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Scarlatescu E, Iba T, Maier CL, Moore H, Othman M, Connors JM, Levy JH. Deranged Balance of Hemostasis and Fibrinolysis in Disseminated Intravascular Coagulation: Assessment and Relevance in Different Clinical Settings. Anesthesiology 2024:141586. [PMID: 38861325 DOI: 10.1097/aln.0000000000005023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
The disruption of hemostasis/fibrinolysis balance leads to disseminated intravascular coagulation, manifested clinically by bleeding or thrombosis, and multiorgan failure. This study reviews hemostatic assessment and therapeutic strategies that restore this balance in critically ill patients.
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Affiliation(s)
- Ecaterina Scarlatescu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania; and Department of Anaesthesia and Intensive Care, Fundeni Clinical Institute, Bucharest, Romania
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Hunter Moore
- Department of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada; School of Baccalaureate Nursing, St. Lawrence College, Kingston, Ontario, Canada; and Clinical Pathology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Jean Marie Connors
- Hematology Division Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina
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Iba T, Tanigawa T, Wada H, Levy JH. The antithrombin activity recovery after substitution therapy is associated with improved 28-day mortality in patients with sepsis-associated disseminated intravascular coagulation. Thromb J 2023; 21:112. [PMID: 37919722 PMCID: PMC10621171 DOI: 10.1186/s12959-023-00556-6] [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: 08/01/2023] [Accepted: 10/23/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Disseminated intravascular coagulation (DIC) is a common and critical complication in sepsis. Antithrombin activity, which is considered a biomarker for disease severity, was measured in septic DIC treated with antithrombin concentrates in this study. METHODS We conducted a retrospective analysis of post-marketing survey data that included 1,800 patients with sepsis-associated DIC and antithrombin activity of 70% or less who were treated with antithrombin concentrates. The changes in sequential organ failure assessment (SOFA) score, DIC score, and antithrombin activity were sequentially assessed. Logistic regression analysis and receiver operating characteristic (ROC) curve analysis were performed to evaluate the performance of antithrombin activity to assess 28-day survival. Furthermore, the relationship between post-treatment antithrombin activity and survival was examined by Logistic regression analysis. RESULTS Sex, baseline SOFA score, baseline antithrombin activities, and the presence of pneumonia and soft tissue infection were significantly associated with 28-day mortality. The area under the curve for mortality was 0.639 for post-treatment antithrombin activity, and higher than those of baseline- and delta antithrombin activities. Logistic regression analysis revealed that higher post-treatment antithrombin activity was associated with better 28-day survival. When post-treatment antithrombin activity was more than 80%, the estimated survival was 88.2%. Whereas, the survival was 74.4% when the antithrombin activity was 80% or less (P < 0.0001). However, the relationship between post-treatment antithrombin activity and 28-day survival was considerably different between patients who recovered from DIC by Day 6 compared to those who did not. Similarly, the estimated 28-day survival, based on antithrombin activity, varied among patients with high and low SOFA scores, and the calculation needs to be adjusted based on the severity of the condition. CONCLUSIONS Post-treatment antithrombin activity measurement was helpful in estimating the 28-day survival in patients with sepsis-associated DIC. However, patient outcomes vary considerably depending on factors that include baseline SOFA score, age, and baseline antithrombin activity. These variables play a substantial role in determining patient prognosis and should be considered when evaluating and interpreting the results.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-Ku, Tokyo, 113-8421, Japan.
| | - Tomoki Tanigawa
- Medical Affairs Section, Research & Development Division, Japan Blood Products Organization, 15F Tamachi Station Tower N 3-1-1 Shibaura, Minato-Ku, Tokyo, Japan
| | - Hideo Wada
- Department of General and Laboratory Medicine, Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
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Iba T, Levy JH, Thachil J, Susen S, Levi M, Scarlatescu E. Communication from the Scientific Standardization Committees of the International Society on Thrombosis and Haemostasis on vascular endothelium-related biomarkers in disseminated intravascular coagulation. J Thromb Haemost 2023; 21:691-699. [PMID: 36696178 DOI: 10.1016/j.jtha.2022.11.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/21/2022] [Accepted: 11/06/2022] [Indexed: 01/26/2023]
Abstract
Disseminated intravascular coagulation (DIC) is not a disease criterion but a pathomechanistic process that accompanies various underlying diseases. According to the International Society on Thrombosis and Haemostasis definition, endothelial injury is an essential component in addition to systemic coagulation activation. Despite this definition, current diagnostic criteria for DIC do not include biomarkers for vascular endothelial injury. Endothelial cells are critical for hemostatic regulation because they produce various antithrombotic substances and express anticoagulant factors at the same time as facilitating coagulation, inflammatory reactions, platelet aggregation, and fibrinolysis with acute injury. Endothelial cells also exhibit various receptors, adhesion molecules, and the critical role of glycocalyx that regulates cellular interactions in thromboinflammation. For clinicians, biomarkers suitable for assessing endothelial injury are not readily available. Although we still do not have ideal biomarkers, antithrombin activity and von Willebrand factor can be candidates for the endothelium-related markers because those reflect the severity and are available in most clinical settings. Further, the dysfunction of endothelial cell in DIC arising from various underlying diseases is likely highly variable. For example, the involvement of endothelial dysfunction is significant in sepsis-induced coagulopathy, while moderate in trauma-induced coagulopathy, and variable in hematologic malignancy-associated coagulopathy. Because of the complexity of disease status associated with DIC, further research searching clinically available endothelium-related biomarkers is expected to establish individualized diagnostic criteria and potential therapeutic approaches.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| | - Sophie Susen
- Department of Hematology and Transfusion, Lille University Hospital, Lille, France
| | - Marcel Levi
- Department of Vascular Medicine, Amsterdam University Medical Center, the Netherlands and Department of Medicine, University College London Hospitals NHS Foundation Trust, and Cardio-metabolic Programme-NIHR UCLH/UCL BRC London, UK
| | - Ecaterina Scarlatescu
- University of Medicine and Pharmacy "Carol Davila," Bucharest and Department of Anaesthesia and Intensive Care, Fundeni Clinical Institute, Bucharest, Romania
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Wiedermann CJ. Antithrombin as Therapeutic Intervention against Sepsis-Induced Coagulopathy and Disseminated Intravascular Coagulation: Lessons Learned from COVID-19-Associated Coagulopathy. Int J Mol Sci 2022; 23:ijms232012474. [PMID: 36293332 PMCID: PMC9604230 DOI: 10.3390/ijms232012474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 10/15/2022] [Accepted: 10/17/2022] [Indexed: 12/04/2022] Open
Abstract
Recent research has contributed significantly to our understanding of the pathogenesis of acute disseminated intravascular coagulation. COVID-19 can be considered as a new underlying condition of disseminated intravascular coagulation. In this narrative review, current evidence is presented regarding biomarker differences between sepsis-induced and COVID-19-associated coagulopathies, supporting the importance of acquired antithrombin deficiency in the early differential diagnosis of septic coagulopathy and its potential impact on treatment with endogenous anticoagulants. Establishing new scoring systems for septic coagulopathy in combination with endogenous anticoagulant biomarker activities may allow for the identification of those in the heterogeneous population of sepsis patients who are more likely to benefit from targeted specific treatment interventions.
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Affiliation(s)
- Christian J. Wiedermann
- Institute of General Practice, Claudiana—College of Health Professions, 39100 Bolzano, Italy;
- Department of Public Health, Medical Decision Making and HTA, University of Health Sciences, Medical Informatics and Technology—Tyrol, 6060 Hall in Tyrol, Austria
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Murao A, Kato T, Yamane T, Honda G, Eguchi Y. Benefit Profile of Thrombomodulin Alfa Combined with Antithrombin Concentrate in Patients with Sepsis-Induced Disseminated Intravascular Coagulation. Clin Appl Thromb Hemost 2022; 28:10760296221077096. [PMID: 35166576 PMCID: PMC8851499 DOI: 10.1177/10760296221077096] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Thrombomodulin alfa (TM-α, recombinant human soluble thrombomodulin) and antithrombin (AT) concentrate are anticoagulant agents for the treatment of disseminated intravascular coagulation (DIC). A post hoc analysis using data from 1198 patients with infection-induced DIC from the post-marketing surveillance of TM-α was conducted. To identify subgroups that benefit from combination therapy, the patients were a priori stratified into four groups by a platelet (Plt) count of 50 × 103/μL and plasma AT level of 50% (groups 1, 2, 3, and 4, with high Plt/high AT, high Plt/low AT, low Plt/high AT, and low Plt/low AT, respectively). Kaplan-Meier survival analysis showed significantly worse survival in groups 2 and 4 had than in group 1 (p = 0.0480, p < 0.0001, respectively), and multivariate analysis showed that concomitant AT concentrate was independently correlated with reduced 28-day mortality only in group 4 (hazard ratio 0.6193; 95% confidence interval, 0.3912-0.9805). The adverse drug reactions (ADRs) and bleeding ADRs were not different among the groups. Patients with both severe thrombocytopenia and AT deficiency are candidates for combined anticoagulant therapy with TM-α and AT concentrate.
