1
|
Páramo JA. Thrombotic risk associated with COVID-19 and diabetes; Is PAI-1 the link? CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2024; 36:227-228. [PMID: 38944564 DOI: 10.1016/j.arteri.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Accepted: 06/05/2024] [Indexed: 07/01/2024]
Affiliation(s)
- José A Páramo
- Servicio de Hematología y Hemoterapia, Clínica Universidad de Navarra, Instituto de investigaciones Sanitaria de Navarra (IdiSNA), Pamplona, Navarra, España.
| |
Collapse
|
2
|
Okazaki E, Barion BG, da Rocha TRF, Di Giacomo G, Ho YL, Rothschild C, Fatobene G, de Carvalho Moraes BDG, Stefanello B, Villaça PR, Rocha VG, Orsi FA. Persistent hypofibrinolysis in severe COVID-19 associated with elevated fibrinolysis inhibitors activity. J Thromb Thrombolysis 2024; 57:721-729. [PMID: 38523179 DOI: 10.1007/s11239-024-02961-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2024] [Indexed: 03/26/2024]
Abstract
Hypercoagulability and reduced fibrinolysis are well-established complications associated with COVID-19. However, the timelines for the onset and resolution of these complications remain unclear. The aim of this study was to evaluate, in a cohort of COVID-19 patients, changes in coagulation and fibrinolytic activity through ROTEM assay at different time points during the initial 30 days following the onset of symptoms in both mild and severe cases. Blood samples were collected at five intervals after symptoms onset: 6-10 days, 11-15 days, 16-20 days, 21-25 days, and 26-30 days. In addition, fibrinogen, plasminogen, PAI-1, and alpha 2-antiplasmin activities were determined. Out of 85 participants, 71% had mild COVID-19. Twenty uninfected individuals were evaluated as controls. ROTEM parameters showed a hypercoagulable state among mild COVID-19 patients beginning in the second week of symptoms onset, with a trend towards reversal after the third week of symptoms. In severe COVID-19 cases, hypercoagulability was observed since the first few days of symptoms, with a tendency towards reversal after the fourth week of symptoms onset. A hypofibrinolytic state was identified in severe COVID-19 patients from early stages and persisted even after 30 days of symptoms. Elevated activity of PAI-1 and alpha 2-antiplasmin was also detected in severe COVID-19 patients. In conclusion, both mild and severe cases of COVID-19 exhibited transient hypercoagulability, reverted by the end of the first month. However, severe COVID-19 cases sustain hypofibrinolysis throughout the course of the disease, which is associated with elevated activity of fibrinolysis inhibitors. Persistent hypofibrinolysis could contribute to long COVID-19 manifestations.
Collapse
Affiliation(s)
- Erica Okazaki
- University of Sao Paulo Medical School, Sao Paulo, Brazil
- Hospital das Clínicas da Faculdade de Medicina de Sao Paulo da USP, 255 - Cerqueira César, Sao Paulo, SP, 05403-000, Brazil
| | - Bárbara Gomes Barion
- University of Sao Paulo Medical School, Sao Paulo, Brazil
- Hospital das Clínicas da Faculdade de Medicina de Sao Paulo da USP, 255 - Cerqueira César, Sao Paulo, SP, 05403-000, Brazil
| | - Tania Rubia Flores da Rocha
- Hospital das Clínicas da Faculdade de Medicina de Sao Paulo da USP, 255 - Cerqueira César, Sao Paulo, SP, 05403-000, Brazil
| | - Giovanna Di Giacomo
- Hospital das Clínicas da Faculdade de Medicina de Sao Paulo da USP, 255 - Cerqueira César, Sao Paulo, SP, 05403-000, Brazil
| | - Yeh-Li Ho
- Hospital das Clínicas da Faculdade de Medicina de Sao Paulo da USP, 255 - Cerqueira César, Sao Paulo, SP, 05403-000, Brazil
| | - Cynthia Rothschild
- Hospital das Clínicas da Faculdade de Medicina de Sao Paulo da USP, 255 - Cerqueira César, Sao Paulo, SP, 05403-000, Brazil
| | | | | | - Bianca Stefanello
- Hospital das Clínicas da Faculdade de Medicina de Sao Paulo da USP, 255 - Cerqueira César, Sao Paulo, SP, 05403-000, Brazil
| | - Paula Ribeiro Villaça
- Hospital das Clínicas da Faculdade de Medicina de Sao Paulo da USP, 255 - Cerqueira César, Sao Paulo, SP, 05403-000, Brazil
| | - Vanderson Geraldo Rocha
- Hospital das Clínicas da Faculdade de Medicina de Sao Paulo da USP, 255 - Cerqueira César, Sao Paulo, SP, 05403-000, Brazil
| | - Fernanda Andrade Orsi
- Hospital das Clínicas da Faculdade de Medicina de Sao Paulo da USP, 255 - Cerqueira César, Sao Paulo, SP, 05403-000, Brazil.
- Department of Pathology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil.
| |
Collapse
|
3
|
He S, Blombäck M, Wallén H. COVID-19: Not a thrombotic disease but a thromboinflammatory disease. Ups J Med Sci 2024; 129:9863. [PMID: 38327640 PMCID: PMC10845889 DOI: 10.48101/ujms.v129.9863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/17/2023] [Accepted: 10/21/2023] [Indexed: 02/09/2024] Open
Abstract
While Coronavirus Disease in 2019 (COVID-19) may no longer be classified as a global public health emergency, it still poses a significant risk at least due to its association with thrombotic events. This study aims to reaffirm our previous hypothesis that COVID-19 is fundamentally a thrombotic disease. To accomplish this, we have undertaken an extensive literature review focused on assessing the comprehensive impact of COVID-19 on the entire hemostatic system. Our analysis revealed that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection significantly enhances the initiation of thrombin generation. However, it is noteworthy that the thrombin generation may be modulated by specific anticoagulants present in patients' plasma. Consequently, higher levels of fibrinogen appear to play a more pivotal role in promoting coagulation in COVID-19, as opposed to thrombin generation. Furthermore, the viral infection can stimulate platelet activation either through widespread dissemination from the lungs to other organs or localized effects on platelets themselves. An imbalance between Von Willebrand Factor (VWF) and ADAMTS-13 also contributes to an exaggerated platelet response in this disease, in addition to elevated D-dimer levels, coupled with a significant increase in fibrin viscoelasticity. This paradoxical phenotype has been identified as 'fibrinolysis shutdown'. To clarify the pathogenesis underlying these hemostatic disorders in COVID-19, we also examined published data, tracing the reaction process of relevant proteins and cells, from ACE2-dependent viral invasion, through induced tissue inflammation, endothelial injury, and innate immune responses, to occurrence of thrombotic events. We therefrom understand that COVID-19 should no longer be viewed as a thrombotic disease solely based on abnormalities in fibrin clot formation and proteolysis. Instead, it should be regarded as a thromboinflammatory disorder, incorporating both classical elements of cellular inflammation and their intricate interactions with the specific coagulopathy.
Collapse
Affiliation(s)
- Shu He
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
- Division of Coagulation Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Margareta Blombäck
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
- Division of Coagulation Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Håkan Wallén
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
4
|
Thaler S, Stöhr D, Kammerer T, Nitschke T, Hoechter DJ, Brandes F, Müller M, Groene P, Schäfer ST. Predictive value of coagulation variables and glycocalyx shedding in hospitalized COVID-19 patients - a prospective observational study. Acta Clin Belg 2023; 78:392-400. [PMID: 37092324 DOI: 10.1080/17843286.2023.2204593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 04/15/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVES Covid-19 disease causes an immense burden on the healthcare system. It has not yet been finally clarified which patients will suffer from a severe course and which will not. Coagulation disorders can be detected in many of these patients. The aim of the present study was therefore to identify variables of the coagulation system including standard and viscoelastometric tests as well as components of glycocalyx damage that predict admission to the intensive care unit. METHODS Adult patients were included within 24 h of admission. Blood samples were analyzed at hospital admission and at ICU admission if applicable. We analyzed group differences and furthermore performed receiver operator characteristics (ROC). RESULTS This study included 60 adult COVID-19 patients. During their hospital stay, 14 patients required ICU treatment. Comparing ICU and non-ICU patients at time of hospital admission, D-dimer (1450 µg/ml (675/2850) vs. 600 µg/ml (500/900); p = 0.0022; cut-off 1050 µg/ml, sensitivity 71%, specificity 89%) and IL-6 (47.6 pg/ml (24.9/85.4 l) vs. 16.1 pg/ml (5.5/34.4); p = 0.0003; cut-off 21.25 pg/ml, sensitivity 86%, specificity 65%) as well as c-reactive protein (92 mg/dl (66.8/131.5) vs. 43.5 mg/dl (26.8/83.3); p = 0.0029; cutoff 54.5 mg/dl, sensitivity 86%, specificity 65%) were higher in patients who required ICU admission. Thromboelastometric variables and markers of glycocalyx damage (heparan sulfate, hyaluronic acid, syndecan-1) at the time of hospital admission did not differ between groups. CONCLUSION General inflammatory variables continue to be the most robust predictors of a severe course of a COVID-19 infection. Viscoelastometric variables and markers of glycocalyx damage are significantly increased upon admission to the ICU without being predictors of ICU admission.
Collapse
Affiliation(s)
- Sarah Thaler
- Department of Anaesthesiology, University Hospital, Munich, Germany
| | - Dana Stöhr
- Department of Anaesthesiology, University Hospital, Munich, Germany
| | - Tobias Kammerer
- Department of Anaesthesiology, University Hospital, Munich, Germany
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Tobias Nitschke
- Department of Anaesthesiology, University Hospital, Munich, Germany
| | | | - Florian Brandes
- Department of Anaesthesiology, University Hospital, Munich, Germany
| | - Martin Müller
- Department of Anaesthesiology, University Hospital, Munich, Germany
| | - Philipp Groene
- Department of Anaesthesiology, University Hospital, Munich, Germany
| | - Simon T Schäfer
- Department of Anaesthesiology, University Hospital, Munich, Germany
| |
Collapse
|
5
|
Rodrigues A, Dias Domingues T, Nobre Jesus G, Garção A, Rodrigues AR, Jacinto Correia C, Leal Pereira C, Correia D, Beleza Á, Ribeiro JM. COVID-19-associated Coagulopathy Characterization using Rotational Thromboelastometry in a Prospective, Observational Cohort Study: The HemoCoV Study. ACTA MEDICA PORT 2023; 36:496-505. [PMID: 37429589 DOI: 10.20344/amp.19475] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 03/31/2023] [Indexed: 07/12/2023]
Abstract
INTRODUCTION COVID-19-associated coagulopathy includes systemic and endothelial inflammation with coagulation dysregulation related to immunothrombosis. The aim of this study was to characterize this complication of SARS-CoV-2 infection in patients with moderate to severe COVID-19. METHODS An open-label, prospective observational study conducted in patients with COVID-19 moderate to severe acute respiratory failure admitted to an intensive care unit (ICU). Coagulation testing, including thromboelastometry, biochemical analysis and clinical variables, were collected at prespecified time points during the 30 days of ICU stay. RESULTS The study included 145 patients, 73.8% male, with a median age of 68 years (interquartile range - IQR 55 - 74). The most prevalent comorbidities were arterial hypertension (63.4%), obesity (44.1%) and diabetes (22.1%). Simplified acute physiology score II (SAPS II) was on average 43.5 (11 - 105) and sequential organ failure assessment (SOFA) at admission was 7.5 (0 - 14). During ICU stay, 66.9% of patients underwent invasive mechanical ventilation and 18.4% extracorporeal membrane oxygenation support; thrombotic and hemorrhagic events occurred in 22.1% and 15.1% of the patients respectively; anticoagulation with heparin was present in 99.2% of patients since early ICU stay. Death occurred in 35% of patients. Longitudinal studies revealed changes in almost all coagulation tests during the ICU stay. SOFA score, lymphocyte counts, some biochemical, inflammatory and coagulation parameters, including hypercoagulability and hypofibrinolysis seen in thromboelastometry, differed significantly (p < 0.05), between ICU admission and discharge. Hypercoagulability and hypofibrinolysis persisted throughout ICU hospitalization, showing higher incidence and severity in non-survivors. CONCLUSION COVID-19-associated coagulopathy is characterized by hypercoagulability and hypofibrinolysis from ICU admission, and persisted throughout the clinical course in severe COVID-19. These changes were more pronounced in patients with higher disease burden and in non-survivors.
Collapse
Affiliation(s)
- Anabela Rodrigues
- Transfusion Medicine Department. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon. Portugal
| | - Tiago Dias Domingues
- Centro de Estatística e Aplicações - CEAUL. Faculdade de Ciências. Universidade de Lisboa. Lisbon. Portugal
| | - Gustavo Nobre Jesus
- Intensive Medicine Department. Clínica Universitária de Medicina Intensiva. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon; Clínica Universitária de Medicina Intensiva. Faculdade de Medicina. Universidade de Lisboa. Lisbon. Portugal
| | - Ana Garção
- Transfusion Medicine Department. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon. Portugal
| | - Ana Rita Rodrigues
- Intensive Medicine Department. Clínica Universitária de Medicina Intensiva. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon. Portugal
| | - Catarina Jacinto Correia
- Transfusion Medicine Department. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon. Portugal
| | - Carla Leal Pereira
- Transfusion Medicine Department. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon. Portugal
| | - Dulce Correia
- Intensive Medicine Department. Clínica Universitária de Medicina Intensiva. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon. Portugal
| | - Álvaro Beleza
- Transfusion Medicine Department. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon. Portugal
| | - João Miguel Ribeiro
- Intensive Medicine Department. Clínica Universitária de Medicina Intensiva. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon. Portugal
| |
Collapse
|
6
|
Blasi A, Lisman T. Abnormal fibrinolysis identified by viscoelastic tests in relation to clinical outcomes: Last call to harmonize criteria for future studies on promising associations. Liver Transpl 2023; 29:665-667. [PMID: 36896971 DOI: 10.1097/lvt.0000000000000119] [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: 02/23/2023] [Accepted: 02/23/2023] [Indexed: 03/11/2023]
Affiliation(s)
- Annabel Blasi
- Department of Anesthesiology, Hospital Clinic of Barcelona, Spain
| | - Ton Lisman
- Department of Surgery, Surgical Research Laboratory, Section of Hepatobiliary Surgery and Liver Transplantation University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| |
Collapse
|
7
|
Toomer KH, Gerber GF, Zhang Y, Daou L, Tushek M, Hooper JE, Francischetti IMB. SARS-CoV-2 infection results in upregulation of Plasminogen Activator Inhibitor-1 and Neuroserpin in the lungs, and an increase in fibrinolysis inhibitors associated with disease severity. EJHAEM 2023; 4:324-338. [PMID: 37206290 PMCID: PMC10188457 DOI: 10.1002/jha2.654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/14/2023] [Accepted: 01/21/2023] [Indexed: 05/21/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection results in coagulation activation although it is usually not associated with consumption coagulopathy. D-dimers are also commonly elevated despite systemic hypofibrinolysis. To understand these unusual features of coronavirus disease 2019 (COVID-19) coagulopathy, 64 adult patients with SARS-CoV-2 infection (36 moderate and 28 severe) and 16 controls were studied. We evaluated the repertoire of plasma protease inhibitors (Serpins, Kunitz, Kazal, Cystatin-like) targeting the fibrinolytic system: Plasminogen Activator Inhibitor-1 (PAI-1), Tissue Plasminogen Activator/Plasminogen Activator Inhibitor-1 complex (t-PA/PAI-1), α-2-Antiplasmin, Plasmin-α2-Antiplasmin Complex, Thrombin-activatable Fibrinolysis Inhibitor (TAFI)/TAFIa, Protease Nexin-1 (PN-1), and Neuroserpin (the main t-PA inhibitor of the central nervous system). Inhibitors of the common (Antithrombin, Thrombin-antithrombin complex, Protein Z [PZ]/PZ inhibitor, Heparin Cofactor II, and α2-Macroglobulin), Protein C ([PC], Protein C inhibitor, and Protein S), contact (Kallistatin, Protease Nexin-2/Amyloid Beta Precursor Protein, and α-1-Antitrypsin), and complement (C1-Inhibitor) pathways, in addition to Factor XIII, Histidine-rich glycoprotein (HRG) and Vaspin were also investigated by enzyme-linked immunosorbent assay. The association of these markers with disease severity was evaluated by logistic regression. Pulmonary expression of PAI-1 and Neuroserpin in the lungs from eight post-mortem cases was assessed by immunohistochemistry. Results show that six patients (10%) developed thrombotic events, and mortality was 11%. There was no significant reduction in plasma anticoagulants, in keeping with a compensated state. However, an increase in fibrinolysis inhibitors (PAI-1, Neuroserpin, PN-1, PAP, and t-PA/PAI-1) was consistently observed, while HRG was reduced. Furthermore, these markers were associated with moderate and/or severe disease. Notably, immunostains demonstrated overexpression of PAI-1 in epithelial cells, macrophages, and endothelial cells of fatal COVID-19, while Neuroserpin was found in intraalveolar macrophages only. These results imply that the lungs in SARS-CoV-2 infection provide anti-fibrinolytic activity resulting in a shift toward a local and systemic hypofibrinolytic state predisposing to (immuno)thrombosis, often in a background of compensated disseminated intravascular coagulation.
