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Infante JB, Esteves GV, Raposo J, de Lacerda JF. Disseminated intravascular coagulation score evolution in 48 h predicts early death in acute promyelocytic leukemia patients. Eur J Haematol 2024; 112:840-844. [PMID: 38305491 DOI: 10.1111/ejh.14177] [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: 10/21/2023] [Revised: 01/13/2024] [Accepted: 01/16/2024] [Indexed: 02/03/2024]
Abstract
INTRODUCTION Early death (ED) is the unsolved issue of acute promyelocytic leukemia (APL). The disseminated intravascular coagulation (DIC) score has been proposed as a marker of bleeding and death in APL; whether its temporal evolution predicts outcomes in APL is unknown. We evaluated whether an increasing score 48 h after diagnosis associates with ED. METHODS Retrospective, single-center study, including patients with newly diagnosed APL between 2000 and 2023, treated with all-transretinoic acid (ATRA) plus anthracycline or arsenic trioxide (ATO). "DIC score worsening" was defined as ≥1 point increase in the score after 48 h, and ED as death within 30 days of diagnosis. RESULTS Eighty-six patients were included, with median age of 46 years (17-82). ED patients (26.7%) more frequently had age >60 years and worsening DIC score after 48 h. These were also the only predictors of ED identified in both univariate and multivariate (OR 4.18, p = .011; OR 7.8, p = .005, respectively) logistic regression analysis. CONCLUSION This is the first study on DIC score evolution in APL-a worsening DIC score 48 h after diagnosis is a strong independent predictive factor of ED. We propose a reduction of the DIC score from diagnosis as a new treatment goal in APL care.
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Affiliation(s)
- Joana Brioso Infante
- Serviço de Hematologia e Transplantação de Medula, Centro Hospitalar Universitário Lisboa Norte-Hospital de Santa Maria, Lisboa, Portugal
- Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Lisboa, Portugal
| | - Graça Vasconcelos Esteves
- Serviço de Hematologia e Transplantação de Medula, Centro Hospitalar Universitário Lisboa Norte-Hospital de Santa Maria, Lisboa, Portugal
- Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - João Raposo
- Serviço de Hematologia e Transplantação de Medula, Centro Hospitalar Universitário Lisboa Norte-Hospital de Santa Maria, Lisboa, Portugal
| | - João Forjaz de Lacerda
- Serviço de Hematologia e Transplantação de Medula, Centro Hospitalar Universitário Lisboa Norte-Hospital de Santa Maria, Lisboa, Portugal
- Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Lisboa, Portugal
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Sun Y, Sun H, Feng J, Wang C, Zheng J, Ma X. IMMUNOSUPPRESSION CORRELATES WITH THE DETERIORATION OF SEPSIS-INDUCED DISSEMINATED INTRAVASCULAR COAGULATION. Shock 2024; 61:666-674. [PMID: 36735379 DOI: 10.1097/shk.0000000000002069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
ABSTRACT Background: The dysregulated host responses play a crucial role in the pathophysiology process of sepsis-induced disseminated intravascular coagulation (DIC). The study aimed to characterize the dynamic alternation of immune-related biomarkers and their relationship with the progression of DIC during sepsis. Methods: A prospective, observational study was conducted in a tertiary care academic hospital. Six hundred forty patients with sepsis were classified into three groups according to the International Society on Thrombosis and Hemostasis (ISTH) score: 383 involved patients without DIC (ISTH = 0), 168 sepsis with nonovert DIC (ISTH = 1-4), and 89 sepsis with overt DIC (ISTH ≥5). Eighteen immune-related biomarkers and six routine coagulation variables were examined at D1, D3, and D7 upon enrollment. The association between the immune parameters and the DIC deterioration was assessed during sepsis. Results: The study showed a 40% coagulation disorder and a 14% incidence of overt DIC in patients with sepsis. The patients with overt DIC displayed pronounced immune disorders from D1 to D7 upon sepsis, which was characterized by the decreased percentage of monocyte HLA-DR (mHLA-DR), increased percentage of regulatory T cells, the levels of procalcitonin, neutrophil CD64 index, and systemic inflammatory cytokines relative to nonovert DIC or non-DIC patients. In multivariate analysis, the combination of anti-inflammatory cytokine IL-10 and mHLA-DR at D1 upon enrollment had a superior predictive value for predicting DIC deterioration in sepsis (area under the curve = 0.87, P < 0.0001). Conclusion: These data illustrate that immunosuppression can crosstalk with coagulation disorder during sepsis and present an additional evaluation tool to predict DIC deterioration.
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Affiliation(s)
- Yini Sun
- Department of Critical Care Medicine, The First Affiliated Hospital of China Medical University, China Medical University, Shenyang, China
| | - Hao Sun
- Department of Clinical Epidemiology and Evidence-based Medicine, the First Affiliated Hospital of China Medical University, China Medical University, Shenyang, China
| | - Jianshuang Feng
- Department of Critical Care Medicine, The First Affiliated Hospital of China Medical University, China Medical University, Shenyang, China
| | - Chaoyang Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of China Medical University, China Medical University, Shenyang, China
| | - Jiayin Zheng
- Department of Critical Care Medicine, The First Affiliated Hospital of China Medical University, China Medical University, Shenyang, China
| | - Xiaochun Ma
- Department of Critical Care Medicine, The First Affiliated Hospital of China Medical University, China Medical University, Shenyang, China
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Bai H, Shen L, Zhang H, Tang N. Clinical value of TAT, PIC and t-PAIC as predictive markers for severe sepsis in pediatric patients. Front Pediatr 2024; 12:1336583. [PMID: 38562140 PMCID: PMC10982468 DOI: 10.3389/fped.2024.1336583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/26/2024] [Indexed: 04/04/2024] Open
Abstract
Objective Sepsis in pediatric patients can progress to severe sepsis, and identifying biomarkers of this progression may permit timely intervention to prevent it. This study aimed to investigate the ability of thrombin-antithrombin complex (TAT), α2-plasmininhibitor-plasmin complex (PIC) and tissue-type plasminogen activator-inhibitor complex (t-PAIC) to predict severe sepsis in pediatrics early. Methods 148 eligible pediatric sepsis patients were enrolled in this study, and were then divided into those who progressed to severe sepsis (n = 50) or not (n = 98). Serum levels of TAT, PIC, and t-PAIC were analysed, and simplified pediatric critical illness score (PCIS) and DIC score were calculated on the day of pediatric sepsis diagnosis. Results Compared with sepsis patients, severe sepsis patients had higher levels of TAT, PIC and t-PAIC. Correlation analysis revealed that TAT, PIC and t-PAIC were significantly correlated with simplified PCIS and DIC score. ROC curve analysis suggested that TAT, PIC and t-PAIC could serve as biomarkers for predicting severe sepsis with the AUC up to 0.862, 0.759 and 0.851, respectively. Stratified analysis demonstrated that the patients with increased levels of TAT, PIC and t-PAIC had worse illness severity and clinical outcome. Univariate logistic regression analysis revealed that TAT, PIC and t-PAIC were all risk factors for severe sepsis, yet only TAT and t-PAIC were independent risk factors in multivariate model. Conclusions TAT, PIC and t-PAIC could serve as biomarkers for predicting severe sepsis, and correlated with illness severity in pediatrics, what's more, serum levels of TAT and t-PAIC may be independent risk factors for pediatric severe sepsis.
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Affiliation(s)
- Huan Bai
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ling Shen
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hailong Zhang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Laboratory Medicine, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Ning Tang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Sun Y, Ding R, Sun H, Liang Y, Ma X. Efficacy and safety of heparin for sepsis-induced disseminated intravascular coagulation (HepSIC): study protocol for a multicenter randomized controlled trial. Trials 2024; 25:4. [PMID: 38167115 PMCID: PMC10759642 DOI: 10.1186/s13063-023-07853-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 12/06/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Disseminated intravascular coagulation (DIC) occurs in 30-50% of septic patients and contributes to high mortality in the intensive care unit (ICU). However, there are few proven interventions for coagulation disorder management in sepsis. Experimental and clinical data have demonstrated that sepsis could benefit from unfractionated heparin (UFH) treatment. To date, there are no large multicenter trials to determine the safety and efficacy of UFH in septic patients with suspected DIC. METHODS A multicenter, double-blinded, placebo-controlled randomized trial is designed to recruit 600 patients who met sepsis 3.0 criteria and suspected DIC. Participants will be randomized (1:1) to receive UFH or saline via continuous intravenous administration for 7 days within 6 h of enrolment. The primary outcome is ICU mortality. The secondary outcome includes 28-day all-cause mortality, the improvement of Sequential Organ Failure Assessment scores, and the incidence of major hemorrhage. Investigators, participants, and statisticians will be blinded to the allocation. DISCUSSION The HepSIC trial is to evaluate the efficacy and safety of UFH on sepsis-related DIC across different areas of China. The small dosage of UFH administration would offer a new potential approach for treating sepsis-related coagulation disorders. ETHICS AND DISSEMINATION Ethical approval was granted by all the ethics committees of 20 participant centers. Results will be disseminated via peer-reviewed publications and presented at conferences. TRIAL REGISTRATION ClinicalTrials.gov NCT02654561. Registered on 13 January 2016.
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Affiliation(s)
- Yini Sun
- Department of Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Renyu Ding
- Department of Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Hao Sun
- Department of Clinical Epidemiology and Evidence-based Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Yingjian Liang
- Department of Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Xiaochun Ma
- Department of Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China.
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Meng Y, Lin Y, Zhang JW, Zou WL, Liu YM, Shen XG, Shen QQ, Wang MM, Shao LN, Feng HY, Zhu Y, Yu JT, Lin B, Zhu B. Aspirin intervention before ICU admission reduced the mortality in critically ill patients with acute kidney injury: results from the MIMIC-IV. Front Pharmacol 2023; 14:1292745. [PMID: 38034989 PMCID: PMC10682711 DOI: 10.3389/fphar.2023.1292745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 10/31/2023] [Indexed: 12/02/2023] Open
Abstract
Background: Aspirin, with its pleiotropic effects such as anti-inflammatory and anti-platelet aggregation, has been widely used for anti-inflammatory, analgesic, and cardiovascular diseases. However, the association between the use of aspirin before the intensive care unit (ICU) and clinical outcomes in critically ill patients with acute kidney injury (AKI) is unknown. Methods: Patients with AKI in this retrospective observational study were selected from the Marketplace for Medical Information in Intensive Care IV (MIMIC-IV). The association between aspirin intervention and 30-day mortality was assessed using Cox proportional hazards model. Logistic regression models were used to assess the association of aspirin intervention with the risks of intracranial hemorrhage, gastrointestinal bleeding and blood transfusion. The propensity score matching (PSM) method was adopted to balance the baseline variables. Sensitivity analysis was performed to validate the results by multiple interpolations for the missing data. Results: The study included 4237 pre-ICU aspirin users and 9745 non-users. In multivariate models, we found a decreased risk of mortality in those who received aspirin before ICU compared to those who did not (30-day:hazard ratio [HR], 0.70; 95% CI, 0.62-0.79; p < 0.001; 90-day:HR, 0.70; 95% CI, 0.63-0.77, p < 0.001; 180-day:HR, 0.72; 95%CI,0.65-0.79, p < 0.001). This benefit was consistent in the post-PSM analyses, sensitivity analyses, and subgroup analyses. Moreover, aspirin intervention was associated with a reduced risk of intracranial hemorrhage and gastrointestinal bleeding (HR, 0.16; 95% CI, 0.10-0.25; p < 0.001; HR, 0.59; 95% CI, 0.38-0.88, p = 0.012) after being adjusted by relating covariates, whereas with a increased risk of blood transfusion (HR, 1.28; 95% CI, 1.16-1.46; p < 0.001). Conclusion: Patients with AKI treated with aspirin before ICU admission might have reduced 30-day, 90-day and 180-day mortality without increasing the risk of intracranial hemorrhage (ICH) or gastrointestinal bleeding, but may increase the risk of transfusion.
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Affiliation(s)
- Yao Meng
- Urology and Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
- Hangzhou Hospital of Traditional Chinese Medicine, Affiliated to Zhejiang Chinese Medical University, Hangzhou, China
| | - Yi Lin
- Hangzhou Hospital of Traditional Chinese Medicine, Affiliated to Zhejiang Chinese Medical University, Hangzhou, China
| | - Jia-Wei Zhang
- Urology and Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Wen-Li Zou
- Urology and Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Yue-Ming Liu
- Urology and Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Xiao-Gang Shen
- Urology and Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Quan-Quan Shen
- Urology and Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Min-Min Wang
- Urology and Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Li-Na Shao
- Urology and Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Hong-Yuan Feng
- Hangzhou Hospital of Traditional Chinese Medicine, Affiliated to Zhejiang Chinese Medical University, Hangzhou, China
| | - Yan Zhu
- Hangzhou Hospital of Traditional Chinese Medicine, Affiliated to Zhejiang Chinese Medical University, Hangzhou, China
| | - Jing-Ting Yu
- Hangzhou Hospital of Traditional Chinese Medicine, Affiliated to Zhejiang Chinese Medical University, Hangzhou, China
| | - Bo Lin
- Urology and Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Bin Zhu
- Urology and Nephrology Center, Department of Nephrology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
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Yuan ZN, Xue YJ, Wang HJ, Qu SN, Huang CL, Wang H, Zhang H, Xing XZ. A nomogram for predicting hospital mortality of critical ill patients with sepsis and cancer: a retrospective cohort study based on MIMIC-IV and eICU-CRD. BMJ Open 2023; 13:e072112. [PMID: 37696627 PMCID: PMC10496690 DOI: 10.1136/bmjopen-2023-072112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 08/23/2023] [Indexed: 09/13/2023] Open
Abstract
OBJECTIVE Sepsis remains a high cause of death, particularly in immunocompromised patients with cancer. The study was to develop a model to predict hospital mortality of septic patients with cancer in intensive care unit (ICU). DESIGN Retrospective observational study. SETTING Medical Information Mart for Intensive Care IV (MIMIC IV) and eICU Collaborative Research Database (eICU-CRD). PARTICIPANTS A total of 3796 patients in MIMIC IV and 549 patients in eICU-CRD were included. PRIMARY OUTCOME MEASURES The model was developed based on MIMIC IV. The internal validation and external validation were based on MIMIC IV and eICU-CRD, respectively. Candidate factors were processed with the least absolute shrinkage and selection operator regression and cross-validation. Hospital mortality was predicted by the multivariable logistical regression and visualised by the nomogram. The model was assessed by the area under the curve (AUC), calibration curve and decision curve analysis curve. RESULTS The model exhibited favourable discrimination (AUC: 0.726 (95% CI: 0.709 to 0.744) and 0.756 (95% CI: 0.712 to 0.801)) in the internal and external validation sets, respectively, and better calibration capacity than Acute Physiology and Chronic Health Evaluation IV in external validation. CONCLUSIONS Despite that the predicted model was based on a retrospective study, it may also be helpful to predict the hospital morality of patients with solid cancer and sepsis.
