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Rogalski P, Rogalska M, Martonik D, Rusak M, Pawlus J, Chociej-Stypulkowska J, Dabrowska M, Flisiak R. Rotational Thromboelastometry (ROTEM ®) in Relation to Inflammatory Biomarkers and Clinical Outcome in COVID-19 Patients. J Clin Med 2023; 12:3919. [PMID: 37373613 DOI: 10.3390/jcm12123919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/01/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
Background: The pathogenesis of hypercoagulability in COVID-19 patients is complex and not fully understood. Rotational thromboelastometry (ROTEM®) is a viscoelastic method that allows the definition of a patient's hemostatic profile. This study aimed to assess the relationship between ROTEM® parameters, the profile of inflammatory cytokines, and clinical outcomes in COVID-19 patients. Methods: A total of 63 participants (n = 29 symptomatic non-ICU COVID-19 patients, and n = 34 healthy controls) were prospectively included in the study. We assessed the relationship between the parameters of three ROTEM® tests (NATEM®, EXTEM®, and FIBTEM®) and levels of CRP, interleukin-8, interleukin-1β, interleukin-6, interleukin-10, tumor necrosis factor, interleukin 12p70, and clinical outcomes. Results: ROTEM® indicated hypercoagulability in COVID-19 patients in all the tests performed. The levels of all inflammatory cytokines were significantly higher in COVID-19 patients. NATEM more frequently detected hypercoagulability in COVID-19 patients compared to EXTEM. The strongest correlations with inflammatory biomarkers and CT severity score were with FIBTEM parameters. The elevated maximum clot elasticity (MCE) in FIBTEM was the strongest predictor of poor outcomes. Conclusions: Increased FIBTEM MCE may be associated with greater severity of COVID-19. Non-activated ROTEM (NATEM test) seems to be more valuable for detecting hypercoagulability in COVID-19 patients compared to the tissue factor activated test (EXTEM).
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Affiliation(s)
- Pawel Rogalski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, 15-276 Białystok, Poland
| | - Magdalena Rogalska
- Department of Infectious Diseases and Hepatology, Medical University of Bialystok, 15-540 Białystok, Poland
| | - Diana Martonik
- Department of Infectious Diseases and Hepatology, Medical University of Bialystok, 15-540 Białystok, Poland
| | - Malgorzata Rusak
- Department of Haematological Diagnostics, Medical University of Bialystok, 15-276 Białystok, Poland
| | - Joanna Pawlus
- Department of Haematological Diagnostics, Medical University of Bialystok, 15-276 Białystok, Poland
| | | | - Milena Dabrowska
- Department of Haematological Diagnostics, Medical University of Bialystok, 15-276 Białystok, Poland
| | - Robert Flisiak
- Department of Infectious Diseases and Hepatology, Medical University of Bialystok, 15-540 Białystok, Poland
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2
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van de Berg TW, Mulder MMG, Alnima T, Nagy M, van Oerle R, Beckers EAM, Hackeng TM, Hulshof AM, Sels JWEM, Henskens YMC, van der Horst ICC, ten Cate H, Spronk HMH, van Bussel BCT. Serial thrombin generation and exploration of alternative anticoagulants in critically ill COVID-19 patients: Observations from Maastricht Intensive Care COVID Cohort. Front Cardiovasc Med 2022; 9:929284. [PMID: 36277784 PMCID: PMC9582511 DOI: 10.3389/fcvm.2022.929284] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
Background COVID-19 associated coagulopathy (CAC) is associated with an increase in thromboembolic events. Current guidelines recommend prophylactic heparins in the management of CAC. However, the efficacy of this strategy in the intensive care population remains uncertain. Objective We aimed to measure thrombin generation (TG) to assess CAC in intensive care unit (ICU) patients receiving thromboprophylaxis with low molecular weight heparin (LMWH) or unfractionated heparin (UFH). In addition, we performed statistical modeling to link TG parameters to patient characteristics and clinical parameters. Lastly, we studied the potency of different anticoagulants as an alternative to LMWH treatment in ex vivo COVID-19 plasma. Patients/Methods We included 33 patients with confirmed COVID-19 admitted at the ICU. TG was measured at least twice over the course of 6 weeks after admission. Thrombin generation parameters peak height and endogenous thrombin potential (ETP) were compared to healthy controls. Results were subsequently correlated with a patient characteristics and laboratory measurements. In vitro spiking in TG with rivaroxaban, dabigatran, argatroban and orgaran was performed and compared to LMWH. Results Anti-Xa levels of all patients remained within the therapeutic range throughout follow-up. At baseline, the mean (SE) endogenous thrombin potential (ETP) was 1,727 (170) nM min and 1,620 (460) nM min for ellagic acid (EA) and tissue factor (TF), respectively. In line with this we found a mean (SE) peak height of 353 (45) nM and 264 (96) nM for EA and TF. Although fluctuating across the weeks of follow-up, TG parameters remained elevated despite thromboprophylaxis. In vitro comparison of LMWHs and direct thrombin inhibitors (e.g., agratroban, dabigatran) revealed a higher efficacy in reducing coagulation potential for direct thrombin inhibition in both ellagic acid (EA) and tissue factor (TF) triggered TG. Conclusion In a sub-group of mechanically ventilated, critically ill COVID-19 patients, despite apparent adequate anti-coagulation doses evaluated by anti-Xa levels, thrombin generation potential remained high during ICU admission independent of age, sex, body mass index, APACHE II score, cardiovascular disease, and smoking status. These observations could, only partially, be explained by (anti)coagulation and thrombosis, inflammation, and multi-organ failure. Our in vitro data suggested that direct thrombin inhibition compared with LMWH might offer an alternate, more effective anticoagulant strategy in COVID-19.
