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Yao Y, Li J, Sun W, Ma C, Ning N, Li J, Ni T, Gui M, Chen Y, Zhao B, Zhang J, Zhu J, Gao C, Sheng H, Mao E. Association Between Nonthyroidal Illness Syndrome and Disseminated Intravascular Coagulation in Sepsis. J Inflamm Res 2024; 17:497-506. [PMID: 38304414 PMCID: PMC10832446 DOI: 10.2147/jir.s442598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 01/23/2024] [Indexed: 02/03/2024] Open
Abstract
Purpose Both nonthyroidal illness syndrome (NTIS) and disseminated intravascular coagulation (DIC) are commonly occurred in sepsis. The objective of this study is to evaluate the association between NTIS and DIC, as well as their impacts on the mortality in adults with sepsis. Patients and methods A total of 1219 septic patients in two Chinese academic centers from October 2012 and October 2022 were enrolled in analysis. We conduct logistic regression models to analyze the independent risk factors for DIC. Modified Poisson regression models are used to estimate the relative risk (RR) of NTIS on the 28 days mortality in septic patients with DIC. Correlation analysis between thyroid function parameters and coagulation parameters is performed with Pearson coefficient be reported. Results DIC is diagnosed on 388 (31.8%) of all the 1219 enrolled septic patients within 72 hours after admission. In multivariate logistic regression models, NTIS (OR 3.19; CI 2.31-4.46; p<0.001) is a statistically significant independent risk factor for DIC after adjustment for potential confounders. Twenty-eight days mortality is significantly higher in DIC patients complicated with NTIS compared with the other DIC patients (23.2% vs 14.0%, p=0.024). This result is also robust in different modified Poisson regression models (Model 1: RR 1.46; CI 1.25-1.70; p<0.001; Model 2: RR 1.35; CI 1.14-1.60; p<0.001; Model 3: RR 1.18; CI 1.02-1.37; p=0.026). Correlation analysis reveals that the thyroid function parameters of FT3, FT4 and TSH only have weak correlations with coagulation parameters of platelet count, fibrinogen, FDP, D-dimers, PT, APTT and INR in sepsis. Conclusion NTIS is an independent risk factor for DIC in adults with sepsis. DIC patients complicated with NTIS have significantly higher severity and higher rate of mortality.
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Affiliation(s)
- Yi Yao
- Departments of Emergency, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, People’s Republic of China
| | - Juan Li
- Department of Emergency, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People’s Republic of China
| | - Wenwu Sun
- Departments of Emergency, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, People’s Republic of China
| | - Chaoping Ma
- Department of Emergency, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People’s Republic of China
| | - Ning Ning
- Departments of Emergency, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, People’s Republic of China
| | - Jiaoyan Li
- Departments of Emergency, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, People’s Republic of China
| | - Tongtian Ni
- Departments of Emergency, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, People’s Republic of China
| | - Menglu Gui
- Departments of Emergency, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, People’s Republic of China
| | - Ying Chen
- Departments of Emergency, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, People’s Republic of China
| | - Bing Zhao
- Departments of Emergency, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, People’s Republic of China
| | - Jiyuan Zhang
- Department of Emergency, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People’s Republic of China
| | - Jiyue Zhu
- Department of General Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People’s Republic of China
| | - Chengjin Gao
- Department of Emergency, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People’s Republic of China
| | - Huiqiu Sheng
- Departments of Emergency, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, People’s Republic of China
| | - Enqiang Mao
- Departments of Emergency, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, People’s Republic of China
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Shibeko AM, Ilin IS, Podoplelova NA, Sulimov VB, Panteleev MA. Chemical Adjustment of Fibrinolysis. Pharmaceuticals (Basel) 2024; 17:92. [PMID: 38256925 PMCID: PMC10819531 DOI: 10.3390/ph17010092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 12/31/2023] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
Fibrinolysis is the process of the fibrin-platelet clot dissolution initiated after bleeding has been stopped. It is regulated by a cascade of proteolytic enzymes with plasmin at its core. In pathological cases, the balance of normal clot formation and dissolution is replaced by a too rapid lysis, leading to bleeding, or an insufficient one, leading to an increased thrombotic risk. The only approved therapy for emergency thrombus lysis in ischemic stroke is recombinant tissue plasminogen activator, though streptokinase or urokinase-type plasminogen activators could be used for other conditions. Low molecular weight compounds are of great interest for long-term correction of fibrinolysis dysfunctions. Their areas of application might go beyond the hematology field because the regulation of fibrinolysis could be important in many conditions, such as fibrosis. They enhance or weaken fibrinolysis without significant effects on other components of hemostasis. Here we will describe and discuss the main classes of these substances and their mechanisms of action. We will also explore avenues of research for the development of new drugs, with a focus on the use of computational models in this field.
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Affiliation(s)
- Alexey M. Shibeko
- Center for Theoretical Problems of Physicochemical Pharmacology, Russian Academy of Sciences, 109029 Moscow, Russia; (A.M.S.); (M.A.P.)
- National Medical Research Center of Pediatric Hematology, Oncology and Immunology Named after Dmitry Rogachev, 117197 Moscow, Russia
| | - Ivan S. Ilin
- Research Computing Center, Lomonosov Moscow State University, 119991 Moscow, Russia; (I.S.I.); (V.B.S.)
- Dimonta, Ltd., 117186 Moscow, Russia
| | - Nadezhda A. Podoplelova
- Center for Theoretical Problems of Physicochemical Pharmacology, Russian Academy of Sciences, 109029 Moscow, Russia; (A.M.S.); (M.A.P.)