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Affiliation(s)
- Zhen-Nan Yuan
- Department of Intensive Care Unit, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 100021, Beijing, China
| | - Yu-Juan Xue
- Department of pediatrics, Peking University People's Hospital, Beijing, China
| | - Hai-Jun Wang
- Department of Intensive Care Unit, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 100021, Beijing, China
| | - Shi-Ning Qu
- Department of Intensive Care Unit, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 100021, Beijing, China
| | - Chu-Lin Huang
- Department of Intensive Care Unit, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 100021, Beijing, China
| | - Hao Wang
- Department of Intensive Care Unit, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 100021, Beijing, China
| | - Hao Zhang
- Department of Intensive Care Unit, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 100021, Beijing, China
| | - Xue-Zhong Xing
- Department of Intensive Care Unit, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 100021, Beijing, China
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Musgrave KM, Scott J, Sendama W, Gardner AI, Dewar F, Lake CJ, Spronk HMH, van Oerle R, Visser M, Ten Cate H, Kesteven P, Fuller A, McDonald D, Knill C, Hulme G, Filby A, Wright SE, Roy AI, Ruchaud-Sparagano MH, Simpson AJ, Rostron AJ. Tissue factor expression in monocyte subsets during human immunothrombosis, endotoxemia and sepsis. Thromb Res 2023; 228:10-20. [PMID: 37263122 DOI: 10.1016/j.thromres.2023.05.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 05/15/2023] [Accepted: 05/17/2023] [Indexed: 06/03/2023]
Abstract
INTRODUCTION Tissue factor expression on monocytes is implicated in the pathophysiology of sepsis-induced coagulopathy. How tissue factor is expressed by monocyte subsets (classical, intermediate and non-classical) is unknown. METHODS Monocytic tissue factor surface expression was investigated during three conditions. Primary human monocytes and microvascular endothelial cell co-cultures were used for in vitro studies. Volunteers received a bolus of lipopolysaccharide (2 ng/kg) to induce endotoxemia. Patients with sepsis, or controls with critical illness unrelated to sepsis, were recruited from four intensive care units. RESULTS Contact with endothelium and stimulation with lipopolysaccharide reduced the proportion of intermediate monocytes. Lipopolysaccharide increased tissue factor surface expression on classical and non-classical monocytes. Endotoxemia induced profound, transient monocytopenia, along with activation of coagulation pathways. In the remaining circulating monocytes, tissue factor was up-regulated in intermediate monocytes, though approximately 60 % of individuals (responders) up-regulated tissue factor across all monocyte subsets. In critically ill patients, tissue factor expression on intermediate and non-classical monocytes was significantly higher in patients with established sepsis than among non-septic patients. Upon recovery of sepsis, expression of tissue factor increased significantly in classical monocytes. CONCLUSION Tissue factor expression in monocyte subsets varies significantly during health, endotoxemia and sepsis.
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Affiliation(s)
- Kathryn M Musgrave
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; Department of Haematology, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jonathan Scott
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Wezi Sendama
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; Department of Respiratory Medicine, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Aaron I Gardner
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Fiona Dewar
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Cameron J Lake
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Henri M H Spronk
- Thrombosis Expertise Center and Carim School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Rene van Oerle
- Thrombosis Expertise Center and Carim School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Mayken Visser
- Thrombosis Expertise Center and Carim School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Hugo Ten Cate
- Thrombosis Expertise Center and Carim School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Patrick Kesteven
- Department of Haematology, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Andrew Fuller
- Flow Cytometry Core Facility, Newcastle University, Newcastle upon Tyne, UK
| | - David McDonald
- Flow Cytometry Core Facility, Newcastle University, Newcastle upon Tyne, UK
| | - Carly Knill
- Flow Cytometry Core Facility, Newcastle University, Newcastle upon Tyne, UK
| | - Gillian Hulme
- Flow Cytometry Core Facility, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew Filby
- Flow Cytometry Core Facility, Newcastle University, Newcastle upon Tyne, UK
| | - Stephen E Wright
- Intensive Care Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Alistair I Roy
- Sunderland Integrated Critical Care Unit, Sunderland Royal Hospital, South Tyneside and Sunderland NHS Foundation Trust, UK
| | | | - A John Simpson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; Department of Respiratory Medicine, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Anthony J Rostron
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; Sunderland Integrated Critical Care Unit, Sunderland Royal Hospital, South Tyneside and Sunderland NHS Foundation Trust, UK.
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Zhang Z, Yan T, Ren D, Zhou J, Liu L, Li J, Fu S, Ni T, Xu W, Yang Y, Chen T, He Y, Zhao Y, Liu J. Low-molecular-weight heparin therapy reduces 28-day mortality in patients with sepsis-3 by improving inflammation and coagulopathy. Front Med (Lausanne) 2023; 10:1157775. [PMID: 37359014 PMCID: PMC10289000 DOI: 10.3389/fmed.2023.1157775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 05/02/2023] [Indexed: 06/28/2023] Open
Abstract
Background and aim Sepsis is a syndromic response to infection and is associated with high mortality, thus imposing a significant global burden of disease. Although low-molecular-weight heparin (LMWH) has been recommended to prevent venous thromboembolism, its anticoagulant and anti-inflammatory effects in sepsis remain controversial. Owing to the modification of the Sepsis-3 definition and diagnostic criteria, further evaluation of the efficacy and benefit population of LMWH is required. Methods We performed a retrospective cohort study to assess whether LMWH improved the inflammation, coagulopathy, and clinical outcomes against Sepsis-3 and to identify the target patients. All patients diagnosed with sepsis at the First Affiliated Hospital of Xi'an Jiaotong University (the largest general hospital in northwest China) from January 2016 to December 2020 were recruited and re-evaluated using Sepsis-3 criteria. Results After 1:1 propensity score matching, 88 pairs of patients were categorized into the treatment and control groups based on subcutaneous LMWH administration. Compared with the control group, a significantly lower 28-day mortality was observed in the LMWH group (26.1 vs. 42.0%, p = 0.026) with a comparable incidence of major bleeding events (6.8 vs. 8.0%, p = 0.773). Cox regression analysis showed that LMWH administration was the independent protective factor for septic patients (aHR, 0.48; 95% CI, 0.29-0.81; p = 0.006). Correspondingly, the LMWH treatment group showed a significant improvement in inflammation and coagulopathy. Further subgroup analysis showed that LMWH therapy was associated with favorable outcomes in patients younger than 60 years and diagnosed with sepsis-induced coagulopathy (SIC), ISTH overt DIC, non-septic shock, or non-diabetics and in patients included in the moderate-risk group (APACHE II score 20-35 or SOFA score 8-12). Conclusion Our study results showed that LMWH improves 28-day mortality by improving inflammatory response and coagulopathy in patients meeting Sepsis-3 criteria. The SIC and ISTH overt DIC scoring systems can better identify septic patients who are likely to benefit more from LMWH administration.
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Affiliation(s)
- Ze Zhang
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Taotao Yan
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Danfeng Ren
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Jingwen Zhou
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Liangru Liu
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Juan Li
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Shan Fu
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Tianzhi Ni
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Weicheng Xu
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Yuan Yang
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Institution of Hepatology, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Tianyan Chen
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Institution of Hepatology, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Yingli He
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Institution of Hepatology, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Yingren Zhao
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
- Institution of Hepatology, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Jinfeng Liu
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
- Institution of Hepatology, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
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Nguyen D, Kantarjian HM, Short NJ, Qiao W, Ning J, Cuglievan B, Daver NG, DiNardo CD, Jabbour EJ, Kadia TM, Borthakur G, Garcia-Manero G, Konopleva MY, Andreeff M, Ravandi-Kashani F, Sasaki K, Issa GC. Early mortality in acute myeloid leukemia with KMT2A rearrangement is associated with high risk of bleeding and disseminated intravascular coagulation. Cancer 2023; 129:1856-1865. [PMID: 36892949 DOI: 10.1002/cncr.34728] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 09/25/2022] [Accepted: 10/26/2022] [Indexed: 03/10/2023]
Abstract
BACKGROUND Acute myeloid leukemia (AML) with rearrangement of lysine methyltransferase 2a gene (KMT2Ar) is characterized by chemotherapy resistance and high rates of relapse. However, additional causes of treatment failure or early mortality have not been well-defined in this entity. METHODS In a retrospective analysis, causes and rates of early mortality following induction treatment were compared between a cohort of adults with KMT2Ar AML (N = 172) and an age-matched cohort of patients with normal karyotype AML (N = 522). RESULTS The 60-day mortality in patients with KMT2Ar AML was 15% compared with 7% with normal karyotype (p = .04). We found a significantly higher occurrence of major bleeding events (p = .005) and total bleeding events (p = .001) in KMT2Ar AML compared with diploid AML. Among evaluable patients with KMT2Ar AML, 93% exhibited overt disseminated intravascular coagulopathy compared with 54% of patients with a normal karyotype before death (p = .03). In a multivariate analysis, KMT2Ar and a monocytic phenotypic were the only independent predictors of any bleeding event in patients who died within 60 days (odds ratio, 3.5; 95% CI, 1.4-10.4; p = .03; odds ratio, 3.2; 95% CI, 1-1-9.4; p = .04, respectively). CONCLUSION In conclusion, early recognition and aggressive management of disseminated intravascular coagulopathy and coagulopathy are important considerations that could mitigate the risk of death during induction treatment in KMT2Ar AML. PLAIN LANGUAGE SUMMARY Acute myeloid leukemia (AML) with rearrangement of KMT2A is characterized by chemotherapy resistance and high rates of relapse. However, additional causes of treatment failure or early mortality have not been well-defined in this entity. In this article, that KMT2A-rearranged AML is demonstrably associated with higher early mortality and an increased risk of bleeding and coagulopathy, specifically, disseminated intravascular coagulation, compared with normal karyotype AML. These findings emphasize the importance of monitoring and mitigating coagulopathy in KMT2A-rearranged leukemia similar to what is done in acute promyelocytic leukemia.
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Affiliation(s)
- Daniel Nguyen
- Department of Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA.,Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Wei Qiao
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jing Ning
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Branko Cuglievan
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naval G Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Elias J Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Guillermo Garcia-Manero
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Marina Y Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Andreeff
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Farhad Ravandi-Kashani
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ghayas C Issa
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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10
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Umemura Y, Nishida T, Yamakawa K, Ogura H, Oda J, Fujimi S. Anticoagulant therapies against sepsis-induced disseminated intravascular coagulation. Acute Med Surg 2023; 10:e884. [PMID: 37670904 PMCID: PMC10475981 DOI: 10.1002/ams2.884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/20/2023] [Accepted: 07/31/2023] [Indexed: 09/07/2023] Open
Abstract
Disseminated intravascular coagulation (DIC) is a frequent but lethal complication in sepsis. Anticoagulant therapies, such as heparin, antithrombin, activated protein C, and recombinant human-soluble thrombomodulin, were expected to regulate the progression of coagulopathy in sepsis. Although a number of randomized controlled trials (RCTs) have evaluated the survival effects of these therapies over the past few decades, there remains no consistent evidence showing a significant survival benefit of anticoagulant therapies. Currently, anticoagulant therapies are not conducted as a standard treatment against sepsis in many countries and regions. However, most of these RCTs were performed overall in patients with sepsis but not in those with sepsis-induced DIC, who were theoretically the optimal target population of anticoagulants. Actually, multiple lines of evidence from observational studies and meta-analyses of the RCTs have suggested that anticoagulant therapies might reduce mortality only when used in septic DIC. In addition, the severity of illness is another essential factor that maximally affects the efficacy of the therapy. Therefore, to provide evidence on the true effect of anticoagulant therapies, the next RCTs must be designed to enroll only patients with sepsis-induced overt DIC and a high severity of illness. To prepare these future RCTs, a novel scientific infrastructure for accurate detection of patients who can receive maximal benefit from anticoagulant therapies also needs to be established.
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Affiliation(s)
- Yutaka Umemura
- Division of Trauma and Surgical Critical CareOsaka General Medical CenterOsakaJapan
- Department of Traumatology and Acute Critical MedicineOsaka University Graduate School of MedicineOsakaJapan
| | - Takeshi Nishida
- Division of Trauma and Surgical Critical CareOsaka General Medical CenterOsakaJapan
- Department of Traumatology and Acute Critical MedicineOsaka University Graduate School of MedicineOsakaJapan
| | - Kazuma Yamakawa
- Department of Emergency MedicineOsaka Medical and Pharmaceutical UniversityTakatsuki, OsakaJapan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical MedicineOsaka University Graduate School of MedicineOsakaJapan
| | - Jun Oda
- Department of Traumatology and Acute Critical MedicineOsaka University Graduate School of MedicineOsakaJapan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical CareOsaka General Medical CenterOsakaJapan
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11
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Zarei E, Tarighat-Esfanjani A, Mahmoodpoor A, Karimi A. The Effect of Nanocurcumin Supplementation on Protein C, Partial Thromboplastin Time, Transforming Growth Factor-β1, and Simplified Acute Physiology Score II in Patients With Systemic Inflammatory Response Syndrome: A Randomized Clinical Trial. Nat Prod Commun 2022. [DOI: 10.1177/1934578x221112818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Systemic inflammatory response syndrome (SIRS) is a general inflammation that involves many patients’ organs in intensive care units and significantly affects the risk of morbidity and mortality. This study aimed to investigate the effect of nanocurcumin on protein C, partial thromboplastin time (PTT), transforming growth factor-β1 (TGF-β1), and simplified acute physiology score II (SAPS II) in patients with SIRS. In this randomized, clinical trial, 40 SIRS-positive patients were randomly assigned to the intervention group who received 160 mg/day of nanocurcumin and the control group that received routine treatment for 10 days. Before, the 5th and 10th days of the study, the SAPS II questionnaire was completed, and protein C, PTT, and TGF-β1 levels were measured. At the end of the study, the PTT levels in the intervention and control groups increased and decreased, respectively. However, the significant increase of protein C levels was shown only in the intervention group. SAPS II scores were also decreased significantly only in the intervention group. There was no significant difference in serum levels of TGF-β1 in both groups. According to the results of this study, supplementation with nanocurcumin can decrease the SAPS II and improve the coagulation status in patients with SIRS.
