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Xie HG, Jiang LP, Tai T, Ji JZ, Mi QY. The Complement System and C4b-Binding Protein: A Focus on the Promise of C4BPα as a Biomarker to Predict Clopidogrel Resistance. Mol Diagn Ther 2024; 28:189-199. [PMID: 38261250 DOI: 10.1007/s40291-023-00691-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2023] [Indexed: 01/24/2024]
Abstract
The complement system plays a dual role in the body, either as a first-line defense barrier when balanced between activation and inhibition or as a potential driver of complement-associated injury or diseases when unbalanced or over-activated. C4b-binding protein (C4BP) was the first circulating complement regulatory protein identified and it functions as an important complement inhibitor. C4BP can suppress the over-activation of complement components and prevent the complement system from attacking the host cells through the binding of complement cleavage products C4b and C3b, working in concert as a cofactor for factor I in the degradation of C4b and C3b, and consequently preventing or reducing the assembly of C3 convertase and C5 convertase, respectively. C4BP, particularly C4BP α-chain (C4BPα), exerts its unique inhibitory effects on complement activation and opsonization, systemic inflammation, and platelet activation and aggregation. It has long been acknowledged that crosstalk or interplay exists between the complement system and platelets. Our unpublished preliminary data suggest that circulating C4BPα exerts its antiplatelet effects through inhibition of both complement activity levels and complement-induced platelet reactivity. Plasma C4BPα levels appear to be significantly higher in patients sensitive to, rather than resistant to, clopidogrel, and we suggest that a plasma C4BPα measurement could be used to predict clopidogrel resistance in the clinical settings.
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Affiliation(s)
- Hong-Guang Xie
- Division of Clinical Pharmacology, General Clinical Research Center, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing, 210006, China.
| | - Li-Ping Jiang
- Division of Clinical Pharmacology, General Clinical Research Center, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing, 210006, China
| | - Ting Tai
- Division of Clinical Pharmacology, General Clinical Research Center, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing, 210006, China
| | - Jin-Zi Ji
- Division of Clinical Pharmacology, General Clinical Research Center, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing, 210006, China
| | - Qiong-Yu Mi
- Division of Clinical Pharmacology, General Clinical Research Center, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing, 210006, China
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Pharmacological Management of Atypical Hemolytic Uremic Syndrome in Pediatric Patients: Current and Future. Paediatr Drugs 2023; 25:193-202. [PMID: 36637720 PMCID: PMC9839393 DOI: 10.1007/s40272-022-00555-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2022] [Indexed: 01/14/2023]
Abstract
Atypical hemolytic uremic syndrome is a thrombotic microangiopathy characterized by hemolysis, thrombocytopenia, and acute kidney injury, usually caused by alternative complement system overactivation due to pathogenic genetic variants or antibodies to components or regulatory factors in this pathway. Previously, a lack of effective treatment for this condition was associated with mortality, end-stage kidney disease, and the risk of disease recurrence after kidney transplantation. Plasma therapy has been used for atypical hemolytic uremic syndrome treatment with inconsistent results. Complement-blocking treatment changed the outcome and prognosis of patients with atypical hemolytic uremic syndrome. Early administration of eculizumab, a monoclonal C5 antibody, leads to improvements in hematologic, kidney, and systemic manifestations in patients with atypical hemolytic uremic syndrome, even with apparent dialysis dependency. Pre- and post-transplant use of eculizumab is effective in the prevention of atypical hemolytic uremic syndrome recurrence. Evidence on eculizumab use in secondary hemolytic uremic syndrome cases is controversial. Recent data favor the restrictive use of eculizumab in carefully selected atypical hemolytic uremic syndrome cases, but close monitoring for relapse after drug discontinuation is emphasized. Prophylaxis for meningococcal infection is important. The long-acting C5 monoclonal antibody ravulizumab is now approved for atypical hemolytic uremic syndrome treatment, enabling a reduction in the dosing frequency and improving the quality of life in patients with atypical hemolytic uremic syndrome. New strategies for additional and novel complement blockage medications in atypical hemolytic uremic syndrome are under investigation.
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Moore HB, Neal MD, Bertolet M, Joughin BA, Yaffe MB, Barrett CD, Bird MA, Tracy RP, Moore EE, Sperry JL, Zuckerbraun BS, Park MS, Cohen MJ, Wisniewski SR, Morrissey JH. Proteomics of Coagulopathy Following Injury Reveals Limitations of Using Laboratory Assessment to Define Trauma-Induced Coagulopathy to Predict Massive Transfusion. ANNALS OF SURGERY OPEN 2022; 3:e167. [PMID: 36177090 PMCID: PMC9514137 DOI: 10.1097/as9.0000000000000167] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 04/18/2022] [Indexed: 10/18/2022] Open
Abstract
Objective Trauma-induced coagulopathy (TIC) is provoked by multiple mechanisms and is perceived to be one driver of massive transfusions (MT). Single laboratory values using prothrombin time (INR) or thrombelastography (TEG) are used to clinically define this complex process. We used a proteomics approach to test whether current definitions of TIC (INR, TEG, or clinical judgement) are sufficient to capture the majority of protein changes associated with MT. Methods Eight level-I trauma centers contributed blood samples from patients available early after injury. TIC was defined as INR >1.5 (INR-TIC), TEG maximum amplitude <50mm (TEG-TIC), or clinical judgement (Clin-TIC) by the trauma surgeon. MT was defined as > 10 units of red blood cells in 24 hours or > 4 units RBC/hour during the first 4 hr. SomaLogic proteomic analysis of 1,305 proteins was performed. Pathways associated with proteins dysregulated in patients with each TIC definition and MT were identified. Results Patients (n=211) had a mean injury severity score of 24, with a MT and mortality rate of 22% and 12%, respectively. We identified 578 SOMAscan analytes dysregulated among MT patients, of which INR-TIC, TEG-TIC, and Clin-TIC patients showed dysregulation only in 25%, 3%, and 4% of these, respectively. TIC definitions jointly failed to show changes in 73% of the protein levels associated with MT, and failed to identify 26% of patients that received a massive transfusion. INR-TIC and TEG-TIC patients showed dysregulation of proteins significantly associated with complement activity. Proteins dysregulated in Clin-TIC or massive transfusion patients were not significantly associated with any pathway. Conclusion These data indicate there are unexplored opportunities to identify patients at risk for massive bleeding. Only a small subset of proteins that are dysregulated in patients receiving MT are statistically significantly dysregulated among patients whose TIC is defined based solely on laboratory measurements or clinical assessment.