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Affiliation(s)
- Atsushi Murao
- Division of Emergency and Intensive Care Unit, Shiga University of Medical Science Hospital, Otsu, Shiga, Japan
| | - Takayuki Kato
- Division of Emergency and Intensive Care Unit, Shiga University of Medical Science Hospital, Otsu, Shiga, Japan
| | - Tetsunobu Yamane
- Division of Emergency and Intensive Care Unit, Shiga University of Medical Science Hospital, Otsu, Shiga, Japan
| | - Goichi Honda
- Medical Affairs Division, Asahi Kasei Pharma Corporation, Yurakucho, Chiyoda-ku, Tokyo, Japan
| | - Yutaka Eguchi
- Department of Critical and Intensive Care Medicine, Shiga University of Medical Science, Seta, Tsukinowa-cho, Otsu, Shiga, Japan
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Makatsariya AD, Slukhanchuk EV, Bitsadze VO, Khizroeva JK, Tretyakova MV, Makatsariya NA, Akinshina SV, Shkoda AS, Pankratyeva LL, Di Renzo GC, Rizzo G, Grigorieva KN, Tsibizova VI, Gris JC, Elalamy I. Neutrophil extracellular traps: a role in inflammation and dysregulated hemostasis as well as in patients with COVID-19 and severe obstetric pathology. OBSTETRICS, GYNECOLOGY AND REPRODUCTION 2021. [DOI: 10.17749/2313-7347/ob.gyn.rep.2021.238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Numerous studies have proven a close relationship between inflammatory diseases and the state of hypercoagulability. In fact, thromboembolic complications represent one of the main causes of disability and mortality in acute and chronic inflammatory diseases, cancer and obstetric complications. Despite this, the processes of hemostasis and immune responses have long been considered separately; currently, work is underway to identify the molecular basis for a relationship between such systems. It has been identified that various pro-inflammatory stimuli are capable of triggering a coagulation cascade, which in turn modulates inflammatory responses. Neutrophil extracellular traps (NETs) are the networks of histones of extracellular DNA generated by neutrophils in response to inflammatory stimuli. The hemostasis is activated against infection in order to minimize the spread of infection and, if possible, inactivate the infectious agent. Another molecular network is based on fibrin. Over the last 10 years, there has been accumulated a whole body of evidence that NETs and fibrin are able to form a united network within a thrombus, stabilizing each other. Similarities and molecular cross-reactions are also present in the processes of fibrinolysis and lysis of NETs. Both NETs and von Willebrand factor (vWF) are involved in thrombosis as well as inflammation. During the development of these conditions, a series of events occurs in the microvascular network, including endothelial activation, NETs formation, vWF secretion, adhesion, aggregation, and activation of blood cells. The activity of vWF multimers is regulated by the specific metalloproteinase ADAMTS-13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13). Studies have shown that interactions between NETs and vWF can lead to arterial and venous thrombosis and inflammation. In addition, the contents released from activated neutrophils or NETs result in decreased ADAMTS-13 activity, which can occur in both thrombotic microangiopathies and acute ischemic stroke. Recently, NETs have been envisioned as a cause of endothelial damage and immunothrombosis in COVID-19. In addition, vWF and ADAMTS-13 levels predict COVID-19 mortality. In this review, we summarize the biological characteristics and interactions of NETs, vWF, and ADAMTS-13, the effect of NETs on hemostasis regulation and discuss their role in thrombotic conditions, sepsis, COVID-19, and obstetric complications.
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Affiliation(s)
| | | | | | | | | | | | | | - A. S. Shkoda
- Vorokhobov City Clinical Hospital № 67, Moscow Healthcare Department
| | - L. L. Pankratyeva
- Vorokhobov City Clinical Hospital № 67, Moscow Healthcare Department; Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Health Ministry of Russian Federation
| | - G. C. Di Renzo
- Sechenov University; Center for Prenatal and Reproductive Medicine, University of Perugia
| | - G. Rizzo
- Sechenov University; University of Rome Tor Vergata
| | | | - V. I. Tsibizova
- Almazov National Medical Research Centre, Health Ministry of Russian Federation
| | - J.-C. Gris
- Sechenov University; University of Montpellier
| | - I. Elalamy
- Sechenov University; Medicine Sorbonne University; Hospital Tenon
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Matsumoto H, Takeba J, Umakoshi K, Kikuchi S, Ohshita M, Annen S, Moriyama N, Nakabayashi Y, Sato N, Aibiki M. ADAMTS13 activity decreases in the early phase of trauma associated with coagulopathy and systemic inflammation: a prospective observational study. Thromb J 2021; 19:17. [PMID: 33712048 PMCID: PMC7953673 DOI: 10.1186/s12959-021-00270-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 03/03/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND We conducted a prospective observational study for investigating the changes in the 13th member of a disintegrin-like and metalloprotease with thrombospondin type 1 motif (ADAMTS13) and its association with the coagulofibrinolytic response in adult trauma patients. METHODS In 39 trauma patients hospitalized for longer than 7 days, time-course changes in biomarkers of coagulofibrinolysis and systemic inflammation along with ADAMTS13 activity were examined. The patients were stratified into three groups based on ADAMTS13 activities on admission (day 0): normal group (≥70%), mildly decreased group (≥50 and < 70%) and moderately decreased group (< 50%). RESULTS Among 39 patients with a median Injury Severity Score (ISS) of 20, 11 patients developed disseminated intravascular coagulation (DIC) and 16 patients required transfusion. Six of 39 patients (15.4%) showed moderate decreased ADAMTS13 activity to < 50%, and 20 patients (51.3%) showed mild drops (≥50 and < 70%). These changes in ADAMTS13 activity on day 0 were significantly correlated with changes in IL-6 and other coagulofibrinolytic markers such as platelet counts, prothrombin time and fibrin/fibrinogen degradation product (FDP). Antithrombin activity (AT) and serum albumin (Alb) level showed significantly positive linear correlations with ADAMTS13 activity (AT: r = 0.513, p < 0.001; Alb: r = 0.647, p < 0.001). Simple logistic regression analyses showed that ADAMTS13 activity, if less than 50%, was significantly correlated with the development of DIC (OR 7.499, 95%CI 1.121-49.242, p = 0.038) and the need for transfusion of fresh frozen plasma (OR 9.000, 95%CI 1.327-61.025, p = 0.028). CONCLUSIONS ADAMTS13 activity decreased even in the early phase of trauma, which was complicated by coagulopathy and systemic inflammation. Furthermore, the decrease in ADAMTS13 activity was correlated with DIC and plasma transfusion.
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Affiliation(s)
- Hironori Matsumoto
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime, 791-0295, Japan.
