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Ahmadi A, Hosseini S, Dorgalaleh A, Hassani S, Tabibian S, Tavasoli B, Shabannezhad A, Taheri M, Shams M. Natural Anticoagulant Protein Levels in Patients With Beta-Thalassemia Major: A Case-Control Study. J Hematol 2024; 13:23-28. [PMID: 38644988 PMCID: PMC11027775 DOI: 10.14740/jh1217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 01/22/2024] [Indexed: 04/23/2024] Open
Abstract
Background β-thalassemia is a group of inherited blood disorders that affect the production of β-globin chains, leading to the reduction or absence of these chains. One of the complications observed in patients with β-thalassemia major (β-TM) is thrombosis, especially in those who receive frequent blood transfusions. This may be due to a decrease in the levels of the natural anticoagulants: protein C (PC), total protein S (PS), and antithrombin (AT). Methods In this case-control study, patients with β-TM, who had received at least 20 packed cell transfusions during their lifetime, were included. Patients with other underlying diseases like bleeding or thrombotic disorders were excluded. Totally, 118 patients with β-TM and 120 healthy individuals were included. Results The mean level of PC and AT was significantly lower in patients with β-TM (48.2 ± 65.4 and 57.42 ± 13.6, respectively) compared to the control group (97.1 ± 21.46 and 81.79 ± 14.3, respectively), with P value of 0.001 and 0.01, respectively. Although the difference was not statistically significant (P = 0.1), a similar trend was observed for total PS (61.12 ± 21.12 for patients versus 72.2 ± 35.2 for the control group). Of note, the decrease in PC, AT, and total PS levels compared to the control group was 50.36%, 27.5%, and 15.34%, respectively. Conclusions It seems that β-TM patients who receive prolonged blood transfusions frequently are at an increased risk of decreased in natural anticoagulants levels and therefore potentially are at risk of thrombosis.
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Affiliation(s)
- Abbas Ahmadi
- Cellular and Molecular Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
- Department of Molecular Medicine, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Soudabeh Hosseini
- Cellular and Molecular Research Center, Iran University of Medical Sciences, Tehran, Iran
- Aliasghar Children Hospital, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | | | - Saeed Hassani
- Department of Medical Laboratory Sciences, School of Paramedical Sciences, Arak University of Medical Sciences, Arak, Iran
| | - Shadi Tabibian
- Iranian Comprehensive Hemophilia Care Center, Tehran, Iran
| | - Behnaz Tavasoli
- Department of Hematology, Faculty of Paramedical Sciences, Bushehr University of Medical Sciences, Bushehr, Iran
| | - Ashkan Shabannezhad
- Department of Hematology, School of Allied Medical Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Mahdi Taheri
- Non-Communicable Pediatric Diseases Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Mahmood Shams
- Cellular and Molecular Biology Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
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2
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Mori F, Angelini C, Farina C. New plasma protein C and protein S concentrate: A synergy for therapeutic purposes. Vox Sang 2024; 119:193-202. [PMID: 38018260 DOI: 10.1111/vox.13567] [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: 07/26/2023] [Revised: 10/24/2023] [Accepted: 11/03/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND AND OBJECTIVES Deficiencies of protein C (PC) or protein S (PS) are rare diseases, characterized by mutations in the PC or PS genes, which encode plasma serine proteases with anti-coagulant activity. Severe PC or PS deficiencies manifest in early life as neonatal purpura fulminans, a life-threatening heamorrhagic condition requiring immediate treatment. First-line treatment involves replacement therapy, followed by maintenance with anti-coagulants. Replacement therapy with specific protein concentrates is currently only limited to PC, and therefore, a PC + PS concentrate represents a useful addition to therapeutic options, particularly for severe PS deficiency. Further, the production of a PC + PS concentrate from unused plasma fractionation intermediates would impact favourably on manufacturing costs, and consequently therapy prices for patients and health systems. MATERIALS AND METHODS Several chromatographic runs were performed on the same unused plasma fractionation intermediates using different supports to obtain a PC/PS concentrate. The best chromatographic mediums were chosen, in terms of specific activity and recovery. A full process of purification including virus inactivation/removal and lyophilization steps was set up. RESULTS The final freeze-dried product had a mean PC concentration of 47.75 IU/mL with 11% of PS, and a mean specific activity of 202.5 IU/mg protein, corresponding to over 12,000-fold purification from plasma. CONCLUSION The development of a novel concentrated PC/PS mixture obtained from a waste fraction of other commercial products could be used for its potential therapeutic role in the management of neonatal purpura fulminans pathology.