Collapse
Affiliation(s)
- Kevin H. Toomer
- Department of PathologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Gloria F. Gerber
- Division of HematologyDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Yifan Zhang
- Department of BiostatisticsJohns Hopkins University Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Laetitia Daou
- Department of PathologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Michael Tushek
- Department of PathologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Jody E. Hooper
- Department of PathologyStanford University School of MedicinePalo AltoCaliforniaUSA
| | | |
Collapse
|
8
|
Matsudo M, Aladio JM, Costa D, Scazziota AS, Swieszkowski S, Perez de la Hoz R. Association of hemostasis and inflammation biomarkers with outcomes in acute coronary syndromes. Blood Coagul Fibrinolysis 2023; 34:179-183. [PMID: 36966807 DOI: 10.1097/mbc.0000000000001208] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
Plaque rupture triggers a prothrombotic response that is counterbalanced by a fibrinolytic response. d -dimer serves as a marker of both processes. Inflammatory mediators are also released, evidenced with the rise of high-sensitive C reactive protein (hsCRP). Current evidence with these biomarkers has shown conflicting results. Determine an association between d -dimer and hsCRP within hospital and 1-year mortality in patients with acute coronary syndromes. In total, 127 patients were included. In-hospital mortality was 5.7%, and 1-year all-cause and cardiovascular mortality were 14.6 and 9.7%, respectively. The median of admission d -dimer for patients who died during hospital stay was higher than those who survived [4.59 (interquartile ranges (IQR) 1.94-6.05 μg/ml fibrinogen equivalent units (FEU)) vs. 0.56 (IQR 0.31-1.12 μg/ml FEU), P = 0.001]. At 1-year follow-up, the median of admission d -dimer for patients who died was significantly higher than those who survived: 1.55 (IQR 0.91-5.08 μg/ml FEU) vs. 0.53 (IQR 0.29-0.90 μg/ml FEU), P < 0.001. Positive d -dimer vs. negative d -dimer at admission analysis evidenced that almost 25% of the positive patients were dead at 1-year follow-up (22.4 vs. 2.4% negative d -dimer, P = 0.011). Multivariate logistic regression analysis showed that d -dimer has an independent association with 1-year mortality [odds ratio 1.06 (95% confidence interval 1.02-1.10), P = 0.006]. Positive significative correlations between d -dimer and hsCRP levels ( R = 0.56, P < 0.001) were found. High levels of admission d -dimer were strongly associated with in-hospital and 1-year mortality. Significant correlations with hsCRP could explain the inflammatory nature that led to poorer outcomes. d -dimer could be useful in risk stratification in acute coronary syndromes; however, a specific threshold should be defined for this type of patient.
Collapse
Affiliation(s)
- Maia Matsudo
- Unidad Coronaria, Hospital de Clinicas Jose de San Martin, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | | | | | | | | | | |
Collapse
|
9
|
Wang T, Zhai Y, Xue H, Zhou W, Ding Y, Nie H. Regulation of Epithelial Sodium Transport by SARS-CoV-2 Is Closely Related with Fibrinolytic System-Associated Proteins. Biomolecules 2023; 13:biom13040578. [PMID: 37189326 DOI: 10.3390/biom13040578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/08/2023] [Accepted: 03/21/2023] [Indexed: 05/17/2023] Open
Abstract
Dyspnea and progressive hypoxemia are the main clinical features of patients with coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Pulmonary pathology shows diffuse alveolar damage with edema, hemorrhage, and the deposition of fibrinogens in the alveolar space, which are consistent with the Berlin Acute Respiratory Distress Syndrome Criteria. The epithelial sodium channel (ENaC) is a key channel protein in alveolar ion transport and the rate-limiting step for pulmonary edema fluid clearance, the dysregulation of which is associated with acute lung injury/acute respiratory distress syndrome. The main protein of the fibrinolysis system, plasmin, can bind to the furin site of γ-ENaC and induce it to an activation state, facilitating pulmonary fluid reabsorption. Intriguingly, the unique feature of SARS-CoV-2 from other β-coronaviruses is that the spike protein of the former has the same furin site (RRAR) with ENaC, suggesting that a potential competition exists between SARS-CoV-2 and ENaC for the cleavage by plasmin. Extensive pulmonary microthrombosis caused by disorders of the coagulation and fibrinolysis system has also been seen in COVID-19 patients. To some extent, high plasmin (ogen) is a common risk factor for SARS-CoV-2 infection since an increased cleavage by plasmin accelerates virus invasion. This review elaborates on the closely related relationship between SARS-CoV-2 and ENaC for fibrinolysis system-related proteins, aiming to clarify the regulation of ENaC under SARS-CoV-2 infection and provide a novel reference for the treatment of COVID-19 from the view of sodium transport regulation in the lung epithelium.
Collapse
Affiliation(s)
- Tingyu Wang
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang 110122, China
| | - Yiman Zhai
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang 110122, China
| | - Hao Xue
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang 110122, China
| | - Wei Zhou
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang 110122, China
| | - Yan Ding
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang 110122, China
| | - Hongguang Nie
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang 110122, China
| |
Collapse
|
10
|
Mykhalchuk DI, Pavlovskyi SA, Pavlovska MO, Drozdov VO, Blagaia AV. FEATURES OF COAGULOPATHY AND SYSTEMIC INFLAMMATION IN PATIENTS AFTER COVID-19 INFECTION. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2023; 75:2907-2914. [PMID: 36723302 DOI: 10.36740/wlek202212103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The aim: To determine the peculiarities of laboratory data concerning blood coagulation and systemic inflammation in COVID-19 patients in three months after discharge and recovery. The state of coagulation, anticoagulation, and fibrinolytic systems, as well as their prognostic value having been well studied in hospitalized COVID-19 patients, their state three months after hospitalization, are not yet well understood. PATIENTS AND METHODS Materials and methods: Methods of randomization, anthropometry, ECG, standard clinical blood testing, immunoenzymometry, immunoanalysis, and primary statistical analysis were used in the study. Anthropometric measurements of patients (n=20), blood samples, blood serum samples, urine samples, and statistical data were the materials of the study. RESULTS Results: Indices of coagulation and systemic inflammation in studied patients after COVID-19 were obtained (PTT, s ; PATPT, s; Fibrinogen, g/L; Platelets ×109 /L; PCT, ng/mL; DD, μg/L; СRP, mg/L; IL -6, pg/mL; IL -10, pg/mL; Cortisol (nM/L); CIC (IU/mL); Ig A (g/L). CONCLUSION Conclusions: Summing up the results obtained, it is possible to assert micro- and macro-vascular thromboses to be common in COVID-19 cases; they are associated with poor prognosis for diseased patients and are not completely investigated; the role of thromboses in COVID-19 course and complications are to be studied as well as the strategies of fibrinolytic therapies for such condition are to be justified. The presence of specific rheological and serological changes in patients even three months after surviving COVID-19 needs further study to understand the necessity of anti-thrombolytic drug uptake for a relatively long time.
Collapse
Affiliation(s)
| | - Serhij A Pavlovskyi
- PRIVATE INSTITUTION OF HIGHER EDUCATION «KYIV INTERNATIONAL UNIVERSITY», KYIV, UKRAINE
| | - Maryna O Pavlovska
- PRIVATE INSTITUTION OF HIGHER EDUCATION «KYIV INTERNATIONAL UNIVERSITY», KYIV, UKRAINE
| | | | | |
Collapse
|
11
|
Determination of reference ranges for the ClotPro® thromboelastometry device in paediatric patients. Br J Anaesth 2023; 130:183-190. [PMID: 36376099 DOI: 10.1016/j.bja.2022.09.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 09/09/2022] [Accepted: 09/24/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND A new thromboelastometry analyser (ClotPro®) was developed with advanced diagnostics. The reference ranges of ClotPro® in children ages 0-16 yr have not been reported. METHODS In this prospective study, venous blood samples from 321 patients were obtained from children undergoing elective surgery after induction of anaesthesia. Reference ranges were defined by calculating the 2.5% and 97.5% percentiles for each age group (0-3 months, 4-12 months, 13-24 months, 2-5 yr, 6-10 yr, and 11-16 yr). RESULTS Reference ranges of the ClotPro® analyser in all age groups demonstrated significant differences in some parameters between age groups. In the first 3 months of life, a significant shortening of the clotting time (CT) in the extrinsically activated test (EX-test) was observed in children aged 0-3 months compared with children of all older age groups (P<0.001), whereas there were no overall differences in the intrinsically activated test (IN-test). In both assays, the clot amplitude 5 and 10 min after CT (A5, A10 value) was significantly higher in the first year of life compared with children older than 1 yr (EX-test and IN-test A5 and A10, respectively; P<0.001). The strength of fibrin polymerisation (FIB-test) was significantly higher in the first 3 months of life (A5 and A10, P<0.003). CONCLUSIONS ClotPro® reference ranges were determined for six paediatric age groups, and show age-dependent differences in specific parameters. These values will be helpful in monitoring haemostasis in paediatric patients and for developing tailored bleeding management protocols. CLINICAL TRIAL REGISTRATION NCT04190615.
Collapse
|
12
|
Watson O, Zaldua JC, Pillai S, Whitley J, Howard M, Lawrence M, Hawkins K, Morris K, Evans PA. The efficacy of low molecular weight heparin is reduced in COVID-19. Clin Hemorheol Microcirc 2023; 84:333-344. [PMID: 36442189 DOI: 10.3233/ch-221635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND A significant degree of mortality and morbidity in COVID-19 is through thromboembolic complications, only partially mitigated by anticoagulant therapy. Reliable markers of infection severity are not fully established. OBJECTIVES This study investigated whether visco-elastic biomarkers predict disease severity on presentation to the Emergency Department (ED) and how they measure response to anticoagulationMETHODS:Patients testing positive for COVID-19 at a large University Teaching Hospital ED were recruited at presentation. Multiple blood samples were taken throughout hospital admission to monitor disease progression with end outcome recorded. Visco-elastic markers, fractal dimension (df) and Time to Gel Point (TGP) which measure the properties of the incipient clot were compared in patients with and without anticoagulation by Low Molecular Weight Heparin (LMWH). RESULTS TGP and df did not predict severity of infection with COVID-19. Although LMWH prolonged TGP, there was no change in df indicating LMWH did not change clot microstructure. CONCLUSIONS Therapeutic efficacy of LMWH appears blunted in COVID-19 infection. This may be due to the inflammatory state creating a resistance to LMWH activity, which may explain why LMWH appears less effective in COVID-19 compared to other disease states. COVID-19 was not predicted by visco-elastic testing at the time of ED presentation.
Collapse
Affiliation(s)
- Oliver Watson
- Welsh Centre for Emergency Medicine Research, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK
- Swansea University Medical School Swansea University, Singleton Park, Swansea, UK
| | - Jun-Cezar Zaldua
- Welsh Centre for Emergency Medicine Research, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK
- Swansea University Medical School Swansea University, Singleton Park, Swansea, UK
| | - Suresh Pillai
- Welsh Centre for Emergency Medicine Research, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK
- Swansea University Medical School Swansea University, Singleton Park, Swansea, UK
| | - Janet Whitley
- Welsh Centre for Emergency Medicine Research, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK
- Swansea University Medical School Swansea University, Singleton Park, Swansea, UK
| | - Matthew Howard
- Welsh Centre for Emergency Medicine Research, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK
- Swansea University Medical School Swansea University, Singleton Park, Swansea, UK
| | - Matthew Lawrence
- Welsh Centre for Emergency Medicine Research, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK
| | - Karl Hawkins
- Swansea University Medical School Swansea University, Singleton Park, Swansea, UK
| | - Keith Morris
- Cardiff Metropolitan University, Llandaff Campus Western Avenue, Cardiff, UK
| | - Phillip Adrian Evans
- Welsh Centre for Emergency Medicine Research, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK
- Swansea University Medical School Swansea University, Singleton Park, Swansea, UK
| |
Collapse
|
13
|
Uzun G, Althaus K, Hammer S, Bakchoul T. Assessment and Monitoring of Coagulation in Patients with COVID-19: A Review of Current Literature. Hamostaseologie 2022; 42:409-419. [PMID: 35477118 DOI: 10.1055/a-1755-8676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Coagulation abnormalities are common in patients with COVID-19 and associated with high morbidity and mortality. It became a daily challenge to navigate through these abnormal laboratory findings and deliver the best possible treatment to the patients. The unique character of COVID-19-induced coagulopathy necessitates not only a dynamic follow-up of the patients in terms of hemostatic findings but also the introduction of new diagnostic methods to determine the overall function of the coagulation system in real time. After the recognition of the high risk of thromboembolism in COVID-19, several professional societies published their recommendations regarding anticoagulation in patients with COVID-19. This review summarizes common hemostatic findings in COVID-19 patients and presents the societal recommendations regarding the use of coagulation laboratory findings in clinical decision-making. Although several studies have investigated coagulation parameters in patients with COVID-19, the methodological shortcomings of published studies as well as the differences in employed anticoagulation regimens that have changed over time, depending on national and international guidelines, limit the applicability of these findings in other clinical settings. Accordingly, evidence-based recommendations for diagnostics during acute COVID-19 infection are still lacking. Future studies should verify the role of coagulation parameters as well as viscoelastic methods in the management of patients with COVID-19.
Collapse
Affiliation(s)
- Günalp Uzun
- Center for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany
| | - Karina Althaus
- Center for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany.,Medical Faculty of Tuebingen, Institute for Clinical and Experimental Transfusion Medicine, Tuebingen, Germany
| | - Stefanie Hammer
- Center for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany
| | - Tamam Bakchoul
- Center for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany.,Medical Faculty of Tuebingen, Institute for Clinical and Experimental Transfusion Medicine, Tuebingen, Germany
| |
Collapse
|
14
|
Peak Plasma Levels of mtDNA Serve as a Predictive Biomarker for COVID-19 in-Hospital Mortality. J Clin Med 2022; 11:jcm11237161. [PMID: 36498735 PMCID: PMC9740249 DOI: 10.3390/jcm11237161] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/27/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022] Open
Abstract
Several predictive biomarkers for coronavirus disease (COVID-19)-associated mortality in critically ill patients have been described. Although mitochondrial DNA (mtDNA) is elevated in patients with COVID-19, the association with coagulation function and its predictive power for mortality is unclear. Accordingly, this study investigates the predictive power of mtDNA for in-hospital mortality in critically ill patients with COVID-19, and whether combining it with thromboelastographic parameters can increase its predictive performance. This prospective explorative study included 29 patients with COVID-19 and 29 healthy matched controls. mtDNA encoding for NADH dehydrogenase 1 (ND1) was quantified using a quantitative polymerase chain reaction analysis, while coagulation function was evaluated using thromboelastometry and impedance aggregometry. Receiver operating characteristic (ROC) curves were used for the prediction of in-hospital mortality. Within the first 24 h, the plasma levels of mtDNA peaked significantly (controls: 65 (28-119) copies/µL; patients: 281 (110-805) at t0, 403 (168-1937) at t24, and 467 (188-952) copies/µL at t72; controls vs. patients: p = 0.02 at t0, p = 0.03 at t24, and p = 0.44 at t72). The mtDNA levels at t24 showed an excellent predictive performance for in-hospital mortality (area under the ROC curve: 0.90 (0.75-0.90)), which could not be improved by the combination with thromboelastometric or aggregometric parameters. Critically ill patients with COVID-19 present an early increase in the plasma levels of ND1 mtDNA, lasting over 24 h. They also show impairments in platelet function and fibrinolysis, as well as hypercoagulability, but these do not correlate with the plasma levels of fibrinogen. The peak plasma levels of mtDNA can be used as a predictive biomarker for in-hospital mortality; however, the combination with coagulation parameters does not improve the predictive validity.
