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Liu J, Xiao J, Wu H, Ye J, Li Y, Zou B, Li Y. A retrospective cohort study of coagulation function in patients with liver cirrhosis receiving cefoperazone/sulbactam with and without vitamin K1 supplementation. Int J Clin Pharm 2024:10.1007/s11096-024-01796-w. [PMID: 39269640 DOI: 10.1007/s11096-024-01796-w] [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: 04/24/2024] [Accepted: 08/14/2024] [Indexed: 09/15/2024]
Abstract
BACKGROUND Cefoperazone/sulbactam is commonly prescribed for the treatment of infected patients with cirrhosis. AIM To investigate the effect of cefoperazone/sulbactam on coagulation in cirrhotic patients and assess the effectiveness of vitamin K1 supplementation in preventing cefoperazone/sulbactam-induced coagulation disorders. METHOD This retrospective cohort study compared coagulation function in 217 cirrhotic patients who received cefoperazone/sulbactam with and without vitamin K1 supplementation (vitamin K1 group, n = 108; non-vitamin K1 group, n = 109). Propensity score matching (PSM) was used to to reduce confounders' influence, the SHapley additive exPlanations (SHAP) model to explore the importance of each variable in coagulation disorders. RESULTS In the non-vitamin K1 group, the post-treatment prothrombin time (PT) was 16.5 ± 6.5 s and the activated partial thromboplastin time (aPTT) was 34.8 ± 9.4 s. These were significantly higher than pre-treatment values (PT: 14.6 ± 2.4 s, p = 0.005; aPTT: 30.4 ± 5.9 s, p < 0.001). In the vitamin K1 group, no differences were observed in PT, thrombin time, or platelet count, except for a slightly elevated post-treatment aPTT (37.0 ± 10.4 s) compared to that of pre-treatment (34.4 ± 7.2 s, p = 0.033). The vitamin K1 group exhibited a lower risk of PT prolongation (OR: 0.211, 95% CI: 0.047-0.678) and coagulation disorders (OR: 0.257, 95% CI: 0.126-0.499) compared to that of the non-vitamin K1 group. Propensity score matching analysis confirmed a reduced risk in the vitamin K1 group for prolonged PT (OR: 0.128, 95% CI: 0.007-0.754) and coagulation disorders (OR: 0.222, 95% CI: 0.076-0.575). Additionally, the vitamin K1 group exhibited lower incidences of PT prolongation, aPTT prolongation, bleeding, and coagulation dysfunction compared to the non-vitamin K1 group. CONCLUSION Cefoperazone/sulbactam use may be linked to a higher risk of PT prolongation and coagulation disorders in cirrhotic patients. Prophylactic use of vitamin K1 can effectively reduce the risk.
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Affiliation(s)
- Jianmo Liu
- Department of Science and Technology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Jingyang Xiao
- Department of Pharmacy, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China
| | - HongFei Wu
- Jiangzhong Pharmaceutical Co., Ltd., Nanchang, 330049, Jiangxi, China
| | - Jinhua Ye
- Department of Pharmacy, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Yun Li
- Department of Pharmacy, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Bin Zou
- Department of Pharmacy, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Yixiu Li
- Department of Pharmacy, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China.
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Pérez L, Sabate A, Gutierrez R, Caballero M, Pujol R, Llaurado S, Peñafiel J, Hereu P, Blasi A. Risk factors associated with blood transfusion in liver transplantation. Sci Rep 2024; 14:19022. [PMID: 39152310 PMCID: PMC11329499 DOI: 10.1038/s41598-024-70078-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 08/12/2024] [Indexed: 08/19/2024] Open
Abstract
To explore preoperative and operative risk factors for red blood cell (RBC) transfusion requirements during liver transplantation (LT) and up to 24 h afterwards. We evaluated the associations between risk factors and units of RBC transfused in 176 LT patients using a log-binomial regression model. Relative risk was adjusted for age, sex, and the model for end-stage liver disease score (MELD) (adjustment 1) and baseline hemoglobin concentration (adjustment 2). Forty-six patients (26.14%) did not receive transfusion. Grafts from cardiac-death donors were used in 32.61% and 31.54% of non-transfused and transfused patients, respectively. The transfused group required more reoperation for bleeding (P = 0.035), longer mechanical ventilation after LT (P < 0.001), and longer ICU length of stay (P < 0.001). MELD and hemoglobin concentrations determined RBC requirements. For each unit of increase in the MELD score, 2% more RBC units were transfused, and non-transfusion was 0.83-fold less likely. For each 10-g/L higher hemoglobin concentration at baseline, 16% less RBC transfused, and non-transfusion was 1.95-fold more likely. Ascites was associated with 26% more RBC transfusions. With an increase of 2 mm from the baseline in the A10FIBTEM measurement of maximum clot firmness, non-transfusion was 1.14-fold more likely. A 10-min longer cold ischemia time was associated with 1% more RBC units transfused, and the presence of post-reperfusion syndrome with 45% more RBC units. We conclude that preoperative correction of anemia should be included in LT. An intervention to prevent severe hypotension and fibrinolysis during graft reperfusion should be explored.Trial register: European Clinical Trials Database (EudraCT 2018-002,510-13) and ClinicalTrials.gov (NCT01539057).