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Affiliation(s)
- Filippo Mori
- Department of Research and Innovation, Kedrion Biopharma, Bolognana, Italy
| | - Cristina Angelini
- Department of Research and Innovation, Kedrion Biopharma, Bolognana, Italy
| | - Claudio Farina
- Department of Research and Innovation, Kedrion Biopharma, Bolognana, Italy
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3
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Chandika P, Tennakoon P, Kim TH, Kim SC, Je JY, Kim JI, Lee B, Ryu B, Kang HW, Kim HW, Kim YM, Kim CS, Choi IW, Park WS, Yi M, Jung WK. Marine Biological Macromolecules and Chemically Modified Macromolecules; Potential Anticoagulants. Mar Drugs 2022; 20:md20100654. [PMID: 36286477 PMCID: PMC9604568 DOI: 10.3390/md20100654] [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: 09/27/2022] [Revised: 10/13/2022] [Accepted: 10/18/2022] [Indexed: 11/07/2022] Open
Abstract
Coagulation is a potential defense mechanism that involves activating a series of zymogens to convert soluble fibrinogen to insoluble fibrin clots to prevent bleeding and hemorrhagic complications. To prevent the extra formation and diffusion of clots, the counterbalance inhibitory mechanism is activated at levels of the coagulation pathway. Contrariwise, this system can evade normal control due to either inherited or acquired defects or aging which leads to unusual clots formation. The abnormal formations and deposition of excess fibrin trigger serious arterial and cardiovascular diseases. Although heparin and heparin-based anticoagulants are a widely prescribed class of anticoagulants, the clinical use of heparin has limitations due to the unpredictable anticoagulation, risk of bleeding, and other complications. Hence, significant interest has been established over the years to investigate alternative therapeutic anticoagulants from natural sources, especially from marine sources with good safety and potency due to their unique chemical structure and biological activity. This review summarizes the coagulation cascade and potential macromolecular anticoagulants derived from marine flora and fauna.
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Affiliation(s)
- Pathum Chandika
- Marine Integrated Biomedical Technology Center, The National Key Research Institutes in Universities, Pukyong National University, Busan 48513, Korea
- Research Center for Marine Integrated Bionics Technology, Pukyong National University, Busan 48513, Korea
| | - Pipuni Tennakoon
- Marine Integrated Biomedical Technology Center, The National Key Research Institutes in Universities, Pukyong National University, Busan 48513, Korea
- Major of Biomedical Engineering, Division of Smart Healthcare and New-Senior Healthcare Innovation Center (BK21 Plus), Pukyong National University, Busan 48513, Korea
| | - Tae-Hee Kim
- Marine Integrated Biomedical Technology Center, The National Key Research Institutes in Universities, Pukyong National University, Busan 48513, Korea
- Research Center for Marine Integrated Bionics Technology, Pukyong National University, Busan 48513, Korea
| | - Se-Chang Kim
- Marine Integrated Biomedical Technology Center, The National Key Research Institutes in Universities, Pukyong National University, Busan 48513, Korea
- Major of Biomedical Engineering, Division of Smart Healthcare and New-Senior Healthcare Innovation Center (BK21 Plus), Pukyong National University, Busan 48513, Korea
| | - Jae-Young Je
- Major of Human Bioconvergence, Division of Smart Healthcare, Pukyong National University, Busan 48513, Korea
| | - Jae-Il Kim
- Major of Food Science and Nutrition, Pukyong National University, Busan 48513, Korea
| | - Bonggi Lee
- Major of Food Science and Nutrition, Pukyong National University, Busan 48513, Korea
| | - BoMi Ryu
- Major of Food Science and Nutrition, Pukyong National University, Busan 48513, Korea
| | - Hyun Wook Kang
- Marine Integrated Biomedical Technology Center, The National Key Research Institutes in Universities, Pukyong National University, Busan 48513, Korea
- Research Center for Marine Integrated Bionics Technology, Pukyong National University, Busan 48513, Korea
- Major of Biomedical Engineering, Division of Smart Healthcare and New-Senior Healthcare Innovation Center (BK21 Plus), Pukyong National University, Busan 48513, Korea
| | - Hyun-Woo Kim
- Marine Integrated Biomedical Technology Center, The National Key Research Institutes in Universities, Pukyong National University, Busan 48513, Korea
- Research Center for Marine Integrated Bionics Technology, Pukyong National University, Busan 48513, Korea
- Department of Marine Biology, Pukyong National University, Busan 48513, Korea
| | - Young-Mog Kim
- Marine Integrated Biomedical Technology Center, The National Key Research Institutes in Universities, Pukyong National University, Busan 48513, Korea
- Research Center for Marine Integrated Bionics Technology, Pukyong National University, Busan 48513, Korea
- Major of Food Science and Technology, Pukyong National University, Busan 48513, Korea
| | - Chang Su Kim
- Department of Orthopedic Surgery, Kosin University Gospel Hospital, Busan 49267, Korea
| | - Il-Whan Choi
- Department of Microbiology, College of Medicine, Inje University, Busan 47392, Korea
| | - Won Sun Park
- Department of Physiology, Institute of Medical Sciences, School of Medicine, Kangwon National University, Chuncheon 24341, Korea
| | - Myunggi Yi
- Research Center for Marine Integrated Bionics Technology, Pukyong National University, Busan 48513, Korea
- Major of Biomedical Engineering, Division of Smart Healthcare and New-Senior Healthcare Innovation Center (BK21 Plus), Pukyong National University, Busan 48513, Korea
| | - Won-Kyo Jung
- Marine Integrated Biomedical Technology Center, The National Key Research Institutes in Universities, Pukyong National University, Busan 48513, Korea
