlatescu
- Department of Anesthesiology and Intensive Care III, Fundeni Clinical Institute, Bucharest, Romania
| | - Dana Tomescu
- Department of Anesthesiology and Intensive Care III, Fundeni Clinical Institute, Bucharest, Romania
- University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
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Chen HW, Kuo HT, Chai CY, Ou JL, Yang RC. Pretreatment of curcumin attenuates coagulopathy and renal injury in LPS-induced endotoxemia. ACTA ACUST UNITED AC 2016; 13:15-23. [PMID: 17621542 DOI: 10.1177/0968051907078605] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Disseminated intravascular coagulation (DIC) is a lethal situation in severe infections, characterized by the systemic formation of microthrombi complicated with bleeding tendency and organ dysfunction. Current clinical trials are not promising. In this study, we investigated the protective effect of curcumin in a lipopolysaccharide (LPS)-induced DIC model in rats. Experimental DIC was induced by sustained infusion of LPS (10 mg/kg body weight) for 4 h through the tail vein. Curcumin (60 mg/kg body weight) was given intraperitoneally 3 h before LPS infusion. Results showed that, in vivo, curcumin reduced the mortality rate of LPS-infused rats by decreasing the circulating TNF-α levels and the consumption of peripheral platelets and plasma fibrinogen. Furthermore, in vivo curcumin also has the effect of preventing the formation of fibrin deposition in the glomeruli of kidney. These results reveal the therapeutic potential of curcumin in infection-related coagulopathy of DIC.
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Affiliation(s)
- Hsiang-Wen Chen
- Department of Microbiology, Faculty of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan.
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Walkey AJ, Quinn EK, Winter MR, McManus DD, Benjamin EJ. Practice Patterns and Outcomes Associated With Use of Anticoagulation Among Patients With Atrial Fibrillation During Sepsis. JAMA Cardiol 2016; 1:682-90. [PMID: 27487456 PMCID: PMC5810586 DOI: 10.1001/jamacardio.2016.2181] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
IMPORTANCE Atrial fibrillation (AF) during sepsis is associated with an increased risk of ischemic stroke during hospitalization, but risks and benefits associated with anticoagulation for AF during sepsis are unclear. OBJECTIVE To determine clinician practice patterns and patient risk of stroke and bleeding associated with use of anticoagulation for AF during sepsis. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study using enhanced administrative claims data from approximately 20% of patients hospitalized in the United States July 1, 2010, to June 30, 2013, examined patients with AF during sepsis who did not have additional indications for therapeutic anticoagulation. Propensity score and instrumental variable analyses were used to evaluate risks of in-hospital stroke and bleeding associated with anticoagulation during sepsis. EXPOSURES Parenteral anticoagulants administered in doses greater than those used for prophylaxis of venous thromboembolism. MAIN OUTCOMES AND MEASURES Ischemic stroke and clinically significant bleeding events during hospitalization. RESULTS Of 113 511 patients hospitalized with AF and sepsis, 38 582 were included in our primary analysis (18 976 men and 19 606 women; mean [SD] age, 74.9 [11.7] years). A total of 13 611 patients (35.3%) received parenteral anticoagulants, while 24 971 (64.7%) did not. Hospital utilization rates of parenteral anticoagulants for AF during sepsis varied (median, 33%; 25th-75th percentile, 25%-43%). CHA2DS2VASc scores (congestive heart failure, hypertension, age ≥75 years [doubled], type 1 or type 2 diabetes, stroke or transient ischemic attack or thromboembolism [doubled], vascular disease [prior myocardial infarction, peripheral artery disease, or aortic plaque], age 65-75 years, sex category [female]) poorly discriminated the risk of ischemic stroke during sepsis (C statistic, 0.526). Among 27 010 propensity score-matched patients, rates of in-hospital ischemic stroke events did not differ significantly between patients who did (174 of 13 505 [1.3%]) and did not (185 of 13 505 [1.4%]) receive parenteral anticoagulation (relative risk [RR], 0.94; 95% CI, 0.77-1.15). Clinically significant bleeding occurred more often among patients who received parenteral anticoagulation (1163 of 13 505 [8.6%]) than patients who did not receive parenteral anticoagulation (979 of 13 505 [7.2%]; RR, 1.21; 95% CI, 1.10-1.32). Risk of ischemic stroke associated with parenteral anticoagulation did not differ significantly between patients with preexisting (RR, 1.12; 95% CI, 0.86-1.44) or newly diagnosed AF (RR, 0.85; 95% CI 0.57-1.27; P = .31 for interaction). Results were robust to multiple sensitivity analyses, including hospital utilization rates of parenteral anticoagulation for AF as an instrument for anticoagulation exposure (RR for stroke, 1.08; 95% CI, 0.62-1.90; RR for bleeding, 1.23; 95% CI, 0.88-1.72). CONCLUSIONS AND RELEVANCE Among patients with AF during sepsis, parenteral anticoagulation was not associated with reduced risk of ischemic stroke and was associated with higher bleeding rates.
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Affiliation(s)
- Allan J Walkey
- Division of Pulmonary and Critical Care Medicine, The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts2Center of Implementation and Improvement Sciences, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Emily K Quinn
- Data Coordinating Center, Boston University School of Public Health, Boston, Massachusetts
| | - Michael R Winter
- Data Coordinating Center, Boston University School of Public Health, Boston, Massachusetts
| | - David D McManus
- Section of Cardiac Pacing and Electrophysiology, Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester
| | - Emelia J Benjamin
- Section of Cardiovascular Medicine, Boston University School of Medicine, Boston, Massachusetts6Section of Preventive Medicine, Boston University School of Medicine, Boston, Massachusetts7Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
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Immature platelet fraction predicts coagulopathy-related platelet consumption and mortality in patients with sepsis. Thromb Res 2016; 144:169-75. [DOI: 10.1016/j.thromres.2016.06.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 05/06/2016] [Accepted: 06/02/2016] [Indexed: 01/25/2023]
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DAMP and DIC: The role of extracellular DNA and DNA-binding proteins in the pathogenesis of DIC. Blood Rev 2016; 30:257-61. [DOI: 10.1016/j.blre.2015.12.004] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 12/11/2015] [Accepted: 12/28/2015] [Indexed: 12/30/2022]
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Ketter P, Yu JJ, Cap AP, Forsthuber T, Arulanandam B. Pentraxin 3: an immune modulator of infection and useful marker for disease severity assessment in sepsis. Expert Rev Clin Immunol 2016; 12:501-7. [PMID: 26982005 DOI: 10.1586/1744666x.2016.1166957] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The acute phase protein pentraxin 3 (PTX3) is a pattern recognition receptor involved in regulation of the host immune response. This relatively newly discovered member of the pentraxin superfamily elicits both immunostimulatory and immunoregulatory functions preventing autoimmune pathology and orchestrated clearance of pathogens through opsonization of damage- and pathogen-associated molecular patterns (DAMP/PAMP). Thus, PTX3 has been described as a possible evolutionary precursor to immunoglobulins. While shown to provide protection against specific bacterial and fungal pathogens, persistent elevation of PTX3 levels following initial onset of infection appear to predict poor patient outcome and may contribute to disease sequelae such as tissue damage and coagulopathy. Measurement of PTX3 following onset of sepsis may improve patient risk assessment and thus be useful in guiding subsequent therapeutic interventions including steroidal anti-inflammatory and altered antibiotic therapies. In this review, we summarize the role of PTX3 in inflammatory syndromes and its utility as a marker of sepsis disease severity.
