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Konishi H, Okamoto K, Shoda K, Arita T, Kosuga T, Morimura R, Komatsu S, Murayama Y, Shiozaki A, Kuriu Y, Ikoma H, Nakanishi M, Ichikawa D, Fujiwara H, Otsuji E. Early thrombomodulin-α administration outcome for acute disseminated intravascular coagulopathy in gastrointestinal surgery. World J Gastroenterol 2017; 23:891-898. [PMID: 28223734 PMCID: PMC5296206 DOI: 10.3748/wjg.v23.i5.891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Revised: 11/11/2016] [Accepted: 11/28/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the efficacy of thrombomodulin (TM)-α for treatment of disseminated intravascular coagulopathy (DIC) in the field of gastrointestinal surgery.
METHODS Thirty-six peri-operative DIC patients in the field of gastrointestinal surgery who were treated with TM-α were retrospectively investigated. The relationships between patient demographics and the efficacy of TM-α were examined. Analysis of survival at 28 d was also performed on some parameters by means of the Kaplan-Meier method. Relationships between the initiation of TM-α and patient demographics were also evaluated.
RESULTS Abscess formation or bacteremia was the most frequent cause of DIC (33%), followed by digestive tract perforation (31%). Twenty-six patients developed DIC after surgery, frequently within 1 wk (81%). TM-α was most often administered within 1 d of the DIC diagnosis (72%) and was continued for more than 3 d (64%). Although bleeding tendency was observed in 7 patients (19%), a hemostatic procedure was not needed. DIC scores, systemic inflammatory response syndrome (SIRS) scores, quick-sequential organ failure assessment (qSOFA) scores, platelet counts, and prothrombin time ratios significantly improved after 1 wk (P < 0.05, for all). The overall survival rate at 28 d was 71%. The duration of TM-α administration (≥ 4 , ≤ 6) and improvements in DIC-associated scores (DIC, SIRS and qSOFA) at 1 wk were significantly better prognostic factors for 28-d survival (P < 0.05, for all). TM-α was administered significantly earlier to patients with severe clinical symptoms, such as high qSOFA scores, sepsis, shock or high lactate values (P < 0.05, for all).
CONCLUSION Early administration of TM-α and improvements in each parameter were essential for treatment of DIC. The diagnosis of patients with mild symptoms requires further study.
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Hagiwara A, Tanaka N, Uemura T, Matsuda W, Kimura A. Can recombinant human thrombomodulin increase survival among patients with severe septic-induced disseminated intravascular coagulation: a single-centre, open-label, randomised controlled trial. BMJ Open 2016; 6:e012850. [PMID: 28039291 PMCID: PMC5223629 DOI: 10.1136/bmjopen-2016-012850] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To determine whether treatment with recombinant human thrombomodulin (rhTM) increases survival among patients with severe septic-induced disseminated intravascular coagulation (DIC). DESIGN Single-centre, open-label, randomised controlled trial. SETTING Single tertiary hospital. PARTICIPANT 92 patients with severe septic-induced DIC. INTERVENTIONS Patients with DIC scores ≥4, as defined by the Japanese Association of Acute Medicine, were diagnosed with DIC. The envelope method was used for randomisation. The treatment group (rhTM group, n=47) was intravenously treated with rhTM within 24 hours of admission (day 0), and the control group (n=45) did not receive any anticoagulants, except in cases of deep venous thrombosis and pulmonary embolism. PRIMARY AND SECONDARY MEASUREMENTS Data were collected on days 0 (admission), 1, 2, 3, 5, 7 and 10. The primary outcome was survival at 28 and 90 days. The secondary end points comprised changes in DIC scores, platelet counts, d-dimer, antithrombin III and C reactive protein levels, and Sequential Organ Failure Assessment (SOFA) scores. All analyses were conducted on an intent-to-treat basis. MAIN RESULTS The 28-day survival rates were 84% and 83% in the control and rhTM groups, respectively (p=0.745, log-rank test). The 90-day survival rates were 73% and 72% in the control and rhTM groups, respectively (p=0.94, log-rank test). Meanwhile, the rates of recovery from DIC (<4) were significantly higher in the rhTM group than in the control group (p=0.001, log-rank test). Relative change from baseline of d-dimer levels was significantly lower in the rhTM group than in the control group, on days 3 and 5. CONCLUSIONS rhTM treatment decreased d-dimer levels and facilitated DIC recovery in patients with severe septic-induced DIC. However, the treatment did not improve survival in this cohort. TRIAL REGISTRATION NUMBER UMIN000008339.
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Affiliation(s)
- Akiyoshi Hagiwara
- Department of Emergency Medicine and Critical Care, National Center for Global Health and Medicine, Tokyo, Japan
| | - Noriko Tanaka
- Biostatistics Section, Department of Data Science Clinical Science Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Tatsuki Uemura
- Department of Emergency Medicine and Critical Care, National Center for Global Health and Medicine, Tokyo, Japan
| | - Wataru Matsuda
- Department of Emergency Medicine and Critical Care, National Center for Global Health and Medicine, Tokyo, Japan
| | - Akio Kimura
- Department of Emergency Medicine and Critical Care, National Center for Global Health and Medicine, Tokyo, Japan
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103
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Carnemolla R, Villa CH, Greineder CF, Zaitsev S, Patel KR, Kowalska MA, Atochin DN, Cines DB, Siegel DL, Esmon CT, Muzykantov VR. Targeting thrombomodulin to circulating red blood cells augments its protective effects in models of endotoxemia and ischemia-reperfusion injury. FASEB J 2016; 31:761-770. [PMID: 27836986 DOI: 10.1096/fj.201600912r] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 10/24/2016] [Indexed: 12/11/2022]
Abstract
Endothelial thrombomodulin (TM) regulates coagulation and inflammation via several mechanisms, including production of activated protein C (APC). Recombinant APC and soluble fragments of TM (sTM) have been tested in settings associated with insufficiency of the endogenous TM/APC pathway, such as sepsis. We previously designed a fusion protein of TM [single-chain variable fragment antibody (scFv)/TM] targeted to red blood cells (RBCs) to improve pharmacokinetics and antithrombotic effects without increasing bleeding. Here, scFv/TM was studied in mouse models of systemic inflammation and ischemia-reperfusion injury. Injected concomitantly with or before endotoxin, scFv/TM provided more potent protection against liver injury and release of pathological mediators than sTM, showing similar efficacy at up to 50-fold lower doses. scFv/TM provided protection when injected after endotoxin, whereas sTM did not, and augmented APC production by thrombin ∼50-fold more than sTM. However, scFv/TM injected after endotoxin did not reduce thrombin/antithrombin complexes; nor did antibodies that block APC anticoagulant activity suppress the prophylactic anti-inflammatory effect of scFv/TM. Therefore, similar to endogenous TM, RBC-anchored scFv/TM activates several protective pathways. Finally, scFv/TM was more effective at reducing cerebral infarct volume and alleviated neurological deficits than sTM after cerebral ischemia/reperfusion injury. These results indicate that RBC-targeted scFv/TM exerts multifaceted cytoprotective effects and may find utility in systemic and focal inflammatory and ischemic disorders.-Carnemolla, R., Villa, C. H., Greineder, C. F., Zaitseva, S., Patel, K. R., Kowalska, M. A., Atochin, D. N., Cines, D. B., Siegel, D. L., Esmon, C. T., Muzykantov, V. R. Targeting thrombomodulin to circulating red blood cells augments its protective effects in models of endotoxemia and ischemia-reperfusion injury.
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Affiliation(s)
- Ronald Carnemolla
- Department of Pharmacology, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; USA.,Center for Targeted Therapeutics and Translational Nanomedicine, Institute for Translational Medicine and Therapeutics, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; USA
| | - Carlos H Villa
- Department of Pharmacology, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; USA.,Center for Targeted Therapeutics and Translational Nanomedicine, Institute for Translational Medicine and Therapeutics, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; USA.,Department of Pathology and Laboratory Medicine, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; USA
| | - Colin F Greineder
- Department of Pharmacology, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; USA.,Center for Targeted Therapeutics and Translational Nanomedicine, Institute for Translational Medicine and Therapeutics, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; USA
| | - Sergei Zaitsev
- Department of Pharmacology, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; USA.,Center for Targeted Therapeutics and Translational Nanomedicine, Institute for Translational Medicine and Therapeutics, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; USA.,Department of Pathology and Laboratory Medicine, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; USA
| | - Kruti R Patel
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - M Anna Kowalska
- Division of Hematology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Institute of Medical Biology, Polish Academy of Sciences, Lodz, Poland
| | - Dmitriy N Atochin
- Division of Cardiology, Cardiovascular Research Center, Massachusetts General Hospital, Charlestown, Massachusetts, USA
| | - Douglas B Cines
- Department of Pathology and Laboratory Medicine, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; USA
| | - Don L Siegel
- Department of Pathology and Laboratory Medicine, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; USA
| | - Charles T Esmon
- Department of Pathology, Coagulation Biology Laboratory, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA; and.,Department of Biochemistry and Molecular Biology, Coagulation Biology Laboratory, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
| | - Vladimir R Muzykantov
- Department of Pharmacology, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; USA; .,Center for Targeted Therapeutics and Translational Nanomedicine, Institute for Translational Medicine and Therapeutics, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; USA
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104
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Tawara S, Sakai T, Matsuzaki O. Anti-inflammatory and anti-fibrinolytic effects of thrombomodulin alfa through carboxypeptidase B2 in the presence of thrombin. Thromb Res 2016; 147:72-79. [DOI: 10.1016/j.thromres.2016.09.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 08/31/2016] [Accepted: 09/13/2016] [Indexed: 11/27/2022]
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105
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Minami K, Sakaguchi Y, Yoshida D, Yamamoto M, Ikebe M, Morita M, Toh Y. Successful treatments with polymyxin B hemoperfusion and recombinant human thrombomodulin for fulminant Clostridium difficile-associated colitis with septic shock and disseminated intravascular coagulation: a case report. Surg Case Rep 2016; 2:76. [PMID: 27468959 PMCID: PMC4965360 DOI: 10.1186/s40792-016-0199-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 07/01/2016] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Clostridium difficile (CD)-associated colitis (CDAC) is endemic and a common nosocomial enteric disease encountered by surgeons in modern hospitals due to prophylactic or therapeutic antibiotic therapies. Currently, the incidence of fulminant CDAC, which readily causes septic shock followed by multiple organ dysfunction syndromes, is increasing. Fulminant CDAC requires surgeons to perform a prompt surgery, such as subtotal colectomy, to remove the septic source. It is known that fulminant CDAC is caused by the shift from an inflammatory response at a local mucosal level to a general systemic inflammatory reaction in which CD toxin-induced mediators' cascades disseminate. Recently, it has been proven that polymyxin B hemoperfusion (PMX-HP) improves septic shock and recombinant human thrombomodulin (rhTM) controls disseminated intravascular coagulation (DIC). In addition, clinically and basically, it has been shown that these treatments can control serous chemical mediators. Therefore, it is considered that these treatments are promising ones for patients with fulminant CDAC. In the current report, we present that these treatments without surgery contributed to the improvement of sepsis due to fulminant CDAC. CASE PRESENTATION We encountered a case who developed fulminant CDAC with septic shock and DIC after laparoscopic gastrectomy for gastric cancer. At admission to the intensive care unit, his APACHE II score was 22, which indicated an estimated risk of hospital death of 42.4 %. Our therapies were not the subtotal colectomy to remove septic sources but the combination treatments with both PMX-HP and rhTM. These combination therapies resulted in excellent outcomes, namely the dramatic improvement of septic shock and DIC and the patient's survival. We speculate that these combination therapies completely inhibit the CD toxin-induced mediators' cascades and correspond to the removal of septic sources. CONCLUSIONS We recommend both PMX-HP and rhTM for patients who develop fulminant CDAC with septic shock and DIC to increase the survival benefit and replace the need for surgical treatment.