Collapse
|
15
|
Hypercoagulability in critically ill patients with COVID 19, an observational prospective study. PLoS One 2022; 17:e0277544. [PMID: 36417476 PMCID: PMC9683576 DOI: 10.1371/journal.pone.0277544] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 10/30/2022] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE COVID 19 is often associated with hypercoagulability and thromboembolic (TE) events. The aim of this study was to assess the characteristics of hypercoagulability and its relationship with new-onset TE events and the composite outcome of need for intubation and/or death in intensive care unit (ICU) patients admitted for COVID. DESIGN Prospective observational study. SETTING Monocentric, intensive care, University Hospital of Clermont Ferrand, France. PATIENTS Patients admitted to intensive care from January 2020 to May 2021 for COVID-19 pneumonia. INTERVENTIONS Standard hemostatic tests and rotational thromboelastometry (ROTEM) were performed on admission and on day 4. Hypercoagulability was defined by at least one of the following criteria: D-dimers > 3000 μg/dL, fibrinogen > 8 g/L, EXTEM CFT below the normal range, EXTEM A5, MCF, Li 60 above the normal range, and EXTEM G-score ((5000 x MCF) / (100-MCF)) ≥ 11 dyne/cm2. MEASUREMENTS AND MAIN RESULTS Of the 133 patients included, 17 (12.7%) developed new-onset TE events, and 59 (44.3%) required intubation and/or died in the ICU. ROTEM was performed in 133 patients on day 1 and in 67 on day 4. Hypercoagulability was present on day 1 in 115 (86.4%) patients. None of the hypercoagulability indices were associated with subsequent new-onset TE events on days 1 and 4 nor with the need for intubation and/or ICU death. Hyperfibrinogenemia > 8g/dL, higher D-dimers and higher EXTEM Li 60 on day 4 were predictive of need for intubation and/or of ICU death. CONCLUSIONS Our study confirmed that most COVID-19 ICU patients have hypercoagulability on admission and almost all on day 4. Hyperfibrinogenemia or fibrinolysis shutdown on day 4 were associated with unfavorable outcome.
Collapse
|
16
|
Heubner L, Petrick PL, Güldner A, Bartels L, Ragaller M, Mirus M, Rand A, Tiebel O, Beyer-Westendorf J, Rößler M, Schmitt J, Koch T, Spieth PM. Extreme obesity is a strong predictor for in-hospital mortality and the prevalence of long-COVID in severe COVID-19 patients with acute respiratory distress syndrome. Sci Rep 2022; 12:18418. [PMID: 36319681 PMCID: PMC9626466 DOI: 10.1038/s41598-022-22107-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 10/10/2022] [Indexed: 11/26/2022] Open
Abstract
Acute Respiratory Distress Syndrome (ARDS) is common in COVID-19 patients and is associated with high mortality. The aim of this observational study was to describe patients' characteristics and outcome, identifying potential risk factors for in-hospital mortality and for developing Long-COVID symptoms. This retrospective study included all patients with COVID-19 associated ARDS (cARDS) in the period from March 2020 to March 2021 who were invasively ventilated at the intensive care unit (ICU) of the University Hospital Dresden, Germany. Between October 2021 and December 2021 patients discharged alive (at minimum 6 months after hospital discharge-midterm survival) were contacted and interviewed about persistent symptoms possibly associated with COVID-19 as well as the quality of their lives using the EQ-5D-5L-questionnaire. Long-COVID was defined as the occurrence of one of the symptoms at least 6 months after discharge. Risk factors for mortality were assessed with Cox regression models and risk factors for developing Long-COVID symptoms by using relative risk (RR) regression. 184 Patients were included in this study (male: n = 134 (73%), median age 67 (range 25-92). All patients were diagnosed with ARDS according to the Berlin Definition. 89% of patients (n = 164) had severe ARDS (Horovitz-index < 100 mmHg). In 27% (n = 49) extracorporeal membrane oxygenation was necessary to maintain gas exchange. The median length of in-hospital stay was 19 days (range 1-60). ICU mortality was 51%, hospital mortality 59%. Midterm survival (median 11 months) was 83% (n = 55) and 78% (n = 43) of these patients presented Long-COVID symptoms with fatigue as the most common symptom (70%). Extreme obesity (BMI > 40 kg/m2) was the strongest predictor for in-hospital mortality (hazard ratio: 3.147, confidence interval 1.000-9.897) and for developing Long-COVID symptoms (RR 1.61, confidence interval 1.26-2.06). In-hospital mortality in severe cARDS patients was high, but > 80% of patients discharged alive survived the midterm observation period. Nonetheless, most patients developed Long-COVID symptoms. Extreme obesity with BMI > 40 kg/m2 was identified as independent risk factor for in-hospital mortality and for developing Long-COVID symptoms.Trial registration DRKS-ID DRKS00027856.
Collapse
Affiliation(s)
- Lars Heubner
- grid.4488.00000 0001 2111 7257Department of Anesthesiology and Intensive Care Medicine, University Hospital “Carl Gustav Carus”, Technische Universität Dresden, Dresden, Germany
| | - Paul Leon Petrick
- grid.4488.00000 0001 2111 7257Department of Anesthesiology and Intensive Care Medicine, University Hospital “Carl Gustav Carus”, Technische Universität Dresden, Dresden, Germany
| | - Andreas Güldner
- grid.4488.00000 0001 2111 7257Department of Anesthesiology and Intensive Care Medicine, University Hospital “Carl Gustav Carus”, Technische Universität Dresden, Dresden, Germany
| | - Lea Bartels
- grid.4488.00000 0001 2111 7257Department of Anesthesiology and Intensive Care Medicine, University Hospital “Carl Gustav Carus”, Technische Universität Dresden, Dresden, Germany
| | - Maximillian Ragaller
- grid.4488.00000 0001 2111 7257Department of Anesthesiology and Intensive Care Medicine, University Hospital “Carl Gustav Carus”, Technische Universität Dresden, Dresden, Germany
| | - Martin Mirus
- grid.4488.00000 0001 2111 7257Department of Anesthesiology and Intensive Care Medicine, University Hospital “Carl Gustav Carus”, Technische Universität Dresden, Dresden, Germany
| | - Axel Rand
- grid.4488.00000 0001 2111 7257Department of Anesthesiology and Intensive Care Medicine, University Hospital “Carl Gustav Carus”, Technische Universität Dresden, Dresden, Germany
| | - Oliver Tiebel
- grid.4488.00000 0001 2111 7257Institute of Clinical Chemistry, University Hospital “Carl Gustav Carus”, Technische Universität Dresden, Dresden, Germany
| | - Jan Beyer-Westendorf
- grid.4488.00000 0001 2111 7257Division of Hematology and Hemostasis, Department of Medicine I Thrombosis Research, University Hospital “Carl Gustav Carus”, Technische Universität Dresden, Dresden, Germany
| | - Martin Rößler
- grid.4488.00000 0001 2111 7257Center for Evidence-Based Healthcare (ZEGV), University Hospital “Carl Gustav Carus” and “Carl Gustav Carus” Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Jochen Schmitt
- grid.4488.00000 0001 2111 7257Center for Evidence-Based Healthcare (ZEGV), University Hospital “Carl Gustav Carus” and “Carl Gustav Carus” Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Thea Koch
- grid.4488.00000 0001 2111 7257Department of Anesthesiology and Intensive Care Medicine, University Hospital “Carl Gustav Carus”, Technische Universität Dresden, Dresden, Germany
| | - Peter Markus Spieth
- grid.4488.00000 0001 2111 7257Department of Anesthesiology and Intensive Care Medicine, University Hospital “Carl Gustav Carus”, Technische Universität Dresden, Dresden, Germany
| |
Collapse
|
17
|
Fabbro M, Patel PA, Henderson RA, Bolliger D, Tanaka KA, Mazzeffi MA. Coagulation and Transfusion Updates From 2021. J Cardiothorac Vasc Anesth 2022; 36:3447-3458. [PMID: 35750604 PMCID: PMC8986228 DOI: 10.1053/j.jvca.2022.03.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 12/02/2022]
Abstract
2021 and the COVID 19 pandemic have brought unprecedented blood shortages worldwide. These deficits have propelled national efforts to reduce blood usage, including limiting elective services and accelerating Patient Blood Management (PBM) initiatives. A host of research dedicated to blood usage and management within cardiac surgery has continued to emerge. The intent of this review is to highlight this past year's research pertaining to PBM and COVID-19-related coagulation changes.
Collapse
|
18
|
Heubner L, Greiner M, Vicent O, Beyer-Westendorf J, Tiebel O, Scholz U, Güldner A, Mirus M, Fries D, Koch T, Spieth PM. Predictive ability of viscoelastic testing using ClotPro® for short-term outcome in patients with severe Covid-19 ARDS with or without ECMO therapy: a retrospective study. Thromb J 2022; 20:48. [PMID: 36038895 PMCID: PMC9421107 DOI: 10.1186/s12959-022-00403-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 08/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND SARS-CoV-2 infections are suspected to trigger the coagulation system through various pathways leading to a high incidence of thromboembolic complications, hypercoagulation and impaired fibrinolytic capacity were previously identified as potentially mechanisms. A reliable diagnostic tool for detecting both is still under discussion. This retrospective study is aimed to examine the prognostic relevance of early viscoelastic testing compared to conventional laboratory tests in COVID-19 patients with acute respiratory distress syndrome (ARDS). METHODS All mechanically ventilated patients with COVID-19 related ARDS treated in our intensive care unit (ICU) between January and March 2021 were included in this study. Viscoelastic testing (VET) was performed using the ClotPro® system after admission to our ICU. Prevalence of thromboembolic events was observed by standardized screening for venous and pulmonary thromboembolism using complete compression ultrasound and thoracic computed tomography pulmonary angiography at ICU admission, respectively. We examined associations between the severity of ARDS at admission to our ICU, in-hospital mortality and the incidence of thromboembolic events comparing conventional laboratory analysis and VET. ECMO related coagulopathy was investigated in a subgroup analysis. The data were analyzed using the Mann-Whitney U test. RESULTS Of 55 patients enrolled in this study, 22 patients required treatment with ECMO. Thromboembolic complications occurred in 51% of all patients. Overall hospital mortality was 55%. In patients with thromboembolic complications, signs of reduced fibrinolytic capacity could be detected in the TPA assay with prolonged lysis time, median 460 s (IQR 350-560) vs 359 s (IQR 287-521, p = 0.073). Patients with moderate to severe ARDS at admission to our ICU showed increased maximum clot firmness as a sign of hypercoagulation in the EX-test (70 vs 67 mm, p < 0.05), FIB-test (35 vs 24 mm, p < 0.05) and TPA-test (52 vs 36 mm, p < 0.05) as well as higher values of inflammatory markers (CRP, PCT and IL6). ECMO patients suffered more frequently from bleeding complications (32% vs 15%). CONCLUSION Although, the predictive value for thromboembolic complications or mortality seems limited, point-of-care viscoelastic coagulation testing might be useful in detecting hypercoagulable states and impaired fibrinolysis in critically ill COVID-19 ARDS patients and could be helpful in identifying patients with a potentially very severe course of the disease.
Collapse
Affiliation(s)
- Lars Heubner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Marvin Greiner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Oliver Vicent
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Jan Beyer-Westendorf
- Division of Hematology and Hemostasis, Department of Medicine I, Thrombosis Research University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Oliver Tiebel
- Institute of Clinical Chemistry, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Ute Scholz
- MVZ Labor Dr. Reising-Ackermann Und Kollegen, Center of Hemostasis, Leipzig, Germany
| | - Andreas Güldner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Martin Mirus
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Dietmar Fries
- Department for General and Surgical Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - Thea Koch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Peter Markus Spieth
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany.
| |
Collapse
|
19
|
Snegovskikh D, Kendall MC, Levinson A, Sarpatwari R, Pisano D, Görlinger K, De Oliveira G. Thromboelastometry Predicts Thromboembolic Events, Hospital Length of Stay, and Mortality in Patients with COVID-19 Infection and Mild Hypoxemia: A Prospective Observational Study. J Blood Med 2022; 13:363-372. [PMID: 35789896 PMCID: PMC9250315 DOI: 10.2147/jbm.s363999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 06/14/2022] [Indexed: 11/23/2022] Open
Abstract
Background The aim of this study was to assess changes in hemostasis and associated outcome of hospitalized patients with COVID-19 infection and mild hypoxemia. Methods Adult patients with COVID-19 infection and hypoxemia admitted to ICU were included in this prospective observational study. The primary outcome was defined as an unfavorable course of the disease if a patient: (1) developed a thromboembolic event while receiving anticoagulation prophylaxis, (2) had prolonged ICU stay, or (3) died. Demographic data, laboratory parameters and thromboelastometry (ROTEM) test results were collected. Results Twenty-five patients were recruited into the study. There were 16 patients with an unfavorable course of the disease. Compared to the 9 patients in the favorable course group, patients with an unfavorable course had a lower platelet count, median difference of 154 (95% CI, 26 to 223 x109/L), P = 0.012, and lower clot firmness parameters in EXTEM assay: amplitude at 20 minutes (A20), median difference of 7 (95% CI, 2 to 11) P = 0.006, maximum clot firmness (MCF), median difference of 6 (95% CI, 3 to 10) P = 0.006 and area under the curve (AUC) with a median difference of 671 (95% CI, 244 to 1029) P = 0.005. They also demonstrated suppression of fibrinolysis: higher lysis index 60, median difference of -3 (95% CI, -6 to 0), P = 0.023. Results of functional fibrinogen (FIBTEM) assay were similar between the groups. Conclusion The platelet count and the results of EXTEM assay, but not FIBTEM assay, were associated with the difference in clinical outcome among patients with COVID-19 infection and hypoxemia. The role of platelets in the outcome of COVID-19 infection calls for further investigation. Future studies on adjusting anticoagulant therapy based on the results of viscoelastic testing may be beneficial.
