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Liao C, Liu G, Li L, Wang J, Ouyang L, Lei P, Fan S. Predictive value of thrombin-antithrombin III complex and tissue plasminogen activator-inhibitor complex biomarkers in assessing the severity of early-stage acute pancreatitis. J Gastroenterol Hepatol 2024. [PMID: 38822643 DOI: 10.1111/jgh.16641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 05/04/2024] [Accepted: 05/20/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND AND AIM The development of acute pancreatitis (AP) is strongly linked to blood clotting and fibrinolysis issues. Modern clinical practices now utilize advanced blood markers like thrombin-antithrombin III complex (TAT), plasmin-α2-plasmin inhibitor complex, thrombomodulin (TM), and tissue plasminogen activator-inhibitor complex (t-PAIC) to assess thrombosis risk. Our study used a highly sensitive chemiluminescence technique to measure these markers in AP patients, aiming to determine their early predictive value for AP severity. METHODS There were 173 patients with AP, all of whom developed symptoms within 72 h; 102 individuals had onset symptoms within 48 h. The biomarkers were measured upon admission before determining the severity of AP. RESULTS The levels of TAT, plasmin-α2-plasmin inhibitor complex, TM, and t-PAIC were significantly higher in the severe acute pancreatitis (SAP) group compared with the mild acute pancreatitis and moderate severe acute pancreatitis groups. For the patients within 72 h of onset, TAT, TM, and t-PAIC predicted the occurrence of SAP. For the patients within 48 h of onset, TAT and t-PAIC predicted the occurrence of SAP. The area under the curve (AUC) of prediction models is similar to Bedside Index for Severity in Acute Pancreatitis (BISAP) but significantly higher than C-reactive protein (P < 0.05). Notably, t-PAIC had a larger AUC than TAT, BISAP, and C-reactive protein. CONCLUSION In the initial 48 h, plasma TAT and t-PAIC levels may predict the development of SAP. Within 72 h, plasma levels of TAT, TM, and t-PAIC may predict the development of SAP, and the TAT + TM + t-PAIC prediction model achieved a maximum AUC of 0.915, comparable to BISAP.
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Affiliation(s)
- Chushu Liao
- Hematology Laboratory, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Guanghua Liu
- Hematology Laboratory, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Lingqian Li
- Hematology Laboratory, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Juan Wang
- Key Laboratory of Study and Discovery of Small Targeted Molecules of Hunan Province, Hunan Normal University, Changsha, China
| | - Long Ouyang
- Key Laboratory of Study and Discovery of Small Targeted Molecules of Hunan Province, Hunan Normal University, Changsha, China
| | - Ping Lei
- Hematology Laboratory, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Shasha Fan
- Department of Oncology, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
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Matsuoka T, Fujishima S, Sasaki J, Gando S, Saitoh D, Kushimoto S, Ogura H, Abe T, Shiraishi A, Mayumi T, Kotani J, Takeyama N, Tsuruta R, Takuma K, Yamashita N, Shiraishi SI, Ikeda H, Shiino Y, Tarui T, Nakada TA, Hifumi T, Otomo Y, Okamoto K, Sakamoto Y, Hagiwara A, Masuno T, Ueyama M, Fujimi S, Yamakawa K, Umemura Y. COAGULOPATHY PARAMETERS PREDICTIVE OF OUTCOMES IN SEPSIS-INDUCED ACUTE RESPIRATORY DISTRESS SYNDROME: A SUBANALYSIS OF THE TWO PROSPECTIVE MULTICENTER COHORT STUDIES. Shock 2024; 61:89-96. [PMID: 38010069 DOI: 10.1097/shk.0000000000002269] [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: 11/29/2023]
Abstract
ABSTRACT Background: Although coagulopathy is often observed in acute respiratory distress syndrome (ARDS), its clinical impact remains poorly understood. Objectives: This study aimed to clarify the coagulopathy parameters that are clinically applicable for prognostication and to determine anticoagulant indications in sepsis-induced ARDS. Method: This study enrolled patients with sepsis-derived ARDS from two nationwide multicenter, prospective observational studies. We explored coagulopathy parameters that could predict outcomes in the Focused Outcome Research on Emergency Care for Acute Respiratory Distress Syndrome, Sepsis, and Trauma (FORECAST) cohort, and the defined coagulopathy criteria were validated in the Sepsis Prognostication in Intensive Care Unit and Emergency Room-Intensive Care Unit (SPICE-ICU) cohort. The correlation between anticoagulant use and outcomes was also evaluated. Results: A total of 181 patients with sepsis-derived ARDS in the FORECAST study and 61 patients in the SPICE-ICU study were included. In a preliminary study, we found the set of prothrombin time-international normalized ratio ≥1.4 and platelet count ≤12 × 10 4 /μL, and thrombocytopenia and elongated prothrombin time (TEP) coagulopathy as the best coagulopathy parameters and used it for further analysis; the odds ratio (OR) of TEP coagulopathy for in-hospital mortality adjusted for confounding was 3.84 (95% confidence interval [CI], 1.66-8.87; P = 0.005). In the validation cohort, the adjusted OR for in-hospital mortality was 32.99 (95% CI, 2.60-418.72; P = 0.002). Although patients without TEP coagulopathy showed significant improvements in oxygenation over the first 4 days, patients with TEP coagulopathy showed no significant improvement (ΔPaO 2 /FiO 2 ratio, 24 ± 20 vs. 90 ± 9; P = 0.026). Furthermore, anticoagulant use was significantly correlated with mortality and oxygenation recovery in patients with TEP coagulopathy but not in patients without TEP coagulopathy. Conclusion: Thrombocytopenia and elongated prothrombin time coagulopathy is closely associated with better outcomes and responses to anticoagulant therapy in sepsis-induced ARDS, and our coagulopathy criteria may be clinically useful.
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Affiliation(s)
- Tadashi Matsuoka
- Department of Emergency and Critical Care Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Seitaro Fujishima
- Center for Preventive Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Junchi Sasaki
- Department of Emergency and Critical Care Medicine, School of Medicine, Keio University, Tokyo, Japan
| | | | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Japan
| | | | | | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Joji Kotani
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Japan
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
| | - Kiyotsugu Takuma
- Emergency and Critical Care Center, Kawasaki Municipal Hospital, Japan
| | - Norio Yamashita
- Department of Emergency and Critical Care Medicine, School of Medicine, Kurume University, Japan
| | | | - Hiroto Ikeda
- Department of Emergency Medicine, Trauma and Resuscitation Center, Teikyo University School of Medicine
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Japan
| | - Takehiko Tarui
- Department of Emergency Medical Care, Kyorin University Faculty Health Sciences, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine Chiba University Graduate School of Medicine, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Japan
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Japan
| | - Akiyoshi Hagiwara
- Center Hospital of the National Center for Global Health and Medicine, Japan
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Japan
| | - Masashi Ueyama
- Department of Trauma, Critical Care Medicine, and Burn Center, Japan Community Healthcare Organization, Chukyo Hospital, Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Japan
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Japan
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3
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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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4
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Fang M, Zha Y, Bao J, Huang R, Han X, Yu C, Zhao D, Wang C, Liu N, Shao M. Evaluation of the Revised ISTH Overt-DIC Score (2018) for Predicting 90-day Mortality in Adult Critically Ill Subjects Undergoing Extracorporeal Membrane Oxygenation. Artif Organs 2022; 46:2442-2452. [PMID: 35639045 DOI: 10.1111/aor.14324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 04/22/2022] [Accepted: 05/18/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Coagulopathy is a common and serious problem in subjects received extracorporeal membrane oxygenation (ECMO), and this study evaluated whether the 2018 diffuse intravascular coagulation (DIC) score established by the International Society on Thrombosis and Hemostasis (ISTH) is associated with 90-day mortality in adult ECMO subjects. METHODS A retrospective study analyzed data from adult subjects receiving ECMO in our hospital from September 2018 to April 2021. Pre-ECMO DIC score and other variables were assessed and compared to predict 90-day mortality. RESULTS Among 103 eligible subjects, 55.3% received V-V ECMO and 44.7% received V-A ECMO. The overall 90-day mortality for study subjects was 54.4%, including 45.6% in the V-V group and 65.2% in the V-A group. Multiple logistic regression analysis showed that after adjusting for sex, sepsis, and APACHE II score, pre-ECMO DIC scores in the total and V-V group predicted 90-day mortality (odds ratio(OR): 1.419, 95% confidence interval (CI): 1.101-1.828; OR: 2.562; 95% CI: 1.452-4.520 ). Receiver operating characteristic (ROC) curves displayed that pre-ECMO DIC score of 4 in the total and V-V group was a good predictor of 90-day mortality (area under the curve (AUC)=0.706, 95% CI:0.606-0.806; AUC=0.737, 95% CI:0.604-0.870). Kaplan-Meier curves demonstrated the 90-day mortality of subjects with pre-ECMO DIC score ≥ 4 in the total and V-V group was higher than that of subjects with DIC score < 4 (hazard ratio (HR): 2.821; 95% CI: 1.632-4.879; HR: 3.864,95% CI: 1.660-8.992). CONCLUSION The pre-ECMO ISTH DIC score was associated with 90-day mortality in adult subjects undergoing ECMO, particularly in the V-V ECMO group.
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Affiliation(s)
- Ming Fang
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - Yutao Zha
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - Junjie Bao
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - Rui Huang
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - Xuan Han
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - Chao Yu
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - Dongsheng Zhao
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - Cui Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - Nian Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - Min Shao
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
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5
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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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Popescu NI, Lupu C, Lupu F. Disseminated intravascular coagulation and its immune mechanisms. Blood 2022; 139:1973-1986. [PMID: 34428280 PMCID: PMC8972096 DOI: 10.1182/blood.2020007208] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 06/02/2021] [Indexed: 11/26/2022] Open
Abstract
Disseminated intravascular coagulation (DIC) is a syndrome triggered by infectious and noninfectious pathologies characterized by excessive generation of thrombin within the vasculature and widespread proteolytic conversion of fibrinogen. Despite diverse clinical manifestations ranging from thrombo-occlusive damage to bleeding diathesis, DIC etiology commonly involves excessive activation of blood coagulation and overlapping dysregulation of anticoagulants and fibrinolysis. Initiation of blood coagulation follows intravascular expression of tissue factor or activation of the contact pathway in response to pathogen-associated or host-derived, damage-associated molecular patterns. The process is further amplified through inflammatory and immunothrombotic mechanisms. Consumption of anticoagulants and disruption of endothelial homeostasis lower the regulatory control and disseminate microvascular thrombosis. Clinical DIC development in patients is associated with worsening morbidities and increased mortality, regardless of the underlying pathology; therefore, timely recognition of DIC is critical for reducing the pathologic burden. Due to the diversity of triggers and pathogenic mechanisms leading to DIC, diagnosis is based on algorithms that quantify hemostatic imbalance, thrombocytopenia, and fibrinogen conversion. Because current diagnosis primarily assesses overt consumptive coagulopathies, there is a critical need for better recognition of nonovert DIC and/or pre-DIC states. Therapeutic strategies for patients with DIC involve resolution of the eliciting triggers and supportive care for the hemostatic imbalance. Despite medical care, mortality in patients with DIC remains high, and new strategies, tailored to the underlying pathologic mechanisms, are needed.
