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Boron M, Hauzer-Martin T, Keil J, Sun XL. Circulating Thrombomodulin: Release Mechanisms, Measurements, and Levels in Diseases and Medical Procedures. TH OPEN 2022; 6:e194-e212. [PMID: 36046203 PMCID: PMC9273331 DOI: 10.1055/a-1801-2055] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 03/11/2022] [Indexed: 12/02/2022] Open
Abstract
Thrombomodulin (TM) is a type-I transmembrane protein that is mainly expressed on endothelial cells and plays important roles in many biological processes. Circulating TM of different forms are also present in biofluids, such as blood and urine. Soluble TM (sTM), comprised of several domains of TM, is the major circulating TM which is generated by either enzymatic or chemical cleavage of the intact protein under different conditions. Under normal conditions, sTM is present in low concentrations (<10 ng/mL) in the blood but is elevated in several pathological conditions associated with endothelial dysfunction such as cardiovascular, inflammatory, infection, and metabolic diseases. Therefore, sTM level has been examined for monitoring disease development, such as disseminated intravascular coagulation (DIC), sepsis and multiple organ dysfunction syndrome in patients with novel coronavirus disease 2019 (COVID-19) recently. In addition, microvesicles (MVs) that contain membrane TM (MV-TM) have been found to be released from activated cells which also contribute to levels of circulating TM in certain diseases. Several release mechanisms of sTM and MV-TM have been reported, including enzymatic, chemical, and TM mutation mechanisms. Measurements of sTM and MV-TM have been developed and explored as biomarkers in many diseases. In this review, we summarize all these advances in three categories as follows: (1) release mechanisms of circulating TM, (2) methods for measuring circulating TM in biological samples, and (3) correlation of circulating TM with diseases. Altogether, it provides a whole picture of recent advances on circulating TM in health and disease.
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Affiliation(s)
- Mallorie Boron
- Department of Chemistry and Chemical and Biomedical Engineering and Center for Gene Regulation in Health and Disease (GRHD), Cleveland State University, Cleveland, Ohio, United States
| | - Tiffany Hauzer-Martin
- Department of Chemistry and Chemical and Biomedical Engineering and Center for Gene Regulation in Health and Disease (GRHD), Cleveland State University, Cleveland, Ohio, United States
| | - Joseph Keil
- Department of Chemistry and Chemical and Biomedical Engineering and Center for Gene Regulation in Health and Disease (GRHD), Cleveland State University, Cleveland, Ohio, United States
| | - Xue-Long Sun
- Department of Chemistry and Chemical and Biomedical Engineering and Center for Gene Regulation in Health and Disease (GRHD), Cleveland State University, Cleveland, Ohio, United States
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Huang HC, Hsiao TS, Liao MH, Tsao CM, Shih CC, Wu CC. Low-dose hydralazine improves endotoxin-induced coagulopathy and multiple organ dysfunction via its anti-inflammatory and anti-oxidative/nitrosative properties. Eur J Pharmacol 2020; 882:173279. [PMID: 32561290 DOI: 10.1016/j.ejphar.2020.173279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 06/01/2020] [Accepted: 06/10/2020] [Indexed: 11/30/2022]
Abstract
Coagulopathy is the major cause of organ injury as well as a strong predictor of mortality in septic patients. Systemic inflammatory response and redox imbalance are regarded as the major causes of sepsis-induced coagulopathy. There is growing evidence that a vasodilator hydralazine has beneficial effects on heart failure, hypertension, and ischemia/reperfusion injury via its antioxidant and anti-inflammatory properties. However, the effects of hydralazine on sepsis have not been examined. Therefore, we evaluated the effects of low-dose hydralazine on coagulopathy and multiple organ dysfunction in septic rats induced by endotoxin. Sepsis-induced coagulopathy was established by intravenous injection of rats with lipopolysaccharide (LPS). The changes of blood pressure, heart rate, blood glucose, hemostatic variables, prothrombin time, organ function indices, interleukin-6 (IL-6) concentration, and nitric oxide (NO) level were assessed during the experimental period. In addition, the aortas, lungs, livers, and kidneys were dissected to analyze superoxide levels and protein expressions. LPS induced (i) coagulopathy, multiple organ dysfunction, and circulatory failure successfully, and (ii) excessive superoxide, NO, and IL-6 production, accompanied by the overexpression of iNOS and Wnt5a in animals. Treatment of LPS-induced septic rats with low-dose hydralazine not only improved coagulopathy but also ameliorated multiple organ dysfunction. These could be due to attenuation of the overproduction of superoxide, NO, and IL-6, which were attributed to reduction of the overexpression of iNOS and Wnt5a. Thus, these findings indicate that low-dose hydralazine could be a potential therapy for sepsis-induced coagulopathy and multiple organ dysfunction via its anti-inflammatory and anti-oxidative/nitrosative properties.
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Affiliation(s)
- Hsieh-Chou Huang
- Department of Anesthesiology and Pain Medicine, Cheng-Hsin General Hospital, Taipei, Taiwan
| | - Tsan-Seng Hsiao
- Department of Pharmacology, National Defense Medical Center, Taipei, Taiwan; Department of Pharmacy, Taichung Armed Forces General Hospital, Taichung, Taiwan
| | - Mei-Hui Liao
- Department of Pharmacology, National Defense Medical Center, Taipei, Taiwan
| | - Cheng-Ming Tsao
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan
| | - Chih-Chin Shih
- Department of Pharmacology, National Defense Medical Center, Taipei, Taiwan; Department of Pharmacy Practice, Tri-Service General Hospital, Taipei, Taiwan.
| | - Chin-Chen Wu
- Department of Pharmacology, National Defense Medical Center, Taipei, Taiwan; Department of Pharmacy Practice, Tri-Service General Hospital, Taipei, Taiwan.