- Research Center for Marine Integrated Bionics Technology, Pukyong National University, Busan 48513, Korea
- Major of Biomedical Engineering, Division of Smart Healthcare and New-Senior Healthcare Innovation Center (BK21 Plus), Pukyong National University, Busan 48513, Korea
- Correspondence:
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Yang X, Rutkovsky AC, Zhou J, Zhong Y, Reese J, Schnell T, Albrecht H, Owens WB, Nagarkatti PS, Nagarkatti M. Characterization of Altered Gene Expression and Histone Methylation in Peripheral Blood Mononuclear Cells Regulating Inflammation in COVID-19 Patients. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2022; 208:1968-1977. [PMID: 35379747 PMCID: PMC9012677 DOI: 10.4049/jimmunol.2101099] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/01/2022] [Indexed: 12/15/2022]
Abstract
The pandemic of COVID-19 has caused >5 million deaths in the world. One of the leading causes of the severe form of COVID-19 is the production of massive amounts of proinflammatory cytokines. Epigenetic mechanisms, such as histone/DNA methylation, miRNA, and long noncoding RNA, are known to play important roles in the regulation of inflammation. In this study, we investigated if hospitalized COVID-19 patients exhibit alterations in epigenetic pathways in their PBMCs. We also compared gene expression profiles between healthy controls and COVID-19 patients. Despite individual variations, the expressions of many inflammation-related genes, such as arginase 1 and IL-1 receptor 2, were significantly upregulated in COVID-19 patients. We also found the expressions of coagulation-related genes Von Willebrand factor and protein S were altered in COVID-19 patients. The expression patterns of some genes, such as IL-1 receptor 2, correlated with their histone methylation marks. Pathway analysis indicated that most of those dysregulated genes were in the TGF-β, IL-1b, IL-6, and IL-17 pathways. A targeting pathway revealed that the majority of those altered genes were targets of dexamethasone, which is an approved drug for COVID-19 treatment. We also found that the expression of bone marrow kinase on chromosome X, a member of TEC family kinases, was increased in the PBMCs of COVID-19 patients. Interestingly, some inhibitors of TEC family kinases have been used to treat COVID-19. Overall, this study provides important information toward identifying potential biomarkers and therapeutic targets for COVID-19 disease.
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Affiliation(s)
- Xiaoming Yang
- Department of Pathology, Microbiology and Immunology, School of Medicine, University of South Carolina, Columbia, SC; and
| | - Alex C Rutkovsky
- Department of Pathology, Microbiology and Immunology, School of Medicine, University of South Carolina, Columbia, SC; and
| | - Juhua Zhou
- Department of Pathology, Microbiology and Immunology, School of Medicine, University of South Carolina, Columbia, SC; and
| | - Yin Zhong
- Department of Pathology, Microbiology and Immunology, School of Medicine, University of South Carolina, Columbia, SC; and
| | - Julian Reese
- Prisma Health Richland Hospital, School of Medicine, University of South Carolina, Columbia, SC
| | - Timothy Schnell
- Prisma Health Richland Hospital, School of Medicine, University of South Carolina, Columbia, SC
| | - Helmut Albrecht
- Prisma Health Richland Hospital, School of Medicine, University of South Carolina, Columbia, SC
| | - William B Owens
- Prisma Health Richland Hospital, School of Medicine, University of South Carolina, Columbia, SC
| | - Prakash S Nagarkatti
- Department of Pathology, Microbiology and Immunology, School of Medicine, University of South Carolina, Columbia, SC; and
| | - Mitzi Nagarkatti
- Department of Pathology, Microbiology and Immunology, School of Medicine, University of South Carolina, Columbia, SC; and
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5
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Zhu T, Tan Q, Xin X, Li F, Zhang K, Liu Z, Tian Y. Proteomic analysis of human articular cartilage unravels the dyscoagulation in osteoarthritis and the potential value of serpinA5 as a biomarker for osteoarthritis. Proteomics Clin Appl 2021; 16:e2100117. [PMID: 34964303 DOI: 10.1002/prca.202100117] [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: 11/22/2021] [Revised: 12/10/2021] [Accepted: 12/21/2021] [Indexed: 11/08/2022]
Abstract
PURPOSE Nowadays, there is no clinically applicable biomarker for osteoarthritis (OA). Therefore, the aim of the study is to discover a potential biomarker for OA. EXPERIMENTAL DESIGN We performed a proteomics of eight cartilage samples (four damaged cartilage and four macroscopically intact cartilage) from four OA patients without any comorbidities to search for valuable OA biomarkers. Four rats underwent bilateral ovariectomy to induce the OA (OVX-OA) model, while another four underwent a sham procedure wherein the ovaries were exteriorized but not removed (SHAM). Selected candidate proteins were further verified in the patients and the OVX-OA animal model. RESULTS A comprehensive cartilage proteome profile of patients with OA was constructed. Additionally, the complement and coagulation cascades were found to be significantly altered, and serpinA5 was chosen as a protein of interest based on biological information analysis. The reduction of serpinA5 in locally damaged cartilage and serum of patients with OA compared to the control group was determined. Furthermore, we found that serpinA5 was decreased in OVX-OA rats compared to that in SHAM rats. CONCLUSIONS AND CLINICAL RELEVANCE Our results suggest that there is dyscoagulation in the OA process and that serpinA5 can serve as a potentially valuable OA biomarker.