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Affiliation(s)
| | - Cristina Lupu
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK; and
| | - Florea Lupu
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK; and
- Department of Cell Biology
- Department of Pathology, and
- Department of Internal Medicine, Oklahoma University Health Sciences Center, Oklahoma City, OK
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7
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Disseminated Intravascular Coagulation Score Is Related to Short-term Mortality in Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation After Cardiac Surgery. ASAIO J 2021; 67:891-898. [PMID: 33470639 DOI: 10.1097/mat.0000000000001333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Disseminated intravascular coagulation (DIC) score is associated with short-term mortality in various conditions but has not been studied in postcardiotomy cardiogenic shock (PCS) patients supported with venoarterial extracorporeal membrane oxygenation (VA-ECMO). The objective of this study was to evaluate the relationship between DIC score at day 1 from VA-ECMO initiation and short-term mortality. We included all PCS patients supported with VA-ECMO at the Beijing Anzhen Hospital between January 2015 and December 2018. Multivariable logistic regression analysis was performed to assess the relationship between DIC score at day 1 and in-hospital mortality, and adjust for potential confounding variables. Of 222 PCS patients treated with VA-ECMO, 145 (65%) patients were weaned from VA-ECMO, and median (IQR) ECMO support duration was five (3-6) days. In-hospital mortality was 53%. The median (IQR) DIC score at day 1 was five (4-6). Patients with DIC score ≥5 at day 1 (overt DIC) had higher in-hospital mortality as compared with patients with DIC score <5 (64% vs. 22%; P < 0.001). After adjusting for age, sex, ECMO indication, and peak serum lactate, a one-point rise in DIC score [OR, 2.20; 95% confidence intervals (CI), 1.64-2.95] or DIC score ≥5 at day 1 (OR, 4.98; 95% CI, 2.42-10.24) was associated with an increased risk of in-hospital mortality. The area under the receiver operating characteristic curve for DIC score at day 1 was 0.76 (95% CI, 0.69-0.82). Our study suggests that DIC score at day 1 is associated with short-term mortality in patients undergoing VA-ECMO after cardiac surgery, independent of age, sex, disease characteristics, and severity of illness.
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8
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Gao TY, Yang WC, Zhou FH, Song Q. Analysis of D-dimer cut-off values for overt DIC diagnosis in exertional heat illness. Medicine (Baltimore) 2020; 99:e23831. [PMID: 33350770 PMCID: PMC7769303 DOI: 10.1097/md.0000000000023831] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 11/20/2020] [Indexed: 01/26/2023] Open
Abstract
The International Society on Thrombosis and Haemostasis (ISTH) scoring system has been used for diagnosing overt disseminated intravascular coagulation (DIC). However, the cut-off points of fibrin-related markers remain unclear. The ability of the ISTH DIC score and Multiple Organ Dysfunction (MODS) score to predict mortality in cases of exertional heat illness (EHI) was tested. In the process, 3 different D-dimer cut-off values for diagnosing overt DIC were evaluated.Data were obtained on the first day of hospitalization for 76 patients with EHI. The DIC score was calculated according to the ISTH scoring system using 3 D-dimer cut-off values.In predicting mortality, methods 1 and 2 had the same sensitivity and specificity, which were 85% and 73.2%, respectively. The sensitivity for method 3 was 70%. Furthermore, the specificity of the DIC score for method 3 was 89%, which was higher than that of the other 2 methods. The correlation coefficients of the DIC and MODS scores of these 3 methods were 0.757, 0.748, and 0.756, respectively. For the prediction of mortality, the area under the receiver operating characteristic (ROC) curve for the DIC scores of these 3 methods was 0.838, 0.842, and 0.85, respectively. Furthermore, the area under the ROC curve of the MODS score was 0.927.The DIC score had a certain predictive power of a poor outcome of EHI patients, but this was not better than the MODS score. The present data may serve as a reference in selecting the appropriate D-dimer cut-off point for the ISTH DIC score.
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Affiliation(s)
- Tie-Ying Gao
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital
- Department of Critical Care Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Wen-Chao Yang
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital
| | - Fei-Hu Zhou
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital
| | - Qing Song
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital
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9
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Khandait H, Gandotra G, Sachdeva S, Kramer CA, Nye D, Golamari R, Jain R. COVID-19 and Hematology-What Do We Know So Far? ACTA ACUST UNITED AC 2020; 2:2631-2636. [PMID: 33134847 PMCID: PMC7590911 DOI: 10.1007/s42399-020-00607-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2020] [Indexed: 01/08/2023]
Abstract
The severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), the causative agent of the novel coronavirus disease 2019 (COVID 19), was reported to the World Health Organization in late 2019. This disease quickly evolved into a public health concern and was declared a pandemic on March 11, 2020. COVID-19's high transmission rate and potential to cause a spectrum of systemic diseases makes it imperative for researchers and clinicians worldwide to collaborate and develop a strategy to manage and contain this disease. Studies have shown a wide range of hematological abnormalities and virus-related coagulopathies in affected patients, resulting in an increased propensity to develop serious thrombotic complications or disseminated intravascular coagulation (DIC) in severe cases. The fatal implications of coagulopathy in the form of pulmonary embolism (PE), myocardial infarction (MI), and cerebral infarction compelled us to study in-depth the pathophysiology and treatment options related to COVID-19. This analysis reviews published reports on patients with confirmed SARS-COV-2 infection and associated coagulopathy, defined as abnormalities in the coagulation parameters prothrombin time (PT), activated partial thromboplastin time (aPTT), antithrombin time, fibrinogen, fibrin degradation products, and D-dimer. In this review, we present the hematological manifestations of COVID-19, focusing on virus-associated coagulopathy and relevant pathophysiology, clinical outcomes, and treatment.
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Affiliation(s)
| | | | | | | | - Derek Nye
- Penn State College of Medicine, Hershey, PA USA
| | - Reshma Golamari
- Division of Hospital Medicine, Department of Medicine, Penn State Hershey Medical Center, Hershey, PA USA
| | - Rohit Jain
- Division of Hospital Medicine, Department of Medicine, Penn State Hershey Medical Center, Hershey, PA USA
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10
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Disseminated Intravascular Coagulation Is an Independent Predictor of Adverse Outcomes in Children in the Emergency Department with Suspected Sepsis. J Pediatr 2020; 225:198-206.e2. [PMID: 32553867 PMCID: PMC7529972 DOI: 10.1016/j.jpeds.2020.06.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 06/03/2020] [Accepted: 06/06/2020] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To evaluate the impact of early disseminated intravascular coagulation (DIC) on illness severity in children using a database of emergency department ED encounters for children with suspected sepsis, in view of similar associations in adults. STUDY DESIGN Laboratory and clinical data were extracted from a registry of emergency department encounters of children with suspected sepsis between April 1, 2012, and June 26, 2017. International Society of Thrombosis and Hemostasis DIC scores were calculated from laboratory values obtained within 24 hours of emergency department admission. Univariate logistic regression, multivariable logistic regression, and Cox regression were used to assess the influence of DIC scores on vasopressor use (primary outcome), mortality, ventilator requirement, pediatric intensive care unit admission, and hospital duration (secondary outcomes). The optimal DIC score cutoff for outcome prediction was determined. RESULTS Of 1653 eligible patients, 284 had DIC scores within 24 hours, including 92 who required vasopressors and 23 who died within 1 year. An initial DIC score of ≥3 was the most sensitive and specific DIC score for predicting adverse outcomes. Those with a DIC score of ≥3 vs <3 had increased odds of vasopressor use in both univariate (OR, 4.48; 95% CI, 2.63-7.62; P < .001) and multivariable (OR, 3.78; 95% CI, 1.82-7.85; P < .001) analyses. Additionally, those with a DIC score of ≥3 vs <3 had increased 1-year mortality with a hazard ratio of 3.55 (95% CI, 1.46-8.64; P = .005). CONCLUSIONS A DIC score of ≥3 was an independent predictor for both vasopressor use and mortality in this pediatric cohort, distinct from the adult overt DIC score cutoff of ≥5.
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11
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Singh P, Schwartz RA. Disseminated intravascular coagulation: A devastating systemic disorder of special concern with COVID-19. Dermatol Ther 2020; 33:e14053. [PMID: 32700813 PMCID: PMC7404500 DOI: 10.1111/dth.14053] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/14/2020] [Accepted: 07/20/2020] [Indexed: 12/13/2022]
Abstract
Disseminated intravascular coagulation (DIC) is linked with severe COVID‐19, prompting considerable concern. DIC can be a devastating systemic disorder. It is often markedly manifest on the skin as acrocyanosis or as petechiae and purpura with progression to hemorrhagic bullae. Subcutaneous hematomas may occur, as may thrombotic findings including necrosis and gangrene. The most common cause is infection, with special emphasis now on COVID‐19. We have reviewed the medical literature under the search terms “Disseminated intravascular coagulation” and “consumption coagulopathy” for the past two decades in the English language using Medline and Google Scholar to update special concerns and considerations, focusing on those with COVID‐19. Skin findings with DIC may be prominent. The severity of cutaneous lesions often correlates with the gravity of systemic disease. DIC is most effectively treated by addressing the underlying cause and resuscitating the patient using supportive measures. It is pivotal to recognize and treat DIC early, before deadly complications, such as multiple organ failure, arise.
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Affiliation(s)
- Parmvir Singh
- Dermatology, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Robert A Schwartz
- Dermatology, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
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12
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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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13
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Jhang WK, Park SJ. Evaluation of Disseminated Intravascular Coagulation in Critically Ill Pediatric Hemato-oncology Patients with Septic Shock. Thromb Haemost 2020; 120:1505-1511. [PMID: 32772349 DOI: 10.1055/s-0040-1714737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Disseminated intravascular coagulation (DIC) is a serious complication in septic shock. This study aimed to evaluate DIC and associated clinical outcomes using the International Society on Thrombosis and Hemostasis (ISTH) and modified ISTH overt DIC scores in critically ill pediatric hemato-oncology patients with septic shock. METHODS Pediatric hemato-oncology patients with septic shock admitted to the pediatric intensive care unit (PICU) of a tertiary children's hospital between January 2013 and February 2020 were included. We modified the ISTH overt DIC score by eliminating the platelet domain and compared the performances of the ISTH and the modified ISTH overt DIC scores in DIC diagnosis and PICU mortality prediction of these patients. RESULTS DIC was diagnosed in 56.4 and 38.5% of patients by ISTH and modified ISTH overt DIC scores, respectively. Patients with DIC showed a higher pediatric risk of mortality (PRISM) III, pediatric sequential organ failure assessment (pSOFA) scores, and PICU mortality than those without DIC (p < 0.05). The modified ISTH overt DIC score was an independent prognostic factor for PICU mortality and showed a larger area under the receiver operating characteristic curve than the ISTH overt DIC score (0.687 vs. 0.695). Addition of the DIC diagnosis improved the performance of PRISM III in predicting PICU mortality. CONCLUSION Critically ill pediatric hemato-oncology patients with septic shock frequently experience DIC, which was adequately evaluated by both ISTH and modified ISTH overt DIC scores. Considering the characteristics of these patients, the modified ISTH overt DIC score may be a promising prognostic factor for clinical outcomes in these critically ill pediatric patients.
