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Preissner KT, Herwald H. Extracellular nucleic acids in immunity and cardiovascular responses: between alert and disease. Thromb Haemost 2017; 117:1272-1282. [PMID: 28594050 DOI: 10.1160/th-16-11-0858] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 03/07/2017] [Indexed: 12/18/2022]
Abstract
Severe inflammatory complications are a potential consequence in patients with predetermined conditions of infections, pulmonary diseases, or cardiovascular disorders. Notably, the amplitude of the inflammatory response towards these complications can dictate the disease progression and outcome. During the recent years, evidence from basic research as well as from clinical studies has identified self-extracellular nucleic acids as important players in the crosstalk between immunity and cardiovascular diseases. These stress- or injury-induced endogenous polymeric macromolecules not only serve as "alarmins" or "Danger-associated molecular patterns" (DAMPs), but their functional repertoire goes far beyond such activities in innate immunity. In fact, (patho-) physiological functions of self-extracellular DNA and RNA are associated and in many cases causally related to arterial and venous thrombosis, atherosclerosis, ischemia-reperfusion injury or tumour progression. Yet, the underlying molecular mechanisms are far from being completely understood. Interestingly enough, however, novel antagonistic approaches in vitro and in vivo, particularly using natural endonucleases or synthetic nucleic acid binding polymers, appear to be promising and safe therapeutic options for future studies. The aim of this review article is to provide an overview of the current state of (patho-) physiological functions of self-extracellular nucleic acids with special emphasis on their role as beneficial / alerting or adverse / damaging factors in connection with immune responses, inflammation, thrombosis, and cardiovascular diseases.
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Affiliation(s)
- Klaus T Preissner
- Klaus T. Preissner, PhD, Department of Biochemistry, Medical School, Justus-Liebig-University, Friedrichstrasse 24, 35392 Giessen, Germany, Tel.: +49 641 994 7500, E-mail:
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O’Connell GC, Petrone AB, Tennant CS, Lucke-Wold N, Kabbani Y, Tarabishy AR, Chantler PD, Barr TL. Circulating extracellular DNA levels are acutely elevated in ischaemic stroke and associated with innate immune system activation. Brain Inj 2017; 31:1369-1375. [PMID: 28585898 DOI: 10.1080/02699052.2017.1312018] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Grant C. O’Connell
- Center for Basic and Translational Stroke Research, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, West Virginia, USA
- Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University, Morgantown, West Virginia, USA
| | - Ashley B. Petrone
- Center for Basic and Translational Stroke Research, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, West Virginia, USA
| | - Connie S. Tennant
- Center for Basic and Translational Stroke Research, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, West Virginia, USA
| | - Noelle Lucke-Wold
- Center for Basic and Translational Stroke Research, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, West Virginia, USA
| | - Yasser Kabbani
- Department of Neuroradiology, Ruby Memorial Hospital, Morgantown, West Virginia, USA
| | - Abdul R. Tarabishy
- Department of Neuroradiology, Ruby Memorial Hospital, Morgantown, West Virginia, USA
| | - Paul D. Chantler
- Center for Cardiovascular and Respiratory Sciences, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, West Virginia, USA
- Division of Exercise Physiology, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Taura L. Barr
- Valtari Bio Incorporated, Morgantown, West Virginia, USA
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103
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Silica particles contribute to the procoagulant activity of DNA and polyphosphate isolated using commercial kits. Blood 2017; 130:88-91. [PMID: 28533308 DOI: 10.1182/blood-2017-03-772848] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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104
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Vokálová L, Lauková L, Čonka J, Melišková V, Borbélyová V, Bábíčková J, Tóthová L, Hodosy J, Vlková B, Celec P. Deoxyribonuclease partially ameliorates thioacetamide-induced hepatorenal injury. Am J Physiol Gastrointest Liver Physiol 2017; 312:G457-G463. [PMID: 28209603 DOI: 10.1152/ajpgi.00446.2016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 02/06/2017] [Accepted: 02/10/2017] [Indexed: 01/31/2023]
Abstract