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Affiliation(s)
- Elham Zarei
- Student Research Committee, Faculty of Nutrition and Food Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ali Tarighat-Esfanjani
- Nutrition Research Center, Faculty of Nutrition and Food Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ata Mahmoodpoor
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Arash Karimi
- Student Research Committee, Faculty of Nutrition and Food Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
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12
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Iba T, Levi M, Thachil J, Levy JH. Disseminated Intravascular Coagulation: The Past, Present, and Future Considerations. Semin Thromb Hemost 2022; 48:978-987. [PMID: 36100234 DOI: 10.1055/s-0042-1756300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Disseminated intravascular coagulation (DIC) has been understood as a consumptive coagulopathy. However, impaired hemostasis is a component of DIC that occurs in a progressive manner. The critical concept of DIC is systemic activation of coagulation with vascular endothelial damage. DIC is the dynamic coagulation/fibrinolysis disorder that can proceed from compensated to decompensated phases, and is not simply impaired hemostasis, a misunderstanding that continues to evoke confusion among clinicians. DIC is a critical step of disease progression that is important to monitor over time. Impaired microcirculation and subsequent organ failure due to pathologic microthrombi formation are the pathophysiologies in sepsis-associated DIC. Impaired hemostasis due to coagulation factor depletion from hemodilution, shock, and hyperfibrinolysis occurs in trauma-associated DIC. Overt-DIC diagnostic criteria have been used clinically for more than 20 years but may not be adequate to detect the compensated phase of DIC, and due to different underlying causes, there is no "one-size-fits-all criteria." Individualized criteria for heterogeneous conditions continue to be proposed to facilitate the diagnosis. We believe that future research will provide therapeutics using new diagnostic criteria. Finally, DIC is also classified as either acute or chronic, and acute DIC results from progressive coagulation activation over a short time and requires urgent management. In this review, we examine the advances in research for DIC.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Marcel Levi
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands.,Department of Medicine, Cardiometabolic Programme-NIHR UCLH/UCL BRC, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina
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13
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El Sehmawy AA, Hassan DA, Elamir RY, Eldesoky NAR, Al Anany MGED, El-Fattah DAA, El Attar S, Abdelbadea A. Assessment of coagulation markers, serum zinc and copper in children with beta-thalassemia major in Egypt. J Trop Pediatr 2022; 68:6709338. [PMID: 36130309 DOI: 10.1093/tropej/fmac079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Thalassemia is one of the commonest single gene disorders usually associated with many complications. Coagulation changes as well as trace elements levels alterations have been described in children with β thalassemia. Activation of coagulation can be assessed by measuring thrombin-antithrombin (TAT) complex, plasmin-antiplasmin (PAP) complex and β-thromboglobulin (β-TG). METHODS A total of 200 children and adolescents were enrolled in the study; 100 were from the Al-Azhar University hospital's pediatric hematology clinic diagnosed as thalassemia major, while the other 100 were apparently healthy volunteers who acted as the control group. Complete blood count, liver function test, kidney function tests, TAT complex, PAP complex, β-TG as indicators of coagulation changes, serum zinc and copper were performed on all participants. RESULTS Significantly higher levels of TAT complex, PAP complex and β-TG in thalassemia children than the controls. Decreased serum zinc and increased serum copper levels in thalassemia children compared to the controls. A negative correlation was observed between the serum level of TAT and hemoglobin level, besides the negative correlation of TAT complex and β-TG with the serum zinc. CONCLUSION Thalassemia major was associated with increased serum level of coagulation activation markers, increased serum copper while decreased serum zinc.
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Affiliation(s)
- Asmaa A El Sehmawy
- Pediatrics Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Donia Ahmed Hassan
- Clinical Pathology Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Reham Yousri Elamir
- Public Health and Community Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | | | | | - Shahinaz El Attar
- Biochemistry Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Alzahra Abdelbadea
- Biochemistry Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
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14
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Alcamo AM, Weiss SL, Fitzgerald JC, Kirschen MP, Loftis LL, Tang SF, Thomas NJ, Nadkarni VM, Nett ST. Outcomes Associated With Timing of Neurologic Dysfunction Onset Relative to Pediatric Sepsis Recognition. Pediatr Crit Care Med 2022; 23:593-605. [PMID: 36165937 PMCID: PMC9524404 DOI: 10.1097/pcc.0000000000002979] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
OBJECTIVES To compare outcomes associated with timing-early versus late-of any neurologic dysfunction during pediatric sepsis. DESIGN Secondary analysis of a cross-sectional point prevalence study. SETTING A total of 128 PICUs in 26 countries. PATIENTS Less than 18 years with severe sepsis on 5 separate days (2013-2014). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients were categorized as having either no neurologic dysfunction or neurologic dysfunction (i.e., present at or after sepsis recognition), which was defined as Glasgow Coma Scale score less than 5 and/or fixed dilated pupils. Our primary outcome was death or new moderate disability (i.e., Pediatric Overall [or Cerebral] Performance Category score ≥3 and change ≥1 from baseline) at hospital discharge, and 87 of 567 severe sepsis patients (15%) had neurologic dysfunction within 7 days of sepsis recognition (61 at sepsis recognition and 26 after sepsis recognition). Primary site of infection varied based on presence of neurologic dysfunction. Death or new moderate disability occurred in 161 of 480 (34%) without neurologic dysfunction, 45 of 61 (74%) with neurologic dysfunction at sepsis recognition, and 21 of 26 (81%) with neurologic dysfunction after sepsis recognition (p < 0.001 across all groups). On multivariable analysis, in comparison with those without neurologic dysfunction, neurologic dysfunction whether at sepsis recognition or after was associated with increased odds of death or new moderate disability (adjusted odds ratio, 4.9 [95% CI, 2.3-10.1] and 10.7 [95% CI, 3.8-30.5], respectively). We failed to identify a difference between these adjusted odds ratios of death or new moderate disability that would indicate a differential risk of outcome based on timing of neurologic dysfunction (p = 0.20). CONCLUSIONS In this severe sepsis international cohort, the presence of neurologic dysfunction during sepsis is associated with worse outcomes at hospital discharge. The impact of early versus late onset of neurologic dysfunction in sepsis on outcome remains unknown, and further work is needed to better understand timing of neurologic dysfunction onset in pediatric sepsis.
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Affiliation(s)
- Alicia M. Alcamo
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Scott L. Weiss
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Julie C. Fitzgerald
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Matthew P. Kirschen
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Laura L. Loftis
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Swee Fong Tang
- Pediatric Intensive Care Unit, Specialist Children’s Hospital, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Neal J. Thomas
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Pediatric Critical Care Medicine, Penn State Hershey Children’s Hospital, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Vinay M. Nadkarni
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sholeen T. Nett
- Department of Pediatric Critical Care Medicine, Children’s Hospital at Dartmouth, Lebanon, New Hampshire, USA
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15
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Li J, Zhou J, Ren H, Teng T, Li B, Wang Y, Xiang L. Clinical Efficacy of Soluble Thrombomodulin, Tissue Plasminogen Activator Inhibitor complex, Thrombin-Antithrombin complex,α2-Plasmininhibitor-Plasmin complex in Pediatric Sepsis. Clin Appl Thromb Hemost 2022; 28:10760296221102929. [PMID: 35603624 PMCID: PMC9134456 DOI: 10.1177/10760296221102929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To investigated the clinical efficacy of Soluble thrombomodulin (sTM), tissue
plasminogen activator inhibitor complex (t-PAI·C),thrombin-antithrombin
complex (TAT),α2-plasmininhibitor-plasmin complex (PIC) in pediatric sepsis
and pediatrics sepsis-induced coagulopathy (pSIC). Methods We prospectively collected patient data with sepsis diagnosed in the PICU of
Shanghai Children's Medical Center from June 2019 to June 2021. sTM,t-PAI·C,
TAT,PIC and classical coagulation laboratory tests (CCTs) were evaluated on
the day of sepsis diagnosis. Results Fifty-nine children were enrolled, There were significant differences in
t-PAI·C (P = 0.001), Plt (P < 0.001), PT (P < 0.001), INR (P <
0.001), aPTT (P < 0.001), and TT (P = 0.048) between the pSIC and
non-pSIC groups, logistic regression analysis showed that Plt (P = 0.032)
was an independent risk factor for pSIC. Logistic regression analysis showed
that sTM (P = 0.007) and Plt (P = 0.016) were independent risk factors for
the outcome in pediatrics sepsis following discharge. The AUC of sTM
combined with Plt on the mortality outcome of children with sepsis at
discharge was 0.889 (95%CI: 0.781,0.956). which was better than that for
PRISM III (AUC, 0.723), pSOFA (AUC, 0.764), and blood Lac (AUC, 0.717) when
sepsis was diagnosed in the PICU. Conclusions The t-PAI·C increased in children with pSIC. The prediction of sepsis outcome
using sTM combined with Plt was better than with PRISM III, pSOFA, or
Lac.Further research is still needed in the future to explore the clinical
value of sTM, TAT, PIC, and t-PAI·C in diagnosis and outcome of pediatrics
sepsis and pSIC.
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Affiliation(s)
- Juanzhen Li
- Department of Critical Care Medicine, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jingyi Zhou
- Ren Ji Hostipal, Shanghai Jiao Tong University School of Medicine, Shanghai,China
| | - Hong Ren
- Department of Critical Care Medicine, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Teng Teng
- Department of Critical Care Medicine, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Biru Li
- Department of Critical Care Medicine, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ying Wang
- Department of Critical Care Medicine, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Long Xiang
- Department of Critical Care Medicine, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Department of Neonatal, Second People’s Hospital of Kashgar, Xinjiang Uygur Autonomous Region, China
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16
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Al-Biltagi M, Hantash EM, El-Shanshory MR, Badr EA, Zahra M, Anwar MH. Plasma D-dimer level in early and late-onset neonatal sepsis. World J Crit Care Med 2022; 11:139-148. [PMID: 36331988 PMCID: PMC9136721 DOI: 10.5492/wjccm.v11.i3.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 03/09/2022] [Accepted: 04/21/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Neonatal sepsis is a life-threatening disease. Early diagnosis is essential, but no single marker of infection has been identified. Sepsis activates a coagulation cascade with simultaneous production of the D-dimers due to lysis of fibrin. D-dimer test reflects the activation of the coagulation system.
AIM To assess the D-dimer plasma level, elaborating its clinicopathological value in neonates with early-onset and late-onset neonatal sepsis.
METHODS The study was a prospective cross-sectional study that included ninety neonates; divided into three groups: Group I: Early-onset sepsis (EOS); Group II: Late-onset sepsis (LOS); and Group III: Control group. We diagnosed neonatal sepsis according to our protocol. C-reactive protein (CRP) and D-dimer assays were compared between EOS and LOS and correlated to the causative microbiological agents.
RESULTS D-dimer was significantly higher in septic groups with a considerably higher number of cases with positive D-dimer. Neonates with LOS had substantially higher levels of D-dimer than EOS, with no significant differences in CRP. Neonates with LOS had a significantly longer hospitalization duration and higher gram-negative bacteriemia and mortality rates than EOS (P < 0.01). Gram-negative bacteria have the highest D-dimer levels (Acinetobacter, Klebsiella, and Pseudomonas) and CRP (Serratia, Klebsiella, and Pseudomonas); while gram-positive sepsis was associated with relatively lower levels. D-dimer had a significant negative correlation with hemoglobin level and platelet count; and a significant positive correlation with CRP, hospitalization duration, and mortality rates. The best-suggested cut-off point for D-dimer in neonatal sepsis was 0.75 mg/L, giving a sensitivity of 72.7% and specificity of 86.7%. The D-dimer assay has specificity and sensitivity comparable to CRP in the current study.
CONCLUSION The current study revealed a significant diagnostic value for D-dimer in neonatal sepsis. D-dimer can be used as an adjunct to other sepsis markers to increase the sensitivity and specificity of diagnosing neonatal sepsis.
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Affiliation(s)
- Mohammed Al-Biltagi
- Department of Pediatrics, Faculty of Medicine, Tanta University, Tanta 31511, Algharbia, Egypt
- Department of Pediatrics, University Medical Center, Arabian Gulf University, Manama 26671, Manama, Bahrain
- Department of Pediatrics, University Medical Center, Bahrain, Dr. Sulaiman Al Habib Medical Group, KSA, Manama 26671, Manama, Bahrain
| | - Ehab M Hantash
- Department of Anatomy, Faculty of Medicine, Tanta University, Tanta 31511, Alghrabia, Egypt
- Neonatology Unit, Department of Pediatrics, Dr. Sulaiman Al Habib Medical Group, Riyadh 11636, Riyadh, Saudi Arabia
| | | | - Enayat Aly Badr
- Department of Clinical Pathology, Faculty of Medicine, Tanta University, Tanta 31511, Alghrabia, Egypt
| | - Mohamed Zahra
- Department of Clinical Pathology, Faculty of Medicine, Tanta University, Tanta 31511, Alghrabia, Egypt
| | - Manar Hany Anwar
- Department of Clinical Pathology, Ministry of Health, Egypt, Tanta 31511, Alghrabia, Egypt
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17
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Guo X, Guo D. A Nomogram Based on Comorbidities and Infection Location to Predict 30 Days Mortality of Immunocompromised Patients in ICU: A Retrospective Cohort Study. Int J Gen Med 2022; 14:10281-10292. [PMID: 34992443 PMCID: PMC8713880 DOI: 10.2147/ijgm.s345632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/08/2021] [Indexed: 11/30/2022] Open
Abstract
Background The existing comorbidity indexes, like Charlson Comorbidity Index (CCI) and the Elixhauser Comorbidity Index (ECI), do not take infection factors into account for critically ill patients with immunocompromise, bringing about a decrease of prediction accuracy. Therefore, we attempted to incorporate infection location into the analysis to construct a rapid comorbidity scoring system independent of laboratory tests. Methods Data were extracted from the Multiparameter Intelligent Monitoring in Intensive Care III database. A total of 3904 critically ill patients with immunocompromise admitted to ICU were enrolled and assigned into training or validation sets according to the date of ICU admission. The predictive nomogram was constructed in the training set based on logistic regression analysis and then undergone validation in the validation set in comparison with SOFA, CCI and ECI. Results Factors eligible for the nomogram included patient’s age, gender, ethnicity, underlying disease of immunocompromise like metastatic cancer and leukemia, possible infection on admission including pulmonary infection, urinary tract infection and blood infection, and one comorbidity, coagulopathy. The nomogram we developed exhibited better discrimination than SOFA, CCI and ECI with an area under the receiver operating characteristic curve (AUC) of 0.739 (95% CI 0.707–0.771) and 0.746 (95% CI 0.713–0.779) in the training and validation sets, respectively. Combining the nomogram and SOFA could bring a new prediction model with a superior predictive effect in both sets (training set AUC = 0.803 95% CI 0.777–0.828, validation set AUC = 0.818 95% CI 0.783–0.854). The calibration curve exhibited coherence between the nomogram and ideal observation for two cohorts (p>0.05). Decision curve analysis revealed the clinical usefulness of the nomogram in both sets. Conclusion We established a nomogram that could provide an accurate assessment of 30 days ICU mortality in critically ill patients with immunocompromise, which can be employed to evaluate the short-term prognosis of those patients and bring more clinical benefits without dependence on laboratory tests.
