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Xiao H, Yu W, Li L, Yin X, Zhai Q, Hu D, Zhang X, Wang F. Trimester-specific reference intervals of hemostasis biomarkers for healthy pregnancy. Scand J Clin Lab Invest 2023; 83:379-383. [PMID: 37491076 DOI: 10.1080/00365513.2023.2233903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 07/02/2023] [Accepted: 07/02/2023] [Indexed: 07/27/2023]
Abstract
Physiological changes in hemostasis during pregnancy have been reported by several authors. This study aimed at establishing reference intervals for the hemostasis biomarkers thrombin-antithrombin complex (TAT), α2-plasmininhibitor-plasmin complex (PIC), thrombomodulin (TM) and tissue plasminogen activator-inhibitor complex (tPAI-C), in healthy pregnancies. After excluding outliers, a total of 496 healthy pregnant women (128 first-trimester, 142 second-trimester, 107 third-trimester and 119 pre-labor) and 103 healthy nonpregnant women were enrolled from Shenzhen Bao'an Women's and Children's Hospital. Hemostasis biomarkers, TAT, PIC, TM and tPAI-C, were measured by using a quantitative chemiluminescence enzyme immunoassay performed on HISCL automated analysers. The median and reference intervals (the 2.5th and 97.5th percentiles) were calculated to establish trimester-specific reference intervals for healthy pregnant women. The reference intervals for TAT, PIC, TM and tPAI-C in the first trimester were 0.7-7.6 1 µg/L, 0.2-0.9 mg/L, 2.8-11.0 TU/ml, and 1.2-6.5 1 µg/L, respectively. The reference intervals in the second trimester were 1.7-12.0 1 µg/L, 0.2-1.0 mg/L, 3.7-11.6 TU/ml, and 2.8-8.8 1 µg/L, respectively. The reference intervals in the third trimester were 2.7-16.1 1 µg/L, 0.1-1.4 mg/L, 2.9-12.9 TU/ml, and 1.9-8.0 1 µg/L, respectively. At pre-labor, the reference intervals were 4.8-32.9 1 µg/L, 0.2-1.9 mg/L, 4.2-12.6 TU/ml, and 2.8-15.4 1 µg/L, respectively. Gestational reference intervals for TAT, PIC, TM and tPAI-C in healthy pregnancies are provided, but only for TAT with increasing concentrations throughout pregnancy, the reference intervals for non-pregnant were not applicable.
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Affiliation(s)
- Haijun Xiao
- Shenzhen Baoan Women's and Children's Hospital, Guangdong, P.R. China
| | - Weijian Yu
- Shenzhen Baoan Women's and Children's Hospital, Guangdong, P.R. China
| | - Lihua Li
- Shenzhen Baoan Women's and Children's Hospital, Guangdong, P.R. China
| | - Xiaoqin Yin
- Shenzhen Longhua New District People's Hospital, P.R. China
| | - Qingna Zhai
- Shenzhen Baoan Women's and Children's Hospital, Guangdong, P.R. China
| | - Die Hu
- Shenzhen Baoan Women's and Children's Hospital, Guangdong, P.R. China
| | - Xiufa Zhang
- Shenzhen Baoan Women's and Children's Hospital, Guangdong, P.R. China
| | - Feng Wang
- Shenzhen Baoan Women's and Children's Hospital, Guangdong, P.R. China
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Ning XL, Shao M. Analysis of prognostic factors in patients with emergency sepsis. World J Clin Cases 2023; 11:5903-5909. [PMID: 37727482 PMCID: PMC10506019 DOI: 10.12998/wjcc.v11.i25.5903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 07/21/2023] [Accepted: 08/07/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Emergency sepsis is a common and serious infectious disease, and its prognosis is influenced by a number of factors. AIM To analyse the factors influencing the prognosis of patients with emergency sepsis in order to provide a basis for individualised patient treatment and care. By retrospectively analysing the clinical data collected, we conducted a comprehensive analysis of factors such as age, gender, underlying disease, etiology and site of infection, inflammatory indicators, multi-organ failure, cardiovascular function, therapeutic measures, immune status and severity of infection. METHODS Data collection: Clinical data were collected from patients diagnosed with acute sepsis, including basic information, laboratory findings, medical history and treatment options. Variable selection: Variables associated with prognosis were selected, including age, gender, underlying disease, etiology and site of infection, inflammatory indicators, multi-organ failure, cardiovascular function, treatment measures, immune status and severity of infection. Data analysis: The data collected are analysed using appropriate statistical methods such as multiple regression analysis and survival analysis. The impact of each factor on prognosis was assessed according to prognostic indicators, such as survival, length of stay and complication rates. RESULTS Descriptive statistics: Descriptive statistics were performed on the data collected from the patients, including their basic characteristics and clinical presentation. CONCLUSION Type 2 diabetes mellitus were independent factors affecting the prognosis of patients with sepsis.
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Affiliation(s)
- Xian-Li Ning
- Department of Emergency, Anqing Municipal Hospital, Anqing 246000, Anhui Province, China
| | - Min Shao
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei 230031, Anhui Province, China
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Zehra Naseem, Khakwani MM, Maaha Ayub, Ahmed Ayaz, Bushra Jamil, Arshad A. SARS-CoV-2 induced coagulopathy and potential role of anticoagulation: Scoping review of literature. Monaldi Arch Chest Dis 2022; 92. [PMID: 35086326 DOI: 10.4081/monaldi.2022.1958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 10/05/2021] [Indexed: 01/08/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can vary on a spectrum of asymptomatic disease to rarer manifestations like hypercoagulability especially among elderly patients admitted in the intensive care unit (ICU) and those with preexisting comorbidities. The exact mechanism behind this phenomenon is still unclear, however studies have shown an association with elevated cytokines and severe inflammatory response which encompasses this disease. Hypercoagulability can be limited to the lungs, or present as systemic manifestations of arterial and venous thrombosis leading to mortal outcomes. Thus, careful evaluation of risk factors should be performed by physicians and treatment with anticoagulants should be modified accordingly. All Coronavirus Disease 2019 (COVID-19) in-patients should receive thromboprophylactic therapy, with increased dosages administered to patients with increased disease severity or those with a high risk. D-dimer levels and sepsis-induced coagulopathy (SIC) score aid in identifying high risk patients and predicting outcome. This article highlights the pathophysiology behind hypercoagulability, its clinical associations and discusses therapeutic modalities to combat this fatal consequence of SARS-CoV-2.
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Affiliation(s)
| | | | - Maaha Ayub
- Medical College, Aga Khan University, Karachi.
| | - Ahmed Ayaz
- Medical College, Aga Khan University, Karachi.
| | - Bushra Jamil
- Department of Medicine, Aga Khan University, Karachi.
| | - Ainan Arshad
- Department of Medicine, Aga Khan University, Karachi.
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Takayama W, Endo A, Morishita K, Otomo Y. Dielectric Blood Coagulometry for the Early Detection of Sepsis-Induced Disseminated Intravascular Coagulation: A Prospective Observational Study. Crit Care Med 2022; 50:e31-e39. [PMID: 34369427 PMCID: PMC8670337 DOI: 10.1097/ccm.0000000000005231] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate the utility of dielectric blood coagulometry for early sepsis-induced disseminated intravascular coagulation diagnosis. DESIGN Single-center, prospective observational study. SETTING Patients with sepsis or septic shock at the Tokyo Medical and Dental University Hospital of Medicine between September 2019 and September 2020. PATIENTS The patients were divided into three groups according to the timing of disseminated intravascular coagulation diagnosis based on the Disseminated Intravascular Coagulation score by the Japanese Association for Acute Medicine: 1) no disseminated intravascular coagulation group, 2) late-diagnosed disseminated intravascular coagulation group: not diagnosed with disseminated intravascular coagulation on day 1 but diagnosed within 48 hours after admission, and 3) disseminated intravascular coagulation group: diagnosed with disseminated intravascular coagulation on day 1. The study evaluated 80 patients (no disseminated intravascular coagulation, 31 [38.8%]; late-diagnosed disseminated intravascular coagulation, 34 (42.5%); disseminated intravascular coagulation, 15 [18.8%]). MEASUREMENTS AND MAIN RESULTS We compared the clinical severity scores and mortality of the groups and assessed the correlation between the dielectric blood coagulometry-derived coagulation marker, thrombin levels, and Disseminated Intravascular Coagulation score using Spearman rank correlation. The mortality rate was 0% (0/31) in the no disseminated intravascular coagulation group, 35.3% (12/34) in the late-diagnosed disseminated intravascular coagulation group, and 33.3% (5/15) in the disseminated intravascular coagulation group. Although the Disseminated Intravascular Coagulation score on day 1 did not reflect disseminated intravascular coagulation in approximately 70% of patients who developed disseminated intravascular coagulation by day 2, dielectric clot strength measured by dielectric blood coagulometry on day 1 strongly correlated with disseminated intravascular coagulation development by day 2 (Spearman ρ = 0.824; p < 0.05) and with thrombin level on day 1 (Spearman ρ = 0.844; p < 0.05). CONCLUSIONS Dielectric blood coagulometry can be used to detect early-phase disseminated intravascular coagulation in patients with sepsis and is strongly correlated with thrombin levels. Larger studies are needed to verify our results for developing clinical applications.
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Affiliation(s)
- Wataru Takayama
- Department of Acute Critical Care and Disaster Medicine, Graduate School of Tokyo Medical and Dental University, Tokyo Medical and Dental University, Tokyo, Japan
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - Akira Endo
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - Koji Morishita
- Department of Acute Critical Care and Disaster Medicine, Graduate School of Tokyo Medical and Dental University, Tokyo Medical and Dental University, Tokyo, Japan
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - Yasuhiro Otomo
- Department of Acute Critical Care and Disaster Medicine, Graduate School of Tokyo Medical and Dental University, Tokyo Medical and Dental University, Tokyo, Japan
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
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Platelet Inhibition Prevents NLRP3 Inflammasome Activation and Sepsis-Induced Kidney Injury. Int J Mol Sci 2021; 22:ijms221910330. [PMID: 34638670 PMCID: PMC8508664 DOI: 10.3390/ijms221910330] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 09/20/2021] [Accepted: 09/23/2021] [Indexed: 01/20/2023] Open
Abstract
Platelets, cellular mediators of thrombosis, are activated during sepsis and are increasingly recognized as mediators of the immune response. Platelet activation is significantly increased in sepsis patients compared to ICU control patients. Despite this correlation, the role of activated platelets in contributing to sepsis pathophysiology remains unclear. We previously demonstrated NOD-like receptor protein 3 inflammasome (NLRP3) inflammasome activation in sepsis-induced platelets from cecal-ligation puncture (CLP) rats. Activated platelets were associated with increased pulmonary edema and glomerular injury in CLP vs. SHAM controls. In this study, we investigated whether inhibition of platelet activation would attenuate NLRP3 activation and renal and pulmonary injury in response to CLP. CLP was performed in male and female Sprague Dawley (SD) rats (n = 10/group) to induce abdominal sepsis and SHAM rats served as controls. A subset of CLP animals was treated with Clopidogrel (10 mg/kg/day, CLP + CLOP) to inhibit platelet activation. At 72 h post-CLP, platelet activation and NLRP3 inflammasome assembly were evaluated, IL-1β and IL-18 were measured in plasma, and tissues, renal and pulmonary pathology, and renal function were assessed. Activated platelets were 7.8 ± 3.6% in Sham, 22 ± 6% in CLP and significantly decreased to 14.5 ± 0.6% in CLP + CLOP (n = 8–10/group, p < 0.05). NLRP3 inflammasome assembly was inhibited in platelets of CLP + CLOP animals vs. CLP. Significant increases in plasma and kidney IL-1β and IL-18 in response to CLP were decreased with Clopidogrel treatment. Renal injury, but not lung histology or renal function was improved in CLP + CLOP vs. CLP. These data provide evidence that activated platelets may contribute to sepsis-induced renal injury, possibly via NLRP3 activation in platelets. Platelets may be a therapeutic target to decrease renal injury in septic patients.