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Affiliation(s)
- Patrick Ketter
- a Blood and Coagulation Program , United States Army Institute of Surgical Research , JBSA-Fort Sam Houston , TX , USA
| | - Jieh-Juen Yu
- b Department of Biology , University of Texas at San Antonio , San Antonio , TX , USA
| | - Andrew P Cap
- a Blood and Coagulation Program , United States Army Institute of Surgical Research , JBSA-Fort Sam Houston , TX , USA
| | - Thomas Forsthuber
- b Department of Biology , University of Texas at San Antonio , San Antonio , TX , USA
| | - Bernard Arulanandam
- b Department of Biology , University of Texas at San Antonio , San Antonio , TX , USA
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Umemura Y, Yamakawa K, Ogura H, Yuhara H, Fujimi S. Efficacy and safety of anticoagulant therapy in three specific populations with sepsis: a meta-analysis of randomized controlled trials. J Thromb Haemost 2016; 14:518-30. [PMID: 26670422 DOI: 10.1111/jth.13230] [Citation(s) in RCA: 184] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 11/25/2015] [Indexed: 11/27/2022]
Abstract
UNLABELLED ESSENTIALS: Most anticoagulant therapy has failed to demonstrate a survival benefit in the overall sepsis population. We conducted separate meta-analyses of anticoagulant therapy in three different populations. Survival benefit was observed only in the septic disseminated intravascular coagulation (DIC) population. Further randomized controlled trials should focus on specific populations with septic DIC. SUMMARY BACKGROUND Although many preclinical trials have indicated the effectiveness and safety of anticoagulant therapy as an adjuvant therapy against sepsis, there is little evidence to support its effectiveness to reduce mortality in the overall population with sepsis in clinical situations. However, several studies suggested that specific anticoagulant therapy may potentially reduce mortality in patients with sepsis-induced disseminated intravascular coagulation (DIC). OBJECTIVE We investigated whether the survival benefit of anticoagulant therapy might pertain to the coagulopathic population with sepsis. METHODS We conducted separate meta-analyses of randomized controlled trials for anticoagulant therapy in three different populations: (i) overall population with sepsis, (ii) population with sepsis-induced coagulopathy, and (iii) population with sepsis-induced DIC. We searched MEDLINE, Scopus, and the Cochrane Central Register of Controlled Trials comparing anticoagulant therapy with placebo or no intervention in sepsis patients. We measured all-cause mortality as the primary outcome and bleeding complications as the secondary outcome. RESULTS We analyzed 24 trials enrolling 14 767 patients. There were no significant reductions in mortality in the overall sepsis population and the population with sepsis-induced coagulopathy. Otherwise, we observed significant reductions in mortality (risk ratio 0.72, 95% confidence interval 0.62-0.85) in the population with sepsis-induced DIC. As adverse events, bleeding complications tended to increase similarly with anticoagulant therapy in all three populations. CONCLUSION Although associated with an increased risk of bleeding, anticoagulant therapy resulted in no survival benefits in the overall sepsis population and even the population with sepsis-induced coagulopathy; beneficial effects on mortality were observed only in the population with sepsis-induced DIC.
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Affiliation(s)
- Y Umemura
- Department of Emergency and Critical Care, Osaka General Medical Center, Osaka, Japan
| | - K Yamakawa
- Department of Emergency and Critical Care, Osaka General Medical Center, Osaka, Japan
| | - H Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - H Yuhara
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - S Fujimi
- Department of Emergency and Critical Care, Osaka General Medical Center, Osaka, Japan
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Lansink MO, Görlinger K, Hartmann M, de Groot H, Effenberger-Neidnicht K. Melatonin does not affect disseminated intravascular coagulation but diminishes decreases in platelet count during subacute endotoxaemia in rats. Thromb Res 2016; 139:38-43. [DOI: 10.1016/j.thromres.2015.10.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 09/30/2015] [Accepted: 10/13/2015] [Indexed: 12/15/2022]
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Asphyxia by Drowning Induces Massive Bleeding Due To Hyperfibrinolytic Disseminated Intravascular Coagulation. Crit Care Med 2016; 43:2394-402. [PMID: 26327200 PMCID: PMC4603369 DOI: 10.1097/ccm.0000000000001273] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To date, no study has systematically investigated the impact of drowning-induced asphyxia on hemostasis. Our objective was to test the hypothesis that asphyxia induces bleeding by hyperfibrinolytic disseminated intravascular coagulation. DESIGN Observational study. SETTING A 2,100-bed tertiary care facility in Vienna, Austria, Europe. PATIENTS All cases of drowning-induced asphyxia (n=49) were compared with other patients with cardiopulmonary resuscitation (n=116) and to patients with acute promyelocytic leukemia (n=83). Six drowning victims were investigated prospectively. To study the mechanism, a forearm-ischemia model was used in 20 volunteers to investigate whether hypoxia releases tissue plasminogen activator. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Eighty percent of patients with drowning-induced asphyxia developed overt disseminated intravascular coagulation within 24 hours. When compared with nondrowning cardiac arrest patients, drowning patients had a 13 times higher prevalence of overt disseminated intravascular coagulation at admission (55% vs 4%; p<0.001). Despite comparable disseminated intravascular coagulation scores, acute promyelocytic leukemia patients had higher fibrinogen but lower d-dimer levels and platelet counts than drowning patients (p<0.001). Drowning victims had a three-fold longer activated partial thromboplastin time (124 s; p<0.001) than both nondrowning cardiac arrest and acute promyelocytic leukemia patients. Hyperfibrinolysis was reflected by up to 1,000-fold increased d-dimer levels, greater than 5-fold elevated plasmin antiplasmin levels, and a complete absence of thrombelastometric clotting patterns, which was reversed by antifibrinolytics and heparinase. Thirty minutes of forearm-ischemia increased tissue plasminogen activator 31-fold (p<0.001). CONCLUSIONS The vast majority of drowning patients develops overt hyperfibrinolytic disseminated intravascular coagulation, partly caused by hypoxia induced tissue plasminogen activator release. Antifibrinolytics and heparinase partially reverse the abnormal clotting patterns. Severe activated partial thromboplastin time prolongation may be a marker of combined hyperfibrinolytic afibrinogenemia and autoheparinization in drowning-related asphyxia.