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Affiliation(s)
- Won Kyoung Jhang
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Seong Jong Park
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
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14
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15
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Xu H, Liu X, Ni H. Clinical significance of miR-19b-3p in patients with sepsis and its regulatory role in the LPS-induced inflammatory response. Eur J Med Res 2020; 25:9. [PMID: 32188465 PMCID: PMC7079357 DOI: 10.1186/s40001-020-00408-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 02/27/2020] [Indexed: 02/07/2023] Open
Abstract
Background MicroRNAs (miRNAs) play important roles in the development and progression of sepsis. This study investigated the clinical value of miR-19b-3p in sepsis patients, and explored its role in regulating inflammatory responses in HUVECs cells. Methods 103 patients with sepsis and 98 healthy individuals were recruited. qRT-PCR was used for the measurement of miR-19b-3p level. Cell viability was evaluated using CCK-8. The protein levels of TNF-α and IL-6 were measured using ELISA. Receiver operating characteristic (ROC) curve and logistic regression analysis were constructed to evaluate the diagnostic and prognostic values of miR-19b-3p in sepsis patients. Results MiR-19b-3p level was significantly reduced in the serum from patients with sepsis compared with healthy controls (P < 0.001). Sepsis patients in the survival group had significantly high miR-19b-3p levels compared with the non-survival group (P < 0.001). MiR-19b-3p was of a good value in predicting sepsis risk, and was an independent prognostic factor for 28-day survival in sepsis patients (OR = 3.226, 95% CI 1.076–9.670, P = 0.037). MiR-19b-3p level was negatively associated with serum levels of IL-6 (r = − 0.852, P < 0.001) and TNF-α (r = − 0.761, P < 0.001). Overexpression of miR-19b-3p alleviated LPS-induced inflammatory response of HUVECs, which was reflected by the decrease of the levels of IL-6 and TNF-α induced by LPS treatment (P < 0.001). Conclusion MiR-19b-3p might be a potential biomarker for the early diagnosis and prognosis of sepsis patients. Overexpression of miR-19b-3p alleviated sepsis-induced inflammatory responses.
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Affiliation(s)
- Huimin Xu
- Department of Infectious Diseases, Linyi People's Hospital, Linyi, 276034, Shandong, China
| | - Xiuwu Liu
- Department of Internal Medicine, Linyi People's Hospital, Linyi, 276034, Shandong, China
| | - Huaijun Ni
- Department of Surgery, Linyi People's Hospital, No. 233, Fenghuang Street, Linyi, 276034, Shandong, China.
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16
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Iba T, Levy JH, Yamakawa K, Thachil J, Warkentin TE, Levi M. Proposal of a two-step process for the diagnosis of sepsis-induced disseminated intravascular coagulation. J Thromb Haemost 2019; 17:1265-1268. [PMID: 31099127 DOI: 10.1111/jth.14482] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 05/02/2019] [Indexed: 01/06/2023]
Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| | - Theodore E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Marcel Levi
- Department of Medicine, University College London Hospitals NHS Foundation Trust, London, UK
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17
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Iba T, Umemura Y, Watanabe E, Wada T, Hayashida K, Kushimoto S. Diagnosis of sepsis-induced disseminated intravascular coagulation and coagulopathy. Acute Med Surg 2019; 6:223-232. [PMID: 31304023 PMCID: PMC6603393 DOI: 10.1002/ams2.411] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 03/05/2019] [Indexed: 12/26/2022] Open
Abstract
Disseminated intravascular coagulation (DIC) is a frequent complication in sepsis. Once patients develop DIC, the mortality rate increases significantly. Moreover, recent studies have suggested that coagulation disorder plays a significant role in the development of organ dysfunction in sepsis. Thus, the early detection of DIC is vital in sepsis care, and the Japanese Association for Acute Medicine established a set of original diagnostic criteria in 2006 (JAAM DIC). Since then, the usefulness of the JAAM DIC has been repeatedly reported, and these criteria have been widely adopted in emergency and critical care settings in Japan. Different criteria have also been released by the International Society on Thrombosis and Haemostasis (ISTH overt-DIC), and the latter criteria are presently considered to be the international standard. Compared with the JAAM DIC, the ISTH overt-DIC criteria are stricter and the timing of diagnosis is later. This discrepancy is because of conceptual differences. As many physicians think sepsis-associated DIC is the target of anticoagulant therapies in Japan, the JAAM DIC criteria were designed to allow the early initiation of treatment. As other countries do not provide DIC-specific treatments, early diagnosis is not necessary, and this situation has led to a significant gap. However, as overt-DIC is a late-phase coagulation disorder, a need for early detection has been advocated, and members of the ISTH have recently proposed the category of sepsis-induced coagulopathy. In this review, we introduce the strengths and weaknesses of the major criteria including JAAM-DIC, ISTH overt-DIC, sepsis-induced coagulopathy, and Japanese Society on Thrombosis and Haemostasis-DIC.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster MedicineJuntendo University Graduate School of MedicineTokyoJapan
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical MedicineOsaka University Graduate School of MedicineOsakaJapan
| | - Eizo Watanabe
- Department of General Medical Science Graduate School of MedicineChiba UniversityChiba CityJapan
- Department of Emergency and Critical Care MedicineEastern Chiba Medical CenterChibaJapan
| | - Takeshi Wada
- Department of Anesthesiology and Critical Care MedicineDivision of Acute and Critical Care MedicineHokkaido University Graduate School of MedicineSapporoJapan
| | - Kei Hayashida
- Department of Emergency and Critical Care MedicineSchool of MedicineKeio UniversityTokyoJapan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care MedicineTohoku University Graduate School of MedicineSendaiJapan
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18
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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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19
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Luo L, Wu Y, Niu T, Han Y, Feng Y, Ding Q, Huang R, Zhang X, Feng J, Hou M, Peng J, Li Y, Zhou Y, Su L, Yang L, Zhou Z, Xue F, Gu J, Zhu T, Wang X, Deng J, Mei H, Hu Y. A multicenter, prospective evaluation of the Chinese Society of Thrombosis and Hemostasis Scoring System for disseminated intravascular coagulation. Thromb Res 2018; 173:131-140. [PMID: 30529391 DOI: 10.1016/j.thromres.2018.11.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 11/11/2018] [Accepted: 11/22/2018] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Disseminated intravascular coagulation (DIC) is a severe complication of critical conditions. There are several scoring systems used for the diagnosis of DIC, including the International Society on Thrombosis and Hemostasis (ISTH) Overt-DIC criteria, the Japanese Ministry of Health and Welfare (JMHW) criteria and the Chinese Society of Thrombosis and Hemostasis scoring system for DIC (CDSS). The objective of this prospective study was to evaluate the accuracy and predictive value of the CDSS. MATERIALS AND METHODS 1318 patients, aged 18-70 years old and suspected of DIC were enrolled from 18 hospitals across China. Participants were divided into two groups for analysis (group 1, non-hematological diseases; group 2, hematological diseases). 242 patients were excluded because of incomplete data collection and failure to follow-up. RESULTS AND CONCLUSIONS The rates of concordance of diagnosis of DIC between the CDSS and two other scoring systems were close to 80%. The area under ROC curves of CDSS had a slight advantage when using the ISTH, JMHW criteria or prognosis as gold standard, respectively. The CDSS DIC was an independent predictor of mortality, and its odds-ratio was superior or comparable to that of the ISTH and JMHW criteria in the two groups. The CDSS DIC score also had a significant correlation with the APACHE II and SOFA score (p < 0.05). In summary, as a quantification standard of the Chinese experts' consensus, the CDSS is conducive to the standardized diagnosis of DIC because of its favorable diagnostic and prognostic utility.
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Affiliation(s)
- Lili Luo
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yingying Wu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Ting Niu
- Department of Hematology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yue Han
- Department of Hematology, First Affiliated Hospital of Soochow University, Suzhou 215006, China
| | - Ying Feng
- Department of Hematology, Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, China
| | - Qiulan Ding
- Department of laboratory medicine, Ruijin Hospital Affiliated to Shanghai JiaoTong University School of Medicine, Shanghai 200025, China
| | - Ruibin Huang
- Department of Hematology, First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - Xiaohui Zhang
- Department of Hematology, Peking University People's Hospital, Beijing 100044, China
| | - Jianming Feng
- Department of Hematology, Qinghai Provincial People's Hospital, Xining 810007, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital of Shandong University, Jinan 250012, China
| | - Jun Peng
- Department of Hematology, Qilu Hospital of Shandong University, Jinan 250012, China
| | - Yan Li
- Department of Hematology, First Hospital of China Medical University, Shenyang 110001, China
| | - Yuhong Zhou
- Department of Hematology, First Affiliated Hospital of Zhejiang Chinese Medical University, Zhejiang 310006, China
| | - Lei Su
- Department of Intensive Care Unit, General Hospital of Guangzhou Military Command, Guangzhou 510010, China
| | - Linhua Yang
- Department of Hematology, Second Hospital of Shanxi Medical University, Shanxi 030001, China
| | - Zeping Zhou
- Department of Hematology, Second Affiliated Hospital of Kunming Medical College, Kunming 650101, China
| | - Feng Xue
- Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - Jian Gu
- Department of Hematology, Clinical Medical College of Yangzhou University, Jiangsu 225001, China
| | - Tienan Zhu
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Xiaomin Wang
- Department of Hematology, People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang 830001, China
| | - Jun Deng
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Heng Mei
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
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Suzuki K, Wada H, Imai H, Iba T, Thachil J, Toh CH. A re-evaluation of the D-dimer cut-off value for making a diagnosis according to the ISTH overt-DIC diagnostic criteria: communication from the SSC of the ISTH. J Thromb Haemost 2018; 16:1442-1444. [PMID: 29846034 DOI: 10.1111/jth.14134] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Indexed: 11/30/2022]
Affiliation(s)
- K Suzuki
- Emergency Critical Care Center, Mie University School of Medicine, Tsu, Mie, Japan
| | - H Wada
- Department of Molecular and Laboratory Medicine, Mie University School of Medicine, Tsu, Mie, Japan
| | - H Imai
- Emergency Critical Care Center, Mie University School of Medicine, Tsu, Mie, Japan
| | - T Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - J Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| | - C-H Toh
- The Roald Dahl Haemostasis & Thrombosis Centre, Royal Liverpool University Hospital, Liverpool, UK
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21
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Iba T, Arakawa M, Levy JH, Yamakawa K, Koami H, Hifumi T, Sato K. Sepsis-Induced Coagulopathy and Japanese Association for Acute Medicine DIC in Coagulopathic Patients with Decreased Antithrombin and Treated by Antithrombin. Clin Appl Thromb Hemost 2018; 24:1020-1026. [PMID: 29695178 PMCID: PMC6714750 DOI: 10.1177/1076029618770273] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Disseminated intravascular coagulation (DIC) in patients with sepsis represents a critical condition. Thus, a simple and rapid diagnosis is required. The purpose of this study was to compare the performances of a recently developed Sepsis-Induced Coagulopathy (SIC) with the Japanese Association for Acute Medicine (JAAM) DIC. Four hundred nine patients with sepsis having coagulopathy and antithrombin activity of less than 70% and treated with antithrombin were retrospectively analyzed, and the SIC and JAAM-DIC criteria on days 1 (before treatment), 2, 4, and 7 were compared. The prevalence of JAAM-DIC on day 1 was significantly higher than that of SIC (91.4% vs 81.8%, P = .003), but there were no differences on days 2, 4, and 7. The mortality rates in the SIC and JAAM-DIC groups were both 23.3%. The specificity to 28-day mortality on day 1 was higher in the SIC group (15.8% vs 9.2%, P = .013). There were no differences in sensitivity on days 1, 2, 4, and 7. Mortality was significantly different between SIC-positive and SIC-negative groups on days 2, 4, and 7 (P < .01, respectively), while significant differences were seen between JAAM-DIC-positive and JAAM-DIC-negative groups only on days 4 and 7 (P < .05, .01, respectively). In summary, the SIC characteristics were similar to the JAAM-DIC group, and the classifications were comparable in terms of mortality prediction. The SIC scoring system is simple, easy to use, and adaptable to the new sepsis definitions and offers an important approach to evaluating patients in emergency and critical care settings.