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Thrombomodulin, Plasminogen Activator Inhibitor-1 and Protein C Levels, and Organ Dysfunction in Sepsis. Crit Care Explor 2019; 1:e0013. [PMID: 32166258 PMCID: PMC7063963 DOI: 10.1097/cce.0000000000000013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Since endothelial function is closely related to organ dysfunction in sepsis and the relationship among endothelial injury, organ dysfunction, and other biomarkers remains unclear, we aimed to evaluate the correlation among endothelial injury, organ dysfunction, and several biomarkers in patients with sepsis. Design This was a retrospective observational study. Setting The study was conducted in a university hospital with 14 mixed ICU beds. Patients ICU patients with sepsis from June 2011 to December 2017 were enrolled in this study. Interventions Endothelial biomarkers (soluble thrombomodulin, plasminogen activator inhibitor-1, and protein C) and markers of inflammation and coagulation were evaluated during the ICU stay. Sequential Organ Failure Assessment scores were assessed for 7 days after ICU admission to determine organ dysfunction. Variables were compared among five stratified groups according to the Sequential Organ Failure Assessment score (0-2, 3-5, 6-8, 9-12, and 13-24). Regression analysis and 95% CIs were used to evaluate trends in biomarkers. Measurements and Main Results The patients were divided into five stratified groups (Sequential Organ Failure Assessment 0-2, n = 159 [20.5%]; Sequential Organ Failure Assessment 3-5, n = 296 [38.2%]; Sequential Organ Failure Assessment 6-8, n = 182 [23.5%]; Sequential Organ Failure Assessment 9-12, n = 75 [9.7%]; Sequential Organ Failure Assessment 13-24, n = 31 [4.0%]). Protein C activity was significantly correlated with the severity of organ dysfunction. It was lower on day 1, increased upon successful treatment, and was significantly higher in groups with lower Sequential Organ Failure Assessment scores. Conclusions Trends and activity of protein C were superior in predicting organ dysfunction compared with other endothelial biomarkers. Monitoring the level of protein C activity is an ideal tool to monitor organ dysfunctions in patients with sepsis.
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Ogura T, Eguchi T, Amano M, Sano T, Nishioka N, Miyano A, Tsujimae M, Tanimura H, Yamada T, Terashima Y, Okada A, Higuchi K. Multicenter clinical experience with recombinant soluble thrombomodulin for disseminated intravascular coagulation associated with severe acute cholecystitis. Thromb Res 2019; 176:74-78. [DOI: 10.1016/j.thromres.2018.12.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 12/12/2018] [Accepted: 12/31/2018] [Indexed: 02/07/2023]
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Xing LY, Yin J, Shao M, Yang YL, Li KY, Xue MM, Mu SC, Sun Z, Zhang YP, Yao CL, Chu X, Tong CY, Song ZJ. Clinical characteristics and prognosis of serous body cavity effusions in patients with sepsis: a retrospective observational study. BMC Anesthesiol 2018; 18:169. [PMID: 30428838 PMCID: PMC6237031 DOI: 10.1186/s12871-018-0621-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 10/17/2018] [Indexed: 12/29/2022] Open
Abstract
Background Cavity effusion is common in patients with infectious diseases. However, the incidence rate and characteristics of serous cavity effusions (SCE) in septic patients are not clear to date. The objective of this study was to investigate the incidence and characteristics of SCE in septic patients and to explore the correlations between the bloody effusions and the illness severity/prognosis in septic patients. Methods From January 2010 to January 2015, a total of 214 patients with severe sepsis and septic shock were enrolled in this retrospective observational study. Thoracentesis or abdominal paracentesis was performed in 45 septic patients because of massive pleural effusions or ascites. The serum concentrations of VEGF, VEGFR, Ang, sICAM-1, sVCAM-1, E-selectin, Serpine1 and VE-cadherin in 45 septic patients underwent paracentesis were measured by enzyme-linked immunosorbent assay (ELISA). Results Of the 214 septic patients, 155 (72.4%) had SCE according to imaging or ultrasound manifestations. 45 subjects with SCE underwent therapeutic thoracentesis or abdominal paracentesis. Effusion laboratory analysis showed that exudates were predominant when compared with transudates (95.6% vs. 4.4%), and 16 (35.6%) patients suffered bloody effusions. Compared with patients with non-bloody effusions, those with bloody effusions showed higher critical illness scores (13 vs. 17 for APACHE II; 7 vs. 9 for SOFA), and higher mortality (6.9% vs. 62.5%). Moreover, patients with bloody effusions had delayed TT and APTT, increased D-dimer concentration, and higher serum levels of CRP and PCT (P < 0.05). In addition, the serum levels of Ang2, sVCAM-1 and E-selectin were significantly higher in patients with bloody effusions than in those with non-bloody effusions (P < 0.05). However, the serum level of VEGFR2 was lower in patients with bloody fluids (P = 0.025). Conclusions The incidence of serous cavity effusion is high in patients with sepsis. The septic patients with bloody effusions suffer a more inflammatory burden and a worse prognosis compared to septic patients with non-bloody effusions.
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Affiliation(s)
- Ling-Yu Xing
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Jun Yin
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Mian Shao
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Yi-Lin Yang
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Ke-Yong Li
- Department of Pharmacology, University of Virginia School of Medicine Charlottesville, Virginia, 22908, USA
| | - Ming-Ming Xue
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Su-Cheng Mu
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Zhan Sun
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Ya-Ping Zhang
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Chen-Ling Yao
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Xun Chu
- Xinhua Hospital, Shanghai Institute for Pediatric Research, Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, People's Republic of China.
| | - Chao-Yang Tong
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China.
| | - Zhen-Ju Song
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China.
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Okuda A, Ogura T, Imanishi M, Miyano A, Nishioka N, Higuchi K. Clinical Impact of Recombinant Soluble Thrombomodulin for Disseminated Intravascular Coagulation Associated with Severe Acute Cholangitis. Gut Liver 2018; 12:471-477. [PMID: 29699063 PMCID: PMC6027841 DOI: 10.5009/gnl17489] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 12/13/2017] [Accepted: 12/14/2017] [Indexed: 12/21/2022] Open
Abstract
Background/Aims Recently, recombinant human soluble thrombomodulin (rTM) has been developed as a new drug for disseminated intravascular coagulation (DIC). This study aims to evaluate the clinical benefit of rTM in patients with sepsis-induced DIC caused by acute cholangitis who underwent biliary drainage. Methods Patients were divided into two groups: the rTM therapy group and the non-rTM therapy group. The primary outcome was the DIC resolution rate at 7 days, and the secondary outcome was 28-day mortality rate. Results Thirty-five patients were treated by rTM, and 36 patients were treated without rTM for DIC. The rate of resolution of DIC at day 7 was significantly higher in the rTM group than in the non-rTM group (82.9% vs 55.6%, p=0.0012). Compared with the non-rTM group, the 28-day survival rate of the r-TM group was significantly higher (rTM vs non-rTM, 91.4% vs 69.4%, p=0.014). According to multivariate analysis, non-rTM (hazard ratio [HR], 2.681) and CRP (HR, 2.370) were factors related to decreased survival. Conclusions rTM treatment may have a positive impact on improving DIC and survival rates in patients with severe acute cholangitis.