- National Medical Research Center of Pediatric Hematology, Oncology and Immunology Named after Dmitry Rogachev, 117197 Moscow, Russia
| | - Vladimir B. Sulimov
- Research Computing Center, Lomonosov Moscow State University, 119991 Moscow, Russia; (I.S.I.); (V.B.S.)
- Dimonta, Ltd., 117186 Moscow, Russia
| | - Mikhail A. Panteleev
- Center for Theoretical Problems of Physicochemical Pharmacology, Russian Academy of Sciences, 109029 Moscow, Russia; (A.M.S.); (M.A.P.)
- National Medical Research Center of Pediatric Hematology, Oncology and Immunology Named after Dmitry Rogachev, 117197 Moscow, Russia
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Cheng J, Zeng H, Chen H, Fan L, Xu C, Huang H, Tang T, Li M. Current knowledge of thrombocytopenia in sepsis and COVID-19. Front Immunol 2023; 14:1213510. [PMID: 37841241 PMCID: PMC10568455 DOI: 10.3389/fimmu.2023.1213510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 09/12/2023] [Indexed: 10/17/2023] Open
Abstract
Thrombocytopenia, characterized by a decrease in platelet count, is commonly observed in sepsis and COVID-19. In sepsis, thrombocytopenia can result from various mechanisms, including impaired platelet production in the bone marrow, accelerated platelet destruction due to increased inflammation, sequestration of platelets in the spleen, immune-mediated platelet destruction, or dysregulated host responses. Similarly, thrombocytopenia has been reported in COVID-19 patients, but the immune-related mechanisms underlying this association remain unclear. Notably, interventions targeting thrombocytopenia have shown potential for improving outcomes in both sepsis and COVID-19 patients. Understanding these mechanisms is crucial for developing effective treatments.
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Affiliation(s)
- Junjie Cheng
- Intensive Care Unit, The Fourth Affiliated Hospital, School of Medicine, Zhejiang University, Yiwu, China
| | - Hanhai Zeng
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Huaijun Chen
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Linfeng Fan
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Chaoran Xu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Huaping Huang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Tianchi Tang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Min Li
- Intensive Care Unit, The Fourth Affiliated Hospital, School of Medicine, Zhejiang University, Yiwu, China
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Napolitano F, Giudice V, Selleri C, Montuori N. Plasminogen System in the Pathophysiology of Sepsis: Upcoming Biomarkers. Int J Mol Sci 2023; 24:12376. [PMID: 37569751 PMCID: PMC10418678 DOI: 10.3390/ijms241512376] [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: 06/27/2023] [Revised: 07/21/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023] Open
Abstract
Severe hemostatic disturbances and impaired fibrinolysis occur in sepsis. In the most serious cases, the dysregulation of fibrinolysis contributes to septic shock, disseminated intravascular coagulation (DIC), and death. Therefore, an analysis of circulating concentrations of pro- and anti-fibrinolytic mediators could be a winning strategy in both the diagnosis and the treatment of sepsis. However, the optimal cutoff value, the timing of the measurements, and their combination with coagulation indicators should be further investigated. The purpose of this review is to summarize all relevant publications regarding the role of the main components of the plasminogen activation system (PAS) in the pathophysiology of sepsis. In addition, the clinical value of PAS-associated biomarkers in the diagnosis and the outcomes of patients with septic syndrome will be explored. In particular, experimental and clinical trials performed in emergency departments highlight the validity of soluble urokinase plasminogen activator receptor (suPAR) as a predictive and prognostic biomarker in patients with sepsis. The measurements of PAI-I may also be useful, as its increase is an early manifestation of sepsis and may precede the development of thrombocytopenia. The upcoming years will undoubtedly see progress in the use of PAS-associated laboratory parameters.
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Affiliation(s)
- Filomena Napolitano
- Department of Translational Medical Sciences, University of Naples “Federico II”, 80138 Naples, Italy;
| | - Valentina Giudice
- Hematology and Transplant Center, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy; (V.G.); (C.S.)
- Department of Medicine and Surgery, University of Salerno, 84081 Baronissi, Italy
| | - Carmine Selleri
- Hematology and Transplant Center, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy; (V.G.); (C.S.)