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Affiliation(s)
- Tengjiao Zhu
- Department of Orthopedic, Peking University Third Hospital, Beijing, P.R. China.,Department of Orthopedic, Peking University International Hospital, Beijing, P.R. China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, P.R. China
| | - Qizhao Tan
- Department of Orthopedic, Peking University Third Hospital, Beijing, P.R. China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, P.R. China
| | - Xing Xin
- Department of Orthopedic, Peking University International Hospital, Beijing, P.R. China
| | - Feng Li
- Department of Orthopedic, Peking University Third Hospital, Beijing, P.R. China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, P.R. China
| | - Ke Zhang
- Department of Orthopedic, Peking University Third Hospital, Beijing, P.R. China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, P.R. China
| | - Zhongjun Liu
- Department of Orthopedic, Peking University Third Hospital, Beijing, P.R. China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, P.R. China
| | - Yun Tian
- Department of Orthopedic, Peking University Third Hospital, Beijing, P.R. China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, P.R. China
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Abstract
PURPOSE OF REVIEW Protein S (PS) is an essential natural anticoagulant. PS deficiency is a major contributor to acquired hypercoagulability. Acquired hypercoagulability causes myocardial infarction, stroke, and deep vein thrombosis in millions of individuals. Yet, despite its importance in hemostasis, PS is the least understood anticoagulant. Even after 40 years since PS was first described, we are still uncovering information about how PS functions. The purpose of this review is to highlight recent findings that advance our understanding of the functions of PS and explain hypercoagulability caused by severe PS deficiency. RECENT FINDINGS PS has long been described as a cofactor for Activated Protein C (APC) and Tissue Factor Pathway Inhibitor (TFPI). However, a recent report describes direct inhibition of Factor IXa (FIXa) by PS, an activity of PS that had been completely overlooked. Thrombophilia is becoming a more frequently reported disorder. Hereditary PS deficiency is an anticoagulant deficiency that results eventually in thrombophilia. In addition, PS deficiency is a predisposing factor for venous thromboembolism (VTE), but an effect of PS deficiency in arterial thrombosis, such as arterial ischemic stroke, is uncertain. Plasma PS concentration decreases in pregnant women. Inherited thrombophilias are important etiologies for recurrent pregnancy loss, and anticoagulation therapy is of benefit to women with recurrent pregnancy loss who had documented only PS deficiency.Hypoxia is a risk factor for VTE, and hypoxia downregulates plasma PS level. Importantly, COVID-19 can lead to hypoxemia because of lung damage from IL6-driven inflammatory responses to the viral infection. Because hypoxia decreases the abundance of the key anticoagulant PS, we surmise that the IL6-induced cytokine explosion combined with hypoxemia causes a drop in PS level that exacerbates the thrombotic risk in COVID-19 patients. SUMMARY This review is intended to advance understanding of the anticoagulant function of an important plasma protein, PS. Despite 40+ years of research, we have not had a complete description of PS biology as it pertains to control of blood coagulation. However, the picture of PS function has become sharper with the recent discovery of FIXa inhibition by PS. Hemostasis mediated by PS now includes regulation of FIXa activity alongside the cofactor activities of PS in the TFPI/APC pathways. In addition, the direct inhibition of FIXa by PS suggests that PS, particularly a small derivative of PS, could be used to treat individuals with PS deficiencies or abnormalities that cause thrombotic complications.