Several recent studies have shown that liver injury is associated with the release of DNA from hepatocytes. This DNA stimulates innate immunity and induces sterile inflammation, exacerbating liver damage. Similar mechanisms have been described for acute renal injury. Deoxyribonuclease degrades cell-free DNA and can potentially prevent some of the induced tissue damage. This study analyzed the effects of thioacetamide-induced hepatorenal injury on plasma DNA in rats. Plasma DNA of both nuclear and mitochondrial origin was higher in thioacetamide-treated animals. Administration of deoxyribonuclease resulted in a mild, nonsignificant decrease in total plasma DNA and plasma DNA of mitochondrial origin but not of nuclear origin. This was accompanied by a decrease in bilirubin, creatinine, and blood urea nitrogen as markers of renal function. In conclusion, the study confirmed the hepatotoxic and nephrotoxic effect of thioacetamide. The associated increase in cell-free DNA seems to be involved in hepatorenal pathogenesis because treatment with deoxyribonuclease resulted in a partial prevention of hepatorenal injury. Further experiments will focus on the effects of long-term treatment with deoxyribonuclease in other clinically more relevant models. Clinical studies should test endogenous deoxyribonuclease activity as a potential risk determinant for kidney or liver failure.NEW & NOTEWORTHY Thioacetamide-induced hepatorenal injury resulted in higher plasma cell-free DNA. Deoxyribonuclease decreased average cell-free DNA of mitochondrial origin but not nuclear origin. Deoxyribonuclease partially prevented hepatorenal injury in rats.
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Affiliation(s)
- Lenka Vokálová
- Institute of Physiology, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Lucia Lauková
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Jozef Čonka
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Veronika Melišková
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Veronika Borbélyová
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Janka Bábíčková
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - L'ubomíra Tóthová
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Július Hodosy
- Institute of Physiology, Faculty of Medicine, Comenius University, Bratislava, Slovakia.,Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Barbora Vlková
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Peter Celec
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia; .,Institute of Pathophysiology, Faculty of Medicine, Comenius University, Bratislava, Slovakia; and.,Department of Molecular Biology, Faculty of Natural Sciences, Comenius University, Bratislava, Slovakia
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105
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Foley JH, Conway EM. Cross Talk Pathways Between Coagulation and Inflammation. Circ Res 2017; 118:1392-408. [PMID: 27126649 DOI: 10.1161/circresaha.116.306853] [Citation(s) in RCA: 373] [Impact Index Per Article: 53.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Accepted: 03/21/2016] [Indexed: 02/06/2023]
Abstract
Anatomic pathology studies performed over 150 years ago revealed that excessive activation of coagulation occurs in the setting of inflammation. However, it has taken over a century since these seminal observations were made to delineate the molecular mechanisms by which these systems interact and the extent to which they participate in the pathogenesis of multiple diseases. There is, in fact, extensive cross talk between coagulation and inflammation, whereby activation of one system may amplify activation of the other, a situation that, if unopposed, may result in tissue damage or even multiorgan failure. Characterizing the common triggers and pathways are key for the strategic design of effective therapeutic interventions. In this review, we highlight some of the key molecular interactions, some of which are already showing promise as therapeutic targets for inflammatory and thrombotic disorders.
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Affiliation(s)
- Jonathan H Foley
- From the Department of Haematology, UCL Cancer Institute, University College London, London, United Kingdom (J.H.F.); Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free NHS Trust, London, United Kingdom (J.H.F.); and Centre for Blood Research, Department of Medicine, University of British Columbia, Vancouver, Canada (E.M.C.)
| | - Edward M Conway
- From the Department of Haematology, UCL Cancer Institute, University College London, London, United Kingdom (J.H.F.); Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free NHS Trust, London, United Kingdom (J.H.F.); and Centre for Blood Research, Department of Medicine, University of British Columbia, Vancouver, Canada (E.M.C.).