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Affiliation(s)
- Hunter B. Moore
- From the Department of Surgery, University of Colorado, Denver, CO
| | - Matthew D. Neal
- Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Marnie Bertolet
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA
| | - Brian A. Joughin
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA
- Koch Institute for Integrative Cancer Research at MIT, Cambridge, MA
- Center for Precision Cancer Medicine
| | - Michael B. Yaffe
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA
- Koch Institute for Integrative Cancer Research at MIT, Cambridge, MA
- Center for Precision Cancer Medicine
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Cambridge, MA
| | - Christopher D. Barrett
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA
- Koch Institute for Integrative Cancer Research at MIT, Cambridge, MA
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Cambridge, MA
| | - Molly A. Bird
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA
- Koch Institute for Integrative Cancer Research at MIT, Cambridge, MA
- Center for Precision Cancer Medicine
| | - Russell P. Tracy
- University of Vermont, Department of Biochemistry, Burlington, VT
| | - Ernest E Moore
- From the Department of Surgery, University of Colorado, Denver, CO
- Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO
| | - Jason L. Sperry
- Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Brian S. Zuckerbraun
- Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Myung S. Park
- Department of Surgery, Mayo Clinic Rochester, Rochester, MN
| | | | | | - James H. Morrissey
- Departments of Biological Chemistry and Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
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4
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Krocker JD, Lee KH, Henriksen HH, Wang YWW, Schoof EM, Karvelsson ST, Rolfsson Ó, Johansson PI, Pedroza C, Wade CE. Exploratory Investigation of the Plasma Proteome Associated with the Endotheliopathy of Trauma. Int J Mol Sci 2022; 23:6213. [PMID: 35682894 PMCID: PMC9181752 DOI: 10.3390/ijms23116213] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/27/2022] [Accepted: 05/30/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The endotheliopathy of trauma (EoT) is associated with increased mortality following injury. Herein, we describe the plasma proteome related to EoT in order to provide insight into the role of the endothelium within the systemic response to trauma. METHODS 99 subjects requiring the highest level of trauma activation were included in the study. Enzyme-linked immunosorbent assays of endothelial and catecholamine biomarkers were performed on admission plasma samples, as well as untargeted proteome quantification utilizing high-performance liquid chromatography and tandem mass spectrometry. RESULTS Plasma endothelial and catecholamine biomarker abundance was elevated in EoT. Patients with EoT (n = 62) had an increased incidence of death within 24 h at 21% compared to 3% for non-EoT (n = 37). Proteomic analysis revealed that 52 out of 290 proteins were differentially expressed between the EoT and non-EoT groups. These proteins are involved in endothelial activation, coagulation, inflammation, and oxidative stress, and include known damage-associated molecular patterns (DAMPs) and intracellular proteins specific to several organs. CONCLUSIONS We report a proteomic profile of EoT suggestive of a surge of DAMPs and inflammation driving nonspecific activation of the endothelial, coagulation, and complement systems with subsequent end-organ damage and poor clinical outcome. These findings support the utility of EoT as an index of cellular injury and delineate protein candidates for therapeutic intervention.
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Affiliation(s)
- Joseph D. Krocker
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (Y.-W.W.W.); (C.E.W.)
| | - Kyung Hyun Lee
- Center for Clinical Research and Evidence-Based Medicine, Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (K.H.L.); (C.P.)
| | - Hanne H. Henriksen
- Center for Endotheliomics CAG, Department of Clinical Immunology, Copenhagen University Hospital, Rigshospitalet, 2200 Copenhagen, Denmark;
| | - Yao-Wei Willa Wang
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (Y.-W.W.W.); (C.E.W.)
| | - Erwin M. Schoof
- Department of Biotechnology and Biomedicine, Technical University of Denmark, 2800 Lyngby, Denmark;
| | - Sigurdur T. Karvelsson
- Center for Systems Biology, University of Iceland, 101 Reykjavik, Iceland; (S.T.K.); (Ó.R.)
| | - Óttar Rolfsson
- Center for Systems Biology, University of Iceland, 101 Reykjavik, Iceland; (S.T.K.); (Ó.R.)
| | - Pär I. Johansson
- Center for Endotheliomics CAG, Department of Clinical Immunology, Rigshospitalet, & Department of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark;
| | - Claudia Pedroza
- Center for Clinical Research and Evidence-Based Medicine, Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (K.H.L.); (C.P.)
| | - Charles E. Wade
- Center for Translational Injury Research, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (Y.-W.W.W.); (C.E.W.)
