Recombinant Thrombomodulin in Disseminated Intravascular Coagulation Associated with Stage IV Solid Tumors: A Nationwide Observational Study in Japan

Treatments and outcomes of neonatal disseminated intravascular coagulation with and without neonatal asphyxia: A retrospective study using nationwide data in Japan

BACKGROUND

Although neonatal disseminated intravascular coagulation (DIC) is associated with high mortality and severe complications, few studies have reported its clinical course. We aimed to describe the characteristics, treatments, and outcomes of neonatal DIC by using a national inpatient database.

METHODS

Using the Japanese Diagnosis Procedure Combination database, we identified 5533 patients with neonatal DIC who were admitted to neonatal intensive care units between July 2010 and March 2020. We categorized the patients into those with asphyxia (n = 2911) and those without asphyxia (n = 2622). We investigated the patient characteristics, treatments, and outcomes. We further categorized neonates with asphyxia according to its severity.

RESULTS

The gestational age of neonates with asphyxia was significantly lower than that of neonates without asphyxia (P < 0.001). Antithrombin was most commonly used for DIC (40%). Neonates with asphyxia were more likely to receive antithrombin (43% vs. 38%; P < 0.001), recombinant human soluble thrombomodulin (28% vs. 20%; P < 0.001), and fresh frozen plasma transfusion (68% vs. 51%; P < 0.001) than those without asphyxia. Neonates with asphyxia had higher in-hospital mortality (17% vs. 10%; P < 0.001), severe bleeding (11% vs. 6.8%; P < 0.001), and hospitalization costs than those without asphyxia. Additionally, neonates with severe asphyxia were more likely to receive several DIC therapies (such as recombinant human soluble thrombomodulin [30% vs. 24%]) and had higher in-hospital mortality (19% vs. 11%) and hospitalization costs than those with mild asphyxia.

CONCLUSIONS

In this large retrospective study of neonatal DIC, patients with asphyxia received several treatments and demonstrated unfavorable outcomes when compared to those without asphyxia.

How to manage coagulopathies in critically ill patients

Coagulopathy is a severe and frequent complication in critically ill patients, for which the pathogenesis and presentation may be variable depending on the underlying disease. Based on the dominant clinical phenotype, the current review differentiates between hemorrhagic coagulopathies, characterized by a hypocoagulable and hyperfibrinolysis state, and thrombotic coagulopathies with a systemic prothrombotic and antifibrinolytic phenotype. We discuss the differences in pathogenesis and treatment of the common coagulopathies.

Effect of Anticoagulant/Antifibrinolytic Combination Therapy on Enhanced Fibrinolytic-Type Disseminated Intravascular Coagulation in End-of-Life Stage Solid Tumor Patients

Thrombotic disorders such as venous thromboembolism and disseminated intravascular coagulation (DIC) are known complications of solid tumors. To date, no reports have described the treatment of enhanced fibrinolytic-type DIC caused by end-of-life stage solid tumors. We encountered three cases of end-of-life stage solid tumors complicated by enhanced fibrinolytic-type DIC with severe bleeding symptoms. In all three cases, bleeding symptoms improved dramatically after intervention for enhanced fibrinolytic-type DIC with heparin(s) and tranexamic acid. Improvements in abnormal coagulation test results were also seen and the need for platelet concentrate transfusion and fresh frozen plasma infusion was able to be eliminated. However, one patient developed multiple cerebral infarctions. In the future, further studies to investigate the need for intervention in enhanced fibrinolytic-type DIC caused by end-of-life stage solid tumors and suitable treatment strategies are warranted.

Thrombomodulin-mediated Inhibition of Neutrophil Extracellular Trap Formation Alleviates Hepatic Ischemia/Reperfusion Injury by Blocking TLR4 in Rats Subjected to Liver Transplantation

BACKGROUND

Hepatic ischemia/reperfusion injury (IRI) is an unavoidable outcome of liver transplantation, during which neutrophil extracellular traps (NETs) may play a critical role in the IRI-induced immune response to inflammation. The purpose of this study was to identify the function of recombinant human thrombomodulin (rTM) in the remission of hepatic IRI after liver transplantation and elucidate the specific mechanism.

METHODS

NET formation was detected in the serum of liver transplantation patients and rats following liver transplantation. Hematoxylin-eosin (HE) staining, terminal deoxynucleotidyl transferase dUTP nick-end labelling (TUNEL) staining, immunohistochemistry and immunofluorescence were used to assess the effect of rTM on NET formation in vitro and in vivo.

RESULTS

We found that rTM markedly inhibited neutrophil formation in NETs, reduced apoptosis in hepatocytes, alleviated rat hepatic IRI and improved liver function. In vitro, rTM inhibited neutrophil formation in NETs, and lipopolysaccharide (LPS) (a Toll-like receptor (TLR)-4 agonist) reversed the inhibitory effect of rTM on NET formation. rTM blocked TLR-4 and the downstream extracellular signal-regulated kinase (ERK)/c-Jun NH2 terminal kinase (JNK) and nicotinamide adenine dinucleotide phosphate (NADPH)/ROS/peptidylarginine deiminase 4 (PAD4) signaling pathways to protect against hepatic IRI and inhibit NET formation. In addition, we demonstrated that combined treatment with rTM and an NADPH oxidative inhibitor had a better effect than either treatment alone.

CONCLUSIONS

NETs are a potential therapeutic target in hepatic IRI, and rTM could be used to prevent IR-induced hepatic injury. In addition, cotargeting NETosis-related signaling pathways might be a novel therapeutic strategy for hepatic IRI treatment.