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Evlakhov VI, Poiasov IZ. [Spontaneous fibrinolysis and possibilities of its acceleration in pulmonary embolism]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:25-31. [PMID: 34166341 DOI: 10.33529/angio2021207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
This review contains the data concerning the mechanisms of spontaneous fibrinolysis in pulmonary vessels and possibilities of its acceleration in pulmonary embolism. The spontaneous fibrinolysis system is known to be sequential and multifactorial, with the interaction of accelerators (t-PA and u-PA) and inhibitors (alpha-2-antiplasmin, PAI-1, TAFI). The fibrinolytic processes take place in case of prevailing reactions of accelerating factors over inhibiting ones. The endothelium of pulmonary vessels possesses pronounced antithrombogenic and profibrinolytic properties, therefore, the processes of fibrinolysis in the pulmonary vascular bed normally occur more intensively than in the vessels of the systemic circulation. The membrane proteins of the endothelium annexins A2 activate plasminogen, whereas thrombomodulin inhibits the activity of PAI-1. The main approaches to increase the fibrinolysis intensity in conditions of pulmonary embolism may be aimed at elevating the activity of fibrinolytic enzymes (enhancing the synthesis of annexins A2, the use of NMDA-receptor antagonists) and suppressing its inhibitors (the use of monoclonal antibodies to alpha-2-antiplasmin, as well as plasminogen activator inhibitor-1 (PAI-1) and thrombin-activatable fibrinolysis inhibitor (TAFI). Promising directions for future research can be the synthesis of a new generation of tissue-type plasminogen activators, and investigations of the possibility of clinical application of antithrombin and thrombomodulin, angiotensin converting enzyme inhibitors and cortisol antagonists. To meet these challenges, it is necessary to develop new models of venous thrombosis and acute pulmonary embolism in different animal species, with the assessment of the changes in the venous haemodynamics and pulmonary microcirculation on the background of administration of a new class of fibrinolytic agents.
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Affiliation(s)
- V I Evlakhov
- Laboratory of Physiology of Visceral Systems named after Academician K.M. Bykov, Institute of Experimental Medicine, Saint Petersburg, Russia
| | - I Z Poiasov
- Laboratory of Physiology of Visceral Systems named after Academician K.M. Bykov, Institute of Experimental Medicine, Saint Petersburg, Russia
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Giustozzi M, Ehrlinder H, Bongiovanni D, Borovac JA, Guerreiro RA, Gąsecka A, Papakonstantinou PE, Parker WAE. Coagulopathy and sepsis: Pathophysiology, clinical manifestations and treatment. Blood Rev 2021; 50:100864. [PMID: 34217531 DOI: 10.1016/j.blre.2021.100864] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/31/2021] [Accepted: 06/22/2021] [Indexed: 12/13/2022]
Abstract
Sepsis is a complex syndrome with a high incidence, increasing by 8.7% annually over the last 20 years. Coagulopathy is a leading factor associated with mortality in patients with sepsis and range from slight thrombocytopenia to fatal disorders, such as disseminated intravascular coagulation (DIC). Platelet reactivity increases during sepsis but prospective trials of antiplatelet therapy during sepsis have been disappointing. Thrombocytopenia is a known predictor of worse prognosis during sepsis. The mechanisms underlying thrombocytopenia in sepsis have yet to be fully understood but likely involves decreased platelet production, platelet sequestration and increased consumption. DIC is an acquired thrombohemorrhagic syndrome, resulting in intravascular fibrin formation, microangiopathic thrombosis, and subsequent depletion of coagulation factors and platelets. DIC can be resolved with treatment of the underlying disorder, which is considered the cornerstone in the management of this syndrome. This review presents the current knowledge on the pathophysiology, diagnosis, and treatment of sepsis-associated coagulopathies.
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Affiliation(s)
- Michela Giustozzi
- Internal Vascular and Emergency Medicine and Stroke Unit, University of Perugia, Perugia, Italy.
| | - Hanne Ehrlinder
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Dario Bongiovanni
- Technical University of Munich, School of Medicine, University hospital rechts der Isar, Department of Internal Medicine I, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany; Department of Cardiovascular Medicine, Humanitas Clinical and Research Center IRCCS and Humanitas University, Rozzano, Milan, Italy
| | - Josip A Borovac
- Department of Pathophysiology, University of Split School of Medicine, Split, Croatia; Clinic for Cardiovascular Diseases, University Hospital of Split (KBC Split), Split, Croatia
| | | | - Aleksandra Gąsecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Panteleimon E Papakonstantinou
- Second Cardiology Department, Evangelismos Hospital, Athens, Greece; Hypertension Unit "ESH Excellence Centre", First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - William A E Parker
- Cardiovascular Research Unit, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
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Fan YW, Liu D, Chen JM, Li WJ, Gao CJ. Fluctuation in red cell distribution width predicts disseminated intravascular coagulation morbidity and mortality in sepsis: a retrospective single-center study. Minerva Anestesiol 2021; 87:52-64. [PMID: 33538418 DOI: 10.23736/s0375-9393.20.14420-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Red cell distribution width (RDW) values increase in many diseases and conditions, including sepsis. However, the relationship between RDW fluctuation and prognosis in patients with sepsis or the likely morbidity associated with sepsis-induced disseminated intravascular coagulation (DIC) has not been previously investigated. This study examined the association between dynamic changes to RDW and DIC occurrence in sepsis, as well as the prognostic significance of changes to RDW during hospital stay in patients with sepsis. METHODS We collected baseline emergency department admissions' data. All RDW values recorded during hospitalization of patients with sepsis were combined to calculate RDW standard deviation (RDW-SD) and the increase rate of RDW; we also collected data on coagulation indicators. The endpoints were 28-day mortality and sepsis-related DIC morbidity. RESULTS Of 232 patients included in our analysis, 66 were diagnosed with DIC (28.4%), and 86 (37.1%) died within 28 days. The RDW-SD and the increase rate of RDW were independent risk factors for 28-day mortality and sepsis-associated DIC morbidity, respectively. The DIC occurrence and mortality rate increased continually with an increasing rate of RDW of at least 6%. CONCLUSIONS The RDW-SD and RDW increase rate shown in the study as the indicators of RDW fluctuation can help predict sepsis-related DIC morbidity and prognosis in patients with sepsis.
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Affiliation(s)
- Yi W Fan
- Department of Emergency, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dan Liu
- Department of Emergency, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jia M Chen
- Department of Emergency, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wen J Li
- Department of Emergency, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Cheng J Gao
- Department of Emergency, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China -
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Weng J, Chen M, Fang D, Liu D, Guo R, Yang S. Therapeutic Plasma Exchange Protects Patients with Sepsis-Associated Disseminated Intravascular Coagulation by Improving Endothelial Function. Clin Appl Thromb Hemost 2021; 27:10760296211053313. [PMID: 34775801 PMCID: PMC8597066 DOI: 10.1177/10760296211053313] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/12/2021] [Accepted: 09/27/2021] [Indexed: 11/16/2022] Open
Abstract
The mortality rate of sepsis-associated disseminated intravascular coagulation (DIC) is high. This study aimed to explore the efficacy of therapeutic plasma exchange (TPE) in sepsis-associated DIC patients by improving endothelial function. A total of 112 sepsis-associated DIC patients were randomly divided into the TPE group (n = 40), the heparin (HP) group (n = 36), and the SHAM group (n = 36). The SHAM group received conventional treatment; the HP group was treated with HP based on conventional treatment; and the TPE group received conventional treatment plus TPE. The differences in thromboelastogram (TEG), platelet (PLT), coagulation function, and the endothelial cell (EC) injury biomarkers at 6 h, 24 h, 48 h, 72 h, and 7 days after TPE were compared among the three groups, and the three groups were compared in terms of Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Sepsis-Related Organ Failure Assessment (SOFA) score, the length of intensive care unit (ICU) hospitalization, 28-day mortality rate, 28-day cumulative survival rate, the incidence of bleeding events, the incidence of acute kidney injury (AKI), and acute respiratory distress syndrome (ARDS). The efficacy of TPE is superior to the HP in increasing PLT, improving coagulation function, increasing the 28-day cumulative survival rate, and reducing the length of ICU hospitalization, 28-day mortality, and the incidence of bleeding events, AKI, and ARDS with statistically significant differences (P < .05). Moreover, the effect of TPE outperforms HP on the EC injury biomarkers with statistically significant differences (P < .05). Our results suggest that TPE may be more effective than HP in the treatment of patients with sepsis-associated DIC. The possible mechanism is via improving endothelial function.
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Affiliation(s)
- Junting Weng
- Affiliated Hospital of Putian University, Putian, China
| | - Min Chen
- Affiliated Hospital of Putian University, Putian, China
| | - Dexiang Fang
- Affiliated Hospital of Putian University, Putian, China
| | - Danjuan Liu
- Affiliated Hospital of Putian University, Putian, China
| | - Rongjie Guo
- Affiliated Hospital of Putian University, Putian, China
| | - Shuzhen Yang
- Affiliated Hospital of Putian University, Putian, China
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Görlinger K, Dirkmann D, Gandhi A, Simioni P. COVID-19-Associated Coagulopathy and Inflammatory Response: What Do We Know Already and What Are the Knowledge Gaps? Anesth Analg 2020; 131:1324-1333. [PMID: 33079850 PMCID: PMC7389937 DOI: 10.1213/ane.0000000000005147] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Patients with coronavirus disease 2019 (COVID-19) frequently experience a coagulopathy associated with a high incidence of thrombotic events leading to poor outcomes. Here, biomarkers of coagulation (such as D-dimer, fibrinogen, platelet count), inflammation (such as interleukin-6), and immunity (such as lymphocyte count) as well as clinical scoring systems (such as sequential organ failure assessment [SOFA], International Society on Thrombosis and Hemostasis disseminated intravascular coagulation [ISTH DIC], and sepsis-induced coagulopathy [SIC] score) can be helpful in predicting clinical course, need for hospital resources (such as intensive care unit [ICU] beds, intubation and ventilator therapy, and extracorporeal membrane oxygenation [ECMO]) and patient's outcome in patients with COVID-19. However, therapeutic options are actually limited to unspecific supportive therapy. Whether viscoelastic testing can provide additional value in predicting clinical course, need for hospital resources and patient's outcome or in guiding anticoagulation in COVID-19-associated coagulopathy is still incompletely understood and currently under investigation (eg, in the rotational thromboelastometry analysis and standard coagulation tests in hospitalized patients with COVID-19 [ROHOCO] study). This article summarizes what we know already about COVID-19-associated coagulopathy and-perhaps even more importantly-characterizes important knowledge gaps.