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5
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Qu D, Li W, Zhang S, Li R, Wang H, Chen B. Traumatic Brain Injury Is Associated With Both Hemorrhagic Stroke and Ischemic Stroke: A Systematic Review and Meta-Analysis. Front Neurosci 2022; 16:814684. [PMID: 35221904 PMCID: PMC8867812 DOI: 10.3389/fnins.2022.814684] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 01/03/2022] [Indexed: 11/13/2022] Open
Abstract
Background Traumatic brain injury (TBI) is considered a risk factor for the development of stroke (Hemorrhagic Stroke and Ischemic Stroke). We performed this systemic review and meta-analysis to determine the association of prior TBI with the subsequent diagnosis of stroke. Methods We systematically searched PubMed, EMBASE, and the Cochrane Library for cohort studies involving TBI patients who subsequently developed stroke. Study selection, data extraction, and quality assessment were performed by two separate researchers. Data were analyzed with random-effects models, and a secondary analysis stratified by the type of stroke was performed. Results Of the 741 identified studies, 6 studies were eligible for inclusion, with more than 2,200,000 participants. TBI predicted the occurrence of stroke in the random-effect model, with a relative risk of 2.14 (95% CI 1.97–2.32, P < 0.001). Furthermore, in the analysis of each type of stroke, TBI was associated with the incidence of ischemic stroke (RR 1.351 95% CI 1.212–1.506, P < 0.001), and TBI was associated with an even greater increase in the incidence of hemorrhagic stroke (RR 6.118 95% CI 5.265–7.108, P < 0.001). Conclusion Our meta-analysis showed that TBI was associated with a more than two-fold increase in the risk of stroke. However, owing to the high degree of heterogeneity, decisions should be made on a patient-by-patient basis. The occurrence of TBI is associated with the development of both hemorrhagic and ischemic stroke, and the risk of hemorrhagic stroke is much higher than that of ischemic stroke in TBI patients.
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Affiliation(s)
- Donghao Qu
- Department of Neurosurgery (Neurotrauma), The First Hospital of Jilin University, Changchun, China
| | - Wenchen Li
- Department of Neurosurgery (Neurotrauma), The First Hospital of Jilin University, Changchun, China
| | - Shuyan Zhang
- Department of Neurosurgery (Neurotrauma), The First Hospital of Jilin University, Changchun, China
| | - Ri Li
- Department of Library, The First Hospital of Jilin University, Changchun, China
| | - Haifeng Wang
- Department of Neurosurgery (Neurotrauma), The First Hospital of Jilin University, Changchun, China
- Haifeng Wang
| | - Bo Chen
- Department of Neurosurgery (Neurotrauma), The First Hospital of Jilin University, Changchun, China
- *Correspondence: Bo Chen
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Fu G, Chen T, Wu J, Jiang T, Tang D, Bonaroti J, Conroy J, Scott MJ, Deng M, Billiar TR. Single-Cell Transcriptomics Reveals Compartment-Specific Differences in Immune Responses and Contributions for Complement Factor 3 in Hemorrhagic Shock Plus Tissue Trauma. Shock 2021; 56:994-1008. [PMID: 33710107 PMCID: PMC8429528 DOI: 10.1097/shk.0000000000001765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Hemorrhagic shock with tissue trauma (HS/T) leads to the activation of a system-wide immune-inflammatory response that involves all organs and body compartments. Recent advances in single-cell analysis permit the simultaneous assessment of transcriptomic patterns in a large number of cells making it feasible to survey the landscape of immune cell responses across numerous anatomic sites. Here, we used single-cell RNA sequencing of leukocytes from the blood, liver, and spleen to identify the major shifts in gene expression by cell type and compartment in a mouse HS/T model. At 6 h, dramatic changes in gene expression were observed across multiple-cell types and in all compartments in wild-type mice. Monocytes from circulation and liver exhibited a significant upregulation of genes associated with chemotaxis and migration and a simultaneous suppression of genes associated with interferon signaling and antigen presentation. In contrast, liver conventional DC exhibited a unique pattern compared with other myeloid cells that included a pronounced increase in major histocompatibility complex class II (MHCII) gene expression. The dominant pattern across all compartments for B and T cells was a suppression of genes associated with cell activation and signaling after HS/T. Using complement factor 3 (C3) knockout mice we unveiled a role for C3 in the suppression of monocyte Major Histocompatibility Complex class II expression and activation of gene expression associated with migration, phagocytosis and cytokine upregulation, and an unexpected role in promoting interferon-signaling in a subset of B and T cells across all three compartments after HS/T. This transcriptomic landscape study of immune cells provides new insights into the host immune response to trauma, as well as a rich resource for further investigation of trauma-induced immune responses and complement in driving interferon signaling.
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Affiliation(s)
- Guang Fu
- Department of General Surgery, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China
- Department of Surgery, University of Pittsburgh, PA, USA
| | - Tianmeng Chen
- Department of Surgery, University of Pittsburgh, PA, USA
- Cellular and Molecular Pathology Program, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
| | - Junru Wu
- Department of General Surgery, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China
- Department of Surgery, University of Pittsburgh, PA, USA
| | - Ting Jiang
- Department of Surgery, University of Pittsburgh, PA, USA
- School of Medicine, Tsinghua University, Beijing, China
| | - Da Tang
- Department of General Surgery, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China
- Department of Surgery, University of Pittsburgh, PA, USA
| | | | - Julia Conroy
- Department of Surgery, University of Pittsburgh, PA, USA
| | - Melanie J Scott
- Department of Surgery, University of Pittsburgh, PA, USA
- Trauma Research Center, University of Pittsburgh, PA, USA
| | - Meihong Deng
- Department of Surgery, University of Pittsburgh, PA, USA
- Department of Surgery, Ohio State University, Ohio, USA
| | - Timothy R Billiar
- Department of Surgery, University of Pittsburgh, PA, USA
- Trauma Research Center, University of Pittsburgh, PA, USA
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7
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Hossain MA, Ahmed N, Gupta V, Bajwa R, Alidoost M, Asif A, Vachharajani T. Post-traumatic thrombotic microangiopathy: What trauma surgeons need to know? Chin J Traumatol 2021; 24:69-74. [PMID: 33518399 PMCID: PMC8071723 DOI: 10.1016/j.cjtee.2021.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 12/10/2020] [Accepted: 12/29/2020] [Indexed: 02/04/2023] Open
Abstract
Thrombotic microangiopathy (TMA) is characterized by systemic microvascular thrombosis, target organ injury, anemia and thrombocytopenia. Thrombotic thrombocytopenic purpura, atypical hemolytic uremic syndrome and Shiga toxin E-coli-related hemolytic uremic syndrome are the three common forms of TMAs. Traditionally, TMA is encountered during pregnancy/postpartum period, malignant hypertension, systemic infections, malignancies, autoimmune disorders, etc. Recently, the patients presenting with trauma have been reported to suffer from TMA. TMA carries a high morbidity and mortality, and demands a prompt recognition and early intervention to limit the target organ injury. Because trauma surgeons are the first line of defense for patients presenting with trauma, the prompt recognition of TMA for these experts is critically important. Early treatment of post-traumatic TMA can help improve the patient outcomes, if the diagnosis is made early. The treatment of TMA is also different from acute blood loss anemia namely in that plasmapheresis is recommended rather than platelet transfusion. This article familiarizes trauma surgeons with TMA encountered in the context of trauma. Besides, it provides a simplified approach to establishing the diagnosis of TMA. Because trauma patients can require multiple transfusions, the development of disseminated intravascular coagulation must be considered. Therefore, the article also provides different features of disseminated intravascular coagulation and TMA. Finally, the article suggests practical points that can be readily applied to the management of these patients.