Collapse
Affiliation(s)
- Denis Snegovskikh
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Mark C Kendall
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Andrew Levinson
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Ravi Sarpatwari
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Dominic Pisano
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany.,Medical Department, Tem Innovations, Munich, Germany
| | - Gildasio De Oliveira
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| |
Collapse
|
20
|
Corey KM, Olson LB, Naqvi IA, Morrison SA, Davis C, Nimjee SM, Que LG, Bachelder RE, Kraft BD, Chen L, Nair SK, Levy JH, Sullenger BA. Suppression of Fibrinolysis and Hypercoagulability, Severity of Hypoxemia, and Mortality in COVID-19 Patients: A Retrospective Cohort Study. Anesthesiology 2022; 137:67-78. [PMID: 35412597 PMCID: PMC9250792 DOI: 10.1097/aln.0000000000004239] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND COVID-19 causes hypercoagulability, but the association between coagulopathy and hypoxemia in critically ill patients has not been thoroughly explored. This study hypothesized that severity of coagulopathy would be associated with acute respiratory distress syndrome severity, major thrombotic events, and mortality in patients requiring intensive care unit-level care. METHODS Viscoelastic testing by rotational thromboelastometry and coagulation factor biomarker analyses were performed in this prospective observational cohort study of critically ill COVID-19 patients from April 2020 to October 2020. Statistical analyses were performed to identify significant coagulopathic biomarkers such as fibrinolysis-inhibiting plasminogen activator inhibitor 1 and their associations with clinical outcomes such as mortality, extracorporeal membrane oxygenation requirement, occurrence of major thrombotic events, and severity of hypoxemia (arterial partial pressure of oxygen/fraction of inspired oxygen categorized into mild, moderate, and severe per the Berlin criteria). RESULTS In total, 53 of 55 (96%) of the cohort required mechanical ventilation and 9 of 55 (16%) required extracorporeal membrane oxygenation. Extracorporeal membrane oxygenation-naïve patients demonstrated lysis indices at 30 min indicative of fibrinolytic suppression on rotational thromboelastometry. Survivors demonstrated fewer procoagulate acute phase reactants, such as microparticle-bound tissue factor levels (odds ratio, 0.14 [0.02, 0.99]; P = 0.049). Those who did not experience significant bleeding events had smaller changes in ADAMTS13 levels compared to those who did (odds ratio, 0.05 [0, 0.7]; P = 0.026). Elevations in plasminogen activator inhibitor 1 (odds ratio, 1.95 [1.21, 3.14]; P = 0.006), d-dimer (odds ratio, 3.52 [0.99, 12.48]; P = 0.05), and factor VIII (no clot, 1.15 ± 0.28 vs. clot, 1.42 ± 0.31; P = 0.003) were also demonstrated in extracorporeal membrane oxygenation-naïve patients who experienced major thrombotic events. Plasminogen activator inhibitor 1 levels were significantly elevated during periods of severe compared to mild and moderate acute respiratory distress syndrome (severe, 44.2 ± 14.9 ng/ml vs. mild, 31.8 ± 14.7 ng/ml and moderate, 33.1 ± 15.9 ng/ml; P = 0.029 and 0.039, respectively). CONCLUSIONS Increased inflammatory and procoagulant markers such as plasminogen activator inhibitor 1, microparticle-bound tissue factor, and von Willebrand factor levels are associated with severe hypoxemia and major thrombotic events, implicating fibrinolytic suppression in the microcirculatory system and subsequent micro- and macrovascular thrombosis in severe COVID-19. EDITOR’S PERSPECTIVE
Collapse
Affiliation(s)
- Kristin M. Corey
- Department of Medicine, Duke University School of Medicine, Durham, NC 27710
| | - Lyra B. Olson
- Duke Medical Scientist Training Program, Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, NC 27710
| | - Ibtehaj A. Naqvi
- Department of Surgery, Duke University School of Medicine, Durham, NC 27710
| | - Sarah A Morrison
- Department of Surgery, Duke University School of Medicine, Durham, NC 27710
| | - Connor Davis
- Duke Institute for Health Innovation, Duke University School of Medicine, Durham, NC 27710
| | - Shahid M. Nimjee
- Department of Neurosurgery, The Ohio State University Medical Center, Columbus, OH 43203
| | - Loretta G. Que
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC 27710
| | - Robin E. Bachelder
- Department of Surgery, Duke University School of Medicine, Durham, NC 27710
| | - Bryan D. Kraft
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC 27710
| | - Lingye Chen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC 27710
| | - Smita K. Nair
- Department of Surgery, Duke University School of Medicine, Durham, NC 27710
| | - Jerrold H. Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC 27710
| | - Bruce A. Sullenger
- Department of Surgery, Duke University School of Medicine, Durham, NC 27710
| |
Collapse
|
21
|
Bolek T, Samoš M, Škorňová I, Schnierer M, Jurica J, Bánovčin P, Staško J, Kubisz P, Mokáň M. Rotational thromboelastometry in patients with type 2 diabetes and mild COVID-19 pneumonia: A pilot prospective study. Medicine (Baltimore) 2022; 101:e29738. [PMID: 35777014 PMCID: PMC9239638 DOI: 10.1097/md.0000000000029738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND It was repeatedly demonstrated that patients with severe COVID-19 pneumonia, as well as patients with type 2 diabetes (T2D) have higher risk of thromboembolic complications. Rotational thromboelastometry (ROTEM®) is a viscoelastic hemostatic assay which allows complex assessment of hemostasis in whole blood. The aim of this study was to compare changes in hemostasis measured by ROTEM® in diabetic and nondiabetic patients with mild COVID-19 pneumonia. METHODS We performed a pilot, prospective, observational study and enrolled 33 consecutive patients (14 with T2D and 19 nondiabetic ones) admitted to regular ward with mild COVID-19 pneumonia. The control group consisted from 11 healthy, nondiabetic blood donors. Blood samples were tested with ROTEM® using INTEM® and EXTEM® reagents. RESULTS We detected significant differences in EXTEM® clotting time (CT), clot formation time (CFT), and maximum clot firmness (MCF) comparing patients with mild COVID-19 pneumonia and healthy donors. However, there were no significant differences in EXTEM®, INTEM®, and HEPTEM® parameters (CT, CFT, and MCF) according to diabetes status. CONCLUSIONS Our study demonstrated hypercoagulation in patients with mild COVID-19 pneumonia. T2D did not affected ROTEM® parameters in patients with mild COVID-19 pneumonia.
Collapse
Affiliation(s)
- Tomáš Bolek
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Matej Samoš
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
- *Correspondence to: Matej Samoš, Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Kollarova 2, 036 59 Martin, Slovak republic (e-mail: )
| | - Ingrid Škorňová
- National Centre of Hemostasis and Thrombosis, Department of Hematology and Blood Transfusion, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Martin Schnierer
- Department of Gastroenterology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Jakub Jurica
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Peter Bánovčin
- Department of Gastroenterology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Ján Staško
- National Centre of Hemostasis and Thrombosis, Department of Hematology and Blood Transfusion, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Peter Kubisz
- National Centre of Hemostasis and Thrombosis, Department of Hematology and Blood Transfusion, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Marián Mokáň
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| |
Collapse
|
22
|
Watson O, Pillai S, Howard M, Cezar-Zaldua J, Whitley J, Burgess B, Lawrence M, Hawkins K, Morris K, Evans PA. Impaired fibrinolysis in severe Covid-19 infection is detectable in early stages of the disease. Clin Hemorheol Microcirc 2022; 82:183-191. [PMID: 35694917 DOI: 10.3233/ch-221491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND A significant degree of mortality and morbidity in Covid-19 is due to thromboembolic disease. Coagulopathy has been well described in critically unwell patients on ICU. There is less clear evidence regarding these changes at the time of presentation to the Emergency Department and the progression of disease over time. OBJECTIVE We sought to investigate whether coagulation markers can predict severity and how they change over the disease course. METHODS Patients presenting to a single University Teaching Hospital were recruited and followed up if PCR was positive. Alongside routine blood testing, Rotational Thromboelastometry (ROTEM) was performed. Outcome data was recorded for all patients, and ROTEM values were compared across outcome groups. RESULTS Extem and Intem Maximum Lysis were significantly reduced in those who died or required an ICU admission, indicating a reduced ability to break down clot mass in the most critically unwell patients. CONCLUSION Comparisons between groups demonstrated that one distinguishing feature between those who require ICU admission or die of Covid-19 compared with those who survive a hospital stay to discharge was the extent to which fibrinolysis could occur. Mortality and morbidity in Covid-19 infection appears in part driven by an inability to break down clot mass.
Collapse
Affiliation(s)
- O Watson
- Welsh Centre for Emergency Medicine Research, Swansea Bay University Health Board.,Swansea University, UK
| | - S Pillai
- Welsh Centre for Emergency Medicine Research, Swansea Bay University Health Board.,Swansea University, UK
| | - M Howard
- Welsh Centre for Emergency Medicine Research, Swansea Bay University Health Board.,Swansea University, UK
| | - J Cezar-Zaldua
- Welsh Centre for Emergency Medicine Research, Swansea Bay University Health Board.,Swansea University, UK
| | - J Whitley
- Welsh Centre for Emergency Medicine Research, Swansea Bay University Health Board.,Swansea University, UK
| | - B Burgess
- Welsh Centre for Emergency Medicine Research, Swansea Bay University Health Board
| | - M Lawrence
- Welsh Centre for Emergency Medicine Research, Swansea Bay University Health Board
| | | | - K Morris
- Cardiff Metropolitan University, UK
| | - P A Evans
- Welsh Centre for Emergency Medicine Research, Swansea Bay University Health Board.,Swansea University, UK
| |
Collapse
|
23
|
Bull BS, Hay KL, Herrmann PC. Fibrin Strands Will Grow from Soluble Fibrin and Hang Up in an In Vitro Microcirculatory Viscoelastic Model: Is This a Major Cause of COVID-19 Associated Coagulopathy? J Clin Med 2022; 11:jcm11082084. [PMID: 35456177 PMCID: PMC9031993 DOI: 10.3390/jcm11082084] [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] [Received: 02/24/2022] [Revised: 03/25/2022] [Accepted: 04/04/2022] [Indexed: 12/04/2022] Open
Abstract
Viscoelastic testing (VET) by both TEG and ROTEM has demonstrated hypercoagulability early in corona virus disease 2019 (COVID-19) associated coagulopathy (CAC). Additional VET studies demonstrated fibrinolytic shutdown late in a majority of severely ill COVID-19 patients with an associated elevation of d-dimer. Elevated d-dimer confirms that coagulation, followed by fibrinolysis, has occurred. These findings imply that, during CAC, three enzymes—thrombin, Factor XIIIa and plasmin—must have acted in sequence. However, limitations in standard VET analyses preclude exploration of the earliest phases of clot induction, as well as clot formation and clot dissolution in flowing blood. Herein, we describe a novel method illuminating aspects of this unexplored area. In addition, we created an in vitro blood flow model in which the interactions of thrombin, Factor XIII and plasmin with fibrinogen can be studied, allowing the determination of soluble fibrin (SF), the highly unstable form of fibrin that precedes the appearance of a visible clot. This model allows the determination of the SF level at which fibrin microclots begin to form.
Collapse
|
24
|
Len P, Iskakova G, Sautbayeva Z, Kussanova A, Tauekelova AT, Sugralimova MM, Dautbaeva AS, Abdieva MM, Ponomarev ED, Tikhonov A, Bekbossynova MS, Barteneva NS. Meta-Analysis and Systematic Review of Coagulation Disbalances in COVID-19: 41 Studies and 17,601 Patients. Front Cardiovasc Med 2022; 9:794092. [PMID: 35360017 PMCID: PMC8962835 DOI: 10.3389/fcvm.2022.794092] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 01/11/2022] [Indexed: 12/14/2022] Open
Abstract
Introduction Coagulation parameters are important determinants for COVID-19 infection. We conducted meta-analysis to assess the association between early hemostatic parameters and infection severity. Methods Electronic search was made for papers that addressed clinical characteristics of COVID-19 patients and disease severity. Results were filtered using exclusion and inclusion criteria and then pooled into a meta-analysis to estimate the standardized mean difference (SMD) with 95% confidence interval (CI) for D-dimers, fibrinogen, prothrombin time, platelet count (PLT), activated partial thromboplastin time. To explore the heterogeneity and robustness of our fundings, sensitivity and subgroup analyses were conducted. Publication bias was assessed with contour-enhanced funnel plots and Egger's test by linear regression. Coagulation parameters data from retrospective cohort study of 451 patients with COVID-19 at National Research Center for Cardiac Surgery were included in meta-analysis of published studies. Results Overall, 41 original studies (17,601 patients) on SARS-CoV-2 were included. For the two groups of patients, stratified by severity, we identified that D-dimers, fibrinogen, activated partial thromboplastin time, and prothrombin time were significantly higher in the severe group [SMD 0.6985 with 95%CI (0.5155; 0.8815); SMD 0.661 with 95%CI (0.3387; 0.9833); SMD 0.2683 with 95%CI (0.1357; 0.4009); SMD 0.284 with 95%CI (0.1472; 0.4208)]. In contrast, PLT was significantly lower in patients with more severe cases of COVID-19 [SMD -0.1684 with 95%CI (-0.2826; -0.0542)]. Neither the analysis by the leave-one-out method nor the influence diagnostic have identified studies that solely cause significant change in the effect size estimates. Subgroup analysis showed no significant difference between articles originated from different countries but revealed that severity assessment criteria might have influence over estimated effect sizes for platelets and D-dimers. Contour-enhanced funnel plots and the Egger's test for D-dimers and fibrinogen revealed significant asymmetry that might be a sign of publication bias. Conclusions The hemostatic laboratory parameters, with exception of platelets, are significantly elevated in patients with severe COVID-19. The two variables with strongest association to disease severity were D-dimers and fibrinogen levels. Future research should aim outside conventional coagulation tests and include analysis of clotting formation and platelet/platelet progenitors characteristics.
Collapse
Affiliation(s)
- Polina Len
- School of Sciences and Humanities, Nazarbayev University, Nur-Sultan, Kazakhstan
| | - Gaukhar Iskakova
- School of Sciences and Humanities, Nazarbayev University, Nur-Sultan, Kazakhstan
| | - Zarina Sautbayeva
- School of Sciences and Humanities, Nazarbayev University, Nur-Sultan, Kazakhstan
| | - Aigul Kussanova
- School of Sciences and Humanities, Nazarbayev University, Nur-Sultan, Kazakhstan
- Core Facilities, Nazarbayev University, Nur-Sultan, Kazakhstan
| | | | | | - Anar S. Dautbaeva
- National Research Center for Cardiac Surgery, Nur-Sultan, Kazakhstan
| | | | - Eugene D. Ponomarev
- School of Biomedical Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Alexander Tikhonov
- School of Sciences and Humanities, Nazarbayev University, Nur-Sultan, Kazakhstan
| | | | - Natasha S. Barteneva
- School of Sciences and Humanities, Nazarbayev University, Nur-Sultan, Kazakhstan
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States
| |
Collapse
|
25
|
Barrett CD, Moore HB, Moore EE, Wang J, Hajizadeh N, Biffl WL, Lottenberg L, Patel PR, Truitt MS, McIntyre RC, Bull TM, Ammons LA, Ghasabyan A, Chandler J, Douglas IS, Schmidt EP, Moore PK, Wright FL, Ramdeo R, Borrego R, Rueda M, Dhupa A, McCaul DS, Dandan T, Sarkar PK, Khan B, Sreevidya C, McDaniel C, Grossman Verner HM, Pearcy C, Anez-Bustillos L, Baedorf-Kassis EN, Jhunjhunwala R, Shaefi S, Capers K, Banner-Goodspeed V, Talmor DS, Sauaia A, Yaffe MB. Study of Alteplase for Respiratory Failure in SARS-CoV-2 COVID-19: A Vanguard Multicenter, Rapidly Adaptive, Pragmatic, Randomized Controlled Trial. Chest 2022; 161:710-727. [PMID: 34592318 PMCID: PMC8474873 DOI: 10.1016/j.chest.2021.09.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/31/2021] [Accepted: 09/20/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Pulmonary vascular microthrombi are a proposed mechanism of COVID-19 respiratory failure. We hypothesized that early administration of tissue plasminogen activator (tPA) followed by therapeutic heparin would improve pulmonary function in these patients. RESEARCH QUESTION Does tPA improve pulmonary function in severe COVID-19 respiratory failure, and is it safe? STUDY DESIGN AND METHODS Adults with COVID-19-induced respiratory failure were randomized from May14, 2020 through March 3, 2021, in two phases. Phase 1 (n = 36) comprised a control group (standard-of-care treatment) vs a tPA bolus (50-mg tPA IV bolus followed by 7 days of heparin; goal activated partial thromboplastin time [aPTT], 60-80 s) group. Phase 2 (n = 14) comprised a control group vs a tPA drip (50-mg tPA IV bolus, followed by tPA drip 2 mg/h plus heparin 500 units/h over 24 h, then heparin to maintain aPTT of 60-80 s for 7 days) group. Patients were excluded from enrollment if they had not undergone a neurologic examination or cross-sectional brain imaging within the previous 4.5 h to rule out stroke and potential for hemorrhagic conversion. The primary outcome was Pao2 to Fio2 ratio improvement from baseline at 48 h after randomization. Secondary outcomes included Pao2 to Fio2 ratio improvement of > 50% or Pao2 to Fio2 ratio of ≥ 200 at 48 h (composite outcome), ventilator-free days (VFD), and mortality. RESULTS Fifty patients were randomized: 17 in the control group and 19 in the tPA bolus group in phase 1 and eight in the control group and six in the tPA drip group in phase 2. No severe bleeding events occurred. In the tPA bolus group, the Pao2 to Fio2 ratio values were significantly (P < .017) higher than baseline at 6 through 168 h after randomization; the control group showed no significant improvements. Among patients receiving a tPA bolus, the percent change of Pao2 to Fio2 ratio at 48 h (16.9% control [interquartile range (IQR), -8.3% to 36.8%] vs 29.8% tPA bolus [IQR, 4.5%-88.7%]; P = .11), the composite outcome (11.8% vs 47.4%; P = .03), VFD (0.0 [IQR, 0.0-9.0] vs 12.0 [IQR, 0.0-19.0]; P = .11), and in-hospital mortality (41.2% vs 21.1%; P = .19) did not reach statistically significant differences when compared with those of control participants. The patients who received a tPA drip did not experience benefit. INTERPRETATION The combination of tPA bolus plus heparin is safe in severe COVID-19 respiratory failure. A phase 3 study is warranted given the improvements in oxygenation and promising observations in VFD and mortality. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT04357730; URL: www. CLINICALTRIALS gov.