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Affiliation(s)
- Xuequn Guo
- Department of Respiratory Medicine, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, Fujian, People's Republic of China
| | - Donghao Guo
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
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18
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Zou ZY, Huang JJ, Luan YY, Yang ZJ, Zhou ZP, Zhang JJ, Yao YM, Wu M. Early prophylactic anticoagulation with heparin alleviates mortality in critically ill patients with sepsis: a retrospective analysis from the MIMIC-IV database. BURNS & TRAUMA 2022; 10:tkac029. [PMID: 36168402 PMCID: PMC9501718 DOI: 10.1093/burnst/tkac029] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/14/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Minimal data exist on anticoagulation use and timing and the dose of heparin in patients with sepsis, and whether heparin use improves sepsis survival remains largely unclear. This study was performed to assess whether heparin administration would provide a survival advantage in critically ill patients with sepsis. METHODS A retrospective cohort study of patients with sepsis in the Medical Information Mart for Intensive Care (MIMIC)-IV database was conducted. Cox proportional hazards model and propensity score matching (PSM) were used to evaluate the outcomes of prophylactic anticoagulation with heparin administered by subcutaneous injection within 48 h of intensive care unit (ICU) admission. The primary outcome was in-hospital mortality. Secondary outcomes included 60-day mortality, length of ICU stay, length of hospital stay and incidence of acute kidney injury (AKI) on day 7. E-Value analysis were used for unmeasured confounding. RESULTS A total of 6646 adult septic patients were included and divided into an early prophylactic heparin group (n = 3211) and a nonheparin group (n = 3435). In-hospital mortality in the heparin therapy group was significantly lower than that in the nonheparin group (prematched 14.7 vs 20.0%, hazard ratio (HR) 0.77, 95% confidence interval (CI) [0.68-0.87], p < 0.001, and postmatched 14.9 vs 18.3%, HR 0.78, 95% CI [0.68-0.89], p < 0.001). Secondary endpoints, including 60-day mortality and length of ICU stay, differed between the heparin and nonheparin groups (p < 0.01). Early prophylactic heparin administration was associated with in-hospital mortality among septic patients in different adjusted covariates (HR 0.71-0.78, p < 0.001), and only administration of five doses of heparin was associated with decreased in-hospital mortality after PSM (HR 0.70, 95% CI 0.56-0.87, p < 0.001). Subgroup analysis showed that heparin use was significantly associated with reduced in-hospital mortality in patients with sepsis-induced coagulopathy, septic shock, sequential organ failure assessment score ≥ 10, AKI, mechanical ventilation, gram-positive bacterial infection and gram-negative bacterial infection, with HRs of 0.74, 0.70, 0.58, 0.74, 0.73, 0.64 and 0.72, respectively (p <0.001). E-Value analysis suggested robustness to unmeasured confounding. CONCLUSIONS This study found an association between early administration prophylactic heparin provided to patients with sepsis and reduced risk-adjusted mortality. A prospective randomized-controlled study should be designed to further assess the relevant findings.
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Affiliation(s)
| | | | | | - Zhen-jia Yang
- Department of Critical Care Medicine and Hospital Infection Prevention and Control, Shenzhen Second People’s Hospital & First Affiliated Hospital of Shenzhen University, Shenzhen 518035, China
- Postgraduate Education, Shantou University Medical College, Shantou 515041, China
| | - Zhi-peng Zhou
- Department of Critical Care Medicine and Hospital Infection Prevention and Control, Shenzhen Second People’s Hospital & First Affiliated Hospital of Shenzhen University, Shenzhen 518035, China
| | - Jing-jing Zhang
- Department of Critical Care Medicine and Hospital Infection Prevention and Control, Shenzhen Second People’s Hospital & First Affiliated Hospital of Shenzhen University, Shenzhen 518035, China
- Postgraduate Education, Shantou University Medical College, Shantou 515041, China
| | | | - Ming Wu
- Correspondence. Yong-ming Yao, ; Ming Wu,
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19
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Wang S, Yang Y, Suen A, Zhu J, Williams B, Hu J, Chen F, Kozar R, Shen S, Li Z, Jeyaram A, Jay SM, Zou L, Chao W. Role of extracellular microRNA-146a-5p in host innate immunity and bacterial sepsis. iScience 2021; 24:103441. [PMID: 34877498 PMCID: PMC8633977 DOI: 10.1016/j.isci.2021.103441] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 11/07/2021] [Accepted: 11/10/2021] [Indexed: 02/06/2023] Open
Abstract
Extracellular miRNAs (ex-miRNAs) mediate intercellular communication and play a role in diverse physiological and pathological processes. Using small RNA sequencing, we identify that miRNAs are the most abundant RNA species in the plasma and differentially expressed in murine and human sepsis, such as miR-146a-5p. Exogenous miR-146a-5p, but not its duplex precursor, induces a strong immunostimulatory response through a newly identified UU-containing motif and TLR7 activation, and an immunotolerance by rapid IRAK-1 protein degradation via TLR7→MyD88 signaling and proteasome activation, whereas its duplex precursor acts by targeting 3' UTR of Irak-1 gene via Ago2 binding. miR-146a knockout in mice offers protection against sepsis with attenuated interleukin-6 (IL-6) storm and organ injury, improved cardiac function, and better survival. In septic patients, the plasma miR-146a-5p concentrations are closely associated with the two sepsis outcome predictors, blood lactate and coagulopathy. These data demonstrate the importance of extracellular miR-146a-5p in innate immune regulation and sepsis pathogenesis.
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Affiliation(s)
- Sheng Wang
- Center for Shock, Trauma and Anesthesiology Research, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Yang Yang
- Center for Shock, Trauma and Anesthesiology Research, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Diagnostic Ultrasound, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Andrew Suen
- Center for Shock, Trauma and Anesthesiology Research, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
| | - Jing Zhu
- Center for Shock, Trauma and Anesthesiology Research, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Brittney Williams
- Center for Shock, Trauma and Anesthesiology Research, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Jiang Hu
- Center for Shock, Trauma and Anesthesiology Research, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Fengqian Chen
- Center for Shock, Trauma and Anesthesiology Research, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Rosemary Kozar
- Program in Trauma & Center for Shock, Trauma and Anesthesiology Research, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Shiqian Shen
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Ziyi Li
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Anjana Jeyaram
- Fischell Department of Bioengineering, A James Clark School of Engineering, University of Maryland, College Park, MD 20742, USA
| | - Steven M. Jay
- Fischell Department of Bioengineering, A James Clark School of Engineering, University of Maryland, College Park, MD 20742, USA
| | - Lin Zou
- Center for Shock, Trauma and Anesthesiology Research, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Wei Chao
- Center for Shock, Trauma and Anesthesiology Research, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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20
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Martín-Rojas RM, Chasco-Ganuza M, Casanova-Prieto S, Delgado-Pinos VE, Pérez-Rus G, Duque-González P, Sancho M, Díez-Martín JL, Pascual-Izquierdo C. A mild deficiency of ADAMTS13 is associated with severity in COVID-19: comparison of the coagulation profile in critically and noncritically ill patients. Blood Coagul Fibrinolysis 2021; 32:458-467. [PMID: 34310402 PMCID: PMC8527912 DOI: 10.1097/mbc.0000000000001068] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 07/09/2021] [Indexed: 11/25/2022]
Abstract
Early descriptions of COVID-19 associated coagulopathy identified it as a disseminated intravascular coagulation (DIC). However, recent studies have highlighted the potential role of endothelial cell injury in its pathogenesis, and other possible underlying mechanisms are being explored. This study aimed to analyse the coagulation parameters of critically and noncritically ill patients with COVID-19 bilateral pneumonia, determine if coagulation factors consumption occurs and explore other potential mechanisms of COVID-19 coagulopathy. Critically and noncritically ill patients with a diagnosis of COVID-19 bilateral pneumonia were recruited. For each patient, we performed basic coagulation tests, quantification of coagulation factors and physiological inhibitor proteins, an evaluation of the fibrinolytic system and determination of von Willebrand Factor (vWF) and ADAMTS13. Laboratory data were compared with clinical data and outcomes. The study involved 62 patients (31 ICU, 31 non-ICU). The coagulation parameters assessment demonstrated normal median prothrombin time (PT), international normalized ratio (INR) and activated partial thromboplastin time (APTT) in our cohort and all coagulation factors were within normal range. PAI-1 median levels were elevated (median 52.6 ng/ml; IQR 37.2-85.7), as well as vWF activity (median 216%; IQR 196-439) and antigen (median 174%; IQR 153.5-174.1). A mild reduction of ADAMTS13 was observed in critically ill patients and nonsurvivors. We demonstrated an inverse correlation between ADAMTS13 levels and inflammatory markers, D-dimer and SOFA score in our cohort. Elevated vWF and PAI-1 levels, and a mild reduction of ADAMTS13 in the most severe patients, suggest that COVID-19 coagulopathy is an endotheliopathy that has shared features with thrombotic microangiopathy.
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Affiliation(s)
| | | | | | | | | | - Patricia Duque-González
- Department of Anesthesiology and Reanimation
- Instituto de Investigación Sanitaria Gregorio Marañon, Madrid, Spain
| | - Milagros Sancho
- Intensive Care Unit, University General Hospital Gregorio Marañon
- Instituto de Investigación Sanitaria Gregorio Marañon, Madrid, Spain
| | - José Luis Díez-Martín
- Department of Hematology
- Universidad Complutense de Madrid
- Instituto de Investigación Sanitaria Gregorio Marañon, Madrid, Spain
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21
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Fibrin Network Formation and Lysis in Septic Shock Patients. Int J Mol Sci 2021; 22:ijms22179540. [PMID: 34502446 PMCID: PMC8431602 DOI: 10.3390/ijms22179540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/13/2021] [Accepted: 08/30/2021] [Indexed: 12/28/2022] Open
Abstract
Background: Septic shock patients are prone to altered fibrinolysis, which contributes to microthrombus formation, organ failure and mortality. However, characterisation of the individual patient’s fibrinolytic capacity remains a challenge due to a lack of global fibrinolysis biomarkers. We aimed to assess fibrinolysis in septic shock patients using a plasma-based fibrin clot formation and lysis (clot–lysis) assay and investigate the association between clot–lysis parameters and other haemostatic markers, organ dysfunction and mortality. Methods: This was a prospective cohort study including adult septic shock patients (n = 34). Clot–lysis was assessed using our plasma-based in-house assay. Platelet count, activated partial thromboplastin time (aPTT), international normalised ratio (INR), fibrinogen, fibrin D-dimer, antithrombin, thrombin generation, circulating fibrinolysis markers and organ dysfunction markers were analysed. Disseminated intravascular coagulation score, Sequential Organ Failure Assessment (SOFA) score and 30-day mortality were registered. Results: Three distinct clot–lysis profiles emerged in the patients: (1) severely decreased fibrin formation (flat clot–lysis curve), (2) normal fibrin formation and lysis and (3) pronounced lysis resistance. Patients with abnormal curves had lower platelet counts (p = 0.05), more prolonged aPTT (p = 0.04), higher lactate (p < 0.01) and a tendency towards higher SOFA scores (p = 0.09) than patients with normal clot–lysis curves. Fibrinogen and fibrin D-dimer were not associated with clot–lysis profile (p ≥ 0.37). Conclusion: Septic shock patients showed distinct and abnormal clot–lysis profiles that were associated with markers of coagulation and organ dysfunction. Our results provide important new insights into sepsis-related fibrinolysis disturbances and support the importance of assessing fibrinolytic capacity in septic shock.
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22
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Giustozzi M, Ehrlinder H, Bongiovanni D, Borovac JA, Guerreiro RA, Gąsecka A, Papakonstantinou PE, Parker WAE. Coagulopathy and sepsis: Pathophysiology, clinical manifestations and treatment. Blood Rev 2021; 50:100864. [PMID: 34217531 DOI: 10.1016/j.blre.2021.100864] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/31/2021] [Accepted: 06/22/2021] [Indexed: 12/13/2022]
Abstract
Sepsis is a complex syndrome with a high incidence, increasing by 8.7% annually over the last 20 years. Coagulopathy is a leading factor associated with mortality in patients with sepsis and range from slight thrombocytopenia to fatal disorders, such as disseminated intravascular coagulation (DIC). Platelet reactivity increases during sepsis but prospective trials of antiplatelet therapy during sepsis have been disappointing. Thrombocytopenia is a known predictor of worse prognosis during sepsis. The mechanisms underlying thrombocytopenia in sepsis have yet to be fully understood but likely involves decreased platelet production, platelet sequestration and increased consumption. DIC is an acquired thrombohemorrhagic syndrome, resulting in intravascular fibrin formation, microangiopathic thrombosis, and subsequent depletion of coagulation factors and platelets. DIC can be resolved with treatment of the underlying disorder, which is considered the cornerstone in the management of this syndrome. This review presents the current knowledge on the pathophysiology, diagnosis, and treatment of sepsis-associated coagulopathies.
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Affiliation(s)
- Michela Giustozzi
- Internal Vascular and Emergency Medicine and Stroke Unit, University of Perugia, Perugia, Italy.
| | - Hanne Ehrlinder
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Dario Bongiovanni
- Technical University of Munich, School of Medicine, University hospital rechts der Isar, Department of Internal Medicine I, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany; Department of Cardiovascular Medicine, Humanitas Clinical and Research Center IRCCS and Humanitas University, Rozzano, Milan, Italy
| | - Josip A Borovac
- Department of Pathophysiology, University of Split School of Medicine, Split, Croatia; Clinic for Cardiovascular Diseases, University Hospital of Split (KBC Split), Split, Croatia
| | | | - Aleksandra Gąsecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Panteleimon E Papakonstantinou
- Second Cardiology Department, Evangelismos Hospital, Athens, Greece; Hypertension Unit "ESH Excellence Centre", First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - William A E Parker
- Cardiovascular Research Unit, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
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23
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Reyes M, Filbin MR, Bhattacharyya RP, Sonny A, Mehta A, Billman K, Kays KR, Pinilla-Vera M, Benson ME, Cosimi LA, Hung DT, Levy BD, Villani AC, Sade-Feldman M, Baron RM, Goldberg MB, Blainey PC, Hacohen N. Plasma from patients with bacterial sepsis or severe COVID-19 induces suppressive myeloid cell production from hematopoietic progenitors in vitro. Sci Transl Med 2021; 13:eabe9599. [PMID: 34103408 PMCID: PMC8432955 DOI: 10.1126/scitranslmed.abe9599] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 12/17/2020] [Accepted: 05/28/2021] [Indexed: 12/16/2022]
Abstract
Bacterial sepsis and severe COVID-19 share similar clinical manifestations and are both associated with dysregulation of the myeloid cell compartment. We previously reported an expanded CD14+ monocyte state, MS1, in patients with bacterial sepsis and validated expansion of this cell subpopulation in publicly available transcriptomics data. Here, using published datasets, we show that the gene expression program associated with MS1 correlated with sepsis severity and was up-regulated in monocytes from patients with severe COVID-19. To examine the ontogeny and function of MS1 cells, we developed a cellular model for inducing CD14+ MS1 monocytes from healthy bone marrow hematopoietic stem and progenitor cells (HSPCs). We found that plasma from patients with bacterial sepsis or COVID-19 induced myelopoiesis in HSPCs in vitro and expression of the MS1 gene program in monocytes and neutrophils that differentiated from these HSPCs. Furthermore, we found that plasma concentrations of IL-6, and to a lesser extent IL-10, correlated with increased myeloid cell output from HSPCs in vitro and enhanced expression of the MS1 gene program. We validated the requirement for these two cytokines to induce the MS1 gene program through CRISPR-Cas9 editing of their receptors in HSPCs. Using this cellular model system, we demonstrated that induced MS1 cells were broadly immunosuppressive and showed decreased responsiveness to stimulation with a synthetic RNA analog. Our in vitro study suggests a potential role for systemic cytokines in inducing myelopoiesis during severe bacterial or SARS-CoV-2 infection.