- Department of Medicine and Surgery, University of Salerno, 84081 Baronissi, Italy
| | - Nunzia Montuori
- Department of Translational Medical Sciences, University of Naples “Federico II”, 80138 Naples, Italy;
- Center for Basic and Clinical Immunology Research (CISI), WAO Center of Excellence, University of Naples “Federico II”, 80138 Naples, Italy
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5
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Coleman JR, Moore EE, Kelher MR, Jones K, Cohen MJ, Banerjee A, Silliman CC. Elucidating the molecular mechanisms of fibrinolytic shutdown after severe injury: The role of thrombin-activatable fibrinolysis inhibitor. J Trauma Acute Care Surg 2023; 94:857-862. [PMID: 36787438 PMCID: PMC10205661 DOI: 10.1097/ta.0000000000003911] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND The mechanisms underlying trauma-induced coagulopathy remain elusive. Hyperfibrinolysis has been linked to increased plasminogen activation and antiprotease consumption; however, the mechanistic players in its counterpart, fibrinolysis shutdown, remain unclear. We hypothesize that thrombin-activatable fibrinolysis inhibitor (TAFI) plays a major role in fibrinolytic shutdown after injury. METHODS As part of this observational cohort study, whole blood was collected from trauma activation patients at a single, level 1 trauma center. Citrated rapid thrombelastography and the following enzyme-linked immunosorbent assays were conducted: thrombin, antithrombin, thrombin-antithrombin complex, TAFI, plasminogen, antiplasmin, plasmin-antiplasmin (PAP), tissue plasminogen activator, plasminogen activator inhibitor 1, and tissue plasminogen activator-plasminogen activator inhibitor 1 complex. Univariate and cluster analysis were performed. RESULTS Overall, 56 patients (median age, 33.5 years; 70% male) were included. The majority (57%) presented after blunt mechanism and with severe injury (median New Injury Severity Score, 27). Two clusters of patients were identified: Group 1 (normal fibrinolysis, n = 21) and Group 2 (fibrinolysis shutdown, n = 35). Group 2 had significantly lower fibrinolysis with a median LY30 of 1.1% (interquartile range [IQR], 0.1-1.9%) versus 2.1% (IQR, 0.5-2.8%) in Group 1; while the median LY30 was within physiologic range, 45% of patients in Group 2 were in shutdown (vs. 24% in Group 1, p = 0.09). Compared with Group 1, Group 2 had significantly higher PAP (median, 4.7 [IQR, 1.7-9.3] vs. 1.4 [1.0-2.1] μg/mL in Group 1; p = 0.002) and higher TAFI (median, 152.5% [IQR, 110.3-190.7%] vs. 121.9% [IQR, 93.2-155.6%]; p = 0.04). There was a strong correlation between PAP and TAFI ( R2 = 0.5, p = 0.0002). CONCLUSION The presented data characterize fibrinolytic shutdown, indicating an initial plasmin burst followed by diminished fibrinolysis, which is distinct from hypofibrinolysis (inadequate plasmin burst and fibrinolysis). After an initial thrombin and plasmin burst (increased PAP), fibrinolysis is inhibited, mediated in part by increased TAFI.
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Affiliation(s)
- Julia R Coleman
- From the Department of Surgery (J.R.C., E.E.M., M.J.C., A.B., C.C.S.), University of Colorado-Denver, Aurora; Department of Surgery (E.E.M.), Ernest E Moore Shock Trauma Center at Denver Health; Department of Cell Biology (K.J.), University of Oklahoma; Vitalant Research Institute (M.R.K.); and Department of Pediatrics (C.C.S.), School of Medicine, University of Colorado Denver, Aurora, Colorado
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6
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Frank CS, Larsen JB. Prognostic Impact of the International Society on Thrombosis and Hemostasis Disseminated Intravascular Coagulation Score in Sepsis: A Systematic Review. Semin Thromb Hemost 2023. [PMID: 36731487 DOI: 10.1055/s-0043-1761216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The International Society on Thrombosis and Haemostasis (ISTH) diagnostic criteria for disseminated intravascular coagulation (DIC) are widely used for DIC diagnosis. However, the prognostic value of the score may vary between different patient populations and settings. This systematic review investigated the association between the ISTH DIC score and mortality in sepsis patients. A literature search was conducted in PubMed and Embase. Inclusion criteria were studies including adult and pediatric patients hospitalized with sepsis, using any sepsis definition, and investigating the association between mortality and the ISTH DIC score. The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. In total, 42 studies were included. A positive association between the ISTH DIC score and mortality was consistently reported, with odds ratios of death in DIC versus non-DIC patients ranging from 1.125 (95% confidence interval [CI]: 0.838-1.511) to 21.008 (95% CI: 1.408-313.405) in adults and from 1.378 (95% CI: 1.004-1.893) to 2.99 (95% CI: 0.54-16.6) in pediatric populations. However, the DIC score only had a low-moderate positive predictive value for mortality, as area under receiver-operator characteristics ranged from 0.602 (95% CI: 0.575-0.630) to 0.815 (95% CI: 0.676-0.954) in adults. Of note, only few studies adjusted for potential confounders such as age, gender, and comorbidity. The ISTH DIC score is consistently associated with sepsis-related mortality but is not a strong positive predictor for mortality. Nevertheless, the score may still have a prognostic value and its use in sepsis is encouraged.
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Affiliation(s)
- Christian Sandberg Frank
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Julie Brogaard Larsen
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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7
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Sotos KE, Goggs R, Stablein AP, Brooks MB. Increased thrombin activatable fibrinolysis inhibitor activity is associated with hypofibrinolysis in dogs with sepsis. Front Vet Sci 2023; 10:1104602. [PMID: 36876005 PMCID: PMC9978197 DOI: 10.3389/fvets.2023.1104602] [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: 11/21/2022] [Accepted: 01/30/2023] [Indexed: 02/18/2023] Open
Abstract
Introduction Disorders of coagulation are well-recognized in dogs with sepsis, but data regarding fibrinolysis disorders are limited. We aimed to characterize fibrinolysis in dogs with sepsis compared to healthy controls. We hypothesized that dogs with sepsis would be hypofibrinolytic, and that hypofibrinolysis would be associated with non-survival. Methods This was a prospective observational cohort study. We enrolled 20 client-owned dogs with sepsis admitted to the Cornell University Hospital for Animals and 20 healthy pet dogs. Coagulation and fibrinolytic pathway proteins including antiplasmin activity (AP), antithrombin activity (AT), thrombin activatable fibrinolysis inhibitor activity (TAFI), D-dimer concentration, fibrinogen concentration, and plasminogen activity were measured and compared between groups. Overall coagulation potential, overall fibrinolysis potential, and overall hemostatic potential were calculated from the curve of fibrin clot formation and lysis over time. Results Compared to healthy controls, dogs with sepsis had lower AT (P = 0.009), higher AP (P = 0.002), higher TAFI (P = 0.0385), and higher concentrations of fibrinogen (P < 0.0001) and D-dimer (P = 0.0001). Dogs with sepsis also had greater overall coagulation potential (P = 0.003), overall hemostatic potential (P = 0.0015), and lower overall fibrinolysis potential (P = 0.0004). The extent of fibrinolysis was significantly negatively correlated with TAFI. No significant differences were observed between survivors and non-survivors. Discussion Dogs with sepsis were hypercoagulable and hypofibrinolytic compared to healthy dogs, suggesting potential utility of thromboprophylaxis in this patient population. The association between high TAFI and low overall fibrinolysis potential might provide a potential mechanism for this hypofibrinolysis.