| | - Jun Takeba
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime, 791-0295, Japan
| | - Kensuke Umakoshi
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime, 791-0295, Japan
| | - Satoshi Kikuchi
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime, 791-0295, Japan
| | - Muneaki Ohshita
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime, 791-0295, Japan
| | - Suguru Annen
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime, 791-0295, Japan
| | - Naoki Moriyama
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime, 791-0295, Japan
| | - Yuki Nakabayashi
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime, 791-0295, Japan
| | - Norio Sato
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime, 791-0295, Japan
| | - Mayuki Aibiki
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime, 791-0295, Japan
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Koyama K, Katayama S, Tonai K, Shima J, Koinuma T, Nunomiya S. Biomarker profiles of coagulopathy and alveolar epithelial injury in acute respiratory distress syndrome with idiopathic/immune-related disease or common direct risk factors. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:283. [PMID: 31426849 PMCID: PMC6699073 DOI: 10.1186/s13054-019-2559-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 07/31/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Altered coagulation and alveolar injury are the hallmarks of acute respiratory distress syndrome (ARDS). However, whether the biomarkers that reflect pathophysiology differ depending on the etiology of ARDS has not been examined. This study aimed to investigate the biomarker profiles of coagulopathy and alveolar epithelial injury in two subtypes of ARDS: patients with direct common risk factors (dARDS) and those with idiopathic or immune-related diseases (iARDS), which are classified as "ARDS without common risk factors" based on the Berlin definition. METHODS This retrospective, observational study included adult patients who were admitted to the intensive care unit (ICU) at a university hospital with a diagnosis of ARDS with no indirect risk factors. Plasma biomarkers (thrombin-antithrombin complex [TAT], plasminogen activator inhibitor [PAI]-1, protein C [PC] activity, procalcitonin [PCT], surfactant protein [SP]-D, and KL-6) were routinely measured during the first 5 days of the patient's ICU stay. RESULTS Among 138 eligible patients with ARDS, 51 were excluded based on the exclusion criteria (n = 41) or other causes of ARDS (n = 10). Of the remaining 87 patients, 56 were identified as having dARDS and 31 as having iARDS. Among the iARDS patients, TAT (marker of thrombin generation) and PAI-1 (marker of inhibited fibrinolysis) were increased, and PC activity was above normal. In contrast, PC activity was significantly decreased, and TAT or PAI-1 was present at much higher levels in dARDS compared with iARDS patients. Significant differences were also observed in PCT, SP-D, and KL-6 between patients with dARDS and iARDS. The receiver operating characteristic (ROC) analysis showed that areas under the ROC curve for PC activity, PAI-1, PCT, SP-D, and KL-6 were similarly high for distinguishing between dARDS and iARDS (PC 0.86, P = 0.33; PAI-1 0.89, P = 0.95; PCT 0.89, P = 0.66; and SP-D 0.88, P = 0.16 vs. KL-6 0.90, respectively). CONCLUSIONS Coagulopathy and alveolar epithelial injury were observed in both patients with dARDS and with iARDS. However, their biomarker profiles were significantly different between the two groups. The different patterns of PAI-1, PC activity, SP-D, and KL-6 may help in differentiating between these ARDS subtypes.
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Affiliation(s)
- Kansuke Koyama
- Division of Intensive Care, Department of Anesthesiology & Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan.
| | - Shinshu Katayama
- Division of Intensive Care, Department of Anesthesiology & Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Ken Tonai
- Division of Intensive Care, Department of Anesthesiology & Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Jun Shima
- Division of Intensive Care, Department of Anesthesiology & Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Toshitaka Koinuma
- Division of Intensive Care, Department of Anesthesiology & Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Shin Nunomiya
- Division of Intensive Care, Department of Anesthesiology & Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
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Dik B, Sonmez G, Faki HE, Bahcivan E. Sulfasalazine treatment can cause a positive effect on LPS-induced endotoxic rats. Exp Anim 2018; 67:403-412. [PMID: 29731490 PMCID: PMC6219878 DOI: 10.1538/expanim.18-0029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The aim of this study, was to determine the effect of sulfasalazine for different periods
of time reduces disseminated intravascular coagulation, inflammation and organ damages by
inhibiting the nuclear factor kappa beta pathway. The study was performed with 30 Wistar
albino rats and the groups were established as Control group, LPS group; endotoxemia was
induced with LPS, SL5 group: sulfasalazine (300 mg/kg, single dose daily) was administered
for 5 days before the LPS-induced endotoxemia, and LS group: sulfasalazine (300 mg/kg,
single dose) was administered similtenously with LPS. Hemogram, biochemical, cytokine
(IL-1β, IL-6, IL-10, TNF-α) and acute phase proteins (HPT, SAA, PGE2) analyzes and
oxidative status values were measured from blood samples at 3 and 6 h after the last
applications in the all groups. The rats were euthanized at 6 h and mRNA
levels of BCL2 and BAX genes were examined from liver
and brain tissues. Sulfasalazine reduced the increased IL-1β, IL-6, TNF-α and
PGE2 levels and significantly increased anti-inflammatory cytokine IL-10
levels. In addition, decreasing of ATIII level was prevented in the SL5 group, and
decreasing of fibrinogen levels were prevented in the LS and SL5 groups within first 3 h.
In LPS group, leukocyte and thrombocyte levels were decreased, however sulfasalazine
application inhibited decreases of leukocyte levels in LS and SL5 groups. In addition,
sulfasalazine inhibited the decrease of total antioxidant capacity and unchanged apoptosis
in brain and liver. In conclusion, the use of sulfasalazine in different durations reduce
the excessive inflammation of endotoxemia cases.
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Affiliation(s)
- Burak Dik
- Department of Pharmacology and Toxicology, Veterinary Faculty, Selcuk University, New Istanbul Highway, 42130 Konya, Turkey
| | - Gonca Sonmez
- Department of Genetics, Veterinary Faculty, Selcuk University, New Istanbul Highway, 42130 Konya, Turkey
| | - Hatice Eser Faki
- Department of Pharmacology and Toxicology, Veterinary Faculty, Selcuk University, New Istanbul Highway, 42130 Konya, Turkey
| | - Emre Bahcivan
- Department of Pharmacology and Toxicology, Veterinary Faculty, Kafkas University, 36300 Kars, Turkey
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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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11
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Matsumoto H, Takeba J, Umakoshi K, Kikuchi S, Ohshita M, Annen S, Moriyama N, Nakabayashi Y, Sato N, Aibiki M. Decreased antithrombin activity in the early phase of trauma is strongly associated with extravascular leakage, but not with antithrombin consumption: a prospective observational study. Thromb J 2018; 16:17. [PMID: 30078997 PMCID: PMC6069797 DOI: 10.1186/s12959-018-0171-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 04/26/2018] [Indexed: 01/26/2023] Open
Abstract
Background We conducted a prospective observational study for investigating coagulofibrinolytic changes and mechanisms of antithrombin (AT) alternations in trauma. Methods Trauma patients hospitalized for more than seven days were analyzed for coagulofibrinolytic biomarkers. The patients were stratified into two groups according to AT activity level on admission (day 0), comprising normal AT and low AT patients. Results Thirty-nine patients (median Injury Severity Score 20) exhibited initial coagulatory activation and triphasic fibrinolytic changes. AT activity did not show a negative linear correlation with levels of thrombin-antithrombin complex (TAT), a marker of coagulation activity and AT consumption, but was strongly correlated with levels of albumin (Alb), an index of vascular permeability, on day 0 (r = 0.702, p < 0.001). Furthermore, Alb was one of the independent predictors for AT on day 0. IL-6 on day 0 and thrombomodulin (TM) levels during the study period, reflecting systemic inflammation and endothelial cell injury, respectively, were significantly higher in the lower AT group (n = 10) than in the normal group (n = 29) (IL-6, p = 0.004; TM, p = 0.017). On days 2 and 4, TAT levels in the lower AT group were significantly higher than in the normal group. Conclusions Trauma caused clear triphasic coagulofibrinolytic changes. Decreased AT in the later phase might lead to a prolonged hypercoagulation. AT reduction in the initial phase of trauma is strongly associated with extravascular leakage as suggested by the association of Alb depletion with IL-6 and TM elevation, but not with AT consumption.
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Affiliation(s)
- Hironori Matsumoto
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime 791-0295 Japan
| | - Jun Takeba
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime 791-0295 Japan
| | - Kensuke Umakoshi
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime 791-0295 Japan
| | - Satoshi Kikuchi
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime 791-0295 Japan
| | - Muneaki Ohshita
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime 791-0295 Japan
| | - Suguru Annen
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime 791-0295 Japan
| | - Naoki Moriyama
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime 791-0295 Japan
| | - Yuki Nakabayashi
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime 791-0295 Japan
| | - Norio Sato
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime 791-0295 Japan
| | - Mayuki Aibiki
- Department of Emergency and Critical Care Medicine, Ehime University, Graduate School of Medicine, Shitsukawa 454, Toon City, Ehime 791-0295 Japan
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12
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Endogenous thrombin potential as marker of procoagulant response that can be useful in early stage of sepsis. Blood Coagul Fibrinolysis 2018; 28:460-467. [PMID: 28166112 DOI: 10.1097/mbc.0000000000000622] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
: Sepsis is associated with complex procoagulant and anticoagulant changes that modify inflammatory response. Identification of coagulation markers that can differentiate useful procoagulant response from adverse alteration of clotting mechanism in patient with sepsis. In total, 150 patients who fulfilled criteria for diagnosis of sepsis were included in this study. Patients were categorized in two groups according to sepsis severity in the first 24 h from intensive care unit admission: sepsis and septic shock. In total, 28-day mortality was assessed. Platelet count, activated partial thromboplastin time, prothrombin time, D-dimer, fibrinogen, protein C, protein S, antithrombin levels, and endogenous thrombin potential were determined within first 24 h from ICU admission. Differences between groups of septic patients were assessed by Mann-Whitney U test. Categorical variables were compared using χ test. Receiver operating characteristic curves were plotted to determine predictive values of variables for sepsis severity prediction. Activated partial thromboplastin time and prothrombin time were significantly prolonged with higher D-dimer, lower fibrinogen, and natural anticoagulant levels (protein C, protein S, and antithrombin) in patients with more severe form of the disease and worse outcome (P < 0.05). Endogenous thrombin potential [area under the curve (AUC) %] was significantly decreased in patients with more severe form of sepsis (66.01 ± 41.51 vs. 83.21 ± 28.83; AUC 0.76) and in patients with worse outcome (67.66 ± 37.79 vs. 81.79 ± 32.15; AUC 0.68; P < 0.05). Evaluation of initial thrombin generation is useful to distinguish between beneficial coagulation activation and hazardous haemostatic alteration, and to predict multiorgan dysfunction development and poor outcome in septic patients.