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Affiliation(s)
- Miguel Reyes
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Michael R Filbin
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Roby P Bhattacharyya
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Center for Bacterial Pathogenesis, Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Abraham Sonny
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Arnav Mehta
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Center for Cancer Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Kyle R Kays
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Mayra Pinilla-Vera
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Maura E Benson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Lisa A Cosimi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Deborah T Hung
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Bruce D Levy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Alexandra-Chloe Villani
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Moshe Sade-Feldman
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Center for Cancer Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Rebecca M Baron
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Marcia B Goldberg
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Center for Bacterial Pathogenesis, Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Paul C Blainey
- Broad Institute of MIT and Harvard, Cambridge, MA, USA.
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
- Koch Institute for Integrative Cancer Research at MIT, Cambridge, MA, USA
| | - Nir Hacohen
- Broad Institute of MIT and Harvard, Cambridge, MA, USA.
- Center for Cancer Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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24
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Larsen JB, Hvas AM. Fibrinolytic Alterations in Sepsis: Biomarkers and Future Treatment Targets. Semin Thromb Hemost 2021; 47:589-600. [PMID: 33878784 DOI: 10.1055/s-0041-1725096] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Sepsis is a life-threatening condition which develops as a dysregulated immune response in the face of infection and which is associated with profound hemostatic disturbances and in the most extreme cases disseminated intravascular coagulation (DIC). In addition, the fibrinolytic system is subject to alterations during infection and sepsis, and impaired fibrinolysis is currently considered a key player in sepsis-related microthrombus formation and DIC. However, we still lack reliable biomarkers to assess fibrinolysis in the clinical setting. Furthermore, drugs targeting the fibrinolytic system have potential value in sepsis patients with severe fibrinolytic disturbances, but these are still being tested in the preclinical stage. The present review provides an overview of key fibrinolytic changes in sepsis, reviews the current literature on potential laboratory markers of altered fibrinolysis in adult sepsis patients, and discusses future perspectives for diagnosis and treatment of fibrinolytic disturbances in sepsis patients.
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Affiliation(s)
- Julie Brogaard Larsen
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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25
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Tokuyasu N, Amisaki M, Hanaki T, Murakami Y, Morimoto M, Uchinaka E, Yagyu T, Goto K, Matsunaga T, Yamamoto M, Takano S, Sakamoto T, Honjo S, Hasegawa T, Fujiwara Y. Clinical Significance of Serum Antithrombin III Activity After Hepatectomy for Hepatocellular Carcinoma. Yonago Acta Med 2021; 64:168-175. [PMID: 34025191 DOI: 10.33160/yam.2021.05.007] [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: 02/02/2021] [Accepted: 03/18/2021] [Indexed: 11/05/2022]
Abstract
Background As antithrombin III (AT-III) is produced in the hepatocytes, its serum activity decreases at the time of liver failure, in addition to ischemia reperfusion injury, vascular endothelial dysfunction, and disseminated intravascular coagulation (DIC). Here, we examined whether the serum AT-III value after hepatectomy could be a prognostic factor for hepatocellular carcinoma (HCC). Methods Of 141 patients who underwent hepatectomy for HCC, data for 101 patients in whom serum AT-III activity was measured on the first postoperative day were extracted. Patients with serum AT-III activity > 50% and ≤ 50% were assigned to high value (72 cases) and low value (29 cases) groups, respectively. We examined the clinical and prognostic differences between these two groups. Results The average age of enrolled patients (83 men and 18 women) was 68.0 years. The 5-year overall survival rate was 88% and 60% in the high and low value groups, respectively (P < 0.01). Furthermore, the 2-year relapse-free survival rate was 71% and 54% in the high and low value groups, respectively (P = 0.03). Conclusion This is the first study to demonstrate that serum AT-III levels on the first postoperative day may serve as a prognostic factor in HCC patients.
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Affiliation(s)
- Naruo Tokuyasu
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Masataka Amisaki
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Takehiko Hanaki
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Yuki Murakami
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Masaki Morimoto
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Ei Uchinaka
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Takuki Yagyu
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Keisuke Goto
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Tomoyuki Matsunaga
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Manabu Yamamoto
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Shuichi Takano
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Teruhisa Sakamoto
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Soichiro Honjo
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Toshimichi Hasegawa
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Yoshiyuki Fujiwara
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
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26
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Lavranou GA, Mentzelopoulos S, Katsaounou P, Siempos I, Kalomenidis I, Geranaki A, Routsi C, Zakynthinos S. Can Coagulation System Disorders and Cytokine and Inflammatory Marker Levels Predict the Temporary Clinical Deterioration or Improvement of Septic Patients on ICU Admission? J Clin Med 2021; 10:jcm10081548. [PMID: 33917002 PMCID: PMC8067680 DOI: 10.3390/jcm10081548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/30/2021] [Accepted: 03/30/2021] [Indexed: 11/16/2022] Open
Abstract
Although coagulation disorders and immune/inflammatory response have been associated with the final outcome of patients with sepsis, their link with thetemporaryclinical deterioration or improvement of patients is unknown. We aimed to investigate this link. We prospectively included consecutive patients admitted to the intensive care unit (ICU) with a suspected diagnosis of infection and evaluated within the first 24 h from admission. Blood levels of many cytokines and inflammatory and coagulation factors were measured and their predictive value was assessed by calculating the Area Under the Receiver Operating Characteristic (AUROC) curves. Patients (n = 102) were allocated in five groups, i.e., sepsis (n = 14), severe sepsis (n = 17), septic shock (n = 28), Systemic Inflammatory Response Syndrome (SIRS) without infection (n = 17), and trauma/surgery without SIRS or infection (n = 26). In septic shock, coagulation factors FVII and FIX and Protein C had AUROCs 0.67-0.78. In severe sepsis, Antithrombin III, Protein C, C-reactive protein, Procalcitonin and Thrombopoietin had AUROCs 0.73-0.75. In sepsis, Tumor Necrosis Factor a, and Interleukins 1β and 10 had AUROCs 0.66-0.72. In patients admitted to the ICU with a suspected diagnosis of infection, coagulation factors and inhibitors, as well as cytokine and inflammatory marker levels, have substantial predictive value in distinct groups of septic patients.
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Affiliation(s)
- Georgia-Athanasia Lavranou
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45-47 Ipsilandou St, GR-10675 Athens, Greece; (G.-A.L.); (S.M.); (P.K.); (I.S.); (I.K.); (C.R.)
| | - Spyros Mentzelopoulos
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45-47 Ipsilandou St, GR-10675 Athens, Greece; (G.-A.L.); (S.M.); (P.K.); (I.S.); (I.K.); (C.R.)
| | - Paraskevi Katsaounou
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45-47 Ipsilandou St, GR-10675 Athens, Greece; (G.-A.L.); (S.M.); (P.K.); (I.S.); (I.K.); (C.R.)
| | - Ilias Siempos
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45-47 Ipsilandou St, GR-10675 Athens, Greece; (G.-A.L.); (S.M.); (P.K.); (I.S.); (I.K.); (C.R.)
| | - Ioannis Kalomenidis
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45-47 Ipsilandou St, GR-10675 Athens, Greece; (G.-A.L.); (S.M.); (P.K.); (I.S.); (I.K.); (C.R.)
| | - Aikaterini Geranaki
- Hematology Laboratory, ‘Evangelismos’ Hospital, 45-47 Ipsilandou St, GR-10675 Athens, Greece;
| | - Christina Routsi
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45-47 Ipsilandou St, GR-10675 Athens, Greece; (G.-A.L.); (S.M.); (P.K.); (I.S.); (I.K.); (C.R.)
| | - Spyros Zakynthinos
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45-47 Ipsilandou St, GR-10675 Athens, Greece; (G.-A.L.); (S.M.); (P.K.); (I.S.); (I.K.); (C.R.)
- Correspondence:
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27
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van Vught LA, Uhel F, Ding C, van‘t Veer C, Scicluna BP, Peters‐Sengers H, Klein Klouwenberg PMC, Nürnberg P, Cremer OL, Schultz MJ, van der Poll T. Consumptive coagulopathy is associated with a disturbed host response in patients with sepsis. J Thromb Haemost 2021; 19:1049-1063. [PMID: 33492719 PMCID: PMC8048632 DOI: 10.1111/jth.15246] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/29/2020] [Accepted: 01/12/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND A prolonged prothrombin time (PT) is a common feature in sepsis indicating consumptive coagulopathy. OBJECTIVES To determine the association between a prolonged PT and aberrations in other host response mechanisms in sepsis. METHODS Patients admitted to the intensive care unit with sepsis were divided in quartiles according to the highest PT value measured within 24 h after admission. The host response was evaluated by measuring 19 plasma biomarkers reflecting pathways implicated in sepsis pathogenesis and by blood leukocyte gene expression profiling. MEASUREMENTS AND MAIN RESULTS Of 1524 admissions for sepsis, 386 (25.3%) involved patients with a normal PT (≤12.7 s); the remaining quartiles entailed 379 (24.9%) patients with a slightly prolonged PT (12.8 ≤ PT ≤ 15.0 s), 383 (25.1%) with an intermediately prolonged PT (15.1 ≤ PT ≤ 17.2 s), and 376 (24.7%) with an extremely prolonged PT (≥17.3 s). While patients with an extremely prolonged PT showed an increased crude mortality up to 1 year after admission, none of the prolonged PT groups was independently associated with 30-day adjusted mortality. Comparison of the host response between patients with a normal PT or an extremely prolonged PT matched for baseline characteristics including severity of disease showed that an extremely prolonged PT was associated with impaired anticoagulant mechanisms, a more disturbed endothelial barrier integrity and increased systemic inflammation, and blood leukocyte transcriptomes indicating more prominent metabolic reprogramming and protein catabolism. CONCLUSION A prolonged PT is associated with stronger anomalies in pathways implicated in the pathogenesis of sepsis, suggesting that activation of coagulation impacts other host response mechanisms.
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Affiliation(s)
- Lonneke A. van Vught
- Center for Experimental and Molecular MedicineAmsterdam University Medical Centerslocation Academic Medical CenterUniversity of AmsterdamAmsterdamthe Netherlands
- The Amsterdam Institute for Infection and ImmunityAmsterdam University Medical CentersAmsterdamthe Netherlands
| | - Fabrice Uhel
- Center for Experimental and Molecular MedicineAmsterdam University Medical Centerslocation Academic Medical CenterUniversity of AmsterdamAmsterdamthe Netherlands
- The Amsterdam Institute for Infection and ImmunityAmsterdam University Medical CentersAmsterdamthe Netherlands
| | - Chao Ding
- Center for Experimental and Molecular MedicineAmsterdam University Medical Centerslocation Academic Medical CenterUniversity of AmsterdamAmsterdamthe Netherlands
- The Amsterdam Institute for Infection and ImmunityAmsterdam University Medical CentersAmsterdamthe Netherlands
- Department of Gastric SurgeryState Key Laboratory of Oncology in South ChinaCollaborative Innovation Center for Cancer MedicineSun Yat‐sen University Cancer CenterGuangzhouChina
| | - Cees van‘t Veer
- Center for Experimental and Molecular MedicineAmsterdam University Medical Centerslocation Academic Medical CenterUniversity of AmsterdamAmsterdamthe Netherlands
- The Amsterdam Institute for Infection and ImmunityAmsterdam University Medical CentersAmsterdamthe Netherlands
| | - Brendon P. Scicluna
- Center for Experimental and Molecular MedicineAmsterdam University Medical Centerslocation Academic Medical CenterUniversity of AmsterdamAmsterdamthe Netherlands
- The Amsterdam Institute for Infection and ImmunityAmsterdam University Medical CentersAmsterdamthe Netherlands
- Department of Clinical Epidemiology and BiostatisticsAmsterdam University Medical CentersAcademic Medical CenterUniversity of AmsterdamAmsterdamthe Netherlands
| | - Hessel Peters‐Sengers
- Center for Experimental and Molecular MedicineAmsterdam University Medical Centerslocation Academic Medical CenterUniversity of AmsterdamAmsterdamthe Netherlands
- The Amsterdam Institute for Infection and ImmunityAmsterdam University Medical CentersAmsterdamthe Netherlands
| | - Peter M. C. Klein Klouwenberg
- Department of Intensive Care MedicineUniversity Medical Center UtrechtUtrechtthe Netherlands
- Department of Medical MicrobiologyUniversity Medical Center UtrechtUtrechtthe Netherlands
- Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Peter Nürnberg
- Cologne Center for Genomics and Center for Molecular Medicine CologneUniversity of CologneCologneGermany
| | - Olaf L. Cremer
- Department of Intensive Care MedicineUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Marcus J. Schultz
- Department of Intensive CareAmsterdam University Medical CentersAcademic Medical CenterUniversity of AmsterdamAmsterdamthe Netherlands
- Mahidol‐Oxford Tropical Medicine Research Unit (MORUMahidol UniversityBangkokThailand
- Nuffield Department of MedicineUniversity of OxfordOxfordUK
| | - Tom van der Poll
- Center for Experimental and Molecular MedicineAmsterdam University Medical Centerslocation Academic Medical CenterUniversity of AmsterdamAmsterdamthe Netherlands
- The Amsterdam Institute for Infection and ImmunityAmsterdam University Medical CentersAmsterdamthe Netherlands
- Division of Infectious DiseasesAmsterdam University Medical CentersAcademic Medical CenterUniversity of AmsterdamAmsterdamthe Netherlands
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28
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Adelborg K, Larsen JB, Hvas AM. Disseminated intravascular coagulation: epidemiology, biomarkers, and management. Br J Haematol 2021; 192:803-818. [PMID: 33555051 DOI: 10.1111/bjh.17172] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Disseminated intravascular coagulation (DIC) is a systemic activation of the coagulation system, which results in microvascular thrombosis and, simultaneously, potentially life-threatening haemorrhage attributed to consumption of platelets and coagulation factors. Underlying conditions, e.g. infection, cancer, or obstetrical complications are responsible for the initiation and propagation of the DIC process. This review provides insights into the epidemiology of DIC and the current understanding of its pathophysiology. It details the use of diagnostic biomarkers, current diagnostic recommendations from international medical societies, and it provides an overview of emerging diagnostic and prognostic biomarkers. Last, it provides guidance on management. It is concluded that timely and accurate diagnosis of DIC and its underlying condition is essential for the prognosis. Treatment should primarily focus on the underlying cause of DIC and supportive treatment should be individualised according to the underlying aetiology, patient's symptoms and laboratory records.