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Affiliation(s)
- Kazuhito Minami
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Notame 3-1-1, Minami-ku, Fukuoka, 811-1395, Japan.
| | - Yoshihisa Sakaguchi
- Department of Gastroenterological Surgery, National Hospital Organization Kyushu Medical Center, Jigyohama 1-8-1, Chuo-ku, Fukuoka, 810-8563, Japan
| | - Daisuke Yoshida
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Notame 3-1-1, Minami-ku, Fukuoka, 811-1395, Japan
| | - Manabu Yamamoto
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Notame 3-1-1, Minami-ku, Fukuoka, 811-1395, Japan
| | - Masahiko Ikebe
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Notame 3-1-1, Minami-ku, Fukuoka, 811-1395, Japan
| | - Masaru Morita
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Notame 3-1-1, Minami-ku, Fukuoka, 811-1395, Japan
| | - Yasushi Toh
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Notame 3-1-1, Minami-ku, Fukuoka, 811-1395, Japan
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106
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Yamakawa K, Umemura Y, Hayakawa M, Kudo D, Sanui M, Takahashi H, Yoshikawa Y, Hamasaki T, Fujimi S. Benefit profile of anticoagulant therapy in sepsis: a nationwide multicentre registry in Japan. Crit Care 2016; 20:229. [PMID: 27472991 PMCID: PMC4966726 DOI: 10.1186/s13054-016-1415-1] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 07/20/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Little evidence supports anticoagulant therapy as effective adjuvant therapy to reduce mortality overall in sepsis. However, several studies suggest that anticoagulant therapy may reduce mortality in specific patients. This study aimed to identify a subset of patients with high benefit profiles for anticoagulant therapy against sepsis. METHODS This post hoc subgroup analysis of a nationwide multicentre retrospective registry was conducted in 42 intensive care units in Japan. Consecutive adult patients with sepsis were included. Treatment effects of anticoagulants, e.g. antithrombin, recombinant thrombomodulin, heparin, and protease inhibitors, were evaluated by stratifying patients according to disseminated intravascular coagulation (DIC) and Sequential Organ Failure Assessment (SOFA) score. Intervention effects of anticoagulant therapy on in-hospital mortality and bleeding complications were analysed using Cox regression analysis stratified by propensity scores. RESULTS Participants comprised 2663 consecutive patients with sepsis; 1247 patients received anticoagulants and 1416 received none. After adjustment for imbalances, anticoagulant administration was significantly associated with reduced mortality only in subsets of patients diagnosed with DIC, whereas similar mortality rates were observed in non-DIC subsets with anticoagulant therapy. Favourable associations between anticoagulant therapy and mortality were observed only in the high-risk subset (SOFA score 13-17; adjusted hazard ratio 0.601; 95 % confidence interval 0.451, 0.800) but not in the subsets of patients with sepsis with low to moderate risk. Although the differences were not statistically significant, there was a consistent tendency towards an increase in bleeding-related transfusions in all SOFA score subsets. CONCLUSIONS The analysis of this large database indicates anticoagulant therapy may be associated with a survival benefit in patients with sepsis-induced coagulopathy and/or very severe disease. TRIAL REGISTRATION University Hospital Medical Information Network Clinical Trial Registry (UMIN-CTR ID: UMIN000012543 ). Registered on 10 December 2013.
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Affiliation(s)
- Kazuma Yamakawa
- Department of Emergency and Critical Care, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan.
- 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 Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Mineji Hayakawa
- Emergency and Critical Care Center, Hokkaido University Hospital, Kita 15 Nishi 7 Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Daisuke Kudo
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Hiroki Takahashi
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yoshiaki Yoshikawa
- Department of Emergency and Critical Care, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Toshimitsu Hamasaki
- Office of Biostatistics and Data Management, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka, 565-8565, Japan
| | - Satoshi Fujimi
- Department of Emergency and Critical Care, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
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107
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Abstract
Extremity injury is a significant burden to those injured in explosive incidents and local ischaemia can result in poor functionality in salvaged limbs. This study examined whether blast injury to a limb resulted in a change in endothelial phenotype leading to changes to the surrounding tissue. The hind limbs of terminally anaesthetized rabbits were subjected to one of four blast exposures (high, medium, low, or no blast). Blood samples were analyzed for circulating endothelial cells pre-injury and at 1, 6, and 11 h postinjury as well as analysis for endothelial activation pre-injury and at 1, 6, and 12 h postinjury. Post-mortem tissue (12 h post-injury) was analysed for both protein and mRNA expression and also for histopathology. The high blast group had significantly elevated levels of circulating endothelial cells 6 h postinjury. This group also had significantly elevated tissue mRNA expression of IL-6, E-selectin, TNF-α, HIF-1, thrombomodulin, and PDGF. There was a significant correlation between blast dose and the degree of tissue pathology (hemorrhage, neutrophil infiltrate, and oedema) with the worst scores in the high blast group. This study has demonstrated that blast injury can activate the endothelium and in some cases cause damage that in turn leads to pathological changes in the surrounding tissue. For the casualty injured by an explosion the damaging effects of hemorrhage and shock could be exacerbated by blast injury and vice versa so that even low levels of blast become damaging, all of which could affect tissue functionality and long-term outcomes.
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108
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Recombinant human soluble thrombomodulin and short-term mortality of infection patients with DIC: a meta-analysis. Am J Emerg Med 2016; 34:1876-82. [PMID: 27452884 DOI: 10.1016/j.ajem.2016.06.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 05/27/2016] [Accepted: 06/01/2016] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Several studies have demonstrated that recombinant human soluble thrombomodulin (rhTM) has potential advantages for the treatment for patients with infection complicated by disseminated intravascular coagulation (DIC). However, whether injection of rhTM can affect the mortality of those patients in clinical treatment remains controversial. Therefore, we conducted a meta-analysis to evaluate the clinical efficacy for patients with infection complicated by DIC. METHODS The PubMed, Web of Science, Embase, and Cochrane Library databases were searched for relevant articles that met the inclusion criteria through April 2016. Reference lists of the retrieved articles were also reviewed. The 28- or 30-day mortality and bleeding risk after using rhTM were evaluated. RESULTS Ten observational studies and 2 randomized controlled trials (RCTs) involving 18288 patients were included in this meta-analysis. The risk ratio for the 28- or 30-day mortality was 0.81 (95% confidence interval, 0.61-1.06) in RCT studies and 0.96 (95% confidence interval, 0.92-1.01) in observational studies. There were no significant differences in the bleeding risk between the rhTM group and the control group. CONCLUSION Based on the current studies, using rhTM for the treatment for infection patients complicated with DIC does not decrease the short-term mortality of those patients. More high-quality RCT studies need to be performed to confirm this finding.
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109
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Okamoto K, Tamura T, Sawatsubashi Y. Sepsis and disseminated intravascular coagulation. J Intensive Care 2016; 4:23. [PMID: 27011792 PMCID: PMC4804491 DOI: 10.1186/s40560-016-0149-0] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 03/04/2016] [Indexed: 12/16/2022] Open
Abstract
Sepsis is frequently complicated by coagulopathy and, in about 35 % of severe cases, by disseminated intravascular coagulation (DIC). In Japan, aggressive treatment of septic DIC is encouraged using antithrombin and recombinant thrombomodulin. The macrophages, monocytes, and neutrophils are a source of TF and participate in the direct activation of the coagulation cascade in the early phases of sepsis. And activated factor X (FXa), which is involved in hemostasis, thrombogenesis, inflammation, and cellular immune responses, induces TF expression in human peripheral monocytes and, conversely, that inhibition of FXa activity reduces TF expression. Both inflammation and coagulation play an important role in DIC due to sepsis. In addition to inflammatory cytokines (TNF-α, IL-1 and so on), HMGB1 has recently been shown to mediate the lethal late phase of sepsis and caused coagulopathy. TM not only binds HMGB1 but also aids the proteolytic cleavage of HMGB1 by thrombin. There have been many reports of the efficacy of recombinant TM and antithrombin for treatment of septic DIC from Japan. Further investigation of the efficacy of recombinant TM and AT in countries other than Japan, as well as the monitoring of medical costs incurred during hospitalization, will help validate the use of TM and AT for treatment of septic DIC.
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Affiliation(s)
- Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, 4-18-1 Nishihon-machi, Yahatahigashi-ku, Kitakyushu 805-8534 Japan ; Department of Surgery 1, School of Medicine, University of Occupational & Environmental Health, 1-1 Iseiogaka, Yahatanishi-ku, Kitakyushu 807-8555 Japan
| | - Toshihisa Tamura
- Department of Surgery 1, School of Medicine, University of Occupational & Environmental Health, 1-1 Iseiogaka, Yahatanishi-ku, Kitakyushu 807-8555 Japan
| | - Yusuke Sawatsubashi
- Department of Surgery 1, School of Medicine, University of Occupational & Environmental Health, 1-1 Iseiogaka, Yahatanishi-ku, Kitakyushu 807-8555 Japan
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110
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Kim SD, Baker P, DeLay J, Wood RD. Thrombomodulin Expression in Tissues From Dogs With Systemic Inflammatory Disease. Vet Pathol 2016; 53:797-802. [DOI: 10.1177/0300985815626571] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Thrombomodulin (TM) is a membrane glycoprotein expressed on endothelial cells, which plays a major role in the protein C anticoagulation pathway. In people with inflammation, TM expression can be down-regulated on endothelial cells and a soluble form released into circulation, resulting in increased risk of thrombosis and disseminated intravascular coagulation. TM is present in dogs; however, there has been minimal investigation of its expression in canine tissues, and the effects of inflammation on TM expression in canine tissues have not been investigated. The objective of this study was to evaluate endothelial TM expression in tissues from dogs with systemic inflammatory diseases. A retrospective evaluation of tissue samples of lung, spleen, and liver from dogs with and without systemic inflammatory diseases was performed using immunohistochemistry (IHC) and a modified manual IHC scoring system. TM expression was significantly reduced in all examined tissues in dogs diagnosed with septic peritonitis or acute pancreatitis.