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13
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Alhamdi Y, Toh CH. Recent advances in pathophysiology of disseminated intravascular coagulation: the role of circulating histones and neutrophil extracellular traps. F1000Res 2017; 6:2143. [PMID: 29399324 PMCID: PMC5785716 DOI: 10.12688/f1000research.12498.1] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2017] [Indexed: 12/29/2022] Open
Abstract
Disseminated intravascular coagulation (DIC) is an acquired condition that develops as a complication of systemic and sustained cell injury in conditions such as sepsis and trauma. It represents major dysregulation and increased thrombin generation in vivo. A poor understanding and recognition of the complex interactions in the coagulation, fibrinolytic, inflammatory, and innate immune pathways have resulted in continued poor management and high mortality rates in DIC. This review focuses attention on significant recent advances in our understanding of DIC pathophysiology. In particular, circulating histones and neutrophil extracellular traps fulfil established criteria in DIC pathogenesis. Both are damaging to the vasculature and highly relevant to the cross talk between coagulation and inflammation processes, which can culminate in adverse clinical outcomes. These molecules have a strong potential to be novel biomarkers and therapeutic targets in DIC, which is still considered synonymous with 'death is coming'.
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Affiliation(s)
- Yasir Alhamdi
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Cheng-Hock Toh
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, UK.,Roald Dahl Haemostasis & Thrombosis Centre, Royal Liverpool University Hospital, Liverpool, UK
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14
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Arioka T, Tawara S, Sata M, Kawasaki K, Matsuzaki O. Thrombomodulin alfa attenuates thrombin-induced leakage of antithrombin through suppression of endothelial vascular hyperpermeability. Thromb Res 2017; 157:170-172. [DOI: 10.1016/j.thromres.2017.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 07/11/2017] [Accepted: 07/14/2017] [Indexed: 11/24/2022]
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15
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Ishikawa M, Yamashita H, Oka N, Ueda T, Kohama K, Nakao A, Kotani J. Antithrombin III improved neutrophil extracellular traps in lung after the onset of endotoxemia. J Surg Res 2016; 208:140-150. [PMID: 27993201 DOI: 10.1016/j.jss.2016.09.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 09/05/2016] [Accepted: 09/21/2016] [Indexed: 01/20/2023]
Abstract
BACKGROUND Coagulation and inflammation are closely linked during acute inflammatory conditions, such as sepsis. Antithrombin (AT) is an anticoagulant that also has anti-inflammatory activities. The effects of therapeutically administering AT III after the onset of endotoxemia or sepsis were not clear. Here, we studied the effects of administering AT III after inducing lethal endotoxemia in mice. METHODS Mice were injected intraperitoneally with lipopolysaccharide (LPS) to induce endotoxemia. AT III was administered 3 h later. We assessed survival and the severity of endotoxemia and quantified plasma cytokine levels and biochemical markers of liver and kidney function. In the lungs, we examined neutrophil accumulation, neutrophil extracellular traps, alveolar wall thickness, and chemokine (C-X-C motif) ligand 1 (cxcl-1), cxcl-2, and high mobility group box 1 expression. RESULTS Administering AT III reduced the severity and mortality of LPS-induced endotoxemia as indicated by 24-h survival of 84% of the mice that received LPS + AT III and only 53% of mice given LPS alone (P < 0.05). AT III treatment attenuated several changes induced in the lungs by endotoxemia including cxcl-2 mRNA expression, high mobility group box 1 protein expression, neutrophil accumulation, alveolar septal thickening, and neutrophil extracellular trap formation. AT III did not decrease plasma cytokine levels or plasma urea nitrogen levels that were upregulated as a result of LPS-induced endotoxemia. CONCLUSIONS Administration of AT III after the onset of endotoxemia improved outcomes in a mouse model. The attenuation of lung inflammation may have a large impact on mortality and morbidity. Because lung inflammation increases the likelihood of mortality from sepsis, AT III could be a useful agent in septic patients.
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Affiliation(s)
- Michiko Ishikawa
- Department of Emergency, Disaster and Critical Care Medicine, Hyogo College of Medicine, Nishinomiya, Japan.
| | - Hayato Yamashita
- Department of Biophysics, Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Nobuki Oka
- Department of Biophysics, Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Takahiro Ueda
- Department of Emergency, Disaster and Critical Care Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Keisuke Kohama
- Department of Emergency, Disaster and Critical Care Medicine, Hyogo College of Medicine, Nishinomiya, Japan; Senri Critical Care Medical Center, Saiseikai Senri Hospital, Osaka, Japan
| | - Atsunori Nakao
- Department of Emergency and Critical Care Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Joji Kotani
- Department of Emergency, Disaster and Critical Care Medicine, Hyogo College of Medicine, Nishinomiya, Japan
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16
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Proposal for new diagnostic criteria for DIC from the Japanese Society on Thrombosis and Hemostasis. Thromb J 2016; 14:42. [PMID: 27708553 PMCID: PMC5039801 DOI: 10.1186/s12959-016-0117-x] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 09/05/2016] [Indexed: 01/15/2023] Open
Abstract
Disseminated intravascular coagulation (DIC) is a serious disease that, in the presence of underlying disease, causes persistent, generalized, marked coagulation activation. Early treatment based on an appropriate diagnosis is very important for improving patients’ prognosis, to which end diagnostic criteria play a key role. Several criteria have been proposed, but each has its strengths and weaknesses, and improved criteria are needed. Widespread use of coagulofibrinolytic markers has elucidated that the pathology of DIC differs greatly as a function of the underlying disease. Thus, discriminating use of DIC diagnostic criteria that take underlying diseases into account is important. DIC diagnostic criteria that are well known in Japan include the Japanese Ministry of Health and Welfare’s old DIC diagnostic criteria (JMHW criteria), the International Society on Thrombosis and Haemostasis’s DIC diagnostic criteria (ISTH criteria), and the Japanese Association for Acute Medicine’s acute-stage DIC diagnostic criteria (JAAM criteria). Those criteria have their respective drawbacks: the sensitivity of the ISTH criteria is poor, the JAAM criteria cannot be applied to all underlying diseases, and the JMHW criteria have poor sensitivity in the case of infections, do not use molecular markers, and result in misdiagnosis. The Japanese Society on Thrombosis and Hemostasis’s newly proposed provisional draft DIC diagnostic criteria (new criteria) use diagnostic criteria classifications of “hematopoietic disorder type”, “infectious type”, and “basic type” based on the underlying pathology. For the hematopoietic disorder type the platelet count is omitted from the score, while for the infectious type, fibrinogen is omitted from the score. Also, points are added if the platelet count decreases with time. In the new criteria, molecular markers and antithrombin activity have been newly included, and as a countermeasure for misdiagnosis, 3 points are deducted if there is liver failure. In this paper, we discuss various problems encountered with DIC diagnosis, and we describe the new criteria together with the events that led to their creation. These new diagnostic criteria take into account the underlying diseases of wide area, and we expect that they will serve clinicians well due to the above adaptations and improvements.