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Affiliation(s)
- Rinku Majumder
- Department of Biochemistry & Molecular Biology, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
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7
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Rebl A, Goldammer T. Under control: The innate immunity of fish from the inhibitors' perspective. FISH & SHELLFISH IMMUNOLOGY 2018; 77:328-349. [PMID: 29631025 DOI: 10.1016/j.fsi.2018.04.016] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 04/04/2018] [Accepted: 04/05/2018] [Indexed: 06/08/2023]
Abstract
The innate immune response involves a concerted network of induced gene products, preformed immune effectors, biochemical signalling cascades and specialised cells. However, the multifaceted activation of these defensive measures can derail or overshoot and, if left unchecked, overwhelm the host. A plenty of regulatory devices therefore mediate the fragile equilibrium between pathogen defence and pathophysiological manifestations. Over the past decade in particular, an almost complete set of teleostean sequences orthologous to mammalian immunoregulatory factors has been identified in various fish species, which prove the remarkable conservation of innate immune-control concepts among vertebrates. This review will present the current knowledge on more than 50 teleostean regulatory factors (plus additional fish-specific paralogs) that are of paramount importance for controlling the clotting cascade, the complement system, pattern-recognition pathways and cytokine-signalling networks. A special focus lies on those immunoregulatory features that have emerged as potential biomarker genes in transcriptome-wide research studies. Moreover, we report on the latest progress in elucidating control elements that act directly with immune-gene-encoding nucleic acids, such as transcription factors, hormone receptors and micro- and long noncoding RNAs. Investigations into the function of teleostean inhibitory factors are still mainly based on gene-expression profiling or overexpression studies. However, in support of structural and in-vitro analyses, evidence from in-vivo trials is also available and revealed many biochemical details on piscine immune regulation. The presence of multiple gene copies in fish adds a degree of complexity, as it is so far hardly understood if they might play distinct roles during inflammation. The present review addresses this and other open questions that should be tackled by fish immunologists in future.
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Affiliation(s)
- Alexander Rebl
- Leibniz Institute for Farm Animal Biology (FBN), Institute of Genome Biology, Fish Genetics Unit, Dummerstorf, Germany.
| | - Tom Goldammer
- Leibniz Institute for Farm Animal Biology (FBN), Institute of Genome Biology, Fish Genetics Unit, Dummerstorf, Germany
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8
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Inflammatory Changes and Coagulopathy in Multiply Injured Patients. THE POLY-TRAUMATIZED PATIENT WITH FRACTURES 2016. [PMCID: PMC7122098 DOI: 10.1007/978-3-662-47212-5_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Severe tissue trauma leads to an early activation of several danger recognition systems, including the complement and the coagulation system, often resulting in an overwhelming almost synchronic pro- and anti-inflammatory response of the host. Although the immune response is associated with beneficial effects at the site of injury including the elimination of exogenous and endogenous danger molecules as well as the initiation of regenerative processes, an exaggerated systemic inflammatory response significantly contributes to posttraumatic complications such as multiple organ failure (MOF) and early death. Besides pre-existing physical conditions, age, gender, and underlying comorbidities, surgical and anesthesiological management after injury is decisive for outcome. Improvements in surgical intensive care have increased number of patients who survive the initial phase after trauma. However, instead of progressing to normal recovery, patients often pass into persistent inflammation, immunosuppression, and catabolism syndrome (PICS). The characterization and management of PICS will require new strategies for direct monitoring and therapeutic intervention into the patient’s immune function. In this chapter, we describe various factors involved in the inflammatory changes after trauma and aim to understand how these factors interact to progress to systemic inflammation, MOF, and PICS.
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9
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Abstract
Coagulation is a dynamic process and the understanding of the blood coagulation system has evolved over the recent years in anaesthetic practice. Although the traditional classification of the coagulation system into extrinsic and intrinsic pathway is still valid, the newer insights into coagulation provide more authentic description of the same. Normal coagulation pathway represents a balance between the pro coagulant pathway that is responsible for clot formation and the mechanisms that inhibit the same beyond the injury site. Imbalance of the coagulation system may occur in the perioperative period or during critical illness, which may be secondary to numerous factors leading to a tendency of either thrombosis or bleeding. A systematic search of literature on PubMed with MeSH terms ‘coagulation system, haemostasis and anaesthesia revealed twenty eight related clinical trials and review articles in last 10 years. Since the balance of the coagulation system may tilt towards bleeding and thrombosis in many situations, it is mandatory for the clinicians to understand physiologic basis of haemostasis in order to diagnose and manage the abnormalities of the coagulation process and to interpret the diagnostic tests done for the same.