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Affiliation(s)
- Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany, and Medical Director, Tem Innovations GmbH, Martin-Kollar-Strasse 15, 81829 Munich, Germany, mobile: +49 1726596069, e-mail:
| | - Daniel Dirkmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany, mobile: +49 201 723 84423,
| | - Ajay Gandhi
- Clinical Affairs, Instrumentation Laboratory India Private Limited, New Delhi, India, 1471-76, Agrawal Millennium Tower II, Plot Number E-4, Netaji Subhash Place, Pitampura, New Delhi, India 110034, mobile: +91 9826870517, e-mail:
| | - Paolo Simioni
- General Internal Medicine and Thrombotic and Haemorrhagic Diseases Units, Department of Medicine, Padova University Hospital, Via Ospedale Civile 105, 35100 Padova, Italy, phone: +39 0498212667, e-mail:
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11
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Cui S, Chen S, Li X, Liu S, Wang F. Prevalence of venous thromboembolism in patients with severe novel coronavirus pneumonia. J Thromb Haemost 2020; 18:1421-1424. [PMID: 32271988 PMCID: PMC7262324 DOI: 10.1111/jth.14830] [Citation(s) in RCA: 1293] [Impact Index Per Article: 323.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 04/04/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Three months ago, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) broke out in Wuhan, China, and spread rapidly around the world. Severe novel coronavirus pneumonia (NCP) patients have abnormal blood coagulation function, but their venous thromboembolism (VTE) prevalence is still rarely mentioned. OBJECTIVES To determine the incidence of VTE in patients with severe NCP. METHODS In this study, 81 severe NCP patients in the intensive care unit (ICU) of Union Hospital (Wuhan, China) were enrolled. The results of conventional coagulation parameters and lower limb vein ultrasonography of these patients were retrospectively collected and analyzed. RESULTS The incidence of VTE in these patients was 25% (20/81), of which 8 patients with VTE events died. The VTE group was different from the non-VTE group in age, lymphocyte counts, activated partial thromboplastin time (APTT), D-dimer, etc. If 1.5 µg/mL was used as the D-dimer cut-off value to predicting VTE, the sensitivity was 85.0%, the specificity was 88.5%, and the negative predictive value (NPV) was 94.7%. CONCLUSIONS The incidence of VTE in patients with severe NCP is 25% (20/81), which may be related to poor prognosis. The significant increase of D-dimer in severe NCP patients is a good index for identifying high-risk groups of VTE.
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Affiliation(s)
- Songping Cui
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Shuo Chen
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xiunan Li
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Shi Liu
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Feng Wang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Respiratory Medicine, Beijing, China
- Beijing Engineering Research Center for Diagnosis and Treatment of Respiratory and Critical Care Medicine (Beijing Chao-Yang Hospital), Beijing, China
- Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China
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12
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Wang Y, Wang H, Zhang C, Zhang C, Yang H, Gao R, Tong Z. Plasma Hsa-miR-92a-3p in correlation with lipocalin-2 is associated with sepsis-induced coagulopathy. BMC Infect Dis 2020; 20:155. [PMID: 32075600 PMCID: PMC7031893 DOI: 10.1186/s12879-020-4853-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 02/06/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Sepsis is a life-threatening situation, and it can be rendered more severe by coagulopathy. We here examine a novel plasma biomarker for sepsis-induced coagulopathy. METHODS A total of 116 patients diagnosed with sepsis were recruited and divided into two groups by whether they also had coagulopathy. Plasma samples were collected on arrival at the intensive care unit. Fifteen sepsis-alone and 15 sepsis-induced coagulopathy plasma samples were mixed and sent for microRNA sequencing. Differently expressed microRNAs were then validated by quantitative reverse transcriptase polymerase chain reaction in 52 sepsis-alone and 34 sepsis-induced coagulopathy patients; plasma lipocalin-2 was measured as well. RESULTS Four microRNAs were selected from microRNA sequencing. Only hsa-mir-92a-3p was differently expressed in the validation set. Its level of expression was significantly lower in sepsis-induced coagulopathy group. Hsa-mir-92a-3p had an area under a receiver operating characteristic curve of 0.660 (95% confidence interval, 0.537, 0.782). The plasma Hsa-mir-92a-3p level was related to activated partial thromboplastin time, prothrombin activity, and plasma lipocalin-2 level. A binary logistic model showed an association between hsa-mir-92a-3p and fibrinogen with SIC. CONCLUSIONS The utility of hsa-mir-92a-3p as a biomarker for sepsis-induced coagulopathy needs more verification, and the regulatory mechanism of hsa-mir-92a-3p in coagulation disorder and its potency as a therapeutic target must be confirmed.
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Affiliation(s)
- Yishan Wang
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, NO. 8, Gong Ti South Road, Chao-Yang District, Beijing, 100020, China
| | - Huijuan Wang
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, NO. 8, Gong Ti South Road, Chao-Yang District, Beijing, 100020, China
| | - Chunfang Zhang
- Department of Anesthesiology, Pain Medicine and Critical Care Medicine, Aviation General Hospital of China Medical University and Beijing Institute of Translational Medicine, Chinese Academy of Sciences, Beijing, 100012, China
| | - Chao Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, NO. 8, Gong Ti South Road, Chao-Yang District, Beijing, 100020, China
| | - Huqin Yang
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, NO. 8, Gong Ti South Road, Chao-Yang District, Beijing, 100020, China
| | - Ruiyue Gao
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, NO. 8, Gong Ti South Road, Chao-Yang District, Beijing, 100020, China
| | - Zhaohui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, NO. 8, Gong Ti South Road, Chao-Yang District, Beijing, 100020, China.
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13
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Yokoyama N, Takaki S, Yokose M, Kuwabara K, Anzai A, Hamada T, Kashiwagi S, Okamura K, Sugawara Y, Goto T. A question is "what are the optimal targets for anticoagulant therapies?". J Intensive Care 2020; 8:17. [PMID: 32082581 PMCID: PMC7020550 DOI: 10.1186/s40560-020-0434-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 01/23/2020] [Indexed: 12/12/2022] Open
Abstract
A high mortality rate is found among septic patients with disseminated intravascular coagulation (DIC). Anticoagulants have been used for treating septic DIC especially in Japanese clinical settings; however, their effectiveness is quite controversial across studies. According to several randomized controlled trials and meta-analyses, antithrombin and recombinant thrombomodulin had no therapeutic benefit in the treatment of sepsis. However, the majority of the previous research did not discuss “septic DIC” but simply “sepsis”, and some reviews showed that anticoagulants were benefit only in septic DIC. Although immunothrombosis plays an important role in early host defense, it can lead to DIC and organ failure if dysregulated. Therefore, we advocate anticoagulant therapies might have beneficial effects, but research on optimal patient selection is currently lacking.
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Affiliation(s)
- Nobuyuki Yokoyama
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, 3-9 Fukuura Kanazawaku, Yokohama, Kanagawa 236-0004 Japan
| | - Shunsuke Takaki
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, 3-9 Fukuura Kanazawaku, Yokohama, Kanagawa 236-0004 Japan
| | - Masashi Yokose
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, 3-9 Fukuura Kanazawaku, Yokohama, Kanagawa 236-0004 Japan
| | - Kaori Kuwabara
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, 3-9 Fukuura Kanazawaku, Yokohama, Kanagawa 236-0004 Japan
| | - Akiko Anzai
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, 3-9 Fukuura Kanazawaku, Yokohama, Kanagawa 236-0004 Japan
| | - Takako Hamada
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, 3-9 Fukuura Kanazawaku, Yokohama, Kanagawa 236-0004 Japan
| | - Shizuka Kashiwagi
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, 3-9 Fukuura Kanazawaku, Yokohama, Kanagawa 236-0004 Japan
| | - Kenta Okamura
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, 3-9 Fukuura Kanazawaku, Yokohama, Kanagawa 236-0004 Japan
| | - Yoh Sugawara
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, 3-9 Fukuura Kanazawaku, Yokohama, Kanagawa 236-0004 Japan
| | - Takahisa Goto
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, 3-9 Fukuura Kanazawaku, Yokohama, Kanagawa 236-0004 Japan
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14
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Thachil J. Managing sepsis-associated coagulopathy remains an enigma. J Thromb Haemost 2019; 17:1586-1589. [PMID: 31376202 DOI: 10.1111/jth.14590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 07/23/2019] [Accepted: 07/23/2019] [Indexed: 01/08/2023]
Affiliation(s)
- Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
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15
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Ito T, Thachil J, Asakura H, Levy JH, Iba T. Thrombomodulin in disseminated intravascular coagulation and other critical conditions-a multi-faceted anticoagulant protein with therapeutic potential. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:280. [PMID: 31416465 PMCID: PMC6694689 DOI: 10.1186/s13054-019-2552-0] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 07/23/2019] [Indexed: 12/11/2022]
Abstract
Thrombomodulin plays a vital role in maintaining intravascular patency due to its anticoagulant, antiinflammatory, and cytoprotective properties. However, under pathological conditions such as sepsis and systemic inflammation, endothelial thrombomodulin expression is downregulated and its function impaired. As a result, administering thrombomodulin represents a potential therapeutic modality. Recently, the effect of recombinant thrombomodulin administration in sepsis-induced coagulopathy was evaluated in a randomized controlled study (SCARLET). A 2.6% 28-day absolute mortality reduction (26.8% vs. 29.4%) was reported in 800 patients studied that was not statistically significant; however, a post hoc analysis revealed a 5.4% absolute mortality reduction among the patients who fulfilled the entry criterion at baseline. The risk of bleeding did not increase compared to placebo control. Favorable effects of thrombomodulin administration have been reported not only in sepsis-induced coagulopathy but also in disseminated intravascular coagulations with various backgrounds. Interestingly, beneficial effects of recombinant thrombomodulin in respiratory, renal, and cardiovascular diseases might depend on its anti-inflammatory mechanisms. In this review, we summarize the accumulated knowledge of endogenous as well as recombinant thrombomodulin from basic to clinical aspects and suggest future directions for this novel therapeutic agent.
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Affiliation(s)
- Takashi Ito
- Department of Systems Biology in Thromboregulation, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8544, Japan.
| | - Jecko Thachil
- Department of Haematology, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Hidesaku Asakura
- Third Department of Internal Medicine, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care and Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
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16
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Ebina M, Fujino K, Inoue A, Ariyoshi K, Eguchi Y. Effects of Serum Albumin Levels on Antithrombin Supplementation Outcomes Among Patients With Sepsis-Associated Coagulopathy: A Retrospective Study. PLASMATOLOGY 2019; 12:1179545X19858361. [PMID: 31258337 PMCID: PMC6589945 DOI: 10.1177/1179545x19858361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 05/24/2019] [Indexed: 01/13/2023]
Abstract
Background Severe sepsis is commonly associated with mortality among critically ill patients and is known to cause coagulopathy. While antithrombin is an anticoagulant used in this setting, serum albumin levels are known to influence serum antithrombin levels. Therefore, this study aimed to evaluate the outcomes of antithrombin supplementation in patients with sepsis-associated coagulopathy, as well as the relationship between serum albumin levels and the effects of antithrombin supplementation. Methods This retrospective study evaluated patients who were >18 years of age and had been admitted to either of two intensive care units for sepsis-associated coagulopathy. The groups that did and did not receive antithrombin supplementation were compared for outcomes up to 1 year after admission. Subgroup analyses were performed for patients with serum albumin levels of <2.5 g/dL or ⩾2.5 g/dL. Results Fifty-one patients received antithrombin supplementation and 163 patients did not. The Cox proportional hazards model revealed that antithrombin supplementation was independently associated with 28-day survival (hazard ratio [HR]: 0.374, P = 0.025) but not with 1 year survival (HR: 0.915, P = 0.752). In addition, among patients with serum albumin levels of <2.5 g/dL, antithrombin supplementation was associated with a significantly lower 28-day mortality rate (9.4% vs 36.8%, P = .009). Conclusion Antithrombin supplementation may improve short-term survival, but not long-term survival, among patients with sepsis-associated coagulopathy.