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17
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Li WJ, Sha M, Ma W, Zhang ZP, Wu YJ, Shi DM. Efficacy evaluation of D-dimer and modified criteria in overt and nonovert disseminated intravascular coagulation diagnosis. Int J Lab Hematol 2016; 38:151-9. [PMID: 26833979 DOI: 10.1111/ijlh.12467] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 11/23/2015] [Indexed: 11/27/2022]
Affiliation(s)
- W. J. Li
- Department of Clinical Laboratory; Suzhou Municipal Hospital affiliated to Nanjing Medical University; Suzhou China
| | - M. Sha
- Department of Clinical Laboratory; Suzhou Municipal Hospital affiliated to Nanjing Medical University; Suzhou China
| | - W. Ma
- Department of Clinical Laboratory; Suzhou Municipal Hospital affiliated to Nanjing Medical University; Suzhou China
| | - Z. P. Zhang
- Department of Clinical Laboratory; Suzhou Municipal Hospital affiliated to Nanjing Medical University; Suzhou China
| | - Y. J. Wu
- Department of Clinical Laboratory; Suzhou Municipal Hospital affiliated to Nanjing Medical University; Suzhou China
| | - D. M. Shi
- Department of Clinical Laboratory; Suzhou Municipal Hospital affiliated to Nanjing Medical University; Suzhou China
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18
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Prochazkova J, Slavik L, Ulehlova J, Prochazka M. The role of tissue factor in normal pregnancy and in the development of preeclampsia: A review. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2015; 159:192-6. [DOI: 10.5507/bp.2014.061] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Accepted: 11/13/2014] [Indexed: 11/23/2022] Open
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Parlato M, Cavaillon JM. Host response biomarkers in the diagnosis of sepsis: a general overview. Methods Mol Biol 2015; 1237:149-211. [PMID: 25319788 DOI: 10.1007/978-1-4939-1776-1_15] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Critically ill patients who display a systemic inflammatory response syndrome (SIRS) are prone to develop nosocomial infections. The challenge remains to distinguish as early as possible among SIRS patients those who are developing sepsis. Following a sterile insult, damage-associated molecular patterns (DAMPs) released by damaged tissues and necrotic cells initiate an inflammatory response close to that observed during sepsis. During sepsis, pathogen-associated molecular patterns (PAMPs) trigger the release of host mediators involved in innate immunity and inflammation through identical receptors as DAMPs. In both clinical settings, a compensatory anti-inflammatory response syndrome (CARS) is concomitantly initiated. The exacerbated production of pro- or anti-inflammatory mediators allows their detection in biological fluids and particularly within the bloodstream. Some of these mediators can be used as biomarkers to decipher among the patients those who developed sepsis, and eventually they can be used as prognosis markers. In addition to plasma biomarkers, the analysis of some surface markers on circulating leukocytes or the study of mRNA and miRNA can be helpful. While there is no magic marker, a combination of few biomarkers might offer a high accuracy for diagnosis.
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Affiliation(s)
- Marianna Parlato
- Unit of Cytokines and Inflammation, Institut Pasteur, 28 rue du Dr Roux, 75724, Paris Cedex 15, France
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20
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Coagulation abnormalities in sepsis. ACTA ACUST UNITED AC 2015; 53:16-22. [DOI: 10.1016/j.aat.2014.11.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 11/16/2014] [Accepted: 11/24/2014] [Indexed: 11/30/2022]
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Abstract
Disseminated intravascular coagulation (DIC) is a reflection of an underlying systemic disorder which affects the coagulation system, simultaneously resulting in pro-coagulant activation, fibrinolytic activation, and consumption coagulopathy and finally may result in organ dysfunction and death. Though septicaemia is the most common cause of DIC, several other conditions can also lead to it. A diagnosis of DIC should be made only in the presence of a causative factor supported by repeated laboratory tests for coagulation profile and clotting factors. An effective scoring system helps to detect an overt DIC and a high score closely correlates with mortality. Treatment of DIC is aimed at combating the underlying disorder followed by supportive management. Low molecular weight heparin is advocated in special situations whereas anti-thrombin III and activated protein C are of doubtful value. Early diagnosis and prompt treatment backed by laboratory support can reduce the morbidity and mortality associated with it. The methodology of search for this review article involved hand search from text books and internet search using Medline (via PubMed) using key words DIC, thrombosis, fibrin degradation products, anti-thrombin and tissue factor for the last 25 years and also recent evidence-based reviews.
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Affiliation(s)
- A Venugopal
- Department of Anaesthesiology, Regional Cancer Centre, Medical College Campus, Thiruvanathapuram, Kerala, India
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22
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Christiaans SC, Wagener BM, Esmon CT, Pittet JF. Protein C and acute inflammation: a clinical and biological perspective. Am J Physiol Lung Cell Mol Physiol 2013; 305:L455-66. [PMID: 23911436 DOI: 10.1152/ajplung.00093.2013] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
The protein C system plays an active role in modulating severe systemic inflammatory processes such as sepsis, trauma, and acute respiratory distress syndrome (ARDS) via its anticoagulant and anti-inflammatory properties. Plasma levels of activated protein C (aPC) are lower than normal in acute inflammation in humans, except early after severe trauma when high plasma levels of aPC may play a mechanistic role in the development of posttraumatic coagulopathy. Thus, following positive results of preclinical studies, a clinical trial (PROWESS) with high continuous doses of recombinant human aPC given for 4 days demonstrated a survival benefit in patients with severe sepsis. This result was not confirmed by subsequent clinical trials, including the recently published PROWESS-SHOCK trial in patients with septic shock and a phase II trial with patients with nonseptic ARDS. A possible explanation for the major difference in outcome between PROWESS and PROWESS-SHOCK trials is that lung-protective ventilation was used for the patients included in the recent PROWESS-SHOCK, but not in the original PROWESS trial. Since up to 75% of sepsis originates from the lung, aPC treatment may not have added enough to the beneficial effect of lung-protective ventilation to show lower mortality. Thus whether aPC will continue to be used to modulate the acute inflammatory response in humans remains uncertain. Because recombinant human aPC has been withdrawn from the market, a better understanding of the complex interactions between coagulation and inflammation is needed before considering the development of new drugs that modulate both coagulation and acute inflammation in humans.
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Affiliation(s)
- Sarah C Christiaans
- Dept. of Anesthesiology, Univ. of Alabama at Birmingham, 619 S. 19th St., JT926, Birmingham, AL 35249.
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Koyama K, Madoiwa S, Tanaka S, Koinuma T, Wada M, Sakata A, Ohmori T, Mimuro J, Nunomiya S, Sakata Y. Evaluation of hemostatic biomarker abnormalities that precede platelet count decline in critically ill patients with sepsis. J Crit Care 2013; 28:556-63. [PMID: 23583072 DOI: 10.1016/j.jcrc.2012.10.069] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 10/07/2012] [Accepted: 10/30/2012] [Indexed: 02/04/2023]
Abstract
PURPOSE The hemostatic biomarkers for early diagnosis of sepsis-associated coagulopathy have not been identified. The purpose of this study was to evaluate hemostatic biomarker abnormalities preceding a decrease in platelet count, which is a surrogate indicator of overt coagulopathy in sepsis. MATERIALS AND METHODS Seventy-five septic patients with a platelet count more than 80×10(3)/μL were retrospectively analyzed. Hemostatic biomarkers at intensive care unit admission were compared between patients with and patients without a subsequent decrease in platelet count (≥30% within 5 days), and the ability of biomarkers to predict a decrease in platelet count was evaluated. RESULTS Forty-two patients (56.0%) developed a subsequent decrease in platelet count. Severity of illness, incidence of organ dysfunction, and 28-day mortality rate were higher in patients with a subsequent decrease in platelet count. There were significant differences between patients with and patients without a subsequent decrease in platelet count in prothrombin time-international normalized ratio, fibrinogen, thrombin-antithrombin complex, antithrombin, protein C (PC), plasminogen, and α2-plasmin inhibitor (α2-PI). Receiver operating characteristic curve analysis showed that PC (area under the curve, 0.869; 95% confidence interval, 0.699-0.951) and α2-PI (area under the curve, 0.885; 95% confidence interval, 0.714-0.959) were strong predictors of a subsequent decrease in platelet count. CONCLUSIONS Decreased PC and α2-PI activity preceded a decrease in platelet count in intensive care unit patients with sepsis.
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Affiliation(s)
- Kansuke Koyama
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, Tochigi, Japan; Research Division of Cell and Molecular Medicine, Center of Molecular Medicine, Jichi Medical University School of Medicine, Tochigi, Japan.
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Abstract
It was suggested more than 30 yrs ago that inhibition of the clotting cascade by natural anticoagulants could decrease the high mortality observed in patients suffering from severe sepsis and septic shock. Unfortunately, this therapeutic "paradigm" has led to a dead end, illustrated by the failure of all randomized trials and the recent withdrawal of recombinant activated protein C. Should we now definitely give up trying to treat septic coagulation disturbances or is there any therapeutic alternative?