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Affiliation(s)
- Sanjeev Palta
- Department of Anaesthesiology and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Richa Saroa
- Department of Anaesthesiology and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Anshu Palta
- Department of Pathology, Government Medical College and Hospital, Chandigarh, India
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10
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Ryan ML, Van Haren RM, Thorson CM, Andrews DM, Perez EA, Neville HL, Sola JE, Proctor KG. Trauma induced hypercoagulablity in pediatric patients. J Pediatr Surg 2014; 49:1295-9. [PMID: 25092093 DOI: 10.1016/j.jpedsurg.2013.11.050] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 10/13/2013] [Accepted: 11/07/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Coagulation changes in pediatric trauma patients are not well defined. To fill this gap, we tested the hypothesis that trauma evokes a hypercoagulable response. METHODS A prospective observational study was conducted in hospitalized patients (age 8months to 14years) admitted for trauma or elective surgery. Informed consent was obtained from the parents and informed assent was obtained in patients 7years of age or older. Coagulation changes were evaluated on fresh whole blood using thromboelastography (TEG) and on stored plasma using assays for special clotting factors. RESULTS Forty three patients (22 trauma, median injury severity score =9; and 21 uninjured controls) were evaluated. For trauma vs control, prothrombin time (PT) was higher by about 10% (p<0.001), but activated partial thromboplastin time was not altered. TEG clotting time (R;p=0.005) and fibrin cross-linking were markedly accelerated (K time, alpha angle; p<0.001) relative to the control patients. d-Dimer, Prothrombin Fragment 1+2, and Plasminogen Activator Inhibitor-1 were all elevated, whereas Protein S activity was reduced (all p<0.01). Importantly, a large fraction of TEG values and clotting factor assays in the pediatric control group were outside the published reference ranges for adults. CONCLUSION A hypercoagulable state is associated with minor trauma in children. More work is needed to determine the functional significance of these changes and to establish normal pediatric reference ranges.
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Affiliation(s)
- Mark L Ryan
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Robert M Van Haren
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Chad M Thorson
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - David M Andrews
- Department of Pathology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Eduardo A Perez
- Dewitt-Daughtry Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Holly L Neville
- Dewitt-Daughtry Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Juan E Sola
- Dewitt-Daughtry Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Kenneth G Proctor
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care, University of Miami Miller School of Medicine, Miami, FL 33136, USA.
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11
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Increased MerTK expression in circulating innate immune cells of patients with septic shock. Intensive Care Med 2013; 39:1556-64. [PMID: 23835724 DOI: 10.1007/s00134-013-3006-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Accepted: 06/20/2013] [Indexed: 01/01/2023]
Abstract
PURPOSE A new pathway of three protein tyrosine kinase receptors, namely, the TAM receptor family [Tyro-3, Axl and Mer tyrosine kinase (MerTK)], has recently been described to negatively control immune responses. The objective of this prospective, observational, clinical study was to investigate the expression patterns of TAM receptors in circulating white blood cells collected from patients with septic shock. METHODS The expression of TAM receptors was measured by flow cytometry in circulating leukocytes from patients with septic shock sampled on days (D) 1-2 (n = 47) and D3-4 (n = 37) after the onset of shock, severe trauma patients at D1-2 after trauma (n = 51) and healthy individuals (n = 23). RESULTS On D1-2 after injury, MerTK was overexpressed in monocytes and neutrophils collected from patients with septic shock in comparison with those collected from healthy volunteers and trauma patients. This phenomenon was also observed for mRNA. Conversely, the expression of Tyro-3 and Axl was higher in monocytes from trauma patients versus healthy volunteers or those in septic shock. MerTK expression between D1-2 and D3-4 remained elevated in patients suffering from septic shock who died or developed an intensive care unit-acquired infection, whereas it decreased in patients who recovered uneventfully. This in vivo observed expression pattern was reproduced ex vivo after the incubation of healthy volunteer cells with plasma from septic shock or trauma patients. CONCLUSIONS MerTK expression in circulating innate immune cells is increased in patients with septic shock in comparison with healthy volunteers and trauma patients. Persistent MerTK overexpression after septic shock is associated with adverse outcome. The role of this family of receptors in the pathophysiology of injury-induced immune dysfunctions deserves to be specifically investigated.
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Ezihe-Ejiofor JA, Hutchinson N. Anticlotting mechanisms 1: physiology and pathology. ACTA ACUST UNITED AC 2013. [DOI: 10.1093/bjaceaccp/mks061] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Higuchi Y, Kubota T, Koyanagi M, Maeda T, Feldman AM, Makino N. Upregulation of anticoagulant proteins, protein S and tissue factor pathway inhibitor, in the mouse myocardium with cardio-specific TNF-α overexpression. Am J Physiol Heart Circ Physiol 2012; 302:H2352-62. [DOI: 10.1152/ajpheart.01026.2011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Heart failure (HF) has been recognized as a hypercoagulable state. However, the natural anticoagulation systems in the failing heart have not been studied. Recent experimental and clinical data have indicated that not only the thrombomodulin (TM)/protein C (PC) pathway but also the protein S (PS)/tissue factor pathway inhibitor (TFPI) system function as potent natural anticoagulants. To investigate the balance between procoagulant and anticoagulant activities in the failing heart, we measured the cardiac expression of tissue factor (TF), type 1 plasminogen activator inhibitor (PAI-1), TM, PC, PS, and TFPI by RT-PCR and/or Western blot analysis in male transgenic (TG) mice with heart-specific overexpression of TNF-α. Both procoagulant (TF and PAI-1) and anticoagulant (PS and TFPI) factors were upregulated in the myocardium of 24-wk-old TG (end-stage HF) but not in that of 4-wk-old TG (early decompensated HF) compared with the wild-type mice. Both factors were also upregulated in the infarcted myocardium at 3 days after coronary ligation in the wild-type mice. The expression of TM was downregulated in the TG heart, and PC was not detected in the hearts. The transcript levels of PS orphan receptors, Mer and Tyro3, but not Axl, were significantly upregulated in the TG heart. Double immunohistochemical staining revealed that myocardial infiltrating CD3-positive T cells may produce PS in the TG myocardium. In conclusion, the PS/TFPI was upregulated in the myocardium of a different etiological model of HF, thus suggesting a role for the PS/TFPI system in the protection of the failing heart under both inflammatory and hypercoagulable states.
