1
|
Waleed MS, Dhulipalla L, Niazi M, Terjanian T, Dhar M. COVID-Induced Thrombotic Thrombocytopenic Purpura: A Case Report and Treatment-Focused Review. Cureus 2024; 16:e57252. [PMID: 38686279 PMCID: PMC11057214 DOI: 10.7759/cureus.57252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2024] [Indexed: 05/02/2024] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare disease that is part of a vast spectrum of thrombotic microangiopathies (TMAs). Despite the rarity of TTP, clinicians must maintain a high suspicion of this disease. The condition is characterized by fever, low platelets, hemolytic anemia, renal abnormalities, and neurological dysfunction. However, all these symptoms are not necessarily present in all the patients. In this review, we describe a case of a 51-year-old female who presented to the emergency department (ED) with chief complaints of dizziness and lightheadedness, subsequently leading to a diagnosis of TTP, caused as a result of COVID-19. This review raises awareness so that there is early recognition of any hematological manifestations associated with COVID-19, reducing the morbidity and mortality associated with the disease. Due to the unpredictability of COVID-19 and its complications, robust research is needed to understand the mechanism and determine which patients are more at risk for adverse outcomes.
Collapse
Affiliation(s)
| | | | - Muhammad Niazi
- Internal Medicine, Northwell Health/Staten Island University Hospital, Staten Island, USA
| | - Terenig Terjanian
- Hematology and Oncology, Staten Island University Hospital, Staten Island, USA
| | - Meekoo Dhar
- Hematology and Oncology, Staten Island University Hospital, Staten Island, USA
| |
Collapse
|
2
|
Seliga AK, Zabłocki K, Bandorowicz-Pikuła J. Palmitate Stimulates Expression of the von Willebrand Factor and Modulates Toll-like Receptors Level and Activity in Human Umbilical Vein Endothelial Cells (HUVECs). Int J Mol Sci 2023; 25:254. [PMID: 38203423 PMCID: PMC10779284 DOI: 10.3390/ijms25010254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 12/12/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
An increased concentration of palmitate in circulation is one of the most harmful factors in obesity. The von Willebrand factor (vWF), a protein involved in haemostasis, is produced and secreted by the vascular endothelium. An increased level of vWF in obese patients is associated with thrombosis and cardiovascular disease. The aim of this study was to investigate a palmitate effect on vWF in endothelial cells and understand the mechanisms of palmitate-activated signalling. Human umbilical vein endothelial cells (HUVECs) incubated in the presence of palmitate, exhibited an increased VWF gene expression, vWF protein maturation, and stimulated vWF secretion. Cardamonin, a Nuclear Factor kappa B (NF-κB) inhibitor, abolished the palmitate effect on VWF expression. The inhibition of Toll-like receptor (TLR) 2 with C29 resulted in the TLR4 overactivation in palmitate-treated cells. Palmitate, in the presence of TLR4 inhibitor TAK-242, leads to a higher expression of TLR6, CD36, and TIRAP. The silencing of TLR4 resulted in an increase in TLR2 level and vice versa. The obtained results indicate a potential mechanism of obesity-induced thrombotic complication caused by fatty acid activation of NF-κB signalling and vWF upregulation and help to identify various compensatory mechanisms related to TLR4 signal transduction.
Collapse
Affiliation(s)
| | | | - Joanna Bandorowicz-Pikuła
- Laboratory of Cellular Metabolism, Nencki Institute of Experimental Biology PAS, 3 Pasteur Str., 02-093 Warsaw, Poland; (A.K.S.); (K.Z.)
| |
Collapse
|
3
|
Yousefi P, Soltani S, Siri G, Rezayat SA, Gholami A, Zafarani A, Razizadeh MH, Alborzi E, Mokhtary‐Irani G, Abedi B, Karampoor S, Tabibzadeh A, Farahani A. Coagulopathy and thromboembolic events a pathogenic mechanism of COVID-19 associated with mortality: An updated review. J Clin Lab Anal 2023; 37:e24941. [PMID: 37431777 PMCID: PMC10431412 DOI: 10.1002/jcla.24941] [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: 02/01/2023] [Revised: 05/24/2023] [Accepted: 06/26/2023] [Indexed: 07/12/2023] Open
Abstract
During 2019, the SARS-CoV-2 emerged from China, and during months, COVID-19 spread in many countries around the world. The expanding data about pathogenesis of this virus could elucidate the exact mechanism by which COVID-19 caused death in humans. One of the pathogenic mechanisms of this disease is coagulation. Coagulation disorders that affect both venous and arterial systems occur in patients with COVID-19. The possible mechanism involved in the coagulation could be excessive inflammation induced by SARS-CoV-2. However, it is not yet clear well how SARS-CoV-2 promotes coagulopathy. However, some factors, such as pulmonary endothelial cell damage and some anticoagulant system disorders, are assumed to have an important role. In this study, we assessed conducted studies about COVID-19-induced coagulopathy to obtain clearer vision of the wide range of manifestations and possible pathogenesis mechanisms.