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Affiliation(s)
- S. D. Kim
- Department of Pathobiology, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | - P. Baker
- Department of Pathobiology, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | - J. DeLay
- Animal Health Laboratory, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | - R. D. Wood
- Department of Pathobiology, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
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111
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Recombinant human soluble thrombomodulin ameliorates cerebral ischemic injury through a high-mobility group box 1 inhibitory mechanism without hemorrhagic complications in mice. J Neurol Sci 2016; 362:278-82. [PMID: 26944163 DOI: 10.1016/j.jns.2016.01.047] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 01/09/2016] [Accepted: 01/21/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND It has been reported that recombinant human soluble thrombomodulin (rhsTM) has a high-mobility group box (HMGB)1 inhibitory effect. Some investigators reported that HMGB1 is associated with ischemic stroke. However, there have been no previous studies to determine whether rhsTM can ameliorate cerebral ischemic injury through its HMGB1 inhibitory mechanism in ischemic stroke. We investigated the effects of rhsTM on cerebral ischemic injury in a 4-h middle cerebral artery occlusion (MCAO) murine model. METHODS rhsTM (1 or 5mg/kg, i.v.) was administered immediately after 4-h MCAO. Infarct volume, motor coordination, plasma HMGB1 level, and hemorrhage volume were evaluated 24h after 4-h MCAO. RESULTS The infarct volume (P<0.05) was reduced by rhsTM in mice subjected to 4-h MCAO in a dose-dependent manner. Moreover, rhsTM (5mg/kg) significantly improved motor coordination determined by the rotarod test (P<0.05), and significantly decreased plasma HMGB1 level compared with vehicle-treated controls (P<0.001). In addition, there was no difference in hemorrhage volume between vehicle-treated controls and the rhsTM treatment group. CONCLUSIONS This represents the first report that rhsTM ameliorates cerebral ischemic injury through an HMGB1 inhibitory mechanism without hemorrhagic complications in mice. Taken together, these observations indicate a palliative effect of rhsTM and suggest new therapeutic possibilities for treatment of ischemic stroke via inhibition of HMGB1.
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112
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Tateishi K, Imaoka M, Matsushita M. Dual modulating functions of thrombomodulin in the alternative complement pathway. Biosci Trends 2016; 10:231-4. [DOI: 10.5582/bst.2016.01052] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | - Mio Imaoka
- Department of Applied Biochemistry, Tokai University
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113
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Aota T, Wada H, Yamashita Y, Matsumoto T, Ohishi K, Suzuki K, Imai H, Usui M, Isaji S, Katayama N. The efficacy of the administration of recombinant human soluble thrombomodulin in patients with DIC. Int J Hematol 2015; 103:173-9. [PMID: 26590919 DOI: 10.1007/s12185-015-1899-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 11/04/2015] [Accepted: 11/09/2015] [Indexed: 01/08/2023]
Abstract
Efficacy of recombinant human soluble thrombomodulin (rhTM), which is frequently used to treat patients with disseminated intravascular coagulation (DIC), was compared with that of gabexate mesilate (GM), which was previously used routinely in the treatment of DIC patients in Japan. Although there was no significant difference in the resolution rates of the patients who were treated with rhTM and GM, the results of our analysis revealed that the mortality rate was significantly higher among infectious disease patients treated with GM than in those treated with rhTM. Levels of fibrinogen and fibrin degradation products (FDP), antithrombin (AT) activity, and thrombin AT complex (TAT) were significantly lower in the DIC patients with infectious diseases, while fibrinogen levels were high. FDP level, D-dimer, platelet count, PT ratio, and DIC score all showed significant improvement following rhTM treatment. There were no significant difference between survivors and non-survivors in terms of DIC score, FDP level, platelet count, AT activity, or in TAT, SF and PPIC levels before rhTM treatment. However, fibrinogen levels were significantly lower in non-survivors than in survivors. These results indicate that rhTM may be superior to GM for the treatment of DIC.
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Affiliation(s)
- Takumi Aota
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, Mie, Japan
| | - Hideo Wada
- Departments of Molecular and Laboratory Medicine, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Yoshiki Yamashita
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, Mie, Japan
| | - Takeshi Matsumoto
- Blood Transfusion Service, Mie University Graduate School of Medicine, Mie, Japan
| | - Kohshi Ohishi
- Blood Transfusion Service, Mie University Graduate School of Medicine, Mie, Japan
| | - Kei Suzuki
- Emergency Critical Care Center, Mie University Graduate School of Medicine, Mie, Japan
| | - Hiroshi Imai
- Emergency Critical Care Center, Mie University Graduate School of Medicine, Mie, Japan
| | - Masanobu Usui
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Shuji Isaji
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Naoyuki Katayama
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, Mie, Japan
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Hifumi T, Fujishima S, Abe T, Kiriu N, Inoue J, Kato H, Koido Y, Kawakita K, Kuroda Y, Sasaki J, Hori S. Prognostic factors of Streptococcus pneumoniae infection in adults. Am J Emerg Med 2015; 34:202-6. [PMID: 26508390 DOI: 10.1016/j.ajem.2015.10.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 10/10/2015] [Accepted: 10/13/2015] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES The mortality of severe sepsis has markedly decreased since the implementation of the Surviving Sepsis Campaign guidelines. The next logical step is to examine the necessity of individualized management guidelines for targeted therapy against specific bacteria. Streptococcus pneumoniae is the leading cause of community-acquired severe sepsis; however, little is known regarding the prognostic factors in adult patients with S pneumoniae sepsis. We aimed to identify prognostic factors in patients with S pneumoniae sepsis and to explore a subgroup of patients at high risk for death with detailed Sequential Organ Failure Assessment (SOFA) score analysis. METHODS We retrospectively reviewed the records of patients with S pneumoniae infection treated between 1st January 2006 and 31st July 2012. We identified prognostic factors for 28-day mortality using univariate and multivariate logistic regression models. RESULTS Of 171 patients (median age, 72 years) with S pneumoniae infection who were included in this study, the 28-day mortality was 17% (29/171). The SOFA score (odds ratio, 2.25; 95% confidence interval, 1.60-3.18; P < .001) and bacteremia (odds ratio, 19.0; 95% confidence interval, 4.06-90.20; P < .001) were identified as prognostic factors for the 28-day mortality. In a subgroup analysis with a cutoff value of the SOFA score determined by receiver operating characteristic analysis, patients with bacteremia and a SOFA score of at least 7 had a significantly higher mortality than did patients without bacteremia and a SOFA score lower than 7 (84% vs 0%, respectively). CONCLUSIONS Bacteremia and a SOFA score at least 7 were independent prognostic factors of poor outcome in S pneumoniae sepsis.
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Affiliation(s)
- Toru Hifumi
- Emergency Medical Center, Kagawa University Hospital, Miki, Kita, Kagawa, Japan.
| | - Seitaro Fujishima
- Center for General Internal Medicine and Education, Keio University Hospital, Shinjuku-ku, Tokyo, Japan
| | - Takayuki Abe
- Center for Clinical Research, Department of Preventive Medicine and Public Health, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Nobuaki Kiriu
- Division of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo, Japan
| | - Junichi Inoue
- Division of Critical Care Medicine and Trauma, Yamanashi Prefectural Central Hospital, Kofu, Yamanashi, Japan
| | - Hiroshi Kato
- Division of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo, Japan
| | - Yuichi Koido
- Division of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo, Japan
| | - Kenya Kawakita
- Emergency Medical Center, Kagawa University Hospital, Miki, Kita, Kagawa, Japan
| | - Yasuhiro Kuroda
- Emergency Medical Center, Kagawa University Hospital, Miki, Kita, Kagawa, Japan
| | - Junichi Sasaki
- Department of Emergency Medicine and Critical Care Medicine, Keio University Hospital, Shinjuku-ku, Tokyo, Japan
| | - Shingo Hori
- Department of Emergency Medicine and Critical Care Medicine, Keio University Hospital, Shinjuku-ku, Tokyo, Japan
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Eguchi T, Tsuji Y, Yamashita H, Fukuchi T, Kanamori A, Matsumoto K, Hasegawa T, Koizumi A, Kitada R, Tsujimae M, Iwatsubo T, Koyama S, Ubukata S, Fujita M, Okada A. Efficacy of recombinant human soluble thrombomodulin in preventing walled-off necrosis in severe acute pancreatitis patients. Pancreatology 2015; 15:485-490. [PMID: 26320826 DOI: 10.1016/j.pan.2015.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 06/04/2015] [Accepted: 08/12/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To investigate the efficacy of recombinant human soluble thrombomodulin (rTM) in preventing the development of walled-off necrosis (WON) in severe acute pancreatitis (SAP) patients. METHODS We retrospectively analyzed 54 SAP patients divided into two groups: SAP patients treated by rTM (rTM group, 24 patients) and not treated by rTM (control group, 30 patients). rTM was administered to patients with disseminated intravascular coagulation (DIC). Initially, on the admission day, we recorded patient severity and pancreatic necrosis/ischemia positive or negative. Then we investigated development of WON using 4 weeks later CT/MRI. Finally we compared the proportions of patients developing WON in the rTM group and the control group. RESULTS On the admission day, the condition of patients treated by rTM was significantly worse than patients in the control group; rTM group vs. CONTROL 71.8 ± 13.9 vs. 59.8 ± 15.3 years for age, 10.7 ± 3.5 vs. 8.0 ± 4.4 for Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and 3.3 ± 1.8 vs. 2.2 ± 1.8 for sequential organ failure assessment (SOFA) score (p < 0.05). We found no significant differences on the admission day in rate of pancreatic necrosis/ischemia between patients treated by rTM and controls (58.3% vs. 63.3%, p = 0.71). Nevertheless, the proportion of patients developing WON was significantly lower among those administered rTM than in those not administered rTM {29.2% (7/24 patients) vs. 56.7% (17/30 patients), p < 0.05}. CONCLUSION Treatment of SAP patients treated by rTM may prevent progression from pancreatic necrosis/ischemia to WON.
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Affiliation(s)
- Takaaki Eguchi
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Yoshihisa Tsuji
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kawaramachi 54, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
| | - Hiroshi Yamashita
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Takumi Fukuchi
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Atsushi Kanamori
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Kei Matsumoto
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Takashi Hasegawa
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Akio Koizumi
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Ryuki Kitada
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Masahiro Tsujimae
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Taro Iwatsubo
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Shintaro Koyama
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Satoshi Ubukata
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Mikio Fujita
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Akihiko Okada
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan.