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Affiliation(s)
- Tom W. van de Berg
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands,Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Mark M. G. Mulder
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands,*Correspondence: Mark M. G. Mulder
| | - Teba Alnima
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Magdolna Nagy
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Rene van Oerle
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands,Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Erik A. M. Beckers
- Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Tilman M. Hackeng
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Anne-Marije Hulshof
- Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Jan-Willem E. M. Sels
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands,Department of Cardiology, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Yvonne M. C. Henskens
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands,Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Iwan C. C. van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Hugo ten Cate
- Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands,Thrombosis Expertise Centre Maastricht, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Henri M. H. Spronk
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands,Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Bas C. T. van Bussel
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands,Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
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Uzun G, Singh A, Abou-Khalel W, Pelzl L, Weich K, Nowak-Harnau S, Althaus K, Bugert P, Klüter H, Bakchoul T. Platelets and Sera from Donors of Convalescent Plasma after Mild COVID-19 Show No Procoagulant Phenotype. Hamostaseologie 2022; 42:S14-S23. [DOI: 10.1055/a-1797-0564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Abstract
AbstractCoronavirus disease-2019 (COVID-19) is associated with increased thromboembolic complications. Long-term alteration in the coagulation system after acute COVID-19 infection is still a subject of research. Furthermore, the effect of sera from convalescent subjects on platelets is not known. In this study, we investigated platelet phenotype, coagulation, and fibrinolysis in COVID-19 convalescent plasma (CCP) donors and analyzed convalescent sera-induced effects on platelets. We investigated CCP donors who had a history of mild COVID-19 infection and donors who did not have COVID-19 were used as controls. We analyzed phosphatidylserine (PS) externalization, CD62p expression, and glycoprotein VI (GPVI) shedding both in platelet-rich plasma (PRP) and after incubation of washed healthy platelets with donors' sera using flow cytometry. Coagulation and fibrinolysis systems were assessed with thromboelastometry. Forty-seven CCP donors (22 males, 25 females; mean age (±SD): 41.4 ± 13.7 years) with a history of mild COVID-19 infection were included. Median duration after acute COVID-19 infection was 97 days (range, 34–401). We did not find an increased PS externalization, CD62p expression, or GPVI shedding in platelets from CCP donors. Sera from CCP donors did not induce PS externalization or GPVI shedding in healthy platelets. Sera-induced CD62p expression was slightly, albeit statistically significantly, lower in CCP donors than in plasma donors without a history of COVID-19. One patient showed increased maximum clot firmness and prolonged lysis time in thromboelastometry. Our findings suggest that procoagulant platelet phenotype is not present after mild COVID-19. Furthermore, CCP sera do not affect the activation status of platelets.