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Affiliation(s)
- Mohammad A. Hossain
- Department of Medicine, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, 07753, USA
| | - Nasim Ahmed
- Department of Surgery, Division of Trauma Surgery, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, 07753, USA,Corresponding author.
| | - Varsha Gupta
- Department of Medicine, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, 07753, USA
| | - Ravneet Bajwa
- Department of Medicine, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, 07753, USA
| | - Marjan Alidoost
- Department of Medicine, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, 07753, USA
| | - Arif Asif
- Department of Medicine, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, 07753, USA
| | - Tushar Vachharajani
- Global Nephrology, Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH, 44103, USA
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Huber-Lang MS, Ignatius A, Köhl J, Mannes M, Braun CK. Complement in trauma-Traumatised complement? Br J Pharmacol 2020; 178:2863-2879. [PMID: 32880897 DOI: 10.1111/bph.15245] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/23/2020] [Accepted: 08/17/2020] [Indexed: 12/17/2022] Open
Abstract
Physical trauma represents a major global burden. The trauma-induced response, including activation of the innate immune system, strives for regeneration but can also lead to post-traumatic complications. The complement cascade is rapidly activated by damaged tissue, hypoxia, exogenous proteases and others. Activated complement can sense, mark and clear both damaged tissue and pathogens. However, excessive and insufficient activation of complement can result in a dysfunctional immune and organ response. Similar to acute coagulopathy, complementopathy can develop with enhanced anaphylatoxin generation and an impairment of complement effector functions. Various remote organ effects are induced or modulated by complement activation. Frequently, established trauma treatments are double-edged. On one hand, they help stabilising haemodynamics and oxygen supply as well as injured organs and on the other hand, they also drive complement activation. Immunomodulatory approaches aim to reset trauma-induced disbalance of complement activation and thus may change surgical trauma management procedures to improve outcome. LINKED ARTICLES: This article is part of a themed issue on Canonical and non-canonical functions of the complement system in health and disease. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v178.14/issuetoc.
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Affiliation(s)
- Markus S Huber-Lang
- Institute of Clinical and Experimental Trauma-Immunology, University Hospital of Ulm, Ulm, Germany
| | - Anita Ignatius
- Institue of Orthopaedic Research and Biomechanics, University Hospital of Ulm, Ulm, Germany
| | - Jörg Köhl
- Institute for Systemic Inflammatory Research, University of Lübeck, Lübeck, Germany.,Division of Immunobiology, Cincinnati Children's Hospital Medical Centre, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Marco Mannes
- Institute of Clinical and Experimental Trauma-Immunology, University Hospital of Ulm, Ulm, Germany
| | - Christian Karl Braun
- Institute of Clinical and Experimental Trauma-Immunology, University Hospital of Ulm, Ulm, Germany.,Department of Paediatrics and Adolescent Medicine, University Hospital of Ulm, Ulm, Germany
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Fletcher-Sandersjöö A, Bellander BM. Is COVID-19 associated thrombosis caused by overactivation of the complement cascade? A literature review. Thromb Res 2020; 194:36-41. [PMID: 32569879 PMCID: PMC7301826 DOI: 10.1016/j.thromres.2020.06.027] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/10/2020] [Accepted: 06/16/2020] [Indexed: 02/08/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 is responsible for the current COVID-19 pandemic resulting in an escalating number of cases and fatalities worldwide. Preliminary evidence from these patients, as well as past coronavirus epidemics, indicates that those infected suffer from disproportionate complement activation as well as excessive coagulation, leading to thrombotic complications and poor outcome. In non-coronavirus cohorts, evidence has accumulated of an interaction between the complement and coagulation systems, with one amplifying activation of the other. A pressing question is therefore if COVID-19 associated thrombosis could be caused by overactivation of the complement cascade? In this review, we summarize the literature on thrombotic complications in COVID-19, complement activation in coronavirus infections, and the crosstalk between the complement and coagulation systems. We demonstrate how the complement system is able to activate the coagulation cascade and platelets, inhibit fibrinolysis and stimulate endothelial cells. We also describe how these interactions see clinical relevance in several disorders where overactive complement results in a prothrombotic clinical presentation, and how it could be clinically relevant in COVID-19.
