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Tanaka S, Ohmine T. A case of abdominal aortic aneurysm presenting as symptomatic disseminated intravascular coagulation treated with endovascular aneurysm repair and postoperative administration of Nafamostat mesylate. Surg Case Rep 2024; 10:124. [PMID: 38750283 PMCID: PMC11096137 DOI: 10.1186/s40792-024-01926-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 05/09/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Cases of abdominal aortic aneurysm discovered as purpura on the extremities with disseminated intravascular coagulation (DIC) are rare. The number of currently established strategies for the control of DIC with aortic aneurysm is limited. CASE PRESENTATION An 85-year-old woman was referred to the hematology department because of purpura on her shoulder and thigh. Enhanced fibrinolytic-type DIC was diagnosed by a blood test. Enhanced computed tomography (CT) revealed 60-mm abdominal aortic and 42-mm right common iliac aneurysms. We performed endovascular aneurysm repair (EVAR) and coiling of the right internal iliac artery with postoperative administration of Nafamostat mesylate. The patient promptly recovered from DIC, and the purpura gradually disappeared. CONCLUSIONS We safely performed EVAR with postoperative administration of Nafamostat mesylate for an abdominal aortic aneurysms that presented as symptomatic DIC.
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Affiliation(s)
- Shinichi Tanaka
- Department of Surgery, Hiroshima Red Cross Hospital & Atomic-Bomb Survivors Hospital, 1-9-6 Sendamachi, Naka-Ku, Hiroshima, 730-8619, Japan.
| | - Takahiro Ohmine
- Department of Surgery, Hiroshima Red Cross Hospital & Atomic-Bomb Survivors Hospital, 1-9-6 Sendamachi, Naka-Ku, Hiroshima, 730-8619, Japan
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2
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Yamada S, Asakura H. How We Interpret Thrombosis with Thrombocytopenia Syndrome? Int J Mol Sci 2024; 25:4956. [PMID: 38732176 PMCID: PMC11084439 DOI: 10.3390/ijms25094956] [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: 03/27/2024] [Revised: 04/16/2024] [Accepted: 04/29/2024] [Indexed: 05/13/2024] Open
Abstract
Platelets play an important role in hemostasis, and a low platelet count usually increases the risk of bleeding. Conditions in which thrombosis occurs despite low platelet counts are referred to as thrombosis with thrombocytopenia syndrome, including heparin-induced thrombocytopenia, vaccine-induced immune thrombotic thrombocytopenia, paroxysmal nocturnal hemoglobinuria, antiphospholipid syndrome, thrombotic microangiopathy (TMA), and disseminated intravascular coagulation. TMA includes thrombotic thrombocytopenic purpura, Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome (HUS), and atypical HUS. Patients with these pathologies present with thrombosis and consumptive thrombocytopenia associated with the activation of platelets and the coagulation system. Treatment varies from disease to disease, and many diseases have direct impacts on mortality and organ prognosis if therapeutic interventions are not promptly implemented. Underlying diseases and the results of physical examinations and general laboratory tests as part of a thorough workup for patients should promptly lead to therapeutic intervention before definitive diagnosis. For some diseases, the diagnosis and initial treatment must proceed in parallel. Utilization of not only laboratory tests but also various scoring systems is important for validating therapeutic interventions based on clinical information.