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106
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Schneck E, Samara O, Koch C, Hecker A, Padberg W, Lichtenstern C, Weigand MA, Uhle F. Plasma DNA and RNA differentially impact coagulation during abdominal sepsis—an explorative study. J Surg Res 2017; 210:231-243. [DOI: 10.1016/j.jss.2016.11.044] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 09/30/2016] [Accepted: 11/23/2016] [Indexed: 12/15/2022]
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Jeffery U, LeVine DN. Canine Neutrophil Extracellular Traps Enhance Clot Formation and Delay Lysis. Vet Pathol 2017; 55:116-123. [PMID: 28346125 DOI: 10.1177/0300985817699860] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Autoimmune diseases increase the risk of thrombosis. Neutrophil extracellular traps (NETs) are webs of DNA and protein that may mediate thrombosis in autoimmune diseases. Human and murine studies show NET-releasing neutrophils within a thrombus promote its growth, but it is unclear to what extent NET fragments released into circulation during inflammation are prothrombotic. This study hypothesized that canine NETs promote clot formation and impair lysis even in the absence of neutrophils. NETs were prepared from PMA-stimulated neutrophils and added to fibrinogen and thrombin or to recalcified pooled canine platelet-poor plasma, tissue factor, and tissue plasminogen activator. Clot formation and lysis were measured spectrophotometrically. NETs did not alter fibrin clot formation, but NETs increased maximum clot formation velocity ( P = .001) and delayed lysis ( P = .009) of plasma clots compared with supernatants from nonstimulated neutrophils. DNase digestion of NETs reduced their effect on clot lysis but not maximum clot formation velocity. This suggested impaired lysis was principally mediated by DNA within NETs but that NET proteins were principally responsible for increased speed of clot formation. Previous reports suggested elastase or histones might be responsible for the effect of NETs on clot formation. Elastase activity was greatly reduced by plasma, and addition of histones to plasma did not increase formation velocity, suggesting these proteins were not responsible for increasing maximum formation velocity. This study showed that NETs enhanced clot formation and impaired clot lysis in canine platelet-poor plasma. These in vitro findings suggest both NET proteins and DNA may contribute to thrombosis in inflammatory disease.
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Affiliation(s)
- Unity Jeffery
- 1 Department of Veterinary Microbiology and Preventative Medicine, College of Veterinary Medicine, Iowa State University, Ames, IA, USA
| | - Dana N LeVine
- 2 Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Iowa State University, Ames, IA, USA
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108
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109
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Promyelocytic extracellular chromatin exacerbates coagulation and fibrinolysis in acute promyelocytic leukemia. Blood 2017; 129:1855-1864. [PMID: 28053193 DOI: 10.1182/blood-2016-09-739334] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 12/20/2016] [Indexed: 12/28/2022] Open
Abstract
Despite routine treatment of unselected acute promyelocytic leukemia (APL) with all-trans-retinoic acid (ATRA), early death because of hemorrhage remains unacceptably common, and the mechanism underlying this complication remains elusive. We have recently demonstrated that APL cells undergo a novel cell death program, termed ETosis, which involves release of extracellular chromatin. However, the role of promyelocytic extracellular chromatin in APL-associated coagulation remains unclear. Our objectives were to identify the novel role of ATRA-promoted extracellular chromatin in inducing a hypercoagulable and hyperfibrinolytic state in APL and to evaluate its interaction with fibrin and endothelial cells (ECs). Results from a series of coagulation assays have shown that promyelocytic extracellular chromatin increases thrombin and plasmin generation, causes a shortening of plasma clotting time of APL cells, and increases fibrin formation. DNase I but not anti-tissue factor antibody could inhibit these effects. Immunofluorescence staining showed that promyelocytic extracellular chromatin and phosphatidylserine on APL cells provide platforms for fibrin deposition and render clots more resistant to fibrinolysis. Additionally, coincubation assays revealed that promyelocytic extracellular chromatin is cytotoxic to ECs, converting them to a procoagulant phenotype. This cytotoxity was blocked by DNase I by 20% or activated protein C by 31%. Our current results thus delineate the pathogenic role of promyelocytic extracellular chromatin in APL coagulopathy. Furthermore, the remaining coagulation disturbance in high-risk APL patients after ATRA administration may be treatable by intrinsic pathway inhibition via accelerating extracellular chromatin degradation.