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Affiliation(s)
- Atsushi Okuda
- Second Department of Internal Medicine, Osaka Medical College, Takatsuki, Japan
| | - Takeshi Ogura
- Second Department of Internal Medicine, Osaka Medical College, Takatsuki, Japan
| | - Miyuki Imanishi
- Second Department of Internal Medicine, Osaka Medical College, Takatsuki, Japan
| | - Akira Miyano
- Second Department of Internal Medicine, Osaka Medical College, Takatsuki, Japan
| | - Nobu Nishioka
- Second Department of Internal Medicine, Osaka Medical College, Takatsuki, Japan
| | - Kazuhide Higuchi
- Second Department of Internal Medicine, Osaka Medical College, Takatsuki, Japan
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Kumar H, Choi H, Jo MJ, Joshi HP, Muttigi M, Bonanomi D, Kim SB, Ban E, Kim A, Lee SH, Kim KT, Sohn S, Zeng X, Han I. Neutrophil elastase inhibition effectively rescued angiopoietin-1 decrease and inhibits glial scar after spinal cord injury. Acta Neuropathol Commun 2018; 6:73. [PMID: 30086801 PMCID: PMC6080383 DOI: 10.1186/s40478-018-0576-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 07/23/2018] [Indexed: 01/13/2023] Open
Abstract
After spinal cord injury (SCI), neutrophil elastase (NE) released at injury site disrupts vascular endothelium integrity and stabilization. Angiopoietins (ANGPTs) are vascular growth factors that play an important role in vascular stabilization. We hypothesized that neutrophil elastase is one of the key determinants of vascular endothelium disruption/destabilization and affects angiopoietins expression after spinal cord injury. To test this, tubule formation and angiopoietins expression were assessed in endothelial cells exposed to different concentrations of recombinant neutropil elastase. Then, the expression of angiopoietin-1, angiopoietin-2, and neutrophil elastase was determined at 3 h and at 1, 3, 5, 7, 14, 21, and 28 days in a clinically relevant model of moderate compression (35 g for 5 min at T10) spinal cord injury. A dichotomy between the levels of angiopoietin-1 and angiopoietin-2 was observed; thus, we utilized a specific neutrophil elastase inhibitor (sivelestat sodium; 30 mg/kg, i.p., b.i.d.) after spinal cord injury. The expression levels of neutropil elastase and angiopoietin-2 increased, and that of angiopoietin-1 decreased after spinal cord injury in rats. The sivelestat regimen, optimized via a pharmacokinetics study, had potent effects on vascular stabilization by upregulating angiopoietin-1 via the AKT pathway and preventing tight junction protein degradation. Moreover, sivelestat attenuated the levels of inflammatory cytokines and chemokines after spinal cord injury and hence subsequently alleviated secondary damage observed as a reduction in glial scar formation and the promotion of blood vessel formation and stabilization. As a result, hindlimb locomotor function significantly recovered in the sivelestat-treated animals as determined by the Basso, Beattie, and Bresnahan scale and footprint analyses. Furthermore, sivelestat treatment attenuated neuropathic pain as assessed by responses to von Frey filaments after spinal cord injury. Thus, our result suggests that inhibiting neutropil elastase by administration of sivelestat is a promising therapeutic strategy to inhibit glial scar and promote functional recovery by upregulating angiopoietin-1 after spinal cord injury.
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Affiliation(s)
- Hemant Kumar
- Department of Neurosurgery, CHA University School of Medicine, CHA Bundang Medical Center, Seongnam-si, Gyeonggi-do, 13496, Republic of Korea
| | - Hyemin Choi
- Department of Neurosurgery, CHA University School of Medicine, CHA Bundang Medical Center, Seongnam-si, Gyeonggi-do, 13496, Republic of Korea
| | - Min-Jae Jo
- Department of Neurosurgery, CHA University School of Medicine, CHA Bundang Medical Center, Seongnam-si, Gyeonggi-do, 13496, Republic of Korea
| | - Hari Prasad Joshi
- Department of Neurosurgery, CHA University School of Medicine, CHA Bundang Medical Center, Seongnam-si, Gyeonggi-do, 13496, Republic of Korea
| | - Manjunatha Muttigi
- Department of Biomedical Science, CHA University, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Dario Bonanomi
- Molecular Neurobiology Laboratory, Division of Neuroscience, San Raffaele Scientific Institute, Milan, Italy
| | - Sung Bum Kim
- Department of Neurosurgery, Kyung Hee University, Dongdaemun-gu, Seoul, 02447, Republic of Korea
| | - Eunmi Ban
- College of Pharmacy, CHA University, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Aeri Kim
- College of Pharmacy, CHA University, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Soo-Hong Lee
- Department of Biomedical Science, CHA University, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Kyoung-Tae Kim
- Department of Neurosurgery, Kyungpook National University Hospital, Kyungpook National University, 130, Dongdeok-ro, Jung-gu, Daegu, 41944, Republic of Korea
- Department of Neurosurgery, School of Medicine,Kyungpook National University, 130, Dongdeok-ro, Jung-gu, Daegu, 41944, Republic of Korea
| | - Seil Sohn
- Department of Neurosurgery, CHA University School of Medicine, CHA Bundang Medical Center, Seongnam-si, Gyeonggi-do, 13496, Republic of Korea
| | - Xiang Zeng
- Department of Histology and Embryology, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, 510080, Guangdong Province, China.
| | - Inbo Han
- Department of Neurosurgery, CHA University School of Medicine, CHA Bundang Medical Center, Seongnam-si, Gyeonggi-do, 13496, Republic of Korea.