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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
| | - Jerrold H Levy
- 2 Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, NC, USA
| | - Kazuma Yamakawa
- 3 Department of Emergency and Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Hiroyuki Koami
- 4 Department of Emergency and Critical Care Medicine, Saga University, Saga, Japan
| | - Toru Hifumi
- 5 Emergency Medical Center, Kagawa University Hospital, Kagawa, Japan
| | - Koichi Sato
- 6 Department of Surgery, Juntendo Shizuoka Hospital, Juntendo University Graduate School of Medicine, Tokyo, Japan
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22
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Louw SJ, Mayne ALH, Mayne ES. Evaluation of the diagnostic utility of individual parameters in the disseminated intravascular coagulation (DIC) panel for use in underresourced settings. Int J Lab Hematol 2018. [PMID: 29532646 DOI: 10.1111/ijlh.12803] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- S J Louw
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.,National Health Laboratory Service, Johannesburg, South Africa
| | - A L H Mayne
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - E S Mayne
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.,National Health Laboratory Service, Johannesburg, South Africa
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Kim HS, Cheon DY, Ha SO, Han SJ, Kim HS, Lee SH, Kim SG, Park S. Early changes in coagulation profiles and lactate levels in patients with septic shock undergoing extracorporeal membrane oxygenation. J Thorac Dis 2018; 10:1418-1430. [PMID: 29707291 DOI: 10.21037/jtd.2018.02.28] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background To investigate the impact of coagulation profiles and lactate levels in patients with septic shock undergoing extracorporeal membrane oxygenation (ECMO). Methods A retrospective analysis of coagulation profiles, including disseminated intravascular coagulation (DIC) score, before and during 48 h of ECMO support [on day 0 (pre-ECMO), day 1, and day 2], was conducted in patients with septic shock undergoing ECMO. Results A total of 37 patients were included, and 15 (40.5%) patients survived. The initial DIC scores did not change in either the pre-ECMO overt-DIC (n=15) or non-overt-DIC (n=22) group after ECMO commencement. However, the DIC scores were significantly higher, at all three time-points, in non-survivors than in survivors. Additionally, the lactate levels improved considerably in the pre-ECMO non-overt-DIC group and in survivors during ECMO support, but not in the pre-ECMO overt DIC group or non-survivors. On a multivariate analysis, the pre-ECMO DIC score was significantly associated with hospital death [odds ratio (OR), 3.935; 95% confidence interval (CI), 1.170-13.230]. Receiver operating characteristic (ROC) curves revealed that the combination of pre-ECMO DIC score plus lactate level was the best predictor of hospital death (area under the curve, 0.879; 0.771-0.987); patients with combined scores >9.35 (the optimal cut-off) exhibited a three-fold higher mortality rate than did those with lower scores (81.8% vs. 26.7%, P=0.001). Conclusions During the early period of ECMO support, the coagulation profiles and lactate levels exhibited different trajectories in survivors and non-survivors. Furthermore, the pre-ECMO DIC score plus lactate level was the best predictor of hospital death.
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Affiliation(s)
- Hyoung Soo Kim
- Department of Cardiothoracic Surgery, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Dae Young Cheon
- Department of Internal Medicine, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Sang Ook Ha
- Department of Emergency Medicine, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Sang Jin Han
- Department of Cardiology, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Hyun-Sook Kim
- Department of Cardiology, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Sun Hee Lee
- Department of Cardiothoracic Surgery, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Sung Gyun Kim
- Department of Nephrology, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Sunghoon Park
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
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24
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Liu J, Li G, Chen C, Chen D, Zhou Q. MiR-6835 promoted LPS-induced inflammation of HUVECs associated with the interaction between TLR-4 and AdipoR1 in lipid rafts. PLoS One 2017; 12:e0188604. [PMID: 29190778 PMCID: PMC5708807 DOI: 10.1371/journal.pone.0188604] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 11/09/2017] [Indexed: 02/07/2023] Open
Abstract
Background High mortality rate of critically-ill patients could be induced by sepsis and septic shock, which is the extremely life threatening. The purpose of this work is to identify and evaluate the potential regulatory mechanism of LPS-induced inflammation associated with miR-6835 and lipid rafts in HUVECs. Methods The 3’ UTR luciferase activity of AdipoR1 was detected, which was predicted the potential target gene of miR-6835. Moreover, the treated HUVECs with or without inhibitors or mimics of miR-6835 were used. Furthermore, the bio-functions of HUVECs were explored. The protein expression levels of SIRT-1, AMPK, and AdipoR1 were assessed, which were involved in the AdipoR1 signaling pathway. Then, the interaction between TLR-4 and AdipoR1 in lipid rafts and its mediation role on LPS-induced inflammation was investigated in HUVECs. Results MiR-6835 targeted directly on AdipoR1, and suppressed its expression in mRNA (mimics of miR-6835: 0.731±0.016 vs control: 1.527±0.015, P<0.001) and proteins levels, then regulated protein expression of SIRT-1 and AMPK, which were the downstream target genes of AdipoR1 signaling pathway. MiR-6835 enhanced LPS-induced inflammation process in HUVECs (TNF-α: LPS+mimics of miR-6835: 1638.51±78.43 vs LPS: 918.73±39.73, P<0.001; IL-6: LPS+mimics of miR-6835: 1249.35±69.51 vs LPS: 687.52±43.64, P<0.001), which was associated with the interaction between TLR-4 and AdipoR1 in lipid rafts. Conclusions MiR-6835 is the key regulator of LPS-induced inflammation process in HUVECs. The interaction between TLR-4 and AdipoR1 mediated by lipid rafts at membrane of HUVECs with inflammation process induced by miR-6835. Our results demonstrated a hopeful strategy for treatment on sepsis by aiming at lipid rafts and miR-6835.
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Affiliation(s)
- Jiao Liu
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, Hubei, People’s Republic of China
| | - Guang Li
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, Hubei, People’s Republic of China
| | - Chuang Chen
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, People’s Republic of China
| | - Dechang Chen
- Department of Emergency and Critical Care Medicine, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, People’s Republic of China
| | - Qingshan Zhou
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, Hubei, People’s Republic of China
- * E-mail:
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25
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Similar but not the same: Differential diagnosis of HLH and sepsis. Crit Rev Oncol Hematol 2017; 114:1-12. [PMID: 28477737 DOI: 10.1016/j.critrevonc.2017.03.023] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 03/17/2017] [Accepted: 03/20/2017] [Indexed: 12/12/2022] Open
Abstract
Differential diagnosis of hemophagocytic lymphohistiocytosis (HLH; hemophagocytic syndrome) and sepsis is critically important because the life-saving aggressive immunosuppressive treatment, required in the effective HLH therapy, is absent in sepsis guidelines. Moreover, HLH may be complicated by sepsis. Hyperinflammation, present in both states, gives an overlapping clinical picture including fever and performance status deterioration. The aim of this review is to provide aid in this challenging diagnostic process. Analysis of clinical features and laboratory results in multiple groups of patients (both adult and pediatric) with either HLH or sepsis allows to propose criteria differentiating these two conditions. The diagnosis of HLH is supported by hyperferritinemia, splenomegaly, marked cytopenias, hypofibrinogenemia, low CRP, characteristic cytokine profile and, only in adults, hypertriglyceridemia. In the presence of these parameters (especially the most characteristic hyperferritinemia), the other HLH criteria should be assessed. Genetic analyses can reveal familial HLH. Hemophagocytosis is neither specific nor sensitive for HLH.
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26
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Toh CH, Alhamdi Y, Abrams ST. Current Pathological and Laboratory Considerations in the Diagnosis of Disseminated Intravascular Coagulation. Ann Lab Med 2017; 36:505-12. [PMID: 27578502 PMCID: PMC5011102 DOI: 10.3343/alm.2016.36.6.505] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 06/21/2016] [Accepted: 07/22/2016] [Indexed: 01/06/2023] Open
Abstract
Systemically sustained thrombin generation in vivo is the hallmark of disseminated intravascular coagulation (DIC). Typically, this is in response to a progressing disease state that is associated with significant cellular injury. The etiology could be infectious or noninfectious, with the main pathophysiological mechanisms involving cross-activation among coagulation, innate immunity, and inflammatory responses. This leads to consumption of both pro- and anticoagulant factors as well as endothelial dysfunction and disrupted homeostasis at the blood vessel wall interface. In addition to the release of tissue plasminogen activator (tPA) and soluble thrombomodulin (sTM) following cellular activation and damage, respectively, there is the release of damage-associated molecular patterns (DAMPs) such as extracellular histones and cell-free DNA. Extracellular histones are increasingly recognized as significantly pathogenic in critical illnesses through direct cell toxicity, the promotion of thrombin generation, and the induction of neutrophil extracellular trap (NET) formation. Clinically, high circulating levels of histones and histone–DNA complexes are associated with multiorgan failure, DIC, and adverse patient outcomes. Their measurements as well as that of other DAMPs and molecular markers of thrombin generation are not yet applicable in the routine diagnostic laboratory. To provide a practical diagnostic tool for acute DIC, a composite scoring system using rapidly available coagulation tests is recommended by the International Society on Thrombosis and Haemostasis. Its usefulness and limitations are discussed alongside the advances and unanswered questions in DIC pathogenesis.