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Grants
- Project PI17/00743 Instituto de Salud Carlos III through
- Project PI17/00743 Instituto de Salud Carlos III through
- Project PI17/00743 Instituto de Salud Carlos III through
- Project PI17/00743 Instituto de Salud Carlos III through
- Project PI17/00743 Instituto de Salud Carlos III through
- Project PI17/00743 Instituto de Salud Carlos III through
- Project PI17/00743 Instituto de Salud Carlos III through
- PT17/0017/0010, PT20/000008 Spanish Clinical Research Network (SCReN) of the Bellvitge Biomedical Research Institute (IDIBELL), Platform SCReN
- PT17/0017/0010, PT20/000008 Spanish Clinical Research Network (SCReN) of the Bellvitge Biomedical Research Institute (IDIBELL), Platform SCReN
- PT17/0017/0010, PT20/000008 Spanish Clinical Research Network (SCReN) of the Bellvitge Biomedical Research Institute (IDIBELL), Platform SCReN
- PT17/0017/0010, PT20/000008 Spanish Clinical Research Network (SCReN) of the Bellvitge Biomedical Research Institute (IDIBELL), Platform SCReN
- PT17/0017/0010, PT20/000008 Spanish Clinical Research Network (SCReN) of the Bellvitge Biomedical Research Institute (IDIBELL), Platform SCReN
- PT17/0017/0010, PT20/000008 Spanish Clinical Research Network (SCReN) of the Bellvitge Biomedical Research Institute (IDIBELL), Platform SCReN
- PT17/0017/0010, PT20/000008 Spanish Clinical Research Network (SCReN) of the Bellvitge Biomedical Research Institute (IDIBELL), Platform SCReN
- PT17/0017/0010, PT20/000008 Spanish Clinical Research Network (SCReN) of the Bellvitge Biomedical Research Institute (IDIBELL), Platform SCReN
- PT17/0017/0010, PT20/000008 Spanish Clinical Research Network (SCReN) of the Bellvitge Biomedical Research Institute (IDIBELL), Platform SCReN
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Affiliation(s)
- Lourdes Pérez
- Department of Anesthesiology, University Hospital of Bellvitge, University of Barcelona Health Campus, IDIBELL, Feixa Llarga S/N. Hospitalet., 08 907, Barcelona, Spain
| | - Antoni Sabate
- Department of Anesthesiology, University Hospital of Bellvitge, University of Barcelona Health Campus, IDIBELL, Feixa Llarga S/N. Hospitalet., 08 907, Barcelona, Spain.