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Martí‐Carvajal AJ, Anand V, Solà I. Treatment for disseminated intravascular coagulation in patients with acute and chronic leukemia. Cochrane Database Syst Rev 2015; 2015:CD008562. [PMID: 26107113 PMCID: PMC7173718 DOI: 10.1002/14651858.cd008562.pub3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Disseminated intravascular coagulation (DIC) is an acquired syndrome characterized by systemic intravascular activation of coagulation, leading to deposition of fibrin in the bloodstream. It may occur in patients with acute and chronic leukemia and is particularly associated with acute promyelocytic leukemia (a subtype of acute myeloid leukemia). OBJECTIVES To assess the clinical benefits and harms of any pharmacological intervention for treating DIC in patients with acute or chronic leukemia. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2015, Issue 05), MEDLINE (1946 to 7 May 2015), LILACS (1982 to 7 May 2015) and African Index Medicus (7 May 2015). There was no language restrictions. We sought additional randomized controlled trials (RCTs) from the World Health Organization International Clinical Trials Registry Platform and the reference lists of primary studies identified. SELECTION CRITERIA RCTs assessing the clinical benefits and harms of interventions for treating DIC in patients with acute and chronic leukemia. DATA COLLECTION AND ANALYSIS Two review authors independently performed trial selection, 'Risk of bias' assessment and data extraction. Primary outcomes were overall mortality, in-hospital mortality from any cause (15-day and 30-day) and adverse events. MAIN RESULTS In this Cochrane Review update we did not include any new RCT compared with the first review version. Accordingly, four RCTs (388 participants) met the inclusion criteria. These trials evaluated the human activated protein C, recombinant human soluble thrombomodulin, tranexamic acid and dermatan sulphate. Included trials reported data on mortality and bleeding. The studies were conducted in Japan, Italy and the Netherlands. We classified the included trials as: 1) including patients with or without leukemia which did not report data for the leukemia subgroup (366 participants); and 2) only including patients with leukemia (22 participants). Overall, the risk of bias of the included trials was high, since the trial authors did not provide a detailed description about trial design and execution.According to the GRADE recommendations, we judged the overall quality of the body of evidence for all prefixed outcomes as 'very low', due to methodological limitations and very small sample size.One trial, including 10 participants with leukemia and comparing dermatan sulphate with heparin, reported no deaths during trial treatment.In terms of bleeding data, we were unable to pool results from two studies that were only conducted with leukemia patients due to the inconsistency in the measurement and reporting of this outcome. One trial, including 12 participants with leukemia, found very low quality evidence that tranexamic acid can reduce the cumulative hemorrhagic score in participants compared with those assigned to placebo (P = 0.0015, very low quality evidence). On the contrary, there is no evidence that dermatan sulphate compared with placebo reduces new events of hemorrhagic diathesis (1/5 (20%) versus 2/5 (40%); RR 0.50; 95% CI 0.06 to 3.91; P = 0.51, very low quality evidence).No thromboembolic complications were reported in either trial that included patients with leukemia only (very low quality evidence). The safety profile was inconclusive.The included trials did not assess overall mortality, resolution of respiratory failure, renal failure or shock. AUTHORS' CONCLUSIONS Due to a lack of new RCTs, our conclusions in this Cochrane Review update are the same as the previous review version. We included four RCTs which reported mortality and bleeding data. It is not possible to determine whether human activated protein C, recombinant human soluble thrombomodulin, tranexamic acid and dermatan sulphate are effective or harmful for patients presenting with DIC related to acute or chronic leukemia. The quality of the evidence was low to very low. Therefore, prescription of these interventions for treating DIC in patients with acute and chronic leukemia can neither be supported nor rejected, unless new evidence from a large high-quality trial alters this conclusion.
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Affiliation(s)
| | - Vidhu Anand
- University of MinnesotaDepartment of Medicine420 Delaware Street SEMayo Mail Code 195MinneapolisMNUSA55455
| | - Ivan Solà
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 171 ‐ Edifici Casa de ConvalescènciaBarcelonaCatalunyaSpain08041
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Hashimoto D, Chikamoto A, Miyanari N, Ohara C, Kuramoto M, Horino K, Ohshima H, Baba H. Recombinant soluble thrombomodulin for postoperative disseminated intravascular coagulation. J Surg Res 2015; 197:405-11. [PMID: 25972310 DOI: 10.1016/j.jss.2015.04.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 03/10/2015] [Accepted: 04/14/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND Thrombomodulin is a thrombin receptor on the endothelial cell surface that plays an important role in the regulation of intravascular coagulation. The purpose of this study was to evaluate the efficacy and safety of treatment with recombinant human soluble thrombomodulin (rhTM) for patients with septic-disseminated intravascular coagulation (DIC) associated with gastroenterological surgery. MATERIALS AND METHODS From April 2011-September 2013, 201 patients with DIC associated with gastroenterological surgery were treated in 16 institutions in Kumamoto, Japan. The patients were diagnosed according to the Japanese Association for Acute Medicine DIC scoring system. The clinical course, mortality rate at 28 d, and adverse events were evaluated retrospectively. RESULTS Forty-five patients were excluded because they did not meet the Japanese Association for Acute Medicine DIC criteria or had an insufficient duration of drug administration. Thus, 156 patients were analyzed. Of these patients, 107 received rhTM at the discretion of the attending surgeon and 49 did not. The most common reason for surgery in both groups was peritonitis due to perforation of the colon. Within 7 d, the platelet count, prothrombin time-international normalized ratio, DIC score, neutrophil count, and C-reactive protein level significantly improved in the rhTM group compared with those in the control. Treatment with rhTM was significantly associated with reduced inhospital mortality at 28 d. The incidence of adverse events did not differ between the two groups. CONCLUSIONS Therapy with rhTM may be associated with reduced inhospital mortality in patients with septic DIC associated with gastroenterological surgery without increasing adverse events.
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Affiliation(s)
- Daisuke Hashimoto
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Akira Chikamoto
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Nobutomo Miyanari
- Department of Surgery, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
| | - Chitoshi Ohara
- Department of Surgery, Kumamoto Saishunso National Hospital, Koshi, Japan
| | - Masafumi Kuramoto
- Department of Surgery, Kumamoto Social Insurance General Hospital, Yatsushiro, Japan
| | - Kei Horino
- Department of Surgery, Kumamoto Rosai Hospital, Yatsushiro, Japan
| | - Hisami Ohshima
- Department of Surgery, Arao Municipal Hospital, Arao, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan.
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Pathak R, Shao L, Ghosh SP, Zhou D, Boerma M, Weiler H, Hauer-Jensen M. Thrombomodulin contributes to gamma tocotrienol-mediated lethality protection and hematopoietic cell recovery in irradiated mice. PLoS One 2015; 10:e0122511. [PMID: 25860286 PMCID: PMC4393275 DOI: 10.1371/journal.pone.0122511] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 02/12/2015] [Indexed: 01/09/2023] Open
Abstract
Systemic administration of recombinant thrombomodulin (TM) confers radiation protection partly by accelerating hematopoietic recovery. The uniquely potent radioprotector gamma tocotrienol (GT3), in addition to being a strong antioxidant, inhibits the enzyme hydroxy-methyl-glutaryl-coenzyme A reductase (HMGCR) and thereby likely modulates the expression of TM. We hypothesized that the mechanism underlying the exceptional radioprotective properties of GT3 partly depends on the presence of endothelial TM. In vitro studies confirmed that ionizing radiation suppresses endothelial TM (about 40% at 4 hr after 5 Gy γ-irradiation) and that GT3 induces TM expression (about 2 fold at the mRNA level after 5 μM GT3 treatment for 4 hr). In vivo survival studies showed that GT3 was significantly more effective as a radioprotector in TM wild type (TM+/+) mice than in mice with low TM function (TMPro/-). After exposure to 9 Gy TBI, GT3 pre-treatment conferred 85% survival in TM+/+ mice compared to only 50% in TMPro/-. Thus, GT3-mediated radiation lethality protection is partly dependent on endothelial TM. Significant post-TBI recovery of hematopoietic cells, particularly leukocytes, was observed in TM+/+ mice (p = 0.003), but not in TMPro/- mice, despite the fact that GT3 induced higher levels of granulocyte colony stimulating factor (G-CSF) in TMPro/- mice (p = 0.0001). These data demonstrate a critical, G-CSF-independent, role for endothelial TM in GT3-mediated lethality protection and hematopoietic recovery after exposure to TBI and may point to new strategies to enhance the efficacy of current medical countermeasures in radiological/nuclear emergencies.
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Affiliation(s)
- Rupak Pathak
- Division of Radiation Health, Department of Pharmaceutical Sciences, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
- * E-mail:
| | - Lijian Shao
- Division of Radiation Health, Department of Pharmaceutical Sciences, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Sanchita P. Ghosh
- Armed Forces Radiobiology Research Institute, USUHS, Bethesda, MD, United States of America
| | - Daohong Zhou
- Division of Radiation Health, Department of Pharmaceutical Sciences, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Marjan Boerma
- Division of Radiation Health, Department of Pharmaceutical Sciences, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Hartmut Weiler
- Blood Research Institute, Blood Center of Wisconsin and the Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Martin Hauer-Jensen
- Division of Radiation Health, Department of Pharmaceutical Sciences, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
- Surgical Service, Central Arkansas Veterans Healthcare System, Little Rock, AR, United States of America
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Takezako N, Sekiguchi N, Nagata A, Homma C, Takezako Y, Noto S, Natori K, Miwa A. Recombinant human thrombomodulin in the treatment of acute myeloid leukemia patients complicated by disseminated intravascular coagulation: retrospective analysis of outcomes between patients treated with heparin and recombinant human thrombomodulin therapy. Thromb Res 2015; 136:20-3. [PMID: 25934464 DOI: 10.1016/j.thromres.2015.03.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Revised: 02/23/2015] [Accepted: 03/30/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND Recombinant thrombomodulin (rTM) is a promising anticoagulant. Improvements in disseminated intravascular coagulation (DIC) and the amelioration of bleeding complications in DIC patients were reported to be greater with rTM therapy than with unfractionated heparin therapy. However, it remains unknown whether rTM therapy affects the outcomes of patients with acute myeloblastic leukemia (AML). DESIGN AND METHOD We retrospectively analyzed 103 patients with AML and compared outcomes between patients treated with low molecular weight heparin therapy and rTM. The diagnostic criteria for DIC were previously proposed by the Japanese Ministry of Health and Welfare. Comparisons between qualitative variables were carried out using the χ(2) test. Survival probabilities were estimated by the Kaplan-Meier method, and differences in survival distributions were evaluated using the log-rank test. RESULTS Forty-seven patients developed DIC due to chemotherapy or their disease status. Fourteen patients were treated with rTM, while 33 patients were treated with low-molecular-weight heparin (LMWH). The log-rank test revealed that overall survival was significantly worse in the DIC group than in the non-DIC group (P=0.003), and was signfiacntly better in the rTM group than the LMWH group (P=0.016). CONCLUSION rTM was more efficient than LMWH because of the improvements it induced in overall survival.