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Affiliation(s)
- Yoshihiro Higuchi
- Department of Cardiovascular and Geriatric medicine, Kyushu University Beppu Hospital, Japan
| | - Toru Kubota
- Department of Cardiology, Fukuoka City Hospital, Fukuoka, Japan; and
| | - Masamichi Koyanagi
- Department of Cardiovascular and Geriatric medicine, Kyushu University Beppu Hospital, Japan
| | - Toyoki Maeda
- Department of Cardiovascular and Geriatric medicine, Kyushu University Beppu Hospital, Japan
| | | | - Naoki Makino
- Department of Cardiovascular and Geriatric medicine, Kyushu University Beppu Hospital, Japan
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Screening, Testing, or Personalized Medicine: Where do Inherited Thrombophilias Fit Best? Obstet Gynecol Clin North Am 2010; 37:87-107, Table of Contents. [DOI: 10.1016/j.ogc.2010.02.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Williams V, Griffiths ABM, Yap ZL, Martin J, Smith G, Couper R, Revesz T. Increased Thrombophilic Tendency in Pediatric Cystic Fibrosis Patients. Clin Appl Thromb Hemost 2009; 16:71-6. [DOI: 10.1177/1076029609334627] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Thrombophilia has recently been reported to be increased in patients with cystic fibrosis (CF). We wanted to determine whether this was applicable to our population with CF and how our patients compared to the previously reported groups. Seventy one pediatric CF patients were assessed for a thrombophilic tendency, using a lupus anticoagulant screen, protein C, protein S, antithrombin assay, and activated protein C resistance (APCR) screen. The incidence of activate protein C resistance (4.2%) was within expected limits for the general population as was the incidence of antithrombin deficiency. However there was a marked increase in the incidence of lupus anticoagulants (18%) and 14% and 19.7% of the patients showed a reduced protein C and protein S, respectively, far in excess of the general population. This increased incidence of thrombophilia was not related to any specific CF phenotype and while perturbed liver function cannot be entirely ruled out, it appeared unlikely to be responsible for all the abnormal coagulation findings. Despite the apparent thrombophilic tendency, no clinically evident thrombotic episodes were noted during the study period. Thrombophilia is of concern because of the increasingly frequent placement of indwelling catheters in CF patients. The precise cause for the thrombophilic tendency in CF patients is unknown at this stage.
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Affiliation(s)
- Vaughan Williams
- Department of Haematology, Women's and Children's Hospital, North Adelaide, South Australia,
| | - Adrian B. M. Griffiths
- Department of Haematology, Women's and Children's Hospital, North Adelaide, South Australia
| | - Zen L. Yap
- Department of Paediatrics, University of Adelaide, South Australia
| | - James Martin
- and Department of Pulmonary, Medicine Women's and Children's Hospital, North Adelaide, South Australia
| | - Gregory Smith
- and Department of Pulmonary, Medicine Women's and Children's Hospital, North Adelaide, South Australia
| | - Richard Couper
- Department of Paediatrics, University of Adelaide, South Australia
| | - Tamas Revesz
- Department of Haematology, Women's and Children's Hospital, North Adelaide, South Australia
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Abstract
BACKGROUND Bleeding is the most frequent cause of preventable death after severe injury. Coagulopathy associated with severe injury complicates the control of bleeding and is associated with increased morbidity and mortality in trauma patients. The causes and mechanisms are multiple and yet to be clearly defined. METHODS Articles addressing the causes and consequences of trauma-associated coagulopathy were identified and reviewed. Clinical situations in which the various mechanistic causes are important were sought along with quantitative estimates of their importance. RESULTS Coagulopathy associated with traumatic injury is the result of multiple independent but interacting mechanisms. Early coagulopathy is driven by shock and requires thrombin generation from tissue injury as an initiator. Initiation of coagulation occurs with activation of anticoagulant and fibrinolytic pathways. This Acute Coagulopathy of Trauma-Shock is altered by subsequent events and medical therapies, in particular acidemia, hypothermia, and dilution. There is significant interplay between all mechanisms. CONCLUSIONS There is limited understanding of the mechanisms by which tissue trauma, shock, and inflammation initiate trauma coagulopathy. Acute Coagulopathy of Trauma-Shock should be considered distinct from disseminated intravascular coagulation as described in other conditions. Rapid diagnosis and directed interventions are important areas for future research.