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Affiliation(s)
- Katherine E Sotos
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Robert Goggs
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Alyssa P Stablein
- Comparative Coagulation Laboratory, Animal Health Diagnostic Center, Cornell University, Ithaca, NY, United States
| | - Marjory B Brooks
- Comparative Coagulation Laboratory, Animal Health Diagnostic Center, Cornell University, Ithaca, NY, United States
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Hayakawa M, Tsuchida T, Honma Y, Mizugaki A, Ooyasu T, Yoshida T, Saito T, Katabami K, Wada T, Maekawa K. Fibrinolytic system activation immediately following trauma was quickly and intensely suppressed in a rat model of severe blunt trauma. Sci Rep 2021; 11:20283. [PMID: 34645889 PMCID: PMC8514435 DOI: 10.1038/s41598-021-99426-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 09/17/2021] [Indexed: 11/29/2022] Open
Abstract
In severe trauma, excessive fibrinolytic activation is associated with an increase in the transfusion volume and mortality rate. However, in the first several hours after a blunt trauma, changes in fibrinolytic activation, suppression, and activation–suppression balance have not yet been elucidated, which the present study aimed to clarify. Anesthetized 9-week-old male Wistar S/T rats experienced severe blunt trauma while being placed inside the Noble–Collip drum. Rats were randomly divided into four groups of seven. The no-trauma group was not exposed to any trauma; the remaining groups were analysed 0, 60, and 180 min after trauma. Immediately following trauma, total tissue-plasminogen activator (tPA) levels significantly increased in the plasma, and the balance of active tPA and active plasminogen activator inhibitor-1 (PAI-1) significantly tipped toward fibrinolytic activation. After trauma, both tPA and PAI-1 levels increased gradually in various organs and active and total PAI-1 levels increased exponentially in the plasma. Total plasma tPA levels 60 min after trauma returned quickly to levels comparable to those in the no-trauma group. In conclusion, fibrinolytic activation was observed only immediately following trauma. Therefore, immediately after trauma, the fibrinolytic system was activated; however, its activation was quickly and intensely suppressed.
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Affiliation(s)
- Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, N14W5, Kita-ku, Sapporo, 060-8648, Japan.
| | - Takumi Tsuchida
- Department of Emergency Medicine, Hokkaido University Hospital, N14W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Yoshinori Honma
- Department of Emergency Medicine, Hokkaido University Hospital, N14W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Asumi Mizugaki
- Department of Emergency Medicine, Hokkaido University Hospital, N14W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Takayoshi Ooyasu
- Department of Emergency Medicine, Hokkaido University Hospital, N14W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Tomonao Yoshida
- Department of Emergency Medicine, Hokkaido University Hospital, N14W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Tomoyo Saito
- Department of Emergency Medicine, Hokkaido University Hospital, N14W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Kenichi Katabami
- Department of Emergency Medicine, Hokkaido University Hospital, N14W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Takeshi Wada
- Department of Emergency Medicine, Hokkaido University Hospital, N14W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Kunihiko Maekawa
- Department of Emergency Medicine, Hokkaido University Hospital, N14W5, Kita-ku, Sapporo, 060-8648, Japan
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Iba T, Umemura Y, Wada H, Levy H. The Roles of Coagulation Disorder and Microthrombosis in Sepsis: Pathophysiology, Diagnosis, and Treatment. Arch Med Res 2021; 52:788-797. [PMID: 34344558 DOI: 10.1016/j.arcmed.2021.07.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 06/28/2021] [Accepted: 07/02/2021] [Indexed: 12/23/2022]
Abstract
The diagnostic criteria of overt disseminated intravascular coagulation (DIC) were established by the International Society on Thrombosis and Haemostasis (ISTH) in 2001. Since then, DIC has long been associated with adverse outcomes. However, recent advances in sepsis shed light on the role of coagulation disorders in the progression of sepsis. Currently, inflammation and coagulation are recognized as the two drivers that promote organ dysfunction in sepsis and septic shock. The ISTH has published new diagnostic criteria for improved management, namely sepsis-induced coagulopathy (SIC), in 2017. SIC is a pragmatic scoring system composed of platelet count, prothrombin time, and organ dysfunction score to detect the early-stage of sepsis-associated DIC. Since overt DIC represents an uncompensated coagulation disorder, a two-step approach using SIC and overt DIC criteria is a novel strategy to evaluate the severity and manage this challenging complication. Although there is no globally agreed on anticoagulant therapy for DIC, the Japanese Surviving Sepsis Campaign Guidelines 2020 recommend using antithrombin and recombinant thrombomodulin for sepsis associated DIC. Since research in this area has been previously reported, an international collaborative study is necessary to develop future diagnostic tools and treatment strategies.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate, School of Medicine, Tokyo, Japan.