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Enhanced expression of cell-specific surface antigens on endothelial microparticles in sepsis-induced disseminated intravascular coagulation. Shock 2016; 43:443-9. [PMID: 25608138 PMCID: PMC4418778 DOI: 10.1097/shk.0000000000000331] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Sepsis-induced disseminated intravascular coagulation (DIC) is a major cause of death in patients admitted to intensive care units. Endothelial injury with microparticle production is reported in the pathogenesis of sepsis. Endothelial microparticles (EMPs) present several cell-specific surface antigens with different bioactivities, for example, tissue factor (TF), thrombomodulin (TM), and endothelial protein C receptor (EPCR). We investigated associations between these three different surface antigen-positive EMPs and sepsis-induced DIC. This cross-sectional study composed of 24 patients with sepsis and 23 healthy controls was conducted from November 2012 to September 2013. Blood samples were collected from patients within 24 h of diagnosis of severe sepsis and from healthy controls. Numbers of TF-positive EMPs (TF EMPs), TM-positive EMPs (TM EMPs), and EPCR-positive EMPs (EPCR EMPs) were measured by flow cytometry immediately thereafter. Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores were assessed in the severe sepsis patients at enrollment. We assessed DIC with the International Society of Thrombosis and Haemostasis (ISTH) overt DIC diagnostic criteria algorithm. Numbers of antigen-positive EMPs were increased significantly in both severe sepsis patients and controls and with the increase in ISTH DIC score. Numbers of TF EMPs and EPCR EMPs correlated significantly with Sequential Organ Failure Assessment score, and numbers of EPCR EMPs correlated significantly with Acute Physiology and Chronic Health Evaluation II score. Numbers of the three antigen-positive EMPs were increased significantly in severe sepsis patients versus those in healthy controls and with the increase of ISTH DIC score, suggesting that the specific bioactivity of each antigen-positive EMP may play a role in the progression of sepsis-induced DIC.
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Alpha-lipoic acid prevents endotoxic shock and multiple organ dysfunction syndrome induced by endotoxemia in rats. Shock 2016; 43:405-11. [PMID: 25514429 DOI: 10.1097/shk.0000000000000295] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Alpha-lipoic acid (ALA), a naturally occurring disulfide derivative of octanoic acid, serves as a strong antioxidant and has been reported to possess anti-inflammatory effects. The aim of the present study is to investigate the preventive and therapeutic effects of ALA on multiple organ dysfunction syndrome (MODS) caused by endotoxemia in rats. Male Wistar rats were intravenously infused with lipopolysaccharide (LPS) (10 mg/kg) to induce endotoxemia. Alpha-lipoic acid 10, 20, or 40 mg/kg was administered intravenously 60 min before (pretreatment) LPS challenge, and ALA 40 mg/kg was administered intravenously 30 min after (posttreatment) LPS challenge. Pretreatment and posttreatment with ALA significantly improved the deleterious hemodynamic changes 8 h after LPS challenge, including hypotension and bradycardia. Alpha-lipoic acid reduced the plasma levels of glutamic pyruvic transaminase, blood urea nitrogen, lactate dehydrogenase, tumor necrosis factor-α, nitric oxide metabolites, and thrombin-antithrombin complex, which increased markedly after LPS challenge. The induction of inducible nitric oxide synthase both in the liver and the lung and vascular superoxide anion production were also significantly suppressed by ALA. Moreover, ALA significantly attenuated LPS-induced caspase-3 activation in cardiomyocytes and improved survival rate. In conclusion, ALA effectively attenuated LPS-induced acute inflammatory response and improved MODS. The antioxidant and anti-inflammatory effects of ALA may contribute to these beneficial effects. Alpha-lipoic acid might be considered as a novel therapeutic strategy in the prevention of sepsis-induced MODS and inflammatory vascular diseases.
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Walkey AJ, Hogarth DK, Lip GYH. Optimizing atrial fibrillation management: from ICU and beyond. Chest 2016; 148:859-864. [PMID: 25951122 DOI: 10.1378/chest.15-0358] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Atrial fibrillation (AF) that newly occurs during critical illness presents challenges for both short- and long-term management. During critical illness, patients with new-onset AF are clinically evaluated for hemodynamic instability owing to the arrhythmia as well as for potentially reversible arrhythmia triggers. Hemodynamically significant AF that persists during critical illness may be treated with heart rate or rhythm control strategies. Recent evidence suggests that patients in whom AF develops during acute illness (eg, sepsis, postoperatively) have high long-term risks for AF recurrence and for AF-associated complications, such as stroke, heart failure, and death. Therefore, we suggest increased efforts to improve communication of AF events between inpatient and outpatient providers and to reassess patients who had experienced new-onset AF during critical illness after they transition to the post-ICU setting. We describe various strategies for the assessment and long-term management of patients with new-onset AF during critical illness.