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The cost-benefit ratio of screening pregnant women for thrombophilia. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2007; 5:189-203. [PMID: 19204775 DOI: 10.2450/2007.0022-07] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Accepted: 06/07/2007] [Indexed: 11/21/2022]
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Brueckmann M, Huhle G, Max M. [Mechanisms of action of recombinant human activated Protein C]. Anaesthesist 2006; 55 Suppl 1:5-15. [PMID: 16520928 DOI: 10.1007/s00101-006-1001-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Human activated protein C (APC) is a serineprotease and one of the most important physiological inhibitors of the coagulation system. Apart from anticoagulative effects, profibrinolytic and anti-inflammatory modes of action have been reported for APC. The administration of recombinant human activated protein C (rhAPC), drotrecogin alfa (activated), Xigris, to patients with severe sepsis and sepsis-induced multi-organ failure reduced mortality in large clinical trials. Anti-apoptotic and immunomodulatory effects of rhAPC have been examined in in vitro experiments and in experimental animal studies. Moreover, a reduction of endothelial cell permeability, enhanced endothelial cell survival as well as improvements of microcirculatory disorders have been proposed for rhAPC. The manifold mechanisms of action of APC may give reasons for its application in diseases other than sepsis, which are characterized by endothelial and microcirculatory dysfunction, e.g. acute pulmonary or renal failure, ischemic stroke, ischemia-reperfusion injury and acute pancreatitis. A better understanding of the anti-inflammatory, anti-apoptotic and immunomodulatory modes of action of APC could be relevant for dosing and mode of application and may lead to a broadening of the indication field for rhAPC.
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Affiliation(s)
- M Brueckmann
- I Medizinische Klinik, Fakultät für Klinische Medizin, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim.
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Abstract
Immediate and early trauma deaths are determined by primary brain injuries, or significant blood loss (haemorrhagic shock), while late mortality is caused by secondary brain injuries and host defence failure. First hits (hypoxia, hypotension, organ and soft tissue injuries, fractures), as well as second hits (e.g. ischaemia/reperfusion injuries, compartment syndromes, operative interventions, infections), induce a host defence response. This is characterized by local and systemic release of pro-inflammatory cytokines, arachidonic acid metabolites, proteins of the contact phase and coagulation systems, complement factors and acute phase proteins, as well as hormonal mediators: it is defined as systemic inflammatory response syndrome (SIRS), according to clinical parameters. However, in parallel, anti-inflammatory mediators are produced (compensatory anti-inflammatory response syndrome (CARS). An imbalance of these dual immune responses seems to be responsible for organ dysfunction and increased susceptibility to infections. Endothelial cell damage, accumulation of leukocytes, disseminated intravascular coagulation (DIC) and microcirculatory disturbances lead finally to apoptosis and necrosis of parenchymal cells, with the development of multiple organ dysfunction syndrome (MODS), or multiple organ failure (MOF). Whereas most clinical trials with anti-inflammatory, anti-coagulant, or antioxidant strategies failed, the implementation of pre- and in-hospital trauma protocols and the principle of damage control procedures have reduced post-traumatic complications. However, the development of immunomonitoring will help in the selection of patients at risk of post-traumatic complications and, thereby, the choice of the most appropriate treatment protocols for severely injured patients.
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Affiliation(s)
- Marius Keel
- Division of Trauma Surgery, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland.
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Abstract
The anticoagulant protein C system regulates the activity of coagulation factors VIIIa and Va, cofactors in the activation of factor X and prothrombin, respectively. Protein C is activated on endothelium by the thrombin-thrombomodulin-EPCR (endothelial protein C receptor) complex. Activated protein C (APC)-mediated cleavages of factors VIIIa and Va occur on negatively charged phospholipid membranes and involve protein cofactors, protein S and factor V. APC also has anti-inflammatory and anti-apoptotic activities that involve binding of APC to EPCR and cleavage of PAR-1 (protease-activated receptor-1). Genetic defects affecting the protein C system are the most common risk factors of venous thrombosis. The protein C system contains multi-domain proteins, the molecular recognition of which will be reviewed.
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Affiliation(s)
- Björn Dahlbäck
- Department of Laboratory Medicine, Clinical Chemistry, Lund University, The Wallenberg laboratory, University Hospital, Malmö, SE-205 02 Malmö, Sweden.
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