| | - Rosa Gutierrez
- Department of Anesthesiology, University Hospital of Cruces, Bilbao, Spain
| | - Marta Caballero
- Department of Anesthesiology, University Hospital of Bellvitge, University of Barcelona Health Campus, IDIBELL, Feixa Llarga S/N. Hospitalet., 08 907, Barcelona, Spain
| | - Roger Pujol
- Department of Anesthesiology, Clinic Hospital, University of Barcelona Health Barcelona, Spain Campus, IDIBAPS, Barcelona, Spain
| | - Sandra Llaurado
- Department of Anesthesiology, University Hospital of Bellvitge, University of Barcelona Health Campus, IDIBELL, Feixa Llarga S/N. Hospitalet., 08 907, Barcelona, Spain
| | - Judith Peñafiel
- UICEC, Biostatistics Unit (UBiDi), University of Barcelona Health Campus. IDIBELL, Barcelona, Spain
| | - Pilar Hereu
- UICEC, Biostatistics Unit (UBiDi), University of Barcelona Health Campus. IDIBELL, Barcelona, Spain
| | - Annabel Blasi
- Department of Anesthesiology, Clinic Hospital, University of Barcelona Health Barcelona, Spain Campus, IDIBAPS, Barcelona, Spain
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Balaceanu LA, Dina I. D-dimers in advanced liver cirrhosis: Useful biomarker or not? Am J Med Sci 2024:S0002-9629(24)01264-3. [PMID: 38788925 DOI: 10.1016/j.amjms.2024.05.017] [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: 04/14/2023] [Revised: 02/03/2024] [Accepted: 05/20/2024] [Indexed: 05/26/2024]
Abstract
In clinical practice, the d-dimer levels rule out venous thromboembolism and diagnose disseminated intravascular coagulation. d-dimers increase in both physiological and pathological conditions. Liver cirrhosis, especially in the final stages, is characterized by complex coagulation and fibrinolysis factor disorders. Multiple mechanisms tried to explain the increased d-dimer levels in patients with liver cirrhosis and ascites. The d-dimer cut-off level used to rule out venous thromboembolism in cirrhosis is higher than that used to confirm the diagnosis of VTE or DIC in noncirrhotic patients. The cut-off d-dimer level used for the prognosis of thrombotic events is not standardized in advanced liver cirrhosis. Thus, it is necessary to update the clinical guidelines regarding the usefulness of d-dimer testing in advanced liver cirrhosis and the cut-off d-dimer levels, which should vary based on the detection method.
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Affiliation(s)
- Lavinia Alice Balaceanu
- Internal Medicine Department, "Carol Davila" University of Medicine and Pharmacy, Emergency Clinical Hospital "Sf. Ioan," Bucharest, Romania.
| | - Ion Dina
- Gastroenterology Department, "Carol Davila" University of Medicine and Pharmacy, Emergency Clinical Hospital "Sf. Ioan," Bucharest, Romania
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Yin H. Enhanced Recovery after Surgery (ERAS) in Postoperative Lung Cancer Patients: A Novel Perioperative Strategy for Preventing Venous Thromboembolism and Improving Quality of Life. TOHOKU J EXP MED 2024; 262:201-209. [PMID: 38171722 DOI: 10.1620/tjem.2023.j105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
This study aimed to assess the impact of enhanced recovery after surgery (ERAS) intervention in preventing venous thromboembolism (VTE) among postoperative lung cancer patients. Conducted from January 2022 to January 2023, the research involved 125 lung cancer patients randomly assigned to either a control group (n = 60) receiving routine care, or an ERAS group (n = 65) which received both routine care and ERAS interventions. The ERAS program comprised a comprehensive series of interventions meticulously implemented throughout the preoperative, intraoperative, and postoperative phases. Thrombotic risk assessment using the Caprini Risk Assessment Model (RAM) was conducted preoperatively and on postoperative day 5 (POD 5), with plasma D-dimer levels measured preoperatively, on POD 1, POD 3, and POD 5. Quality of life and patient satisfaction were assessed at discharge using the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Lung Cancer Module 13 (QLQ-LC13) and The Newcastle Satisfaction with Nursing Scale (NSNS), respectively. The ERAS group demonstrated significantly lower Caprini RAM scores on POD 5 compared to the control group, with lower D-dimer levels on POD 3 and POD 5. The incidence of VTE was lower in the ERAS group (1.54%) compared to the control group (11.67%) during hospitalization. At discharge, the ERAS group showed improved quality of life, with higher satisfaction scores for nursing care and their hospital stay. ERAS nursing interventions effectively mitigate thrombotic risk, improve D-dimer levels, enhance postoperative quality of life, and elevate patient satisfaction among individuals undergoing lung cancer surgery.