| | - Yutaka Umemura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan; Department of Traumatology and Acute Critical Medicine, Osaka, University Graduate School of Medicine, Osaka, Japan
| | - Hideo Wada
- Department of General Medicine, Mie Prefectural General Medical Center, Mie, Japan
| | - H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University, School of Medicine, Durham, NC, USA
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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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Larsen JB, Hvas AM. Fibrinolytic Alterations in Sepsis: Biomarkers and Future Treatment Targets. Semin Thromb Hemost 2021; 47:589-600. [PMID: 33878784 DOI: 10.1055/s-0041-1725096] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Sepsis is a life-threatening condition which develops as a dysregulated immune response in the face of infection and which is associated with profound hemostatic disturbances and in the most extreme cases disseminated intravascular coagulation (DIC). In addition, the fibrinolytic system is subject to alterations during infection and sepsis, and impaired fibrinolysis is currently considered a key player in sepsis-related microthrombus formation and DIC. However, we still lack reliable biomarkers to assess fibrinolysis in the clinical setting. Furthermore, drugs targeting the fibrinolytic system have potential value in sepsis patients with severe fibrinolytic disturbances, but these are still being tested in the preclinical stage. The present review provides an overview of key fibrinolytic changes in sepsis, reviews the current literature on potential laboratory markers of altered fibrinolysis in adult sepsis patients, and discusses future perspectives for diagnosis and treatment of fibrinolytic disturbances in sepsis patients.
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Affiliation(s)
- Julie Brogaard Larsen
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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12
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D-dimer corrected for thrombin and plasmin generation is a strong predictor of mortality in patients with sepsis. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2019; 18:304-311. [PMID: 31855152 DOI: 10.2450/2019.0175-19] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/16/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND D-dimer (DD) is the most used fibrin-related marker and has been proposed, either alone or in combination with other variables, as prognostic factor in patients with sepsis. However, DD generation depends on both coagulation and fibrinolysis, meaning that it may give false negative results in conditions associated with marked fibrinolytic inhibition such as sepsis. In this study, we tested whether correction of DD for thrombin and plasmin generation could improve its prognostic significance in septic patients. MATERIAL AND METHODS We performed a nested study in 269 septic patients from the ALBIOS trial. DD, prothrombin fragment 1+2 (F1+2) and plasmin-antiplasmin complex (PAP) were assayed at day 1. Corrected DD (DDcorr) was calculated by the formula DD×PAP/F1+2, such that the lower the DDcorr the greater the imbalance in favour of fibrin formation over fibrin lysis, and vice-versa. Primary outcome was 90-day mortality. RESULTS DDcorr showed a J-shaped relationship with mortality, which was highest in the first DDcorr tertile (low fibrinolysis), intermediate in the 3rd (high fibrinolysis), and lowest in the 2nd (balanced fibrinolysis), suggesting an increased risk whenever the coagulation-fibrinolysis balance is tilted (p<0.0001). Neither DD, nor PAP or F1+2 showed a comparable association with mortality. DDcorr was an independent prognostic factor in multivariable Cox models and significantly improved risk stratification (cNRI≥0.28). Finally, by combining DDcorr and SOFA tertiles, we developed a score with high discriminatory power. DISCUSSION DDcorr is a good marker of the in vivo coagulation-fibrinolysis balance and displays a prognostic value in sepsis much higher than DD.
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Raveh Y, Souki F, Livingstone J, Beduschi T, Vianna R, Rodriguez Y, Nicolau-Raducu R. Fibrinolytic Shutdown Is Associated With Intraoperative Thrombosis and Hemorrhage During Visceral Transplant. Semin Cardiothorac Vasc Anesth 2019; 23:300-308. [DOI: 10.1177/1089253219848441] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Objective. End-stage liver disease is characterized by a precarious imbalance of hemostasis. Detrimental consequences of hypofibrinolysis, also known as fibrinolytic shutdown, have been recently demonstrated, and its significance in visceral (ie, an allograft that contains the intestine) transplant remains unknown. Design and Setting. To fill this gap, following institutional review board approval, this retrospective study included 49 adult recipients of visceral allografts (14 “visceral allograft without the liver” and 35 “multivisceral” with the liver) transplanted between 2010 and 2018 in a single university hospital, and for whom pre-incisional thromboelastography was available. Based on percent clot lysis 30 minutes after maximal amplitude, patients were stratified into 3 fibrinolysis phenotypes: fibrinolytic shutdown, physiologic fibrinolysis, and hyperfibrinolysis. Results. Fibrinolytic shutdown occurred in 57% of patients, with higher incidence in recipients of multivisceral transplant (69%) compared with visceral allograft without liver (29%) allografts ( P = .04). Fibrinolytic shutdown was associated with an increase in both intraoperative thrombosis and hemorrhage. Intraoperative thrombosis (18%) occurred only with multivisceral transplant, and accounted for 36% of in-hospital mortality. A clinically meaningful reduction in incidence of intraoperative thrombosis was noted in recipients who received intravenous heparin thromboprophylaxis. Logistic regression identified pretransplant platelet count as a risk factor for fibrinolytic shutdown (odds ratio = 0.992, 95% confidence interval = [0.984-0.998]; χ2= 7.8, P = .005). Conclusions. This study highlights fibrinolytic shutdown as a dominant and clinically important feature of the hemostatic imbalance in recipients undergoing visceral transplantation.