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Affiliation(s)
- Naoki Takezako
- Department of Hematology, National Hospital Organization Disaster Medical Center of Japan, 3256 Midori-cho, Tachikawa, Tokyo, 190-0014, Japan; Department of Medical Informatics, National Hospital Organization Disaster Medical Center of Japan, 3256 Midori-cho, Tachikawa, Tokyo, 190-0014, Japan.
| | - Naohiro Sekiguchi
- Department of Hematology, National Hospital Organization Disaster Medical Center of Japan, 3256 Midori-cho, Tachikawa, Tokyo, 190-0014, Japan
| | - Akihisa Nagata
- Department of Hematology, National Hospital Organization Disaster Medical Center of Japan, 3256 Midori-cho, Tachikawa, Tokyo, 190-0014, Japan
| | - Chiho Homma
- Department of Hematology, National Hospital Organization Disaster Medical Center of Japan, 3256 Midori-cho, Tachikawa, Tokyo, 190-0014, Japan
| | - Yayoi Takezako
- Department of General Internal Medicine, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan; Division of Community and Family Medicine, Center for Community Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi-ken, 329-0498, Japan
| | - Satoshi Noto
- Department of Hematology, National Hospital Organization Disaster Medical Center of Japan, 3256 Midori-cho, Tachikawa, Tokyo, 190-0014, Japan
| | - Kazuhiko Natori
- Department of Hematology and Oncology, Toho University Medical Centre, 6-11-1 Oomorinishi, Oota-ku, Tokyo, 143-8541, Japan
| | - Akiyoshi Miwa
- Department of Hematology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655, Japan
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Yamakawa K, Aihara M, Ogura H, Yuhara H, Hamasaki T, Shimazu T. Recombinant human soluble thrombomodulin in severe sepsis: a systematic review and meta-analysis. J Thromb Haemost 2015; 13:508-19. [PMID: 25581687 DOI: 10.1111/jth.12841] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 01/04/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although recombinant human soluble thrombomodulin (rhTM) is a widely used novel anticoagulant agent for disseminated intravascular coagulation (DIC) in Japan, its clinical efficacy in sepsis-induced DIC has not been demonstrated convincingly. OBJECTIVE To assess the benefits and harms of rhTM in sepsis-induced DIC patients. METHODS We conducted a systematic review and meta-analysis of rhTM therapy for sepsis-induced DIC for both randomized controlled trials (RCTs) and observational studies (retrospective case-control studies and/or prospective cohort studies) separately. All-cause mortality (28-30 days) as efficacy and serious bleeding complications as adverse effect were measured as primary outcomes. We assessed body of evidence quality at the outcome level by using the Grading of Evidence, Assessment, Development and Evaluation (GRADE) approach. RESULTS We analyzed 12 studies (838 patients/3 RCTs; 571 patients/9 observational studies). Pooled relative risk was 0.81 (95% CI, 0.62-1.06) in the RCTs, indicating non-significant reduction in mortality, and 0.59 (95% CI, 0.45-0.77) in the observational studies. Meta-regression analysis revealed a significant negative slope between effect size of rhTM therapy and baseline mortality rate in individual studies (P = 0.012), suggesting that probability of a beneficial effect with rhTM therapy increases with increasing baseline risk. Risk of serious bleeding complications was not significantly different between rhTM and control groups. We judged the quality of evidence as moderate for mortality and serious bleeding. CONCLUSIONS The rhTM was associated with a trend in reduction of mortality at 28-30 days in sepsis-induced DIC patients. Further large rigorous trials are needed to confirm or refute these findings before implications for practice are clear.
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Affiliation(s)
- K Yamakawa
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
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Levi M, Sivapalaratnam S. Hemostatic abnormalities in critically ill patients. Intern Emerg Med 2015; 10:287-96. [PMID: 25537442 DOI: 10.1007/s11739-014-1176-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Accepted: 12/09/2014] [Indexed: 12/17/2022]
Abstract
Hemostatic abnormalities frequently occur in critically ill patients and may vary from prolonged global clotting tests or isolated thrombocytopenia, to composite defects, such as consumption coagulopathies. There are many reasons for a disturbed coagulation in intensive care patients, and each of these underlying syndromes may require specific therapeutic intervention. Hence, an adequate differential diagnosis and initiation of proper (supportive) therapeutic strategies are critical to decrease morbidity and mortality in critically ill patients with hemostatic abnormalities.
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Affiliation(s)
- Marcel Levi
- Department of Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands,
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Izumikawa T, Kitagawa H. Amino acid sequence surrounding the chondroitin sulfate attachment site of thrombomodulin regulates chondroitin polymerization. Biochem Biophys Res Commun 2015; 460:233-7. [PMID: 25772620 DOI: 10.1016/j.bbrc.2015.03.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Accepted: 03/03/2015] [Indexed: 11/24/2022]
Abstract
Thrombomodulin (TM) is a cell-surface glycoprotein and a critical mediator of endothelial anticoagulant function. TM exists as both a chondroitin sulfate (CS) proteoglycan (PG) form and a non-PG form lacking a CS chain (α-TM); therefore, TM can be described as a part-time PG. Previously, we reported that α-TM bears an immature, truncated linkage tetrasaccharide structure (GlcAβ1-3Galβ1-3Galβ1-4Xyl). However, the biosynthetic mechanism to generate part-time PGs remains unclear. In this study, we used several mutants to demonstrate that the amino acid sequence surrounding the CS attachment site influences the efficiency of chondroitin polymerization. In particular, the presence of acidic residues surrounding the CS attachment site was indispensable for the elongation of CS. In addition, mutants defective in CS elongation did not exhibit anti-coagulant activity, as in the case with α-TM. Together, these data support a model for CS chain assembly in which specific core protein determinants are recognized by a key biosynthetic enzyme involved in chondroitin polymerization.
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Affiliation(s)
- Tomomi Izumikawa
- Department of Biochemistry, Kobe Pharmaceutical University, Higashinada-ku, Kobe 658-8558, Japan
| | - Hiroshi Kitagawa
- Department of Biochemistry, Kobe Pharmaceutical University, Higashinada-ku, Kobe 658-8558, Japan.
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Tagami T, Matsui H, Fushimi K, Yasunaga H. Use of recombinant human soluble thrombomodulin in patients with sepsis-induced disseminated intravascular coagulation after intestinal perforation. Front Med (Lausanne) 2015; 2:7. [PMID: 25767801 PMCID: PMC4341430 DOI: 10.3389/fmed.2015.00007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 02/08/2015] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Anticoagulant therapy has been evaluated with respect to its potential usefulness in reducing the high mortality rates associated with severe sepsis, including sepsis-induced disseminated intravascular coagulation (DIC) after intestinal perforation. We examined the hypothesis that recombinant human soluble thrombomodulin (rhTM) is effective in the treatment of patients with septic shock with sepsis-induced DIC after laparotomy for intestinal perforation. METHODS We performed propensity-score and instrumental variable analyses of the Japanese Diagnosis Procedure Combination in-patient database, a nationwide administrative database. The main outcome was 28-day in-hospital all-cause mortality. RESULTS We categorized eligible patients (n = 2202) from 622 hospitals into the rhTM group (n = 726) and control group (n = 1476). Propensity-score matching created 621 matched pairs of patients with and without rhTM. There was neither significant difference in 28-day mortality between the two groups in the unmatched analysis (rhTM vs. control, 25.3 vs. 23.4%, respectively; difference, 1.9%; 95% CI, -1.9 to 5.7) nor in the propensity-score-matched analysis (rhTM vs. control, 26.1 vs. 24.8%, respectively; difference, 1.3%; 95% CI, -3.6 to 6.1). The logistic analysis showed no significant association between the use of rhTM and the mortality in propensity-score-matched patients (OR, 1.1; 95% CI, 0.82-1.4). The instrumental variable analyses, using the hospital rhTM-prescribing proportion as the variable, found that receipt of rhTM was not associated with the reduction in the mortality (risk difference, -6.7%; 95% CI, -16.4 to 3.0). CONCLUSION We found no association between administration of rhTM and 28-day mortality in mechanically ventilated patients with septic shock and concurrent DIC after intestinal perforation.
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Affiliation(s)
- Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Informatics and Policy, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Suetani K, Okuse C, Nakahara K, Michikawa Y, Noguchi Y, Suzuki M, Morita R, Sato N, Kato M, Itoh F. Thrombomodulin in the management of acute cholangitis-induced disseminated intravascular coagulation. World J Gastroenterol 2015; 21:533-540. [PMID: 25593469 PMCID: PMC4292285 DOI: 10.3748/wjg.v21.i2.533] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Accepted: 07/11/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the need for thrombomodulin (rTM) therapy for disseminated intravascular coagulation (DIC) in patients with acute cholangitis (AC)-induced DIC.
METHODS: Sixty-six patients who were diagnosed with AC-induced DIC and who were treated at our hospital were enrolled in this study. The diagnoses of AC and DIC were made based on the 2013 Tokyo Guidelines and the DIC diagnostic criteria as defined by the Japanese Association for Acute Medicine, respectively. Thirty consecutive patients who were treated with rTM between April 2010 and September 2013 (rTM group) were compared to 36 patients who were treated without rTM (before the introduction of rTM therapy at our hospital) between January 2005 and January 2010 (control group). The two groups were compared in terms of patient characteristics at the time of DIC diagnosis (including age, sex, primary disease, severity of cholangitis, DIC score, biliary drainage, and anti-DIC drugs), the DIC resolution rate, DIC score, the systemic inflammatory response syndrome (SIRS) score, hematological values, and outcomes. Using logistic regression analysis based on multivariate analyses, we also examined factors that contributed to persistent DIC.