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Abstract
Critically ill patients with acute kidney injury (AKI) are heterogeneous on pathophysiology and prognosis. The role of endothelial damage in the pathogenesis of refractory AKI has not been clarified. The aim was to determine if biomarkers of endothelial damage, independently of the inflammatory insult on the kidney, can predict recovery of acute kidney injury. METHODS From the "Procalcitonin And Survival Study" multicenter intensive care unit cohort, followed for 28 days after admission, we included patients without chronic kidney disease, who survived >24 h after admission and with plasma samples at admission available for biomarker analysis. We defined AKI by the "Kidney Disease: Improving Global Outcomes" guidelines and recovery of prior kidney function as alive for five consecutive days after admission with no need for renal replacement therapy and creatinine levels consistently below ×1.5 the level before admission. We adjusted models for age, gender, vasopressor treatment, mechanical ventilation and levels of creatinine, procalcitonin, platelets, and bilirubin at admission. RESULTS Of a total 213 with AKI at admission, 99 recovered prior kidney function during follow-up. Endothelial damage on admission, measured by Soluble Thrombomodulin (sTM), was the strongest predictor of a reduced chance of recovery of prior kidney function (sTM in the highest vs. three lower quartiles hazard ratio 0.39; 95% confidence interval 0.21-0.73, P = 0.003). In contrast, the degree of the initial inflammatory insult on the kidney, measured by neutrophil gelatinase-associated lipocalin (NGAL), failed to predict this outcome (NGAL in highest vs. three lower quartiles hazard ratio = 1.20; 95% CI 0.72-2.00; P = 0.48). Procalcitonin, a specific marker of bacterial infection, was also associated with the rate of recovery (PCT in highest vs. three lower quartiles hazard ratio = 0.59; 95% CI 0.36-0.98; P = 0.04). CONCLUSION AKI patients with high levels of sTM had a reduced chance of recovering prior renal function. Our findings support disintegration of the endothelium as a critical point in the pathogenesis of AKI that is refractory to treatment.
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Coagulation abnormalities identified by thromboelastometry in patients with severe sepsis. Blood Coagul Fibrinolysis 2017; 28:163-170. [DOI: 10.1097/mbc.0000000000000572] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Eguchi T, Tsuji Y, Yamashita H, Fukuchi T, Kanamori A, Matsumoto K, Hasegawa T, Koizumi A, Kitada R, Tsujimae M, Iwatsubo T, Koyama S, Ubukata S, Fujita M, Okada A. Efficacy of recombinant human soluble thrombomodulin in preventing walled-off necrosis in severe acute pancreatitis patients. Pancreatology 2015; 15:485-490. [PMID: 26320826 DOI: 10.1016/j.pan.2015.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 06/04/2015] [Accepted: 08/12/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To investigate the efficacy of recombinant human soluble thrombomodulin (rTM) in preventing the development of walled-off necrosis (WON) in severe acute pancreatitis (SAP) patients. METHODS We retrospectively analyzed 54 SAP patients divided into two groups: SAP patients treated by rTM (rTM group, 24 patients) and not treated by rTM (control group, 30 patients). rTM was administered to patients with disseminated intravascular coagulation (DIC). Initially, on the admission day, we recorded patient severity and pancreatic necrosis/ischemia positive or negative. Then we investigated development of WON using 4 weeks later CT/MRI. Finally we compared the proportions of patients developing WON in the rTM group and the control group. RESULTS On the admission day, the condition of patients treated by rTM was significantly worse than patients in the control group; rTM group vs. CONTROL 71.8 ± 13.9 vs. 59.8 ± 15.3 years for age, 10.7 ± 3.5 vs. 8.0 ± 4.4 for Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and 3.3 ± 1.8 vs. 2.2 ± 1.8 for sequential organ failure assessment (SOFA) score (p < 0.05). We found no significant differences on the admission day in rate of pancreatic necrosis/ischemia between patients treated by rTM and controls (58.3% vs. 63.3%, p = 0.71). Nevertheless, the proportion of patients developing WON was significantly lower among those administered rTM than in those not administered rTM {29.2% (7/24 patients) vs. 56.7% (17/30 patients), p < 0.05}. CONCLUSION Treatment of SAP patients treated by rTM may prevent progression from pancreatic necrosis/ischemia to WON.
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Affiliation(s)
- Takaaki Eguchi
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Yoshihisa Tsuji
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kawaramachi 54, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
| | - Hiroshi Yamashita
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Takumi Fukuchi
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Atsushi Kanamori
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Kei Matsumoto
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Takashi Hasegawa
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Akio Koizumi
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Ryuki Kitada
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Masahiro Tsujimae
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Taro Iwatsubo
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Shintaro Koyama
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Satoshi Ubukata
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Mikio Fujita
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Akihiko Okada
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan.
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Ostrowski SR, Haase N, Müller RB, Møller MH, Pott FC, Perner A, Johansson PI. Association between biomarkers of endothelial injury and hypocoagulability in patients with severe sepsis: a prospective study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:191. [PMID: 25907781 PMCID: PMC4423170 DOI: 10.1186/s13054-015-0918-5] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 04/10/2015] [Indexed: 12/22/2022]
Abstract
Introduction Patients with severe sepsis often present with concurrent coagulopathy, microcirculatory failure and evidence of vascular endothelial activation and damage. Given the critical role of the endothelium in balancing hemostasis, we investigated single-point associations between whole blood coagulopathy by thrombelastography (TEG) and plasma/serum markers of endothelial activation and damage in patients with severe sepsis. Methods A post-hoc multicenter prospective observational study in a subgroup of 184 patients from the Scandinavian Starch for Severe Sepsis/Septic Shock (6S) Trial. Study patients were admitted to two Danish intensive care units. Inclusion criteria were severe sepsis, pre-intervention whole blood TEG measurement and a plasma/serum research sample available from baseline (pre-intervention) for analysis of endothelial-derived biomarkers. Endothelial-derived biomarkers were measured in plasma/serum by enzyme-linked immunosorbent assay (syndecan-1, thrombomodulin, protein C (PC), tissue-type plasminogen activator and plasminogen activator inhibitor-1). Pre-intervention TEG, functional fibrinogen (FF) and laboratory and clinical data, including mortality, were retrieved from the trial database. Results Most patients presented with septic shock (86%) and pulmonary (60%) or abdominal (30%) focus of infection. The median (IQR) age was 67 years (59 to 75), and 55% were males. The median SOFA and SAPS II scores were 8 (6 to 10) and 56 (41 to 68), respectively, with 7-, 28- and 90-day mortality rates being 21%, 39% and 53%, respectively. Pre-intervention (before treatment with different fluids), TEG reaction (R)-time, angle and maximum amplitude (MA) and FF MA all correlated with syndecan-1, thrombomodulin and PC levels. By multivariate linear regression analyses, higher syndecan-1 and lower PC were independently associated with TEG and FF hypocoagulability at the same time-point: 100 ng/ml higher syndecan-1 predicted 0.64 minutes higher R-time (SE 0.25), 1.78 mm lower TEG MA (SE 0.87) and 0.84 mm lower FF MA (SE 0.42; all P <0.05), and 10% lower protein C predicted 1.24 mm lower TEG MA (SE 0.31). Conclusions In our cohort of patients with severe sepsis, higher circulating levels of biomarkers of mainly endothelial damage were independently associated with hypocoagulability assessed by TEG and FF. Endothelial damage is intimately linked to coagulopathy in severe sepsis. Trial registration Clinicaltrials.gov number: NCT00962156. Registered 13 July 2009.