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Affiliation(s)
- Cheng Hock Toh
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom.,Roald Dahl Haemostasis & Thrombosis Centre, Royal Liverpool University Hospital, Liverpool, United Kingdom.
| | - Yasir Alhamdi
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Simon T Abrams
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
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27
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Proposal for new diagnostic criteria for DIC from the Japanese Society on Thrombosis and Hemostasis. Thromb J 2016; 14:42. [PMID: 27708553 PMCID: PMC5039801 DOI: 10.1186/s12959-016-0117-x] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 09/05/2016] [Indexed: 01/15/2023] Open
Abstract
Disseminated intravascular coagulation (DIC) is a serious disease that, in the presence of underlying disease, causes persistent, generalized, marked coagulation activation. Early treatment based on an appropriate diagnosis is very important for improving patients’ prognosis, to which end diagnostic criteria play a key role. Several criteria have been proposed, but each has its strengths and weaknesses, and improved criteria are needed. Widespread use of coagulofibrinolytic markers has elucidated that the pathology of DIC differs greatly as a function of the underlying disease. Thus, discriminating use of DIC diagnostic criteria that take underlying diseases into account is important. DIC diagnostic criteria that are well known in Japan include the Japanese Ministry of Health and Welfare’s old DIC diagnostic criteria (JMHW criteria), the International Society on Thrombosis and Haemostasis’s DIC diagnostic criteria (ISTH criteria), and the Japanese Association for Acute Medicine’s acute-stage DIC diagnostic criteria (JAAM criteria). Those criteria have their respective drawbacks: the sensitivity of the ISTH criteria is poor, the JAAM criteria cannot be applied to all underlying diseases, and the JMHW criteria have poor sensitivity in the case of infections, do not use molecular markers, and result in misdiagnosis. The Japanese Society on Thrombosis and Hemostasis’s newly proposed provisional draft DIC diagnostic criteria (new criteria) use diagnostic criteria classifications of “hematopoietic disorder type”, “infectious type”, and “basic type” based on the underlying pathology. For the hematopoietic disorder type the platelet count is omitted from the score, while for the infectious type, fibrinogen is omitted from the score. Also, points are added if the platelet count decreases with time. In the new criteria, molecular markers and antithrombin activity have been newly included, and as a countermeasure for misdiagnosis, 3 points are deducted if there is liver failure. In this paper, we discuss various problems encountered with DIC diagnosis, and we describe the new criteria together with the events that led to their creation. These new diagnostic criteria take into account the underlying diseases of wide area, and we expect that they will serve clinicians well due to the above adaptations and improvements.
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28
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Chung HY, Hupe DC, Otto GP, Sprenger M, Bunck AC, Dorer MJ, Bockmeyer CL, Deigner HP, Gräler MH, Claus RA. Acid Sphingomyelinase Promotes Endothelial Stress Response in Systemic Inflammation and Sepsis. Mol Med 2016; 22:412-423. [PMID: 27341515 DOI: 10.2119/molmed.2016.00140] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 06/02/2016] [Indexed: 01/08/2023] Open
Abstract
The pathophysiology of sepsis involves activation of acid sphingomyelinase (SMPD1) with subsequent generation of the bioactive mediator ceramide. We herein evaluated the hypothesis that the enzyme exerts biological effects in endothelial stress response. Plasma-secreted sphingomyelinase activity, ceramide generation and lipid raft formation were measured in human microcirculatory endothelial cells (HMEC-1) stimulated with serum obtained from sepsis patients. Clustering of receptors relevant for signal transduction was studied by immuno staining. The role of SMPD1 for macrodomain formation was tested by pharmacological inhibition. To confirm the involvement of the stress enzyme, direct inhibitors (amino bisphosphonates) and specific downregulation of the gene was tested with respect to ADAMTS13 expression and cytotoxicity. Plasma activity and amount of SMPD1 were increased in septic patients dependent on clinical severity. Increased breakdown of sphingomyelin to ceramide in HMECs was observed following stimulation with serum from sepsis patients in vitro. Hydrolysis of sphingomyelin, clustering of receptor complexes, such as the CD95L/Fas-receptor, as well as formation of ceramide enriched macrodomains was abrogated using functional inhibitors (desipramine and NB6). Strikingly, the stimulation of HMECs with serum obtained from sepsis patients or mixture of proinflammatory cytokines resulted in cytotoxicity and ADAMTS13 downregulation which was abrogated using desipramine, amino bisphosphonates and genetic inhibitors. SMPD1 is involved in the dysregulation of ceramide metabolism in endothelial cells leading to macrodomain formation, cytotoxicity and downregulation of ADAMTS13 expression. Functional inhibitors, such as desipramine, are capable to improve endothelial stress response during sepsis and might be considered as a pharmacological treatment strategy to favor the outcome.
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Affiliation(s)
- Ha-Yeun Chung
- Center for Sepsis Control & Care (CSCC), Jena University Hospital, Germany.,Department for Anesthesiology & Intensive Care Medicine, Jena University Hospital, Germany
| | - Daniel C Hupe
- Department for Anesthesiology & Intensive Care Medicine, Jena University Hospital, Germany
| | - Gordon P Otto
- Center for Sepsis Control & Care (CSCC), Jena University Hospital, Germany.,Department for Anesthesiology & Intensive Care Medicine, Jena University Hospital, Germany
| | - Marcel Sprenger
- Department for Anesthesiology & Intensive Care Medicine, Jena University Hospital, Germany
| | - Alexander C Bunck
- Department of Radiology, University Hospital Cologne, Cologne, Germany
| | - Michael J Dorer
- Department for Anesthesiology & Intensive Care Medicine, Jena University Hospital, Germany
| | - Clemens L Bockmeyer
- Department of Nephropathology, University Hospital Erlangen, Erlangen, Germany
| | - Hans-Peter Deigner
- Hochschule Furtwangen University, Faculty Medical and Life Sciences, Villingen-Schwenningen, Germany.,Fraunhofer Institute for Cell Therapy and Immunology IZI, Leipzig, Germany
| | - Markus H Gräler
- Center for Sepsis Control & Care (CSCC), Jena University Hospital, Germany.,Department for Anesthesiology & Intensive Care Medicine, Jena University Hospital, Germany
| | - Ralf A Claus
- Center for Sepsis Control & Care (CSCC), Jena University Hospital, Germany.,Department for Anesthesiology & Intensive Care Medicine, Jena University Hospital, Germany
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29
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Jhang WK, Ha EJ, Park SJ. Evaluation of Disseminated Intravascular Coagulation Scores in Critically Ill Pediatric Patients. Pediatr Crit Care Med 2016; 17:e239-46. [PMID: 27028791 DOI: 10.1097/pcc.0000000000000705] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Disseminated intravascular coagulation is a complex systemic thrombohemorrahgic disorder, which may contribute to organ failure. We aimed to compare the detection rate of the disseminated intravascular coagulation, early in the course of ICU admission, of the two disseminated intravascular coagulation scoring systems defined by International Society on Thrombosis and Hemostasis and Japanese Association for Acute Medicine criteria and the prognostic value of disseminated intravascular coagulation scores in critically ill pediatric patients. DESIGN Single-center retrospective observational study. SETTING PICU in a tertiary care children's hospital. PATIENTS Pediatric patients admitted in the PICU between January 2013 and December 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 191 patients were included. Among them, 15.7% and 29.8% of the patients were diagnosed with disseminated intravascular coagulation by International Society on Thrombosis and Hemostasis and Japanese Association for Acute Medicine criteria, respectively. The diagnostic concordance rate between the International Society on Thrombosis and Hemostasis and Japanese Association for Acute Medicine scoring systems was 52.6%. As the Pediatric Risk of Mortality III, the modified Sequential Organ Failure Assessment, and the Pediatric Multiple Organ Dysfunction Syndrome scores increased, the percentage of patients with disseminated intravascular coagulation increased stepwise. The disseminated intravascular coagulation scores correlated well with these severity scores. Overall, the 28-day mortality was 9.9%. There were significant differences in most variables consisting of the International Society on Thrombosis and Hemostasis and Japanese Association for Acute Medicine scoring systems between survivor and nonsurvivors. Patients detected to have disseminated intravascular coagulation by the International Society on Thrombosis and Hemostasis and Japanese Association for Acute Medicine scoring systems showed higher mortality than patients without disseminated intravascular coagulation. The areas under the receiver operating characteristic curve of the Japanese Association for Acute Medicine score and International Society on Thrombosis and Hemostasis score were 0.788 (95% CI, 0.675-0.900) and 0.716 (95% CI, 0.598-0.834), respectively. CONCLUSIONS Both the International Society on Thrombosis and Hemostasis and the Japanese Association for Acute Medicine scoring systems are useful for detection of the disseminated intravascular coagulation in critically ill pediatric patients. These scores correlate well with other severity scores, including Pediatric Risk of Mortality III, modified Sequential Organ Failure Assessment, and Pediatric Multiple Organ Dysfunction Syndrome. Disseminated intravascular coagulation scores are also significantly associated with 28-day mortality, suggesting that these could be promising prognostic factors.
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Affiliation(s)
- Won Kyoung Jhang
- All authors: Division of Pediatric Critical Care medicine, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
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30
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Park JY, Park S, Park SY, Sim YS, Kim JH, Hwang YI, Jang SH, Jung KS. Day 3 versus Day 1 Disseminated Intravascular Coagulation Score among Sepsis Patients: A Prospective Observational Study. Anaesth Intensive Care 2016; 44:57-64. [DOI: 10.1177/0310057x1604400110] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The role of disseminated intravascular coagulation (DIC) has not been extensively studied in patients with sepsis. A prospective study was performed in a single university hospital. The incidences of DIC at day 1 (<24 hours post-sepsis diagnosis) and day 3 (48 to 72 hours) were investigated among patients with sepsis. The International Society of Thrombosis and Haemostasis criteria for DIC were used. Among 381 patients initially screened, 219 were enrolled in this study and the incidences of overt DIC were 27.9% and 30.1% on day 1 and day 3, respectively. Patients with pneumonia had a lower incidence of DIC on day 1, but a higher hospital mortality rate compared to those with non-pneumonia sepsis. In multivariate models, although day 1 and day 3 DIC scores were not associated with hospital mortality after adjusting for existing severity scores, the change in DIC scores (odds ratio 1.862; 95% confidence interval 1.061 to 3.266) exhibited a significant association. Day 3 DIC scores were more accurate in predicting hospital mortality than day 1 DIC scores ( P <0.001), especially in patients with non-pneumonia sepsis. However, DIC scores did not give additional discriminative power to the existing prognostic scores in predicting mortality of patients with sepsis. In conclusion, the change in DIC score was significantly associated with hospital mortality. Patients with pneumonia sepsis had a lower incidence of DIC on day 1, despite their higher disease severity and mortality rate, compared to those with other sources of sepsis.
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Affiliation(s)
- J. Y. Park
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Seoul, Korea
| | - S. Park
- Division of Pulmonary, Allergy and Critical Care Medicine and Department of Internal Medicine, Hallym University Sacred Heart Hospital, Seoul, Korea
| | - S. Y. Park
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Seoul, Korea
| | - Y. S. Sim
- Division of Pulmonary, Allergy and Critical Care Medicine and Department of Internal Medicine, Kangnam Sacred Heart Hospital, Seoul, Korea
| | - J. H. Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Seoul, Korea
| | - Y. I. Hwang
- Division of Pulmonary, Allergy and Critical Care Medicine and Department of Internal Medicine, Hallym University Sacred Heart Hospital, Seoul, Korea
| | - S. H. Jang
- Division of Pulmonary, Allergy and Critical Care Medicine and Department of Internal Medicine, Hallym University Sacred Heart Hospital, Seoul, Korea
| | - K. S. Jung
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Seoul, Korea
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31
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Kell DB, Pretorius E. The simultaneous occurrence of both hypercoagulability and hypofibrinolysis in blood and serum during systemic inflammation, and the roles of iron and fibrin(ogen). Integr Biol (Camb) 2015; 7:24-52. [PMID: 25335120 DOI: 10.1039/c4ib00173g] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Although the two phenomena are usually studied separately, we summarise a considerable body of literature to the effect that a great many diseases involve (or are accompanied by) both an increased tendency for blood to clot (hypercoagulability) and the resistance of the clots so formed (hypofibrinolysis) to the typical, 'healthy' or physiological lysis. We concentrate here on the terminal stages of fibrin formation from fibrinogen, as catalysed by thrombin. Hypercoagulability goes hand in hand with inflammation, and is strongly influenced by the fibrinogen concentration (and vice versa); this can be mediated via interleukin-6. Poorly liganded iron is a significant feature of inflammatory diseases, and hypofibrinolysis may change as a result of changes in the structure and morphology of the clot, which may be mimicked in vitro, and may be caused in vivo, by the presence of unliganded iron interacting with fibrin(ogen) during clot formation. Many of these phenomena are probably caused by electrostatic changes in the iron-fibrinogen system, though hydroxyl radical (OH˙) formation can also contribute under both acute and (more especially) chronic conditions. Many substances are known to affect the nature of fibrin polymerised from fibrinogen, such that this might be seen as a kind of bellwether for human or plasma health. Overall, our analysis demonstrates the commonalities underpinning a variety of pathologies as seen in both hypercoagulability and hypofibrinolysis, and offers opportunities for both diagnostics and therapies.