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Kushimoto S, Wada H, Kawasugi K, Okamoto K, Uchiyama T, Seki Y, Hatada T, Imai H, Nobori T. Increased Ratio of Soluble Fibrin Formation/Thrombin Generation in Patients With DIC. Clin Appl Thromb Hemost 2012; 18:628-32. [DOI: 10.1177/1076029612451648] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The generation of thrombin–antithromin (AT) complex (TAT) or soluble fibrin (SF) was prospectively compared with prothrombin fragment 1 + 2 (F1 + 2) generation in patients with disseminated intravascular coagulation (DIC). The plasma levels of TAT, SF, and F1 + 2 were significantly higher in the DIC group than in the non-DIC group. The differences in these levels between the DIC group and non-DIC group were significantly related to infections and hematopoietic tumors. There were no significant differences in the TAT/F1 + 2 ratio between DIC and non-DIC patients, but the SF/F1 + 2 ratio was significantly higher in the DIC group than the non-DIC group. The plasma AT activity was significantly higher in patients with DIC with resolution than in those without resolution, and in survivors than in nonsurvivors. These findings suggest that the ratio of TAT/thrombin is constant between the patients with and without DIC but that the ratio of fibrin formation/thrombin might increase in DIC.
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Affiliation(s)
- Shigeki Kushimoto
- Division of Emergency Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hideo Wada
- Department of Molecular and Laboratory Medicine, Mie University School of Medicine, Tsu, Japan
| | - Kazuo Kawasugi
- Department of Internal Medicine, Teikyo University School of Medicine, Itabashi, Japan
| | - Kohji Okamoto
- First Department of Surgery, University of Occupational and Environmental Health School of Medicine, KitaKyushu, Japan
| | - Toshimasa Uchiyama
- Department of Internal Medicine, National Hospital Organization Takasaki General Medical Center, Takasaki, Japan
| | - Yoshinobu Seki
- Department of Internal Medicine, Shibata Hospital-Niigata Prefectural Hospital, Shibata, Japan
| | - Tsuyoshi Hatada
- Emergency Critical Care Center, Mie University Hospital, Tsu, Japan
| | - Hiroshi Imai
- Emergency Critical Care Center, Mie University Hospital, Tsu, Japan
| | - Tsutomu Nobori
- Department of Molecular and Laboratory Medicine, Mie University School of Medicine, Tsu, Japan
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Hatada T, Wada H, Kawasugi K, Okamoto K, Uchiyama T, Kushimoto S, Seki Y, Okamura T, Imai H, Kaneko T, Nobori T. Analysis of the cutoff values in fibrin-related markers for the diagnosis of overt DIC. Clin Appl Thromb Hemost 2011; 18:495-500. [PMID: 22203032 DOI: 10.1177/1076029611429786] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Fibrin-related markers (FRMs) such as fibrin and fibrinogen degradation products (FDPs), d-dimer, and soluble fibrin monomer complex (SFMC) were prospectively evaluated in 522 patients using the overt disseminated intravascular coagulation (DIC) diagnostic criteria. The differences in all FRMs between the DIC group and the non-DIC group, and those between the survivors and nonsurvivors were significant in the patients with infections. In an analysis of all patients, DIC score cutoff values of 2 and 3 points for FDP, d-dimer, and SFMC were recommended to be 8.3 and 42.0 μg/mL, 2.4 and 22.0 μg/mL, and 3.4 and 138.0 μg/mL, respectively. In conclusion, the adequate cutoff value is thus considered to be useful for both making a diagnosis of DIC and for predicting the outcome. Fibrin-related markers are therefore thought to be more useful for making a diagnosis of DIC based on infections than based on any other underlying disorders.
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Affiliation(s)
- Tsuyoshi Hatada
- Emergency Critical Care Center, Mie University Hospital, Tsu, Japan
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27
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Chu AJ. Tissue factor, blood coagulation, and beyond: an overview. Int J Inflam 2011; 2011:367284. [PMID: 21941675 PMCID: PMC3176495 DOI: 10.4061/2011/367284] [Citation(s) in RCA: 122] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 06/16/2011] [Accepted: 06/18/2011] [Indexed: 12/18/2022] Open
Abstract
Emerging evidence shows a broad spectrum of biological functions of tissue factor (TF). TF classical role in initiating the extrinsic blood coagulation and its direct thrombotic action in close relation to cardiovascular risks have long been established. TF overexpression/hypercoagulability often observed in many clinical conditions certainly expands its role in proinflammation, diabetes, obesity, cardiovascular diseases, angiogenesis, tumor metastasis, wound repairs, embryonic development, cell adhesion/migration, innate immunity, infection, pregnancy loss, and many others. This paper broadly covers seminal observations to discuss TF pathogenic roles in relation to diverse disease development or manifestation. Biochemically, extracellular TF signaling interfaced through protease-activated receptors (PARs) elicits cellular activation and inflammatory responses. TF diverse biological roles are associated with either coagulation-dependent or noncoagulation-mediated actions. Apparently, TF hypercoagulability refuels a coagulation-inflammation-thrombosis circuit in “autocrine” or “paracrine” fashions, which triggers a wide spectrum of pathophysiology. Accordingly, TF suppression, anticoagulation, PAR blockade, or general anti-inflammation offers an array of therapeutical benefits for easing diverse pathological conditions.
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Affiliation(s)
- Arthur J Chu
- Division of Biological and Physical Sciences, Delta State University, Cleveland, MS 38733, USA
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Kawasugi K, Wada H, Hatada T, Okamoto K, Uchiyama T, Kushimoto S, Seki Y, Okamura T, Nobori T. Prospective evaluation of hemostatic abnormalities in overt DIC due to various underlying diseases. Thromb Res 2011; 128:186-90. [PMID: 21429565 DOI: 10.1016/j.thromres.2011.02.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Revised: 02/15/2011] [Accepted: 02/20/2011] [Indexed: 01/03/2023]
Abstract
Patients with suspected disseminated intravascular coagulation (DIC) were prospectively evaluated for various types of underlying diseases, and the usefulness of hemostatic markers were examined for each patient with DIC due to various underlying diseases. The main underlying disease of DIC was infectious diseases, hematologic malignancies, and solid tumors, and a high resolution rate from DIC was observed in obstetric diseases and hematologic malignancies. The diagnosis of DIC was related to a poor outcome in trauma/burn victims and those with infectious disease. In the main underlying disease, it is suggested that DIC would be excluded in patients with hematologic malignancies or solid tumors with a platelet count of more than 100,000/μl and in the patients with an FDP of less than 10 μg/ml, and fibrinogen of less than 100mg/dl, suggesting the presence of DIC. The prothrombin time was a sensitive marker, but fibrinogen levels were not sensitive for DIC due to infectious diseases. The plasmin plasmin inhibitor complex in hematologic malignancy, and soluble fibrin monomer complex, antithrombin and thrombomodulin in patients with infectious disease, were sensitive markers for the diagnosis of DIC. Although hemostatic markers were useful for the diagnosis of DIC, the usefulness varied depending on the different underlying diseases.
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Affiliation(s)
- Kazuo Kawasugi
- Department of Internal Medicine, Teikyo University School of Medicine, Itabashi
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Wada H, Hatada T, Okamoto K, Uchiyama T, Kawasugi K, Mayumi T, Gando S, Kushimoto S, Seki Y, Madoiwa S, Okamura T, Toh CH. Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC. Am J Hematol 2010; 85:691-4. [PMID: 20645433 DOI: 10.1002/ajh.21783] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Diagnostic criteria for non-overt disseminated intravascular coagulation (DIC) have been proposed by the International Society of Thrombosis and Hemostasis, but are not useful for the diagnosis of early phase of overt-DIC (pre-DIC). Therefore, in the current study the non-overt DIC diagnostic criteria were modified using the global coagulation tests, the change rate in the global coagulation tests and molecular hemostatic markers to detect the pre-DIC state and were prospectively evaluated in 613 patients with underlying DIC disease. The frequencies of patients with DIC (DIC positive), late onset DIC, and without DIC (DIC absent) were 29.5%, 7.2%, and 63.3%, respectively. The modified non-overt-DIC criteria can correctly predict 43/44 patients (97.7%) who were DIC absent at admission and became DIC positive, within a week (late onset DIC state). The mortality rate was higher in DIC positive compared with pre-DIC (37.6% vs. 22.7%, P < 0.05) or DIC negative (37.6 vs. 13.7%, P < 0.01). It was also significantly higher in pre-DIC compared with DIC negative (P < 0.05). Thus, these modified non-overt DIC diagnostic criteria might therefore be useful for the diagnosis of early-phase DIC.
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Affiliation(s)
- Hideo Wada
- Department of Molecular and Laboratory Medicine, Mie University School of Medicine, Tsu, Mie, Japan.