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Affiliation(s)
| | - Hidesaku Asakura
- Department of Hematology, Kanazawa University Hospital, Takaramachi 13-1, Kanazawa City 920-8640, Ishikawa, Japan;
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3
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Zhao X, Yang S, Lei R, Liu Y, Duan Q, Li J, Sun L. Value of novel thrombotic markers for predicting occurrence of the malignant cerebral artery infarction: a prospective clinical study. Front Neurol 2023; 14:1238742. [PMID: 38099069 PMCID: PMC10719929 DOI: 10.3389/fneur.2023.1238742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 11/06/2023] [Indexed: 12/17/2023] Open
Abstract
Objective This study investigated the diagnostic performance of thrombin-antithrombin complex (TAT), plasmin-α2 plasmin inhibitor complex (PIC), tissue plasminogen activator-plasminogen activator inhibitor complex (t-PAIC), and thrombomodulin (TM) in predicting the progression of massive cerebral infarction to the malignant cerebral artery infarction. Method A total of 71 patients with massive cerebral infarction confirmed by imaging examination were divided into malignant cerebral artery infarction group (MCAI) and non-malignant cerebral artery infarction group (NMCAI) based on whether they progressed to MCAI after admission. TAT, PIC, t-PAIC, and TM were measured immediately after admission. The predictive performance was analyzed by the receiver characteristic operating curve (ROC). Result The median plasma concentrations of TM, PIC, TAT, and t-PAIC in the MCAI patients at admission were 10.65 IU/mL, 1.17 μg/mL, 12.25 ng/mL, and 13.85 ng/mL, respectively, which were higher than those in the NMCAI patients (9.00 IU/mL, 1.07 μg/mL, 4.60 ng/mL, and 8.70 ng/mL), and the difference was statistically significant (p = 0.045, p = 0.035, p = 0.004, and p = 0.003). Elevated plasma t-PAIC concentration was shown to be an independent risk factor for progression of massive cerebral infarction to MCAI (OR = 1.131) by multivariate logistic regression analysis. ROC curve analysis showed that t-PAIC was the best predictor of MCAI (AUC = 74.7%), with a sensitivity of 75.0% and specificity of 75.9% when t-PAIC concentration was ≥12.4 ng/mL; TAT had the highest specificity in predicting MCAI, with a specificity of 90.7% when the TAT concentration was ≥13.5 ng/mL. Conclusion The detection of PIC, TAT, t-PAIC, and TM is a comprehensive assessment of vascular endothelial damage and activation of the coagulation and fibrinolytic systems and has predictive value for poor prognosis in patients with MCAI. The widespread use of these tests will likely greatly improve the early diagnosis rate of MCAI.
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Affiliation(s)
- Xiaoxia Zhao
- Department of Neurology, Shanxi Provincial Peoples Hospital, Taiyuan, China
| | - Siyu Yang
- Department of Neurology, Fifth Hospital of Shanxi Medical University, Taiyuan, China
| | - Ruining Lei
- Department of Neurology, Fifth Hospital of Shanxi Medical University, Taiyuan, China
| | - Yi Liu
- Department of Neurology, Shanxi Provincial Peoples Hospital, Taiyuan, China
| | - Qiaoyan Duan
- Clinical Laboratory, Shanxi Provincial Peoples Hospital, Taiyuan, China
| | - Jundong Li
- Medical Imaging Department, Shanxi Provincial Peoples Hospital, Taiyuan, China
| | - Lei Sun
- Zhao Furun Famous Doctor Studio in Shanxi Province, Taiyuan, China
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Ezaki M, Wada H, Ichikawa Y, Ikeda N, Shiraki K, Yamamoto A, Moritani I, Shimaoka M, Shimpo H. Plasma Soluble Fibrin Is Useful for the Diagnosis of Thrombotic Diseases. J Clin Med 2023; 12:jcm12072597. [PMID: 37048680 PMCID: PMC10095172 DOI: 10.3390/jcm12072597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/13/2023] [Accepted: 03/28/2023] [Indexed: 04/01/2023] Open
Abstract
Background: Soluble fibrin (SF) is a form of fibrinogen that is activated by thrombin and is considered to be useful for the diagnosis of the prethrombotic state or thrombosis. Methods: Plasma levels of fibrin-related markers (FRMs), such as SF, D-dimer, fibrinogen, and fibrin degradation prioduct (FDP) levels in critically ill patients, were examined for the diagnosis of disseminated intravascular coagulation (DIC), venous thromboembolism (VTE), peripheral arterial thromboembolism (PATE), acute myocardial infarction (AMI), and acute cerebral infarction (ACI). Results: FRMs showed the usefulness in diagnosing DIC and VTE and the cutoff values of D-dimer, FDP, and SF for DIC were 7.2–7.8 μg/mL, 10.0 μg/mL, and 9.5 μg/mL, respectively. The cutoff values of D-dimer and FDP for VTE were similar to the 97.5th percentile values of healthy volunteers, while the cutoff value of SF was 6.9 μg/mL. In AMI and ACI, the cutoff values of D-dimer and FDP were lower than the 97.5 percentile values of healthy volunteers. A receiver operating characteristic analysis for all thrombosis cases showed that an adequate cutoff value in only SF among FRMs was higher than the confidence interval of healthy volunteers. Only SF had high sensitivity for thrombosis, as the FDP/SF ratio was markedly low for ACI, AMI and VTE. Conclusions: FRMs, especially D-dimer and FDP, were useful for diagnosing thrombosis with hyperfibrinolysis (e.g., DIC). As SF showed high sensitivity for predominantly thrombotic diseases, including arterial thrombosis, such as ACI and AMI, a high SF value suggests the possibility of an association with thrombosis. Finally, SF is the most useful marker for raising suspicion of an association with thrombosis, especially arterial thrombosis.