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Affiliation(s)
- Alexander Fletcher-Sandersjöö
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - Bo-Michael Bellander
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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10
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Ikezoe T. Advances in the diagnosis and treatment of disseminated intravascular coagulation in haematological malignancies. Int J Hematol 2020; 113:34-44. [PMID: 32902759 DOI: 10.1007/s12185-020-02992-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/22/2020] [Accepted: 08/28/2020] [Indexed: 11/26/2022]
Abstract
Haematological malignancies, including acute leukaemia and non-Hodgkin lymphoma, are one of the underlying diseases that frequently cause disseminated intravascular coagulation (DIC), an acquired thrombotic disorder. Concomitant DIC is associated with the severity of the underlying disease and poor prognosis. The Japanese Society on Thrombosis and Hemostasis released the new DIC diagnostic criteria in 2017. This criteria include coagulation markers such as soluble fibrin and the thrombin-antithrombin complex to more accurately evaluate the hypercoagulable state in patients. Among several groups of anticoagulants available, recombinant human soluble thrombomodulin is most frequently used to treat DIC caused by haematological malignancies in Japan. DIC is remitted in parallel with the improvement of the underlying haematological diseases; thus, there is room for debate regarding whether the treatment of DIC would improve the prognosis of patients. Haematopoietic stem cell transplantation as well as the recently introduced chimeric antigen receptor (CAR)-T-cell therapy are innovative therapies to produce a cure in a subset of patients with haematological malignancies. However, coagulopathy frequently occurs after these therapies, which limits the success of the treatment. For example, DIC is noted in approximately 50% of patients after CAT-T-cell therapy in conjunction with cytokine release syndrome. Hematopoietic stem cell transplantation (HSCT) causes endotheliitis, which triggers coagulopathy and the development of potentially lethal complications, such as sinusoidal obstruction syndrome/veno-occlusive disease and transplant-associated thrombotic microangiopathy. This review article describes the pathogenesis, clinical manifestation, diagnosis, and treatment of DIC caused by haematological malignancies, CAR-T-cell therapy, and HSCT.
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Affiliation(s)
- Takayuki Ikezoe
- Department of Haematology, Fukushima Medical University, Fukushima, 960-1295, Japan.
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11
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Li B, Zhou X, Yi TL, Xu ZW, Peng DW, Guo Y, Guo YM, Cao YL, Zhu L, Zhang S, Cheng SX. Bloodletting Puncture at Hand Twelve Jing-Well Points Improves Neurological Recovery by Ameliorating Acute Traumatic Brain Injury-Induced Coagulopathy in Mice. Front Neurosci 2020; 14:403. [PMID: 32581664 PMCID: PMC7290011 DOI: 10.3389/fnins.2020.00403] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 04/02/2020] [Indexed: 12/14/2022] Open
Abstract
Traumatic brain injury (TBI) contributes to hypocoagulopathy associated with prolonged bleeding and hemorrhagic progression. Bloodletting puncture therapy at hand twelve Jing-well points (BL-HTWP) has been applied as a first aid measure in various emergent neurological diseases, but the detailed mechanisms of the modulation between the central nervous system and systemic circulation after acute TBI in rodents remain unclear. To investigate whether BL-HTWP stimulation modulates hypocoagulable state and exerts neuroprotective effect, experimental TBI model of mice was produced by the controlled cortical impactor (CCI), and treatment with BL-HTWP was immediately made after CCI. Then, the effects of BL-HTWP on the neurological function, cerebral perfusion state, coagulable state, and cerebrovascular histopathology post-acute TBI were determined, respectively. Results showed that BL-HTWP treatment attenuated cerebral hypoperfusion and improve neurological recovery post-acute TBI. Furthermore, BL-HTWP stimulation reversed acute TBI-induced hypocoagulable state, reduced vasogenic edema and cytotoxic edema by regulating multiple hallmarks of coagulopathy in TBI. Therefore, we conclude for the first time that hypocoagulopathic state occurs after acute experimental TBI, and the neuroprotective effect of BL-HTWP relies on, at least in part, the modulation of hypocoagulable state. BL-HTWP therapy may be a promising strategy for acute severe TBI in the future.
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Affiliation(s)
- Bo Li
- Tianjin Key Laboratory of Neurotrauma Repair, Institute of Neurotrauma Repair of Characteristic Medical Center of Chinese People's Armed Police Force (PAP), Tianjin, China.,Acupuncture Research Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Xiu Zhou
- Tianjin Key Laboratory of Neurotrauma Repair, Institute of Neurotrauma Repair of Characteristic Medical Center of Chinese People's Armed Police Force (PAP), Tianjin, China
| | - Tai-Long Yi
- Tianjin Key Laboratory of Neurotrauma Repair, Institute of Neurotrauma Repair of Characteristic Medical Center of Chinese People's Armed Police Force (PAP), Tianjin, China
| | - Zhong-Wei Xu
- Central Laboratory of Logistics University of Chinese People's Armed Police Force (PAP), Tianjin, China
| | - Ding-Wei Peng
- Tianjin Key Laboratory of Neurotrauma Repair, Institute of Neurotrauma Repair of Characteristic Medical Center of Chinese People's Armed Police Force (PAP), Tianjin, China
| | - Yi Guo
- Acupuncture Research Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yong-Ming Guo
- Acupuncture Research Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yu-Lin Cao
- Zhenxigu Medical Research Center, Beijing, China
| | - Lei Zhu
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Sai Zhang
- Tianjin Key Laboratory of Neurotrauma Repair, Institute of Neurotrauma Repair of Characteristic Medical Center of Chinese People's Armed Police Force (PAP), Tianjin, China
| | - Shi-Xiang Cheng
- Tianjin Key Laboratory of Neurotrauma Repair, Institute of Neurotrauma Repair of Characteristic Medical Center of Chinese People's Armed Police Force (PAP), Tianjin, China
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Svenungsson E, Antovic A. The antiphospholipid syndrome - often overlooked cause of vascular occlusions? J Intern Med 2020; 287:349-372. [PMID: 31957081 DOI: 10.1111/joim.13022] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 01/09/2020] [Indexed: 01/25/2023]
Abstract
The antiphospholipid syndrome (APS) was fully recognized as a clinical entity in the early 1980s. Still, more than 30 years later, the epidemiology of APS is not well described, and furthermore, APS remains a challenge in terms of both diagnostic issues and clinical praxis involving a wide range of specialties. To date, there are no diagnostic criteria for APS. The present classification criteria rely on a combination of clinical manifestations and persistently positive tests for antiphospholipid antibodies (aPL). Clinical symptoms comprise vascular thrombosis, which can affect any vascular bed, including venous, microvascular and arterial vessels, and a set of pregnancy morbidities including early and late miscarriages, foetal death and preeclampsia. APS is more frequent among patients with other autoimmune diseases, and it is especially common in systemic lupus erythematosus (SLE). Importantly, APS symptoms can present in almost any medical specialty, but general knowledge and most previous clinical studies have essentially been confined to haematology, rheumatology and obstetrics/gynaecology. However, recent data demonstrate a relatively high prevalence of aPL also in patients from the general population who suffer from vascular occlusions or pregnancy complications. It is important that these patients are recognized by the general health care since APS is a treatable condition. This review aims to summarize the present knowledge on the history, pathogenesis, clinical manifestations and treatment of APS in order to urge a wide range of clinicians to consider comprehensive assessment of all patients where the diagnosis APS may be conceivable.