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Affiliation(s)
- Masatomo Ebina
- Department of Emergency Medicine and Intensive Care, Shiga University of Medical Science, Otsu, Japan
| | - Kazunori Fujino
- Department of Emergency Medicine and Intensive Care, Shiga University of Medical Science, Otsu, Japan
| | - Akira Inoue
- Department of Emergency Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Koichi Ariyoshi
- Department of Emergency Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yutaka Eguchi
- Department of Emergency Medicine and Intensive Care, Shiga University of Medical Science, Otsu, Japan
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17
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Iba T, Umemura Y, Watanabe E, Wada T, Hayashida K, Kushimoto S. Diagnosis of sepsis-induced disseminated intravascular coagulation and coagulopathy. Acute Med Surg 2019; 6:223-232. [PMID: 31304023 PMCID: PMC6603393 DOI: 10.1002/ams2.411] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 03/05/2019] [Indexed: 12/26/2022] Open
Abstract
Disseminated intravascular coagulation (DIC) is a frequent complication in sepsis. Once patients develop DIC, the mortality rate increases significantly. Moreover, recent studies have suggested that coagulation disorder plays a significant role in the development of organ dysfunction in sepsis. Thus, the early detection of DIC is vital in sepsis care, and the Japanese Association for Acute Medicine established a set of original diagnostic criteria in 2006 (JAAM DIC). Since then, the usefulness of the JAAM DIC has been repeatedly reported, and these criteria have been widely adopted in emergency and critical care settings in Japan. Different criteria have also been released by the International Society on Thrombosis and Haemostasis (ISTH overt-DIC), and the latter criteria are presently considered to be the international standard. Compared with the JAAM DIC, the ISTH overt-DIC criteria are stricter and the timing of diagnosis is later. This discrepancy is because of conceptual differences. As many physicians think sepsis-associated DIC is the target of anticoagulant therapies in Japan, the JAAM DIC criteria were designed to allow the early initiation of treatment. As other countries do not provide DIC-specific treatments, early diagnosis is not necessary, and this situation has led to a significant gap. However, as overt-DIC is a late-phase coagulation disorder, a need for early detection has been advocated, and members of the ISTH have recently proposed the category of sepsis-induced coagulopathy. In this review, we introduce the strengths and weaknesses of the major criteria including JAAM-DIC, ISTH overt-DIC, sepsis-induced coagulopathy, and Japanese Society on Thrombosis and Haemostasis-DIC.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster MedicineJuntendo University Graduate School of MedicineTokyoJapan
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical MedicineOsaka University Graduate School of MedicineOsakaJapan
| | - Eizo Watanabe
- Department of General Medical Science Graduate School of MedicineChiba UniversityChiba CityJapan
- Department of Emergency and Critical Care MedicineEastern Chiba Medical CenterChibaJapan
| | - Takeshi Wada
- Department of Anesthesiology and Critical Care MedicineDivision of Acute and Critical Care MedicineHokkaido University Graduate School of MedicineSapporoJapan
| | - Kei Hayashida
- Department of Emergency and Critical Care MedicineSchool of MedicineKeio UniversityTokyoJapan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care MedicineTohoku University Graduate School of MedicineSendaiJapan
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18
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Ozden MGN, Koksal G, Oz H. Comparison of Antithrombin III and Pentoxifylline Treatments in Gram Negative Sepsis Patients Developing Disseminated Intravascular Coagulation. Medeni Med J 2019; 34:233-238. [PMID: 32821443 PMCID: PMC7433740 DOI: 10.5222/mmj.2019.05935] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 07/24/2019] [Indexed: 12/12/2022] Open
Abstract
Objective: The aim of this study was to evaluate the effects of antithrombin III (AT III) and pentoxifylline treatments on the gram negative septic patients with disseminated intravascular coagulation (DIC). Method: For six days after plasma AT III activity dropped lower than 80% in Gram-patients who developed DIC were treated with AT III (90-120 IU/kg/day in 6 hours) or pentoxifylline (1.5 mg/kg/h in 6 hours) Fibrinogen, FDP, D-dimer, complete blood count, AT III activity, and DIC scores were calculated and recorded. Results: The coagulation tests, AT III activity and FDP started to improve from the second day of treatment with both treatments (p<0.05). D-Dimer started to decrease on the second day of treatment with pentoxifylline (p<0.001) and fourth day of AT III treatment (p<0.05). Fibrinogen levels decreased on the second day of pentoxifylline treatment (p<0.05) and on the last day of AT III treatment (p<0.001). DIC scores started to decrease on the last day of treatment with AT III treatment (p<0.001) and on the third day of treatment with pentoxifylline (p<0.05). Conclusion: Both ATIII and pentoxifylline treatments had positive effects on fibrinogen, FDP, D-Dimer, AT III activity and DIC scores in patients with Gram-negative sepsis who developed DIC.
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Affiliation(s)
- Mesure Gul Nihan Ozden
- Istanbul Medeniyet University Göztepe Training and Research Hospital, Department of Anesthesiology and Reanimation, Istanbul, Turkey
| | - Guniz Koksal
- Istanbul University Cerrahpasa, Medical Faculty, Department of Anesthesiology and Reanimation, Istanbul, Turkey
| | - Huseyin Oz
- Istanbul Medipol University, Department of Anesthesiology and Reanimation, Istanbul, Turkey
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19
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Comparison of gabexate mesilate and nafamostat mesilate for disseminated intravascular coagulation associated with hematological malignancies. Int J Hematol 2018; 109:141-146. [PMID: 30536180 DOI: 10.1007/s12185-018-02567-w] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 11/28/2018] [Accepted: 11/29/2018] [Indexed: 10/27/2022]
Abstract
We evaluated clinical outcomes of disseminated intravascular coagulation (DIC) in patients with hematological malignancies treated with synthetic protease inhibitors (SPIs) and compared the effects of gabexate mesilate (FOY) and nafamostat mesilate (FUT). We retrospectively examined 127 patients [acute myeloid leukemia (n = 48), acute lymphoblastic leukemia (n = 25), and non-Hodgkin lymphoma (n = 54)] with DIC, who were diagnosed according to Japanese Ministry of Health, Labour and Welfare criteria and treated with SPIs [FOY (n = 55) and FUT (n = 72)] at our hospital from 2006 to 2015. The DIC resolution rates on days 7 and 14 were 42.6% and 62.4%, respectively. No significant differences were observed in DIC resolution rates between the FUT and FOY groups [40.3% vs. 45.5% (day 7), P = 0.586; 56.3% vs. 69.8% (day 14), P = 0.179, respectively]. Multivariate analysis revealed that response to chemotherapy was the only independent predictor of DIC resolution on days 7 and 14 (ORR 2.81, 95% CI 1.32-5.98, P = 0.007; ORR 2.51, 95% CI 1.12-5.65, P = 0.026). Resolution of DIC was correlated with improvement of background hematological malignancies, and no significant differences were observed between the two SPIs.
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20
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Mochizuki K, Mori K, Nakamura Y, Uchimido R, Kamijo H, Takeshige K, Nitta K, Imamura H. Early Changes in the Sequential Organ Failure Assessment Score Among Patients With Sepsis-Induced Disseminated Intravascular Coagulation. Clin Appl Thromb Hemost 2018; 24:332S-339S. [PMID: 30486666 PMCID: PMC6714847 DOI: 10.1177/1076029618814346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
It is unclear whether initial infection control or anticoagulant therapy exerts a greater
effect on early changes in the Sequential Organ Failure Assessment (SOFA) score among
patients with sepsis-induced disseminated intravascular coagulation (DIC). This
retrospective propensity score cohort study aimed to evaluate whether adequacy of
infection control or anticoagulation therapy had a greater effect on early changes in the
SOFA scores among 52 patients with sepsis-induced DIC. Inadequate initial infection
control was associated with a lower 28-day survival rate among patients with
sepsis-induced DIC (odds ratio [OR]: 0.116, 95% confidence interval [CI]: 0.022-0.601;
P = .010); however, the adequacy was not associated with an early
improvement in the SOFA score. However, despite adjusting for inadequate initial infection
control, administration of recombinant human soluble thrombomodulin was associated with an
early improvement in the SOFA score (OR: 5.058, 95% CI: 1.047-24.450; P =
.044). Therefore, early changes in the SOFA score within 48 hours after the DIC diagnosis
were more strongly affected by the administration of recombinant human soluble
thrombomodulin than the adequacy of initial infection control.
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Affiliation(s)
- Katsunori Mochizuki
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kotaro Mori
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yuta Nakamura
- Department of Emergency Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Ryo Uchimido
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Hiroshi Kamijo
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kanako Takeshige
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kenichi Nitta
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hiroshi Imamura
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Matsumoto, Japan
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21
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Iba T, Arakawa M, Ohchi Y, Arai T, Sato K, Wada H, Levy JH. Prediction of Early Death in Patients With Sepsis-Associated Coagulation Disorder Treated With Antithrombin Supplementation. Clin Appl Thromb Hemost 2018; 24:145S-149S. [PMID: 30198317 PMCID: PMC6714842 DOI: 10.1177/1076029618797474] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
For success in clinical trials, eliminating inclusion of patients with irreversible
recovery is important. The purpose of this study was to identify the patient population
who do not survive for more than 3 days. A total of 449 patients with sepsis suspected of
having disseminated intravascular coagulation (DIC) and treated with antithrombin were
examined. The patient characteristics, baseline sequential organ failure assessment (SOFA)
score, DIC score, and hemostatic markers were retrospectively analyzed in relation to
early death (died within 3 days). At the end of day 3, a total of 419 patients had
survived and 30 patients had died. A logistic regression analysis revealed a significant
association between early death and the baseline prothrombin time-international normalized
ratio PT-INR (P <.05) and the total SOFA score (P
<.01). In contrast, neither the platelet count, fibrinogen/fibrin degradation products,
and antithrombin activity nor the DIC score was associated with early death. Although the
accuracy for predicting early death defined by either baseline PT-INR of ≥1.57 or total
SOFA score of more than 13 was not high enough, that of “high-risk of early death (PT-INR
≥ 1.57 and SOFA score ≥ 13)” was 83.5%. Furthermore, the negative predictive of this
category was 96.0%. The baseline SOFA score and PT-INR were associated with early death
among patients with sepsis-associated coagulation disorders. Patients who do not meet the
“high-risk of early death” criteria were likely to survive for more than 3 days and
therefore should be considered for future therapeutic clinical trials.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Makoto Arakawa
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Yoshifumi Ohchi
- Department of Anesthesiology and Intensive Care, Oita University, Oita, Japan
| | - Takao Arai
- Department of Emergency and Critical Care Medicine, Trauma and Emergency Center, Hachioji Medical Center, Tokyo Medical University, Tokyo, Japan
| | - Koichi Sato
- Department of Surgery, Juntendo Shizuoka Hospital, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Wada
- Department of Molecular Laboratory Medicine, Mie University Graduate School of Medicine, Mie, Japan
| | - Jerrold H Levy
- Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, NC, USA
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22
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Iba T, Levy JH, Hirota T, Hiki M, Sato K, Murakami T, Nagaoka I. Protection of the endothelial glycocalyx by antithrombin in an endotoxin-induced rat model of sepsis. Thromb Res 2018; 171:1-6. [PMID: 30216821 DOI: 10.1016/j.thromres.2018.09.042] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 08/02/2018] [Accepted: 09/04/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Injury and loss of the endothelial glycocalyx occur during the early phase of sepsis. We previously showed that antithrombin has a protective effect on this structure in vitro. Here, we investigated the possible protective effects of antithrombin in an animal model of sepsis. METHODS Wistar rats were injected with endotoxin, and circulating levels of syndecan-1, hyaluronan, albumin, lactate and other biomarkers were measured in an antithrombin-treated group and an untreated control group (n = 6 in each group). Intravital microscopy was used to observe leukocyte adhesion, microcirculation, and syndecan-1 staining. RESULTS The circulating levels of syndecan-1 and hyaluronan were significantly reduced in the antithrombin-treated group, compared with the untreated controls. Lactate levels and albumin reduction were significantly attenuated in the antithrombin-treated group. Intravital microscopic observation revealed that both leukocyte adhesion and blood flow were better maintained in the treatment group. The syndecan-1 lining was disrupted after endotoxin treatment, and this derangement was attenuated by treatment with antithrombin. CONCLUSION Antithrombin effectively maintained microcirculation and vascular integrity by protecting the glycocalyx in a rat sepsis model.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Jerrold H Levy
- Department of Anesthesiology and Critical Care, Duke University School of Medicine, United States of America.