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Affiliation(s)
- Sisse Rye Ostrowski
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark.
| | - Nicolai Haase
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet Blegdamsvej 9, DK-2100, Copenhagen, Denmark.
| | - Rasmus Beier Müller
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet Blegdamsvej 9, DK-2100, Copenhagen, Denmark.
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet Blegdamsvej 9, DK-2100, Copenhagen, Denmark.
| | - Frank Christian Pott
- Department of Intensive Care, Copenhagen University Hospital, Bispebjerg Hospital, Bispebjerg Bakke 23, DK-2400, Copenhagen, Denmark.
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet Blegdamsvej 9, DK-2100, Copenhagen, Denmark.
| | - Pär Ingemar Johansson
- Department of Surgery, Division of Acute Care Surgery, Centre for Translational Injury Research (CeTIR), University of Texas Medical School at Houston, 6410 Fannin Street UPB 1100, Houston, TX, 77030, USA.
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Miyoshi S, Ito R, Katayama H, Dote K, Aibiki M, Hamada H, Okura T, Higaki J. Combination therapy with sivelestat and recombinant human soluble thrombomodulin for ARDS and DIC patients. Drug Des Devel Ther 2014; 8:1211-9. [PMID: 25214765 PMCID: PMC4159222 DOI: 10.2147/dddt.s68030] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Neutrophil elastase, alveolar thrombin generation, and fibrin deposition play crucial roles in the development of acute respiratory distress syndrome (ARDS) and disseminated intravascular coagulation (DIC). However, the usefulness of combination therapy with a selective neutrophil elastase inhibitor, sivelestat, and recombinant human soluble thrombomodulin (rhTM) for patients with ARDS and DIC remains unknown. METHODS We conducted a retrospective data analysis of 142 ARDS patients with DIC to assess the effects of sivelestat combined with rhTM. Patients were divided into four groups: control (no sivelestat or rhTM treatment), sivelestat treatment alone, rhTM treatment alone, and combined treatment with sivelestat and rhTM. A Cox proportional hazard model was used to assess subject mortality rates. The efficacy of these drugs was evaluated based on survival rate, number of ventilator-free days, and change in PaO2/FIO2 (P/F) ratios and DIC scores before and at 7 days after a diagnosis of ARDS with DIC. RESULTS Multivariate analysis showed that patient age, combination therapy, gas exchange, organ failure, cause, associated disease score, and serum C-reactive protein levels were predictors of mortality for patients with ARDS and DIC. As compared with untreated controls, combination therapy significantly improved the 60-day survival rate of patients with ARDS and DIC. There were significantly more ventilator-free days for those who received combination therapy than for untreated controls. P/F ratios and DIC scores were significantly improved with sivelestat alone, rhTM alone, or their combination as compared with untreated controls. CONCLUSION Our results suggest that combined treatment with sivelestat and rhTM has beneficial effects on survival and the respiratory and DIC status of patients with ARDS and DIC.
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Affiliation(s)
- Seigo Miyoshi
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Ryoji Ito
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Hitoshi Katayama
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Kentaro Dote
- Intensive Care Division, Ehime University Hospital, Toon, Ehime, Japan
| | - Mayuki Aibiki
- Department of Emergency and Critical Care Medicine, School of Medicine, Ehime University, Shitsukawa, Toon, Ehime, Japan
| | - Hironobu Hamada
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
- Department of Physical Analysis and Therapeutic Sciences, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi, Minami-ku, Hiroshima, Japan
| | - Takafumi Okura
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Jitsuo Higaki
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
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Coagulopathy, catecholamines, and biomarkers of endothelial damage in experimental human endotoxemia and in patients with severe sepsis: A prospective study. J Crit Care 2013; 28:586-96. [DOI: 10.1016/j.jcrc.2013.04.010] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Revised: 03/24/2013] [Accepted: 04/21/2013] [Indexed: 02/01/2023]
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Miyoshi S, Hamada H, Ito R, Katayama H, Irifune K, Suwaki T, Nakanishi N, Kanematsu T, Dote K, Aibiki M, Okura T, Higaki J. Usefulness of a selective neutrophil elastase inhibitor, sivelestat, in acute lung injury patients with sepsis. DRUG DESIGN DEVELOPMENT AND THERAPY 2013; 7:305-16. [PMID: 23596346 PMCID: PMC3627345 DOI: 10.2147/dddt.s42004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Neutrophil elastase plays a crucial role in the development of acute lung injury (ALI) in patients with systemic inflammatory response syndrome (SIRS). The clinical efficacy of the neutrophil elastase inhibitor, sivelestat, for patients with ALI associated with SIRS has not been convincingly demonstrated. The aim of this study was to determine if there are clinical features of patients with this condition that affect the efficacy of sivelestat. METHODS This was a retrospective study of 110 ALI patients with SIRS. Clinical information, including the etiology of ALI, the number of organs failing, scoring systems for assessing the severity of illness, and laboratory data, was collected at the time of diagnosis. Information on the number of ventilator-free days (VFDs) and changes in PaO(2)/F(I)O(2) (ΔP/F) before and 7 days after the time of ALI diagnosis was also collected. The effect of sivelestat on ALI patients was also examined based on whether they had sepsis and whether their initial serum procalcitonin level was ≥0.5 ng/mL. RESULTS There were 70 patients who were treated with sivelestat and 40 control patients. VFDs and ΔP/F were significantly higher in the treated patients than in the control patients. However, there was no significant difference in the patient survival rate between the two groups. Sivelestat was more effective in ALI patients with a PaO(2)/F(I)O(2) ratio ≥ 140 mmHg or sepsis. Sivelestat significantly prolonged survival and led to higher VFDs and increased ΔP/F in septic patients and patients with initial serum procalcitonin levels ≥ 0.5 ng/mL. CONCLUSION The results may facilitate a future randomized controlled trial to determine whether sivelestat is beneficial for ALI patients with sepsis.