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Affiliation(s)
- Allan J Walkey
- Division of Pulmonary and Critical Care Medicine, The Pulmonary Center, Boston University School of Medicine, Boston, MA.
| | - D Kyle Hogarth
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Gregory Y H Lip
- Centre for Cardiovascular Sciences, University of Birmingham, Birmingham, England; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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83
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Kell DB, Kenny LC. A Dormant Microbial Component in the Development of Preeclampsia. Front Med (Lausanne) 2016; 3:60. [PMID: 27965958 PMCID: PMC5126693 DOI: 10.3389/fmed.2016.00060] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 11/04/2016] [Indexed: 12/12/2022] Open
Abstract
Preeclampsia (PE) is a complex, multisystem disorder that remains a leading cause of morbidity and mortality in pregnancy. Four main classes of dysregulation accompany PE and are widely considered to contribute to its severity. These are abnormal trophoblast invasion of the placenta, anti-angiogenic responses, oxidative stress, and inflammation. What is lacking, however, is an explanation of how these themselves are caused. We here develop the unifying idea, and the considerable evidence for it, that the originating cause of PE (and of the four classes of dysregulation) is, in fact, microbial infection, that most such microbes are dormant and hence resist detection by conventional (replication-dependent) microbiology, and that by occasional resuscitation and growth it is they that are responsible for all the observable sequelae, including the continuing, chronic inflammation. In particular, bacterial products such as lipopolysaccharide (LPS), also known as endotoxin, are well known as highly inflammagenic and stimulate an innate (and possibly trained) immune response that exacerbates the inflammation further. The known need of microbes for free iron can explain the iron dysregulation that accompanies PE. We describe the main routes of infection (gut, oral, and urinary tract infection) and the regularly observed presence of microbes in placental and other tissues in PE. Every known proteomic biomarker of "preeclampsia" that we assessed has, in fact, also been shown to be raised in response to infection. An infectious component to PE fulfills the Bradford Hill criteria for ascribing a disease to an environmental cause and suggests a number of treatments, some of which have, in fact, been shown to be successful. PE was classically referred to as endotoxemia or toxemia of pregnancy, and it is ironic that it seems that LPS and other microbial endotoxins really are involved. Overall, the recognition of an infectious component in the etiology of PE mirrors that for ulcers and other diseases that were previously considered to lack one.
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Affiliation(s)
- Douglas B. Kell
- School of Chemistry, The University of Manchester, Manchester, UK
- The Manchester Institute of Biotechnology, The University of Manchester, Manchester, UK
- Centre for Synthetic Biology of Fine and Speciality Chemicals, The University of Manchester, Manchester, UK
- *Correspondence: Douglas B. Kell,
| | - Louise C. Kenny
- The Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
- Department of Obstetrics and Gynecology, University College Cork, Cork, Ireland
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Geier C, Schröder J, Tamm A, Dietz S, Nuding S, Holder K, Khandanpour Ö, Werdan K, Ebelt H. Influence of the serum levels of immunoglobulins on clinical outcomes in medical intensive-care patients. Med Klin Intensivmed Notfmed 2015; 112:30-37. [PMID: 26681382 DOI: 10.1007/s00063-015-0121-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 08/30/2015] [Accepted: 09/30/2015] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Endogenous immunoglobulins (Igs) are of fundamental importance in the host defense after microbial infections. However, the therapeutic administration of intravenous IgG (IVIgG) has not yet been shown to improve clinical outcomes in patients suffering from sepsis, and in the case of IgM-containing preparations (IVIgGMA) the positive evidence is only weak. Recently published studies implicate that Ig levels on admission could have an impact on the patient's response to IVIg treatment and on outcomes of critically ill patients. METHODS In this noninterventional study, the serum levels of IgG, IgM, and IgA were determined in 340 medical patients on ICU admission, and clinical outcomes were prospectively recorded (ICU mortality, need for renal replacement therapy (RRT), need for mechanical ventilation, substitution of coagulation factors, and amount of red cell transfusions). Patients were prospectively grouped according to their main reason for ICU admission (sepsis, respiratory failure, cardiovascular diseases, acute renal failure, postoperative condition, state after cardiopulmonal resuscitation, gastrointestinal diseases, and others). RESULTS AND DISCUSSION There was no correlation between the Ig levels on admission and ICU mortality neither in the total cohort of medical ICU patients nor in any prespecified subgroup. However, in a logistic regression model that was adjusted for APACHE II score on admission, an increase in serum IgG was associated with a reduced need for mechanical ventilation in patients suffering from cardiovascular disease. On the other hand, in patients suffering from sepsis, an increased level of IgM was linked to an increased administration of coagulation factors. CONCLUSION Our data do not support the hypothesis that serum levels of immunoglobulins are linked to mortality in medical ICU patients.
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Affiliation(s)
- C Geier
- Department of Medicine III, University Hospital Halle, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - J Schröder
- Department of Medicine III, University Hospital Halle, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - A Tamm
- Department of Medicine III, University Hospital Halle, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - S Dietz
- Department of Medicine III, University Hospital Halle, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - S Nuding
- Department of Medicine III, University Hospital Halle, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - K Holder
- Department of Medicine III, University Hospital Halle, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - Ö Khandanpour
- Department of Medicine III, University Hospital Halle, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - K Werdan
- Department of Medicine III, University Hospital Halle, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - H Ebelt
- Department of Medicine II, Catholic Hospital "St. Johann Nepomuk", Haarbergstr. 72, 99097, Erfurt, Germany.
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Ito T, Kakihana Y, Maruyama I. Thrombomodulin as an intravascular safeguard against inflammatory and thrombotic diseases. Expert Opin Ther Targets 2015; 20:151-8. [PMID: 26558419 DOI: 10.1517/14728222.2016.1086750] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Thrombomodulin is a transmembrane protein expressed on the surface of endothelial cells. It plays an important role in regulating inflammation as well as coagulation within blood vessels. Recently, a recombinant form of an extracellular fragment of thrombomodulin (rTM) has been developed and is expected to be useful for patients suffering from inflammatory and thrombotic diseases. AREAS COVERED We initially focus on the physiological and biochemical features of thrombomodulin, including its distribution, structure and function. We then discuss potential therapeutic applications of rTM. EXPERT OPINION Thrombomodulin exerts anticoagulant and anti-inflammatory effects, in part through activated protein C (APC)-dependent mechanisms. Although recombinant human APC (rhAPC) failed to improve the survival of patients with septic shock and has now been withdrawn from the market, rTM may have some advantages over rhAPC. First, rTM may have less risk of bleeding complications than rhAPC, because rTM needs thrombin to act as an anticoagulant and thus its anticoagulant power can be automatically adjusted by the amount of existing thrombin. Second, the APC-independent actions of rTM might confer benefits, including the suppression of complements, endotoxin (representative pathogen-associated molecular pattern) and high-mobility group box 1 protein (prototypical damage-associated molecular pattern) through the lectin-like domain of rTM.