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Affiliation(s)
- Minoru Ezaki
- Department of Central Laboratory, Mie Prefectural General Medical Center, Yokkaichi 510-0885, Japan
| | - Hideo Wada
- Department of General and Laboratory Medicine, Mie Prefectural General Medical Center, Yokkaichi 510-0885, Japan;
| | - Yuhuko Ichikawa
- Department of Central Laboratory, Mie Prefectural General Medical Center, Yokkaichi 510-0885, Japan
| | - Nozomi Ikeda
- Department of Central Laboratory, Mie Prefectural General Medical Center, Yokkaichi 510-0885, Japan
| | - Katsuya Shiraki
- Department of General and Laboratory Medicine, Mie Prefectural General Medical Center, Yokkaichi 510-0885, Japan;
- Correspondence: ; Tel.: +81-59-345-2321
| | - Akitaka Yamamoto
- Department of Emergency and Critical Care Center, Mie Prefectural General Medical Center, Yokkaichi 510-0885, Japan
| | - Isao Moritani
- Department of Gastroenterology, Mie Prefectural General Medical Center, Yokkaichi 510-0885, Japan
| | - Motomu Shimaoka
- Department of Molecular Pathobiology and Cell Adhesion Biology, Mie University Graduate School of Medicine, Tsu 514-8507, Japan
| | - Hideto Shimpo
- Mie Prefectural General Medical Center, Yokkaichi 510-0885, Japan
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Yamada S, Asakura H, Kubo M, Sakai K, Miyamoto T, Matsumoto M. Distinguishing immune-mediated thrombotic thrombocytopenic purpura from septic disseminated intravascular coagulation using plasma levels of haptoglobin and factor XIII activity. Res Pract Thromb Haemost 2023; 7:100076. [PMID: 36861115 PMCID: PMC9969072 DOI: 10.1016/j.rpth.2023.100076] [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] [Received: 10/31/2022] [Revised: 12/21/2022] [Accepted: 01/12/2023] [Indexed: 02/10/2023] Open
Abstract
Background Both immune-mediated thrombotic thrombocytopenic purpura (iTTP) and septic disseminated intravascular coagulation (DIC) are life-threatening disorders developed by platelet-consuming microvascular thrombi and necessitate immediate therapeutic interventions. Although severe deficiencies of plasma haptoglobin in iTTP and factor XIII (FXIII) activity in septic DIC have been reported, few studies have focused on the possibility of using these markers to distinguish between iTTP and septic DIC. Objectives We investigated whether the plasma levels of haptoglobin and FXIII activity could be helpful for differential diagnosis. Methods Thirty-five patients with iTTP and 30 with septic DIC were enrolled in the study. Patient characteristics, coagulation, and fibrinolytic markers were collected from the clinical data. Plasma haptoglobin and FXIII activities were measured using chromogenic Enzyme-Linked Immuno Sorbent Assay and an automated instrument, respectively. Results The median plasma haptoglobin level was 0.39 mg/dL and 54.20 mg/dL in the iTTP and septic DIC groups, respectively. The median plasma FXIII activities were 91.3% and 36.3% in the iTTP and septic DIC groups, respectively. In the receiver operating characteristic curve analysis, the cutoff level of plasma haptoglobin was 2.868 mg/dL and the area under the curve was 0.832. The cutoff level for plasma FXIII activity and the area under the curve were 76.0% and 0.931, respectively. The thrombotic thrombocytopenic purpura (TTP)/DIC index was defined by FXIII activity (percentage) and haptoglobin (milligrams per decilitre). Laboratory TTP was defined as an index ≥60 and laboratory DIC <60. The sensitivity and specificity of the TTP/DIC index were 94.3% and 86.7%, respectively. Conclusion The TTP/DIC index, composed of plasma levels of haptoglobin and FXIII activity, is useful in differentiating iTTP from septic DIC.
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Affiliation(s)
- Shinya Yamada
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan,Department of Hematology, Kanazawa University Hospital, Kanazawa, Japan
| | - Hidesaku Asakura
- Department of Hematology, Kanazawa University Hospital, Kanazawa, Japan
| | - Masayuki Kubo
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Kazuya Sakai
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | | | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan,Correspondence Masanori Matsumoto, Department of Blood Transfusion Medicine, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan.