RESULTS: There were no differences between the rTM group and the control group in terms of the patients’ backgrounds other than administration. DIC resolution rates on day 9 were higher in the rTM group than in the control group (83.3% vs 52.8%, P < 0.01). The mean DIC scores on day 7 were lower in the rTM group than in the control group (2.1 ± 2.1 vs 3.5 ± 2.3, P = 0.02). The mean SIRS scores on day 3 were significantly lower in the rTM group than in the control group (1.1 ± 1.1 vs 1.8 ± 1.1, P = 0.03). Mortality on day 28 was 13.3% in the rTM group and 27.8% in the control group; these rates were not significantly different (P = 0.26). Multivariate analysis identified only the absence of biliary drainage as significantly associated with persistent DIC (P < 0.01, OR = 12, 95%CI: 2.3-60). Although the difference did not reach statistical significance, primary diseases (malignancies) (P = 0.055, OR = 3.9, 95%CI: 0.97-16) and the non-use of rTM had a tendency to be associated with persistent DIC (P = 0.08, OR = 4.3, 95%CI: 0.84-22).
CONCLUSION: The add-on effects of rTM are anticipated in the treatment of AC-induced DIC, although biliary drainage for AC remains crucial.
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Tagami T, Matsui H, Horiguchi H, Fushimi K, Yasunaga H. Recombinant human soluble thrombomodulin and mortality in severe pneumonia patients with sepsis-associated disseminated intravascular coagulation: an observational nationwide study. J Thromb Haemost 2015; 13:31-40. [PMID: 25393713 DOI: 10.1111/jth.12786] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 11/06/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND The association between recombinant human soluble thrombomodulin (rhTM) use and mortality in patients with sepsis-associated disseminated intravascular coagulation (DIC) remains controversial. OBJECTIVES To examine the hypothesis that rhTM could be effective in the treatment of patients with sepsis-associated DIC following severe pneumonia. METHODS Propensity score and instrumental variable analyses using a nationwide administrative database, the Japanese Diagnosis Procedure Combination inpatient database, were used. The main outcome was 28-day in-hospital all-cause mortality. RESULTS Eligible patients (n = 6342) from 936 hospitals were categorized into the rhTM group (n = 1280) or control group (n = 5062). Propensity score matching created a matched cohort of 1140 pairs with and without rhTM. No significant difference in 28-day mortality was documented between the two groups in the unmatched analysis (rhTM vs. control, 37.0%, 474/1280 vs. 36.9%, 1866/5062; odds ratio [OR], 1.00; 95%CI, 0.98-1.03), nor in the propensity-matched analysis (37.6%, 429/1140 vs. 37.0%, 886/1140; OR, 1.01; 95%CI, 0.93-1.10). The logistic regression analysis did not show a significant association between the use of rhTM and 28-day mortality in propensity-matched patients (OR, 1.00; 95%CI, 0.87-1.22). An analysis using the hospital rhTM-prescribing rate as an instrumental variable found that receipt of rhTM was not associated with reduction in mortality at 28 days (risk difference, 0.008; 95% CI, -0.08-0.98). CONCLUSIONS This large retrospective nationwide study demonstrated that there might be little association between the use of rhTM and mortality in severe pneumonia patients with sepsis-associated DIC. A multinational randomized trial is required to confirm this.
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Affiliation(s)
- T Tagami
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan; Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
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Mouksassi MS, Marier JF, Bax L, Osawa Y, Tsuruta K. Population pharmacokinetic analysis of thrombomodulin alfa to support dosing rationale in patients with renal impairment. Clin Pharmacol Drug Dev 2014; 4:210-7. [PMID: 27140801 DOI: 10.1002/cpdd.163] [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: 03/21/2014] [Accepted: 08/25/2014] [Indexed: 11/06/2022]
Abstract
Thrombomodulin alfa is a soluble recombinant human thrombomodulin that was reported to enhance the reversal of disseminated intravascular coagulation (DIC) in subjects with sepsis or hematologic malignancy and reduce mortality in subjects with sepsis and DIC. Population pharmacokinetic (PK) analysis of thrombomodulin alfa was performed based on rich samples collected in 24 healthy subjects (0.02 and 0.06 mg/kg) and sparse samples collected in 368 subjects with sepsis and DIC (0.06 mg/kg). Sources of variability (baseline characteristics, markers of renal/liver function, hematocrit, and disease severity) were explored using non-linear mixed effect modeling to support dosing rationale in patients with sepsis and DIC. Plasma concentrations of thrombomodulin alfa were best fitted with a one-compartment model. Body weight and creatinine clearance were important covariates describing the PK of thrombomodulin alfa. Typical CL values in patients with normal renal function, or mild, moderate and severe renal impairment were 0.158, 0.145, 0.128, and 0.105 L/h, respectively. Based on simulations, a 0.06 mg/kg dosing of thrombomodulin alfa is expected to result in drug exposure within the therapeutic range of the product (300-5,400 ng/mL), with minimum risks of bleeding in patient with normal and impaired renal functions.
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Affiliation(s)
| | | | - Leon Bax
- Pharsight, a Certara Company, Sunnyvale, CA, USA
| | - Yutaka Osawa
- Asahi Kasei Pharma America Corporation, Waltham, MA, USA
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Akahoshi T, Sugimori H, Kaku N, Tokuda K, Nagata T, Noda E, Morita M, Hashizume M, Maehara Y. Comparison of recombinant human thrombomodulin and gabexate mesylate for treatment of disseminated intravascular coagulation (DIC) with sepsis following emergent gastrointestinal surgery: a retrospective study. Eur J Trauma Emerg Surg 2014; 41:531-8. [PMID: 26038004 DOI: 10.1007/s00068-014-0478-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 11/06/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Recombinant thrombomodulin (rTM) has been available in Japan since 2008, but there is concern about its association with postoperative hemorrhage. The efficacy and safety of rTM were examined in patients with disseminated intravascular coagulation (DIC) caused by a septic condition after gastrointestinal surgery. METHODS Forty-two patients were emergently admitted to the intensive care unit after emergent gastrointestinal surgery in Kyushu University Hospital from May 2008 to April 2013. Of these patients, 22 had DIC (defined as an acute DIC score ≥ 4). All but three patients received treatment with gabexate mesylate (GM) (n = 9) or rTM (n = 10). The causes of sepsis were peritonitis with colorectal perforation, anastomotic leakage, and intestinal necrosis. Acute DIC score, sepsis-related organ failure assessment score, platelet count, and a variety of biochemical parameters were compared between rTM and GM recipients after treatment administration. RESULTS There were no significant differences between the groups for any parameter except C-reactive protein levels. The CRP level tended to be lower in the rTM group than in the GM group. Acute DIC score in the rTM group resolved significantly earlier than that in the GM group. No patient stopped the administration of rTM because of postoperative bleeding. CONCLUSION rTM may be an effective therapeutic drug for the treatment of septic patients with DIC following emergent gastrointestinal surgery.
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Affiliation(s)
- T Akahoshi
- Department of Disaster and Emergency Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan. .,Emergency and Critical Care Center, Kyushu University, Fukuoka, Japan. .,Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - H Sugimori
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - N Kaku
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - K Tokuda
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - T Nagata
- Department of Disaster and Emergency Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - E Noda
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - M Morita
- Emergency and Critical Care Center, Kyushu University, Fukuoka, Japan
| | - M Hashizume
- Department of Disaster and Emergency Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Y Maehara
- Emergency and Critical Care Center, Kyushu University, Fukuoka, Japan.,Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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Wada H, Okamoto K, Iba T, Kushimoto S, Kawasugi K, Gando S, Madoiwa S, Uchiyama T, Mayumi T, Seki Y. Addition of recommendations for the use of recombinant human thrombomodulin to the "Expert consensus for the treatment of disseminated intravascular coagulation in Japan". Thromb Res 2014; 134:924-5. [PMID: 25135793 DOI: 10.1016/j.thromres.2014.07.033] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 06/28/2014] [Accepted: 07/30/2014] [Indexed: 11/17/2022]
Affiliation(s)
- H Wada
- Department of Molecular and Laboratory Medicine, Mie University School of Medicine, Tsu, Japan.
| | - K Okamoto
- Department of Emergency Medicine, Juntendo University, Tokyo, Japan
| | - T Iba
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Japan
| | - S Kushimoto
- Department of Internal Medicine, Teikyo University School of Medicine, Itabashi, Japan
| | - K Kawasugi
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - S Gando
- Research Division of Cell and Molecular Medicine, Center for Molecular Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - S Madoiwa
- Department of Internal Medicine, National Hospital Organization Takasaki General Medical Center, Takasaki, Japan
| | - T Uchiyama
- Department of Emergency Medicine, University of Occupational and Environmental Health School of Medicine, Kitakyushu, Japan
| | - T Mayumi
- Department of Internal Medicine, Shibata Hospital-Niigata Prefectural Hospital, Shibata, Japan
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Ishizuka M, Tago K, Kubota K. Impact of prothrombin time–International Normalized Ratio on outcome of patients with septic shock receiving polymyxin B cartridge hemoperfusion. Surgery 2014; 156:168-75. [DOI: 10.1016/j.surg.2014.03.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 03/10/2014] [Indexed: 11/16/2022]
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Eguchi Y, Gando S, Ishikura H, Saitoh D, Mimuro J, Takahashi H, Kitajima I, Tsuji H, Matsushita T, Tsujita R, Nagao O, Sakata Y. Post-marketing surveillance data of thrombomodulin alfa: sub-analysis in patients with sepsis-induced disseminated intravascular coagulation. J Intensive Care 2014; 2:30. [PMID: 25520842 PMCID: PMC4267702 DOI: 10.1186/2052-0492-2-30] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 04/07/2014] [Indexed: 11/18/2022] Open
Abstract
Background Thrombomodulin alfa (TM-α, recombinant thrombomodulin) significantly improved disseminated intravascular coagulation (DIC) when compared with heparin therapy in a phase III study. Post-marketing surveillance of TM-α was performed to evaluate the effects and safety in patients with sepsis-induced DIC. Methods From May 2008 to April 2010, a total of 1,787 patients with sepsis-induced DIC treated with TM-α were registered. DIC was diagnosed based on the Japanese Association for Acute Medicine (JAAM) criteria. The DIC resolution and survival rates on day 28 after the last TM-α administration, and changes in DIC, systemic inflammatory response syndrome (SIRS), and sequential organ failure assessment (SOFA) scores and coagulation and inflammation markers were evaluated. Results The most frequent underlying disease was infectious focus-unknown sepsis (29.8%). The mean ± SD values of age, dose, and the duration of TM-α administration were 64.7 ± 20.3 years, 297.3 ± 111.4 U/kg/day, and 5.6 ± 3.4 days, respectively. A total of 1,320 subjects (73.9%) received combined administration with other anticoagulants. Both coagulation and inflammation markers, such as fibrin/fibrinogen degradation products, prothrombin time ratio, thrombin-antithrombin complex, and C-reactive protein, as well as JAAM DIC, SIRS, and SOFA scores, significantly and simultaneously decreased after TM-α administration (p < 0.001). DIC resolution and 28-day survival rates were 44.4% and 66.0%, respectively. The 28-day survival rate decreased significantly according to the duration of DIC before TM-α administration (p < 0.001). Total adverse drug reactions (ADRs), bleeding ADRs, and serious bleeding adverse events occurred in 126 (7.1%), 98 (5.5%), and 121 (6.8%) subjects, respectively. On day 28, after the last TM-α administration available for an antibody test, only one patient was positive for anti-TM-α antibodies (0.11%). Conclusion Our results suggest that TM-α is most effective for treating patients with sepsis-induced DIC when administered within the first 3 days after diagnosis.