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Affiliation(s)
- Seigo Miyoshi
- Department of Integrated Medicine and Informatics, Ehime University, Graduate School of Medicine, Toon
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Ostrowski SR, Berg RMG, Windeløv NA, Meyer MAS, Plovsing RR, Møller K, Johansson PI. Discrepant fibrinolytic response in plasma and whole blood during experimental endotoxemia in healthy volunteers. PLoS One 2013; 8:e59368. [PMID: 23555024 PMCID: PMC3598702 DOI: 10.1371/journal.pone.0059368] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 02/13/2013] [Indexed: 01/07/2023] Open
Abstract
Background Sepsis induces early activation of coagulation and fibrinolysis followed by late fibrinolytic shutdown and progressive endothelial damage. The aim of the present study was to investigate and compare the functional hemostatic response in whole blood and plasma during experimental human endotoxemia by the platelet function analyzer, Multiplate and by standard and modified thrombelastography (TEG). Methods Prospective physiologic study of nine healthy male volunteers undergoing endotoxemia by means of a 4-hour infusion of E. coli lipopolysaccharide (LPS, 0.5 ng/kg/hour), with blood sampled at baseline and at 4 h and 6 h. Physiological and standard biochemical data and coagulation tests, TEG (whole blood: TEG, heparinase-TEG, Functional Fibrinogen; plasma: TEG±tissue-type plasminogen activator (tPA)) and Multiplate (TRAPtest, ADPtest, ASPItest, COLtest) were recorded. Mixed models with Tukey post hoc tests and correlations were applied. Results Endotoxemia induced acute SIRS with increased HR, temperature, WBC, CRP and procalcitonin and decreased blood pressure. It also induced a hemostatic response with platelet consumption and reduced APTT while INR increased (all p<0.05). Platelet aggregation decreased (all tests, p<0.05), whereas TEG whole blood clot firmness increased (G, p = 0.05). Furthermore, during endotoxemia (4 h), whole blood fibrinolysis increased (clot lysis time (CLT), p<0.001) and Functional Fibrinogen clot strength decreased (p = 0.049). After endotoxemia (6 h), whole blood fibrinolysis was reduced (CLT, p<0.05). In contrast to findings in whole blood, the plasma fibrin clot became progressively more resistant towards tPA-induced fibrinolysis at both 4 h and 6 h (p<0.001). Conclusions Endotoxemia induced a hemostatic response with reduced primary but enhanced secondary hemostasis, enhanced early fibrinolysis and fibrinogen consumption followed by downregulation of fibrinolysis, with a discrepant fibrinolytic response in plasma and whole blood. The finding that blood cells are critically involved in the vasculo-fibrinolytic response to acute inflammation is important given that disturbances in the vascular system contribute significantly to morbidity and mortality in critically ill patients.
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Affiliation(s)
- Sisse R Ostrowski
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Copenhagen, Denmark.
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Thrombomodulin alfa in the treatment of infectious patients complicated by disseminated intravascular coagulation: subanalysis from the phase 3 trial. Shock 2011; 35:349-54. [PMID: 21068698 DOI: 10.1097/shk.0b013e318204c019] [Citation(s) in RCA: 144] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To investigate treatment effects of thrombomodulin alfa (TM-α) in patients with disseminated intravascular coagulation (DIC) having infection as the underlying disease, retrospective subanalysis of a double-blind, randomized controlled phase 3 trial was conducted. In the phase 3 trial, 227 DIC patients (full-analysis set) having infection and/or hematologic malignancy as the underlying disease received either TM-α (0.06 mg·kg for 30 min once daily) or heparin (8 U·kg·h for 24 h) for 6 days using the double-dummy method. Among these patients, 147 patients with noninfectious comorbidity leading to severe thrombocytopenia (e.g., hematologic malignancy, or aplastic anemia) were excluded from the present analysis, and 80 patients with infectious disease and DIC were extracted and subjected to the present retrospective subanalysis. Disseminated intravascular coagulation resolution rates were determined using the DIC diagnostic criteria for critically ill patients at 7 days, and mortality rates were evaluated at 28 days. In the TM-α and heparin groups, DIC resolution rates were 67.5% (27/40) and 55.6% (20/36), and 28-day mortality rates were 21.4% (9/42) and 31.6% (12/38), respectively. Mortality rates of patients who recovered from DIC were 3.7% (1/27) in the TM-α group and 15% (3/20) in the heparin group. These results suggest TM-α may be valuable in the treatment of DIC associated with infection.
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Sivelestat (selective neutrophil elastase inhibitor) improves the mortality rate of sepsis associated with both acute respiratory distress syndrome and disseminated intravascular coagulation patients. Shock 2010; 33:14-8. [PMID: 19487982 DOI: 10.1097/shk.0b013e3181aa95c4] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Neutrophil elastase plays an important role in the development of acute respiratory distress syndrome (ARDS) and disseminated intravascular coagulation (DIC) in sepsis. Sivelestat is a selective neutrophil elastase inhibitor. It is possible that sivelestat improves the outcome of septic patients associated with ARDS and DIC. A retrospective data analysis of septic patients associated with ARDS and DIC was conducted to investigate the effects of sivelestat. Observational period was 5 days after admission to intensive care unit (ICU). The study included 167 septic patients associated with ARDS and DIC. Control group included 133 patients without sivelestat, and sivelestat group included 34 patients started to deadministered sivelestat on the admission to ICU. The lung injury scores and Pa(O2)/Fl(O2) ratio of the sivelestat group were significantly more severe than those of the control group from days 1 to 4. On day 5, the lung injury score and Pa(O2)/Fl(O2) ratio of the sivelestat group improved to the same levels of those of the control group. The DIC score of sivelestat group improved on day 3 in comparison to day 1, and those of control group remained unchanged until day 4. The length of ICU stay of the sivelestat group was significantly shorter than that of the control group. A stepwise multiple logistic-regression analysis showed the sivelestat administration to be an independent predictor of survival of the septic patients associated with both ARDS and DIC. The length of ICU stay of the sivelestat group was significantly shorter than that of the control group. In addition, sivelestat administration was found to be an independent predictor of survival of those patients.