| | - Tatsuhiko Hirota
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Makoto Hiki
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Koichi Sato
- Department of Surgery, Juntendo Shizuoka Hospital, Juntendo University Graduate School of Medicine, Japan.
| | - Taisuke Murakami
- Department of Host Defense and Biochemical Research, Juntendo University Graduate School of Medicine, Japan.
| | - Isao Nagaoka
- Department of Host Defense and Biochemical Research, Juntendo University Graduate School of Medicine, Japan.
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Andersson U, Yang H, Harris H. High-mobility group box 1 protein (HMGB1) operates as an alarmin outside as well as inside cells. Semin Immunol 2018. [DOI: 10.1016/j.smim.2018.02.011] [Citation(s) in RCA: 157] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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24
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Iba T, Arakawa M, Di Nisio M, Gando S, Anan H, Sato K, Ueki Y, Levy JH, Thachil J. Newly Proposed Sepsis-Induced Coagulopathy Precedes International Society on Thrombosis and Haemostasis Overt-Disseminated Intravascular Coagulation and Predicts High Mortality. J Intensive Care Med 2018; 35:643-649. [PMID: 29720054 DOI: 10.1177/0885066618773679] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Disseminated intravascular coagulation (DIC) has been recognized as an urgent and critical condition in patients with sepsis. Therefore, unfamiliar and time-consuming tests or a complex scoring system are not suitable for diagnosis. Sepsis-induced coagulopathy (SIC), a newly proposed category delineated by a few global coagulation tests, has been established as an early warning sign for DIC. The purpose of this study was to elucidate the characteristics of SIC, especially in relation to the score of the International Society on Thrombosis and Haemostasis (ISTH) for overt DIC. METHOD A data set for 332 patients with sepsis who were suspected to have DIC, antithrombin activity <70%, and treated with antithrombin substitution was utilized to examine the relationship between SIC and overt DIC. The performance of SIC calculated at baseline (ie, before treatment) as well as on days 2, 4, or 7 was analyzed in terms of its ability to predict 28-day mortality and overt DIC. RESULTS At baseline, 149 (98.7%) of 151 patients with overt DIC according to the ISTH definition were diagnosed as having SIC. Of the 49, 46 (93.9%) patients who developed overt DIC between days 2 and 4 had received a prior diagnosis of SIC. The sensitivity of baseline SIC for the prediction of death was significantly higher than that of overt DIC (86.8% vs 64.5%, P < .001). The sensitivity of SIC on days 2, 4, and 7 was significantly higher than those of overt DIC (96.1%, 92.3%, and 84.4% vs 67.1%, 57.7%, and 50.0%, P < .001, .001, and .001, respectively), although the specificity of SIC was lower at all time points.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Hongo Bunkyo-ku, Tokyo, Japan
| | - Makoto Arakawa
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Hongo Bunkyo-ku, Tokyo, Japan
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, University G.D'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Tokyo, Japan
| | - Hideaki Anan
- Emergency Medical Center, Fujisawa City Hospital, Tokyo, Japan
| | - Koichi Sato
- Department of Surgery, Juntendo Shizuoka Hospital, Juntendo University Graduate School of Medicine, Hongo Bunkyo-ku, Tokyo, Japan
| | - Yutaka Ueki
- Department of Acute Critical Care and Disaster Medicine, Tokyo Medical and Dental University, Bunkyō, Tokyo, Japan
| | - Jerrold H Levy
- Department of Anesthesiology and Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, United Kingdom
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Iba T, Arakawa M, Levy JH, Yamakawa K, Koami H, Hifumi T, Sato K. Sepsis-Induced Coagulopathy and Japanese Association for Acute Medicine DIC in Coagulopathic Patients with Decreased Antithrombin and Treated by Antithrombin. Clin Appl Thromb Hemost 2018; 24:1020-1026. [PMID: 29695178 PMCID: PMC6714750 DOI: 10.1177/1076029618770273] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Disseminated intravascular coagulation (DIC) in patients with sepsis represents a critical condition. Thus, a simple and rapid diagnosis is required. The purpose of this study was to compare the performances of a recently developed Sepsis-Induced Coagulopathy (SIC) with the Japanese Association for Acute Medicine (JAAM) DIC. Four hundred nine patients with sepsis having coagulopathy and antithrombin activity of less than 70% and treated with antithrombin were retrospectively analyzed, and the SIC and JAAM-DIC criteria on days 1 (before treatment), 2, 4, and 7 were compared. The prevalence of JAAM-DIC on day 1 was significantly higher than that of SIC (91.4% vs 81.8%, P = .003), but there were no differences on days 2, 4, and 7. The mortality rates in the SIC and JAAM-DIC groups were both 23.3%. The specificity to 28-day mortality on day 1 was higher in the SIC group (15.8% vs 9.2%, P = .013). There were no differences in sensitivity on days 1, 2, 4, and 7. Mortality was significantly different between SIC-positive and SIC-negative groups on days 2, 4, and 7 (P < .01, respectively), while significant differences were seen between JAAM-DIC-positive and JAAM-DIC-negative groups only on days 4 and 7 (P < .05, .01, respectively). In summary, the SIC characteristics were similar to the JAAM-DIC group, and the classifications were comparable in terms of mortality prediction. The SIC scoring system is simple, easy to use, and adaptable to the new sepsis definitions and offers an important approach to evaluating patients in emergency and critical care settings.
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Affiliation(s)
- Toshiaki Iba
- 1 Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Makoto Arakawa
- 1 Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Jerrold H Levy
- 2 Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, NC, USA
| | - Kazuma Yamakawa
- 3 Department of Emergency and Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Hiroyuki Koami
- 4 Department of Emergency and Critical Care Medicine, Saga University, Saga, Japan
| | - Toru Hifumi
- 5 Emergency Medical Center, Kagawa University Hospital, Kagawa, Japan
| | - Koichi Sato
- 6 Department of Surgery, Juntendo Shizuoka Hospital, Juntendo University Graduate School of Medicine, Tokyo, Japan
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Iba T, Di Nisio M, Thachil J, Wada H, Asakura H, Sato K, Saitoh D. A Proposal of the Modification of Japanese Society on Thrombosis and Hemostasis (JSTH) Disseminated Intravascular Coagulation (DIC) Diagnostic Criteria for Sepsis-Associated DIC. Clin Appl Thromb Hemost 2018; 24:439-445. [PMID: 28747069 PMCID: PMC6714647 DOI: 10.1177/1076029617720069] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Sepsis-associated disseminated intravascular coagulation (DIC) carries a high risk of death. Thus, a simple tool to quickly establish DIC diagnosis is required. The purpose of this study was to introduce the simple and reliable tool for the prediction of outcome in patients with sepsis complicated by coagulopathy. We investigated the performance of simplified Japanese Society on Thrombosis and Hemostasis (JSTH) DIC diagnostic criteria. In this study, we conducted a retrospective, multicenter survey in 107 general emergency and critical care centers in secondary and tertiary care hospitals. A total of 918 patients with sepsis-associated coagulopathy who underwent antithrombin supplementation were examined. The relationships between patient mortality and each of the baseline (ie, before treatment) JSTH-DIC diagnostic criteria were examined. A reduced platelet count, increased prothrombin time (PT) ratio, and lower antithrombin activity were correlated with 28-day mortality, while fibrinogen and fibrin degradation product (FDP) level were not. Thus, the number of points assigned to FDP levels was reduced from 3 to 1 (above 20 μg/mL). The simplified JSTH diagnostic criteria combining platelet count, PT ratio, antithrombin activity, and FDP level (reduction in the maximum score) strongly predicted 28-day mortality and allowed us to diagnose a larger/similar number of patients with DIC as compared to the original JSTH-DIC. The simplified JSTH-DIC diagnostic criteria show a similar performance to JSTH-DIC criteria in patients with septic coagulopathy. The lower number of laboratory markers used in the simplified JSTH-DIC score may increase its applicability and routine use in emergency and critical care setting.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate
School of Medicine, Tokyo, Japan
| | - Marcello Di Nisio
- Department of Ageing Sciences, University G D’Annunzio of Chieti-Pescara,
Chieti, Italy
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, United
Kingdom
| | - Hideo Wada
- Department of Molecular Laboratory Medicine, Mie University Graduate School
of Medicine, Mie, Japan
| | - Hidesaku Asakura
- Third Department of Internal Medicine, Kanazawa University Graduate School
of Medical Science, Kanazawa, Japan
| | - Koichi Sato
- Department of Surgery, Juntendo Shizuoka Hospital, Juntendo University
Graduate School of Medicine, Tokyo, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical
College, Tokorozawa, Japan
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Hayakawa M, Yamakawa K, Kudo D, Ono K. Optimal Antithrombin Activity Threshold for Initiating Antithrombin Supplementation in Patients With Sepsis-Induced Disseminated Intravascular Coagulation: A Multicenter Retrospective Observational Study. Clin Appl Thromb Hemost 2018. [PMID: 29514467 PMCID: PMC6714723 DOI: 10.1177/1076029618757346] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Low-dose antithrombin supplementation therapy (1500 IU/d for 3 days) improves outcomes in patients with sepsis-induced disseminated intravascular coagulation (DIC). This retrospective study evaluated the optimal antithrombin activity threshold to initiate supplementation, and the effects of supplementation therapy in 1033 patients with sepsis-induced DIC whose antithrombin activity levels were measured upon admission to 42 intensive care units across Japan. Of the 509 patients who had received antithrombin supplementation therapy, in-hospital mortality was significantly reduced only in patients with very low antithrombin activity (≤43%; bottom quartile; adjusted hazard ratio: 0.603; 95% confidence interval: 0.368-0.988; P = .045). Similar associations were not observed in patients with low, moderate, or normal antithrombin activity levels. Supplementation therapy did not correlate with the incidence of bleeding requiring transfusion. The adjusted hazard ratios for in-hospital mortality increased gradually with antithrombin activity only when initial activity levels were very low to normal but plateaued thereafter. We conclude that antithrombin supplementation therapy in patients with sepsis-induced DIC and very low antithrombin activity may improve survival without increasing the risk of bleeding.