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110
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Avriel A, Rozenberg D, Raviv Y, Heimer D, Bar-Shai A, Gavish R, Sheynin J, Douvdevani A. Prognostic utility of admission cell-free DNA levels in patients with chronic obstructive pulmonary disease exacerbations. Int J Chron Obstruct Pulmon Dis 2016; 11:3153-3161. [PMID: 28003743 PMCID: PMC5158140 DOI: 10.2147/copd.s113256] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Chronic obstructive pulmonary disease exacerbations (COPDEs) are associated with increased morbidity and mortality. Cell-free DNA (cfDNA) is a novel biomarker associated with clinical outcomes in several disease states but has not been studied in COPD. The objectives of this study were to assess cfDNA levels during a COPDE, to evaluate the association of cfDNA with clinical parameters and to explore the prognostic implications of cfDNA levels on long-term survival. Methods This was an observational study that assessed cfDNA levels in patients admitted to hospital for a COPDE. Plasma cfDNA levels of COPDE patients were compared to those of matched stable COPD patients and healthy controls. Multivariable and Cox regression analyses were used to assess the association of cfDNA levels with blood gas parameters and long-term survival. Results A total of 62 patients (46 males, forced expiratory volume in 1 second [FEV1] 38%±13%) were included. The median cfDNA levels on admission for COPDE patients was 1,634 ng/mL (interquartile range [IQR] 1,016–2,319) compared to 781 ng/mL (IQR 523–855) for stable COPD patients, matched for age and disease severity, and 352 ng/mL (IQR 209–636) for healthy controls (P<0.0001, for both comparisons). cfDNA was correlated with partial arterial pressure of carbon dioxide (PaCO2, r=0.35) and pH (r=−0.35), P=0.01 for both comparisons. In a multivariable analysis, PaCO2 was the only independent predictor of cfDNA. Using a cfDNA level of 1,924 ng/mL (threshold for abnormal PaCO2), those with high levels had a trend for increased 5-year mortality risk adjusted for age, sex and FEV1% (hazard ratio 1.92, 95% confidence interval 0.93–3.95, P=0.08). Conclusion Plasma cfDNA might offer a novel technique to identify COPD patients at increased risk of poor outcomes, but the prognostic utility of this measurement requires further study.
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Affiliation(s)
- Avital Avriel
- Department of Medicine, Pulmonology Institute, Soroka Medical Center, Ben-Gurion University, Beer-Sheva, Israel
| | - Dmitry Rozenberg
- Division of Respirology, Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Yael Raviv
- Department of Medicine, Pulmonology Institute, Soroka Medical Center, Ben-Gurion University, Beer-Sheva, Israel
| | - Dov Heimer
- Department of Medicine, Pulmonology Institute, Soroka Medical Center, Ben-Gurion University, Beer-Sheva, Israel
| | - Amir Bar-Shai
- Department of Medicine, Pulmonology Institute, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv
| | - Rachel Gavish
- Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel
| | - Jony Sheynin
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA; Department of Clinical Biochemistry, Faculty of Health Sciences, Soroka Medical Center, Ben-Gurion University, Beer-Sheva, Israel
| | - Amos Douvdevani
- Department of Clinical Biochemistry, Faculty of Health Sciences, Soroka Medical Center, Ben-Gurion University, Beer-Sheva, Israel
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Ramirez GA, Manfredi AA, Rovere-Querini P, Maugeri N. Bet on NETs! Or on How to Translate Basic Science into Clinical Practice. Front Immunol 2016; 7:417. [PMID: 27790216 PMCID: PMC5063843 DOI: 10.3389/fimmu.2016.00417] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 09/27/2016] [Indexed: 02/04/2023] Open
Affiliation(s)
- Giuseppe A Ramirez