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Daudel F, Kessler U, Folly H, Lienert JS, Takala J, Jakob SM. Thromboelastometry for the assessment of coagulation abnormalities in early and established adult sepsis: a prospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R42. [PMID: 19331653 PMCID: PMC2689486 DOI: 10.1186/cc7765] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Revised: 03/06/2009] [Accepted: 03/30/2009] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The inflammatory response to an invading pathogen in sepsis leads to complex alterations in hemostasis by dysregulation of procoagulant and anticoagulant factors. Recent treatment options to correct these abnormalities in patients with sepsis and organ dysfunction have yielded conflicting results. Using thromboelastometry (ROTEM(R)), we assessed the course of hemostatic alterations in patients with sepsis and related these alterations to the severity of organ dysfunction. METHODS This prospective cohort study included 30 consecutive critically ill patients with sepsis admitted to a 30-bed multidisciplinary intensive care unit (ICU). Hemostasis was analyzed with routine clotting tests as well as thromboelastometry every 12 hours for the first 48 hours, and at discharge from the ICU. Organ dysfunction was quantified using the Sequential Organ Failure Assessment (SOFA) score. RESULTS Simplified Acute Physiology Score II and SOFA scores at ICU admission were 52 +/- 15 and 9 +/- 4, respectively. During the ICU stay the clotting time decreased from 65 +/- 8 seconds to 57 +/- 5 seconds (P = 0.021) and clot formation time (CFT) from 97 +/- 63 seconds to 63 +/- 31 seconds (P = 0.017), whereas maximal clot firmness (MCF) increased from 62 +/- 11 mm to 67 +/- 9 mm (P = 0.035). Classification by SOFA score revealed that CFT was slower (P = 0.017) and MCF weaker (P = 0.005) in patients with more severe organ failure (SOFA >or= 10, CFT 125 +/- 76 seconds, and MCF 57 +/- 11 mm) as compared with patients who had lower SOFA scores (SOFA <10, CFT 69 +/- 27, and MCF 68 +/- 8). Along with increasing coagulation factor activity, the initially increased International Normalized Ratio (INR) and prolonged activated partial thromboplastin time (aPTT) corrected over time. CONCLUSIONS Key variables of ROTEM(R) remained within the reference ranges during the phase of critical illness in this cohort of patients with severe sepsis and septic shock without bleeding complications. Improved organ dysfunction upon discharge from the ICU was associated with shortened coagulation time, accelerated clot formation, and increased firmness of the formed blood clot when compared with values on admission. With increased severity of illness, changes of ROTEM(R) variables were more pronounced.
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Affiliation(s)
- Fritz Daudel
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse, 3010 Bern, Switzerland.
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Effect of insulin therapy on coagulation and fibrinolysis in medical intensive care patients. Crit Care Med 2008; 36:1475-80. [PMID: 18434900 DOI: 10.1097/ccm.0b013e31816f7bae] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Most intensive care deaths beyond the first few days of critical illness are attributable to nonresolving organ failure, either due to or coinciding with sepsis. One of the mechanisms that is thought to contribute to the pathogenesis of organ failure is microvascular thrombosis. Recently, we reported significant improved survival and prevention of organ failure with the use of intensive insulin therapy to maintain normoglycemia for at least several days. We hypothesize that intensive insulin therapy also prevents severe coagulation abnormalities thereby contributing to less organ failure and better survival. DESIGN This was a preplanned subanalysis of a large randomized controlled study, conducted at a university hospital medical intensive care unit. The intervention was strict blood glucose control to normoglycemia with insulin. RESULTS Mortality of intensive insulin-treated patients was lower than that of conventionally treated patients for all classes of upon-admission disseminated intravascular coagulation (DIC) scores, except for those patients with overt DIC scores of 6 or higher (for DIC < 5, p = 0.003; for DIC > or = 5, p = 0.4). There was no effect of insulin therapy on any of the fibrinolytic, coagulation, or inflammatory parameters tested. CONCLUSIONS This negative observation does not support a key role for these systems in explaining the clinical benefit of intensive insulin therapy, although a short-lived effect within 5 days of treatment cannot be excluded.
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Miyake Y, Iwasaki Y, Makino Y, Kobashi H, Takaguchi K, Ando M, Sakaguchi K, Shiratori Y. Prognostic factors for fatal outcomes prior to receiving liver transplantation in patients with non-acetaminophen-related fulminant hepatic failure. J Gastroenterol Hepatol 2007; 22:855-61. [PMID: 17565642 DOI: 10.1111/j.1440-1746.2007.04874.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND AIM Many patients continue to die due to the rapid development of cerebral edema and/or multiple organ failure prior to receiving a liver transplantation. METHODS We investigated the prognostic factors associated with 1-week fatal outcomes after the diagnosis of fulminant hepatic failure, which were associated with fatal outcomes prior to receiving liver transplantation, in 104 patients with non-acetaminophen-related fulminant hepatic failure. RESULTS With a multivariate logistic regression analysis, age (>40 years), systemic inflammatory response syndrome (SIRS) and plasma prothrombin activities (<or=10%) were significantly associated with fatal outcomes at 1 week after diagnosis in 104 patients. At the time of diagnosis, 50 patients (48%) were in a state of SIRS. Significant differences were observed between patients with and without SIRS regarding the period from the initial symptoms to the diagnosis of fulminant hepatic failure, hepatic coma grade, serum alanine aminotransferase level, serum creatinine level and plasma prothrombin activity. With a multivariate logistic regression analysis, age (>40 years), cause of fulminant hepatic failure (viral hepatitis), plasma prothrombin activity (<or=10%) and no administration of protease inhibitor were significantly associated with the 1-week fatal outcomes of 50 patients with SIRS. CONCLUSIONS Patients with SIRS exhibited hepatic failure of increased severity and SIRS may reduce the probability of receiving a liver transplantation. In order to estimate the efficacy of protease inhibitor for patients with SIRS, a prospective randomized trial is required.