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Affiliation(s)
- Takashi Ito
- a Kagoshima University , Graduate School of Medical and Dental Sciences, Department of Emergency and Critical Care Medicine , Kagoshima , Japan.,b Kagoshima University , Graduate School of Medical and Dental Sciences, Department of Systems Biology in Thromboregulation , Kagoshima , Japan
| | - Yasuyuki Kakihana
- a Kagoshima University , Graduate School of Medical and Dental Sciences, Department of Emergency and Critical Care Medicine , Kagoshima , Japan
| | - Ikuro Maruyama
- b Kagoshima University , Graduate School of Medical and Dental Sciences, Department of Systems Biology in Thromboregulation , Kagoshima , Japan
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86
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van Bijnen STA, Wouters D, van Mierlo GJ, Muus P, Zeerleder S. Neutrophil activation and nucleosomes as markers of systemic inflammation in paroxysmal nocturnal hemoglobinuria: effects of eculizumab. J Thromb Haemost 2015; 13:2004-11. [PMID: 26333021 DOI: 10.1111/jth.13125] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 08/14/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND Paroxysmal nocturnal hemoglobinuria (PNH) is characterized by complement-mediated hemolysis and a high risk of life-threatening venous and arterial thrombosis. Uncontrolled complement activation and the release of cell-free heme may result in systemic inflammation, neutrophil activation, and the release of procoagulant neutrophilic proteases. Eculizumab, an antibody to complement factor C5, inhibits hemolysis and reduces thrombotic risk. OBJECTIVES To study neutrophil activation and nucleosome levels in relation to thrombosis in PNH patients before and during treatment with eculizumab. PATIENTS/METHODS In 51 untreated PNH patients, including 20 patients before and after commencing eculizumab treatment, we have assessed neutrophil activation by measuring elastase-α1 -antitrypsin (EA) complexes and circulating nucleosomes, as established markers for systemic inflammation and cell death. RESULTS Nucleosomes (median; range; 95% confidence interval [CI]), but not EA complexes, were higher in PNH patients with a history of thrombosis (16; 7-264; 0.3-94 U mL(-1) , n = 12) than in those without (6; 6-35; 7-11 U mL(-1) , n = 39) or controls (8; 6-23; 7-12 U mL(-1) , n = 17). EA complexes, but not nucleosomes, decreased promptly and markedly upon eculizumab treatment. EA complexes (estimated marginal means; 95% CI) remained low at ≥ 12 weeks (50; 34-67) compared with baseline (12; -6 to 29). CONCLUSIONS The increased nucleosome levels in PNH patients with a history of thrombosis suggest systemic inflammation and/or cell death. Neutrophil activation markers did not differ between patients with and without a history of thrombosis and healthy controls. Interestingly, basal neutrophil activation in PNH patients significantly decreases on treatment with eculizumab, indicating that neutrophil activation is C5a driven.
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Affiliation(s)
| | - D Wouters
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - G J van Mierlo
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - P Muus
- Department of Hematology, RadboudUMC, Nijmegen, the Netherlands
| | - S Zeerleder
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory AMC, University of Amsterdam, Amsterdam, the Netherlands
- Department of Hematology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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miR-96 and miR-330 overexpressed and targeted AQP5 in lipopolysaccharide-induced rat lung damage of disseminated intravascular coagulation. Blood Coagul Fibrinolysis 2015; 25:731-7. [PMID: 24806323 DOI: 10.1097/mbc.0000000000000133] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Disseminated intravascular coagulation (DIC) is a severe clinical condition that can lead to or aggravate the development of multiple organ dysfunction syndrome. Of all types of organ damage, lung damage is the most frequent and most severe. In DIC patients, lung damage is primarily characterized by pulmonary edema. Aquaporin (AQP) 5 is the chief AQP in the lungs and it plays a key role in many processes, including water transport in normal and abnormal lungs. Here we demonstrate that expression of AQP5 and two microRNAs, miR-96 and miR-330, in rat lung of lipopolysaccharide (LPS)-induced DIC. We also show that both miR-96 and miR-330 can regulate the expression of AQP5 by binding with its 3'-untranslated region (UTR) by luciferase activity assay. These results suggest that microRNAs are involved in lung damage in LPS-induced rat DIC and can be a potential target for molecular therapy.
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88
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Koike Y, Tanaka K, Kobayashi M, Toiyama Y, Inoue Y, Mohri Y, Uchida K, Mizoguchi A, Kusunoki M. Dynamic pathology for leukocyte–platelet formation in sepsis model. J Surg Res 2015; 195:188-95. [DOI: 10.1016/j.jss.2014.05.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 04/26/2014] [Accepted: 05/02/2014] [Indexed: 12/11/2022]
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Yoshimura J, Yamakawa K, Ogura H, Umemura Y, Takahashi H, Morikawa M, Inoue Y, Fujimi S, Tanaka H, Hamasaki T, Shimazu T. Benefit profile of recombinant human soluble thrombomodulin in sepsis-induced disseminated intravascular coagulation: a multicenter propensity score analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:78. [PMID: 25883031 PMCID: PMC4367899 DOI: 10.1186/s13054-015-0810-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Accepted: 02/13/2015] [Indexed: 02/08/2023]
Abstract
Introduction The safety and efficacy of recombinant human soluble thrombomodulin (rhTM) have been demonstrated, with promising evidence suggestive of efficacy for patients with severe sepsis involving coagulopathy in a phase IIb randomized controlled trial. However, the benefit profiles of rhTM have not been elucidated. The purpose of this study was to explore whether patients with greater disease severity, determined according to the Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores, would experience treatment benefit from rhTM administration. Methods This was a post hoc, subgroup analysis of a multicenter retrospective cohort study conducted in three Japanese tertiary referral hospitals. Patients with sepsis-induced disseminated intravascular coagulation (DIC) who required ventilator management were included. We stratified patients into several strata according to disease severity, determined by APACHE II and SOFA scores, using classification and regression trees for survival data. Intervention effects, expressed as hazard ratios (HR), were analyzed using Cox regression analysis adjusted for a propensity model to detect subgroup heterogeneity of the effects of rhTM on in-hospital mortality. Results Participants were 162 patients with sepsis-induced DIC; 68 of these patients received rhTM and 94 did not. After adjusting for imbalances, rhTM administration was significantly associated with reduced mortality in high-risk patients (APACHE II: 24 to 29; HR: 0.281; 95% confidence interval (CI): 0.093 to 0.850; P = 0.025). A similar nonsignificant tendency was observed in the very high-risk subset (APACHE II: ≥30; HR: 0.529; 95% CI: 0.202 to 1.387; P = 0.195) but was not evident in the moderate-risk subset of patients (APACHE II: <24; HR: 0.814; 95% CI: 0.351 to 1.884; P = 0.630). A similar tendency was observed in analysis of SOFA scores (moderate-risk subset (SOFA: <11), P = 0.368; high-risk subset (SOFA: ≥11), P = 0.042). Conclusions Survival benefit was observed with rhTM treatment in sepsis-induced DIC and high risk of death according to baseline APACHE II and SOFA scores.