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Affiliation(s)
- Mineji Hayakawa
- 1 Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Kazuma Yamakawa
- 2 Department of Emergency Medicine, Osaka General Medical Center, Osaka, Japan
| | - Daisuke Kudo
- 3 Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kota Ono
- 4 Clinical Research and Medical Innovation Center, Hokkaido University Hospital, Sapporo, Japan
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Iba T, Levy JH. Inflammation and thrombosis: roles of neutrophils, platelets and endothelial cells and their interactions in thrombus formation during sepsis. J Thromb Haemost 2018; 16:231-241. [PMID: 29193703 DOI: 10.1111/jth.13911] [Citation(s) in RCA: 288] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Indexed: 12/12/2022]
Abstract
The inflammatory response and the activation of coagulation are two important responses in a host's defense against infection. These mechanisms do not work independently, but cooperate in a complex and synchronous manner. Recent research has also shed light on the critical role of thrombus formation, which prevents the dissemination of microorganisms. The cellular components of blood vessels, i.e. leukocytes, platelets, erythrocytes, and vascular endothelial cells, play significant roles in the development of thrombi in combination with activation of the coagulation system. In addition to the cellular components, alarmins such as histones and high-mobility group box 1, microparticles and secreted granule proteins are all important for clot formation. In this summary, we review the pathophysiology of sepsis-induced coagulopathy and the role of cellular components and critical factors released from damaged cells. In addition, we review important therapeutic approaches that have been developed, are under investigation and are currently available in certain countries, including antithrombin, recombinant thrombomodulin, anti-Toll-like receptor 4 therapy, anti-damage associated molecular pattern therapy, and hemoadsorption with a polymyxin B-immobilized fiber column.
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Affiliation(s)
- T Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - J H Levy
- Department of Anesthesiology and Surgery, Duke University School of Medicine, Durham, NC, USA
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29
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Protective effect of a newly developed fucose-deficient recombinant antithrombin against histone-induced endothelial damage. Int J Hematol 2018; 107:528-534. [DOI: 10.1007/s12185-018-2402-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 01/03/2018] [Accepted: 01/12/2018] [Indexed: 10/18/2022]
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Hayakawa M. Management of disseminated intravascular coagulation: current insights on antithrombin and thrombomodulin treatments. Open Access Emerg Med 2017; 10:25-29. [PMID: 29343993 PMCID: PMC5749552 DOI: 10.2147/oaem.s135909] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Sepsis and septic shock are frequently complicated by disseminated intravascular coagulation (DIC), which decreases the survival rate of patients with sepsis. In the past, large international randomized controlled trials (RCTs) using physiological anticoagulants for sepsis-induced DIC were not performed; however, RCTs have been conducted for sepsis and/or septic shock. In these trials, physiological anticoagulants did not show any beneficial effects compared with placebo for the treatment of sepsis and/or septic shock. In Japan, DIC treatments using antithrombin (AT) and/or recombinant human soluble thrombomodulin (rhTM) are common for patients with sepsis-induced DIC. Recently, large propensity score analyses demonstrated that AT and rhTM improved survival in patients with sepsis-induced DIC. Furthermore, post hoc analyses and meta-analyses that selected patients with sepsis-induced DIC from the previous large international RCTs indicated that physiological anticoagulants improved survival without increasing the associated sepsis-induced DIC bleeding. DIC treatments, such as AT and rhTM, may demonstrate beneficial effects when they are targeted at patients with sepsis-induced DIC only.
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Affiliation(s)
- Mineji Hayakawa
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
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31
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Iba T, Hagiwara A, Saitoh D, Anan H, Ueki Y, Sato K, Gando S. Effects of combination therapy using antithrombin and thrombomodulin for sepsis-associated disseminated intravascular coagulation. Ann Intensive Care 2017; 7:110. [PMID: 29098447 PMCID: PMC5668219 DOI: 10.1186/s13613-017-0332-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 10/25/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND No single anticoagulant has been proven effective for sepsis-associated disseminated intravascular coagulation (DIC). Thus, the concomitant use of antithrombin concentrate and recombinant thrombomodulin has been conceived. This observational study was conducted to investigate the efficacy and safety of this combination therapy. METHODS A total of 510 septic DIC patients who received antithrombin substitution were retrospectively analyzed. Among them, 228 were treated with antithrombin and recombinant thrombomodulin (combination therapy) and the rest were treated with antithrombin alone (monotherapy). Propensity score matching created 129 matched pairs, and 28-day all-cause mortality, DIC scores, the sequential organ failure assessment (SOFA) scores, and the incidence of bleeding were compared. RESULTS A log-rank test revealed a significant association between combination therapy and a lower 28-day mortality rate (hazard ratio 0.49, 95% confidence interval 0.29-0.82, P = 0.006) in the matched pairs. The DIC scores and the SOFA scores in the combination therapy group were significantly lower than those in the monotherapy group on Day 4 and Day 7. The incidence of bleeding did not differ between the groups (2.11 vs. 2.31%, P = 1.000). CONCLUSIONS The current study demonstrated the potential benefit of adding recombinant thrombomodulin to antithrombin. The co-administration of these two anticoagulants was associated with reduced mortality among patients with sepsis-induced DIC without increasing the risk of bleeding.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Akiyoshi Hagiwara
- National Center for Global Health and Medicine, Emergency Medicine and Critical Care, Tokyo, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokyo, Japan
| | - Hideaki Anan
- Emergency Medical Center, Fujisawa City Hospital, Fujisawa, Japan
| | - Yutaka Ueki
- Department of Acute Critical Care and Disaster Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Koichi Sato
- Department of Surgery, Juntendo Shizuoka Hospital, Juntendo University Graduate School of Medicine, Izunokuni-shi, Japan
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Kell DB, Pretorius E. To What Extent Are the Terminal Stages of Sepsis, Septic Shock, Systemic Inflammatory Response Syndrome, and Multiple Organ Dysfunction Syndrome Actually Driven by a Prion/Amyloid Form of Fibrin? Semin Thromb Hemost 2017; 44:224-238. [PMID: 28778104 PMCID: PMC6193370 DOI: 10.1055/s-0037-1604108] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A well-established development of increasing disease severity leads from sepsis through systemic inflammatory response syndrome, septic shock, multiple organ dysfunction syndrome, and cellular and organismal death. Less commonly discussed are the equally well-established coagulopathies that accompany this. We argue that a lipopolysaccharide-initiated (often disseminated intravascular) coagulation is accompanied by a proteolysis of fibrinogen such that formed fibrin is both inflammatory and resistant to fibrinolysis. In particular, we argue that the form of fibrin generated is amyloid in nature because much of its normal α-helical content is transformed to β-sheets, as occurs with other proteins in established amyloidogenic and prion diseases. We hypothesize that these processes of amyloidogenic clotting and the attendant coagulopathies play a role in the passage along the aforementioned pathways to organismal death, and that their inhibition would be of significant therapeutic value, a claim for which there is considerable emerging evidence.
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Affiliation(s)
- Douglas B Kell
- School of Chemistry, The University of Manchester, Manchester, United Kingdom.,Manchester Institute of Biotechnology, The University of Manchester, Manchester, United Kingdom.,Centre for Synthetic Biology of Fine and Speciality Chemicals, The University of Manchester, Manchester, United Kingdom
| | - Etheresia Pretorius
- Department of Physiological Sciences, Stellenbosch University, Matieland, South Africa
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Koami H, Sakamoto Y, Sakurai R, Ohta M, Imahase H, Yahata M, Umeka M, Miike T, Nagashima F, Iwamura T, Yamada KC, Inoue S. The efficacy and associated bleeding complications of recombinant antithrombin supplementation among intensive care unit patients. Thromb Res 2017; 157:84-89. [PMID: 28711778 DOI: 10.1016/j.thromres.2017.06.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 06/12/2017] [Accepted: 06/27/2017] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The aim of this study was to evaluate the efficacy and complications of recombinant antithrombin (rAT) supplementation for adult patients with disseminated intravascular coagulation (DIC) compared with conventional plasma derived AT (pAT) treatment in the intensive care unit. MATERIALS AND METHODS This study was performed in a single national university hospital in Japan. Adult patients from April 2015 to March 2016 with DIC were divided into two groups based on the type of AT agent used: the pAT group (n=24) and the rAT group (n=21). Patient demographics, medical history, diagnosis, blood tests, various clinical scores, AT activity, complications, and clinical outcome were collected and analyzed retrospectively. RESULTS Significantly higher SIRS and APACHEII scores were confirmed in the rAT group than the pAT group. The initial dose of AT was significantly higher in the rAT group than in the pAT group. ATIII values before and after initial supplementation and during their ten-day clinical course were statistically similar between two groups. During the same period, 10 bleeding adverse events were found and there was no significant difference between both groups. Significantly more cases of the rAT group were administered with recombinant thrombomodulin concomitantly than those of the pAT group. Despite significantly more severe patients in rAT group, the clinical outcomes were the same in each group. CONCLUSIONS Compared with pAT, the supplementation of rAT indicates clinical effectiveness without increasing the risk of bleeding complications in adult DIC patients with low AT activity.
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Affiliation(s)
- Hiroyuki Koami
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, Saga, Japan.
| | - Yuichiro Sakamoto
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, Saga, Japan.
| | - Ryota Sakurai
- Advanced Emergency Care Center, Saga University Hospital, Saga, Japan.
| | - Miho Ohta
- Advanced Emergency Care Center, Saga University Hospital, Saga, Japan.
| | - Hisashi Imahase
- Advanced Emergency Care Center, Saga University Hospital, Saga, Japan.
| | - Mayuko Yahata
- Advanced Emergency Care Center, Saga University Hospital, Saga, Japan.
| | - Mitsuru Umeka
- Advanced Emergency Care Center, Saga University Hospital, Saga, Japan.
| | - Toru Miike
- Advanced Emergency Care Center, Saga University Hospital, Saga, Japan.
| | - Futoshi Nagashima
- Division of Trauma Surgery and Surgical Critical Care, Faculty of Medicine, Saga University, Saga, Japan.
| | - Takashi Iwamura
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, Saga, Japan.
| | | | - Satoshi Inoue
- Division of Trauma Surgery and Surgical Critical Care, Faculty of Medicine, Saga University, Saga, Japan.