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Yamada S, Suga Y, Morishita E, Asakura H. Effect of Anticoagulant/Antifibrinolytic Combination Therapy on Enhanced Fibrinolytic-Type Disseminated Intravascular Coagulation in End-of-Life Stage Solid Tumor Patients. J Palliat Med 2023; 26:307-311. [PMID: 36108152 DOI: 10.1089/jpm.2022.0249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Thrombotic disorders such as venous thromboembolism and disseminated intravascular coagulation (DIC) are known complications of solid tumors. To date, no reports have described the treatment of enhanced fibrinolytic-type DIC caused by end-of-life stage solid tumors. We encountered three cases of end-of-life stage solid tumors complicated by enhanced fibrinolytic-type DIC with severe bleeding symptoms. In all three cases, bleeding symptoms improved dramatically after intervention for enhanced fibrinolytic-type DIC with heparin(s) and tranexamic acid. Improvements in abnormal coagulation test results were also seen and the need for platelet concentrate transfusion and fresh frozen plasma infusion was able to be eliminated. However, one patient developed multiple cerebral infarctions. In the future, further studies to investigate the need for intervention in enhanced fibrinolytic-type DIC caused by end-of-life stage solid tumors and suitable treatment strategies are warranted.
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Affiliation(s)
- Shinya Yamada
- Department of Hematology, Kanazawa University Hospital, Ishikawa, Japan
| | - Yukio Suga
- Department of Clinical Pharmacy and Healthcare Science, Faculty of Pharmacy, Institute of Medical, Pharmaceutical and Health Science, Kanazawa University, Ishikawa, Japan
| | - Eriko Morishita
- Department of Hematology, Kanazawa University Hospital, Ishikawa, Japan
| | - Hidesaku Asakura
- Department of Hematology, Kanazawa University Hospital, Ishikawa, Japan
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7
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Suzuki N, Suzuki N, Kawaguchi Y, Okamoto S, Kanematsu T, Katsumi A, Suzuki A, Tamura S, Kojima T, Kiyoi H, Matsushita T. The usefulness of tranexamic acid for bleeding symptoms of chronic consumptive coagulopathy complicated by aortic disease: a single-institute, retrospective study of 14 patients. Thromb J 2023; 21:10. [PMID: 36698142 PMCID: PMC9878879 DOI: 10.1186/s12959-022-00429-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 11/04/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Tranexamic acid (TXA) is an antifibrinolytic drug that blocks lysine-binding sites on the profibrinolytic enzyme plasminogen. Aortic diseases with chronic consumption coagulopathy may lead to disseminated intravascular coagulation (DIC) and cause fatal bleeding. Although the use of antifibrinolytic agents in DIC is generally not recommended due to enhanced fibrin deposition risking thrombotic symptoms, the efficacy of TXA has been reported in several cases of DIC with aortic diseases. However, the efficacy and safety of TXA for bleeding symptoms of chronic consumption coagulopathy with aortic diseases have not been studied in detail. METHODS We evaluated the efficacy of TXA in 14 patients with chronic consumptive coagulopathy due to aortic disease complicated by bleeding symptoms. Changes in coagulation and fibrinolysis parameters from baseline were analyzed with Wilcoxon matched-pairs signed-rank tests, excluding missing values. Kaplan-Meier curves were used to analyze overall survival. RESULTS Median age was 78.5 years (range, 66-89 years) and median observation period was 448 days (range, 0-2282 days). Twelve patients had chronic renal failure and 1 patient had chronic liver failure. Before starting treatment, median Japanese Ministry of Health and Welfare DIC diagnostic criteria score was 8 (range, 4-11) and median platelet count was 64 × 109/L (range, 25-97 × 109/L). Twelve patients underwent evaluation of bleeding symptoms after introduction of TXA, and 10 of those 12 patients showed improved bleeding tendencies within 30 days (median, 5.0 days). One patient with chronic liver failure showed worsening of bleeding symptoms. Although only one patient was initiated TXA in combination with anticoagulants, no significant worsening of thrombotic events was observed within 30 days. CONCLUSIONS TXA therapy appears effective against chronic consumptive coagulopathy with bleeding due to aortic disease, with few side effects.