Collapse
Affiliation(s)
- Christopher D Barrett
- Department of Surgery, Boston University School of Medicine, Boston, MA; Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Koch Institute for Integrative Cancer Research, Center for Precision Cancer Medicine, Departments of Biological Engineering and Biology, Massachusetts Institute of Technology, Cambridge, MA
| | - Hunter B Moore
- Department of Surgery, University of Colorado Denver, Aurora, CO
| | - Ernest E Moore
- Department of Surgery, University of Colorado Denver, Aurora, CO; Ernest E. Moore Shock Trauma Center at Denver Health, Department of Surgery, Denver, CO.
| | - Janice Wang
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY
| | - Negin Hajizadeh
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Department of Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA
| | - Lawrence Lottenberg
- Department of Surgery, St. Mary's Medical Center, Florida Atlantic University, West Palm Beach, FL
| | - Purvesh R Patel
- Department of Medicine, Baylor College of Medicine, Houston, Dallas, TX
| | - Michael S Truitt
- Department of Surgery, Methodist Dallas Medical Center, Dallas, TX
| | | | - Todd M Bull
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Denver, Aurora, CO
| | - Lee Anne Ammons
- Ernest E. Moore Shock Trauma Center at Denver Health, Department of Surgery, Denver, CO
| | - Arsen Ghasabyan
- Ernest E. Moore Shock Trauma Center at Denver Health, Department of Surgery, Denver, CO
| | - James Chandler
- Ernest E. Moore Shock Trauma Center at Denver Health, Department of Surgery, Denver, CO
| | - Ivor S Douglas
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Denver Health Medical Center, Denver, CO
| | - Eric P Schmidt
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Denver Health Medical Center, Denver, CO
| | - Peter K Moore
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Denver, Aurora, CO
| | | | - Ramona Ramdeo
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY
| | - Robert Borrego
- Division of Pulmonary/Critical Care Medicine, Department of Medicine, Scripps Memorial Hospital La Jolla, La Jolla, CA
| | - Mario Rueda
- Division of Pulmonary/Critical Care Medicine, Department of Medicine, Scripps Memorial Hospital La Jolla, La Jolla, CA
| | - Achal Dhupa
- Division of Trauma/Acute Care Surgery, Department of Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA
| | - D Scott McCaul
- Division of Trauma/Acute Care Surgery, Department of Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA
| | - Tala Dandan
- Division of Trauma/Acute Care Surgery, Department of Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA
| | - Pralay K Sarkar
- Department of Medicine, Baylor College of Medicine, Houston, Dallas, TX
| | - Benazir Khan
- Department of Medicine, Baylor College of Medicine, Houston, Dallas, TX
| | | | - Conner McDaniel
- Department of Surgery, Methodist Dallas Medical Center, Dallas, TX
| | | | | | - Lorenzo Anez-Bustillos
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Elias N Baedorf-Kassis
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Rashi Jhunjhunwala
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Krystal Capers
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Valerie Banner-Goodspeed
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Daniel S Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Angela Sauaia
- Ernest E. Moore Shock Trauma Center at Denver Health, Department of Surgery, Denver, CO; Colorado School of Public Health and Department of Surgery, University of Colorado Denver, Denver, CO
| | - Michael B Yaffe
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Koch Institute for Integrative Cancer Research, Center for Precision Cancer Medicine, Departments of Biological Engineering and Biology, Massachusetts Institute of Technology, Cambridge, MA
| |
Collapse
|
26
|
Onishi T, Shimonishi N, Takeyama M, Furukawa S, Ogiwara K, Nakajima Y, Kasahara K, Nishio K, Yoshimoto K, Inoue S, Kawaguchi M, Fukushima H, Saito Y, Yoshiji H, Muro S, Tsuruya K, Okada S, Sugie K, Kawaguchi R, Nishikubo T, Yamazaki M, Oda Y, Kawabe T, Onishi K, Nishio T, Nogami K. The balance of comprehensive coagulation and fibrinolytic potential is disrupted in patients with moderate to severe COVID-19. Int J Hematol 2022; 115:826-837. [PMID: 35171446 PMCID: PMC8852977 DOI: 10.1007/s12185-022-03308-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 02/07/2022] [Accepted: 02/07/2022] [Indexed: 12/19/2022]
Abstract
Coagulation and fibrinolytic mechanisms are enhanced in patients with coronavirus (COVID-19), but disturbances in the balance of both functions in COVID-19 patients remain unclear. We assessed global coagulation and fibrinolysis in plasma from 167 COVID-19 patients (mild/moderate/severe: 62/88/17, respectively) on admission using clot-fibrinolysis waveform analysis (CFWA). Maximum coagulation velocity (|min1|) and maximum fibrinolysis velocity (|FL-min1|) were expressed as ratios relative to normal plasma. Ten patients (6.0%) developed thrombosis, 5 (3.0%) had bleeding tendency, and 13 (7.8%) died during admission. FDP levels increased with severity of COVID-19 symptoms (mild/moderate/severe; median 2.7/4.9/9.9 μg/mL, respectively). The |min1| ratios were elevated in all categories (1.27/1.61/1.58) in keeping with enhanced coagulation potential, with significant differences between mild cases and moderate to severe cases. The |FL-min1| ratios were also elevated in all groups (1.19/1.39/1.40), reflecting enhanced fibrinolytic potential. These data identified coagulation dominance in moderate to severe cases, but balanced coagulation and fibrinolysis in mild cases. There were significant differences in FDP and TAT, but no significant differences in |min1| or |FL-min1| ratios, between patients with and without thrombosis. CFWA monitoring of coagulation and fibrinolysis dynamics could provide valuable data for understanding hemostatic changes and disease status in COVID-19 patients.
Collapse
Affiliation(s)
- Tomoko Onishi
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Masahiro Takeyama
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Yuto Nakajima
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Kei Kasahara
- Center for Infectious Diseases, Nara Medical University, Kashihara, Japan
| | - Kenji Nishio
- Department of General Medicine, Nara Medical University, Kashihara, Japan
| | - Kiyomi Yoshimoto
- Department of General Medicine, Nara Medical University, Kashihara, Japan
| | - Satoki Inoue
- Department of Anesthesiology, Nara Medical University, Kashihara, Japan
| | | | - Hidetada Fukushima
- Emergency and Critical Care Medicine, Nara Medical University, Kashihara, Japan
| | - Yoshihiko Saito
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan
| | - Hitoshi Yoshiji
- Department of Gastroenterology, Nara Medical University, Kashihara, Japan
| | - Shigeo Muro
- Department of Respiratory Medicine, Nara Medical University, Kashihara, Japan
| | - Kazuhiko Tsuruya
- Department of Nephrology, Nara Medical University, Kashihara, Japan
| | - Sadanori Okada
- Department of Diabetes and Endocrinology, Nara Medical University, Kashihara, Japan
| | - Kazuma Sugie
- Department of Neurology, Nara Medical University, Kashihara, Japan
| | - Ryuji Kawaguchi
- Department of Obstetrics and Gynecology, Nara Medical University, Kashihara, Japan
| | - Toshiya Nishikubo
- Neonatal Intensive Care Unit, Nara Medical University, Kashihara, Japan
| | - Masaharu Yamazaki
- Central Clinical Laboratory, Nara Medical University Hospital, Kashihara, Japan
| | - Yukio Oda
- SEKISUI MEDICAL CO., LTD, Tokyo, Japan
| | | | | | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| |
Collapse
|
27
|
Pavoni V, Gianesello L, Pazzi M, Dattolo P, Prisco D. Questions about COVID-19 associated coagulopathy: possible answers from the viscoelastic tests. J Clin Monit Comput 2022; 36:55-69. [PMID: 34264472 PMCID: PMC8280589 DOI: 10.1007/s10877-021-00744-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/09/2021] [Indexed: 12/30/2022]
Abstract
Abnormal coagulation parameters are often observed in patients with coronavirus disease 2019 (COVID-19) and the severity of derangement has been associated with a poor prognosis. The COVID-19 associated coagulopathy (CAC) displays unique features that include a high risk of developing thromboembolic complications. Viscoelastic tests (VETs), such as thromboelastometry (ROTEM), thromboelastography (TEG) and Quantra Hemostasis Analyzer (Quantra), provide "dynamic" data on clot formation and dissolution; they are used in different critical care settings, both in hemorrhagic and in thrombotic conditions. In patients with severe COVID-19 infection VETs can supply to clinicians more information about the CAC, identifying the presence of hypercoagulable and hypofibrinolysis states. In the last year, many studies have proposed to explain the underlying characteristics of CAC; however, there remain many unanswered questions. We tried to address some of the important queries about CAC through VETs analysis.
Collapse
Affiliation(s)
- Vittorio Pavoni
- Emergency Department and Critical Care Area, Anesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Lara Gianesello
- Department of Anesthesia and Intensive Care, Orthopedic Anesthesia, University-Hospital Careggi, Largo Palagi, 1, 50139, Florence, Italy.
| | - Maddalena Pazzi
- Emergency Department and Critical Care Area, Anesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Pietro Dattolo
- Nephrology Unit Florence 1, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| |
Collapse
|
28
|
Thangaraju K, Katneni U, Akpan IJ, Tanaka K, Thomas T, Setua S, Reisz JA, Cendali F, Gamboni F, Nemkov T, Kahn S, Wei AZ, Valk JE, Hudson KE, Roh DJ, Moriconi C, Zimring JC, D'Alessandro A, Spitalnik SL, Francis RO, Buehler PW. The Impact of Age and BMI on the VWF/ADAMTS13 Axis and Simultaneous Thrombin and Plasmin Generation in Hospitalized COVID-19 Patients. Front Med (Lausanne) 2022; 8:817305. [PMID: 35087853 PMCID: PMC8786628 DOI: 10.3389/fmed.2021.817305] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 12/08/2021] [Indexed: 11/13/2022] Open
Abstract
Aging and obesity independently contribute toward an endothelial dysfunction that results in an imbalanced VWF to ADAMTS13 ratio. In addition, plasma thrombin and plasmin generation are elevated and reduced, respectively, with increasing age and also with increasing body mass index (BMI). The severity risk of Corona Virus Disease 2019 (COVID-19) increases in adults older than 65 and in individuals with certain pre-existing health conditions, including obesity (>30 kg/m2). The present cross-sectional study focused on an analysis of the VWF/ADAMTS13 axis, including measurements of von Willebrand factor (VWF) antigen (VWF:AG), VWF collagen binding activity (VWF:CBA), Factor VIII antigen, ADAMTS13 antigen, and ADAMTS13 activity, in addition to thrombin and plasmin generation potential, in a demographically diverse population of COVID-19 negative (−) (n = 288) and COVID-19 positive (+) (n = 543) patient plasmas collected at the time of hospital presentation. Data were analyzed as a whole, and then after dividing patients by age (<65 and ≥65) and independently by BMI [<18.5, 18.5–24.9, 25–29.9, >30 (kg/m2)]. These analyses suggest that VWF parameters (i.e., the VWF/ADAMTS13 activity ratio) and thrombin and plasmin generation differed in COVID-19 (+), as compared to COVID-19 (−) patient plasma. Further, age (≥65) more than BMI contributed to aberrant plasma indicators of endothelial coagulopathy. Based on these findings, evaluating both the VWF/ADAMTS13 axis, along with thrombin and plasmin generation, could provide insight into the extent of endothelial dysfunction as well as the plasmatic imbalance in coagulation and fibrinolysis potential, particularly for at-risk patient populations.
Collapse
Affiliation(s)
- Kiruphagaran Thangaraju
- Department of Pathology, Department of Pediatrics, Center for Blood Oxygen Transport and Hemostasis, University of Maryland, Baltimore, MD, United States
| | - Upendra Katneni
- Department of Pathology, Department of Pediatrics, Center for Blood Oxygen Transport and Hemostasis, University of Maryland, Baltimore, MD, United States
| | - Imo J Akpan
- Division of Hematology/Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, United States
| | - Kenichi Tanaka
- Department of Anesthesiology, University of Maryland, Baltimore, MD, United States.,Department of Anesthesiology, University of Oklahoma College of Medicine, Oklahoma City, OK, United States
| | - Tiffany Thomas
- Department of Pathology & Cell Biology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Saini Setua
- Department of Pathology, Department of Pediatrics, Center for Blood Oxygen Transport and Hemostasis, University of Maryland, Baltimore, MD, United States
| | - Julie A Reisz
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver - Anschutz Medical Campus, Aurora, CO, United States
| | - Francesca Cendali
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver - Anschutz Medical Campus, Aurora, CO, United States
| | - Fabia Gamboni
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver - Anschutz Medical Campus, Aurora, CO, United States
| | - Travis Nemkov
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver - Anschutz Medical Campus, Aurora, CO, United States
| | - Stacie Kahn
- Division of Hematology/Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, United States
| | - Alexander Z Wei
- Division of Hematology/Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, United States
| | - Jacob E Valk
- Department of Pathology & Cell Biology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Krystalyn E Hudson
- Department of Pathology & Cell Biology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - David J Roh
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Chiara Moriconi
- Department of Pathology & Cell Biology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - James C Zimring
- Department of Pathology, University of Virginia, Charlottesville, VA, United States
| | - Angelo D'Alessandro
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver - Anschutz Medical Campus, Aurora, CO, United States
| | - Steven L Spitalnik
- Department of Pathology & Cell Biology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Richard O Francis
- Department of Pathology & Cell Biology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Paul W Buehler
- Department of Pathology, Department of Pediatrics, Center for Blood Oxygen Transport and Hemostasis, University of Maryland, Baltimore, MD, United States
| |
Collapse
|
29
|
Aires RB, Soares AADSM, Gomides APM, Nicola AM, Teixeira-Carvalho A, da Silva DLM, de Gois ET, Xavier FD, Martins FP, Santos GPJ, Schulte HL, Luz IS, Espindola LS, do Amaral LR, Felicori LF, Naves LA, de Carvalho MRM, Gomes MDS, Nóbrega OT, Albuquerque P, Fontes W, Gomes CM, Kurizky PS, Albuquerque CP, Martins-Filho OA, da Mota LMH. Thromboelastometry demonstrates endogenous coagulation activation in nonsevere and severe COVID-19 patients and has applicability as a decision algorithm for intervention. PLoS One 2022; 17:e0262600. [PMID: 35030224 PMCID: PMC8759688 DOI: 10.1371/journal.pone.0262600] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 12/28/2021] [Indexed: 12/17/2022] Open
Abstract
In patients with severe forms of COVID-19, thromboelastometry has been reported to display a hypercoagulant pattern. However, an algorithm to differentiate severe COVID-19 patients from nonsevere patients and healthy controls based on thromboelastometry parameters has not been developed. Forty-one patients over 18 years of age with positive qRT-PCR for SARS-CoV-2 were classified according to the severity of the disease: nonsevere (NS, n = 20) or severe (S, n = 21). A healthy control (HC, n = 9) group was also examined. Blood samples from all participants were tested by extrinsic (EXTEM), intrinsic (INTEM), non-activated (NATEM) and functional assessment of fibrinogen (FIBTEM) assays of thromboelastometry. The thrombodynamic potential index (TPI) was also calculated. Severe COVID-19 patients exhibited a thromboelastometry profile with clear hypercoagulability, which was significantly different from the NS and HC groups. Nonsevere COVID-19 cases showed a trend to thrombotic pole. The NATEM test suggested that nonsevere and severe COVID-19 patients presented endogenous coagulation activation (reduced clotting time and clot formation time). TPI data were significantly different between the NS and S groups. The maximum clot firmness profile obtained by FIBTEM showed moderate/elevated accuracy to differentiate severe patients from NS and HC. A decision tree algorithm based on the FIBTEM-MCF profile was proposed to differentiate S from HC and NS. Thromboelastometric parameters are a useful tool to differentiate the coagulation profile of nonsevere and severe COVID-19 patients for therapeutic intervention purposes.