Collapse
Affiliation(s)
- Parastoo Yousefi
- Department of Virology, School of MedicineIran University of Medical SciencesTehranIran
| | - Saber Soltani
- Department of Virology, School of Public HealthTehran University of Medical SciencesTehranIran
| | - Goli Siri
- Department of Internal Medicine, Amir Alam HospitalTehran University of Medical SciencesTehranIran
| | - Sara Akhavan Rezayat
- Department of Health Care Management and Economics, School of Public HealthTehran University of Medical SciencesTehranIran
| | - Ali Gholami
- School of MedicineArak University of Medical SciencesArakIran
| | - Alireza Zafarani
- Department of Hematology and Blood Banking, Faculty of Allied MedicineIran University of Medical SciencesTehranIran
| | | | - Ehsan Alborzi
- Department of Virology, School of MedicineIran University of Medical SciencesTehranIran
| | - Golnaz Mokhtary‐Irani
- Department of Virology, Faculty of MedicineAhvaz Jondishapur University of Medical SciencesAhvazIran
| | - Behnam Abedi
- Department of Medical Laboratory SciencesKhomein University of Medical SciencesKhomeinIran
| | - Sajad Karampoor
- Department of Virology, School of MedicineIran University of Medical SciencesTehranIran
- Gastrointestinal and Liver Diseases Research CenterIran University of Medical SciencesTehranIran
| | - Alireza Tabibzadeh
- Department of Virology, School of MedicineIran University of Medical SciencesTehranIran
| | - Abbas Farahani
- Department of Medical Laboratory SciencesKhomein University of Medical SciencesKhomeinIran
- Molecular and Medicine Research CenterKhomein University of Medical SciencesKhomeinIran
| |
Collapse
|
4
|
Vassiliou AG, Vrettou CS, Keskinidou C, Dimopoulou I, Kotanidou A, Orfanos SE. Endotheliopathy in Acute COVID-19 and Long COVID. Int J Mol Sci 2023; 24:ijms24098237. [PMID: 37175942 PMCID: PMC10179170 DOI: 10.3390/ijms24098237] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 04/28/2023] [Accepted: 04/30/2023] [Indexed: 05/15/2023] Open
Abstract
The pulmonary endothelium is a highly regulated organ that performs a wide range of functions under physiological and pathological conditions. Since endothelial dysfunction has been demonstrated to play a direct role in sepsis and acute respiratory distress syndrome, its role in COVID-19 has also been extensively investigated. Indeed, apart from the COVID-19-associated coagulopathy biomarkers, new biomarkers were recognised early during the pandemic, including markers of endothelial cell activation or injury. We systematically searched the literature up to 10 March 2023 for studies examining the association between acute and long COVID-19 severity and outcomes and endothelial biomarkers.
Collapse
Affiliation(s)
- Alice G Vassiliou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece
| | - Charikleia S Vrettou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece
| | - Chrysi Keskinidou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece
| | - Ioanna Dimopoulou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece
| | - Anastasia Kotanidou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece
| | - Stylianos E Orfanos
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece
| |
Collapse
|
5
|
van den Berg J, Haslbauer JD, Stalder AK, Romanens A, Mertz KD, Studt JD, Siegemund M, Buser A, Holbro A, Tzankov A. Von Willebrand factor and the thrombophilia of severe COVID-19: in situ evidence from autopsies. Res Pract Thromb Haemost 2023; 7:100182. [PMID: 37333991 PMCID: PMC10192064 DOI: 10.1016/j.rpth.2023.100182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 04/29/2023] [Accepted: 05/08/2023] [Indexed: 06/20/2023] Open
Abstract
Background COVID-19 is accompanied by a hypercoagulable state and characterized by microvascular and macrovascular thrombotic complications. In plasma samples from patients with COVID-19, von Willebrand factor (VWF) levels are highly elevated and predictive of adverse outcomes, especially mortality. Yet, VWF is usually not included in routine coagulation analyses, and histologic evidence of its involvement in thrombus formation is lacking. Objectives To determine whether VWF, an acute-phase protein, is a bystander, ie, a biomarker of endothelial dysfunction, or a causal factor in the pathogenesis of COVID-19. Methods We compared autopsy samples from 28 patients with lethal COVID-19 to those from matched controls and systematically assessed for VWF and platelets by immunohistochemistry. The control group comprised 24 lungs, 23 lymph nodes, and 9 hearts and did not differ significantly from the COVID-19 group in age, sex, body mass index (BMI), blood group, or anticoagulant use. Results In lungs, assessed for platelets by immunohistochemistry for CD42b, microthrombi were more frequent in patients with COVID-19 (10/28 [36%] vs 2/24 [8%]; P = .02). A completely normal pattern of VWF was rare in both groups. Accentuated endothelial staining was found in controls, while VWF-rich thrombi were only found in patients with COVID-19 (11/28 [39%] vs 0/24 [0%], respectively; P < .01), as were NETosis thrombi enriched with VWF (7/28 [25%] vs 0/24 [0%], respectively; P < .01). Forty-six percent of the patients with COVID-19 had VWF-rich thrombi, NETosis thrombi, or both. Trends were also seen in pulmonary draining lymph nodes (7/20 [35%] vs 4/24 [17%]; P = .147), where the overall presence of VWF was very high. Conclusion We provide in situ evidence of VWF-rich thrombi, likely attributable to COVID-19, and suggest that VWF may be a therapeutic target in severe COVID-19.