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Affiliation(s)
- Kasper Adelborg
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Denmark
| | - Julie B Larsen
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Denmark
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29
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The effect of recombinant human soluble thrombomodulin on renal function and mortality in septic disseminated intravascular coagulation patients with acute kidney injury: a retrospective study. J Intensive Care 2020; 8:94. [PMID: 33308326 PMCID: PMC7729679 DOI: 10.1186/s40560-020-00512-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 12/04/2020] [Indexed: 12/25/2022] Open
Abstract
Background Clinical evidence showing the effectiveness of recombinant human soluble thrombomodulin (rhTM) for treating sepsis-induced disseminated intravascular coagulation (DIC) and organ dysfunction (particularly renal injury) is limited because of differences in the inclusion criteria and disease severity among patients. This study aimed to assess the association between rhTM and outcomes in septic DIC patients with acute kidney injury (AKI). Methods This retrospective observational study analyzed the data of patients who were admitted to the intensive care unit (ICU) of a single center between January 2012 and December 2018, and diagnosed with sepsis-induced DIC and AKI. Data were extracted as follows: patients’ characteristics; DIC score, as calculated by the Japanese Association for Acute Medicine and the International Society of Thrombosis and Hemostasis criteria; serum creatinine levels; and ICU and 28-day mortality rates. The primary outcome was the dependence on renal replacement therapy (RRT) at ICU discharge. The propensity score (PS) was calculated using the following variables: age, sex, septic shock at admission, DIC score, and KDIGO classification. Subsequently, logistic regression analysis was performed using the PS to evaluate the outcome. Results In total, 97 patients were included in this study. Of these, 52 (53.6%) patients had received rhTM. The dependence on RRT at ICU discharge was significantly lower in the rhTM than in the non-rhTM group (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.19–0.97; P = 0.043). The serum creatinine levels at ICU discharge (OR, 0.31; 95% CI, 0.13–0.72; P = 0.007) and hospital discharge (OR, 0.25; 95% CI, 0.11–0.60; P = 0.002, respectively), and the 28-day mortality rate (OR, 0.40; 95% CI, 0.17–0.93; P = 0.033) were significantly lower in the rhTM than in the non-rhTM group. Moreover, the Kaplan–Meier survival curve revealed significantly lower mortality rates in the rhTM than in the non-rhTM group (P = 0.009). No significant differences in the DIC score and AKI severity were observed between the groups. Conclusions Among sepsis-induced DIC patients with AKI, rhTM administration was associated with lower dependence on RRT at ICU discharge, improvement in renal function, and lower 28-day mortality rate.
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30
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Hanff TC, Mohareb AM, Giri J, Cohen JB, Chirinos JA. Thrombosis in COVID-19. Am J Hematol 2020; 95:1578-1589. [PMID: 32857878 PMCID: PMC7674272 DOI: 10.1002/ajh.25982] [Citation(s) in RCA: 194] [Impact Index Per Article: 48.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/18/2020] [Accepted: 08/24/2020] [Indexed: 12/17/2022]
Abstract
Thrombotic complications are frequent in COVID-19 and contribute significantly to mortality and morbidity. We review several mechanisms of hypercoagulability in sepsis that may be upregulated in COVID-19. These include immune-mediated thrombotic mechanisms, complement activation, macrophage activation syndrome, antiphospholipid antibody syndrome, hyperferritinemia, and renin-angiotensin system dysregulation. We highlight biomarkers within each pathway with potential prognostic value in COVID-19. Lastly, recent observational studies have evaluated a role for the expanded use of therapeutic anticoagulation in COVID-19. We review strengths and weaknesses of these studies, and we also discuss the hypothetical benefit and anticipated challenges of fibrinolytic therapy in COVID-19.
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Affiliation(s)
- Thomas C. Hanff
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, Philadelphia, PA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Amir M. Mohareb
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Jay Giri
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, Philadelphia, PA
| | - Jordana B. Cohen
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Julio A. Chirinos
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, Philadelphia, PA
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31
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Walborn A, Rondina M, Fareed J, Hoppensteadt D. Development of an Algorithm to Predict Mortality in Patients With Sepsis and Coagulopathy. Clin Appl Thromb Hemost 2020; 26:1076029620902849. [PMID: 32129085 PMCID: PMC7288806 DOI: 10.1177/1076029620902849] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Sepsis is a systemic response to infection with a high rate of mortality and
complex pathophysiology involving inflammation, infection response, hemostasis,
endothelium, and platelets. The purpose of this study was to develop an equation
incorporating biomarker levels at intensive care unit (ICU) admission to predict
mortality in patients with sepsis, based on the hypothesis that a combination of
biomarkers representative of multiple physiological systems would provide
improved predictive value. Plasma samples and clinical data were collected from
103 adult patients with sepsis at the time of ICU admission. Biomarker levels
were measured using commercially available methods. A 28-day mortality was used
as the primary end point. Stepwise linear regression modeling was performed to
generate a predictive equation for mortality. Differences in biomarker levels
between survivors were quantified using the Mann-Whitney test and the area under
the receiver operating curve (AUC) was used to describe predictive ability.
Significant differences (P < .05) were observed between
survivors and nonsurvivors for plasminogen activator inhibitor 1 (AUC = 0.70),
procalcitonin (AUC = 0.77), high mobility group box 1 (AUC = 0.67), interleukin
(IL) 6 (AUC = 0.70), IL-8 (AUC = 0.70), protein C (AUC = 0.71), angiopoietin-2
(AUC = 0.76), endocan (AUC = 0.58), and platelet factor 4 (AUC = 0.70). A
predictive equation for mortality was generated using stepwise linear regression
modeling, which incorporated procalcitonin, vascular endothelial growth factor,
the IL-6:IL-10 ratio, endocan, and platelet factor 4, and demonstrated a better
predictive value for patient outcome than any individual biomarker (AUC = 0.87).
The use of mathematical modeling resulted in the development of a predictive
equation for sepsis-associated mortality with performance than any individual
biomarker or clinical scoring system which incorporated biomarkers
representative of multiple systems.
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Affiliation(s)
- Amanda Walborn
- Departments of Pathology, Loyola University Medical Center, Maywood, IL, USA.,Departments of Pharmacology, Loyola University Medical Center, Maywood, IL, USA
| | - Matthew Rondina
- Department of Internal Medicine and the Molecular Medicine Program, University of Utah and the GRECC, George E. Wahlen VAMC, Salt Lake City, UT, USA
| | - Jawed Fareed
- Departments of Pathology, Loyola University Medical Center, Maywood, IL, USA.,Departments of Pharmacology, Loyola University Medical Center, Maywood, IL, USA
| | - Debra Hoppensteadt
- Departments of Pathology, Loyola University Medical Center, Maywood, IL, USA.,Departments of Pharmacology, Loyola University Medical Center, Maywood, IL, USA
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Winer LK, Salyer C, Beckmann N, Caldwell CC, Nomellini V. Enigmatic role of coagulopathy among sepsis survivors: a review of coagulation abnormalities and their possible link to chronic critical illness. Trauma Surg Acute Care Open 2020; 5:e000462. [PMID: 33094168 PMCID: PMC7570228 DOI: 10.1136/tsaco-2020-000462] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 08/27/2020] [Accepted: 09/14/2020] [Indexed: 12/23/2022] Open
Abstract
There are sparse clinical data addressing the persistence of disordered coagulation in sepsis and its role in chronic critical illness. Coagulopathy in the absence of anticoagulant therapy and/or liver disease can be highly variable in sepsis, but it tends to be prolonged in patients in the intensive care unit with a length of stay greater than 14 days. These coagulation abnormalities tend to precede multisystem organ failure and persistence of these coagulation derangements can predict 28-day mortality. The studies evaluated in this review consistently link sepsis-associated coagulopathy to poor long-term outcomes and indicate that disordered coagulation is associated with unfavorable outcomes in chronic critical illness. However, the causative mechanism and the definitive link remain unclear. Longer follow-up and more granular data will be required to fully understand coagulopathy in the context of chronic critical illness.
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Affiliation(s)
- Leah K Winer
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Christen Salyer
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Nadine Beckmann
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Charles C Caldwell
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Department of Research, Shriners Hospitals for Children Cincinnati, Cincinnati, Ohio, USA
| | - Vanessa Nomellini
- Department of Research, Shriners Hospitals for Children Cincinnati, Cincinnati, Ohio, USA.,Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, University of Cincinnati Academic Health Center, Cincinnati, Ohio, USA
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Boscolo A, Spiezia L, De Cassai A, Pasin L, Pesenti E, Zatta M, Zampirollo S, Andreatta G, Sella N, Pettenuzzo T, Rose K, Simioni P, Navalesi P. Are thromboelastometric and thromboelastographic parameters associated with mortality in septic patients? A systematic review and meta-analysis. J Crit Care 2020; 61:5-13. [PMID: 33049490 DOI: 10.1016/j.jcrc.2020.09.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/21/2020] [Accepted: 09/30/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Thromboelastometry/elastography (ROTEM/TEG) showed promising results for diagnosis of sepsis-induced coagulopathy, but their association with the outcome is unclear. Our aim was to assess any difference in ROTEM/TEG measurements between septic survivors and non-survivors. METHODS Pubmed, Web of Science, Embase and Cochrane Library databases were investigated. The research aimed to include any randomized or observational study: i) on septic adult patients admitted to Intensive Care Unit (ICU) or Emergency Department (ED); ii) including ROTEM/TEG; iii) assessing mortality. RESULTS Seven prospective and four retrospective observational studies (952 patients) were included. According to the INTEM/kaolin-assay, clotting time (CT)/R (standardized mean difference(SMD) -0.29, 95% CI -0.49 to -0.09, p = 0.004) and clot formation time (CFT)/K (SMD -0.42, 95% CI -0.78 to -0.06, p = 0.02) were shorter in survivors. According to the EXTEM-assay, CT was shorter (MD -11.66 s, 95% CI -22.59 to -0.73, p = 0.04), while MCF was higher (MD 3.49 mm, 95% CI 0.43 to 6.55, p = 0.03) in survivors. A hypocoagulable profile was more frequent in non-survivors (OR 0.31, 95%CI 0.18 to 0.55, p < 0.0001). Overall, the risk of bias of the included studies was moderate and the quality of evidence low. CONCLUSIONS Hypocoagulability and lower MCF in EXTEM may be associated with higher mortality in sepsis.
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Affiliation(s)
- Annalisa Boscolo
- Anaesthesia and Intensive Care Unit, Padua University Hospital, Italy.
| | - Luca Spiezia
- Department of Medicine, Thrombotic and Haemorrhagic Diseases Unit, University of Padua, Italy
| | | | - Laura Pasin
- Anaesthesia and Intensive Care Unit, Padua University Hospital, Italy
| | - Elisa Pesenti
- Department of Medicine-DIMED, University of Padua, Italy
| | - Matteo Zatta
- Department of Medicine-DIMED, University of Padua, Italy
| | | | | | - Nicolò Sella
- Department of Medicine-DIMED, University of Padua, Italy
| | | | - Kirstin Rose
- Department of Obstetrics and Gynaecology, Royal Alexandria Hospital, Paisley, Scotland, United Kingdom
| | - Paolo Simioni
- Department of Medicine, Thrombotic and Haemorrhagic Diseases Unit, University of Padua, Italy
| | - Paolo Navalesi
- Anaesthesia and Intensive Care Unit, Padua University Hospital, Italy; Department of Medicine-DIMED, University of Padua, Italy
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Jackson Chornenki NL, Dwivedi DJ, Kwong AC, Zamir N, Fox-Robichaud AE, Liaw PC. Identification of hemostatic markers that define the pre-DIC state: A multi-center observational study. J Thromb Haemost 2020; 18:2524-2531. [PMID: 32573898 DOI: 10.1111/jth.14973] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/05/2020] [Accepted: 06/08/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND A limitation of diagnostic scoring systems for disseminated intravascular coagulation (DIC) is that once DIC is identified, it may be in a state of irreversible deterioration. OBJECTIVES To identify hemostatic markers that can identify the pre-DIC state. METHODS This was a multi-center observational study of 357 septic patients. The incidence of DIC was determined using the International Society on Thrombosis and Haemostasis (ISTH) DIC Score. Markers of interest include components of the DIC score: protein C (PC), antithrombin (AT), and citrullinated histones (H3Cit), which is a marker of NETosis. RESULTS Out of 357 sepsis patients, 236 patients did not develop DIC (without-DIC), 79 patients had DIC on Day 1 (overt-DIC), and 42 patients developed DIC after Day 1 (pre-DIC). Compared to without-DIC patients, pre-DIC patients had decreased platelet count, increased international normalized ratio (INR), decreased PC and AT, and increased H3Cit. In contrast, D-dimer and fibrinogen levels did not differ between pre-DIC and without-DIC patients. Using receiver operating characteristics (ROC) analysis, we found that platelet count and INR in combination with PC and AT could discriminate pre-DIC from without-DIC. The area under the curve in the ROC analysis was 0.83 (95% confidence interval, 0.76 to 0.89). CONCLUSION Our study suggests that platelets and INR in combination with PC and AT can identify the pre-DIC state in septic patients. In contrast, D-dimer increased and fibrinogen decreased in the late (ie, overt) stages of DIC. Our data also suggest that NETosis contributes to the onset of DIC in sepsis.
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Affiliation(s)
- Nicholas L Jackson Chornenki
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Thrombosis and Atherosclerosis Research Institute (TaARI), Hamilton, ON, Canada
| | - Dhruva J Dwivedi
- Thrombosis and Atherosclerosis Research Institute (TaARI), Hamilton, ON, Canada
| | - Andrew C Kwong
- Thrombosis and Atherosclerosis Research Institute (TaARI), Hamilton, ON, Canada
| | - Nasim Zamir
- Thrombosis and Atherosclerosis Research Institute (TaARI), Hamilton, ON, Canada
| | - Alison E Fox-Robichaud
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Thrombosis and Atherosclerosis Research Institute (TaARI), Hamilton, ON, Canada
| | - Patricia C Liaw
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Thrombosis and Atherosclerosis Research Institute (TaARI), Hamilton, ON, Canada
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Orsi FA, De Paula EV, Santos FDO, Teruchkin MM, Campêlo DHC, Mello TT, Chindamo MC, Macedo AVS, Rocha AT, Ramacciotti E, Nascimento ACK, Annichino-Bizzacchi J, Lourenco DM, Guerra JCDC, Rezende SM, Cavalheiro Filho C. Guidance on diagnosis, prevention and treatment of thromboembolic complications in COVID-19: a position paper of the Brazilian Society of Thrombosis and Hemostasis and the Thrombosis and Hemostasis Committee of the Brazilian Association of Hematology, Hemotherapy and Cellular Therapy. Hematol Transfus Cell Ther 2020; 42:300-308. [PMID: 32565232 PMCID: PMC7293502 DOI: 10.1016/j.htct.2020.06.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 06/03/2020] [Indexed: 12/15/2022] Open
Abstract
Hemostatic abnormalities and thrombotic risk associated with coronavirus disease 2019 (COVID-19) are among the most discussed topics in the management of this disease. The aim of this position paper is to provide the opinion of Brazilian experts on the thromboprophylaxis and management of thrombotic events in patients with suspected COVID-19, in the sphere of healthcare in Brazil. To do so, the Brazilian Society of Thrombosis and Hemostasis (BSTH) and the Thrombosis and Hemostasis Committee of the Brazilian Association of Hematology, Hemotherapy and Cellular Therapy (ABHH) have constituted a panel of experts to carefully review and discuss the available evidence about this topic. The data discussed in this document was reviewed by May 9, 2020. Recommendations and suggestions reflect the opinion of the panel and should be reviewed periodically as new evidence emerges.