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Affiliation(s)
- Yehuda Raveh
- University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - Fouad Souki
- University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | | | - Thiago Beduschi
- University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - Rodrigo Vianna
- University of Miami/Jackson Memorial Hospital, Miami, FL, USA
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Abstract
OBJECTIVES Hemolysis is a known complication of pediatric extracorporeal membrane oxygenation associated with renal failure and mortality. We sought to identify predictors of hemolysis in pediatric extracorporeal membrane oxygenation patients and determine its influence on outcomes. DESIGN Retrospective, single-center study. SETTING Urban, quaternary care center pediatric and neonatal ICU. PATIENTS Ninety-six patients requiring extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Daily measurements of plasma-free hemoglobin were obtained while patients were on extracorporeal membrane oxygenation. Patients with a prior extracorporeal membrane oxygenation run, on extracorporeal membrane oxygenation for less than 24 hours, or without complete medical records were excluded from the study. Ninety-six patients met inclusion criteria, of which, 25 patients (26%) had plasma-free hemoglobin greater than 30 mg/dL. Of those patients, 15 of 25(60%) had plasma-free hemoglobin greater than 50 mg/dL, and 21 of 25(84%) occurred during the first 7 days on extracorporeal membrane oxygenation. Compared with patients without hemolysis, those with hemolysis were younger (0.2 mo [0.06-3.2 mo] vs 8.2 mo [0.6-86 mo]; p < 0.001), had a higher pericannulation international normalized ratio (3.9 [3.5-5.5] vs 2.6 [1.8-3.7]; p = 0.003), lower pericannulation platelet count (33 × 10/μL [22-42 × 10/μL] vs 61 × 10/μL [38-86 × 10/μL]; p < 0.001), and had a less negative inlet pressure (-3.5 mm Hg [-14 to 11.5 mm Hg] vs -19 mm Hg [-47 to 0 mm Hg]; p = 0.01). A greater proportion of patients with hemolysis had a heparin assay less than 0.2 mg/dL (50% vs 17%; p = 0.001) and had fluid removal via slow continuous ultrafiltration (32% vs 6%; p < 0.001). Patients with hemolysis had increased risk of in-hospital mortality (odds ratio 10.0; 95% CI 3.4-32; p < 0.001). On multivariable analysis, continuous ultrafiltration (odds ratio, 8.0; 95% CI, 1.9-42; p = 0.007) and pericannulation international normalized ratio greater than 3.5 (odds ratio, 7.2; 95% CI, 2.3-26; p = 0.001) were significantly associated with hemolysis. CONCLUSIONS Hemolysis is a common complication of pediatric extracorporeal membrane oxygenation. We found that patients with hemolysis (plasma-free hemoglobin > 30 mg/dL) had a 10-fold increase in in-hospital mortality. In our study cohort, hemolysis was associated with continuous ultrafiltration use, but not continuous renal replacement therapy. Additionally, our results suggest that the degree of coagulopathy (international normalized ratio > 3.5) at the time of cannulation influences hemolysis. Additional prospective studies are necessary to define further strategies to prevent hemolysis and improve outcomes in pediatric extracorporeal membrane oxygenation patients.
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Papageorgiou C, Jourdi G, Adjambri E, Walborn A, Patel P, Fareed J, Elalamy I, Hoppensteadt D, Gerotziafas GT. Disseminated Intravascular Coagulation: An Update on Pathogenesis, Diagnosis, and Therapeutic Strategies. Clin Appl Thromb Hemost 2018; 24:8S-28S. [PMID: 30296833 PMCID: PMC6710154 DOI: 10.1177/1076029618806424] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Disseminated intravascular coagulation (DIC) is an acquired clinicobiological
syndrome characterized by widespread activation of coagulation leading to fibrin
deposition in the vasculature, organ dysfunction, consumption of clotting
factors and platelets, and life-threatening hemorrhage. Disseminated
intravascular coagulation is provoked by several underlying disorders (sepsis,
cancer, trauma, and pregnancy complicated with eclampsia or other calamities).
Treatment of the underlying disease and elimination of the trigger mechanism are
the cornerstone therapeutic approaches. Therapeutic strategies specific for DIC
aim to control activation of blood coagulation and bleeding risk. The clinical
trials using DIC as entry criterion are limited. Large randomized, phase III
clinical trials have investigated the efficacy of antithrombin (AT), activated
protein C (APC), tissue factor pathway inhibitor (TFPI), and thrombomodulin (TM)
in patients with sepsis, but the diagnosis of DIC was not part of the inclusion
criteria. Treatment with APC reduced 28-day mortality of patients with severe
sepsis, including patients retrospectively assigned to a subgroup with
sepsis-associated DIC. Treatment with APC did not have any positive effects in
other patient groups. The APC treatment increased the bleeding risk in patients
with sepsis, which led to the withdrawal of this drug from the market. Treatment
with AT failed to reduce 28-day mortality in patients with severe sepsis, but a
retrospective subgroup analysis suggested possible efficacy in patients with
DIC. Clinical studies with recombinant TFPI or TM have been carried out showing
promising results. The efficacy and safety of other anticoagulants (ie,
unfractionated heparin, low-molecular-weight heparin) or transfusion of platelet
concentrates or clotting factor concentrates have not been objectively
assessed.