Collapse
Affiliation(s)
- Jana van den Berg
- Department of Hematology, University Hospital Basel, Basel, Switzerland
| | - Jasmin D Haslbauer
- Department of Pathology, Institute of Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
- Department of Pathology, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Anna K Stalder
- Department of Pathology, Institute of Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
| | - Anna Romanens
- Department of Oncology, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Kirsten D Mertz
- Department of Pathology, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Jan-Dirk Studt
- Department of Medical Oncology and Hematology, University Hospital Zürich, Zürich, Switzerland
| | - Martin Siegemund
- Intensive Care Unit, Department of Acute Medicine, University Hospital, Basel, Switzerland
| | - Andreas Buser
- Department of Hematology, University Hospital Basel, Basel, Switzerland
- Regional Blood Transfusion Service, Swiss Red Cross, Basel, Switzerland
| | - Andreas Holbro
- Department of Hematology, University Hospital Basel, Basel, Switzerland
- Regional Blood Transfusion Service, Swiss Red Cross, Basel, Switzerland
| | - Alexandar Tzankov
- Department of Pathology, Institute of Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
| |
Collapse
|
6
|
Liatsos GD. SARS-CoV-2 induced liver injury: Incidence, risk factors, impact on COVID-19 severity and prognosis in different population groups. World J Gastroenterol 2023; 29:2397-2432. [PMID: 37179584 PMCID: PMC10167898 DOI: 10.3748/wjg.v29.i16.2397] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/17/2023] [Accepted: 04/07/2023] [Indexed: 04/24/2023] Open
Abstract
Liver is unlikely the key organ driving mortality in coronavirus disease 2019 (COVID-19) however, liver function tests (LFTs) abnormalities are widely observed mostly in moderate and severe cases. According to this review, the overall prevalence of abnormal LFTs in COVID-19 patients ranges from 2.5% to 96.8% worldwide. The geographical variability in the prevalence of underlying diseases is the determinant for the observed discrepancies between East and West. Multifactorial mechanisms are implicated in COVID-19-induced liver injury. Among them, hypercytokinemia with "bystander hepatitis", cytokine storm syndrome with subsequent oxidative stress and endotheliopathy, hypercoagulable state and immuno-thromboinflammation are the most determinant mechanisms leading to tissue injury. Liver hypoxia may also contribute under specific conditions, while direct hepatocyte injury is an emerging mechanism. Except for initially observed severe acute respiratory distress syndrome corona virus-2 (SARS-CoV-2) tropism for cholangiocytes, more recent cumulative data show SARS-CoV-2 virions within hepatocytes and sinusoidal endothelial cells using electron microscopy (EM). The best evidence for hepatocellular invasion by the virus is the identification of replicating SARS-CoV-2 RNA, S protein RNA and viral nucleocapsid protein within hepatocytes using in-situ hybridization and immunostaining with observed intrahepatic presence of SARS-CoV-2 by EM and by in-situ hybridization. New data mostly derived from imaging findings indicate possible long-term sequelae for the liver months after recovery, suggesting a post-COVID-19 persistent live injury.
Collapse
Affiliation(s)
- George D Liatsos
- Department of Internal Medicine, Hippokration General Hospital, Athens 11527, Attiki, Greece
| |
Collapse
|
7
|
Saxena P, Muthu J. COVID-19 and Sickle Cell Disease: Two Independent Risk Factors for Venous Thromboembolism. Cureus 2023; 15:e37226. [PMID: 37159776 PMCID: PMC10163976 DOI: 10.7759/cureus.37226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2023] [Indexed: 04/08/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been widely documented as a multi-systemic illness and associated with an increased incidence of thromboses. Likewise, sickle cell disease (SCD) is a hematologic disease responsible for widespread effects on the vasculature and is also associated with elevated thrombotic risk. In this review, we examine the incidence rates of venous thromboembolism (VTE) in SCD and COVID-19 independently and review the mechanisms of coagulopathy associated with both diseases. We describe the possible associations and commonalities between VTE mechanisms, as both diseases cause widespread inflammation that influences each tenet of Virchow's triad. We also discuss current anticoagulation guideline recommendations for the prevention of VTE events in each of these diseases. We report on current literature to date describing rates of VTE in SCD-COVID-19 patients and outline prospective areas of research to further understand the possible synergistic influence of coagulopathy in these patients. The association between SCD and COVID-19 remains a largely under-researched area of coagulopathy in current hematology and thrombotic literature, and our report lays out potential future prospects in the field.