Collapse
Affiliation(s)
- Rodrigo B. Aires
- Programa de Pós-graduação em Ciências Médicas da Faculdade de Medicina da Universidade de Brasília (UnB), Brasília, Distrito Federal, Brazil
- Serviço de Anestesiologia, Hospital Santa Lúcia Sul, Brasília, Distrito Federal, Brazil
- * E-mail: (RBA); (PSK)
| | - Alexandre A. de S. M. Soares
- Programa de Pós-graduação em Ciências Médicas da Faculdade de Medicina da Universidade de Brasília (UnB), Brasília, Distrito Federal, Brazil
| | - Ana Paula M. Gomides
- Faculdade de Ciências da Saúde, Centro Universitário de Brasília, Brasília, Distrito Federal, Brazil
| | - André M. Nicola
- Programa de Pós-graduação em Ciências Médicas da Faculdade de Medicina da Universidade de Brasília (UnB), Brasília, Distrito Federal, Brazil
| | - Andréa Teixeira-Carvalho
- Grupo Integrado de Pesquisa em Biomarcadores, Fundação Oswaldo Cruz (FIOCRUZ), Belo Horizonte, Minas Gerais, Brazil
| | - Dayde Lane M. da Silva
- Departamento de Farmácia, Universidade de Brasília (UnB), Brasília, Distrito Federal, Brazil
| | - Eliana T. de Gois
- Programa de Pós-graduação em Ciências Médicas da Faculdade de Medicina da Universidade de Brasília (UnB), Brasília, Distrito Federal, Brazil
- Unidade de Clínica Médica, Hospital Regional do Gama (HRG), Brasília, Distrito Federal, Brazil
| | - Flávia D. Xavier
- Programa de Pós-graduação em Ciências Médicas da Faculdade de Medicina da Universidade de Brasília (UnB), Brasília, Distrito Federal, Brazil
| | - Francielle P. Martins
- Programa de Pós-graduação em Ciências Médicas da Faculdade de Medicina da Universidade de Brasília (UnB), Brasília, Distrito Federal, Brazil
- Núcleo de Gestão Interna de Leitos, Hospital Regional da Asa Norte (HRAN), Brasília, Distrito Federal, Brazil
| | - Gabriela P. J. Santos
- Programa de Pós-graduação em Ciências Médicas da Faculdade de Medicina da Universidade de Brasília (UnB), Brasília, Distrito Federal, Brazil
- Unidade de Medicina Interna, Hospital Regional de Taguatinga, Brasília, Distrito Federal, Brazil
| | - Heidi Luise Schulte
- Programa de Pós-graduação em Ciências Médicas da Faculdade de Medicina da Universidade de Brasília (UnB), Brasília, Distrito Federal, Brazil
| | - Isabelle S. Luz
- Laboratório de Bioquímica e Química de Proteínas, Departamento de Biologia Celular, Instituto de Ciências Biológicas, Universidade de Brasília (UnB), Brasília, Distrito Federal, Brazil
| | - Laila S. Espindola
- Programa de Pós-graduação em Ciências Médicas da Faculdade de Medicina da Universidade de Brasília (UnB), Brasília, Distrito Federal, Brazil
- Laboratório de Farmacognosia, Faculdade de Ciências da Saúde, Universidade de Brasília (UnB), Brasília, Distrito Federal, Brazil
| | - Laurence R. do Amaral
- Laboratório de Bioinformática e Análises Moleculares, Rede Multidisciplinar de Pesquisa, Ciência e Tecnologia (RMPCT), Universidade Federal de Uberlândia, Patos de Minas, Minas Gerais, Brazil
| | - Liza F. Felicori
- Laboratório de Biologia Sintética e Biomiméticos, Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
| | - Luciana A. Naves
- Programa de Pós-graduação em Ciências Médicas da Faculdade de Medicina da Universidade de Brasília (UnB), Brasília, Distrito Federal, Brazil
- Serviço de Endocrinologia, Hospital Universitário de Brasília, Universidade de Brasília (UnB), Brasília, Distrito Federal, Brazil
| | - Maíra R. M. de Carvalho
- Programa de Pós-graduação em Ciências Médicas da Faculdade de Medicina da Universidade de Brasília (UnB), Brasília, Distrito Federal, Brazil
- Unidade de Medicina Interna, Hospital Regional da Asa Norte (HRAN), Brasília, Distrito Federal, Brazil
| | - Matheus de S. Gomes
- Laboratório de Bioinformática e Análises Moleculares, Rede Multidisciplinar de Pesquisa, Ciência e Tecnologia (RMPCT), Universidade Federal de Uberlândia, Patos de Minas, Minas Gerais, Brazil
| | - Otávio T. Nóbrega
- Programa de Pós-graduação em Ciências Médicas da Faculdade de Medicina da Universidade de Brasília (UnB), Brasília, Distrito Federal, Brazil
| | - Patrícia Albuquerque
- Faculdade UnB Ceilândia, Universidade de Brasília (UnB), Brasília, Distrito Federal, Brazil
| | - Wagner Fontes
- Laboratório de Bioquímica e Química de Proteínas, Departamento de Biologia Celular, Instituto de Ciências Biológicas, Universidade de Brasília (UnB), Brasília, Distrito Federal, Brazil
| | - Ciro M. Gomes
- Programa de Pós-graduação em Ciências Médicas da Faculdade de Medicina da Universidade de Brasília (UnB), Brasília, Distrito Federal, Brazil
- Serviço de Dermatologia, Hospital Universitário de Brasília, Universidade de Brasília (UnB), Brasília, Distrito Federal, Brazil
| | - Patricia S. Kurizky
- Programa de Pós-graduação em Ciências Médicas da Faculdade de Medicina da Universidade de Brasília (UnB), Brasília, Distrito Federal, Brazil
- Serviço de Dermatologia, Hospital Universitário de Brasília, Universidade de Brasília (UnB), Brasília, Distrito Federal, Brazil
- * E-mail: (RBA); (PSK)
| | - Cleandro P. Albuquerque
- Programa de Pós-graduação em Ciências Médicas da Faculdade de Medicina da Universidade de Brasília (UnB), Brasília, Distrito Federal, Brazil
- Serviço de Reumatologia, Hospital Universitário de Brasília, Universidade de Brasília (UnB), Brasília, Distrito Federal, Brazil
| | - Olindo A. Martins-Filho
- Grupo Integrado de Pesquisa em Biomarcadores, Fundação Oswaldo Cruz (FIOCRUZ), Belo Horizonte, Minas Gerais, Brazil
| | - Licia Maria H. da Mota
- Programa de Pós-graduação em Ciências Médicas da Faculdade de Medicina da Universidade de Brasília (UnB), Brasília, Distrito Federal, Brazil
- Serviço de Reumatologia, Hospital Universitário de Brasília, Universidade de Brasília (UnB), Brasília, Distrito Federal, Brazil
| |
Collapse
|
30
|
Current and novel biomarkers of thrombotic risk in COVID-19: a Consensus Statement from the International COVID-19 Thrombosis Biomarkers Colloquium. Nat Rev Cardiol 2022; 19:475-495. [PMID: 35027697 PMCID: PMC8757397 DOI: 10.1038/s41569-021-00665-7] [Citation(s) in RCA: 153] [Impact Index Per Article: 76.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2021] [Indexed: 02/06/2023]
Abstract
Coronavirus disease 2019 (COVID-19) predisposes patients to thrombotic and thromboembolic events, owing to excessive inflammation, endothelial cell activation and injury, platelet activation and hypercoagulability. Patients with COVID-19 have a prothrombotic or thrombophilic state, with elevations in the levels of several biomarkers of thrombosis, which are associated with disease severity and prognosis. Although some biomarkers of COVID-19-associated coagulopathy, including high levels of fibrinogen and D-dimer, were recognized early during the pandemic, many new biomarkers of thrombotic risk in COVID-19 have emerged. In this Consensus Statement, we delineate the thrombotic signature of COVID-19 and present the latest biomarkers and platforms to assess the risk of thrombosis in these patients, including markers of platelet activation, platelet aggregation, endothelial cell activation or injury, coagulation and fibrinolysis as well as biomarkers of the newly recognized post-vaccine thrombosis with thrombocytopenia syndrome. We then make consensus recommendations for the clinical use of these biomarkers to inform prognosis, assess disease acuity, and predict thrombotic risk and in-hospital mortality. A thorough understanding of these biomarkers might aid risk stratification and prognostication, guide interventions and provide a platform for future research.
Collapse
|
31
|
Fattorutto M, Bouckaert Y, Brauner J, Franck S, Bouton F, Heuse D, Bouckaert C, Bruyneel A. Pragmatic study of a thromboprophylaxis algorithm in critically ill patients with SARS-COV-2 infection. J Thromb Thrombolysis 2022; 53:58-66. [PMID: 34173169 PMCID: PMC8233177 DOI: 10.1007/s11239-021-02514-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/16/2021] [Indexed: 01/08/2023]
Abstract
The optimal thromboprophylactic strategy for patients affected by Coronavirus disease 2019 (COVID-19) has been debated among experts. This study evaluated the safety and efficacy of a thromboprophylaxis algorithm. This was a retrospective, single-center study in critically ill patients admitted to the intensive care unit (University affiliated Hospital) for acute respiratory failure due to Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV-2). From March 16 to April 9, 2020, thromboprophylaxis was adjusted according to weight (control group, n = 19) and after this date, thromboprophylaxis depended on an algorithm based on thrombotic and hemorrhagic risk factors (protocol group, n = 13). With regard to safety (number of major bleeding events and blood transfusions), the groups were not significantly different. With regard to efficacy, the number of thrombotic events decreased from 37 to 0%, p = 0.025 after implementation of the algorithm. Also, peak fibrinogen dropped from 8.6 (7.2-9.3) to 6.5 (4.6-8.4) g/L, p = 0.041 and D-dimers from 2194 (1464-3763) to 1486 (900-2582) ng/mL, p = 0.0001. In addition, length of stay declined from 19 (10-31) to 5 (3-19) days, p = 0.009. In conclusion, a tailored thromboprophylaxis algorithm (risk stratification based on clinical parameters and biological markers) reduce thrombotic phenomena in critically ill COVID-19 patients without increasing major bleeding.
Collapse
Affiliation(s)
- Maurizio Fattorutto
- Department of Anesthesiology, Centre Hospitalier Universitaire Tivoli, Avenue Max Buset 34, 7100, La Louvière, Belgium.
| | - Yves Bouckaert
- Intensive Care Unit, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
| | - Jonathan Brauner
- Department of Clinical Biology/Blood Bank, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
| | - Stéphane Franck
- Intensive Care Unit, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
| | - Fabrice Bouton
- Intensive Care Unit, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
| | - Danielle Heuse
- Intensive Care Unit, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
| | | | - Arnaud Bruyneel
- Intensive Care Unit, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
- School of Public Health, Université Libre Bruxelles, Brussels, Belgium
| |
Collapse
|
32
|
Infanger L, Dibiasi C, Schaden E, Ulbing S, Wiegele M, Lacom C, Gratz J. Comparison of the New Viscoelastic Coagulation Analyzer ClotPro® With ROTEM® Delta and Conventional Coagulation Tests in Critically Ill Patients With COVID-19. Front Med (Lausanne) 2021; 8:777145. [PMID: 34869496 PMCID: PMC8635118 DOI: 10.3389/fmed.2021.777145] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 10/27/2021] [Indexed: 12/12/2022] Open
Abstract
Background: Viscoelastic coagulation testing has been suggested to help manage coagulopathy in critically ill patients with COVID-19. However, results from different viscoelastic devices are not readily comparable. ClotPro® is a novel thromboelastometry analyzer offering a wider range of commercially available assays. Methods: We compared the results from ClotPro with results from the well-established ROTEM® Delta device and conventional coagulation tests in critically ill patients with COVID-19. Results: Viscoelastic parameters indicated the presence of a potentially hypercoagulable state in the majority of patients. In up to 95 paired measurements, we found strong correlations between several parameters routinely used in clinical practice: (i) EX test vs. EXTEM CT, A5, A10, MCF, (ii) IN test vs. INTEM A5, A10, MCF, and (iii) FIB test vs. FIBTEM A5, A10, MCF (all R > 0.7 and p < 0.001). In contrast, IN test CT vs. INTEM CT showed only a moderate correlation (R = 0.53 and p < 0.001). Clot strength parameters of both devices exhibited strong correlations with platelet counts and fibrinogen levels (all R > 0.7 and p < 0.001). Divergent correlations of intrinsically activated assays with aPTT and anti-factor Xa activity were visible. Regarding absolute differences of test results, considerable delta occurred in CT, CFT, and clot strength parameters (all p < 0.001) between both devices. Conclusions: Several parameters obtained by ClotPro show strong correlations with ROTEM Delta. Due to weak correlations of intrinsically activated clotting times and considerable absolute differences in a number of parameters, our findings underline the need for device-specific algorithms in this patient cohort.
Collapse
Affiliation(s)
- Lukas Infanger
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Christoph Dibiasi
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Eva Schaden
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Stefan Ulbing
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Marion Wiegele
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Conrad Lacom
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Johannes Gratz
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
33
|
Rajsic S, Breitkopf R, Bachler M, Treml B. Diagnostic Modalities in Critical Care: Point-of-Care Approach. Diagnostics (Basel) 2021; 11:diagnostics11122202. [PMID: 34943438 PMCID: PMC8700511 DOI: 10.3390/diagnostics11122202] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 02/07/2023] Open
Abstract
The concept of intensive care units (ICU) has existed for almost 70 years, with outstanding development progress in the last decades. Multidisciplinary care of critically ill patients has become an integral part of every modern health care system, ensuing improved care and reduced mortality. Early recognition of severe medical and surgical illnesses, advanced prehospital care and organized immediate care in trauma centres led to a rise of ICU patients. Due to the underlying disease and its need for complex mechanical support for monitoring and treatment, it is often necessary to facilitate bed-side diagnostics. Immediate diagnostics are essential for a successful treatment of life threatening conditions, early recognition of complications and good quality of care. Management of ICU patients is incomprehensible without continuous and sophisticated monitoring, bedside ultrasonography, diverse radiologic diagnostics, blood gas analysis, coagulation and blood management, laboratory and other point-of-care (POC) diagnostic modalities. Moreover, in the time of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, particular attention is given to the POC diagnostic techniques due to additional concerns related to the risk of infection transmission, patient and healthcare workers safety and potential adverse events due to patient relocation. This review summarizes the most actual information on possible diagnostic modalities in critical care, with a special focus on the importance of point-of-care approach in the laboratory monitoring and imaging procedures.
Collapse
Affiliation(s)
- Sasa Rajsic
- General and Surgical Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria; (S.R.); (M.B.)
| | - Robert Breitkopf
- Transplant Surgical Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria;
| | - Mirjam Bachler
- General and Surgical Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria; (S.R.); (M.B.)
| | - Benedikt Treml
- General and Surgical Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria; (S.R.); (M.B.)
- Correspondence:
| |
Collapse
|
34
|
Brain D, Plant-Hately A, Heaton B, Arshad U, David C, Hedrich C, Owen A, Liptrott NJ. Drug delivery systems as immunomodulators for therapy of infectious disease: Relevance to COVID-19. Adv Drug Deliv Rev 2021; 178:113848. [PMID: 34182016 PMCID: PMC8233062 DOI: 10.1016/j.addr.2021.113848] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/10/2021] [Accepted: 06/22/2021] [Indexed: 02/07/2023]
Abstract
The emergence of SARS-CoV-2, and the ensuing global pandemic, has resulted in an unprecedented response to identify therapies that can limit uncontrolled inflammation observed in patients with moderate to severe COVID-19. The immune pathology behind COVID-19 is complex and involves the activation and interaction of multiple systems including, but not limited to, complement, inflammasomes, endothelial as well as innate and adaptive immune cells to bring about a convoluted profile of inflammation, coagulation and tissue damage. To date, therapeutic approaches have focussed on inhibition of coagulation, untargeted immune suppression and/or cytokine-directed blocking agents. Regardless of recently achieved improvements in individual patient outcomes and survival rates, improved and focussed approaches targeting individual systems involved is needed to further improve prognosis and wellbeing. This review summarizes the current understanding of molecular and cellular systems involved in the pathophysiology of COVID-19, and their contribution to pathogen clearance and damage to then discuss possible therapeutic options involving immunomodulatory drug delivery systems as well as summarising the complex interplay between them.
