Increased plasminogen activator inhibitor results in a hypofibrinolytic state in adolescents with obesity: in vivo and ex vivo evidence

Increasing obesity is associated with lower postoperative bleeding in coronary bypass patients

OBJECTIVE

Despite inherent comorbidities, obese cardiac surgical patients paradoxically had shown lower morbidity and mortality, although the nature of this association is still unclear. Thus, the authors intended in this large registry-based study to investigate the impact of obesity on short- and long-term postoperative outcomes, focusing on bleeding and transfusion requirements.

DESIGN

Retrospective registry study.

SETTING

Three university hospitals.

PARTICIPANTS

A cohort of 12,330 prospectively compiled data from coronary bypass grafting patients undergoing surgery between 2007 to 2020 were retrieved from the Western Denmark Heart Registry.

INTERVENTIONS

The parameters were analyzed to assess the association between body mass index (BMI) and the selected outcome parameters.

MEASUREMENTS AND MAIN RESULTS

The crude data showed a clear statistically significant association in postoperative drainage from 637 (418-1108) mL in underweight patients with BMI <18.5 kg/m² to 427 (295-620) mL in severely obese patients with BMI ≥40 kg/m² (p < 0.0001, Kruskal-Wallis). Further, 50.0% of patients with BMI <18.5 received an average of 451 mL/m² in red blood cell transfusions, compared to 16.7% of patients with BMI >40 receiving 84 mL/m². The obese groups were less often submitted to reexploration due to bleeding, and fewer received perioperative hemostatics, inotropes, and vasoconstrictors. The crude data showed increasing 30-day and 6-month mortality with lower BMI, whereas the one-year mortality showed a V-shaped pattern, but BMI had no independent impact on mortality in logistic regression analysis.

CONCLUSION

Patients with high BMI may carry protection against postoperative bleeding after cardiac surgery, probably secondary to an inherent hypercoagulable state, whereas underweight patients carry a higher risk of bleeding and worse outcomes.

Fibrinolysis in Patients with Liver Disease

Patients with liver disease acquire complex changes in their hemostatic system. Historically, these patients were considered to have a bleeding tendency related, in part, to a hyperfibrinolytic state. However, studies using more modern fibrinolysis tests have questioned the presence of a hyperfibrinolytic state in patients with liver disease and its association with bleeding risk. It may be that the sickest patients with liver disease do have fibrinolytic abnormalities. However, the debate on the fibrinolytic state of patients with (decompensated) cirrhosis or critically ill liver disease is complicated by the fact that hypo- and hyperfibrinolysis have been poorly defined. This could, in part, be explained by the lack of reliable tests that assess a patient's fibrinolytic status. Moreover, large clinical studies on the relationship between bleeding and fibrinolysis in patients with liver disease are scarce. Here, we provide an overview of the current knowledge on fibrinolysis in various types of liver diseases and possible implications as a target for therapeutic strategies in liver disease. As antifibrinolytic therapy has been shown to be safe and effective during liver transplantation, it could potentially be of use in patients with (either laboratory-established or suspected) hyperfibrinolysis-related bleeding.

Slow fusion pore expansion creates a unique reaction chamber for co-packaged cargo

A lumenal secretory granule protein can slow fusion pore dilation and thus its own discharge. Bohannon et al. demonstrate another outcome: the creation of a nanoscale chemical reaction chamber for granule contents in which the pH is suddenly neutralized upon fusion.

A lumenal secretory granule protein, tissue plasminogen activator (tPA), greatly slows fusion pore dilation and thereby slows its own discharge. We investigated another outcome of the long-lived narrow fusion pore: the creation of a nanoscale chemical reaction chamber for granule contents in which the pH is suddenly neutralized upon fusion. Bovine adrenal chromaffin cells endogenously express both tPA and its primary protein inhibitor, plasminogen activator inhibitor 1 (PAI). We found by immunocytochemistry that tPA and PAI are co-packaged in the same secretory granule. It is known that PAI irreversibly and covalently inactivates tPA at neutral pH. We demonstrate with zymography that the acidic granule lumen protects tPA from inactivation by PAI. Immunocytochemistry, total internal reflection fluorescence (TIRF) microscopy, and polarized TIRF microscopy demonstrated that co-packaged PAI and tPA remain together in granules for many seconds in the nanoscale reaction chamber, more than enough time to inhibit tPA and create a new secreted protein species.