Collapse
|
8
|
Bugatti A, Filippini F, Messali S, Giovanetti M, Ravelli C, Zani A, Ciccozzi M, Caruso A, Caccuri F. The D405N Mutation in the Spike Protein of SARS-CoV-2 Omicron BA.5 Inhibits Spike/Integrins Interaction and Viral Infection of Human Lung Microvascular Endothelial Cells. Viruses 2023; 15:v15020332. [PMID: 36851546 PMCID: PMC9962894 DOI: 10.3390/v15020332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/19/2023] [Accepted: 01/22/2023] [Indexed: 01/26/2023] Open
Abstract
Severe COVID-19 is characterized by angiogenic features, such as intussusceptive angiogenesis, endothelialitis, and activation of procoagulant pathways. This pathological state can be ascribed to a direct SARS-CoV-2 infection of human lung ECs. Recently, we showed the capability of SARS-CoV-2 to infect ACE2-negative primary human lung microvascular endothelial cells (HL-mECs). This occurred through the interaction of an Arg-Gly-Asp (RGD) motif, endowed on the Spike protein at position 403-405, with αvβ3 integrin expressed on HL-mECs. HL-mEC infection promoted the remodeling of cells toward a pro-inflammatory and pro-angiogenic phenotype. The RGD motif is distinctive of SARS-CoV-2 Spike proteins up to the Omicron BA.1 subvariant. Suddenly, a dominant D405N mutation was expressed on the Spike of the most recently emerged Omicron BA.2, BA.4, and BA.5 subvariants. Here we demonstrate that the D405N mutation inhibits Omicron BA.5 infection of HL-mECs and their dysfunction because of the lack of Spike/integrins interaction. The key role of ECs in SARS-CoV-2 pathogenesis has been definitively proven. Evidence of mutations retrieving the capability of SARS-CoV-2 to infect HL-mECs highlights a new scenario for patients infected with the newly emerged SARS-CoV-2 Omicron subvariants, suggesting that they may display less severe disease manifestations than those observed with previous variants.
Collapse
Affiliation(s)
- Antonella Bugatti
- Section of Microbiology, Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy
| | - Federica Filippini
- Section of Microbiology, Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy
| | - Serena Messali
- Section of Microbiology, Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy
| | - Marta Giovanetti
- Laboratório de Flavivirus, Instituto Oswaldo Cruz, Rio de Janeiro 21040-900, Brazil
- Department of Science and Technology for Humans and the Environment, University Campus Bio-Medico of Rome, 00128 Rome, Italy
| | - Cosetta Ravelli
- Section of General Pathology, Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy
| | - Alberto Zani
- Section of Microbiology, Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy
| | - Massimo Ciccozzi
- Unit of Medical Statistics and Molecular Epidemiology, University Campus Bio-Medico of Rome, 00128 Rome, Italy
| | - Arnaldo Caruso
- Section of Microbiology, Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy
- Institute of Human Virology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Francesca Caccuri
- Section of Microbiology, Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy
- Correspondence: ; Tel.: +39-030-3995650
| |
Collapse
|
9
|
Huang JJ, Wang CW, Liu Y, Zhang YY, Yang NB, Yu YC, Jiang Q, Song QF, Qian GQ. Role of the extracellular matrix in COVID-19. World J Clin Cases 2023; 11:73-83. [PMID: 36687194 PMCID: PMC9846981 DOI: 10.12998/wjcc.v11.i1.73] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 12/14/2022] [Accepted: 12/23/2022] [Indexed: 01/04/2023] Open
Abstract
An outbreak of coronavirus disease 2019 (COVID-19) has spread globally, with over 500 million cases and 6 million deaths to date. COVID-19 is associated with a systemic inflammatory response and abnormalities of the extracellular matrix (ECM), which is also involved in inflammatory storms. Upon viral infection, ECM proteins are involved in the recruitment of inflammatory cells and interference with target organ metabolism, including in the lungs. Additionally, serum biomarkers of ECM turnover are associated with the severity of COVID-19 and may serve as potential targets. Consequently, understanding the expression and function of ECM, particularly of the lung, during severe acute respiratory syndrome of the coronavirus 2 infection would provide valuable insights into the mechanisms of COVID-19 progression. In this review, we summarize the current findings on ECM, such as hyaluronic acid, matrix metalloproteinases, and collagen, which are linked to the severity and inflammation of COVID-19. Some drugs targeting the extracellular surface have been effective. In the future, these ECM findings could provide novel perspectives on the pathogenesis and treatment of COVID-19.