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Affiliation(s)
- Fernanda Andrade Orsi
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas (FCM-Unicamp), Campinas, SP, Brazil.
| | - Erich V De Paula
- Centro de Hematologia e Hemoterapia da Universidade Estadual de Campinas (Hemocentro-Unicamp), Campinas, SP, Brazil
| | | | | | | | | | - Maria Chiara Chindamo
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil; Barra D'Or Hospital, Rede D'Or São Luiz, Rio de Janeiro, RJ, Brazil
| | | | - Ana Thereza Rocha
- Faculdade de Medicina da Bahia da Universidade Federal da Bahia (FMB-UFBA), Salvador, BA, Brazil; Escola Bahiana de Medicina e Saúde Pública, Salvador, BA, Brazil
| | - Eduardo Ramacciotti
- Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), São Paulo, SP, Brazil; Hospital Christóvão da Gama, Grupo Leforte, Santo André, SP, Brazil; Loyola University Medical Center, Maywood, IL, United States
| | | | - Joyce Annichino-Bizzacchi
- Centro de Hematologia e Hemoterapia da Universidade Estadual de Campinas (Hemocentro-Unicamp), Campinas, SP, Brazil
| | | | - João Carlos de Campos Guerra
- Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil; Centro de Hematologia de São Paulo (CHSP), São Paulo, SP, Brazil
| | - Suely Meireles Rezende
- Faculdade de Medicina da Universidade Federal de Minas Gerais (FM/UFMG), Belo Horizonte, MG, Brazil
| | - Cyrillo Cavalheiro Filho
- Hospital Sírio-libanês, São Paulo, SP, Brazil; Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (Incor FMUSP), São Paulo, SP, Brazil
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36
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Reyes M, Filbin MR, Bhattacharyya RP, Sonny A, Mehta A, Billman K, Kays KR, Pinilla-Vera M, Benson ME, Cosimi LA, Hung DT, Levy BD, Villani AC, Sade-Feldman M, Baron RM, Goldberg MB, Blainey PC, Hacohen N. Induction of a regulatory myeloid program in bacterial sepsis and severe COVID-19. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2020. [PMID: 32908980 DOI: 10.1101/2020.09.02.280180] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
A recent estimate suggests that one in five deaths globally are associated with sepsis 1 . To date, no targeted treatment is available for this syndrome, likely due to substantial patient heterogeneity 2,3 and our lack of insight into sepsis immunopathology 4 . These issues are highlighted by the current COVID-19 pandemic, wherein many clinical manifestations of severe SARS-CoV-2 infection parallel bacterial sepsis 5-8 . We previously reported an expanded CD14+ monocyte state, MS1, in patients with bacterial sepsis or non-infectious critical illness, and validated its expansion in sepsis across thousands of patients using public transcriptomic data 9 . Despite its marked expansion in the circulation of bacterial sepsis patients, its relevance to viral sepsis and association with disease outcomes have not been examined. In addition, the ontogeny and function of this monocyte state remain poorly characterized. Using public transcriptomic data, we show that the expression of the MS1 program is associated with sepsis mortality and is up-regulated in monocytes from patients with severe COVID-19. We found that blood plasma from bacterial sepsis or COVID-19 patients with severe disease induces emergency myelopoiesis and expression of the MS1 program, which are dependent on the cytokines IL-6 and IL-10. Finally, we demonstrate that MS1 cells are broadly immunosuppressive, similar to monocytic myeloid-derived suppressor cells (MDSCs), and have decreased responsiveness to stimulation. Our findings highlight the utility of regulatory myeloid cells in sepsis prognosis, and the role of systemic cytokines in inducing emergency myelopoiesis during severe bacterial and SARS-CoV-2 infections.
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Levi M. Relevance and diagnosis of disseminated intravascular coagulation associated with cardiovascular disease. Eur J Intern Med 2020; 79:27-28. [PMID: 32768159 DOI: 10.1016/j.ejim.2020.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 07/31/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Marcel Levi
- University College London Hospitals NHS Foundation Trust, Department of Medicine (1) and Cardiometabolic Programme-NIHR UCLH/UCL BRC (2), London, UK.
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Tiscia GL, Favuzzi G, De Laurenzo A, Cappucci F, Fischetti L, di Mauro L, Miscio G, Mirijello A, Chinni E, Grandone E. Reduction of ADAMTS13 Levels Predicts Mortality in SARS-CoV-2 Patients. TH OPEN 2020; 4:e203-e206. [PMID: 32879905 PMCID: PMC7456602 DOI: 10.1055/s-0040-1716379] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- Giovanni L Tiscia
- Research Unit of Thrombosis and Hemostasis, Fondazione IRCCS "Casa Sollievo della Sofferenza," San Giovanni Rotondo, Italy
| | - Giovanni Favuzzi
- Research Unit of Thrombosis and Hemostasis, Fondazione IRCCS "Casa Sollievo della Sofferenza," San Giovanni Rotondo, Italy
| | - Antonio De Laurenzo
- Research Unit of Thrombosis and Hemostasis, Fondazione IRCCS "Casa Sollievo della Sofferenza," San Giovanni Rotondo, Italy
| | - Filomena Cappucci
- Research Unit of Thrombosis and Hemostasis, Fondazione IRCCS "Casa Sollievo della Sofferenza," San Giovanni Rotondo, Italy
| | - Lucia Fischetti
- Research Unit of Thrombosis and Hemostasis, Fondazione IRCCS "Casa Sollievo della Sofferenza," San Giovanni Rotondo, Italy
| | - Lazzaro di Mauro
- Transfusion Medicine and Laboratory Department, Fondazione IRCCS "Casa Sollievo della Sofferenza," San Giovanni Rotondo, Italy
| | - Giuseppe Miscio
- Transfusion Medicine and Laboratory Department, Fondazione IRCCS "Casa Sollievo della Sofferenza," San Giovanni Rotondo, Italy
| | - Antonio Mirijello
- Medical Department, Fondazione IRCCS "Casa Sollievo della Sofferenza," San Giovanni Rotondo, Italy
| | - Elena Chinni
- Research Unit of Thrombosis and Hemostasis, Fondazione IRCCS "Casa Sollievo della Sofferenza," San Giovanni Rotondo, Italy
| | - Elvira Grandone
- Research Unit of Thrombosis and Hemostasis, Fondazione IRCCS "Casa Sollievo della Sofferenza," San Giovanni Rotondo, Italy
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Gozzo L, Viale P, Longo L, Vitale DC, Drago F. The Potential Role of Heparin in Patients With COVID-19: Beyond the Anticoagulant Effect. A Review. Front Pharmacol 2020; 11:1307. [PMID: 32973526 PMCID: PMC7472559 DOI: 10.3389/fphar.2020.01307] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 08/07/2020] [Indexed: 12/20/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is responsible of variable clinical manifestations, ranging from no symptoms to severe pneumonia with acute respiratory distress syndrome, septic shock, and multi-organ failure resulting in death. To date no specific antiviral drug have been approved for COVID-19, so the treatment of the disease is mainly focused on symptomatic treatment and supportive care. Moreover, there are no treatments of proven efficacy to reduce the progression of the disease from mild/moderate to severe/critical. An activation of the coagulation cascade leading to severe hypercoagulability has been detected in these patients, therefore early anticoagulation may reduce coagulopathy, microthrombus formation, and the risk of organ damages. The role of heparin in COVID-19 is supported by a lot of studies describing its pleiotropic activity but it must be proven in clinical trials. Several protocols have been designed to assess the risk-benefit profile of heparin (low-molecular-weight or unfractionated heparin) in hospitalized subjects. Although prophylactic doses may be adequate in most patients, it is important to wait the results of clinical trials in order to define the appropriate effective dose able to improve disease outcome.
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Affiliation(s)
- Lucia Gozzo
- Clinical Pharmacology Unit/Regional Pharmacovigilance Centre, University Hospital of Catania, Catania, Italy
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant’Orsola, University of Bologna, Bologna, Italy
| | - Laura Longo
- Clinical Pharmacology Unit/Regional Pharmacovigilance Centre, University Hospital of Catania, Catania, Italy
| | - Daniela Cristina Vitale
- Clinical Pharmacology Unit/Regional Pharmacovigilance Centre, University Hospital of Catania, Catania, Italy
| | - Filippo Drago
- Clinical Pharmacology Unit/Regional Pharmacovigilance Centre, University Hospital of Catania, Catania, Italy
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
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Pavoni V, Gianesello L, Pazzi M, Stera C, Meconi T, Frigieri FC. Evaluation of coagulation function by rotation thromboelastometry in critically ill patients with severe COVID-19 pneumonia. J Thromb Thrombolysis 2020; 50:281-286. [PMID: 32394236 PMCID: PMC7211560 DOI: 10.1007/s11239-020-02130-7] [Citation(s) in RCA: 156] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Critically ill patients with COVID-19 pneumonia suffered both high thrombotic and bleeding risk. The effect of SARS-CoV-2 on coagulation and fibrinolysis is not well known. We conducted a retrospective study of critically ill patients admitted to an intensive care unit (ICU) a cause of severe COVID-19 pneumonia and we evaluated coagulation function using rotational thromboelastometry (ROTEM) on day of admission (T0) and 5 (T5) and 10 (T10) days after admission to ICU. Coagulation standard parameters were also evaluated. Forty patients were enrolled into the study. The ICU and the hospital mortality were 10% and 12.5%, respectively. On ICU admission, prothrombin time was slightly reduced and it increased significantly at T10 (T0 = 65.1 ± 9.8 vs T10 = 85.7 ± 1.5, p = 0.002), while activated partial thromboplastin time and fibrinogen values were higher at T0 than T10 (32.2 ± 2.9 vs 27.2 ± 2.1, p = 0.017 and 895.1 ± 110 vs 332.5 ± 50, p = 0.002, respectively); moreover, whole blood thromboelastometry profiles were consistent with hypercoagulability characterized by an acceleration of the propagation phase of blood clot formation [i.e., CFT below the lower limit in INTEM 16/40 patients (40%) and EXTEM 20/40 patients (50%)] and significant higher clot strength [MCF above the upper limit in INTEM 20/40 patients (50%), in EXTEM 28/40 patients (70%) and in FIBTEM 29/40 patients (72.5%)]; however, this hypercoagulable state persists in the first five days, but it decreases ten day after, without returning to normal values. No sign of secondary hyperfibrinolysis or sepsis induced coagulopathy (SIC) were found during the study period. In six patients (15%) a deep vein thrombosis and in 2 patients (5%) a thromboembolic event, were found; 12 patients (30%) had a catheter-related thrombosis. ROTEM analysis confirms that patients with severe COVID-19 pneumonia had a hypercoagulation state that persisted over time.
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Affiliation(s)
- Vittorio Pavoni
- Emergency Department and Critical Care Area, Anesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Lara Gianesello
- Department of Anesthesia and Intensive Care, Orthopedic Anesthesia, University-Hospital Careggi, Florence, Italy.
| | - Maddalena Pazzi
- Emergency Department and Critical Care Area, Anesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Caterina Stera
- Emergency Department and Critical Care Area, Anesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Tommaso Meconi
- Emergency Department and Critical Care Area, Anesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Francesca Covani Frigieri
- Emergency Department and Critical Care Area, Anesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
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Boscolo A, Spiezia L, Campello E, Bertini D, Lucchetta V, Piasentini E, De Cassai A, Simioni P. Whole-blood hypocoagulable profile correlates with a greater risk of death within 28 days in patients with severe sepsis. Korean J Anesthesiol 2020; 73:224-231. [PMID: 31906608 PMCID: PMC7280891 DOI: 10.4097/kja.19396] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 01/06/2020] [Indexed: 12/29/2022] Open
Abstract
Background Hypocoagulability and impaired platelet function have been associated with a high risk of death in sepsis. The aim of this cohort study was to determine whether sepsis-induced hypocoagulability and platelet dysfunction (assessed by ROTEM® and MULTIPLATE®, respectively) are increased in sepsis patients who died within 28 days after diagnosis compared with patients who died between 29 and 90 days after diagnosis. Methods Consecutive patients admitted to the intensive care unit of Padova University Hospital from March 2015 to March 2018 for severe sepsis were considered. We collected blood samples from all patients to determine ROTEM® and MULTIPLATE® parameters. Each enrolled patient underwent a 90-day follow-up and the mortality rate was recorded. Results Of 120 patients, 36 (30%) died within 28 days post-diagnosis (Group A), 23 (19%) died between days 29 and 90 post-diagnosis (Group B), and 61 (51%) were alive after 90 days (survivors). The clotting time in the ROTEM® test and clot formation time in the EXTEM test were significantly more prolonged in Group A than in B. Both groups showed a significantly higher hypocoagulability than survivors in the EXTEM test. MULTIPLATE® platelet function analysis showed that platelet function was significantly lower in Group A than in Group B. Conclusions The present study showed that the combination of thromboelastometry and impedance aggregometry may help identifying sepsis patients at high risk of short-term death. Larger studies are warranted to corroborate our results.
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Affiliation(s)
- Annalisa Boscolo
- Anesthesia and Intensive Care Unit, Department of Medicine, Padova University Hospital, Padova, Italy
| | - Luca Spiezia
- Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padova University Hospital, Padua, Italy
| | - Elena Campello
- Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padova University Hospital, Padua, Italy
| | - Diana Bertini
- Anesthesia and Intensive Care Unit, Department of Medicine, Padova University Hospital, Padova, Italy
| | - Vittorio Lucchetta
- Anesthesia and Intensive Care Unit, Department of Medicine, Padova University Hospital, Padova, Italy
| | - Eleonora Piasentini
- Anesthesia and Intensive Care Unit, Department of Medicine, Padova University Hospital, Padova, Italy
| | - Alessandro De Cassai
- Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padova University Hospital, Padua, Italy
| | - Paolo Simioni
- Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padova University Hospital, Padua, Italy
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Williams B, Neder J, Cui P, Suen A, Tanaka K, Zou L, Chao W. Toll-like receptors 2 and 7 mediate coagulation activation and coagulopathy in murine sepsis. J Thromb Haemost 2019; 17:1683-1693. [PMID: 31211901 PMCID: PMC7197442 DOI: 10.1111/jth.14543] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 06/10/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Sepsis is a life-threatening condition often manifested as marked inflammation and severe coagulopathy. Toll-like receptors (TLRs) play a pivotal role in inflammation, organ dysfunction and mortality in animal sepsis. OBJECTIVES To investigate the role of TLR signaling in mediating sepsis-induced coagulopathy (SIC) in a mouse model. METHODS Polymicrobial sepsis was created by cecal ligation and puncture (CLP) or fecal slurry peritoneal injection. To quantify global clotting function, two viscoelastic assays were performed with rotational thromboelastometry, and the results were presented as maximum clot firmness (MCF): (a) EXTEM to test tissue factor (TF)-initiated clot formation; and (b) FIBTEM to test EXTEM in the presence of a platelet inhibitor, cytochalasin D. Plasma coagulation factors were quantified with ELISA. TF gene expression and protein expression were determined with real-time quantitative reverse transcription PCR and flow cytometry, respectively. RESULTS Between 4 and 24 hours after CLP surgery, wild-type mice showed significant MCF reduction in both EXTEM and FIBTEM tests. This was accompanied by marked thrombocytopenia and a significant increase in the levels of plasminogen activator inhibitor-1, plasma TF, and D-dimer. In comparison, TLR2-/- and TLR7-/- CLP mice showed preserved MCF and platelet counts, and near-normal plasma TF levels. Bone marrow-derived macrophages treated with a TLR2 agonist Pam3cys-Ser-(Lys)4 (Pam3cys) or a TLR7 agonist (R837) showed marked increases in TF gene expression and protein expression. MicroRNA-146a, a newly identified proinflammatory mediator that is upregulated during sepsis, induced TF production via a TLR7-dependent mechanism. CONCLUSIONS Murine sepsis leads to an increased procoagulant response, thrombocytopenia, and global coagulopathy. TLR2 and TLR7 play an important role in procoagulant production and in SIC.