- Unit of Internal Medicine and Immunology, IRCCS Ospedale San Raffaele, Milano, Italy; Università Vita-Salute San Raffaele, Milano, Italy; Division of Immunology, Transplantation and Infectious Diseases, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Angelo A Manfredi
- Unit of Internal Medicine and Immunology, IRCCS Ospedale San Raffaele, Milano, Italy; Università Vita-Salute San Raffaele, Milano, Italy; Division of Immunology, Transplantation and Infectious Diseases, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Patrizia Rovere-Querini
- Unit of Internal Medicine and Immunology, IRCCS Ospedale San Raffaele, Milano, Italy; Università Vita-Salute San Raffaele, Milano, Italy; Division of Immunology, Transplantation and Infectious Diseases, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Norma Maugeri
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS Ospedale San Raffaele , Milano , Italy
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Abstract
In recent years, the traditional view of the hemostatic system as being regulated by a coagulation factor cascade coupled with platelet activation has been increasingly challenged by new evidence that activation of the immune system strongly influences blood coagulation and pathological thrombus formation. Leukocytes can be induced to express tissue factor and release proinflammatory and procoagulant molecules such as granular enzymes, cytokines, and damage-associated molecular patterns. These mediators can influence all aspects of thrombus formation, including platelet activation and adhesion, and activation of the intrinsic and extrinsic coagulation pathways. Leukocyte-released procoagulant mediators increase systemic thrombogenicity, and leukocytes are actively recruited to the site of thrombus formation through interactions with platelets and endothelial cell adhesion molecules. Additionally, phagocytic leukocytes are involved in fibrinolysis and thrombus resolution, and can regulate clearance of platelets and coagulation factors. Dysregulated activation of leukocyte innate immune functions thus plays a role in pathological thrombus formation. Modulation of the interactions between leukocytes or leukocyte-derived procoagulant materials and the traditional hemostatic system is an attractive target for the development of novel antithrombotic strategies.
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113
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Kimball AS, Obi AT, Diaz JA, Henke PK. The Emerging Role of NETs in Venous Thrombosis and Immunothrombosis. Front Immunol 2016; 7:236. [PMID: 27446071 PMCID: PMC4921471 DOI: 10.3389/fimmu.2016.00236] [Citation(s) in RCA: 146] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 06/02/2016] [Indexed: 12/11/2022] Open
Abstract
Venous thrombosis (VT), a leading cause of morbidity and mortality worldwide, has recently been linked to neutrophil activation and release of neutrophil extracellular traps (NETs) via a process called NETosis. The use of various in vivo thrombosis models and genetically modified mice has more precisely defined the exact role of NETosis in the pathogenesis of VT. Translational large animal VT models and human studies have confirmed the presence of NETs in pathologic VT. Activation of neutrophils, with subsequent NETosis, has also been linked to acute infection. This innate immune response, while effective for bacterial clearance from the host by formation of an intravascular bactericidal "net," also triggers thrombosis. Intravascular thrombosis related to such innate immune mechanisms has been coined immunothrombosis. Dysregulated immunothrombosis has been proposed as a mechanism of pathologic micro- and macrovascular thrombosis in sepsis and autoimmune disease. In this focused review, we will address the dual role of NETs in the pathogenesis of VT and immunothrombosis.