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Affiliation(s)
- Naruko Suzuki
- grid.27476.300000 0001 0943 978XDepartment of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobuaki Suzuki
- grid.437848.40000 0004 0569 8970Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Yuka Kawaguchi
- grid.27476.300000 0001 0943 978XDepartment of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shuichi Okamoto
- grid.437848.40000 0004 0569 8970Department of Clinical Laboratory, Nagoya University Hospital, Nagoya, Japan
| | - Takeshi Kanematsu
- grid.437848.40000 0004 0569 8970Department of Clinical Laboratory, Nagoya University Hospital, Nagoya, Japan
| | - Akira Katsumi
- grid.419257.c0000 0004 1791 9005Department of Hematology, National Center of Geriatrics and Gerontology, Obu, Japan
| | - Atsuo Suzuki
- grid.437848.40000 0004 0569 8970Department of Medical Technique, Nagoya University Hospital, Nagoya, Japan
| | - Shogo Tamura
- grid.27476.300000 0001 0943 978XDepartment of Integrated Health Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan ,grid.39158.360000 0001 2173 7691Present address: Department of Medical Laboratory Science, Hokkaido University Graduate School of Health Science, Sapporo, Japan
| | | | - Hitoshi Kiyoi
- grid.27476.300000 0001 0943 978XDepartment of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tadashi Matsushita
- grid.437848.40000 0004 0569 8970Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
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8
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(Conservative treatment of chronic disseminated intravascular coagulation caused by chronic dissection and aneurysm of thoracoabdominal aorta with rivaroxaban). COR ET VASA 2022. [DOI: 10.33678/cor.2022.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Tonai K, Katayama S, Koyama K, Sata N, Tomioka Y, Imahase H, Nunomiya S. Association between hypomagnesemia and coagulopathy in sepsis: a retrospective observational study. BMC Anesthesiol 2022; 22:359. [PMID: 36424547 PMCID: PMC9685885 DOI: 10.1186/s12871-022-01903-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 11/11/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Hypomagnesemia reportedly has significant associations with poor clinical outcomes such as increased mortality and septic shock in patients with sepsis. Although the mechanism underlying these outcomes mostly remains unclear, some experimental data suggest that magnesium deficiency could potentiate coagulation activation in sepsis. However, in sepsis, the association between serum magnesium levels and coagulopathy, including disseminated intravascular coagulation (DIC), remains unknown. Thus, we aimed to investigate the relationship between serum magnesium levels and coagulation status and the association between hypomagnesemia and DIC in patients with sepsis. METHODS This retrospective observational study was conducted at the intensive care unit (ICU) of a university hospital from June 2011 to December 2017. Patients older than 19 years who met the Sepsis-3 definition were included. We categorized patients into three groups according to their serum magnesium levels: hypomagnesemia (< 1.6 mg/dL), normal serum magnesium level (1.6-2.4 mg/dL), and hypermagnesemia (> 2.4 mg/dL). We investigated the association between serum magnesium levels and overt DIC at the time of ICU admission according to the criteria of the International Society on Thrombosis and Haemostasis. RESULTS Among 753 patients included in this study, 181 had DIC, 105 had hypomagnesemia, 552 had normal serum magnesium levels, and 96 had hypermagnesemia. Patients with hypomagnesemia had a more activated coagulation status indicated by lower platelet counts, lower fibrinogen levels, higher prothrombin time-international normalized ratios, higher thrombin-antithrombin complex, and more frequent DIC than those with normal serum magnesium levels and hypermagnesemia (DIC: 41.9% vs. 20.6% vs. 24.0%, P < 0.001). The coagulation status in patients with hypomagnesemia was more augmented toward suppressed fibrinolysis than that in patients with normal serum magnesium levels and hypermagnesemia. Multivariate logistic regression revealed that hypomagnesemia was independently associated with DIC (odds ratio, 1.69; 95% confidence interval, 1.00-2.84; P = 0.048) after adjusting for several confounding variables. CONCLUSIONS Patients with hypomagnesemia had a significantly activated coagulation status and suppressed fibrinolysis. Hypomagnesemia was independently associated with DIC in patients with sepsis. Therefore, the treatment of hypomagnesemia may be a potential therapeutic strategy for the treatment of coagulopathy in sepsis.