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Affiliation(s)
- Günalp Uzun
- Centre for Clinical Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Anurag Singh
- Institute for Clinical and Experimental Transfusion Medicine, Medical Faculty of Tübingen, University Hospital of Tübingen, Tübingen, Germany
| | - Wissam Abou-Khalel
- Centre for Clinical Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Lisann Pelzl
- Institute for Clinical and Experimental Transfusion Medicine, Medical Faculty of Tübingen, University Hospital of Tübingen, Tübingen, Germany
| | - Karoline Weich
- Centre for Clinical Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Stefanie Nowak-Harnau
- Centre for Clinical Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Karina Althaus
- Centre for Clinical Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
- Institute for Clinical and Experimental Transfusion Medicine, Medical Faculty of Tübingen, University Hospital of Tübingen, Tübingen, Germany
| | - Peter Bugert
- Institute of Transfusion Medicine and Immunology, Medical Faculty Mannheim, Heidelberg University, Hessen, Mannheim, Germany
| | - Harald Klüter
- Institute of Transfusion Medicine and Immunology, Medical Faculty Mannheim, Heidelberg University, Hessen, Mannheim, Germany
| | - Tamam Bakchoul
- Centre for Clinical Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
- Institute for Clinical and Experimental Transfusion Medicine, Medical Faculty of Tübingen, University Hospital of Tübingen, Tübingen, Germany
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Putra A, Widyatmoko A, Ibrahim S, Amansyah F, Amansyah F, Berlian MA, Retnaningsih R, Pasongka Z, Sari FE, Rachmad B. Case series of the first three severe COVID-19 patients treated with the secretome of hypoxia-mesenchymal stem cells in Indonesia. F1000Res 2022; 10:228. [PMID: 35350705 DOI: 10.12688/f1000research.51191.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2021] [Indexed: 01/31/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the outbreak of coronavirus disease 2019 (COVID-19), which has been rapidly spreading. Several guideline therapies have been proposed as a possible treatment for SARS-CoV-2, however, these therapies are not sufficient to treat a severe condition of SARS-CoV-2 infection characterised by the increase of D-dimer and C-reactive protein (CRP) levels, and patchy ground-glass opacities (GGOs). Secretome-mesenchymal stem cells (S-MSCs) produced by MSCs under hypoxia could excessively release several anti-inflammatory cytokines and growth factors to control the COVID-19 cytokine storm and accelerate lung injury improvement. This is the first study investigating the clinical outcomes of three severe COVID-19 patients admitted to the intensive care unit of three different hospitals in Indonesia treated with S-MSCs. The decrease of D-dimer and CRP level was reported for all patients treated with S-MSCs. This was in line with improvement of pulmonary radiology, blood gas level, and hematologic assessment. In conclusion, these cases suggest that S-MSCs could effectively control D-dimer, CRP level and GGOs of severe COVID-19 patients associated with recovered pulmonary function.
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Affiliation(s)
- Agung Putra
- Stem Cell and Cancer Research (SCCR), Faculty of Medicine, Universitas Islam Sultan Agung (Unissula), Semarang, Central Java, Indonesia.,Department of Postgraduate Biomedical Science, Faculty of Medicine, Universitas Islam Sultan Agung (Unissula), Semarang, Central Java, Indonesia.,Department of Pathological Anatomy, Faculty of Medicine,, Universitas Islam Sultan Agung (Unissula), Semarang, Central Java, Indonesia
| | - Agus Widyatmoko
- Department of Internal Medicine, Faculty of Medicine, Universitas Muhammadiyah Yogyakarta, Yogyakarta, Yogyakarta, Indonesia
| | - Sugeng Ibrahim
- Stem Cell and Cancer Research (SCCR), Faculty of Medicine, Universitas Islam Sultan Agung (Unissula), Semarang, Central Java, Indonesia.,Department of Molecular Biology, Faculty of Medicine, Universitas Katholik (Unika) Soegijapranata, Semarang, Central Java, Indonesia
| | - Fajar Amansyah
- Department of Internal Medicine, Bhayangkara Hospital, Makassar, South Sulawesi, Indonesia
| | - Farid Amansyah
- Department of Internal Medicine, Bhayangkara Hospital, Makassar, South Sulawesi, Indonesia
| | - Mukti Arja Berlian
- Department of Internal Medicine, Dr. Esnawan Antariksa Air Force Hospital, Jakarta, Jakarta, Indonesia
| | - Retnaningsih Retnaningsih
- Department of Neurology and Intensive Care Unit, Kariadi Hospital, Universitas Diponegoro, Semarang, Central Java, Indonesia
| | | | - Flora Eka Sari
- Department of Pulmonary Medicine, Dr. Esnawan Antariksa Air Force Hospital, Jakarta, Jakarta, Indonesia
| | - Basuki Rachmad
- Department of Intensive Care Unit, Gatot Soebroto Army Hospital, Jakarta, Jakarta, Indonesia
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5
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Current and novel biomarkers of thrombotic risk in COVID-19: a Consensus Statement from the International COVID-19 Thrombosis Biomarkers Colloquium. Nat Rev Cardiol 2022; 19:475-495. [PMID: 35027697 PMCID: PMC8757397 DOI: 10.1038/s41569-021-00665-7] [Citation(s) in RCA: 153] [Impact Index Per Article: 76.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2021] [Indexed: 02/06/2023]
Abstract
Coronavirus disease 2019 (COVID-19) predisposes patients to thrombotic and thromboembolic events, owing to excessive inflammation, endothelial cell activation and injury, platelet activation and hypercoagulability. Patients with COVID-19 have a prothrombotic or thrombophilic state, with elevations in the levels of several biomarkers of thrombosis, which are associated with disease severity and prognosis. Although some biomarkers of COVID-19-associated coagulopathy, including high levels of fibrinogen and D-dimer, were recognized early during the pandemic, many new biomarkers of thrombotic risk in COVID-19 have emerged. In this Consensus Statement, we delineate the thrombotic signature of COVID-19 and present the latest biomarkers and platforms to assess the risk of thrombosis in these patients, including markers of platelet activation, platelet aggregation, endothelial cell activation or injury, coagulation and fibrinolysis as well as biomarkers of the newly recognized post-vaccine thrombosis with thrombocytopenia syndrome. We then make consensus recommendations for the clinical use of these biomarkers to inform prognosis, assess disease acuity, and predict thrombotic risk and in-hospital mortality. A thorough understanding of these biomarkers might aid risk stratification and prognostication, guide interventions and provide a platform for future research.