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Affiliation(s)
- E Svenungsson
- From the, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - A Antovic
- From the, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Does Complement-Mediated Hemostatic Disturbance Occur in Traumatic Brain Injury? A Literature Review and Observational Study Protocol. Int J Mol Sci 2020; 21:ijms21051596. [PMID: 32111078 PMCID: PMC7084711 DOI: 10.3390/ijms21051596] [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: 01/09/2020] [Revised: 02/07/2020] [Accepted: 02/25/2020] [Indexed: 12/11/2022] Open
Abstract
Despite improvements in medical triage and tertiary care, traumatic brain injury (TBI) remains associated with significant morbidity and mortality. Almost two-thirds of patients with severe TBI develop some form of hemostatic disturbance, which contributes to poor outcome. In addition, the complement system, which is abundant in the healthy brain, undergoes significant intra- and extracranial amplification following TBI. Previously considered to be structurally similar but separate systems, evidence of an interaction between the complement and coagulation systems in non-TBI cohorts has accumulated, with the activation of one system amplifying the activation of the other, independent of their established pathways. However, it is not known whether this interaction exists in TBI. In this review we summarize the available literature on complement activation following TBI, and the crosstalk between the complement and coagulation systems. We demonstrate how the complement system interacts with the coagulation cascade by activating the intrinsic coagulation pathway and by bypassing the initial cascade and directly producing thrombin as well. This crosstalk also effects platelets, where evidence points to a relationship with the complement system on multiple levels, with complement anaphylatoxins being able to induce disproportionate platelet activation and adhesion. The complement system also stimulates thrombosis by inhibiting fibrinolysis and stimulating endothelial cells to release prothrombotic microparticles. These interactions see clinical relevance in several disorders where a deficiency in complement regulation seems to result in a prothrombotic clinical presentation. Finally, based on these observations, we present the outline of an observational cohort study that is currently under preparation and aimed at assessing how complement influences coagulation in patients with isolated TBI.
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Abstract
In sepsis, coagulation is activated and there is an increased risk of developing a consumptive coagulopathy with attendant increase in mortality. The processes that regulate hemostasis evolved as a component of the inflammatory response to infection. Many points of interaction occur on the endothelial cell surface linking the 2 cell types in the initiation and regulation of hemostasis and inflammation. Consequently, inflammation stimulates both platelets and endothelial cells in ways that affect both hemostasis and the immune response. Platelets are also prime drivers of the inflammatory response. This article discusses the pathways wherein inflammation regulates platelet and endothelial cell function.
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Affiliation(s)
- Tom van der Poll
- Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Center of Experimental and Molecular Medicine & Division of Infectious Diseases, Meibergdreef 9, Room G2-130, Amsterdam 1105AZ, the Netherlands
| | - Robert I Parker
- Department of Pediatrics, Pediatric Hematology/Oncology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794-8111, USA.
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Ability of Fibrin Monomers to Predict Progressive Hemorrhagic Injury in Patients with Severe Traumatic Brain Injury. Neurocrit Care 2019; 33:182-195. [PMID: 31797276 DOI: 10.1007/s12028-019-00882-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Progressive hemorrhagic injury (PHI) is common in patients with severe traumatic brain injury (TBI) and is associated with poor outcomes. TBI-associated coagulopathy is frequent and has been described as risk factor for PHI. This coagulopathy is a dynamic process involving hypercoagulable and hypocoagulable states either one after the other either concomitant. Fibrin monomers (FMs) are a direct marker of thrombin action and thus reflect coagulation activation. This study sought to determine the ability of FM to predict PHI after severe TBI. METHODS We conducted a prospective, observational study including all severe TBI patients admitted in the trauma center. Between September 2011 and September 2016, we enrolled patients with severe TBI into the derivation cohort. Between October 2016 and December 2018, we recruited the validation cohort on the same basis. Study protocol included FM measurements and standard coagulation test at admission and two computed tomography (CT) scans (upon arrival and at least 6 h thereafter). A PHI was defined by an increment in size of initial lesion (25% or more) or the development of a new hemorrhage in the follow-up CT scan. Multivariate logistic regression analysis was applied to identify predictors of PHI. RESULTS Overall, 106 patients were included in the derivation cohort. Fifty-four (50.9%) experienced PHI. FM values were higher in these patients (151 [136.8-151] vs. 120.5 [53.3-151], p < 0.0001). The ROC curve demonstrated that FM had a fair accuracy to predict the occurrence of PHI with an area under curve of 0.7 (95% CI [0.6-0.79]). The best threshold was determined at 131.7 μg/ml. In the validation cohort of 54 patients, this threshold had a negative predictive value of 94% (95% CI [71-100]) and a positive predictive value of 49% (95% CI [32-66]). The multivariate logistic regression analysis identified 2 parameters associated with PHI: FM ≥ 131.7 (OR 6.8; 95% CI [2.8-18.1]) and Marshall category (OR 1.7; 95% CI [1.3-2.2]). Coagulopathy was not associated with PHI (OR 1.3; 95% CI [0.5-3.0]). The proportion of patients with an unfavorable functional neurologic outcome at 6-months follow-up was higher in patients with positive FM: 59 (62.1%) versus 16 (29.1%), p < 0.0001. CONCLUSIONS FM levels at admission had a fair accuracy to predict PHI in patients with severe TBI. FM values ≥ 131.7 μg/ml are independently associated with the occurrence of PHI.