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Affiliation(s)
- Chrysoula Papageorgiou
- Service Anesthésie, Réanimation Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Georges Jourdi
- INSERM UMRS1140, Université Paris Descartes, Paris, France.,Service d'Hématologie Biologique, Hôpital Cochin, Assistance Publique des Hôpitaux de Paris, France
| | - Eusebe Adjambri
- Département d'Hématologie, Faculté de Pharmacie, Université Félix Houphouët Boigny, Abidjan, Côte d'Ivoire
| | - Amanda Walborn
- Department of Pathology, Cardiovascular Institute Loyola University Chicago, Maywood, IL, USA
| | - Priya Patel
- Department of Pathology, Cardiovascular Institute Loyola University Chicago, Maywood, IL, USA
| | - Jawed Fareed
- Department of Pathology, Cardiovascular Institute Loyola University Chicago, Maywood, IL, USA
| | - Ismail Elalamy
- Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique Hoôpitaux de Paris, Paris, France.,Cancer Biology and Therapeutics, Centre de Recherche Saint-Antoine, Institut National de la Santé et de la Recherche Médicale, INSERM U938 and Faculté de Médecine Pierre et Marie Curie (UPMC), Sorbonne Universities, Paris, France
| | - Debra Hoppensteadt
- Department of Pathology, Cardiovascular Institute Loyola University Chicago, Maywood, IL, USA
| | - Grigoris T Gerotziafas
- Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique Hoôpitaux de Paris, Paris, France.,Cancer Biology and Therapeutics, Centre de Recherche Saint-Antoine, Institut National de la Santé et de la Recherche Médicale, INSERM U938 and Faculté de Médecine Pierre et Marie Curie (UPMC), Sorbonne Universities, Paris, France
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17
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Scarlatescu E, Tomescu D, Arama SS. Sepsis-Associated Coagulopathy. ACTA ACUST UNITED AC 2016; 2:156-163. [PMID: 29967855 DOI: 10.1515/jccm-2016-0024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 09/29/2016] [Indexed: 11/15/2022]
Abstract
Systemic inflammatory activation in sepsis often leads to coagulation activation, but the relationship is bilateral, as coagulation also modulates the inflammatory response. This close associate has significant consequences for the pathogenesis of microvascular thrombosis and organ dysfunction in sepsis. While coagulation activation can be beneficial for immune defense, it can also be detrimental once it becomes widespread and uncontrolled. The knowledge of the pathophysiologic mechanisms involved in the interaction between infection and coagulation may lead to the better timing for the administration of targeted antithrombotic therapies in septic patients. This brief review highlights the pathophysiologic pathways leading to the prothrombotic state in sepsis and the mechanisms that play a role in the interaction between infection and coagulation.
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Affiliation(s)
- Ecaterina Scarlatescu
- Department of Anesthesiology and Intensive Care III, Fundeni Clinical Institute, Bucharest, Romania
| | - Dana Tomescu
- Department of Anesthesiology and Intensive Care III, Fundeni Clinical Institute, Bucharest, Romania
- University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
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19
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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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20
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Hyperfibrinolysis, physiologic fibrinolysis, and fibrinolysis shutdown: the spectrum of postinjury fibrinolysis and relevance to antifibrinolytic therapy. J Trauma Acute Care Surg 2015; 77:811-7; discussion 817. [PMID: 25051384 DOI: 10.1097/ta.0000000000000341] [Citation(s) in RCA: 316] [Impact Index Per Article: 35.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Fibrinolysis is a physiologic process maintaining patency of the microvasculature. Maladaptive overactivation of this essential function (hyperfibrinolysis) is proposed as a pathologic mechanism of trauma-induced coagulopathy. Conversely, the shutdown of fibrinolysis has also been observed as a pathologic phenomenon. We hypothesize that there is a level of fibrinolysis between these two extremes that have a survival benefit for the severely injured patients. METHODS Thrombelastography and clinical data were prospectively collected on trauma patients admitted to our Level I trauma center from 2010 to 2013. Patients with an Injury Severity Score (ISS) of 15 or greater were evaluated. The percentage of fibrinolysis at 30 minutes by thrombelastography was used to stratify three groups as follows: hyperfibrinolysis (≥3%), physiologic (0.081-2.9%), and shutdown (0-0.08%). The threshold for hyperfibrinolysis was based on existing literature. The remaining groups were established on a cutoff of 0.8%, determined by the highest point of specificity and sensitivity for mortality on a receiver operating characteristic curve. RESULTS One hundred eighty patients were included in the study. The median age was 42 years (interquartile range [IQR], 28-55 years), 70% were male, and 21% had penetrating injuries. The median ISS was 29 (IQR, 22-36), and the median base deficit was 9 mEq/L (IQR, 6-13 mEq/L). Distribution of fibrinolysis was as follows: shutdown, 64% (115 of 180); physiologic, 18% (32 of 180); and hyperfibrinolysis, 18% (33 of 180). Mortality rates were lower for the physiologic group (3%) compared with the hyperfibrinolysis (44%) and shutdown (17%) groups (p = 0.001). CONCLUSION We have identified a U-shaped distribution of death related to the fibrinolysis system in response to major trauma, with a nadir in mortality, with level of fibrinolysis after 30 minutes between 0.81% and 2.9%. Exogenous inhibition of the fibrinolysis system in severely injured patients requires careful selection, as it may have an adverse affect on survival. LEVEL OF EVIDENCE Prognostic study, level III.