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Iba T, Fowler L. Is polymyxin B-immobilized fiber column ineffective for septic shock? A discussion on the press release for EUPHRATES trial. J Intensive Care 2017; 5:40. [PMID: 28690852 PMCID: PMC5496228 DOI: 10.1186/s40560-017-0236-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 06/27/2017] [Indexed: 12/26/2022] Open
Abstract
The efficacy of polymyxin B-immobilized (PMX) fiber column on septic shock is still under debate. Recently, the result from "Evaluating the Use of Polymyxin B Hemoperfusion in a Randomized controlled trial of Adults Treated for Endotoxemia and Septic shock (EUPHRATES)" trial has been announced as a press release. According to that report, less than a 5% mortality difference was recognized in the "per protocol population" (n = 244, 31.9 vs. 36.9%) and the decrease was not statistically significant. However, among the patients in refractory shock with a multiple organ dysfunction score of more than 9 and an EAA between 0.6 and 0.9, a 10.7% reduction in 28-day mortality was recognized (p = 0.0474) when they received two sessions of hemoperfusion using the PMX fiber column. Since this favorable effect was obtained from "post hoc" analysis, further study is expected.
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Affiliation(s)
- Toshiaki Iba
- Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421 Japan
| | - Lucy Fowler
- Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421 Japan.,University of Birmingham, Birmingham, UK
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35
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Iba T, Sasaki T, Ohshima K, Sato K, Nagaoka I, Thachil J. The Comparison of the Protective Effects of α- and β-Antithrombin against Vascular Endothelial Cell Damage Induced by Histone in Vitro. TH OPEN 2017; 1:e3-e10. [PMID: 31249909 PMCID: PMC6524836 DOI: 10.1055/s-0037-1603926] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Antithrombin is a promising option for the treatment of sepsis, and vascular endothelium is an important target for this fatal condition. Here, we aimed to evaluate the protective effects of different glycoforms of antithrombin on histone-induced endothelial cell damage and explore the responsible mechanisms in an experimental model in vitro. Endothelial cells were treated in vitro using histone H4 to induce cellular damage. Various doses of either α- or β-antithrombin were used as treatment interventions, and both cell viability and the levels of lactate dehydrogenase (LDH) in the medium were assessed. Endothelial cell damage was also assessed using microscopic examination and immunofluorescent staining with anti-syndecan-4 and anti-antithrombin antibodies. As a result, both glycoforms of antithrombin significantly improved cell viability when administered at a physiological dose (150 μg/mL). Cellular injury as evaluated using the LDH level was significantly suppressed by β-antithrombin at a supranormal dose (600 μg/mL). Microscopic observation suggested that β-antithrombin suppressed the endothelial cell damage more efficiently than α-antithrombin. β-Antithrombin suppressed the intensity of syndecan-4 staining which became evident after treatment with histone H4, more prominently than α-antithrombin. The distribution of antithrombin was identical to that of syndecan-4. In conclusion, both α- and β-antithrombin can protect vascular endothelial cells from histone H4-induced damage, although the effect was stronger for β-antithrombin. The responsible mechanisms might involve the binding of antithrombin to the glycocalyx on the endothelial surface. These results provide a theoretical basis for the application of antithrombin to the prevention and treatment of sepsis-related endothelial damage.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Tetsuya Sasaki
- Nihon Pharmaceutical Co. Ltd., Research Laboratory, Narita, Japan
| | | | - Koichi Sato
- Department of Surgery, Juntendo Shizuoka Hospital, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Isao Nagaoka
- Department of Host Defense and Biochemical Research, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, United Kingdom
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Scarlatescu E, Tomescu D, Arama SS. Anticoagulant Therapy in Sepsis. The Importance of Timing. ACTA ACUST UNITED AC 2017; 3:63-69. [PMID: 29967873 PMCID: PMC5769917 DOI: 10.1515/jccm-2017-0011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 03/24/2017] [Indexed: 11/25/2022]
Abstract
Sepsis associated coagulopathy is due to the inflammation-induced activation of coagulation pathways concomitant with dysfunction of anticoagulant and fibrinolytic systems, leading to different degrees of haemostasis dysregulation. This response is initially beneficial, contributing to antimicrobial defence, but when control is lost coagulation activation leads to widespread microvascular thrombosis and subsequent organ failure. Large clinical trials of sepsis-related anticoagulant therapies failed to show survival benefits, but posthoc analysis of databases and several smaller studies showed beneficial effects of anticoagulants in subgroups of patients with early sepsis-induced disseminated intravascular coagulation. A reasonable explanation could be the difference in timing of anticoagulant therapy and patient heterogeneity associated with large trials. Proper selection of patients and adequate timing are required for treatment to be successful. The time when coagulation activation changes from advantageous to detrimental represents the right moment for the administration of coagulation-targeted therapy. In this way, the defence function of the haemostatic system is preserved, and the harmful effects of overwhelming coagulation activation are avoided.
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Affiliation(s)
- Ecaterina Scarlatescu
- Department of Anesthesiology and Intensive Care III, Fundeni Clinical Institute, Bucharest, Romania
| | - Dana Tomescu
- Department of Anesthesiology and Intensive Care III, Fundeni Clinical Institute, Bucharest, Romania.,University of Medicine and Pharmacy, "Carol Davila", Bucharest, Romania
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Tagami T, Matsui H, Moroe Y, Fukuda R, Shibata A, Tanaka C, Unemoto K, Fushimi K, Yasunaga H. Antithrombin use and 28-day in-hospital mortality among severe-burn patients: an observational nationwide study. Ann Intensive Care 2017; 7:18. [PMID: 28220452 PMCID: PMC5318343 DOI: 10.1186/s13613-017-0244-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Accepted: 02/10/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Previous studies have suggested that antithrombin may be beneficial for treating coagulopathy in patients with severe burns. However, robust evidence for this idea is lacking. We examined the hypothesis that antithrombin may be effective in treating patients with severe burns. METHODS We performed propensity score-matched analyses of the nationwide administrative Japanese Diagnosis Procedure Combination inpatient database. We identified patients with severe burns (burn index ≥ 10) who were recorded in the database from 1 July 2010 to 31 March 2013. We compared patients who were administered antithrombin within 2 days of admission (antithrombin group) and those who were not administered antithrombin (control group). The main outcomes were 28-day mortality and ventilator-free days (VFDs). RESULTS Eligible patients (n = 3223) from 618 hospitals were categorized into either an antithrombin group (n = 152) or control group (n = 3071). Propensity score matching created a matched cohort of 103 pairs with and without antithrombin. Twenty-eight-day mortality was lower in the antithrombin group compared with the control group in propensity-matched analysis (control vs. antithrombin, 47.6 vs. 33.0%; difference, 14.6%; 95% confidence interval [CI] 1.2-28.0). Cox regression analysis showed a significant difference in 28-day in-hospital mortality between the control and antithrombin propensity-matched groups (hazard ratio 0.58; 95% CI 0.37-0.90). There were significantly more VFDs in the antithrombin compared with the control group in propensity score-matched analysis (control vs. antithrombin, 12.6 vs. 16.4 days; difference -3.7; 95% CI -7.2 to -0.12). CONCLUSIONS This nationwide database study demonstrated that antithrombin use may improve 28-day survival and increase VFDs in patients with severe burns. Further prospective studies are required to confirm these results.
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Affiliation(s)
- Takashi Tagami
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 1138555, Japan. .,Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan.
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 1138555, Japan
| | - Yuuta Moroe
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
| | - Reo Fukuda
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
| | - Ami Shibata
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
| | - Chie Tanaka
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
| | - Kyoko Unemoto
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Informatics and Policy, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 1138555, Japan
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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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Extracellular vesicles and blood diseases. Int J Hematol 2017; 105:392-405. [PMID: 28130731 DOI: 10.1007/s12185-017-2180-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/09/2017] [Accepted: 01/09/2017] [Indexed: 01/19/2023]
Abstract
Extracellular vesicles (EVs) are small membrane vesicles released from many different cell types by the exocytic budding of the plasma membrane in response to cellular activation or apoptosis. EVs disseminate various bioactive effectors originating from the parent cells and transfer functional RNA and protein between cells, enabling them to alter vascular function and induce biological responses involved in vascular homeostasis. Although most EVs in human blood originate from platelets, EVs are also released from leukocytes, erythrocytes, endothelial cells, smooth muscle cells, and cancer cells. EVs were initially thought to be small particles with procoagulant activity; however, they can also evoke cellular responses in the immediate microenvironments and transport microRNAs (miRNA) into target cells. In this review, we summarize the recent literature relevant to EVs, including a growing list of clinical disorders that are associated with elevated EV levels. These studies suggest that EVs play roles in various blood diseases.
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Iba T, Thachil J. Is protein C zymogen really ineffective for ALL cases of sepsis including septic DIC? Intensive Care Med 2016; 43:152-153. [PMID: 27822595 DOI: 10.1007/s00134-016-4615-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
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Gmyr V, Bonner C, Moerman E, Tournoys A, Delalleau N, Quenon A, Thevenet J, Chetboun M, Kerr-Conte J, Pattou F, Hubert T, Jourdain M. Human Recombinant Antithrombin (ATryn ®) Administration Improves Survival and Prevents Intravascular Coagulation After Intraportal Islet Transplantation in a Piglet Model. Cell Transplant 2016; 26:309-317. [PMID: 27938471 DOI: 10.3727/096368916x693554] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Human islet transplantation is a viable treatment option for type 1 diabetes mellitus (T1DM). However, pancreatic islet inflammation after transplantation induced by innate immune responses is likely to hinder graft function. This is mediated by incompatibility between islets and the blood interface, known as instant blood-mediated inflammatory reaction (IBMIR). Herein we hypothesized that portal venous administration of islet cells with human recombinant antithrombin (ATryn®), a serine protease inhibitor (serpin), which plays a central role in the physiological regulation of coagulation and exerts indirect anti-inflammatory activities, may offset coagulation abnormalities such as disseminated intravascular coagulation (DIC) and IBMIR. The current prospective, randomized experiment was conducted using an established preclinical pig model. Three groups were constituted for digested pancreatic tissue transplantation (0.15 ml/kg): control, NaCl 0.9% (n = 7); gold standard, heparin (25 UI/kg) (n = 7); and human recombinant ATryn® (500 UI/kg) (n = 7). Blood samples were collected over time (T0 to 24 h), and biochemical, coagulation, and inflammatory parameters were evaluated. In both the control and heparin groups, one animal died after a portal thrombosis, while no deaths occurred in the ATryn®-treated group. As expected, islet transplantation was associated with an increase in plasma IL-6 or TNF-α levels in all three groups. However, DIC was only observed in the control group, an effect that was suppressed after ATryn® administration. ATryn® administration increased antithrombin activity by 800%, which remained at 200% for the remaining period of the study, without any hemorrhagic complications. These studies suggest that coadministration of ATryn® and pancreatic islets via intraportal transplantation may be a valuable therapeutic approach for DIC without risk for islets and subjects.