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Affiliation(s)
- Hui Yin
- Lung Cancer Center, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University
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Huang Z, Huang DX, Wang YY, Jiang LJ, Wang YH, Dai J, Kang X, Wen Y, He SY. Features of thromboelastogram in populations exposed to or transferring from high altitude. Heliyon 2024; 10:e25223. [PMID: 38322976 PMCID: PMC10845907 DOI: 10.1016/j.heliyon.2024.e25223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 01/21/2024] [Accepted: 01/23/2024] [Indexed: 02/08/2024] Open
Abstract
Background Thromboelastogram (TEG) is an effective indicator that monitors the dynamic changes of blood coagulation in real-time. It still remains controversial about the performance and influence of coagulation at high altitude. The present study intends to describe comprehensively the clinical features of TEG in populations exposed to or transferring from high altitude. Methods Two groups were recruited in the present study. Group A included young males who worked at high-altitude (4888 m or 5418 m) areas for some time, while Group B included young males who had recently returned from high-altitude (4888 m or 5418 m) areas. Medical examinations were performed using portable devices. Spearman's test was used to evaluate the correlations between thromboelastogram (TEG) variables and other variables. Logistic regression analysis was used to analyze the factors affecting various abnormal TEG variables. Results A total of 51 adult males were included in the two groups. Significantly increased reaction time (R) and decreased maximum amplitude (MA) were found in group B (P < 0.05). No significant differences were observed in the comparisons of K and angle between the two groups. Various TEG variables were identified to be correlated with different coagulation and biochemical variables. Logistic regression analysis demonstrated that abnormal R was independently associated with direct bilirubin, and abnormal K was independently associated with the platelet count in Group A (P < 0.05). However, none of the factors were independently associated with abnormal TEG variables in Group B. Conclusion Populations exposed to or transferring from high altitudes are characterized by different TEG characteristics. Our findings give a comprehensive description of the complex interaction between TEG indexes, coagulation dynamics, and hematological parameters, which can help guide the development of appropriate medical approaches tailored to the unique needs of these populations.
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Affiliation(s)
- Zhu Huang
- Pancreatic Injury and Repair Key Laboratory of Sichuan Province, The General Hospital of Western Theater Command, Chengdu, 610000, China
- Department of General Surgery, The General Hospital of Western Theater Command, Chengdu, 610000, China
| | - Dong-xin Huang
- Pancreatic Injury and Repair Key Laboratory of Sichuan Province, The General Hospital of Western Theater Command, Chengdu, 610000, China
- Department of General Surgery, The General Hospital of Western Theater Command, Chengdu, 610000, China
- College of Medicine, Southwest Jiaotong University, Chengdu, 610000, China
| | - Yan-yan Wang
- Pancreatic Injury and Repair Key Laboratory of Sichuan Province, The General Hospital of Western Theater Command, Chengdu, 610000, China
- Department of Clinical Laboratory, The General Hospital of Western Theater Command, Chengdu, 610000, China
| | - Li-juan Jiang
- Department of General Surgery, The General Hospital of Western Theater Command, Chengdu, 610000, China
| | - Yong-hua Wang
- Department of Nursing, The General Hospital of Western Theater Command, Chengdu, 610000, China
| | - Jing Dai
- Laboratory of Basic Medicine, The General Hospital of Western Theater Command, Chengdu, 610000, China
| | - Xia Kang
- Pancreatic Injury and Repair Key Laboratory of Sichuan Province, The General Hospital of Western Theater Command, Chengdu, 610000, China
| | - Yi Wen
- Pancreatic Injury and Repair Key Laboratory of Sichuan Province, The General Hospital of Western Theater Command, Chengdu, 610000, China
- Department of General Surgery, The General Hospital of Western Theater Command, Chengdu, 610000, China
| | - Si-yi He
- Pancreatic Injury and Repair Key Laboratory of Sichuan Province, The General Hospital of Western Theater Command, Chengdu, 610000, China
- Department of Cardiac Surgery, The General Hospital of Western Theater Command, Chengdu, 610000, China
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Hvas CL, Larsen JB. The Fibrinolytic System and Its Measurement: History, Current Uses and Future Directions for Diagnosis and Treatment. Int J Mol Sci 2023; 24:14179. [PMID: 37762481 PMCID: PMC10532028 DOI: 10.3390/ijms241814179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/13/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
The fibrinolytic system is a key player in keeping the haemostatic balance, and changes in fibrinolytic capacity can lead to both bleeding-related and thrombosis-related disorders. Our knowledge of the fibrinolytic system has expanded immensely during the last 75 years. From the first successful use of thrombolysis in myocardial infarction in the 1960s, thrombolytic therapy is now widely implemented and has reformed treatment in vascular medicine, especially ischemic stroke, while antifibrinolytic agents are used routinely in the prevention and treatment of major bleeding worldwide. Despite this, this research field still holds unanswered questions. Accurate and timely laboratory diagnosis of disturbed fibrinolysis in the clinical setting remains a challenge. Furthermore, despite growing evidence that hypofibrinolysis plays a central role in, e.g., sepsis-related coagulopathy, coronary artery disease, and venous thromboembolism, there is currently no approved treatment of hypofibrinolysis in these settings. The present review provides an overview of the fibrinolytic system and history of its discovery; measurement methods; clinical relevance of the fibrinolytic system in diagnosis and treatment; and points to future directions for research.