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Affiliation(s)
- Yasuhiro Miyake
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
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Wilson KM, Smith AI, Phillips DJ. Stimulatory effects of lipopolysaccharide on endothelial cell activin and follistatin. Mol Cell Endocrinol 2006; 253:30-5. [PMID: 16697104 DOI: 10.1016/j.mce.2006.03.041] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2006] [Revised: 03/07/2006] [Accepted: 03/29/2006] [Indexed: 10/24/2022]
Abstract
Activin A and its binding protein, follistatin, are released into the circulation following acute systemic inflammation. In this study, we determined the activin and follistatin response of ovine aortic endothelial cells to lipopolysaccharide (LPS). Exposure to LPS for 1h, mimicking a transient inflammatory event, elicited significant increases in activin betaA subunit mRNA or activin A release, with larger, more prolonged increases evident with continuous exposure. On the other hand, follistatin increases were only evident with prolonged exposure to LPS and following increases in activin A release. While cell-associated activin A increased with LPS exposure, levels were lower than those secreted, whereas the opposite was apparent for follistatin. In summary, our findings suggest that vascular endothelial cells, while capable of releasing activin A and follistatin following inflammatory stimulation, are unlikely to be responsible for the rapid release of activin A in vivo following inflammatory challenge.
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Affiliation(s)
- Kathryn M Wilson
- Monash Institute of Medical Research, Monash University, Vic. 3800, Australia
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Donati A, Cornacchini O, Loggi S, Caporelli S, Conti G, Falcetta S, Alò F, Pagliariccio G, Bruni E, Preiser JC, Pelaia P. A comparison among portal lactate, intramucosal sigmoid Ph, and deltaCO2 (PaCO2 - regional Pco2) as indices of complications in patients undergoing abdominal aortic aneurysm surgery. Anesth Analg 2004; 99:1024-1031. [PMID: 15385343 DOI: 10.1213/01.ane.0000132543.65095.2c] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Our aim in this observational, prospective, noncontrolled study was to detect, in 29 patients who underwent abdominal aortic aneurysm (AAA) surgery, correlations between the incidence of postoperative organ failure and intraoperative changes in arterial and portal blood lactate; changes in intramucosal sigmoid pH (pHi); differences between sigmoid Pco(2) and arterial Pco(2) (DeltaCO(2)); and hemoglobin (Hb). Hb, arterial blood lactate concentrations, pHi, and DeltaCO(2) (air tonometry) were recorded at the start of anesthesia (T0), before aorta clamping (T1), 30 minutes after clamping (T2), and at the end of surgery (T3). Portal venous lactate concentrations were recorded at T1 and T2. Patients were stratified into two groups: group A patients had no postoperative organ failure, and group B patients had one or more organ failures. As compared with group A (n = 16), group B patients (n = 13) had a lower pHi value at T2 and T3 and a higher DeltaCO(2) at T3. A pHi value of <7.15 was a predictor of organ failure, with a sensitivity of 92.3%, a specificity of 68.8%, and positive and negative predictive values of 70.6% and 91.7%, respectively, whereas a DeltaCO(2) value of >28 mm Hg predicted later organ failure with a sensitivity of 92.3%, a specificity of 62.5%, and positive and negative predictive values of 66.6% and 90.9%, respectively. Portal venous lactate concentrations were larger in group B at T2 (P < 0.001), and an increase >or=5 g/dL predicted later postoperative organ failure with a sensitivity of 92.3%, a specificity of 100%, and positive and negative predictive values of 100% and 94.1%, respectively. The comparison of the receiving operator characteristic curves to test the discrimination of each variable and the logistic regression analysis revealed that the increase in portal lactate was the best predictor for the development of postoperative organ failure. Hb concentration was significantly smaller in group B at T0 (13.8 +/- 1.0 g/dL versus 12.2 +/- 2.2 g/dL) and T2 (10.9 +/- 1.2 g/dL versus 9.1 +/- 1.9 g/dL). In conclusion, both pHi and DeltaCO(2) are reasonably sensitive prognostic indices of organ failures after AAA surgery, but they are less specific and accurate than portal venous lactate.
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Affiliation(s)
- Abele Donati
- *Department of Neuroscience, Anesthesia and Intensive Care Unit, and †Department of Vascular Surgery, Marche Polytechnique University, Ancona, Italy; and ‡Department of Intensive Care, University Hospital of Liege, Liege, Belgium
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Affiliation(s)
- Warren R Summer
- Section of Pulmonary/Critical Care Medicine, Department of Medicine, School of Medicine, Louisiana State University Health Sciences Center, New Orleans, Louisiana 70112, USA.
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Tancabelic J, Haun SE. Management of coagulopathy with recombinant factor VIIa in a neonate with echovirus type 7. Pediatr Blood Cancer 2004; 43:170-6. [PMID: 15236286 DOI: 10.1002/pbc.20078] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A 5-day-old newborn presented with neonatal enteroviral infection. The patient's hospital course was complicated by acute liver dysfunction, renal insufficiency, fluid overload, respiratory failure, hypertension, catheter related thrombosis, Klebsiella pneumoniae sepsis, intracerebral and intraventricular hemorrhage, and disseminated intravascular coagulation (DIC). Administration of fresh frozen plasma (FFP) and cryoprecipitate failed to control the patient's hemostasis and led to significant fluid overload. Recombinant activated factor VII (rFVIIa, Novoseven NovoNordisk, Bagsvaerd, Denmark) was given to the neonate as a bolus (rFVIIa at 60-80 microg/kg body weight), followed by a continuous infusion (2.5-16 microg/kg/hr). Recombinant activated factor VII controlled hemostasis, until the patient's liver function recovered. The patient's blood product requirement significantly decreased and his fluid overload resolved. Administration of rFVIIa appears to have stabilized the coagulation process. The patient appears to have fully recovered from the infection's complications.
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Affiliation(s)
- Jakica Tancabelic
- University of South Dakota School of Medicine, Department of Pediatrics, Pediatric Critical Care Medicine, Sioux Falls, South Dakota 57117, USA.
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