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Affiliation(s)
- Douglas B Kell
- School of Chemistry and The Manchester Institute of Biotechnology, The University of Manchester, 131, Princess St, Manchester M1 7DN, Lancs, UK.
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32
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Di Nisio M, Thachil J, Squizzato A. Management of disseminated intravascular coagulation: A survey of the International Society on Thrombosis and Haemostasis. Thromb Res 2015; 136:239-42. [DOI: 10.1016/j.thromres.2015.05.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 05/18/2015] [Accepted: 05/21/2015] [Indexed: 10/23/2022]
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Ekaney ML, Bockmeyer CL, Sossdorf M, Reuken PA, Conradi F, Schuerholz T, Blaess MF, Friedman SL, Lösche W, Bauer M, Claus RA. Preserved Expression of mRNA Coding von Willebrand Factor-Cleaving Protease ADAMTS13 by Selenite and Activated Protein C. Mol Med 2015; 21:355-63. [PMID: 25860876 DOI: 10.2119/molmed.2014.00202] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 04/03/2015] [Indexed: 12/16/2022] Open
Abstract
In sepsis, the severity-dependent decrease of von Willebrand factor (VWF)-inactivating protease, a disintegrin and metalloproteinase with thrombospondin motifs 13 (ADAMTS13), results in platelet aggregation and consumption, leading to sepsis-associated thrombotic microangiopathy (TMA) and organ failure. Previous reports assessing its functional deficiency have pinpointed involvement of autoantibodies or mutations to propagate thrombotic thrombocytopenic purpura (TTP). However, mechanisms of acquired ADAMTS13 deficiency during host response remain unclear. To enhance understanding of ADAMTS13 deficiency in sepsis, we evaluated changes in expression of mRNA coding ADAMTS13 during septic conditions using primary cellular sources of the protease. We hypothesized that proinflammatory cytokines and constituents of serum from septic patients affect the transcriptional level of ADAMTS13 in vitro, and previously recommended therapeutic agents as adjunctive therapy for sepsis interact therewith. Cultured hepatic stellate cells (HSCs), endothelial cells (HMEC) and human precision-cut liver slices as an ex vivo model were stimulated with sepsis prototypic cytokines, bacterial endotoxin and pooled serum obtained from septic patients. Stimulation resulted in a significant decrease in ADAMTS13 mRNA between 10% and 80% of basal transcriptional rates. Costimulation of selenite or recombinant activated protein C (APC) with serum prevented ADAMTS13 decrease in HSCs and increased ADAMTS13 transcripts in HMEC. In archived clinical samples, the activity of ADAMTS13 in septic patients treated with APC (n = 5) increased with an accompanying decrease in VWF propeptide as surrogate for improved endothelial function. In conclusion, proinflammatory conditions of sepsis repress mRNA coding ADAMTS13 and the ameliorating effect by selenite and APC may support the concept for identification of beneficial mechanisms triggered by these drugs at a molecular level.
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Affiliation(s)
- Michael L Ekaney
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany.,Clinic for Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | | | - Maik Sossdorf
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany.,Clinic for Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Philipp A Reuken
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany.,Clinic for Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Florian Conradi
- Clinic for Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Tobias Schuerholz
- Department for Interdisciplinary Intensive Care, University Hospital Aachen, Aachen, Germany
| | - Markus F Blaess
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany.,Clinic for Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Scott L Friedman
- Mount Sinai School of Medicine, New York, New York, United States of America
| | - Wolfgang Lösche
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany.,Clinic for Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Michael Bauer
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany.,Clinic for Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Ralf A Claus
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany.,Clinic for Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
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34
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Levi M. Diagnosis and treatment of disseminated intravascular coagulation. Int J Lab Hematol 2014; 36:228-36. [PMID: 24750668 DOI: 10.1111/ijlh.12221] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Accepted: 02/28/2014] [Indexed: 12/20/2022]
Abstract
Disseminated intravascular coagulation (DIC) is a condition in which systemic activation of coagulation without a specific localization occurs, resulting in extensive formation of intravascular fibrin, particularly in small and midsize vessels. Disseminated intravascular coagulation may lead to several altered coagulation parameters, including a low platelet count, abnormal global clotting assays, low levels of physiological anticoagulant proteases, or increased fibrin degradation products. Also, more complex assays for activation of coagulation factors or pathways may indicate involvement of these molecules in DIC. None of these tests alone, however, can accurately ascertain or rebuff a diagnosis of DIC. Nonetheless, a combination of readily available routine assays may be instrumental in establishing a diagnosis of DIC and can also be useful to point to a subset of patients with DIC that may need definite, often costly, interventions in the hemostatic system. Current insights on relevant etiological pathways that may contribute to the occurrence of DIC have led to innovative therapeutic and adjunctive approaches to patient with DIC. Management options directed at the amelioration of hemostatic activation may tentatively be indicated and were found to be advantageous in experimental and clinical investigations. These treatments encompass elimination of tissue factor-mediated thrombin generation or restitution of normal anticoagulant function.
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Affiliation(s)
- M Levi
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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35
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Yin Q, Liu B, Chen Y, Zhao Y, Li C. Prognostic value of the International Society on Thrombosis and Haemostasis scoring system for overt disseminated intravascular coagulation in emergency department sepsis. Infection 2014; 42:629-37. [PMID: 24557707 DOI: 10.1007/s15010-014-0600-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Accepted: 02/03/2014] [Indexed: 01/16/2023]
Abstract
PURPOSE The International Society on Thrombosis and Haemostasis (ISTH) scoring system is a useful tool to diagnosis overt disseminated intravascular coagulation in clinical practice. The main purposes of this study were to investigate the prognostic value of the ISTH score in emergency department (ED) sepsis and compare the ISTH score with two established scoring systems, the Sequential Organ Failure Assessment (SOFA) score and Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and two biomarkers,procalcitonin (PCT) and C-reactive protein (CRP). METHODS Septic patients were consecutively enrolled from the ED of Beijing Chaoyang Hospital, China. The ISTH score, SOFA score and APACHE II score were calculated, and PCT and CRP levels were measured on enrollment. A 30-day follow-up was performed. RESULTS A total of 680 septic patients were enrolled in this study. The Cox regression analysis showed that the ISTH score had a greater effect on 30-day mortality prediction, and the receiver operating characteristic curve analysis showed that the accuracy of the ISTH score in prediction of 30-day mortality was better than the SOFA score, the APACHE II score, PCT and CRP. Combination of the ISTH score and CRP can enhance the predictive accuracy of 30-day mortality. CONCLUSION The ISTH score is a valuable scoring system in the prognosis evaluation in ED sepsis.
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Affiliation(s)
- Q Yin
- Emergency Department of Beijing Chaoyang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Beijing, 100020, China
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36
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Koyama K, Madoiwa S, Nunomiya S, Koinuma T, Wada M, Sakata A, Ohmori T, Mimuro J, Sakata Y. Combination of thrombin-antithrombin complex, plasminogen activator inhibitor-1, and protein C activity for early identification of severe coagulopathy in initial phase of sepsis: a prospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R13. [PMID: 24410881 PMCID: PMC4056264 DOI: 10.1186/cc13190] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 01/06/2014] [Indexed: 02/04/2023]
Abstract
Introduction Current criteria for early diagnosis of coagulopathy in sepsis are limited. We postulated that coagulopathy is already complicated with sepsis in the initial phase, and severe coagulopathy or disseminated intravascular coagulation (DIC) becomes overt after progressive consumption of platelet and coagulation factors. To determine early diagnostic markers for severe coagulopathy, we evaluated plasma biomarkers for association with subsequent development of overt DIC in patients with sepsis. Methods A single-center, prospective observational study was conducted in an adult ICU at a university hospital. Plasma samples were obtained from patients with sepsis at ICU admission. Fourteen biomarkers including global markers (platelet count, prothrombin time, activated partial thromboplastin time, fibrinogen and fibrin degradation product (FDP)); markers of thrombin generation (thrombin-antithrombin complex (TAT) and soluble fibrin); markers of anticoagulants (protein C (PC) and antithrombin); markers of fibrinolysis (plasminogen, α2-plasmin inhibitor (PI), plasmin-α2-PI complex, and plasminogen activator inhibitor (PAI)-1); and a marker of endothelial activation (soluble E-selectin) were assayed. Patients who had overt DIC at baseline were excluded, and the remaining patients were followed for development of overt DIC in 5 days, and for mortality in 28 days. Results A total of 77 patients were enrolled, and 37 developed overt DIC within the following 5 days. Most patients demonstrated hemostatic abnormalities at baseline with 98.7% TAT, 97.4% FDP and 88.3% PC. Most hemostatic biomarkers at baseline were significantly associated with subsequent development of overt DIC. Notably, TAT, PAI-1 and PC discriminated well between patients with and without developing overt DIC (area under the receiver operating characteristic curve (AUROC), 0.77 (95% confidence interval, 0.64 to 0.86); 0.87 (0.78 to 0.92); 0.85 (0.76 to 0.91), respectively), and using the three together, significantly improved the AUROC up to 0.95 (vs. TAT, PAI-1, and PC). Among the significant diagnostic markers for overt DIC, TAT and PAI-1 were also good predictors of 28-day mortality (AUROC, 0.77 and 0.81, respectively). Conclusions Severe coagulation and fibrinolytic abnormalities on ICU admission were associated with subsequent development of overt DIC. A single measurement of TAT, PAI-1, and PC activity could identify patients with ongoing severe coagulopathy, early in the course of sepsis.