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Affiliation(s)
- Jumpei Yoshimura
- Department of Emergency and Critical Care, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan.
| | - Kazuma Yamakawa
- Department of Emergency and Critical Care, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan.
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Yutaka Umemura
- Department of Emergency and Critical Care, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan.
| | - Hiroki Takahashi
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Miki Morikawa
- Department of Emergency and Critical Care Medicine, Juntendo University, Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan.
| | - Yoshiaki Inoue
- Department of Emergency and Critical Care Medicine, Juntendo University, Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan.
| | - Satoshi Fujimi
- Department of Emergency and Critical Care, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan.
| | - Hiroshi Tanaka
- Department of Emergency and Critical Care Medicine, Juntendo University, Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan.
| | - Toshimitsu Hamasaki
- Office of Biostatistics and Data Management, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka, 565-8565, Japan.
| | - Takeshi Shimazu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan.
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90
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Ikezoe T. Thrombomodulin/activated protein C system in septic disseminated intravascular coagulation. J Intensive Care 2015; 3:1. [PMID: 25705426 PMCID: PMC4336127 DOI: 10.1186/s40560-014-0050-7] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 08/14/2014] [Indexed: 11/10/2022] Open
Abstract
The thrombomodulin (TM)/activated protein C (APC) system plays an important role in maintaining the homeostasis of thrombosis and hemostasis and maintaining vascular integrity in vivo. TM expressed on vascular endothelium binds to thrombin, forming a 1:1 complex and acts as an anticoagulant. In addition, the thrombin-TM complex activates protein C to produce APC, which inactivates factors VIIIa and Va in the presence of protein S, thereby inhibiting further thrombin formation. Intriguingly, APC possesses anti-inflammatory as well as cytoprotective activities. Moreover, the extracellular domain of TM also possesses APC-independent anti-inflammatory and cytoprotective activities. Of note, the TM/APC system is compromised in disseminated intravascular coagulation (DIC) caused by sepsis due to various mechanisms, including cleavage of cell-surface TM by exaggerated cytokines and proteases produced by activated inflammatory cells. Thus, it is reasonable to assume that reconstitution of the TM/APC system by recombinant proteins would alleviate sepsis and DIC. On the basis of the success of the Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) trial, the FDA approved the use of recombinant human APC (rhAPC) for severe sepsis patients in 2002. However, subsequent clinical trials failed to show clinical benefits for rhAPC, and an increased incidence of hemorrhage-related adverse events was noted, which prompted the industry to withdraw rhAPC from the market. On the other hand, recombinant human soluble TM (rTM) has been used for treatment of individuals with DIC since 2008 in Japan, and a phase III clinical trial evaluating the efficacy of rTM in severe sepsis patients with coagulopathy is now ongoing in the USA, South America, Asia, Australia, European Union, and other countries. This review article discusses the molecular mechanisms by which the TM/APC system produces anticoagulant as well as anti-inflammatory and cytoprotective activities in septic DIC patients.
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Affiliation(s)
- Takayuki Ikezoe
- Department of Hematology and Respiratory Medicine, Kochi University, Nankoku, Kochi, 783-8505 Japan
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91
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Nomura S. Critically ill Patients and Platelet-Derived Microparticles. J Atheroscler Thromb 2015; 22:752-3. [DOI: 10.5551/jat.ed019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Shosaku Nomura
- First Department of Internal Medicine, Kansai Medical University
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92
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Abstract
Thrombosis is generally considered harmful because it compromises the blood supply to organs. However, recent studies have suggested that thrombosis under certain circumstances plays a major physiological role in early immune defense against invading pathogens. This defensive role of thrombosis is now referred to as immunothrombosis. Activated monocytes and neutrophils are two major inducers of immunothrombosis. Monocytes and neutrophils are activated when they detect pathogen-associated molecular patterns (PAMPs) and damage-associated molecular patterns (DAMPs). Detection of PAMPs and DAMPs triggers tissue factor expression on monocytes and neutrophil extracellular trap (NET) release by neutrophils, promoting immunothrombosis. Although tissue factor-mediated and NET-mediated immunothrombosis plays a role in early host defense against bacterial dissemination, uncontrolled immunothrombosis may lead to disseminated intravascular coagulation.
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Affiliation(s)
- Takashi Ito
- Department of Emergency and Critical Care Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan ; Department of Systems Biology in Thromboregulation, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
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93
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Jiang L, Jiang S, Feng X, Ma Y, Zhang M. The efficacy and safety of different anticoagulants on patients with severe sepsis and derangement of coagulation: a protocol for network meta-analysis of randomised controlled trials. BMJ Open 2014; 4:e006770. [PMID: 25534216 PMCID: PMC4275679 DOI: 10.1136/bmjopen-2014-006770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 11/17/2014] [Accepted: 11/18/2014] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Sepsis is the leading cause of mortality in non-cardiological critically ill patients. There are as many as 20 million cases of sepsis annually worldwide, with a mortality rate of around 35%. It has been reported that the dysregulation of haemostatic system due to the interaction between coagulation system and inflammatory response is a strong predictor of mortality in patients with severe sepsis. In this context, several anticoagulants have been evaluated in recent years. However, the results of these studies were inconsistent and even contradictory. In addition, there is insufficient evidence comparing the efficacy and safety of different anticoagulants. The purpose of our study is to carry out a systematic review and network meta-analysis comparing the efficacy and safety of different anticoagulants for severe sepsis based on existing randomised controlled trials (RCTs) and ranking these anticoagulants for practical consideration. METHODS AND ANALYSIS PubMed, EMBASE and Cochrane Library databases will be systematically searched for eligible studies. Randomised controlled trials (RCT) on anticoagulant therapy for severe sepsis with multiple outcome measures will be included. The Cochrane Risk of Bias Tool will be used to assess the quality of included studies. The primary outcomes are mortality and bleeding events. The secondary outcomes include the length of intensive care stay, the length of hospital stay and duration of mechanical ventilation. Direct pairwise meta-analysis (DMA), indirect treatment comparison meta-analysis (ITC) and network meta-analysis (NMA) will be conducted to compare different anticoagulants. ETHICS AND DISSEMINATION Ethical approval is not required given that this is a protocol for a systematic review. The protocol of this systematic review will be disseminated in a peer-reviewed journal and presented at a relevant conference. TRIAL REGISTRATION NUMBER This protocol has been registered in PROSPERO (http://www.crd.york.ac.uk/PROSPERO/) under registration number CRD42014013886.