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Affiliation(s)
- Ken Tonai
- grid.410804.90000000123090000Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498 Japan
| | - Shinshu Katayama
- grid.410804.90000000123090000Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498 Japan
| | - Kansuke Koyama
- grid.410804.90000000123090000Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498 Japan
| | - Naho Sata
- grid.410804.90000000123090000Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498 Japan
| | - Yoshihiro Tomioka
- grid.410804.90000000123090000Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498 Japan
| | - Hisashi Imahase
- grid.410804.90000000123090000Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498 Japan
| | - Shin Nunomiya
- grid.410804.90000000123090000Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498 Japan
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Coagulopathy and Fibrinolytic Pathophysiology in COVID-19 and SARS-CoV-2 Vaccination. Int J Mol Sci 2022; 23:ijms23063338. [PMID: 35328761 PMCID: PMC8955234 DOI: 10.3390/ijms23063338] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 03/03/2022] [Accepted: 03/15/2022] [Indexed: 02/06/2023] Open
Abstract
Coronavirus Disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is frequently complicated by thrombosis. In some cases of severe COVID-19, fibrinolysis may be markedly enhanced within a few days, resulting in fatal bleeding. In the treatment of COVID-19, attention should be paid to both coagulation activation and fibrinolytic activation. Various thromboses are known to occur after vaccination with SARS-CoV-2 vaccines. Vaccine-induced immune thrombotic thrombocytopenia (VITT) can occur after adenovirus-vectored vaccination, and is characterized by the detection of anti-platelet factor 4 antibodies by enzyme-linked immunosorbent assay and thrombosis in unusual locations such as cerebral venous sinuses and visceral veins. Treatment comprises high-dose immunoglobulin, argatroban, and fondaparinux. Some VITT cases show marked decreases in fibrinogen and platelets and marked increases in D-dimer, suggesting the presence of enhanced-fibrinolytic-type disseminated intravascular coagulation with a high risk of bleeding. In the treatment of VITT, evaluation of both coagulation activation and fibrinolytic activation is important, adjusting treatments accordingly to improve outcomes.
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Recurrent Bleeding after Head Trauma Caused by Acquired Factor XIII Deficiency. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4109. [PMID: 35186643 PMCID: PMC8846273 DOI: 10.1097/gox.0000000000004109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 12/14/2021] [Indexed: 11/26/2022]
Abstract
Factor XIII (FXIII) is the final factor in the coagulation cascade. FXIII plays a critical role in clot stabilization by cross-linking fibrin and making the clot denser and stiffer. FXIII plays crucial roles in platelet clot retraction, wound healing, and tissue repair. When FXIII is deficient, unusual bleeding that persists for several days, delayed healing, and morbid granulation may occur. We present a case of acquired FXIII deficiency presenting as recurrent bleeding after head trauma. A 66-year-old man fell from a ladder and sustained a head injury. The patient had a history of postremission acute myeloid leukemia and Stanford type B aortic dissection and was on three antihypertensives but no antiplatelets or anticoagulants. Approximately 1 month postinjury, the patient suddenly experienced repeated bleeding and hematoma. Routine coagulation tests were normal; therefore, we suspected another type of coagulation disorder. Low FXIII activity was identified 39 days postinjury. We immediately administered concentrated human coagulation FXIII (Fibrogammin P). The patient’s head contusion was completely healed by day 55 postinjury. Acquired FXIII deficiency should be considered when routine coagulation test results are normal. Plastic surgeons who treat injuries routinely must be cognizant of FXIII deficiency because the condition can be life-threatening and early detection is important. Whenever the process of wound healing is unusual or hematoma and bleeding recur unexpectedly with no clear explanation—despite suitable treatments—FXIII deficiency should be suspected and, if present, must be appropriately treated without delay.