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Gando S, Saitoh D, Ogura H, Fujishima S, Mayumi T, Araki T, Ikeda H, Kotani J, Kushimoto S, Miki Y, Shiraishi SI, Suzuki K, Suzuki Y, Takeyama N, Takuma K, Tsuruta R, Yamaguchi Y, Yamashita N, Aikawa N. A multicenter, prospective validation study of the Japanese Association for Acute Medicine disseminated intravascular coagulation scoring system in patients with severe sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R111. [PMID: 23787004 PMCID: PMC4056654 DOI: 10.1186/cc12783] [Citation(s) in RCA: 142] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 06/20/2013] [Indexed: 12/28/2022]
Abstract
Introduction To validate the Japanese Association for Acute Medicine (JAAM) disseminated intravascular coagulation (DIC) scoring system in patients with severe sepsis, we conducted a multicenter, prospective study at 15 critical care centers in tertiary care hospitals. Methods This study included 624 severe sepsis patients. JAAM DIC was scored on the day of diagnosis of severe sepsis (day 1) and day 4. Scores for disease severity and organ dysfunction were also evaluated. Results The prevalence of JAAM DIC was 46.8% (292/624), and 21% of the DIC patients were scored according to the reduction rate of platelets. The JAAM DIC patients were more seriously ill and exhibited more severe systemic inflammation, a higher prevalence of multiple organ dysfunction syndrome (MODS) and worse outcomes than the non-DIC patients. Disease severity, systemic inflammation, MODS and the mortality rate worsened in accordance with an increased JAAM DIC score on day 1. The Kaplan-Meier curves demonstrated lower 1-year survival in the JAAM DIC patients than in those without DIC (log-rank test P <0.001). The JAAM DIC score on day 1 (odds ratio = 1.282, P <0.001) and the Delta JAAM DIC score (odds ratio = 0.770, P <0.001) were independent predictors of 28-day death. Dynamic changes in the JAAM DIC score from days 1 to 4 also affected prognoses. The JAAM DIC scoring system included all patients who met the International Society on Thrombosis and Haemostasis overt DIC criteria on day 1. The International Society on Thrombosis and Haemostasis scoring system missed a large number of nonsurvivors recognized by the JAAM scoring system. Conclusions The JAAM DIC scoring system exhibits good prognostic value in predicting MODS and poor prognosis in patients with severe sepsis and can detect more patients requiring treatment. Conducting repeated daily JAAM scoring increases the ability to predict the patient's prognosis.
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Koyama K, Madoiwa S, Tanaka S, Koinuma T, Wada M, Sakata A, Ohmori T, Mimuro J, Nunomiya S, Sakata Y. Evaluation of hemostatic biomarker abnormalities that precede platelet count decline in critically ill patients with sepsis. J Crit Care 2013; 28:556-63. [PMID: 23583072 DOI: 10.1016/j.jcrc.2012.10.069] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 10/07/2012] [Accepted: 10/30/2012] [Indexed: 02/04/2023]
Abstract
PURPOSE The hemostatic biomarkers for early diagnosis of sepsis-associated coagulopathy have not been identified. The purpose of this study was to evaluate hemostatic biomarker abnormalities preceding a decrease in platelet count, which is a surrogate indicator of overt coagulopathy in sepsis. MATERIALS AND METHODS Seventy-five septic patients with a platelet count more than 80×10(3)/μL were retrospectively analyzed. Hemostatic biomarkers at intensive care unit admission were compared between patients with and patients without a subsequent decrease in platelet count (≥30% within 5 days), and the ability of biomarkers to predict a decrease in platelet count was evaluated. RESULTS Forty-two patients (56.0%) developed a subsequent decrease in platelet count. Severity of illness, incidence of organ dysfunction, and 28-day mortality rate were higher in patients with a subsequent decrease in platelet count. There were significant differences between patients with and patients without a subsequent decrease in platelet count in prothrombin time-international normalized ratio, fibrinogen, thrombin-antithrombin complex, antithrombin, protein C (PC), plasminogen, and α2-plasmin inhibitor (α2-PI). Receiver operating characteristic curve analysis showed that PC (area under the curve, 0.869; 95% confidence interval, 0.699-0.951) and α2-PI (area under the curve, 0.885; 95% confidence interval, 0.714-0.959) were strong predictors of a subsequent decrease in platelet count. CONCLUSIONS Decreased PC and α2-PI activity preceded a decrease in platelet count in intensive care unit patients with sepsis.
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Affiliation(s)
- Kansuke Koyama
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, Tochigi, Japan; Research Division of Cell and Molecular Medicine, Center of Molecular Medicine, Jichi Medical University School of Medicine, Tochigi, Japan.
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Toh CH, Alhamdi Y. Current consideration and management of disseminated intravascular coagulation. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2013; 2013:286-291. [PMID: 24319193 DOI: 10.1182/asheducation-2013.1.286] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Disseminated intravascular coagulation (DIC) is a devastating clinical condition that is characterized by the loss of normal hemostatic control in response to sustained and systemic cell injury. The inciting injury may be from infection, trauma, or malignancy, but the consequent pathophysiology is multifactorial involving intertwined feedback loops between the coagulant, immune, and inflammatory pathways. Central to this is thrombin generation, but the ubiquitous nature of its in vivo functional consequences can make it difficult to dissect away the separate but overlapping components to the clinical problem. Therefore, early recognition and resolution of the precipitating events leading to DIC remains the central tenet to clinical care. This article refreshes our conceptual understanding of DIC pathogenesis and draws in recent advances in the cycle of cell death caused by extracellular nuclear proteins. It also aims to delineate recognition of response pathways that can be predominantly procoagulant or profibrinolytic to enable a more personalized and evidence-based approach to be delivered to the patient with DIC.
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Affiliation(s)
- Cheng Hock Toh
- 1Roald Dahl Haemostasis and Thrombosis Centre, Royal Liverpool University Hospital, Liverpool, United Kingdom; and
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Blome S, Meindl-Böhmer A, Nowak G, Moennig V. Disseminated intravascular coagulation does not play a major role in the pathogenesis of classical swine fever. Vet Microbiol 2012; 162:360-368. [PMID: 23107658 DOI: 10.1016/j.vetmic.2012.10.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2012] [Revised: 09/28/2012] [Accepted: 10/05/2012] [Indexed: 11/25/2022]
Abstract
Classical swine fever (CSF) is a multi-systemic disease that can be accompanied by severe haemorrhagic lesions. The underlying pathogenetic mechanisms are still far from being understood, though disseminated intravascular coagulation (DIC) was discussed as a major factor. In the presented study, the direct thrombin inhibitor hirudin was used in an attempt to elucidate the role of the coagulation system in the pathogenesis of CSF-induced haemorrhagic lesions. Two groups of piglets (n=5) were infected with highly virulent CSF virus (CSFV) strain CSF0634. One group underwent daily treatment with hirudin, the other served as untreated challenge infection control. Assessment of clinical signs using a clinical score system, coagulation tests, and blood counts were performed daily. Both groups developed acute-lethal CSF with haemorrhagic lesions. Although changes in the coagulation system were seen in the late stages of CSFV infection, our results strongly suggest that DIC does not present the crucial event in the pathogenesis of haemorrhagic lesions.
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Affiliation(s)
- Sandra Blome
- Institute of Diagnostic Virology, Friedrich-Loeffler-Institute, Suedufer 10, 17493 Greiswald, Insel Riems, Germany.
| | - Alexandra Meindl-Böhmer
- Lower Saxony State Office for Consumer Protection and Food Safety, Veterinarian Task Force, 26029 Oldenburg, Germany
| | - Götz Nowak
- Research Unit "Pharmacological Hemostaseology", Friedrich Schiller University Jena, Drackendorfer Str. 1, 07747 Jena, Germany
| | - Volker Moennig
- Institute for Virology, Department of Infectious Diseases, University of Veterinary Medicine Hannover, Buenteweg 17, 30559 Hannover, Germany
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Di Nisio M, Baudo F, Cosmi B, D'Angelo A, De Gasperi A, Malato A, Schiavoni M, Squizzato A. Diagnosis and treatment of disseminated intravascular coagulation: Guidelines of the Italian Society for Haemostasis and Thrombosis (SISET). Thromb Res 2012; 129:e177-84. [DOI: 10.1016/j.thromres.2011.08.028] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Revised: 08/21/2011] [Accepted: 08/28/2011] [Indexed: 02/08/2023]
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Levi M, Schultz M, van der Poll T. Coagulation biomarkers in critically ill patients. Crit Care Clin 2011; 27:281-97. [PMID: 21440202 DOI: 10.1016/j.ccc.2010.12.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This article discusses coagulation biomarkers in critically ill patients where coagulation abnormalities occur frequently and may have a major impact on the outcome. An adequate explanation for the cause is important, since many underlying disorders may require specific treatment and supportive therapy directed at the underlying condition. Deficiencies in platelets and coagulation factors in bleeding patients or patients at risk for bleeding can be achieved by transfusion of platelet concentrate or plasma products, respectively. Prohemostatic treatment may be beneficial in case of severe bleeding, whereas restoring physiological anticoagulant pathways may be helpful in patients with sepsis and disseminated intravascular coagulation.
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Affiliation(s)
- Marcel Levi
- Department of Vascular Medicine and Internal Medicine, Academic Medical Centre F-4, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Kawasugi K, Wada H, Hatada T, Okamoto K, Uchiyama T, Kushimoto S, Seki Y, Okamura T, Nobori T. Prospective evaluation of hemostatic abnormalities in overt DIC due to various underlying diseases. Thromb Res 2011; 128:186-90. [PMID: 21429565 DOI: 10.1016/j.thromres.2011.02.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Revised: 02/15/2011] [Accepted: 02/20/2011] [Indexed: 01/03/2023]
Abstract
Patients with suspected disseminated intravascular coagulation (DIC) were prospectively evaluated for various types of underlying diseases, and the usefulness of hemostatic markers were examined for each patient with DIC due to various underlying diseases. The main underlying disease of DIC was infectious diseases, hematologic malignancies, and solid tumors, and a high resolution rate from DIC was observed in obstetric diseases and hematologic malignancies. The diagnosis of DIC was related to a poor outcome in trauma/burn victims and those with infectious disease. In the main underlying disease, it is suggested that DIC would be excluded in patients with hematologic malignancies or solid tumors with a platelet count of more than 100,000/μl and in the patients with an FDP of less than 10 μg/ml, and fibrinogen of less than 100mg/dl, suggesting the presence of DIC. The prothrombin time was a sensitive marker, but fibrinogen levels were not sensitive for DIC due to infectious diseases. The plasmin plasmin inhibitor complex in hematologic malignancy, and soluble fibrin monomer complex, antithrombin and thrombomodulin in patients with infectious disease, were sensitive markers for the diagnosis of DIC. Although hemostatic markers were useful for the diagnosis of DIC, the usefulness varied depending on the different underlying diseases.