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Affiliation(s)
- Brittney Williams
- Translational Research Program, Department of Anesthesiology & Center for Shock Trauma and Anesthesiology Research, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jessica Neder
- Translational Research Program, Department of Anesthesiology & Center for Shock Trauma and Anesthesiology Research, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ping Cui
- Translational Research Program, Department of Anesthesiology & Center for Shock Trauma and Anesthesiology Research, University of Maryland School of Medicine, Baltimore, Maryland
| | - Andrew Suen
- Translational Research Program, Department of Anesthesiology & Center for Shock Trauma and Anesthesiology Research, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kenichi Tanaka
- Translational Research Program, Department of Anesthesiology & Center for Shock Trauma and Anesthesiology Research, University of Maryland School of Medicine, Baltimore, Maryland
| | - Lin Zou
- Translational Research Program, Department of Anesthesiology & Center for Shock Trauma and Anesthesiology Research, University of Maryland School of Medicine, Baltimore, Maryland
| | - Wei Chao
- Translational Research Program, Department of Anesthesiology & Center for Shock Trauma and Anesthesiology Research, University of Maryland School of Medicine, Baltimore, Maryland
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Britton GW, Babcock C, Colombo CJ. All Organ Dysfunctions Are Equal…But Some Are More Equal Than Others. Crit Care Med 2019; 46:818-819. [PMID: 29652709 DOI: 10.1097/ccm.0000000000003042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Garrett W Britton
- Department of Medicine, Critical Care Section, Walter Reed National Military Medical Center, Bethesda, MD Department of Medicine, Critical Care Section, Dwight David Eisenhower Army Medical Center, Fort Gordon, GA
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Iba T, Arakawa M, Mochizuki K, Nishida O, Wada H, Levy JH. Usefulness of Measuring Changes in SOFA Score for the Prediction of 28-Day Mortality in Patients With Sepsis-Associated Disseminated Intravascular Coagulation. Clin Appl Thromb Hemost 2019; 25:1076029618824044. [PMID: 30808223 PMCID: PMC6714949 DOI: 10.1177/1076029618824044] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The primary end point for sepsis trial is 28-day mortality. However, additional methods
for determining the efficacy may have benefits. The purpose of this study was to search a
useful indicator of anticoagulant therapy in patients with sepsis with disseminated
intravascular coagulation (DIC). Data from 323 patients with sepsis with coagulopathy
treated with antithrombin supplementation were analyzed. The changes in the Sequential
Organ Failure Assessment (Δ SOFA) score, the overt-DIC (Δ overt-DIC) score, and the
Japanese Society for Acute Medicine DIC (Δ JAAM DIC) score from baseline to day 7 were
retrospectively analyzed in relation to the 28-day mortality. Significant correlations
were found between the 28-day mortality and Δ SOFA, Δ overt-DIC score, and Δ JAAM DIC
score. The accuracy of the prediction was higher for Δ SOFA (80.5%) than for Δ overt-DIC
(66.7%, P < .001). The areas under the curve for mortality calculated
using a receiver operating characteristic curve analysis were 0.812 for Δ SOFA, 0.655 for
Δ overt-DIC, and 0.693 for Δ JAAM DIC. The mortality rate was significantly lower among
cases with an improved SOFA score compared to those without an improvement. The Δ SOFA had
the strongest association with the 28-day mortality in patients with sepsis and DIC.
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Affiliation(s)
- Toshiaki Iba
- 1 Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Makoto Arakawa
- 1 Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Katsunori Mochizuki
- 2 Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Osamu Nishida
- 3 Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Hideo Wada
- 4 Department of Molecular Laboratory Medicine, Mie University Graduate School of Medicine, Tsu, Japan
| | - Jerrold H Levy
- 5 Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, NC, USA
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Affiliation(s)
- Marie Scully
- Department of Haematology University College London HospitalLondonUK
- Cardiometabolic Programme‐NIHR UCLH/UCL BRC LondonUK
| | - Marcel Levi
- Cardiometabolic Programme‐NIHR UCLH/UCL BRC LondonUK
- Department of Medicine UCLH London UK
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Mei H, Jiang Y, Luo L, Huang R, Su L, Hou M, Wang X, Deng J, Hu Y. Evaluation the combined diagnostic value of TAT, PIC, tPAIC, and sTM in disseminated intravascular coagulation: A multi-center prospective observational study. Thromb Res 2019; 173:20-26. [DOI: 10.1016/j.thromres.2018.11.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 09/14/2018] [Accepted: 11/11/2018] [Indexed: 01/21/2023]
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Zallocco F, Osimani P, Carloni I, Romagnoli V, Angeloni S, Cazzato S. Assessment of clinical outcome of children with sepsis outside the intensive care unit. Eur J Pediatr 2018; 177:1775-1783. [PMID: 30225636 DOI: 10.1007/s00431-018-3247-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 08/07/2018] [Accepted: 09/10/2018] [Indexed: 12/20/2022]
Abstract
In 2016, in order to identify adult patients with sepsis who are likely to have poor outcomes, the Third International Consensus Definitions Task Force introduced a new bedside index, called the quick Sepsis-related Organ Failure Assessment (qSOFA) score. However, these new criteria have not been validated in the pediatric population. In this study, we sought to assess the qSOFA score for children with sepsis, who are being treated outside the pediatric intensive care units. The qSOFA criteria were revised and applied to a study population of 89 pediatric patients with sepsis, admitted in a pediatric tertiary referral center from 2006 to 2016. The analysis of prognostic performance of qSOFA score for the prediction of severe sepsis showed a sensitivity of 46% (95% CI, 27-67%), a specificity of 74% (95% CI, 62-85%), a positive predictive value of 43% (95% CI, 34-52%), and a negative predictive value of 77% (95% CI, 71-82%). The area under ROC curve for qSOFA score ≥ 2 was 0.602 (95% CI 0.492-0.705).Conclusion: The qSOFA score showed a low accuracy to identify children in the pediatric ward at risk for severe sepsis. Clinical tools are needed to facilitate the diagnosis of impending organ dysfunction in pediatric infection outside of the ICU. What is Known: • One of the major challenges for clinicians is to identify and recognize children with sepsis and impending organ dysfunction, in the emergency and in the pediatric department. • In 2016, members of the Sepsis-3 task force proposed qSOFA, an empirically derived score using simple clinical criteria, to assist clinicians in identifying adult patients with sepsis at risk for poor outcome. What is New: • qSOFA demonstrated insufficient clinical value to be recommended as a screening tool for pediatric sepsis outside ICU. • D-dimer level and blood glucose may be useful biomarkers to identify children at risk for severe sepsis.
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Affiliation(s)
- Federica Zallocco
- Pediatrics and Infectious Disease Unit, G. Salesi Children's Hospital, Ancona, Italy
| | - Patrizia Osimani
- Pediatrics and Infectious Disease Unit, G. Salesi Children's Hospital, Ancona, Italy
| | - Ines Carloni
- Pediatrics and Infectious Disease Unit, G. Salesi Children's Hospital, Ancona, Italy
| | - Vittorio Romagnoli
- Pediatrics and Infectious Disease Unit, G. Salesi Children's Hospital, Ancona, Italy
| | - Silvia Angeloni
- Pediatrics and Infectious Disease Unit, G. Salesi Children's Hospital, Ancona, Italy
| | - Salvatore Cazzato
- Pediatrics and Infectious Disease Unit, G. Salesi Children's Hospital, Ancona, Italy. .,Pediatrics and Infectious Disease Unit, Department of Mother and Child Health, G. Salesi Children's Hospital, Via Corridoni 11, 60123, Ancona, Italy.
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Van Steenkiste T, Ruyssinck J, De Baets L, Decruyenaere J, De Turck F, Ongenae F, Dhaene T. Accurate prediction of blood culture outcome in the intensive care unit using long short-term memory neural networks. Artif Intell Med 2018; 97:38-43. [PMID: 30420241 DOI: 10.1016/j.artmed.2018.10.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 10/11/2018] [Accepted: 10/23/2018] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Blood cultures are often performed in the intensive care unit (ICU) to detect bloodstream infections and identify pathogen type, further guiding treatment. Early detection is essential, as a bloodstream infection can give cause to sepsis, a severe immune response associated with an increased risk of organ failure and death. PROBLEM STATEMENT The early clinical detection of a bloodstream infection is challenging but rapid targeted treatment, within the first place antimicrobials, substantially increases survival chances. As blood cultures require time to incubate, early clinical detection using physiological signals combined with indicative lab values is pivotal. OBJECTIVE In this work, a novel method is constructed and explored for the potential prediction of the outcome of a blood culture test. The approach is based on a temporal computational model which uses nine clinical parameters measured over time. METHODOLOGY We use a bidirectional long short-term memory neural network, a type of recurrent neural network well suited for tasks where the time lag between a predictive event and outcome is unknown. Evaluation is performed using a novel high-quality database consisting of 2177 ICU admissions at the Ghent University Hospital located in Belgium. RESULTS The network achieves, on average, an area under the receiver operating characteristic curve of 0.99 and an area under the precision-recall curve of 0.82. In addition, our results show that predicting several hours upfront is possible with only a small decrease in predictive power. In this setting, it outperforms traditional non-temporal, machine learning models. CONCLUSION Our proposed computational model accurately predicts the outcome of blood culture tests using nine clinical parameters. Moreover, it can be used in the ICU as an early warning system to detect patients at risk of blood stream infection.
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Affiliation(s)
- Tom Van Steenkiste
- Ghent University - imec, IDLab, Department of Information Technology, Technologiepark 15, B-9052, Ghent, Belgium.
| | - Joeri Ruyssinck
- Ghent University - imec, IDLab, Department of Information Technology, Technologiepark 15, B-9052, Ghent, Belgium.
| | - Leen De Baets
- Ghent University - imec, IDLab, Department of Information Technology, Technologiepark 15, B-9052, Ghent, Belgium.
| | - Johan Decruyenaere
- Ghent University Hospital, Department of Internal Medicine, De Pintelaan 185, B-9050 Ghent, Belgium.
| | - Filip De Turck
- Ghent University - imec, IDLab, Department of Information Technology, Technologiepark 15, B-9052, Ghent, Belgium.
| | - Femke Ongenae
- Ghent University - imec, IDLab, Department of Information Technology, Technologiepark 15, B-9052, Ghent, Belgium.
| | - Tom Dhaene
- Ghent University - imec, IDLab, Department of Information Technology, Technologiepark 15, B-9052, Ghent, Belgium.
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Levi M. Pathogenesis and diagnosis of disseminated intravascular coagulation. Int J Lab Hematol 2018; 40 Suppl 1:15-20. [PMID: 29741245 DOI: 10.1111/ijlh.12830] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Accepted: 02/07/2018] [Indexed: 12/12/2022]
Abstract
Several clinical conditions, in particular those associated with a systemic inflammatory response, can cause some degree of activation of coagulation but when the procoagulant stimulus is sufficiently severe and overcomes the natural anticoagulant mechanisms of coagulation, disseminated intravascular coagulation (DIC) may occur. The clinical manifestations of DIC encompass multiorgan dysfunction caused by fibrin-platelet clots in the microcirculation, and bleeding caused by consumption of platelets and coagulation factors. Molecular mechanisms that play a role in inflammation-induced effects on coagulation have been recognized in much detail. Exposure of blood to tissue factor is the most common trigger, whereas the intravascular coagulation is propagated due to loss of function of physiological anticoagulants and impaired fibrinolysis. In patients with DIC, various abnormalities in routine coagulation parameters may be observed, including thrombocytopenia, prolonged global coagulation assays, or high levels of fibrin split products. In addition, more sophisticated tests for activation of individual factors or pathways of coagulation may point to specific involvement of these components in the pathogenesis of the disorder. A combination of readily available tests is usually sufficient in establishing the diagnosis of DIC, and for this purpose, several scoring algorithms have been developed. Some specific clinical situations may elicit coagulation responses that can be distinguished from DIC or may occur in combination with DIC, including dilutional coagulopathy, liver failure-related coagulation derangement, and thrombotic microangiopathies.
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Affiliation(s)
- M Levi
- Department of Medicine, University College London Hospitals NHS Foundation Trust, London, UK.,Cardiometabolic Programme-NIHR UCLH/UCL BRC, London, UK
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Walborn A, Williams M, Fareed J, Hoppensteadt D. International Normalized Ratio Relevance to the Observed Coagulation Abnormalities in Warfarin Treatment and Disseminated Intravascular Coagulation. Clin Appl Thromb Hemost 2018; 24:1033-1041. [PMID: 29848060 PMCID: PMC6714745 DOI: 10.1177/1076029618772353] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
The development of coagulation abnormalities is common in patients with sepsis. Sepsis-associated coagulopathy (SAC) is typically diagnosed by prothrombin time (PT) prolongation or elevated international normalized ratio (INR) in conjunction with reduced platelet count. INR is also used to monitor warfarin-treated patients. However, due to the different natures of SAC and warfarin anticoagulation, it is likely that the same INR value provides different information in these two patient populations. The purpose of this study was to compare measures of coagulation function and clotting factor levels in patients with SAC to those observed in patients receiving warfarin anticoagulation. Deidentified plasma samples were collected at baseline from patients diagnosed with SAC and from patients receiving warfarin. These plasma samples were evaluated for PT/INR, activated partial thromboplastin time (aPTT), fibrinogen, and functional and immunologic levels of factors VII, IX, and X. Both aPTT and fibrinogen correlated with INR in patients with SAC, but not in patients treated with warfarin. Factors VII, IX, and X showed an inverse relationship with INR in the anticoagulated patients; however, no relationship between factor level and INR was observed in patients with SAC. Distinct patterns of coagulopathy were observed in patients with SAC and patients receiving warfarin anticoagulation, and equivalent INR values were associated with distinct coagulation profiles in the two patient groups. These results suggest that an abnormal INR provides different information about the coagulation status in patients with disseminated intravascular coagulation than in patients receiving warfarin. This may indicate that an equivalently increased INR predicts different bleeding risks in these two patient groups.
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Affiliation(s)
- Amanda Walborn
- Department of Pathology, Loyola University Medical Center, Maywood, IL, USA
- Department of Pharmacology, Loyola University Medical Center, Maywood, IL, USA
| | - Mark Williams
- Division of Pulmonary and Critical Care Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jawed Fareed
- Department of Pathology, Loyola University Medical Center, Maywood, IL, USA
- Department of Pharmacology, Loyola University Medical Center, Maywood, IL, USA
| | - Debra Hoppensteadt
- Department of Pathology, Loyola University Medical Center, Maywood, IL, USA
- Department of Pharmacology, Loyola University Medical Center, Maywood, IL, USA
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