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Affiliation(s)
- Libing Jiang
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of emergency Medicine, Zhejiang University, Hangzhou, China
| | - Shouyin Jiang
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of emergency Medicine, Zhejiang University, Hangzhou, China
| | - Xia Feng
- The Second Department of Respiration, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Yuefeng Ma
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of emergency Medicine, Zhejiang University, Hangzhou, China
| | - Mao Zhang
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of emergency Medicine, Zhejiang University, Hangzhou, China
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Misztal T, Rusak T, Tomasiak M. Clinically relevant HOCl concentrations reduce clot retraction rate via the inhibition of energy production in platelet mitochondria. Free Radic Res 2014; 48:1443-53. [DOI: 10.3109/10715762.2014.960866] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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95
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Wang C, Chi C, Guo L, Wang X, Guo L, Sun J, Sun B, Liu S, Chang X, Li E. Heparin therapy reduces 28-day mortality in adult severe sepsis patients: a systematic review and meta-analysis. Crit Care 2014; 18:563. [PMID: 25318353 PMCID: PMC4213495 DOI: 10.1186/s13054-014-0563-4] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 10/01/2014] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION There are approximately 19 million new cases of sepsis worldwide each year. Among them, more than one quarter of patients die. We aimed to assess the effects of heparin on short-term mortality in adult patients with sepsis and severe sepsis. METHODS We searched electronic databases (Medline, Embase, and Cochrane Library databases; the Cochrane Controlled Trials Register) and conference proceedings (Web of Knowledge (Conference Proceedings Citation Index - Science, Conference Proceedings Citation Index - Social Sciences & Humanities)) from inception to July 2014, expert contacts and relevant websites. Controlled trials of heparin versus placebo in sepsis or severe sepsis were identified. In total two reviewers independently assessed eligibility, and four authors independently extracted data; consensus was reached by conference. We used the chi-square test and I2 to assess statistical heterogeneity (P <0.05). The primary analysis was based on the fixed-effect model to produce pooled odds ratios with 95% confidence intervals. RESULTS A total of nine publications were included in the meta-analysis. Heparin decreased 28-day mortality (n = 3,482, OR = 0.656, 95% CI = 0.562 to 0.765, P <0.0001). According to the meta-analysis of 28-day mortality, heterogeneity was not found among the eight randomized clinical trials (RCTs) (I2 = 0.0%). Heparin had no effect on bleeding events in sepsis (seven RCTs, n = 2,726; OR = 1.063; 95% CI = 0.834 to 1.355; P = 0.623; and I2 = 20.9%). Subgroup analysis demonstrated that the sample size may be a source of heterogeneity, but experimental design was not. CONCLUSIONS Heparin may reduce 28-day mortality in patients with severe sepsis, at the same time, there was no increase in the risk of bleeding in the heparin group. We recommend the use of heparin for sepsis and severe sepsis.
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Affiliation(s)
- Changsong Wang
- />Department of Anesthesiology, First Affiliated Hospital of Harbin Medical University, No 23 Youzheng Street, Nangang District, Harbin, Heilongjiang 150001 China
| | - Chunjie Chi
- />Department of Anesthesiology, First Affiliated Hospital of Harbin Medical University, No 23 Youzheng Street, Nangang District, Harbin, Heilongjiang 150001 China
| | - Lei Guo
- />Department of Anesthesiology, First Affiliated Hospital of Harbin Medical University, No 23 Youzheng Street, Nangang District, Harbin, Heilongjiang 150001 China
| | - Xiaoyang Wang
- />Department of Anesthesiology, First Affiliated Hospital of Harbin Medical University, No 23 Youzheng Street, Nangang District, Harbin, Heilongjiang 150001 China
| | - Libo Guo
- />Department of Anesthesiology, First Affiliated Hospital of Harbin Medical University, No 23 Youzheng Street, Nangang District, Harbin, Heilongjiang 150001 China
| | - Jiaxiao Sun
- />Department of Anesthesiology, First Affiliated Hospital of Quan Zhou, No. 151 Yanjiang West Road, Yuexiu, Quan Zhou, Guangdong China
| | - Bo Sun
- />Department of Anesthesiology, First Affiliated Hospital of Harbin Medical University, No 23 Youzheng Street, Nangang District, Harbin, Heilongjiang 150001 China
| | - Shanshan Liu
- />Department of Anesthesiology, First Affiliated Hospital of Harbin Medical University, No 23 Youzheng Street, Nangang District, Harbin, Heilongjiang 150001 China
| | - Xuenan Chang
- />Department of Anesthesiology, Tianjin Huanhu Hospital, No. 122 Qixiangtai Road, Hexi, Tian Jin 300060 China
| | - Enyou Li
- />Department of Anesthesiology, First Affiliated Hospital of Harbin Medical University, No 23 Youzheng Street, Nangang District, Harbin, Heilongjiang 150001 China
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Lemańska-Perek A, Polańska B, Krzyżanowska-Gołąb D, Kątnik-Prastowska I. Occurrence of soluble supra-molecular FN–fibrin complexes in the plasma of children with recurrent respiratory infection. Ann Clin Biochem 2014; 52:441-7. [DOI: 10.1177/0004563214556650] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2014] [Indexed: 11/16/2022]
Abstract
Objectives Fibronectin (FN) is able to bind fibrin and FN–fibrin complexes and is found in the plasma of some patients suffering from inflammatory disease. The present study was undertaken to determine whether soluble supra-molecular FN–fibrin complexes were present in the plasma of children with recurrent respiratory infections (RRI). Design and methods The frequency of occurrence and relative amounts of the supra-molecular FN–fibrin forms, concentrations of immunoglobulins and numbers of natural killer cells (NK) were determined in the plasma of children with recurrent respiratory infections. The frequencies of these parameters were compared with their frequencies in the plasma of children with acute respiratory infections and plasma from healthy children. Results SDS-agarose immunoblotting of patients’ plasma revealed the presence of several additional FN–fibrin bands, with decreasing electrophoretic mobilities and increasing molecular masses of 750 kDa, 1000 kDa, 1300 kDa, 1600 kDa and 1900 kDa. Such FN–fibrin complexes occurred with higher frequency and in larger amounts in the plasma of children with RRI and acute infection than they did in plasma from normal children. Moreover, bands above 1000 kDa were absent in most young healthy individuals. The occurrence of FN–fibrin complexes did not correlate with either immunoglobulin concentrations, or with the number of NK cells. Conclusions The occurrence of plasma supra-molecular FN–fibrin complexes is associated with acute and recurrent respiratory infections of children.