Collapse
Affiliation(s)
- Danielle Brain
- Immunocompatibility Group, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK,Centre of Excellence for Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Alex Plant-Hately
- Immunocompatibility Group, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK,Centre of Excellence for Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Bethany Heaton
- Immunocompatibility Group, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK,Centre of Excellence for Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Usman Arshad
- Centre of Excellence for Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Christopher David
- Immunocompatibility Group, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK,Centre of Excellence for Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Christian Hedrich
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK,Department of Rheumatology, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Andrew Owen
- Centre of Excellence for Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Neill J. Liptrott
- Immunocompatibility Group, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK,Centre of Excellence for Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK,Corresponding author at: Materials Innovation Factory, University of Liverpool, Liverpool, UK
| |
Collapse
|
35
|
Bahraini M, Dorgalaleh A. The Impact of SARS-CoV-2 Infection on Blood Coagulation and Fibrinolytic Pathways: A Review of Prothrombotic Changes Caused by COVID-19. Semin Thromb Hemost 2021; 48:19-30. [PMID: 34695858 DOI: 10.1055/s-0041-1736166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The cardinal pathology of coronavirus disease 2019 (COVID-19) is a primary infection of pulmonary tract cells by severe acute respiratory syndrome coronavirus 2, provoking a local inflammatory response, often accompanied by cytokine storm and acute respiratory distress syndrome, especially in patients with severe disease. Systemic propagation of the disease may associate with thrombotic events, including deep vein thrombosis, pulmonary embolism, and thrombotic microangiopathy, which are important causes of morbidity and mortality in patients with COVID-19. This narrative review describes current knowledge of the pathophysiological mechanisms of COVID-19-associated coagulopathy, with focus on prothrombotic changes in hemostatic mediators, including plasma levels of clotting factors, natural anticoagulants, components of fibrinolytic system, and platelets. It will also highlight the central role of endothelial cells in COVID-19-associated coagulopathy. This narrative review discusses also potential therapeutic strategies for managing thrombotic complications. Awareness by medical experts of contributors to the pathogenesis of thrombotic events in COVID-19 is imperative to develop therapeutics not limited to regular anticoagulants. Instituting cooperation among medical personnel and researchers may lessen this novel virus' impact now, and in the event of recurrence.
Collapse
Affiliation(s)
- Mehran Bahraini
- Department of Hematology and Blood Transfusion, School of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Akbar Dorgalaleh
- Department of Hematology and Blood Transfusion, School of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
36
|
Benoit R, Nougier C, Desmurs-Clavel H, Simon M, Dargaud Y. The modification of the thrombin generation assay for the clinical assessment of hypercoagulability in patients receiving heparin therapy. Int J Lab Hematol 2021; 44:371-378. [PMID: 34643035 DOI: 10.1111/ijlh.13735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/28/2021] [Accepted: 10/02/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND Heparin diminishes thrombin generation (TG) because it decreases the survival time of thrombin in plasma. Under heparin therapy, the TG curve therefore does not reflect the true hemostatic status of the patient. AIM We investigated how far the in vitro addition of a heparin antagonist can restore the underlying TG capacity. MATERIALS & METHODS Five different heparin antagonists were tested: polybrene, protamine sulfate, heparinase type 1, heparinase HEP-TEM, and (Z-GGR)2 -rhodamine (P2Rho). RESULTS AND CONCLUSION Polybrene, P2Rho, and heparinase HEP-TEM effectively neutralized heparin at prophylactic and therapeutical doses of both low molecular weight and unfractionated heparin. The advantages and limits of each molecule and the most favorable combinations of TG-trigger and antagonist are discussed.
Collapse
Affiliation(s)
- Remi Benoit
- Laboratoire d'Hematologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Lyon, France
| | - Christophe Nougier
- Laboratoire d'Hematologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Lyon, France
| | - Helene Desmurs-Clavel
- Service de Medecine Interne, Hopital Edouard Herriot, Lyon, France.,GEMMAT, Groupe d'Etude Multidisciplinaire en Maladies Thrombotiques, Lyon, France
| | - Marie Simon
- GEMMAT, Groupe d'Etude Multidisciplinaire en Maladies Thrombotiques, Lyon, France.,Service de Medecine Intensive Reanimation, Hopital Edouard Herriot, Lyon, France
| | - Yesim Dargaud
- Laboratoire d'Hematologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Lyon, France.,GEMMAT, Groupe d'Etude Multidisciplinaire en Maladies Thrombotiques, Lyon, France.,Unite d'Hemostase Clinique Hopital Cardiologique Louis Pradel, Lyon, France.,UR4609 Hemostase&Thrombose, Universite Claude Bernard Lyon 1, Lyon, France
| |
Collapse
|
37
|
Maier CL, Sarker T, Szlam F, Sniecinski RM. COVID-19 patient plasma demonstrates resistance to tPA-induced fibrinolysis as measured by thromboelastography. J Thromb Thrombolysis 2021; 52:766-771. [PMID: 33829396 PMCID: PMC8026096 DOI: 10.1007/s11239-021-02438-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2021] [Indexed: 01/22/2023]
Abstract
Patients critically ill with COVID-19 are at risk for thrombotic events despite prophylactic anticoagulation. Impaired fibrinolysis has been proposed as an underlying mechanism. Our objective was to determine if fibrinolysis stimulated by tissue plasminogen activator (tPA) differed between COVID patients and controls. Plasma from 14 COVID patients on prophylactic heparin therapy was obtained and compared with heparinized plasma from 14 different healthy donors to act as controls. Kaolin activated thromboelastography with heparinase was utilized to obtain baseline measurements and then repeated with the addition of 4 nM tPA. Baseline fibrinogen levels were higher in COVID plasma as measured by maximum clot amplitude (43.6 ± 6.9 mm vs. 23.2 ± 5.5 mm, p < 0.0001) and Clauss assay (595 ± 135 mg/dL vs. 278 ± 44 mg/dL, p < 0.0001). With the addition of tPA, fibrinolysis at 30 min after MA (LY30%) was lower (37.9 ± 16.5% vs. 58.9 ± 18.3%, p = 0.0035) and time to 50% lysis was longer (48.8 ± 16.3 vs. 30.5 ± 15.4 min, p = 0.0053) in the COVID-19 samples. Clotting times and rate of fibrin polymerization ('R' or 'α' parameters) were largely the same in both groups. Clot from COVID patients contains a higher fibrin content compared to standard controls and shows resistance to fibrinolysis induced by tPA. These findings suggest the clinical efficacy of thrombolytics may be reduced in COVID-19 patients.
Collapse
Affiliation(s)
- Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Tania Sarker
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Fania Szlam
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Roman M Sniecinski
- Department of Anesthesiology, Emory University Hospital, Emory University School of Medicine, 3rd Floor, 1364 Clifton Rd, NE, Atlanta, GA, 30322, USA.
| |
Collapse
|
38
|
Vasovic LV, Littlejohn J, Alqunaibit D, Dillard A, Qiu Y, Rand S, Bronstein M, Gibson CJ, Kelly AG, Lee C, Minneman JA, Narayan M, Shou J, Smith KE, Villegas CV, Winchell RJ, Cushing MM, Barie PS. Rotational thromboelastometry in patients with acute respiratory distress syndrome owing to coronavirus disease 2019: Is there a viscoelastic fingerprint and a role for predicting thrombosis? Surgery 2021; 171:1092-1099. [PMID: 35090739 PMCID: PMC8426191 DOI: 10.1016/j.surg.2021.08.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 08/09/2021] [Accepted: 08/27/2021] [Indexed: 12/29/2022]
Abstract
Objectives We evaluated rotational thromboelastometry tracings in 44 critically ill coronavirus disease 2019 patients, to determine whether there is a viscoelastic fingerprint and to test the hypothesis that the diagnosis and prediction of venous thromboembolism would be enhanced by the addition of rotational thromboelastometry testing. Results Rotational thromboelastometry values reflected an increase in clot strength for the EXTEM, INTEM, and FIBTEM assays beyond the reference range. No hyperfibrinolysis was noted. Fibrinolysis shutdown was present but did not correlate with thrombosis; 32% (14/44) of patients experienced a thrombotic episode. For every 1 mm increase of FIBTEM maximum clot formation, the odds of developing thrombosis increased 20% (95% confidence interval, 0–40%, P = .043), whereas for every 1,000 ng/mL increase in D-dimer, the odds of thrombosis increased by 70% (95% confidence interval, 20%–150%, P = .004), after adjustment for age and sex (AUC 0.96, 95% confidence interval, 0.90–1.00). There was a slight but significant improvement in model performance after adding FIBTEM maximum clot formation and EXTEM clot formation time to D-dimer in a multivariable model (P = .04). Conclusions D-dimer concentrations were more predictive of thrombosis in our patient population than any other parameter. Rotational thromboelastometry confirmed the hypercoagulable state of coronavirus disease 2019 intensive care unit patients. FIBTEM maximum clot formation and EXTEM clot formation time increased the predictability for thrombosis compared with only using D-dimer. Rotational thromboelastometry analysis is most useful in augmenting the information provided by the D-dimer concentration for venous thromboembolism risk assessment when the D-dimer concentration is between 1,625 and 6,900 ng/dL, but the enhancement is modest. Fibrinolysis shutdown did not correlate with thrombosis.
Collapse
Affiliation(s)
- Ljiljana V Vasovic
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY
| | - James Littlejohn
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY.
| | | | - Alicia Dillard
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY
| | - Yuqing Qiu
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Sophie Rand
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY
| | | | | | - Anton G Kelly
- Department of Surgery, Weill Cornell Medicine New York, NY
| | - Christina Lee
- Department of Surgery, Weill Cornell Medicine New York, NY
| | | | - Mayur Narayan
- Department of Surgery, Weill Cornell Medicine New York, NY
| | - Jian Shou
- Department of Surgery, Weill Cornell Medicine New York, NY
| | - Kira E Smith
- Department of Surgery, Weill Cornell Medicine New York, NY
| | | | | | - Melissa M Cushing
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY
| | - Philip S Barie
- Department of Surgery, Weill Cornell Medicine New York, NY; Department of Medicine, Weill Cornell Medicine, New York, NY
| |
Collapse
|
39
|
Gaddh M, Maier CL. Interdisciplinary Approach to Thrombosis Management in COVID-19 at a Large Academic Center. JCO Oncol Pract 2021; 17:517-521. [PMID: 34019440 PMCID: PMC8457792 DOI: 10.1200/op.20.01056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/29/2021] [Accepted: 04/23/2021] [Indexed: 12/27/2022] Open
Abstract
There is an increasing recognition of association of COVID-19 with a distinct coagulopathy and increased risk of thrombosis. Unfortunately, effective strategies to prevent and treat thrombosis in this patient population remain uncertain. In the setting of a worsening pandemic, there is an urgent need to provide practical guidance to the clinicians on management of the coagulopathy, while waiting for the results from large systematic trials to establish best practices. At our institution, we convened an interdisciplinary group of 25 experts in the field of thrombosis from different medical specialties to review available literature and brainstorm management strategies. The group provided a 3-tiered anticoagulation algorithm for patients with COVID-19 along with a pathway for multidisciplinary review of difficult or refractory cases, which are described in this manuscript. In these unprecedented times where medical decision making is made difficult by both the novelty of the disease and paucity of robust data, clinical algorithms such as the one presented here may prove to be helpful for frontline providers caring for individual patients.
Collapse
Affiliation(s)
- Manila Gaddh
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA
| | - Cheryl L. Maier
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| |
Collapse
|
40
|
Levy JH, Iba T, Olson LB, Corey KM, Ghadimi K, Connors JM. COVID-19: Thrombosis, thromboinflammation, and anticoagulation considerations. Int J Lab Hematol 2021; 43 Suppl 1:29-35. [PMID: 34288441 PMCID: PMC8444926 DOI: 10.1111/ijlh.13500] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/06/2021] [Accepted: 02/11/2021] [Indexed: 12/13/2022]
Abstract
Vascular endothelial injury is a hallmark of acute infection at both the microvascular and macrovascular levels. The hallmark of SARS‐CoV‐2 infection is the current COVID‐19 clinical sequelae of the pathophysiologic responses of hypercoagulability and thromboinflammation associated with acute infection. The acute lung injury that initially occurs in COVID‐19 results from vascular and endothelial damage from viral injury and pathophysiologic responses that produce the COVID‐19–associated coagulopathy. Clinicians should continue to focus on the vascular endothelial injury that occurs and evaluate potential therapeutic interventions that may benefit those with new infections during the current pandemic as they may also be of benefit for future pathogens that generate similar thromboinflammatory responses. The current Accelerating COVID‐19 Therapeutic Interventions and Vaccines (ACTIV) studies are important projects that will further define our management strategies. At the time of writing this report, two mRNA vaccines are now being distributed and will hopefully have a major impact on slowing the global spread and subsequent thromboinflammatory injury we see clinically in critically ill patients.
Collapse
Affiliation(s)
- Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Lyra B Olson
- Duke University School of Medicine, Durham, NC, USA
| | - Kristen M Corey
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Kamrouz Ghadimi
- Departments of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, NC, USA
| | - Jean M Connors
- Department of Medicine, Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
41
|
The Prothrombotic State Associated with SARS-CoV-2 Infection: Pathophysiological Aspects. Mediterr J Hematol Infect Dis 2021; 13:e2021045. [PMID: 34276914 PMCID: PMC8265369 DOI: 10.4084/mjhid.2021.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 06/08/2021] [Indexed: 01/08/2023] Open
Abstract
Severe coronavirus disease-2019 (COVID-19) is frequently associated with microvascular thrombosis, especially in the lung, or macrovascular thrombosis, mainly venous thromboembolism, which significantly contributes to the disease mortality burden. COVID-19 patients also exhibit distinctive laboratory abnormalities that are compatible with a prothrombotic state. The key event underlying COVID-19-associated thrombotic complications is an excessive host inflammatory response to severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection generating multiple inflammatory mediators, mainly cytokines and complement activation products. The latter, along with the virus itself, the increased levels of angiotensin II and hypoxia, drive the major cellular changes promoting thrombosis, which include: (1) aberrant expression of tissue factor by activated alveolar epithelial cells, monocytes-macrophages and neutrophils, and production of other prothrombotic factors by activated endothelial cells (ECs) and platelets; (2) reduced expression of physiological anticoagulants by dysfunctional ECs, and (3) suppression of fibrinolysis by the endothelial overproduction of plasminogen activator inhibitor-1 and, likely, by heightened thrombin-mediated activation of thrombin-activatable fibrinolysis inhibitor. Moreover, upon activation or death, neutrophils and other cells release nuclear materials that are endowed with potent prothrombotic properties. The ensuing thrombosis significantly contributes to lung injury and, in most severe COVID-19 patients, to multiple organ dysfunction. Insights into the pathogenesis of COVID-19-associated thrombosis may have implications for the development of new diagnostic and therapeutic tools.
Collapse
|
42
|
Goswami J, MacArthur TA, Sridharan M, Pruthi RK, McBane RD, Witzig TE, Park MS. A Review of Pathophysiology, Clinical Features, and Management Options of COVID-19 Associated Coagulopathy. Shock 2021; 55:700-716. [PMID: 33378321 PMCID: PMC8122038 DOI: 10.1097/shk.0000000000001680] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ABSTRACT There is increasing evidence that novel coronavirus disease 2019 (COVID-19) leads to a significant coagulopathy, a phenomenon termed "COVID-19 associated coagulopathy." COVID-19 has been associated with increased rates of both venous and arterial thromboembolic events, a source of significant morbidity and mortality in this disease. Further evidence suggests a link between the inflammatory response and coagulopathy associated with COVID-19. This presents a unique set of challenges for diagnosis, prevention, and treatment of thrombotic complications. In this review, we summarize and discuss the current literature on laboratory coagulation disruptions associated with COVID-19 and the clinical effects of thromboembolic events including pulmonary embolism, deep vein thrombosis, peripheral arterial thrombosis, and acute ischemic stroke in COVID-19. Endothelial injury and augmented innate immune response are implicated in the development of diffuse macro- and microvascular thrombosis in COVID-19. The pathophysiology of COVID-19 associated coagulopathy is an important determinant of appropriate treatment and monitoring of these complications. We highlight the importance of diagnosis and management of dysregulated coagulation in COVID-19 to improve outcomes in COVID-19 patients with thromboembolic complications.