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Affiliation(s)
- Christine Lodberg Hvas
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, 8200 Aarhus N, Denmark;
- Department of Clinical Medicine, Faculty of Health Sciences, Aarhus University, 8200 Aarhus N, Denmark
| | - Julie Brogaard Larsen
- Department of Clinical Medicine, Faculty of Health Sciences, Aarhus University, 8200 Aarhus N, Denmark
- Department of Clinical Biochemistry, Regional Hospital Horsens, 8700 Horsens, Denmark
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Rautou PE, Caldwell SH, Villa E. Bleeding and Thrombotic Complications in Patients With Cirrhosis: A State-of-the-Art Appraisal. Clin Gastroenterol Hepatol 2023; 21:2110-2123. [PMID: 37121529 DOI: 10.1016/j.cgh.2023.04.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 04/02/2023] [Accepted: 04/14/2023] [Indexed: 05/02/2023]
Abstract
Much has evolved over the past 25 years regarding our understanding of the coagulopathy of liver disease. Paradoxically, this form of coagulopathy is relatively hypercoagulability despite the common clinical impression of a hemorrhagic tendency. The latter is largely driven by portal-mesenteric venous pressure (ie, portal hypertension) and has little to do with hemostatic pathways. It cannot be emphasized enough that the INR does not offer a meaningful measure in this situation and may lead to interventions such as fresh frozen plasma that can actually worsen portal pressure and hence pressure-driven bleeding. With regard to procedure-related bleeding, we point out substantial differences in the definition of high-risk procedures and propose a new operational definition dependent on the applicability of local hemostatic measures, although this requires further investigation. The common occurrence of venous thrombosis in these patients requires careful consideration of hemostatic pathways and overall risk and benefit of intervention. The decision regarding anticoagulation therapy needs to be driven not only by a global assessment including history of non-portal hypertensive-related bleeding, but also by fall risk which can result in head trauma in patients prone to encephalopathy. This is probably best estimated by frailty but has yet to be adequately investigated. In the background of these concerns, several superimposed and complex conditions including infections and renal dysfunction should be taken into account. Inherited forms of thrombophilia in the setting of cirrhosis perhaps do not outweigh the thrombophilia inherent to liver disease but warrant further consideration.
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Affiliation(s)
- Pierre-Emmanuel Rautou
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France; Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Stephen H Caldwell
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Virginia, Charlottesville, Virginia.
| | - Erica Villa
- Gastroenterology Unit, CHIMOMO Department, University of Modena and Reggio Emilia, Modena, Italy; IRCCS Saverio de Bellis, Castellana Grotte, Italy
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Hisada Y, Sachetto ATA, Mackman N. Circulating tissue factor-positive extracellular vesicles and their association with thrombosis in different diseases. Immunol Rev 2022; 312:61-75. [PMID: 35708588 DOI: 10.1111/imr.13106] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 05/27/2022] [Indexed: 12/23/2022]
Abstract
Tissue factor (TF) is a procoagulant protein released from activated host cells, such as monocytes, and tumor cells on extracellular vesicles (EVs). TF + EVs are observed in the circulation of patients with various types of diseases. In this review, we will summarize the association between TF + EVs and activation of coagulation and survival in different types of diseases, including cancer, sepsis, and infections with different viruses, such as human immunodeficiency virus (HIV), influenza A virus (IAV), and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We will also discuss the source of TF + EVs in various diseases. EVTF activity is associated with thrombosis in pancreatic cancer patients and coronavirus disease 2019 patients (COVID-19) and with disseminated intravascular coagulation in cancer patients. EVTF activity is also associated with worse survival in patients with cancer and COVID-19. Monocytes are the major sources of TF + EVs in sepsis, and viral infections, such as HIV, Ebola virus, and SARS-CoV-2. In contrast, alveolar epithelial cells are the major source of TF + EVs in bronchoalveolar lavage fluid in COVID-19 and influenza A patients. These studies indicate that EVTF activity could be used as a biomarker to identify patients that have an increased risk of coagulopathy and mortality.
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Affiliation(s)
- Yohei Hisada
- Division of Hematology, Department of Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ana Teresa Azevedo Sachetto
- Division of Hematology, Department of Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Nigel Mackman
- Division of Hematology, Department of Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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