Collapse
Affiliation(s)
- Jia-Jia Huang
- School of Medicine, Ningbo University, Ningbo 315000, Zhejiang Province, China
| | - Chu-Wen Wang
- School of Medicine, Ningbo University, Ningbo 315000, Zhejiang Province, China
| | - Ying Liu
- School of Medicine, Ningbo University, Ningbo 315000, Zhejiang Province, China
| | - Ying-Ying Zhang
- School of Medicine, Ningbo University, Ningbo 315000, Zhejiang Province, China
| | - Nai-Bin Yang
- Department of Infectious Diseases, Ningbo First Hospital, Ningbo 315000, Zhejiang Province, China
| | - Yu-Chun Yu
- Department of Endocrinology, Ningbo Ninth Hospital, Ningbo 315000, Zhejiang Province, China
| | - Qi Jiang
- Department of Digestive, Ningbo First Hospital, Ningbo 315000, Zhejiang Province, China
| | - Qi-Fa Song
- Medical Data Center, Ningbo First Hospital, Ningbo 315000, Zhejiang Province, China
| | - Guo-Qing Qian
- Department of Infectious Diseases, Ningbo First Hospital, Ningbo 315000, Zhejiang Province, China
| |
Collapse
|
10
|
Mild-to-Moderate COVID-19 Convalescents May Present Pro-Longed Endothelium Injury. J Clin Med 2022; 11:jcm11216461. [PMID: 36362687 PMCID: PMC9658558 DOI: 10.3390/jcm11216461] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/28/2022] [Accepted: 10/29/2022] [Indexed: 11/06/2022] Open
Abstract
Background: The SARS-CoV-2 pandemic posed a great threat to public health, healthcare systems and the economy worldwide. It became clear that, in addition to COVID-19 and acute disease, the condition that develops after recovery may also negatively impact survivors’ health and quality of life. The damage inflicted by the viral infection on endothelial cells was identified quite early on as a possible mechanism underlying the so-called post-COVID syndrome. It became an urgent matter to establish whether convalescents present chronic endothelial impairment, which could result in an increased risk of cardiovascular and thrombotic complications. Methods: In this study, we measured the levels of CRP, ICAM-1, VCAM-1, E-selectin and syndecan-1 as markers of inflammation and endothelial injury in generally healthy convalescents selected from blood donors and compared these to a healthy control group. Results: We found higher concentrations of E-selectin and a lower level of syndecan-1 in convalescents in comparison to those of the control group. Conclusion: Based on our results, it can be concluded that, at least 6 months after infection, there is only slight evidence of endothelial dysfunction in COVID-19 convalescents who do not suffer from other comorbidities related to endothelial impairment.
Collapse
|
11
|
Krysko O, Bourne JH, Kondakova E, Galova EA, Whitworth K, Newby ML, Bachert C, Hill H, Crispin M, Stamataki Z, Cunningham AF, Pugh M, Khan AO, Rayes J, Vedunova M, Krysko DV, Brill A. Severity of SARS-CoV-2 infection is associated with high numbers of alveolar mast cells and their degranulation. Front Immunol 2022; 13:968981. [PMID: 36225927 PMCID: PMC9548604 DOI: 10.3389/fimmu.2022.968981] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/05/2022] [Indexed: 11/25/2022] Open
Abstract
Background The systemic inflammatory response post-SARS-CoV-2 infection increases pro-inflammatory cytokine production, multi-organ damage, and mortality rates. Mast cells (MC) modulate thrombo-inflammatory disease progression (e.g., deep vein thrombosis) and the inflammatory response post-infection. Objective To enhance our understanding of the contribution of MC and their proteases in SARS-CoV-2 infection and the pathogenesis of the disease, which might help to identify novel therapeutic targets. Methods MC proteases chymase (CMA1), carboxypeptidase A3 (CPA3), and tryptase beta 2 (TPSB2), as well as cytokine levels, were measured in the serum of 60 patients with SARS-CoV-2 infection (30 moderate and 30 severe; severity of the disease assessed by chest CT) and 17 healthy controls by ELISA. MC number and degranulation were quantified by immunofluorescent staining for tryptase in lung autopsies of patients deceased from either SARS-CoV-2 infection or unrelated reasons (control). Immortalized human FcεR1+c-Kit+ LUVA MC were infected with SARS-CoV-2, or treated with its viral proteins, to assess direct MC activation by flow cytometry. Results The levels of all three proteases were increased in the serum of patients with COVID-19, and strongly correlated with clinical severity. The density of degranulated MC in COVID-19 lung autopsies was increased compared to control lungs. The total number of released granules and the number of granules per each MC were elevated and positively correlated with von Willebrand factor levels in the lung. SARS-CoV-2 or its viral proteins spike and nucleocapsid did not induce activation or degranulation of LUVA MC in vitro. Conclusion In this study, we demonstrate that SARS-CoV-2 is strongly associated with activation of MC, which likely occurs indirectly, driven by the inflammatory response. The results suggest that plasma MC protease levels could predict the disease course, and that severe COVID-19 patients might benefit from including MC-stabilizing drugs in the treatment scheme.