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Yazar E, Bulbul A, Avci G, Er A, Uney K, Elmas M, Tras B. Effects of enrofloxacin, flunixin meglumine and dexamethasone on disseminated intravascular coagulation, cytokine levels and adenosine deaminase activity in endotoxaemia in rats. Acta Vet Hung 2010; 58:357-67. [PMID: 20713326 DOI: 10.1556/avet.58.2010.3.8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The aim of this study was to determine the effects of drugs used in the treatment of endotoxaemia on disseminated intravascular coagulation, cytokine levels and adenosine deaminase activities in endotoxaemic rats. Rats were divided into seven groups. Lipopolysaccharide (LPS) was injected into all groups, including the positive control group. The other six groups received the following drugs: enrofloxacin (ENR), flunixin meglumine (FM), low-dose dexamethasone (DEX), high-dose DEX, ENR + FM + low-dose DEX, and ENR + FM + high-dose DEX. After the treatments, serum and plasma samples were collected at 0, 1, 2, 4, 6, 8, 12, 24 and 48 hours (h). A coagulometer was used to determine the levels of coagulation values, while ELISA was used to assay serum cytokines and adenosine deaminase (ADA). Low-dose DEX alone and combined treatments depressed the levels of cytokines and ADA (from 371 to 70 IU/L at 6 h) significantly and inhibited the decrease of coagulation values (antithrombin from 67 to 140% at 6 h, fibrinogen from 54 to 252 mg/dL at 6 h). In summary, FM + high-dose DEX may be the preferred treatment of endotoxaemia because of its highest effectiveness. FM plus high-dose DEX may be a new therapy for endotoxaemic domestic animals.
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Affiliation(s)
- Enver Yazar
- 1 University of Selcuk Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine 42031 Campus, Konya Turkey
| | - Aziz Bulbul
- 2 University of Afyon Kocatepe Department of Physiology Afyon Turkey
| | - Gulcan Avci
- 3 University of Afyon Kocatepe Department of Biochemistry, Faculty of Veterinary Medicine Afyon Turkey
| | - Ayse Er
- 1 University of Selcuk Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine 42031 Campus, Konya Turkey
| | - Kamil Uney
- 1 University of Selcuk Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine 42031 Campus, Konya Turkey
| | - Muammer Elmas
- 1 University of Selcuk Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine 42031 Campus, Konya Turkey
| | - Bunyamin Tras
- 1 University of Selcuk Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine 42031 Campus, Konya Turkey
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Koyama T, Yamada T, Morikawa M, Tanaka R, Yamamura M, Araki N, Yamada T, Shimada S, Minakami H. Marked gestational edema as a clinical sign of life-threatening condition. J Obstet Gynaecol Res 2010; 36:861-5. [DOI: 10.1111/j.1447-0756.2010.01191.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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32
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Okamoto K, Wada H, Hatada T, Uchiyama T, Kawasugi K, Mayumi T, Gando S, Kushimoto S, Seki Y, Madoiwa S, Asakura H, Koga S, Iba T, Maruyama I. Frequency and hemostatic abnormalities in pre-DIC patients. Thromb Res 2010; 126:74-8. [PMID: 20452653 DOI: 10.1016/j.thromres.2010.03.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Revised: 03/23/2010] [Accepted: 03/28/2010] [Indexed: 11/29/2022]
Abstract
Disseminated intravascular coagulation (DIC) sometimes has a poor outcome, and therefore early diagnosis and treatment are required. This study prospectively evaluated the hemostatic abnormalities and the onset of DIC in 613 patients with underlying diseases to identify a useful marker for diagnosing Pre-DIC. Pre-DIC was defined as the condition of patients within a week before the onset of DIC. Initially, 34.4% of patients were diagnosed with DIC, and about 8.5% of the patients without DIC were diagnosed as DIC within a week after registration (pre-DIC). The mortality of DIC, Pre-DIC and "without DIC" was 35.3%, 32.4% and 17.2%, respectively. All hemostatic parameters were significantly worse in "DIC" than "without DIC" and the values of the prothrombin time ratio, platelet count and fibrin monomer complex could classify the three groups; "DIC", "pre-DIC" and "without DIC". No useful marker was identified that provided an adequate cutoff value to differentiate "pre-DIC" from "without DIC". A multivariate analysis identified clinical symptoms that were related to poor outcome. DIC must be treated immediately; there is no specific marker to identify pre-DIC.
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Affiliation(s)
- Kohji Okamoto
- First Department of Surgery, University of Occupational and Environmental Health School of Medicine, KitaKyushu, Japan
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The response of antithrombin III activity after supplementation decreases in proportion to the severity of sepsis and liver dysfunction. Shock 2009; 30:649-52. [PMID: 18496242 DOI: 10.1097/shk.0b013e318173e396] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The decrease in the antithrombin III activity is thought to result from consumption by ongoing coagulation, degradation by neutrophil elastase, capillary leak syndrome, and impaired synthesis. A retrospective data analysis of patients with sepsis was conducted to investigate the response of antithrombin III activity after supplementation in patients with sepsis, and to determine what factors affect the response of antithrombin III activity. The study included 42 patients with sepsis, 75 patients with severe sepsis, and 65 patients with septic shock, who were administered antithrombin III. Antithrombin III activity, platelet counts, coagulation, and fibrinolytic markers were collected before administration and 24 h after the supplementation. In the patients with septic shock, the response of antithrombin III activity after supplementation was 0.37% +/- 1.21%/IU per kg body weight, which was significantly lower in comparison with those in the patients with sepsis (1.81 +/- 1.75; P < 0.001) or severe sepsis (1.36 +/- 1.65; P < 0.001). The patients with liver dysfunction had significantly lower response to antithrombin III activity than that of the patients without liver dysfunction (P < 0.0001). A stepwise multiple linear regression analysis revealed that the severity of sepsis and liver function were independent predictors for the response to antithrombin III activity. These results suggest that the response to antithrombin III supplementation may be affected by both a systemic inflammation and impaired synthesis in patients with sepsis.
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34
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Levi M, Toh CH, Thachil J, Watson HG. Guidelines for the diagnosis and management of disseminated intravascular coagulation. Br J Haematol 2009; 145:24-33. [DOI: 10.1111/j.1365-2141.2009.07600.x] [Citation(s) in RCA: 757] [Impact Index Per Article: 50.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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35
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Aibiki M, Fukuoka N, Nishiyama T, Maekawa S, Shirakawa Y. Differences in antithrombin III activities by administration method in critical patients with disseminated intravascular coagulation: a pharmacokinetic study. Shock 2007; 28:141-7. [PMID: 17515857 DOI: 10.1097/shk.0b013e31803422c4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pharmacokinetic (PK) data for antithrombin III (AT) are limited in the critical patients. We therefore performed PK analysis using a two-compartment model and also examined whether plasma AT activity would change depending on two administration methods, AT agent at 500 U/8 h (divided group) or 1,500 U/24 h (combined group) for 3 days, a regulated dosage for disseminated intravascular coagulation (DIC) treatment in Japan, in critical patients with DIC. Clinical prospective randomized study. A high care unit in a university hospital. Twenty-four consecutive critical patients with DIC. Ages ranged from 34 to 91 years. Acute physiology age and chronic health evaluation II scores were 25 to 35. Antithrombin III activities in the combined group caused remarkable transient increases but returned to near the preadministration level 24 h after the infusion. Antithrombin III level in the divided group showed small elevations on each session; therefore, steady increases were found after serial administrations of the agent. On the third day, AT trough activities in the divided group were significantly higher than those in the combined group (P = 0.005). However, peak AT activities in the combined group after AT administration were higher than those in the divided group throughout the study (P = 0.024). Aggravation of bleeding tendency occurred more frequently in the combined group (P = 0.03). Half-life times on the distribution phase in both groups were remarkably shorter than those of previously reported control in congenital AT deficiency. This suggests an increased vascular permeability in the critical patients in this study. Distribution volume in the patients here increased significantly as compared with the previous controls. This is the first PK report using a two-compartment model to demonstrate that remarkable increases in vascular permeability and distribution volume occur in critical patients with DIC, and if the same dose is administered intermittently in such PK situation, AT administration in divided manner can maintain plasma AT trough activity higher than that in the combined method.
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Affiliation(s)
- Mayuki Aibiki
- Department of Emergency Medicine, School of Medicine, Ehime University, 454 Shitsukawa, Tohon, Ehime 791-0295, Japan.