Collapse
Affiliation(s)
- Julie Goswami
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
| | - Taleen A. MacArthur
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
| | - Meera Sridharan
- Department of Hematology, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
| | - Rajiv K. Pruthi
- Department of Hematology, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
| | - Robert D. McBane
- Department of Hematology, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
- Division of Vascular Cardiology, Department of Cardiovascular Disease, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
| | - Thomas E. Witzig
- Department of Hematology, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
| | - Myung S. Park
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
| |
Collapse
|
43
|
Juneja GK, Castelo M, Yeh CH, Cerroni SE, Hansen BE, Chessum JE, Abraham J, Cani E, Dwivedi DJ, Fraser DD, Slessarev M, Martin C, McGilvray S, Gross PL, Liaw PC, Weitz JI, Kim PY. Biomarkers of coagulation, endothelial function, and fibrinolysis in critically ill patients with COVID-19: A single-center prospective longitudinal study. J Thromb Haemost 2021; 19:1546-1557. [PMID: 33826233 PMCID: PMC8250276 DOI: 10.1111/jth.15327] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 03/26/2021] [Accepted: 03/30/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Immunothrombosis and coagulopathy in the lung microvasculature may lead to lung injury and disease progression in coronavirus disease 2019 (COVID-19). We aim to identify biomarkers of coagulation, endothelial function, and fibrinolysis that are associated with disease severity and may have prognostic potential. METHODS We performed a single-center prospective study of 14 adult COVID-19(+) intensive care unit patients who were age- and sex-matched to 14 COVID-19(-) intensive care unit patients, and healthy controls. Daily blood draws, clinical data, and patient characteristics were collected. Baseline values for 10 biomarkers of interest were compared between the three groups, and visualized using Fisher's linear discriminant function. Linear repeated-measures mixed models were used to screen biomarkers for associations with mortality. Selected biomarkers were further explored and entered into an unsupervised longitudinal clustering machine learning algorithm to identify trends and targets that may be used for future predictive modelling efforts. RESULTS Elevated D-dimer was the strongest contributor in distinguishing COVID-19 status; however, D-dimer was not associated with survival. Variable selection identified clot lysis time, and antigen levels of soluble thrombomodulin (sTM), plasminogen activator inhibitor-1 (PAI-1), and plasminogen as biomarkers associated with death. Longitudinal multivariate k-means clustering on these biomarkers alone identified two clusters of COVID-19(+) patients: low (30%) and high (100%) mortality groups. Biomarker trajectories that characterized the high mortality cluster were higher clot lysis times (inhibited fibrinolysis), higher sTM and PAI-1 levels, and lower plasminogen levels. CONCLUSIONS Longitudinal trajectories of clot lysis time, sTM, PAI-1, and plasminogen may have predictive ability for mortality in COVID-19.
Collapse
Affiliation(s)
- Ganeem K Juneja
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
- Department of Medical Sciences, McMaster University, Hamilton, ON, Canada
| | - Matthew Castelo
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Calvin H Yeh
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
| | - Samantha E Cerroni
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Bettina E Hansen
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - James E Chessum
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
- Department of Medical Sciences, McMaster University, Hamilton, ON, Canada
| | - Joel Abraham
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
- Department of Medical Sciences, McMaster University, Hamilton, ON, Canada
| | - Erblin Cani
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
- Department of Medical Sciences, McMaster University, Hamilton, ON, Canada
| | - Dhruva J Dwivedi
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Douglas D Fraser
- Lawson Health Research Institute, London, ON, Canada
- Pediatrics, Western University, London, ON, Canada
- Clinical Neurological Sciences, Western University, London, ON, Canada
- Physiology & Pharmacology, Western University, London, ON, Canada
| | - Marat Slessarev
- Lawson Health Research Institute, London, ON, Canada
- Medicine, Western University, London, ON, Canada
| | - Claudio Martin
- Lawson Health Research Institute, London, ON, Canada
- Medicine, Western University, London, ON, Canada
| | - Scott McGilvray
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
| | - Peter L Gross
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Patricia C Liaw
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Paul Y Kim
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
44
|
|
45
|
|
46
|
Hulshof AM, Brüggemann RAG, Mulder MMG, van de Berg TW, Sels JWEM, Olie RH, Spaetgens B, Streng AS, Verhezen P, van der Horst ICC, Ten Cate H, Spronk HMH, van Bussel BCT, Henskens YMC. Serial EXTEM, FIBTEM, and tPA Rotational Thromboelastometry Observations in the Maastricht Intensive Care COVID Cohort-Persistence of Hypercoagulability and Hypofibrinolysis Despite Anticoagulation. Front Cardiovasc Med 2021; 8:654174. [PMID: 33981736 PMCID: PMC8107372 DOI: 10.3389/fcvm.2021.654174] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/05/2021] [Indexed: 01/14/2023] Open
Abstract
Background: Coronavirus Disease 2019 (COVID-19) patients often present with thromboembolic events. In COVID-19 patients, routine hemostatic assays cannot correctly identify patients at risk for thromboembolic events. Viscoelastic testing with rotational thromboelastometry (ROTEM) might improve the characterization of COVID-19-associated coagulopathy. Objective: To unravel underlying coagulopathy and fibrinolysis over time as measured by serial assessment heparin-independent (FIBTEM and EXTEM) and fibrinolysis illustrating (tissue plasminogen activator; tPA) ROTEM assays. Patients/Methods: Between April 23 and June 12, consecutive adult patients enrolled within the Maastricht Intensive Care COVID (MaastrICCht) cohort were included, and a comprehensive set of clinical, physiological, pharmaceutical, and laboratory variables were collected daily. Twice per week, EXTEM, FIBTEM, and tPA ROTEM were performed. Clotting time (CT), clot formation time (CFT), maximum clot firmness (MCF), lysis onset time (LOT), and lysis time (LT) were determined to assess clot development and breakdown and were compared to routine hemostatic assays. Results: In 36 patients, 96 EXTEM/FIBTEM and 87 tPA ROTEM tests were performed during a 6-week follow-up. CT prolongation was present in 54% of EXTEM measurements, which were not matched by prothrombin time (PT) in 37%. Respectively, 81 and 99% of all EXTEM and FIBTEM MCF values were above the reference range, and median MCF remained elevated during follow-up. The ROTEM fibrinolysis parameters remained prolonged with median LOT consequently >49 min and unmeasurable LT in 56% of measurements, suggesting a severe hypofibrinolytic phenotype. Conclusion: ROTEM tests in COVID-19 ICU patients show hypercoagulability and severe hypofibrinolysis persisting over at least 6 weeks.
Collapse
Affiliation(s)
- Anne-Marije Hulshof
- Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Renée A G Brüggemann
- Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Mark M G Mulder
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Tom W van de Berg
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Jan-Willem E M Sels
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Renske H Olie
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands.,Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands.,Thrombosis Expert Centre Maastricht, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Bart Spaetgens
- Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Alexander S Streng
- Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Paul Verhezen
- Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Iwan C C van der Horst
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands.,Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Hugo Ten Cate
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands.,Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands.,Thrombosis Expert Centre Maastricht, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Henri M H Spronk
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Bas C T van Bussel
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands.,Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
| | - Yvonne M C Henskens
- Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, Netherlands
| |
Collapse
|
47
|
Bareille M, Hardy M, Douxfils J, Roullet S, Lasne D, Levy JH, Stépanian A, Susen S, Frère C, Lecompte T, Mullier F. Viscoelastometric Testing to Assess Hemostasis of COVID-19: A Systematic Review. J Clin Med 2021; 10:jcm10081740. [PMID: 33923851 PMCID: PMC8072929 DOI: 10.3390/jcm10081740] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 02/06/2023] Open
Abstract
Infection by SARS-CoV-2 is associated with a high risk of thrombosis. The laboratory documentation of hypercoagulability and impaired fibrinolysis remains a challenge. Our aim was to assess the potential usefulness of viscoelastometric testing (VET) to predict thrombotic events in COVID-19 patients according to the literature. We also (i) analyzed the impact of anticoagulation and the methods used to neutralize heparin, (ii) analyzed whether maximal clot mechanical strength brings more information than Clauss fibrinogen, and (iii) critically scrutinized the diagnosis of hypofibrinolysis. We performed a systematic search in PubMed and Scopus databases until 31st December 2020. VET methods and parameters, and patients' features and outcomes were extracted. VET was performed for 1063 patients (893 intensive care unit (ICU) and 170 non-ICU, 44 studies). There was extensive heterogeneity concerning study design, VET device used (ROTEM, TEG, Quantra and ClotPro) and reagents (with non-systematic use of heparin neutralization), timing of assay, and definition of hypercoagulable state. Notably, only 4 out of 25 studies using ROTEM reported data with heparinase (HEPTEM). The common findings were increased clot mechanical strength mainly due to excessive fibrinogen component and impaired to absent fibrinolysis, more conspicuous in the presence of an added plasminogen activator. Only 4 studies out of the 16 that addressed the point found an association of VETs with thrombotic events. So-called functional fibrinogen assessed by VETs showed a variable correlation with Clauss fibrinogen. Abnormal VET pattern, often evidenced despite standard prophylactic anticoagulation, tended to normalize after increased dosing. VET studies reported heterogeneity, and small sample sizes do not support an association between the poorly defined prothrombotic phenotype of COVID-19 and thrombotic events.
Collapse
Affiliation(s)
- Marion Bareille
- Namur Thrombosis and Hemostasis Center (NTHC), CHU UCL Namur, Université Catholique de Louvain, 5530 Yvoir, Belgium;
- Correspondence:
| | - Michaël Hardy
- Service D’anesthésiologie, CHU UCL Namur, Université Catholique de Louvain, 5530 Yvoir, Belgium;
| | - Jonathan Douxfils
- Namur Thrombosis and Hemostasis Center (NTHC), Département de Pharmacie, Université de Namur, 5000 Namur, Belgium;
- Qualiblood S.A., 5000 Namur, Belgium
| | - Stéphanie Roullet
- CHU Bordeaux, Service D’Anesthésie-Réanimation Tripode, 33000 Bordeaux, France;
- Biologie des Maladies Cardiovasculaire, University Bordeaux, INSERM U1034, 33600 Pessac, France
| | - Dominique Lasne
- Laboratoire D’hématologie Générale, Hôpital Universitaire Necker-Enfants Malades, AP-HP, 75015 Paris, France;
| | - Jerrold H. Levy
- Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC 27710, USA;
| | - Alain Stépanian
- Hôpital Lariboisière, Service D’Hématologie Biologique, Institut de Recherche Saint-Louis, Université de Paris, AP-HP Nord-Université de Paris, EA 3518, 75010 Paris, France;
| | - Sophie Susen
- Laboratoire D’Hématologie-Hémostase, Université de Lille, CHU Lille, 59037 Lille, France;
| | - Corinne Frère
- Department of Hematology, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, INSERM UMRS_1166, Sorbonne Université, 75013 Paris, France;
| | - Thomas Lecompte
- Départements de Médecine, Service D’angiologie et D’hémostase et Faculté de Médecine Geneva Platelet Group (GpG), Université de Genève et Hôpitaux Universitaires de Genève, 1205 Genève, Switzerland;
| | - François Mullier
- Namur Thrombosis and Hemostasis Center (NTHC), CHU UCL Namur, Université Catholique de Louvain, 5530 Yvoir, Belgium;
| |
Collapse
|
48
|
Sjöström A, Wersäll JD, Warnqvist A, Farm M, Magnusson M, Oldner A, Ågren A, Antovic J, Bruzelius M. Platelet Count Rose While D-Dimer Levels Dropped as Deaths and Thrombosis Declined-An Observational Study on Anticoagulation Shift in COVID-19. Thromb Haemost 2021; 121:1610-1621. [PMID: 33831964 DOI: 10.1055/a-1477-3829] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND High levels of D-dimer and low platelet counts are associated with poor outcome in coronavirus disease 2019 (COVID-19). As anticoagulation appeared to improve survival, hospital-wide recommendations regarding higher doses of anticoagulation were implemented on April 9, 2020. OBJECTIVES To investigate if trends in D-dimer levels and platelet counts were associated with death, thrombosis, and the shift in anticoagulation. METHODS Retrospective cohort study of 429 patients with COVID-19 at Karolinska University Hospital. Information on D-dimer levels and platelet counts was obtained from laboratory databases and clinical data from medical records. RESULTS Thirty-day mortality and thrombosis rates were 19% and 18%, respectively. Pulmonary embolism was common, 65/83 (78%). Increased D-dimer levels in the first week in hospital were significantly associated with death and thrombosis (odds ratio [OR]: 6.06; 95% confidence interval [CL]: 2.10-17.5 and 3.11; 95% CI: 1.20-8.10, respectively). If platelet count increased more than 35 × 109/L per day, the mortality and thrombotic risk decreased (OR: 0.16; 95% CI: 0.06-0.41, and OR: 0.36; 95% CI: 0.17-0.80). After implementation of updated hospital-wide recommendations, the daily mean significantly decreased regarding D-dimer levels while platelet counts rose; -1.93; 95% CI: -1.00-2.87 mg/L FEU (fibrinogen-equivalent unit) and 65; 95% CI: 54-76 ×109/L, and significant risk reductions for death and thrombosis were observed; OR: 0.48; 95% CI: 0.25-0.92 and 0.35; 95% CI: 0.17-0.72. CONCLUSION In contrast to D-dimer levels, increase of platelet count over the first week in hospital was associated with improved survival and reduced thrombotic risk. The daily mean levels of D-dimer dropped while the platelet counts rose, coinciding with increased anticoagulation and a decline in thrombotic burden and mortality.
Collapse
Affiliation(s)
- Anna Sjöström
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Clinical Chemistry, Karolinska University Laboratory, Stockholm, Sweden
| | | | - Anna Warnqvist
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Maria Farm
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Clinical Chemistry, Karolinska University Laboratory, Stockholm, Sweden
| | - Maria Magnusson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Coagulation Unit, Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Oldner
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.,Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Ågren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Coagulation Unit, Department of Hematology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Jovan Antovic
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Clinical Chemistry, Karolinska University Laboratory, Stockholm, Sweden
| | - Maria Bruzelius
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Coagulation Unit, Department of Hematology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
49
|
Görlinger K, Almutawah H, Almutawaa F, Alwabari M, Alsultan Z, Almajed J, Alwabari M, Alsultan M, Shahwar D, Yassen KA. The role of rotational thromboelastometry during the COVID-19 pandemic: a narrative review. Korean J Anesthesiol 2021; 74:91-102. [PMID: 33440114 PMCID: PMC8024216 DOI: 10.4097/kja.21006] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 01/11/2021] [Indexed: 02/08/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic is currently recognized as a global health crisis. This viral infection is frequently associated with hypercoagulability, with a high incidence of thromboembolic complications that can be fatal. In many situations, the standard coagulation tests (SCT) fail to detect this state of hypercoagulability in patients with COVID-19 since clotting times are either not or only mildly affected. The role of viscoelastic tests such as rotational thromboelastometry (ROTEM®) during this pandemic is explored in this review. COVID-19-associated coagulopathy, as measured using the rotational thromboelastometry parameters, can vary from hypercoagulability due to increased fibrin polymerization and decreased fibrinolysis to bleeding from hypocoagulability. The use of a multimodal diagnostic and monitoring approach, including both rotational thromboelastometry and SCT, such as plasma fibrinogen and D-dimer concentrations, is recommended. Rotational thromboelastometry provides comprehensive information about the full coagulation status of each patient and detects individual variations. Since COVID-19-associated coagulopathy is a very dynamic process, the phenotype can change during the course of infection and in response to anticoagulation therapy. Data from published literature provide evidence that the combination of rotational thromboelastometry and SCT analysis is helpful in detecting hemostasis issues, guiding anticoagulant therapy, and improving outcomes in COVID-19 patients. However, more research is needed to develop evidence-based guidelines and protocols.
Collapse
Affiliation(s)
- Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
- Tem Innovations, Munich, Germany
| | - Hawra Almutawah
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Fatimah Almutawaa
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Maryam Alwabari
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Zahra Alsultan
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Jumanah Almajed
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Mahmoud Alwabari
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Maryam Alsultan
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Duri Shahwar
- Division of Anesthesia, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Khaled Ahmed Yassen
- Division of Anesthesia, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| |
Collapse
|
50
|
Meizoso JP, Moore HB, Moore EE. Fibrinolysis Shutdown in COVID-19: Clinical Manifestations, Molecular Mechanisms, and Therapeutic Implications. J Am Coll Surg 2021; 232:995-1003. [PMID: 33766727 PMCID: PMC7982779 DOI: 10.1016/j.jamcollsurg.2021.02.019] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 02/06/2023]
Abstract
The COVID-19 pandemic has introduced a global public health threat unparalleled in our history. The most severe cases are marked by ARDS attributed to microvascular thrombosis. Hypercoagulability, resulting in a profoundly prothrombotic state, is a distinct feature of COVID-19 and is accentuated by a high incidence of fibrinolysis shutdown. The aims of this review were to describe the manifestations of fibrinolysis shutdown in COVID-19 and its associated outcomes, review the molecular mechanisms of dysregulated fibrinolysis associated with COVID-19, and discuss potential implications and therapeutic targets for patients with severe COVID-19.
Collapse
Affiliation(s)
- Jonathan P Meizoso
- Ernest E Moore Shock Trauma Center, Denver Health Medical Center, University of Colorado, Denver, CO.
| | - Hunter B Moore
- Division of Transplant Surgery, University of Colorado, Denver, CO
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center, Denver Health Medical Center, University of Colorado, Denver, CO
| |
Collapse
|