Collapse
Affiliation(s)
- Olga Krysko
- Upper Airways Research Laboratory, Department of Head and Skin, Ghent University, Ghent, Belgium
| | - Joshua H. Bourne
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Elena Kondakova
- Institute of Biology and Biomedicine, Department of Basic and Medical Genetics, National Research Lobachevsky State University of Nizhniy Novgorod, Nizhniy Novgorod, Russia
| | - Elena A. Galova
- University Clinic of Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - Katharine Whitworth
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Maddy L. Newby
- School of Biological Sciences, University of Southampton, Southampton, United Kingdom
| | - Claus Bachert
- Upper Airways Research Laboratory, Department of Head and Skin, Ghent University, Ghent, Belgium
| | - Harriet Hill
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Max Crispin
- School of Biological Sciences, University of Southampton, Southampton, United Kingdom
| | - Zania Stamataki
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Adam F. Cunningham
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Matthew Pugh
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Abdullah O. Khan
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Julie Rayes
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Maria Vedunova
- Institute of Biology and Biomedicine, Department of Basic and Medical Genetics, National Research Lobachevsky State University of Nizhniy Novgorod, Nizhniy Novgorod, Russia
| | - Dmitri V. Krysko
- Institute of Biology and Biomedicine, Department of Basic and Medical Genetics, National Research Lobachevsky State University of Nizhniy Novgorod, Nizhniy Novgorod, Russia
- Department of Pathophysiology, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- Cell Death Investigation and Therapy Laboratory, Department of Human Structure and Repair, Ghent University and Cancer Research Institute Ghent (CRIG), Ghent, Belgium
| | - Alexander Brill
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| |
Collapse
|
12
|
Sojka M, Drelich-Zbroja A, Kuczyńska M, Cheda M, Dąbrowska I, Kopyto E, Halczuk I, Zbroja M, Cyranka W, Jargiełło T. Ischemic and Hemorrhagic Cerebrovascular Events Related to COVID-19 Coagulopathy and Hypoxemia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11823. [PMID: 36142094 PMCID: PMC9517511 DOI: 10.3390/ijerph191811823] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/12/2022] [Accepted: 09/15/2022] [Indexed: 06/16/2023]
Abstract
Since the very beginning of the COVID-19 pandemic, numerous researchers have made an effort to determine the molecular composition of the SARS-CoV-2 virus, and the exact pathomechanism through which the virus exerts such a devastating effect on the host/infected organism. Recent scientific evidence highlights the affinity of the virus towards ACE2 receptors, which are widespread in multiple human systems, including the central nervous system (CNS) and cerebral vessels. Such an affinity may explain endothelial dysfunction and damage that is observed in COVID-positive patients in histopathological studies, with subsequent dysregulation of the cerebral circulation leading to transient or acute cerebrovascular accidents. In this paper, we aimed to evaluate the effects of COVID-related hypoxemia and direct viral invasion on the cerebral circulation, with special respect to the postulated pathomechanism, vulnerable groups of patients, clinical course and outcomes, as well as diagnostic imaging findings.
Collapse
Affiliation(s)
- Michał Sojka
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-090 Lublin, Poland
| | - Anna Drelich-Zbroja
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-090 Lublin, Poland
| | - Maryla Kuczyńska
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-090 Lublin, Poland
| | - Mateusz Cheda
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-090 Lublin, Poland
| | - Izabela Dąbrowska
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-090 Lublin, Poland
| | - Ewa Kopyto
- Students’ Scientific Society at the Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-090 Lublin, Poland
| | - Izabela Halczuk
- Students’ Scientific Society at the Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-090 Lublin, Poland
| | - Monika Zbroja
- Students’ Scientific Society at the Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-090 Lublin, Poland
| | - Weronika Cyranka
- Students’ Scientific Society at the Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-090 Lublin, Poland
| | - Tomasz Jargiełło
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-090 Lublin, Poland
| |
Collapse
|
13
|
Mortazavi-Jahromi SS, Aslani M. Dysregulated miRNAs network in the critical COVID-19: An important clue for uncontrolled immunothrombosis/thromboinflammation. Int Immunopharmacol 2022; 110:109040. [PMID: 35839566 PMCID: PMC9271492 DOI: 10.1016/j.intimp.2022.109040] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 07/02/2022] [Accepted: 07/06/2022] [Indexed: 11/17/2022]
Abstract
Known as a pivotal immunohemostatic response, immunothrombosis is activated to restrict the diffusion of pathogens. This beneficial intravascular defensive mechanism represents the close interaction between the immune and coagulation systems. However, its uncontrolled form can be life-threatening to patients with the critical coronavirus disease 2019 (COVID-19). Hyperinflammation and ensuing cytokine storm underlie the activation of the coagulation system, something which results in the provocation of more immune-inflammatory responses by the thrombotic mediators. This vicious cycle causes grave clinical complications and higher risks of mortality. Classified as an evolutionarily conserved family of the small non-coding RNAs, microRNAs (miRNAs) serve as the fine-tuners of genes expression and play a key role in balancing the pro/anticoagulant and pro-/anti-inflammatory factors maintaining homeostasis. Therefore, any deviation from their optimal expression levels or efficient functions can lead to severe complications. Despite their extensive effects on the molecules and processes involved in uncontrolled immunothrombosis, some genetic agents and uncontrolled immunothrombosis-induced interfering factors (e.g., miRNA-single nucleotide polymorphysms (miR-SNPs), the complement system components, nicotinamide adenine dinucleotide phosphate (NADPH) oxidases, and reactive oxygen species (ROS)) have apparently disrupted their expressions/functions. This review study aims to give an overview of the role of miRNAs in the context of uncontrolled immunothrombosis/thromboinflammation accompanied by some presumptive interfering factors affecting their expressions/functions in the critical COVID-19. Detecting, monitoring, and resolving these interfering agents mafy facilitate the design and development of the novel miRNAs-based therapeutic approaches to the reduction of complications incidence and mortality in patients with the critical COVID-19.