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36
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Aibiki M, Fukuoka N, Umakoshi K, Ohtsubo S, Kikuchi S. Serum albumin levels anticipate antithrombin III activities before and after antithrombin III agent in critical patients with disseminated intravascular coagulation. Shock 2007; 27:139-44. [PMID: 17224787 DOI: 10.1097/01.shk.0000239762.90335.68] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Elevated thrombin-antithrombin complex (TAT) or decreased serum albumin levels suggest heightened vascular permeability in disseminated intravascular coagulation (DIC). In such a situation, plasma antithrombin III (AT-III) may decrease because of the leakage. We thus examined whether AT-III activity before and after administration of an AT-III agent changed depending on plasma TAT and/or serum albumin levels in 20 consecutive patients with DIC. We also analyzed the pharmacokinetics for AT-III using a two-compartment model. Serum albumin levels before AT-III administration correlated with preadministered and postadministered AT-III activity, but TAT levels did not. Regardless of TAT levels, AT-III trough activity on the third day increased significantly. In patients with albumin levels of 2.5 g/dL or less, AT-III trough levels on the third day were significantly lower than those with higher levels of albumin. The half-life of the distribution phase for AT-III agent in the patients was shortened to less than one third the value reported in congenital AT-III deficiency, suggesting increased vascular permeability in the acute state patients here. The distribution volume of the agent increased remarkably compared with the previous control. We report here for the first time that in critical patients with DIC, plasma AT-III levels before and after AT-III administration could be predicted by preadministered serum albumin levels, but not by TAT. These findings could be explained by the pharmacokinetic profile, increased vascular permeability and distribution volume, observed in critical patients.
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Affiliation(s)
- Mayuki Aibiki
- Department of Emergency Medicine, School of Medicine, Ehime University, Ehime, and Pharmacy Division, Kagawa University Hospital, Kagawa, Japan.
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37
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Tanaka KA, Levy JH. Regulation of Thrombin Activity—Pharmacologic and Structural Aspects. Hematol Oncol Clin North Am 2007; 21:33-50. [PMID: 17258117 DOI: 10.1016/j.hoc.2006.11.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Thrombin is an essential serine protease for survival. Since the discovery of heparin in the early twentieth century, significant advances have been made in the understanding of thrombin structure and function in coagulation system. Endogenous anticoagulant proteins in blood tightly regulate thrombin generation, but additional anticoagulant agents may be necessary to suppress excessive thrombin formation or defective anticoagulant proteins. Despite the availability of an array of anticoagulant agents based on chemical and biological engineering technologies, anticoagulation therapy remains a challenge for clinicians in terms of balancing bleeding and thrombosis. The aim of this article is to review endogenous serine protease inhibitors and novel antithrombotic agents in relation to pharmacologic regulation of thrombin.
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Affiliation(s)
- Kenichi A Tanaka
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, Emory Healthcare, 1364 Clifton Road N.E., Atlanta, GA 30322, USA.
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Gando S, Wada H, Asakura H, Iba T, Eguchi Y, Okamoto K, Ohtomo Y, Kawasugi K, Koga S, Koseki K, Tsuji H, Mayumi T, Murata A, Nakagawa M, Endo S. Evaluation of new Japanese diagnostic criteria for disseminated intravascular coagulation in critically ill patients. Clin Appl Thromb Hemost 2005; 11:71-6. [PMID: 15678275 DOI: 10.1177/107602960501100108] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
New Japanese diagnostic criteria were prepared for disseminated intravascular coagulation (DIC) in critically ill patients and their usefulness was compared with the criteria of the International Society of Thrombosis and Haemostasis (ISTH) and those of the Japan Ministry of Health and Welfare (JMHW). In a retrospective study of patients with platelet counts of less than 150 x10(3)/mL, 52 cases (33.3%), 66 cases (42.3%), and 101 cases (64.7%) were diagnosed as DIC by the ISTH, JMHW, and new Japanese DIC criteria, respectively. The DIC state as diagnosed by the new Japanese DIC criteria included both DIC states as diagnosed by ISTH or JMHW criteria. Some DIC states diagnosed by the JMHW criteria included those diagnosed by ISHT criteria but this was not universal. The mortality of DIC as diagnosed by the ISTH or JMHW criteria was markedly high, compared to that for DIC diagnosed by the new Japanese criteria. The mortality of patients without DIC by ISTH was also high when they were diagnosed as DIC by the new Japanese criteria. The frequency of DIC by each set of diagnostic criteria was significantly higher in patients with infection than in those without infection. The mortality of DIC by each set of diagnostic criteria was significantly higher in patients with infection than in those without infection, and the mortality of overt-DIC by ISTH diagnostic criteria was also high in patients without infection.
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Affiliation(s)
- Satoshi Gando
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University, Graduate School of Medicine, Sapporo-city, Japan
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Iba T, Kidokoro A, Fukunaga M, Sugiyama K, Sawada T, Kato H. Association between the severity of sepsis and the changes in hemostatic molecular markers and vascular endothelial damage markers. Shock 2005; 23:25-9. [PMID: 15614127 DOI: 10.1097/01.shk.0000144422.32647.b6] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
It is well known that disorders of coagulation and fibrinolysis play a major role in the development of organ dysfunction during sepsis. Furthermore, the importance of the early initiation of anticoagulation therapy for severe cases has been emphasized based on the success of recent clinical trials. The purpose of this study is to search for useful markers for predicting organ dysfunction. Plasma samples were prospectively collected from 78 patients within 48 h after the onset of sepsis. Hemostatic markers and endothelial damage markers were compared between the patients with and without organ dysfunction. The WBC and platelet counts were not different between the groups. In contrast, fibrin/fibrinogen degradation products, D-dimer, thrombin-antithrombin complex, plasmin alpha2-antiplasmin complex, soluble fibrin, and total plasminogen activator inhibitor-1 were significantly higher, and the antithrombin activity and protein C levels were lower in the patients with organ dysfunction. Thus, the changes in the hemostatic molecular markers were associated with organ dysfunction from an early stage of sepsis, and antithrombin and protein C activities were found to be the most reliable markers.
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Affiliation(s)
- Toshiaki Iba
- Department of Surgery, Juntendo Urayasu Hospital, Juntendo University School of Medicine, Urayasu, Chiba 279-0021, Japan.
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Ontachi Y, Asakura H, Funada H, Takami A, Saito M, Morishita E, Yamazaki M, Mizutani T, Kaneda M, Ito T, Nakao S. An idiopathic skin eruption resembling a butterfly rash in a septic patient with disseminated intravascular coagulation following bone marrow transplantation. Blood Coagul Fibrinolysis 2004; 15:255-9. [PMID: 15060423 DOI: 10.1097/00001721-200404000-00010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A 31-year-old man who underwent chemotherapy and bone marrow transplantation to treat acute myeloblastic leukemia was admitted to our department complaining of high fever and hypotension. His physical examination revealed warm shock state, eruptions resembling that seen in systemic lupus erythematosus on his face and cyanosis in his fingers. We diagnosed septic shock and idiopathic skin eruption on his face. Following treatment with blood transfusion, anticoagulant, antibiotics, respirator and continuous arteriovenous hemofiltration and dialysis, the patient's condition gradually improved. The eruptions on his face first observed at admission progressed with a worsening of his disseminated intravascular coagulation (DIC), and subsided with an improvement in his DIC. A biopsy of the eruption was taken and pathological findings of the eruption revealed multiple micro-fibrin depositions of the dermis. The skin necrosis in purpura fulminans often begins in the distal extremities. But our patient developed this uncommon skin eruption on his face. Patients with an idiopathic skin eruption resembling a butterfly rash in a septic patient should be considered to complicate DIC as in the present case.
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Affiliation(s)
- Yasuo Ontachi
- Department of Internal Medicine (III), Kanazawa University School of Medicine, Takaramachi 13-1, Kanazawa 920-8641, Japan.
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Abstract
Disseminated intravascular coagulation (DIC) is a clinicopathologic syndrome resulting from a multitude of underlying causes that manifests itself clinically as hemostatic/fibrinolytic failure. There is much debate on the definition, diagnosis, and treatment of DIC, a situation that is most likely the result of the multifaceted clinical presentation of the syndrome and the fact that patient outcome is often influenced by the underlying disease process. The fact that DIC increases morbidity and mortality in critical care patients is well established, but the exact mechanism of what specifically occurs on a microvascular level is still often argued.
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Affiliation(s)
- Barbara L Dallap
- Department of Clinical Studies, University of Pennsylvania School of Veterinary Medicine, New Bolton Center, 382 West Street Road, Kennett Square, PA 19348, USA.
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