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12
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Yamada S, Asakura H. Vaccine-induced immune thrombotic thrombocytopenia: Update on diagnosis and management considering different resources: Comment from Yamada et al. J Thromb Haemost 2022; 20:540-541. [PMID: 35060303 DOI: 10.1111/jth.15618] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 11/19/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Shinya Yamada
- Department of Hematology, Kanazawa University Hospital, Ishikawa, Japan
| | - Hidesaku Asakura
- Department of Hematology, Kanazawa University Hospital, Ishikawa, Japan
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13
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Therapeutic Strategies for Disseminated Intravascular Coagulation Associated with Aortic Aneurysm. Int J Mol Sci 2022; 23:ijms23031296. [PMID: 35163216 PMCID: PMC8836167 DOI: 10.3390/ijms23031296] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/05/2022] [Accepted: 01/22/2022] [Indexed: 01/22/2023] Open
Abstract
Aortic aneurysms are sometimes associated with enhanced-fibrinolytic-type disseminated intravascular coagulation (DIC). In enhanced-fibrinolytic-type DIC, both coagulation and fibrinolysis are markedly activated. Typical cases show decreased platelet counts and fibrinogen levels, increased concentrations of fibrin/fibrinogen degradation products (FDP) and D-dimer, and increased FDP/D-dimer ratios. Thrombin-antithrombin complex or prothrombin fragment 1 + 2, as markers of coagulation activation, and plasmin-α2 plasmin inhibitor complex, a marker of fibrinolytic activation, are all markedly increased. Prolongation of prothrombin time (PT) is not so obvious, and the activated partial thromboplastin time (APTT) is rather shortened in some cases. As a result, DIC can be neither diagnosed nor excluded based on PT and APTT alone. Many of the factors involved in coagulation and fibrinolysis activation are serine proteases. Treatment of enhanced-fibrinolytic-type DIC requires consideration of how to control the function of these serine proteases. The cornerstone of DIC treatment is treatment of the underlying pathology. However, in some cases surgery is either not possible or exacerbates the DIC associated with aortic aneurysm. In such cases, pharmacotherapy becomes even more important. Unfractionated heparin, other heparins, synthetic protease inhibitors, recombinant thrombomodulin, and direct oral anticoagulants (DOACs) are agents that inhibit serine proteases, and all are effective against DIC. Inhibition of activated coagulation factors by anticoagulants is key to the treatment of DIC. Among them, DOACs can be taken orally and is useful for outpatient treatment. Combination therapy of heparin and nafamostat allows fine-adjustment of anticoagulant and antifibrinolytic effects. While warfarin is an anticoagulant, this agent is ineffective in the treatment of DIC because it inhibits the production of coagulation factors as substrates without inhibiting activated coagulation factors. In addition, monotherapy using tranexamic acid in cases of enhanced-fibrinolytic-type DIC may induce fatal thrombosis. If tranexamic acid is needed for DIC, combination with anticoagulant therapy is of critical importance.
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Yagi T, Nakamura H, Wakamatsu T, Imura Y, Tamiya H, Sabe H, Yamashita K, Watanabe M, Takenaka S. Primary breast angiosarcoma with disseminated intravascular coagulation is successfully treated with self-subcutaneous unfractionated heparin calcium injection: A case report. Mol Clin Oncol 2021; 14:104. [PMID: 33815793 PMCID: PMC8010513 DOI: 10.3892/mco.2021.2266] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/26/2021] [Indexed: 11/19/2022] Open
Abstract
Angiosarcoma is a rare sarcoma with a poor prognosis and is prone to disseminated intravascular coagulation (DIC), where DIC often interferes with chemotherapy. Primary angiosarcoma of the breast (PASB) is a type of angiosarcoma that is located in mammary parenchyma and is not associated with radiation exposure. The current study reported a 47-year-old female with DIC associated with PASB. The DIC of the patient relapsed during mono-chemotherapy with paclitaxel (PTX) after first-line anticoagulant therapy using thrombomodulin-α. The second-line danaparoid sodium therapy, followed by self-subcutaneous injection of unfractionated heparin calcium (UFH), resulted in long-term stabilization of DIC. Under this second-line anticoagulant therapy, the patient continued chemotherapy and chemoradiotherapy for >13 months in the outpatient setting without impairment of quality of life. The present case suggested that self-subcutaneous injections of UFH may be a useful therapeutic option for long-term control of DIC associated with PASB. However, further prospective clinical trails are needed to verify the efficacy of self-subcutaneous injection of UFH in similar settings.
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Affiliation(s)
- Toshinari Yagi
- Department of Outpatient Chemotherapy, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Harumi Nakamura
- Department of Diagnostic Pathology and Cytology, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Toru Wakamatsu
- Department of Orthopedic Surgery, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Yoshinori Imura
- Department of Orthopedic Surgery, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Hironari Tamiya
- Department of Orthopedic Surgery, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Hideaki Sabe
- Department of Orthopedic Surgery, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Katsunari Yamashita
- Department of Orthopedic Surgery, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Makiyo Watanabe
- Department of Orthopedic Surgery, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Satoshi Takenaka
- Department of Orthopedic Surgery, Osaka International Cancer Institute, Osaka 541-8567, Japan
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