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Schwameis M, Schörgenhofer C, Assinger A, Steiner MM, Jilma B. VWF excess and ADAMTS13 deficiency: a unifying pathomechanism linking inflammation to thrombosis in DIC, malaria, and TTP. Thromb Haemost 2014; 113:708-18. [PMID: 25503977 DOI: 10.1160/th14-09-0731] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 10/27/2014] [Indexed: 12/15/2022]
Abstract
Absent or severely diminished activity of ADAMTS13 (A Disintegrin And Metalloprotease with a ThromboSpondin type 1 motif, member 13) resulting in the intravascular persistence and accumulation of highly thrombogenic ultra large von Willebrand factor (UL-VWF) multimers is the pathophysiological mechanism underlying thrombotic thrombocytopenic purpura. Reduced VWF-cleaving protease levels, however, are not uniquely restricted to primary thrombotic microangiopathy (TMA), e. g. thrombotic thrombocytopenic purpura, but also occur in other life-threatening thrombocytopenic conditions: severely decreased ADAMTS13 activity is seen in severe sepsis, disseminated intravascular coagulation (DIC) and complicated malarial infection. The clinical relevance of these secondary thrombotic microangiopathies is increasingly recognised, but its therapeutic implications have not yet been determined. The presence of a secondary TMA in certain diseases may define patient groups which possibly could benefit from ADAMTS13 replacement or a VWF-targeting therapy. This short-review focuses on the role of UL-VWF multimers in secondary TMA and discusses the potential of investigational therapies as candidates for the treatment of TTP. In conclusion, prospective clinical trials on the effectiveness of protease replacementin vivo seem reasonable. Carefully selected patients with secondary TMA may benefit from therapies primarily intended for the use in patients with TTP.
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Affiliation(s)
| | | | | | | | - Bernd Jilma
- Bernd Jilma, MD, Department of Clinical Pharmacology, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria, Tel.: +43 1 40400 29810, Fax: +43 1 40400 29990, E-mail:
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Immunophenotyping and protein profiling of Fontan-associated plastic bronchitis airway casts. Ann Am Thorac Soc 2013; 10:98-107. [PMID: 23607837 DOI: 10.1513/annalsats.201209-080oc] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Plastic bronchitis (PB) is a rare and deadly condition that is characterized by the formation of airway casts. It most frequently occurs in children with underlying congenital heart disease that has been surgically palliated by the Fontan procedure. The Fontan circulation results in above-normal central venous pressure, and it has been hypothesized that the formation of airway casts is due to lymph leak. Knowledge of plastic bronchitis pathogenesis is poor and stems mostly from published case reports. OBJECTIVES To garner information about cast pathogenesis by characterizing inflammatory cell phenotypes in existing formalin-preserved, paraffin-embedded samples and generating protein and cytokine-chemokine profiles of airway cast homogenates. METHODS We used immunofluorescence confocal microscopy, state-of-the-science proteomics, and a cytokine array assay to immunophenotype cellular content and to generate protein and cytokine profiles of plastic bronchitis airway casts, respectively. MEASUREMENTS AND MAIN RESULTS Neutrophils, eosinophils, macrophages, and B lymphocytes were identified in cast samples; there were notably fewer T lymphocytes. Fibrin(ogen) was an abundant protein in the cast proteome. Histone H4 was also abundant, and immunofluorescence microscopy demonstrated it to be mostly extracellular. The cytokine profile of plastic bronchitis casts was proinflammatory. CONCLUSIONS Plastic bronchitis airway casts from children with Fontan physiology are composed of fibrin and are cellular and inflammatory in nature, providing evidence that their formation cannot be explained simply by lymph leak into the airways. Consequences of cellular necrosis including extracellular histones and the apparent low number of T cells indicate that a derangement in inflammation resolution likely contributes to cast formation.
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Wada T, Gando S, Mizugaki A, Yanagida Y, Jesmin S, Yokota H, Ieko M. Coagulofibrinolytic changes in patients with disseminated intravascular coagulation associated with post-cardiac arrest syndrome--fibrinolytic shutdown and insufficient activation of fibrinolysis lead to organ dysfunction. Thromb Res 2013; 132:e64-9. [PMID: 23726093 DOI: 10.1016/j.thromres.2013.05.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Revised: 04/12/2013] [Accepted: 05/07/2013] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Post-cardiac arrest syndrome (PCAS) is often associated with disseminated intravascular coagulation (DIC), thus leading to the development of multiple organ dysfunction syndrome (MODS). The aim of this study was to examine the pathophysiological relationships between coagulation, fibrinolysis and fibrinolytic shutdown by evaluating the levels of coagulofibrinolytic markers, including soluble fibrin, thrombin-activatable fibrinolysis inhibitor (TAFI), tissue plasminogen activator-plasminogen activator inhibitor-1 complex (tPAIC), plasmin-alpha2 plasmin inhibitor complex (PPIC), neutrophil elastase and fibrin degradation product by neutrophil elastase (EXDP). MATERIALS AND METHODS Fifty-two resuscitated patients were divided into two groups: 22 DIC and 30 non-DIC patients. RESULTS The levels of soluble fibrin, PPIC, tPAIC, EXDP and neutrophil elastase in the DIC patients with PCAS were significantly higher than those observed in the non-DIC patients. The values of the tPAIC and JAAM DIC scores were found to be independent predictors of increased SOFA scores in the DIC patients. The MODS patients demonstrated significantly higher levels of soluble fibrin and tPAIC; however, the levels of TAFI and EXDP were identical between the patients with and without MODS. In addition, positive correlations were observed between the levels of tPAIC and EXDP in the patients with non-MODS; however, no correlations were observed between these markers in the MODS patients. CONCLUSIONS Thrombin activation and fibrinolytic shutdown play important roles in the development of organ dysfunction in PCAS patients. Neutrophil elastase-mediated fibrinolysis cannot overcome the fibrinolytic shutdown that occurs in DIC patients with PCAS, thus resulting in the development of MODS.
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Affiliation(s)
- Takeshi Wada
- 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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