Collapse
Affiliation(s)
- Seyed Shahabeddin Mortazavi-Jahromi
- Department of Immunology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran; Department of Cellular and Molecular Biology, Kish International Campus, University of Tehran, Kish, Iran.
| | - Mona Aslani
- Department of Immunology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
| |
Collapse
|
14
|
de Seabra Rodrigues Dias IR, Cao Z, Kwok HF. Adamalysins in COVID-19 - Potential mechanisms behind exacerbating the disease. Biomed Pharmacother 2022; 150:112970. [PMID: 35658218 PMCID: PMC9010236 DOI: 10.1016/j.biopha.2022.112970] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/31/2022] [Accepted: 04/12/2022] [Indexed: 01/12/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19), caused by the SARS-CoV-2 virus, is a current pandemic that has resulted in nearly 250 million cases and over 5 million deaths. While vaccines have been developed to prevent infection, and most COVID-19 cases end up being fairly light, there are severe cases of COVID-19 that may end up in death, even with adequate healthcare treatment. New options to combat this disease's effects, therefore, could prove to be invaluable in saving lives. Adamalysins are proteins that have several roles in regulating different functions in the human body but are also known to have functions in inflammation. They are also known to have roles in several different diseases, including COVID-19, where ADAM17, in particular, is now well-known to have a prominent role, but also several diseases which include comorbidities that may worsen cases of COVID-19. Therefore, investigating the functions of adamalysins in disease may give us clues to the molecular workings of COVID-19 as well as potentially new therapeutic targets. Understanding these molecular mechanisms may also allow for an understanding of the mechanisms behind the rare severe side effects that occur in response to current COVID-19 vaccines, which may lead to better monitoring measures for people who may be more at risk of developing these side effects. This review investigates the known roles and functions of adamalysins in disease, including what is currently known of their involvement in COVID-19, and how these functions might be involved.
Collapse
Affiliation(s)
- Ivo Ricardo de Seabra Rodrigues Dias
- Department of Biomedical Sciences, Faculty of Health Sciences, University of Macau, Avenida de Universidade, Taipa, Macau SAR,Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Avenida de Universidade, Taipa, Macau SAR
| | - Zhijian Cao
- State Key Laboratory of Virology and Modern Virology Research Center, College of Life Sciences, Wuhan University, Wuhan 430072, Hubei, China,Co-corresponding author
| | - Hang Fai Kwok
- Department of Biomedical Sciences, Faculty of Health Sciences, University of Macau, Avenida de Universidade, Taipa, Macau SAR,Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Avenida de Universidade, Taipa, Macau SAR,Corresponding author at: Department of Biomedical Sciences, Faculty of Health Sciences, University of Macau, Avenida de Universidade, Taipa, Macau SAR
| |
Collapse
|
15
|
Boknäs N, Laine C, Hillarp A, Macwan AS, Gustafsson KM, Lindahl TL, Holmström M. Associations between hemostatic markers and mortality in COVID-19 – Compounding effects of D-dimer, antithrombin and PAP complex. Thromb Res 2022; 213:97-104. [PMID: 35316719 PMCID: PMC8930184 DOI: 10.1016/j.thromres.2022.03.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 03/05/2022] [Accepted: 03/14/2022] [Indexed: 02/08/2023]
Abstract
In this single-center cohort study, we applied a panel of laboratory markers to characterize hemostatic function in 217 consecutive patients that underwent testing for COVID-19 as they were admitted to Linköping University Hospital between April and June 2020. In the 96 patients that tested positive for SARS-CoV-2 (COVID-19+), the cumulative incidences of death and venous thromboembolism were 24.0% and 19.8% as compared to 12.4% (p = 0.031) and 11.6% (p = 0.13) in the 121 patients that tested negative (COVID-19−). In COVID-19+ patients, we found pronounced increases in plasma levels of von Willebrand factor (vWF) and fibrinogen. Excess mortality was observed in COVID-19+ patients with the following aberrations in hemostatic markers: high D-dimer, low antithrombin or low plasmin-antiplasmin complex (PAP) formation, with Odds Ratios (OR) for death of 4.7 (95% confidence interval (CI95) 1.7–12.9; p = 0.003) for D-dimer >0.5 mg/L, 5.9 (CI95 1.8–19.7; p = 0.004) for antithrombin (AT) ˂0.85 kIU/l and 4.9 (CI95 1.3–18.3; p = 0.019) for PAP < 1000 μg/L. Compounding increases in mortality was observed in COVID-19+ patients with combined defects in markers of fibrinolysis and coagulation, with ORs for death of 15.7 (CI95 4.3–57; p < 0.001) for patients with PAP <1000 μg/L and D-dimer >0.5 mg/L and 15.5 (CI95 2.8–87, p = 0.002) for patients with PAP <1000 μg/L and AT ˂0.85 kIU/L. We observed an elevated fraction of incompletely degraded D-dimer fragments in COVID-19+ patients with low PAP, indicating impaired fibrinolytic breakdown of cross-linked fibrin.