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Affiliation(s)
- Anna Lemańska-Perek
- Department of Chemistry and Immunochemistry, Wrocław University of Medicine, Wroclaw, Poland
| | - Bożena Polańska
- 3rd Department and Clinic of Paediatrics, Immunology and Rheumatology of Developmental Age, Wrocław University of Medicine, Wroclaw, Poland
| | | | - Iwona Kątnik-Prastowska
- Department of Chemistry and Immunochemistry, Wrocław University of Medicine, Wroclaw, Poland
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Tagami T, Matsui H, Horiguchi H, Fushimi K, Yasunaga H. Antithrombin and mortality in severe pneumonia patients with sepsis-associated disseminated intravascular coagulation: an observational nationwide study. J Thromb Haemost 2014; 12:1470-9. [PMID: 24943516 DOI: 10.1111/jth.12643] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND The association between antithrombin use and mortality in patients with sepsis-associated disseminated intravascular coagulation (DIC) remains controversial. OBJECTIVES To examine the hypothesis that antithrombin could be effective in the treatment of patients with sepsis-associated DIC following severe pneumonia. METHODS Propensity score and instrumental variable analyses were performed by use of a nationwide administrative database, the Japanese Diagnosis Procedure Combination inpatient database. The main outcome was 28-day mortality. RESULTS Severe pneumonia patients diagnosed with sepsis-associated DIC (n = 9075) were categorized into antithrombin (n = 2663) and control (n = 6412) groups. Propensity score matching created a matched cohort of 2194 pairs of patients with and without antithrombin use. Mortality differences were found between the two groups (antithrombin vs. control: unmatched, 40.8% vs. 45.7%; propensity-matched, 40.6% vs. 44.2%; inverse probability-weighted, 41.1% vs. 45.1%). Multiple logistic regression analyses showed an association between antithrombin use and 28-day mortality (unmatched with propensity score adjusted, adjusted odds ratio [OR] 0.87, 95% confidence interval [CI] 0.78-0.97; propensity-matched, adjusted OR 0.85, 95% CI 0.75-0.97; inverse probability-weighted, adjusted OR 0.85, 95% CI 0.79-0.90). An analysis with the hospital antithrombin-prescribing rate as an instrumental variable showed that receipt of antithrombin was associated with a 9.9% (95% CI 3.5-16.3) reduction in 28-day mortality. CONCLUSIONS This retrospective, large, nationwide database study demonstrates that antithrombin administration may be associated with reduced 28-day mortality in patients with severe pneumonia and sepsis-associated DIC. A large, multinational randomized trial is required.
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Affiliation(s)
- T Tagami
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, University of Tokyo, Tokyo, Japan; Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
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Pravda J. Metabolic theory of septic shock. World J Crit Care Med 2014; 3:45-54. [PMID: 24892019 PMCID: PMC4038812 DOI: 10.5492/wjccm.v3.i2.45] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 01/21/2014] [Accepted: 03/04/2014] [Indexed: 02/06/2023] Open
Abstract
Septic shock is a life threatening condition that can develop subsequent to infection. Mortality can reach as high as 80% with over 150000 deaths yearly in the United States alone. Septic shock causes progressive failure of vital homeostatic mechanisms culminating in immunosuppression, coagulopathy and microvascular dysfunction which can lead to refractory hypotension, organ failure and death. The hypermetabolic response that accompanies a systemic inflammatory reaction places high demands upon stored nutritional resources. A crucial element that can become depleted early during the progression to septic shock is glutathione. Glutathione is chiefly responsible for supplying reducing equivalents to neutralize hydrogen peroxide, a toxic oxidizing agent that is produced during normal metabolism. Without glutathione, hydrogen peroxide can rise to toxic levels in tissues and blood where it can cause severe oxidative injury to organs and to the microvasculature. Continued exposure can result in microvascular dysfunction, capillary leakage and septic shock. It is the aim of this paper to present evidence that elevated systemic levels of hydrogen peroxide are present in septic shock victims and that it significantly contributes to the development and progression of this frequently lethal condition.
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Treatment effects of xuebijing injection in severe septic patients with disseminated intravascular coagulation. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2014; 2014:949254. [PMID: 24778706 PMCID: PMC3979062 DOI: 10.1155/2014/949254] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Revised: 02/18/2014] [Accepted: 02/19/2014] [Indexed: 12/29/2022]
Abstract
The treatment effects of Xuebijing (XBJ) injection in severe septic patients with disseminated intravascular coagulation (DIC) were investigated in this study. 171 severe septic patients with DIC were divided into the control group (n = 83) or intervention group (n = 88). Routine therapies were administered in both groups, and XBJ injection was administered additionally in the intervention group. Incidence of DIC, clinical severity scores, and coagulation parameters at 7 days after administration of XBJ injection were compared between the two groups, and short-term prognosis was evaluated by 28-day mortality. Compared with the control group, incidence of DIC in the intervention group was significantly lower at 7 days after administration of XBJ injection (P < 0.001). In addition, differences of platelet count and prothrombin time were significantly greater in the intervention group than in the control group (P all <0.05), and similar results were also found for differences of the Mortality in Emergency Department Sepsis score and Acute Physiology and Chronic Health Evaluation II score (P all <0.05). Furthermore, 28-day mortality was significantly lower in the intervention group (P = 0.034). These results demonstrate that XBJ injection can effectively treat DIC caused by severe sepsis and improve short-term prognosis of severe septic patients with DIC.
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