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Lendak D, Mihajlovic D, Mitic G, Ubavic M, Novakov-Mikic A, Boban J, Brkic S. Complement component consumption in sepsis correlates better with hemostatic system parameters than with inflammatory biomarkers. Thromb Res 2018; 170:126-132. [PMID: 30172999 DOI: 10.1016/j.thromres.2018.08.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/19/2018] [Accepted: 08/21/2018] [Indexed: 12/27/2022]
Abstract
INTRODUCTION The aim of this study was to investigate the role of C3 and C4 complement components in prediction of sepsis outcome. The secondary aim was to determine relationship between complement components and other inflammatory parameters, and parameters of hemostasis. METHODS One-hundred-thirty-seven patients with sepsis (Sepsis-3 criteria) were included in the study. Routine laboratory markers, predictive APACHEII and SOFA scores, concentrations of C3 and C4, activated partial thromboplastin time (aPTT), prothrombin time (PT), thrombin time (TT), fibrinogen, antithrombin (AT), protein C (PC), protein S (PS), endogenous thrombin potential (ETP), thrombomodulin, and D-dimer were available. Concentrations of C3 and C4 were correlated with the disease outcome, predictive scores, inflammatory markers and parameters of hemostasis. Statistical analysis was performed using the non-parametric approach and significance was set at p < 0.05. RESULTS A significant depletion of the complement was observed in non-survivors (AUCROCC3 = 0.692, pC3 < 0.001,AUCROCC4 = 0.672, pC4 = 0.001). There was a significant negative correlation of C3and C4with APACHEII and SOFA (C3-APACHEII ρ = -0.364, p = 0.011, C3-SOFA ρ = -0.460, p < 0.001), aPTT (ρ = -0.407, p < 0.001), PT (ρ = -0.408, p < 0.001), and D-dimer (ρ = -0.274, p = 0.001). A significant positive correlation was observed with natural anticoagulants (C3-AT ρ = 0.493, p < 0.001; C3-PC ρ = 0.450, p < 0.001; C3-PS ρ = 0.345, p < 0.001), fibrinogen (ρ = 0.481, p < 0.001),and ETP (ρ = 0.384, p < 0.001). C3 and C4 correlated significantly only with CRP (ρ = 0.207, p = 0.015), while no significant correlations with procalcitonin and WBC were detected. Results were similar for C4 and C3, although C3 presented higher correlation coefficients. CONCLUSION In septic patients with poorer outcome, a significant depletion of the complement system was observed. Concentrations of complement components demonstrated stronger correlations with coagulation parameters than with inflammatory biomarkers.
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Affiliation(s)
- Dajana Lendak
- Department for Infectious Diseases, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia; Clinical Center of Vojvodina, Clinic for Infectious Diseases, Hajduk Veljkova 3, 21000 Novi Sad, Serbia.
| | - Dunja Mihajlovic
- Department for Anesthesiology and Perioperative Medicine, Faculty of Medicine, University of Novi Sad, Serbia; Clinical Center of Vojvodina, Emergency Center, Hajduk Veljkova 3, 21000 Novi Sad, Serbia.
| | - Gorana Mitic
- Department for Pathophysiology, Faculty of Medicine, University of Novi Sad, Serbia; Laboratory Medicine Center, Department for Hematology, Hemostasis and Prevention of Thrombosis, Clinical Center of Vojvodina, Hajduk Veljkova 3, Novi Sad, Serbia.
| | - Milan Ubavic
- Health Care Institution for Laboratory Diagnostics, Medlab, Ilije Ognjanovića 1, 21000 Novi Sad, Serbia.
| | - Aleksandra Novakov-Mikic
- Department for Gynecology and Obstetrics, Faculty of Medicine, University of Novi Sad, Serbia; Clinical Center of Vojvodina, Clinic of Gynecology and Obstetrics, Hajduk Veljkova 1, 21000 Novi Sad, Serbia.
| | - Jasmina Boban
- Department for Radiology, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, Novi Sad, Vojvodina, Serbia.
| | - Snežana Brkic
- Department for Infectious Diseases, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia; Clinical Center of Vojvodina, Clinic for Infectious Diseases, Hajduk Veljkova 3, 21000 Novi Sad, Serbia.
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17
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Complement links platelets to innate immunity. Semin Immunol 2018; 37:43-52. [DOI: 10.1016/j.smim.2018.01.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 01/30/2018] [Accepted: 01/31/2018] [Indexed: 12/11/2022]
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18
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Keragala CB, Draxler DF, McQuilten ZK, Medcalf RL. Haemostasis and innate immunity - a complementary relationship: A review of the intricate relationship between coagulation and complement pathways. Br J Haematol 2017; 180:782-798. [PMID: 29265338 DOI: 10.1111/bjh.15062] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Coagulation and innate immunity are linked evolutionary processes that orchestrate the host defence against invading pathogens and injury. The complement system is integral to innate immunity and shares numerous interactions with components of the haemostatic pathway, helping to maintain physiological equilibrium. The term 'immunothrombosis' was introduced in 2013 to embrace this process, and has become an area of much recent interest. What is less apparent in the literature however is an appreciation of the clinical manifestations of the coagulation-complement interaction and the consequences of dysregulation of either system, as seen in many inflammatory and thrombotic disease states, such as sepsis, trauma, atherosclerosis, antiphospholipid syndrome (APS), paroxysmal nocturnal haemoglobinuria (PNH) and some thrombotic microangiopathies to name a few. The growing appreciation of this immunothrombotic phenomenon will foster the drive for novel therapies in these disease states, including anticoagulants as immunomodulators and targeted molecular therapies.