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Affiliation(s)
- Andrew S Kimball
- Section of Vascular Surgery, Conrad Jobst Vascular Research Laboratories, Department of Surgery, University of Michigan , Ann Arbor, MI , USA
| | - Andrea T Obi
- Section of Vascular Surgery, Conrad Jobst Vascular Research Laboratories, Department of Surgery, University of Michigan , Ann Arbor, MI , USA
| | - Jose A Diaz
- Section of Vascular Surgery, Conrad Jobst Vascular Research Laboratories, Department of Surgery, University of Michigan , Ann Arbor, MI , USA
| | - Peter K Henke
- Section of Vascular Surgery, Conrad Jobst Vascular Research Laboratories, Department of Surgery, University of Michigan , Ann Arbor, MI , USA
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Moore HB, Moore EE, Liras IN, Gonzalez E, Harvin JA, Holcomb JB, Sauaia A, Cotton BA. Acute Fibrinolysis Shutdown after Injury Occurs Frequently and Increases Mortality: A Multicenter Evaluation of 2,540 Severely Injured Patients. J Am Coll Surg 2016; 222:347-55. [PMID: 26920989 DOI: 10.1016/j.jamcollsurg.2016.01.006] [Citation(s) in RCA: 195] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 01/06/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Fibrinolysis is a physiologic process that maintains microvascular patency by breaking down excessive fibrin clot. Hyperfibrinolysis is associated with a doubling of mortality. Fibrinolysis shutdown, an acute impairment of fibrinolysis, has been recognized as a risk factor for increased mortality. The purpose of this study was to assess the incidence and outcomes of fibrinolysis phenotypes in 2 urban trauma centers. STUDY DESIGN Injured patients included in the analysis were admitted between 2010 and 2013, were 18 years of age or older, and had an Injury Severity Score (ISS) > 15. Admission fibrinolysis phenotypes were determined by the clot lysis at 30 minutes (LY30): shutdown ≤ 0.8%, physiologic 0.9% to 2.9%, and hyperfibrinolysis ≥ 3%. Logistic regression was used to adjust for age, arrival blood pressure, ISS, mechanism, and facility. RESULTS There were 2,540 patients who met inclusion criteria. Median age was 39 years (interquartile range [IQR] 26 to 55 years) and median ISS was 25 (IQR 20 to 33), with a mortality rate of 21%. Fibrinolysis shutdown was the most common phenotype (46%) followed by physiologic (36%) and hyperfibrinolysis (18%). Hyperfibrinolysis was associated with the highest death rate (34%), followed by shutdown (22%), and physiologic (14%, p < 0.001). The risk of mortality remained increased for hyperfibrinolysis (odds ratio [OR] 3.3, 95% CI 2.4 to 4.6, p < 0.0001) and shutdown (OR 1.6, 95% CI 1.3 to 2.1, p = 0.0003) compared with physiologic when adjusting for age, ISS, mechanism, head injury, and blood pressure (area under the receiver operating characteristics curve 0.82, 95% CI 0.80 to 0.84). CONCLUSIONS Fibrinolysis shutdown is the most common phenotype on admission and is associated with increased mortality. These data provide additional evidence of distinct phenotypes of coagulation impairment and that individualized hemostatic therapy may be required.
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Affiliation(s)
- Hunter B Moore
- Department of Surgery, University of Colorado Denver/Denver Health Medical Center, Denver, CO.
| | - Ernest E Moore
- Department of Surgery, University of Colorado Denver/Denver Health Medical Center, Denver, CO
| | - Ioannis N Liras
- Department of Surgery, University of Texas Health Science Center at Houston/Memorial Hermann, Houston, TX
| | - Eduardo Gonzalez
- Department of Surgery, University of Colorado Denver/Denver Health Medical Center, Denver, CO
| | - John A Harvin
- Department of Surgery, University of Texas Health Science Center at Houston/Memorial Hermann, Houston, TX
| | - John B Holcomb
- Department of Surgery, University of Texas Health Science Center at Houston/Memorial Hermann, Houston, TX
| | - Angela Sauaia
- Department of Surgery, University of Colorado Denver/Denver Health Medical Center, Denver, CO
| | - Bryan A Cotton
- Department of Surgery, University of Texas Health Science Center at Houston/Memorial Hermann, Houston, TX
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