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6
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Putra A, Widyatmoko A, Ibrahim S, Amansyah F, Amansyah F, Berlian MA, Retnaningsih R, Pasongka Z, Sari FE, Rachmad B. Case series of the first three severe COVID-19 patients treated with the secretome of hypoxia-mesenchymal stem cells in Indonesia. F1000Res 2021; 10:228. [PMID: 35350705 PMCID: PMC8927740 DOI: 10.12688/f1000research.51191.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2021] [Indexed: 01/21/2024] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the outbreak of coronavirus disease 2019 (COVID-19), which has been rapidly spreading. Several guideline therapies have been proposed as a possible treatment for SARS-CoV-2, however, these therapies are not sufficient to treat a severe condition of SARS-CoV-2 infection characterised by the increase of D-dimer and C-reactive protein (CRP) levels, and patchy ground-glass opacities (GGOs). Secretome-mesenchymal stem cells (S-MSCs) produced by MSCs under hypoxia could excessively release several anti-inflammatory cytokines and growth factors to control the COVID-19 cytokine storm and accelerate lung injury improvement. This is the first study investigating the clinical outcomes of three severe COVID-19 patients admitted to the intensive care unit of three different hospitals in Indonesia treated with S-MSCs. The decrease of D-dimer and CRP level was reported for all patients treated with S-MSCs. This was in line with improvement of pulmonary radiology, blood gas level, and hematologic assessment. In conclusion, these cases suggest that S-MSCs could effectively control D-dimer, CRP level and GGOs of severe COVID-19 patients associated with recovered pulmonary function.
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Affiliation(s)
- Agung Putra
- Stem Cell and Cancer Research (SCCR), Faculty of Medicine, Universitas Islam Sultan Agung (Unissula), Semarang, Central Java, Indonesia
- Department of Postgraduate Biomedical Science, Faculty of Medicine, Universitas Islam Sultan Agung (Unissula), Semarang, Central Java, Indonesia
- Department of Pathological Anatomy, Faculty of Medicine,, Universitas Islam Sultan Agung (Unissula), Semarang, Central Java, Indonesia
| | - Agus Widyatmoko
- Department of Internal Medicine, Faculty of Medicine, Universitas Muhammadiyah Yogyakarta, Yogyakarta, Yogyakarta, Indonesia
| | - Sugeng Ibrahim
- Stem Cell and Cancer Research (SCCR), Faculty of Medicine, Universitas Islam Sultan Agung (Unissula), Semarang, Central Java, Indonesia
- Department of Molecular Biology, Faculty of Medicine, Universitas Katholik (Unika) Soegijapranata, Semarang, Central Java, Indonesia
| | - Fajar Amansyah
- Department of Internal Medicine, Bhayangkara Hospital, Makassar, South Sulawesi, Indonesia
| | - Farid Amansyah
- Department of Internal Medicine, Bhayangkara Hospital, Makassar, South Sulawesi, Indonesia
| | - Mukti Arja Berlian
- Department of Internal Medicine, Dr. Esnawan Antariksa Air Force Hospital, Jakarta, Jakarta, Indonesia
| | - Retnaningsih Retnaningsih
- Department of Neurology and Intensive Care Unit, Kariadi Hospital, Universitas Diponegoro, Semarang, Central Java, Indonesia
| | | | - Flora Eka Sari
- Department of Pulmonary Medicine, Dr. Esnawan Antariksa Air Force Hospital, Jakarta, Jakarta, Indonesia
| | - Basuki Rachmad
- Department of Intensive Care Unit, Gatot Soebroto Army Hospital, Jakarta, Jakarta, Indonesia
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