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Affiliation(s)
- Charithani B Keragala
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Vic., Australia
| | - Dominik F Draxler
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Vic., Australia
| | - Zoe K McQuilten
- Transfusion Research Unit and Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Vic., Australia
| | - Robert L Medcalf
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Vic., Australia
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Maegele M, Schöchl H, Menovsky T, Maréchal H, Marklund N, Buki A, Stanworth S. Coagulopathy and haemorrhagic progression in traumatic brain injury: advances in mechanisms, diagnosis, and management. Lancet Neurol 2017; 16:630-647. [PMID: 28721927 DOI: 10.1016/s1474-4422(17)30197-7] [Citation(s) in RCA: 189] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 05/08/2017] [Accepted: 05/30/2017] [Indexed: 01/28/2023]
Abstract
Normal haemostasis depends on an intricate balance between mechanisms of bleeding and mechanisms of thrombosis, and this balance can be altered after traumatic brain injury (TBI). Impaired haemostasis could exacerbate the primary insult with risk of initiation or aggravation of bleeding; anticoagulant use at the time of injury can also contribute to bleeding risk after TBI. Many patients with TBI have abnormalities on conventional coagulation tests at admission to the emergency department, and the presence of coagulopathy is associated with increased morbidity and mortality. Further blood testing often reveals a range of changes affecting platelet numbers and function, procoagulant or anticoagulant factors, fibrinolysis, and interactions between the coagulation system and the vascular endothelium, brain tissue, inflammatory mechanisms, and blood flow dynamics. However, the degree to which these coagulation abnormalities affect TBI outcomes and whether they are modifiable risk factors are not known. Although the main challenge for management is to address the risk of hypocoagulopathy with prolonged bleeding and progression of haemorrhagic lesions, the risk of hypercoagulopathy with an increased prothrombotic tendency also warrants consideration.
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Affiliation(s)
- Marc Maegele
- Department for Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Center, University Witten/Herdecke, Cologne, Germany; Institute for Research in Operative Medicine, University Witten/Herdecke, Cologne, Germany.
| | - Herbert Schöchl
- Department for Anaesthesiology and Intensive Care Medicine, AUVA Trauma Academic Teaching Hospital, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Tomas Menovsky
- Department for Neurosurgery, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
| | - Hugues Maréchal
- Department of Anaesthesiology and Intensive Care Medicine, CRH La Citadelle, Liège, Belgium
| | - Niklas Marklund
- Department of Clinical Sciences, Division of Neurosurgery, University Hospital of Southern Sweden, Lund University, Lund, Sweden
| | - Andras Buki
- Department of Neurosurgery, The MTA-PTE Clinical Neuroscience MR Research Group, Janos Szentagothai Research Center, Hungarian Brain Research Program, University of Pécs, Pécs, Hungary
| | - Simon Stanworth
- NHS Blood and Transplant/Oxford University Hospitals NHS Foundation Trust, University of Oxford, John Radcliffe Hospital, Oxford, UK
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Abstract
Hemolytic uremic syndrome (HUS) is a thrombotic microangiopathy characterized by intravascular hemolysis, thrombocytopenia, and acute kidney failure. HUS is usually categorized as typical, caused by Shiga toxin-producing Escherichia coli (STEC) infection, as atypical HUS (aHUS), usually caused by uncontrolled complement activation, or as secondary HUS with a coexisting disease. In recent years, a general understanding of the pathogenetic mechanisms driving HUS has increased. Typical HUS (ie, STEC-HUS) follows a gastrointestinal infection with STEC, whereas aHUS is associated primarily with mutations or autoantibodies leading to dysregulated complement activation. Among the 30% to 50% of patients with HUS who have no detectable complement defect, some have either impaired diacylglycerol kinase ε (DGKε) activity, cobalamin C deficiency, or plasminogen deficiency. Some have secondary HUS with a coexisting disease or trigger such as autoimmunity, transplantation, cancer, infection, certain cytotoxic drugs, or pregnancy. The common pathogenetic features in STEC-HUS, aHUS, and secondary HUS are simultaneous damage to endothelial cells, intravascular hemolysis, and activation of platelets leading to a procoagulative state, formation of microthrombi, and tissue damage. In this review, the differences and similarities in the pathogenesis of STEC-HUS, aHUS, and secondary HUS are discussed. Common for the pathogenesis seems to be the vicious cycle of complement activation, endothelial cell damage, platelet activation, and thrombosis. This process can be stopped by therapeutic complement inhibition in most patients with aHUS, but usually not those with a DGKε mutation, and some patients with STEC-HUS or secondary HUS. Therefore, understanding the pathogenesis of the different forms of HUS may prove helpful in clinical practice.
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Abstract
Extracellular histones promote platelet aggregation and thrombosis; this is followed by induction of coagulation disorder, which results in exhaustion of coagulation factors. Complement component 5 (C5) is known to be associated with platelet aggregation and coagulation system activation. To date, the pathological mechanism underlying liver injury has remained unclear. Here, we investigated whether C5 promotes liver injury associated with histone-induced lethal thrombosis. C5-sufficient and C5-deficient mice received single tail vein injections of purified, unfractionated histones obtained from calf thymus (45–75 μg/g). Subsequently, the mice were monitored for survival for up to 72 h. Based on the survival data, the 45 μg/g dose was used for analysis of blood cell count, liver function, blood coagulation ability, and promotion of platelet aggregation and platelet/leukocyte aggregate (PLA) production by extracellular histones. C5-deficient mice were protected from lethal thrombosis and had milder thrombocytopenia, consumptive coagulopathy, and liver injury with embolism and lower PLA production than C5-sufficient mice. These results indicate that C5 is associated with coagulation disorders, PLA production, and embolism-induced liver injury. In conclusion, C5 promotes liver injury associated with histone-induced lethal thrombosis.
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What's New in Shock, Military Supplement September 2016. Shock 2016; 46:1-3. [PMID: 27496598 DOI: 10.1097/shk.0000000000000705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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