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Aota T, Wada H, Fujimoto N, Yamashita Y, Matsumoto T, Ohishi K, Suzuki K, Imai H, Usui M, Isaji S, Uchiyama T, Seki Y, Katayama N. Evaluation of the Diagnostic Criteria for the Basic Type of DIC Established by the Japanese Society of Thrombosis and Hemostasis. Clin Appl Thromb Hemost 2016; 23:838-843. [PMID: 27729561 DOI: 10.1177/1076029616672582] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
We evaluated the diagnostic criteria for disseminated intravascular coagulation (DIC), which was published by the Japanese Society of Thrombosis and Hemostasis (JSTH), in 232 patients with suspected DIC without hematopoietic injury or infection. The diagnoses of the patients were as follows: DIC (n = 116), pre-DIC (n = 54), and non-DIC (n = 63). The efficacy of the diagnostic criteria for DIC was evaluated using a receiver operating characteristic analysis. The area under the curve and odds ratio for the global coagulation test (GCT) scores in the diagnosis of "DIC" were high, whereas those for the diagnosis of "DIC and pre-DIC" were low, suggesting that the addition of a reduced platelet count (RPC), antithrombin (AT), and soluble fibrin (SF)/thrombin AT (TAT) complex was required to diagnose DIC and pre-DIC. When the GCT score with the RPC, AT, and TAT/SF values was used, the cutoff DIC score for the diagnosis of DIC or DIC and pre-DIC was 6 points. For predicting the outcome, a scoring system that used the GCT result was useful, but the addition of RPC, AT, or SF/TAT was not. The modified diagnostic criteria of JSTH, which included the GCT score and the RPC, AT, and TAT/SF values, were useful for diagnosing both DIC and pre-DIC.
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Affiliation(s)
- Takumi Aota
- 1 Department of Hematology and Oncology, Mie University Graduate School of Medicine, Mie, Japan
| | - Hideo Wada
- 2 Department of Molecular and Laboratory Medicine, Mie University Graduate School of Medicine, Mie, Japan
| | - Naoki Fujimoto
- 2 Department of Molecular and Laboratory Medicine, Mie University Graduate School of Medicine, Mie, Japan
| | - Yoshiki Yamashita
- 1 Department of Hematology and Oncology, Mie University Graduate School of Medicine, Mie, Japan
| | - Takeshi Matsumoto
- 3 Blood Transfusion Service, Mie University Graduate School of Medicine, Mie, Japan
| | - Kohshi Ohishi
- 3 Blood Transfusion Service, Mie University Graduate School of Medicine, Mie, Japan
| | - Kei Suzuki
- 4 Emergency Critical Care Center, Mie University Graduate School of Medicine, Mie, Japan
| | - Hiroshi Imai
- 4 Emergency Critical Care Center, Mie University Graduate School of Medicine, Mie, Japan
| | - Masanobu Usui
- 5 Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Shuji Isaji
- 5 Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Toshimasa Uchiyama
- 6 Department of Laboratory Medicine, Takasaki General Medical center, Takasaki, Japan
| | - Yoshinobu Seki
- 7 Department of Hematology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Naoyuki Katayama
- 1 Department of Hematology and Oncology, Mie University Graduate School of Medicine, Mie, Japan
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The valuable diagnosis of DIC and pre-DIC and prediction of a poor outcome by the evaluation of diagnostic criteria for DIC in patients with hematopoietic injury established by the Japanese Society of Thrombosis and Hemostasis. Thromb Res 2016; 147:80-84. [PMID: 27710855 DOI: 10.1016/j.thromres.2016.09.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 08/31/2016] [Accepted: 09/27/2016] [Indexed: 12/28/2022]
Abstract
OBJECTIVE We evaluated the modified diagnostic criteria for disseminated intravascular coagulation (DIC), which was published by the Japanese Society of Thrombosis and Hemostasis (JSTH), in 274 suspected DIC patients with hematopoietic injury. MATERIALS AND METHODS The diagnoses of the patients were as follows: DIC (n=125); pre-DIC (n=42) and non-DIC (n=107). The efficacy of the diagnostic criteria for DIC was evaluated using a receiver operating characteristic (ROC) analysis. RESULTS The area under the curve (ARC) and odd's ratio for the global coagulation test (GCT) scores in the diagnosis of "DIC" were high, while those for the diagnosis of "DIC and pre-DIC" were low, suggesting that the addition of antithrombin (AT) and soluble fibrin (SF)/thrombin antithrobin complex (TAT) was required to diagnose "DIC and pre-DIC". Although the addition of the AT and SF/TAT values to the GCT did not increase its ability to predict a poor outcome, the JSTH's modified diagnostic criteria scores were correlated with the odds ratio for death. DISCUSSION AND CONCLUSION The JSTH's modified diagnostic criteria for DIC, which included the GCT score, and the AT, and TAT/SF values, were useful for diagnosing DIC and pre-DIC, and predicting a poor outcome.
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Iba T, Di Nisio M, Thachil J, Wada H, Asakura H, Sato K, Kitamura N, Saitoh D. Revision of the Japanese Association for Acute Medicine (JAAM) disseminated intravascular coagulation (DIC) diagnostic criteria using antithrombin activity. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:287. [PMID: 27629997 PMCID: PMC5024432 DOI: 10.1186/s13054-016-1468-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 08/26/2016] [Indexed: 12/21/2022]
Abstract
Background With advances in the treatment of sepsis, the systemic inflammatory response syndrome (SIRS) has been losing its prognostic power. Since the SIRS category is no longer used for the diagnosis of sepsis, the disseminated intravascular coagulation (DIC) diagnostic criteria released by Japanese Association for Acute Medicine (JAAM) should be modified. Thus, the purpose of this study was to examine the appropriateness of replacing the SIRS score with antithrombin activity in JAAM-DIC diagnostic criteria. Methods We analyzed data from 819 septic patients who had received recombinant thrombomodulin. The relationships between the 28-day mortality rate and baseline laboratory and clinical parameters were examined using univariate and multivariate analyses, and the impact of replacing the SIRS criteria with antithrombin activity was evaluated. Results The SIRS score, prothrombin time ratio, and antithrombin activity were associated with the 28-day mortality rate (P values = 0.013, 0.018, and 0.003, respectively, by multivariate analysis). A modified version of the JAAM-DIC diagnostic criteria using an antithrombin activity <70 % was capable of diagnosing the identical number (n = 706) and a similar severity of patients (mortality, 34.6 % versus 34.8 %). Conclusion Since anticoagulant therapy is expected to be more effective in patients with more severe coagulation disorders, the modified version of the JAAM-DIC diagnostic criteria might be useful for discriminating patients with sepsis who are good candidates for anticoagulant therapy.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Marcello Di Nisio
- Department of Medical, Oral and Biotechnological Sciences, University G D'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Oxford Road, Manchester, UK
| | - Hideo Wada
- Department of Molecular Laboratory Medicine, Mie University Graduate School of Medicine, 2-174, Tsu, Mie, Japan
| | - Hidesaku Asakura
- Third Department of Internal Medicine, Kanazawa University, Graduate School of Medical Science, 13-1, Kanazawa, Japan
| | - Koichi Sato
- Department of Surgery, Juntendo Shizuoka Hospital, Juntendo University Graduate School of Medicine, 1129, Izunokuni-shi, Shizuoka, Japan
| | - Naoya Kitamura
- Recomodulin Strategy Planning Department, Pharmaceuticals Sales Division, Asahi Kasei Pharma Corporation, 1-105, Kanda, Tokyo, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Saitama, Japan
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Antithrombin supplementation and risk of bleeding in patients with sepsis-associated disseminated intravascular coagulation. Thromb Res 2016; 145:46-50. [PMID: 27479532 DOI: 10.1016/j.thromres.2016.07.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 07/22/2016] [Accepted: 07/26/2016] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Although antithrombin is commonly used for the treatment of sepsis-associated disseminated intravascular coagulation (DIC) in Japan, the factors influencing the incidence of bleeding complications have not been sufficiently studied. The purpose of this survey was to identify the factors that predict clinically relevant bleeding in patients receiving antithrombin for DIC. METHODS We analyzed data from 1026 sepsis-associated DIC patients with a baseline antithrombin activity ≤70% who underwent antithrombin supplementation at two dosages (1500IU/day or 3000IU/day) for three consecutive days. The patients' demographic characteristics, parameters before and after the treatment, and co-administered anticoagulants were analyzed in relation to the bleeding events. RESULTS Overall, 55 patients (5.36%) experienced bleeding events (major bleeding: 1.75%). Logistic regression analysis revealed that sustained DIC>7days was significantly associated with bleeding (odds ratio: 2.761, P=0.001). In contrast, the higher dose of antithrombin or the co-administration of recombinant thrombomodulin or heparins were not associated with bleeding events. CONCLUSION A higher dose of antithrombin or the concomitant use of other anticoagulants were not associated with bleeding events. On the other hand, sustained DIC lasting more than one week was associated with an increased risk of bleeding in patients with sepsis-associated DIC.
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Thachil J. Disseminated intravascular coagulation - new pathophysiological concepts and impact on management. Expert Rev Hematol 2016; 9:803-14. [PMID: 27314681 DOI: 10.1080/17474086.2016.1203250] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Disseminated intravascular coagulation (DIC) is an intermediary mechanism of disease which develops secondary to many causes including sepsis, trauma and malignancies. This review attempts to summarise the new pathophysiological developments and the impact they have on the current and future management of DIC. AREAS COVERED Several publications detailing the pathophysiology of DIC and the clinical management were identified using a pubmed search. Expert commentary: In recent years, on the initiatives of the international society of thrombosis and haemostasis, important advances have been made on the diagnostic aspect of DIC. In addition, several researchers have focused on the pathophysiology of the condition which is likely to provide better diagnostic markers and targeted therapy. However, some confusion still exists in the definition and management of DIC since various specialists understands the mechanisms involved in DIC from different perspectives.
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Affiliation(s)
- Jecko Thachil
- a Department of Haematology , Central Manchester University Hospitals NHS Foundation Trust , Manchester , UK
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Abstract
Abstract
Anesthesiologists may encounter patients with disseminated intravascular coagulation, a potential complication of severe sepsis or major trauma. This practical guide discusses the clinical approach, laboratory diagnosis, and current management of this condition.
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Aota T, Wada H, Yamashita Y, Matsumoto T, Ohishi K, Suzuki K, Imai H, Usui M, Isaji S, Asakura H, Okamoto K, Katayama N. An Evaluation of the Modified Diagnostic Criteria for DIC Established by the Japanese Society of Thrombosis and Hemostasis. Clin Appl Thromb Hemost 2016; 23:579-584. [DOI: 10.1177/1076029616654263] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Objective: We evaluated the modified diagnostic criteria for disseminated intravascular coagulation (DIC), which was published by the Japanese Society of Thrombosis and Hemostasis (JSTH) in 108 patients with suspected infectious DIC. Material and methods: The diagnoses of the patients were as follows: DIC (n = 63), pre-DIC (n = 22), and non-DIC (n = 45). The efficacy of the diagnostic criteria for DIC was evaluated using a receiver–operating characteristic analysis. Results: Although the area under the curve for global coagulation test (GCT) scores in the diagnosis of “DIC” was high that for the diagnosis of “DIC and pre-DIC” was low, suggesting that the addition of antithrombin (AT), soluble fibrin (SF)/thrombin–AT complex (TAT), and reduced platelet count (PLT) values was required to diagnose “DIC and pre-DIC.” Using GCT score with the AT, SF/TAT, and reduced PLT values, the cutoff value of the DIC score for the diagnosis of “DIC and pre-DIC” was 5 points. Discussion and conclusion: The modified JSTH’s diagnostic criteria for DIC, which used the GCT score and the reduced PLT, AT, and TAT/SF values, were useful for diagnosing “DIC and pre-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, Mie, 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
| | - Hidesaku Asakura
- Department of Hematology, Kanazawa University Hospital, Kanazawa, Japan
| | - Kohji Okamoto
- Department of Surgery, Yahata Municipal Hospital, Fukuoka, Japan
| | - Naoyuki Katayama
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, Mie, Japan
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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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