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Affiliation(s)
- Yutaka Eguchi
- Department of Critical and Intensive Care Medicine, Shiga University of Medical Science, Shiga, Japan ; The Japanese Society on Thrombosis and Hemostasis Post-Marketing Surveillance Committee for Recomodulin® Injection, Tokyo, Japan
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
| | - Hiroyasu Ishikura
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Daizoh Saitoh
- Division of Traumatology, National Defense Medical College Research Institute, National Defense Medical College, Saitama, Japan
| | - Jun Mimuro
- Division of Cell and Molecular Medicine, Center for Molecular Medicine, Jichi Medical University, School of Medicine, Tochigi, Japan ; The Japanese Society on Thrombosis and Hemostasis Post-Marketing Surveillance Committee for Recomodulin® Injection, Tokyo, Japan
| | - Hoyu Takahashi
- Department of Internal Medicine, Niigata Prefectural Kamo Hospital, Niigata, Japan ; The Japanese Society on Thrombosis and Hemostasis Post-Marketing Surveillance Committee for Recomodulin® Injection, Tokyo, Japan
| | - Isao Kitajima
- Department of Clinical Laboratory and Molecular Pathology, Graduate School of Medical and Pharmaceutical Science, University of Toyama, Toyama, Japan ; The Japanese Society on Thrombosis and Hemostasis Post-Marketing Surveillance Committee for Recomodulin® Injection, Tokyo, Japan
| | - Hajime Tsuji
- Department of Blood Transfusion, Kyoto Prefectural University of Medicine, Kyoto, Japan ; The Japanese Society on Thrombosis and Hemostasis Post-Marketing Surveillance Committee for Recomodulin® Injection, Tokyo, Japan
| | - Tadashi Matsushita
- Department of Transfusion Medicine, Nagoya University Hospital, Aichi, Japan ; The Japanese Society on Thrombosis and Hemostasis Post-Marketing Surveillance Committee for Recomodulin® Injection, Tokyo, Japan
| | - Ryuichi Tsujita
- ART Project, Pharmaceuticals Sales Division, Asahi Kasei Pharma Corporation, Tokyo, Japan
| | - Osamu Nagao
- Post-Marketing Surveillance Dept. Reliability Assurance Center, Asahi Kasei Pharma Corporation, Tokyo, Japan
| | - Yoichi Sakata
- Division of Cell and Molecular Medicine, Center for Molecular Medicine, Jichi Medical University, School of Medicine, Tochigi, Japan ; The Japanese Society on Thrombosis and Hemostasis Post-Marketing Surveillance Committee for Recomodulin® Injection, Tokyo, Japan
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Asakura H, Takahashi H, Tsuji H, Matsushita T, Ninomiya H, Honda G, Mimuro J, Eguchi Y, Kitajima I, Sakata Y. Post-marketing surveillance of thrombomodulin alfa, a novel treatment of disseminated intravascular coagulation - safety and efficacy in 1,032 patients with hematologic malignancy. Thromb Res 2014; 133:364-70. [PMID: 24440141 DOI: 10.1016/j.thromres.2013.12.033] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 11/28/2013] [Accepted: 12/28/2013] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Post-marketing surveillance of thrombomodulin alfa (TM-α) was performed to evaluate safety and efficacy in patients with disseminated intravascular coagulation (DIC) with hematologic malignancy. MATERIALS AND METHODS All patients treated with TM-α from May 2008 to April 2010 in Japan were included. Information about baseline characteristics, safety, and efficacy were collected. The DIC resolution rate, survival rate on Day 28 after the last TM-α administration, and changes in DIC score and coagulation tests were evaluated. RESULTS The underlying diseases associated with DIC were acute myeloid leukemia (except for acute promyelocytic leukemia, n=350), lymphoma (n=199), acute promyelocytic leukemia (n=172), acute lymphoblastic leukemia (n=156), myelodysplastic syndromes (n=61), and other (n=94). The incidence rates of bleeding-related adverse events and adverse drug reactions were 17.8% and 4.6%, respectively. In subjects with bleeding symptoms at baseline, 55.0% were assessed as disappeared or improved based on symptoms after TM-α treatment. The DIC resolution and survival rates were 55.9% and 70.7%, respectively. The DIC score and coagulation tests including thrombin-antithrombin complex (TAT) were significantly improved. Coagulation tests were significantly improved after TM-α treatment even in subjects whose clinical course of underlying disease was assessed as unchanged or exacerbated. CONCLUSIONS This surveillance confirmed the safety and efficacy of TM-α in clinical practice, thus TM-α may be an ideal treatment for patients with DIC based upon hematologic malignancy.
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Affiliation(s)
- Hidesaku Asakura
- Department of Internal Medicine (III), Kanazawa University School of Medicine, Kanazawa, Japan.
| | - Hoyu Takahashi
- Department of Internal Medicine, Niigata Prefectural Kamo Hospital, Niigata, Japan; The Japanese Society on Thrombosis and Hemostasis Post-Marketing Surveillance Committee for Recomodulin(®) Injection
| | - Hajime Tsuji
- Department of Blood Transfusion, Kyoto Prefectural University of Medicine, Kyoto, Japan; The Japanese Society on Thrombosis and Hemostasis Post-Marketing Surveillance Committee for Recomodulin(®) Injection
| | - Tadashi Matsushita
- Department of Transfusion Medicine, Nagoya University Hospital, Aichi, Japan; The Japanese Society on Thrombosis and Hemostasis Post-Marketing Surveillance Committee for Recomodulin(®) Injection
| | - Hideyuki Ninomiya
- ART project, Pharmaceutical Sales Division Asahi Kasei Pharma Corporation, Tokyo, Japan
| | - Goichi Honda
- ART project, Pharmaceutical Sales Division Asahi Kasei Pharma Corporation, Tokyo, Japan
| | - Jun Mimuro
- Division of Cell and Molecular Medicine, Center for Molecular Medicine, Jichi Medical University, School of Medicine, Tochigi, Japan; The Japanese Society on Thrombosis and Hemostasis Post-Marketing Surveillance Committee for Recomodulin(®) Injection
| | - Yutaka Eguchi
- Critical and Intensive Care Medicine, Shiga University of Medical Science, Shiga, Japan; The Japanese Society on Thrombosis and Hemostasis Post-Marketing Surveillance Committee for Recomodulin(®) Injection
| | - Isao Kitajima
- Department of Clinical Laboratory and Molecular Pathology, Graduate School of Medical and Pharmaceutical Science, University of Toyama, Toyama, Japan; The Japanese Society on Thrombosis and Hemostasis Post-Marketing Surveillance Committee for Recomodulin(®) Injection
| | - Yoichi Sakata
- Division of Cell and Molecular Medicine, Center for Molecular Medicine, Jichi Medical University, School of Medicine, Tochigi, Japan; The Japanese Society on Thrombosis and Hemostasis Post-Marketing Surveillance Committee for Recomodulin(®) Injection
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Kawasaki Y, Suyama K, Ono A, Oikawa T, Ohara S, Suzuki Y, Sakai N, Hosoya M. Efficacy of recombinant human soluble thrombomodulin for childhood hemolytic uremic syndrome. Pediatr Int 2013; 55:e139-42. [PMID: 24134770 DOI: 10.1111/ped.12165] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 06/03/2013] [Accepted: 06/14/2013] [Indexed: 12/01/2022]
Abstract
Recombinant human soluble thrombomodulin (rhTM) is a promising therapeutic natural anticoagulant and is used clinically for the treatment of disseminated intravascular coagulation (DIC). Herein is reported the cases of two HUS children treated with rhTM. The patients were diagnosed as having typical HUS on the basis of thrombocytopenia, hemolytic anemia, acute renal failure, and the detection Escherichia coli 0157. I.v. rhTM was started as an anti-coagulant drug. At 2 days after the first treatment in both patients, fibrin/fibrinogen degradation products and d-dimer levels were significantly decreased, and there was a subsequent slight improvement in thrombocytopenia, and a decrease in serum lactate dehydrogenase level. Urinary protein excretion gradually diminished and a decrease in serum creatinine level was observed. The patients did not require dialysis therapy. The present results suggest that rhTM may be a safe and effective treatment for DIC complicated with HUS in children.
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Affiliation(s)
- Yukihiko Kawasaki
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima, Japan
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Early coagulation disorder after allogeneic stem cell transplantation is a strong prognostic factor for transplantation-related mortality, and intervention with recombinant human thrombomodulin improves the outcome: a single-center experience. Int J Hematol 2013; 98:533-42. [DOI: 10.1007/s12185-013-1443-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 09/11/2013] [Accepted: 09/11/2013] [Indexed: 01/04/2023]
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A Randomized, Double-Blind, Placebo-Controlled, Phase 2b Study to Evaluate the Safety and Efficacy of Recombinant Human Soluble Thrombomodulin, ART-123, in Patients With Sepsis and Suspected Disseminated Intravascular Coagulation*. Crit Care Med 2013; 41:2069-79. [DOI: 10.1097/ccm.0b013e31828e9b03] [Citation(s) in RCA: 219] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Gando S, Saitoh D, Ogura H, Fujishima S, Mayumi T, Araki T, Ikeda H, Kotani J, Kushimoto S, Miki Y, Shiraishi SI, Suzuki K, Suzuki Y, Takeyama N, Takuma K, Tsuruta R, Yamaguchi Y, Yamashita N, Aikawa N. A multicenter, prospective validation study of the Japanese Association for Acute Medicine disseminated intravascular coagulation scoring system in patients with severe sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R111. [PMID: 23787004 PMCID: PMC4056654 DOI: 10.1186/cc12783] [Citation(s) in RCA: 142] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 06/20/2013] [Indexed: 12/28/2022]
Abstract
Introduction To validate the Japanese Association for Acute Medicine (JAAM) disseminated intravascular coagulation (DIC) scoring system in patients with severe sepsis, we conducted a multicenter, prospective study at 15 critical care centers in tertiary care hospitals. Methods This study included 624 severe sepsis patients. JAAM DIC was scored on the day of diagnosis of severe sepsis (day 1) and day 4. Scores for disease severity and organ dysfunction were also evaluated. Results The prevalence of JAAM DIC was 46.8% (292/624), and 21% of the DIC patients were scored according to the reduction rate of platelets. The JAAM DIC patients were more seriously ill and exhibited more severe systemic inflammation, a higher prevalence of multiple organ dysfunction syndrome (MODS) and worse outcomes than the non-DIC patients. Disease severity, systemic inflammation, MODS and the mortality rate worsened in accordance with an increased JAAM DIC score on day 1. The Kaplan-Meier curves demonstrated lower 1-year survival in the JAAM DIC patients than in those without DIC (log-rank test P <0.001). The JAAM DIC score on day 1 (odds ratio = 1.282, P <0.001) and the Delta JAAM DIC score (odds ratio = 0.770, P <0.001) were independent predictors of 28-day death. Dynamic changes in the JAAM DIC score from days 1 to 4 also affected prognoses. The JAAM DIC scoring system included all patients who met the International Society on Thrombosis and Haemostasis overt DIC criteria on day 1. The International Society on Thrombosis and Haemostasis scoring system missed a large number of nonsurvivors recognized by the JAAM scoring system. Conclusions The JAAM DIC scoring system exhibits good prognostic value in predicting MODS and poor prognosis in patients with severe sepsis and can detect more patients requiring treatment. Conducting repeated daily JAAM scoring increases the ability to predict the patient's prognosis.