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Affiliation(s)
- Kazuo Kawasugi
- Department of Internal Medicine, Teikyo University School of Medicine, Itabashi
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Lee JH, Song J. Diagnosis of non-overt disseminated intravascular coagulation made according to the International Society on Thrombosis and Hemostasis criteria with some modifications. THE KOREAN JOURNAL OF HEMATOLOGY 2010; 45:260-3. [PMID: 21253428 PMCID: PMC3023052 DOI: 10.5045/kjh.2010.45.4.260] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Revised: 11/22/2010] [Accepted: 12/14/2010] [Indexed: 11/17/2022]
Abstract
Background An early diagnosis of disseminated intravascular coagulation (DIC) before its progression to an overt stage is necessary for early treatment and positive outcomes. In 2001, the Scientific and Standardization Committee (SCC) of the International Society on Thrombosis and Hemostasis (ISTH) proposed new criteria for the preclinical diagnosis of overt and non-overt DICs. We investigated the clinical usefulness of the modified ISTH criteria for non-overt DIC diagnosis. Methods We enrolled 296 DIC patients (170 males and 126 females) admitted and evaluated at the Gangnam Severance Hospital, Seoul, Korea, between March 2006 and April 2007. Hemostatic tests, including platelet counts, prothrombin time (PT), D-dimer levels with antithrombin, and protein-C levels, were evaluated by excluding negative scores with clinical signs, in which more than 5 points of interest denoted non-overt DIC. Mortality rates were also evaluated. Results There were 289 patients with increased D-dimer levels and significant parametric changes suggesting DIC progression. Protein C and antithrombin levels were lower (99.2% each) and appeared earlier in patients with non-overt DIC than in patients with overt DIC. In all, 125 (43.3%) patients had non-overt DIC and, of which 27 died (mortality rate, 21.6%). The sensitivity and specificity for mortality were 73.0% and 55.9%, respectively, which were same as those for the original ISTH criteria. Conclusion The modified ISTH criteria can be used for the early detection of non-overt DIC, and may be useful for the improvement of outcomes of non-overt DIC patients.
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Affiliation(s)
- Jong Hwa Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Wada H, Hatada T, Okamoto K, Uchiyama T, Kawasugi K, Mayumi T, Gando S, Kushimoto S, Seki Y, Madoiwa S, Okamura T, Toh CH. Modified non-overt DIC diagnostic criteria predict the early phase of overt-DIC. Am J Hematol 2010; 85:691-4. [PMID: 20645433 DOI: 10.1002/ajh.21783] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Diagnostic criteria for non-overt disseminated intravascular coagulation (DIC) have been proposed by the International Society of Thrombosis and Hemostasis, but are not useful for the diagnosis of early phase of overt-DIC (pre-DIC). Therefore, in the current study the non-overt DIC diagnostic criteria were modified using the global coagulation tests, the change rate in the global coagulation tests and molecular hemostatic markers to detect the pre-DIC state and were prospectively evaluated in 613 patients with underlying DIC disease. The frequencies of patients with DIC (DIC positive), late onset DIC, and without DIC (DIC absent) were 29.5%, 7.2%, and 63.3%, respectively. The modified non-overt-DIC criteria can correctly predict 43/44 patients (97.7%) who were DIC absent at admission and became DIC positive, within a week (late onset DIC state). The mortality rate was higher in DIC positive compared with pre-DIC (37.6% vs. 22.7%, P < 0.05) or DIC negative (37.6 vs. 13.7%, P < 0.01). It was also significantly higher in pre-DIC compared with DIC negative (P < 0.05). Thus, these modified non-overt DIC diagnostic criteria might therefore be useful for the diagnosis of early-phase DIC.
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Affiliation(s)
- Hideo Wada
- Department of Molecular and Laboratory Medicine, Mie University School of Medicine, Tsu, Mie, Japan.
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Fischer CM, Yano K, Aird WC, Shapiro NI. Abnormal coagulation tests obtained in the emergency department are associated with mortality in patients with suspected infection. J Emerg Med 2010; 42:127-32. [PMID: 20542399 DOI: 10.1016/j.jemermed.2010.05.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2009] [Revised: 12/07/2009] [Accepted: 05/02/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND Early recognition of acute organ dysfunction in emergency department (ED) patients with suspected infection may help select patients at increased risk of mortality. The hematologic system is often overlooked in the evaluation and management of patients with infection because it is poorly circumscribed and serves a multitude of functions. STUDY OBJECTIVES We examine the hypothesis that abnormalities in commonly and easily obtained markers of coagulation function (international normalized ratio [INR], partial thromboplastin time [PTT], and platelet count [PLT]) are associated with mortality in ED patients admitted to the hospital with suspected infection. METHODS DESIGN Secondary analysis of a prospective observational cohort study. SETTING Urban tertiary care university hospital with 50,000 annual ED visits. PATIENTS Included patients: adults (age 18 ≥ years) evaluated in the ED for a suspected infection, had an INR, PTT, and PLT obtained during the ED stay, admitted to the hospital. Excluded patients: on oral anticoagulant therapy, received heparin, or pre-existing severe liver disease. RESULTS There were 1688 patients included. The in-hospital mortality rate was 5.9%. After adjusting for elderly status, comorbid illness burden, and severity of illness, elevated INR was associated with a 2.9 (95% confidence interval [CI] 1.6-5.2) increased odds of death, and a low platelet count (< 150,000/uL) was associated with 2.0 (95% CI 1.2-3.3) increased odds of death. The C-statistic for the model was 0.80. CONCLUSION We found an independent association between abnormalities in the coagulation system and mortality in ED patients with suspected infection. These findings underscore the close interaction between inflammation and coagulation and provide evidence that these simple laboratory tests should be routinely considered during the early evaluation of the infected patient.
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Affiliation(s)
- Christopher M Fischer
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Complement inhibition decreases the procoagulant response and confers organ protection in a baboon model of Escherichia coli sepsis. Blood 2010; 116:1002-10. [PMID: 20466856 DOI: 10.1182/blood-2010-02-269746] [Citation(s) in RCA: 137] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Severe sepsis leads to massive activation of coagulation and complement cascades that could contribute to multiple organ failure and death. To investigate the role of the complement and its crosstalk with the hemostatic system in the pathophysiology and therapeutics of sepsis, we have used a potent inhibitor (compstatin) administered early or late after Escherichia coli challenge in a baboon model of sepsis-induced multiple organ failure. Compstatin infusion inhibited sepsis-induced blood and tissue biomarkers of complement activation, reduced leucopenia and thrombocytopenia, and lowered the accumulation of macrophages and platelets in organs. Compstatin decreased the coagulopathic response by down-regulating tissue factor and PAI-1, diminished global blood coagulation markers (fibrinogen, fibrin-degradation products, APTT), and preserved the endothelial anticoagulant properties. Compstatin treatment also improved cardiac function and the biochemical markers of kidney and liver damage. Histologic analysis of vital organs collected from animals euthanized after 24 hours showed decreased microvascular thrombosis, improved vascular barrier function, and less leukocyte infiltration and cell death, all consistent with attenuated organ injury. We conclude that complement-coagulation interplay contributes to the progression of severe sepsis and blocking the harmful effects of complement activation products, especially during the organ failure stage of severe sepsis is a potentially important therapeutic strategy.
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Okamoto K, Wada H, Hatada T, Uchiyama T, Kawasugi K, Mayumi T, Gando S, Kushimoto S, Seki Y, Madoiwa S, Asakura H, Koga S, Iba T, Maruyama I. Frequency and hemostatic abnormalities in pre-DIC patients. Thromb Res 2010; 126:74-8. [PMID: 20452653 DOI: 10.1016/j.thromres.2010.03.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Revised: 03/23/2010] [Accepted: 03/28/2010] [Indexed: 11/29/2022]
Abstract
Disseminated intravascular coagulation (DIC) sometimes has a poor outcome, and therefore early diagnosis and treatment are required. This study prospectively evaluated the hemostatic abnormalities and the onset of DIC in 613 patients with underlying diseases to identify a useful marker for diagnosing Pre-DIC. Pre-DIC was defined as the condition of patients within a week before the onset of DIC. Initially, 34.4% of patients were diagnosed with DIC, and about 8.5% of the patients without DIC were diagnosed as DIC within a week after registration (pre-DIC). The mortality of DIC, Pre-DIC and "without DIC" was 35.3%, 32.4% and 17.2%, respectively. All hemostatic parameters were significantly worse in "DIC" than "without DIC" and the values of the prothrombin time ratio, platelet count and fibrin monomer complex could classify the three groups; "DIC", "pre-DIC" and "without DIC". No useful marker was identified that provided an adequate cutoff value to differentiate "pre-DIC" from "without DIC". A multivariate analysis identified clinical symptoms that were related to poor outcome. DIC must be treated immediately; there is no specific marker to identify pre-DIC.
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Affiliation(s)
- Kohji Okamoto
- First Department of Surgery, University of Occupational and Environmental Health School of Medicine, KitaKyushu, Japan
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Koseoglu Z, Ozkan OV, Semerci E, Aslan A, Yetim I, Ucar E, Kuvandik G, Temiz M, Borazan A. The relationship between mortality and inflammation in patients with gastrointestinal bleeding. J Int Med Res 2010; 37:1508-14. [PMID: 19930858 DOI: 10.1177/147323000903700528] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The objective of this study was to investigate the association between mortality and inflammation in patients who were admitted to the emergency room with gastrointestinal bleeding. Patients (n = 96) managed at two medical centres were included in the study. Initial levels of serum C-reactive protein (CRP), haemoglobin and albumin, and leucocyte and thrombocyte counts for 28 patients who died were compared with those for the 68 patients who survived and were successfully discharged. The data were analysed using the chi(2)-test. Serum levels of CRP and leucocyte counts were significantly higher, and albumin and haemoglobin were significantly lower in patients who died compared with patients who survived. The increased levels of serum CRP and leucocyte counts, and decreased levels of albumin and haemoglobin were found to be independent risk factors for mortality. It is concluded that increased serum CRP levels and leucocyte counts combined with decreased albumin and haemoglobin levels on admission to the emergency room may be used as predictive factors of mortality in patients with gastrointestinal bleeding.
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Affiliation(s)
- Zikret Koseoglu
- Department of Emergency Medicine, Adana Numune Education and Research Hospital, Adana, Turkey.
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Evaluation of modified non-overt DIC criteria on the prediction of poor outcome in patients with sepsis. Thromb Res 2010; 126:18-23. [PMID: 20079919 DOI: 10.1016/j.thromres.2009.12.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Revised: 11/09/2009] [Accepted: 12/02/2009] [Indexed: 11/21/2022]
Abstract
BACKGROUND The diagnostic performance of modified criteria for non-overt disseminated intravascular coagulation (DIC) with the addition of antithrombin (AT) levels, protein C (PC) levels, and organ system failure scoring (OSF) to the International Society on Thrombosis and Hemostasis (ISTH) criteria for non-overt DIC was studied to determine the effect on predicting poor outcome in patients with sepsis. METHODS In total, 135 consecutive patients were studied. Hemostatic markers (platelet count, prothrombin time, D-dimer, AT, PC) were examined on days 0, 1, 2, 3, 4, and 7. ISTH overt and non-overt DIC scoring, OSF, and 28-day mortality were analyzed. RESULTS The numbers of patients with overt DIC, non-overt DIC and non-DIC were 42, 17 and 76 respectively. The 28-day mortality rates for ISTH overt DIC, ISTH non-overt DIC, and non-DIC were 47.6, 47.1, and 9.2%, respectively. By adding AT and PC to the ISTH non-overt DIC criteria, the 28-day mortality rate of overt DIC, non-overt DIC, and non-DIC changed to 47.6, 25.0, and 6.7%, respectively. By adding OSF to the ISTH non-overt DIC criteria to predict 28-day mortality in septic patients, receiver operating characteristic (ROC) curve analysis demonstrated that the area under the curve (AUC) of ISTH non-overt DIC (0.777) was significantly increased to 0.878 (P=0.018). However, neither AT nor PC increased the AUC. CONCLUSIONS Addition of OSF to the ISTH criteria for non-overt DIC gives a better prediction of poor outcome in patients with sepsis.
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