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Nakahara K, Okuse C, Adachi S, Suetani K, Kitagawa S, Okano M, Michikawa Y, Takagi R, Shigefuku R, Itoh F. Use of antithrombin and thrombomodulin in the management of disseminated intravascular coagulation in patients with acute cholangitis. Gut Liver 2013; 7:363-70. [PMID: 23710320 PMCID: PMC3661971 DOI: 10.5009/gnl.2013.7.3.363] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 07/12/2012] [Accepted: 07/27/2012] [Indexed: 12/23/2022] Open
Abstract
Background/Aims To evaluate the usefulness and safety of treating disseminated intravascular coagulation (DIC) complicating cholangitis primarily with antithrombin (AT) and thrombomodulin (rTM). Methods A DIC treatment algorithm was determined on the basis of plasma AT III levels at the time of DIC diagnosis and DIC score changes on treatment day 3. Laboratory data and DIC scores were assessed prospectively at 2-day intervals. Results DIC reversal rates >75% were attained on day 7. In the DIC reversal group, statistically significant differences from baseline were observed in interleukin-6 and C-reactive protein levels within 5 days. Patients with no DIC score improvements after treatment with AT alone experienced slow improvement on a subsequent combination therapy with rTM. Although a subgroup with biliary drainage showed greater improvement in DIC scores than did the nondrainage subgroup, the mean DIC score showed improvement even in the nondrainage subgroup alone. Gastric cancer bleeding that was treated conservatively occurred in one patient. As for day 28 outcomes, three patients died from concurrent malignancies. Conclusions Although this algorithm was found to be useful and safe for DIC patients with cholangitis, it may be better to administer rTM and AT simultaneously from day 1 if the plasma AT III level is less than 70%.
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Affiliation(s)
- Kazunari Nakahara
- Department of Gastroenterology and Hepatology, St. Marianna University School of Medicine, Kawasaki, Japan
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Chinen Y, Kuroda J, Ohshiro M, Shimura Y, Mizutani S, Nagoshi H, Sasaki N, Nakayama R, Kiyota M, Yamamoto-Sugitani M, Kobayashi T, Matsumoto Y, Horiike S, Taniwaki M. Low ADAMTS-13 activity during hemorrhagic events with disseminated intravascular coagulation. Int J Hematol 2013; 97:511-9. [PMID: 23494361 DOI: 10.1007/s12185-013-1308-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 03/01/2013] [Accepted: 03/03/2013] [Indexed: 01/23/2023]
Abstract
Disseminated intravascular coagulation (DIC) is a life-threatening complication, and its control is essential for therapeutic success. Recombinant human soluble thrombomodulin alfa (rTM) is a novel therapeutic agent for DIC. The efficacy of rTM in the treatment of DIC is reportedly superior to that of conventional anti-DIC treatments, such as unfractionated heparin or low molecular weight heparin, but hemorrhagic events occasionally interfere with the therapeutic benefits of rTM. We assessed the clinical features of 20 consecutive patients who were given rTM for DIC associated with various hematologic disorders. Eight patients achieved remission of both primary disease and DIC, eight died due to progression of the primary disease, and four died of various hemorrhagic complications. Assessment of 16 biomarkers for coagulation showed that the four patients who died of hemorrhagic complications despite remission of their primary disease showed lower ADAMTS-13 (a disintegrin and metalloproteinase with a thrombospondin Type 1 motif, member 13) plasma activity than other patients (P = 0.016). The optimal cut-off level of ADAMTS-13 for predicting risk of hemorrhagic complications was 42 % (P = 0.007). Plasma ADAMTS-13 activity determined at diagnosis of DIC may help predict the risk of hemorrhagic events during and/or following DIC treatment with hematologic disorders.
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Affiliation(s)
- Yoshiaki Chinen
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, Japan
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Yamakawa K, Ogura H, Fujimi S, Morikawa M, Ogawa Y, Mohri T, Nakamori Y, Inoue Y, Kuwagata Y, Tanaka H, Hamasaki T, Shimazu T. Recombinant human soluble thrombomodulin in sepsis-induced disseminated intravascular coagulation: a multicenter propensity score analysis. Intensive Care Med 2013; 39:644-52. [PMID: 23361628 PMCID: PMC3607733 DOI: 10.1007/s00134-013-2822-2] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Accepted: 12/09/2012] [Indexed: 02/06/2023]
Abstract
Purpose Evidence of efficacy and safety of, and especially mortality related to, recombinant human thrombomodulin (rhTM) treatment for sepsis-induced disseminated intravascular coagulation (DIC) is limited. We hypothesized that patients with sepsis-induced DIC receiving treatment with rhTM would have improved mortality compared with those with similar acuity who did not. Methods This retrospective cohort study conducted in three tertiary referral hospitals in Japan between January 2006 and June 2011 included all patients with sepsis-induced DIC who required ventilator management. Primary endpoint was in-hospital mortality, with duration of intensive care unit treatment, changes in DIC scores and rate of bleeding complications as secondary endpoints. Regression technique was used to develop a propensity model adjusted for baseline imbalances between groups. Results Eligible were 162 patients with sepsis-induced DIC; 68 patients received rhTM and 94 did not. Patients receiving rhTM had higher severity of illness according to baseline characteristics. After adjusting for these imbalances by stratified propensity score analysis, treatment with rhTM was significantly associated with reduced in-hospital mortality (adjusted hazard ratio, 0.45; 95 % confidential interval, 0.26–0.77; p = 0.013). An association between rhTM treatment and higher numbers of intensive care unit-free days, ventilator-free days, and vasopressor-free days were observed. DIC scores were significantly decreased in the rhTM group compared with the control group in the early period after rhTM treatment, whereas the incidence of bleeding-related adverse events did not differ between the two groups. Conclusions Therapy with rhTM may be associated with reduced in-hospital mortality in adult mechanically ventilated patients with sepsis-induced DIC.
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Affiliation(s)
- Kazuma Yamakawa
- 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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Korte W. Peri- und intraoperative Gerinnungsstörungen und ihre Therapieempfehlungen. VISZERALMEDIZIN 2013. [DOI: 10.1159/000356071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Recombinant human soluble thrombomodulin improves mortality and respiratory dysfunction in patients with severe sepsis. J Trauma Acute Care Surg 2012; 72:1150-7. [PMID: 22673239 DOI: 10.1097/ta.0b013e3182516ab5] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Respiratory dysfunction associated with severe sepsis is a serious condition leading to poor prognosis. Activation of coagulation is a consequence of and contributor to ongoing lung injury in severe sepsis. The purpose of this study was to examine the efficacy of recombinant human soluble thrombomodulin (rhTM), a novel anticoagulant agent, for treating patients with sepsis-induced disseminated intravascular coagulation (DIC) in terms of mortality and respiratory dysfunction. METHODS This study comprised 86 consecutive patients with sepsis-induced DIC who required ventilator management. The initial 45 patients were treated without rhTM (control group), and the following 41 patients were given rhTM (0.06 mg/kg/d) for 6 days (rhTM group). Patients were followed up for 90 days after study entry. Sequential Organ Failure Assessment (SOFA) score and lung injury score were recorded until 7 days after entry. RESULTS The baseline characteristic of severity of illness was significantly higher in the rhTM group than in the control group. Nevertheless, 90-day mortality rate in the rhTM group was significantly lower than that in the control group (37% vs. 58%, p = 0.038). There was a significant difference in the serial change of SOFA score from baseline to day 7 between the two groups (p = 0.009). Both the respiratory component of the SOFA score and the lung injury score in the rhTM group were significantly lower compared with the control group (p = 0.034 and p < 0.001, respectively). CONCLUSIONS rhTM may have a significant beneficial effect on mortality and respiratory dysfunction in patients with sepsis-induced DIC. LEVEL OF EVIDENCE III, therapeutic study.
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Thrombomodulin: a bifunctional modulator of inflammation and coagulation in sepsis. Crit Care Res Pract 2012; 2012:614545. [PMID: 22482044 PMCID: PMC3299293 DOI: 10.1155/2012/614545] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Revised: 12/01/2011] [Accepted: 12/01/2011] [Indexed: 01/08/2023] Open
Abstract
Deregulated interplay between inflammation and coagulation plays a pivotal role in the pathogenesis of sepsis. Therapeutic approaches that simultaneously target both inflammation and coagulation hold great promise for the treatment of sepsis. Thrombomodulin is an endogenous anticoagulant protein that, in cooperation with protein C and thrombin-activatable fibrinolysis inhibitor, serves to maintain the endothelial microenvironment in an anti-inflammatory and anticoagulant state. A recombinant soluble form of thrombomodulin has been approved to treat patients suffering from disseminated intravascular coagulation (DIC) and has thus far shown greater therapeutic potential than heparin. A phase II clinical trial is currently underway in the USA to study the efficacy of thrombomodulin for the treatment of sepsis with DIC complications. This paper focuses on the critical roles that thrombomodulin plays at the intersection of inflammation and coagulation and proposes the possible existence of interactions with integrins via protein C. Finally, we provide a rationale for the clinical application of thrombomodulin for alleviating sepsis.
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Kudo D, Shinozawa Y, Yamanouchi S, Endo T, Sato T, Furukawa H, Nomura R, Kushimoto S. Treatment effect of thrombomodulin-^|^alpha; on septic disseminated intravascular coagulation (DIC): a historical cohort study. ACTA ACUST UNITED AC 2012. [DOI: 10.3918/jsicm.19.359] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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What's New in SHOCK, April 2011? Shock 2011. [DOI: 10.1097/shk.0b013e31820f1fbe] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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