Collapse
|
16
|
De Michele M, Kahan J, Berto I, Schiavo OG, Iacobucci M, Toni D, Merkler AE. Cerebrovascular Complications of COVID-19 and COVID-19 Vaccination. Circ Res 2022; 130:1187-1203. [PMID: 35420916 PMCID: PMC9005103 DOI: 10.1161/circresaha.122.319954] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The risk of stroke and cerebrovascular disease complicating infection with SARS-CoV-2 has been extensively reported since the onset of the pandemic. The striking efforts of many scientists in cooperation with regulators and governments worldwide have rapidly brought the development of a large landscape of vaccines against SARS-CoV-2. The novel DNA and mRNA vaccines have offered great flexibility in terms of antigen production and led to an unprecedented rapidity in effective and safe vaccine production. However, as mass vaccination has progressed, rare but catastrophic cases of thrombosis have occurred in association with thrombocytopenia and antibodies against PF4 (platelet factor 4). This catastrophic syndrome has been named vaccine-induced immune thrombotic thrombocytopenia. Rarely, ischemic stroke can be the symptom onset of vaccine-induced immune thrombotic thrombocytopenia or can complicate the course of the disease. In this review, we provide an overview of stroke and cerebrovascular disease as a complication of the SARS-CoV-2 infection and outline the main clinical and radiological characteristics of cerebrovascular complications of vaccinations, with a focus on vaccine-induced immune thrombotic thrombocytopenia. Based on the available data from the literature and from our experience, we propose a therapeutic protocol to manage this challenging condition. Finally, we highlight the overlapping pathophysiologic mechanisms of SARS-CoV-2 infection and vaccination leading to thrombosis.
Collapse
Affiliation(s)
- Manuela De Michele
- Stroke Unit, Emergency Department (M.D.M., I.B., O.G.S., D.T.), Sapienza University of Rome, Italy
| | - Joshua Kahan
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY (J.K., A.E.M.)
| | - Irene Berto
- Stroke Unit, Emergency Department (M.D.M., I.B., O.G.S., D.T.), Sapienza University of Rome, Italy
| | - Oscar G. Schiavo
- Stroke Unit, Emergency Department (M.D.M., I.B., O.G.S., D.T.), Sapienza University of Rome, Italy
| | - Marta Iacobucci
- Neuroradiology Unit, Department of Human Neurosciences (M.I.), Sapienza University of Rome, Italy
| | - Danilo Toni
- Stroke Unit, Emergency Department (M.D.M., I.B., O.G.S., D.T.), Sapienza University of Rome, Italy
| | - Alexander E. Merkler
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY (J.K., A.E.M.)
| |
Collapse
|
17
|
D’Ardes D, Boccatonda A, Cocco G, Fabiani S, Rossi I, Bucci M, Guagnano MT, Schiavone C, Cipollone F. Impaired coagulation, liver dysfunction and COVID-19: Discovering an intriguing relationship. World J Gastroenterol 2022; 28:1102-1112. [PMID: 35431501 PMCID: PMC8985482 DOI: 10.3748/wjg.v28.i11.1102] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 08/09/2021] [Accepted: 02/15/2022] [Indexed: 02/06/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is, at present, one of the most relevant global health problems. In the literature hepatic alterations have been described in COVID-19 patients, and they are mainly represented by worsening of underlying chronic liver disease leading to hepatic decompensation and liver failure with higher mortality. Several potential mechanisms used by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to cause liver damage have been hypothesized. COVID-19 primary liver injury is less common than secondary liver injury. Most of the available data demonstrate how liver damage in SARS-CoV-2 infection is likely due to systemic inflammation, and it is less likely mediated by a cytopathic effect directed on liver cells. Moreover, liver alterations could be caused by hypoxic injury and drugs (antibiotics and non-steroidal anti-inflammatory drugs, remdesivir, tocilizumab, tofacitinib and dexamethasone). SARS-CoV-2 infection can induce multiple vascular district atherothrombosis by affecting simultaneously cerebral, coronary and peripheral vascular beds. Data in the literature highlight how the virus triggers an exaggerated immune response, which added to the cytopathic effect of the virus can induce endothelial damage and a prothrombotic dysregulation of hemostasis. This leads to a higher incidence of symptomatic and confirmed venous thrombosis and of pulmonary embolisms, especially in central, lobar or segmental pulmonary arteries, in COVID-19. There are currently fewer data for arterial thrombosis, while myocardial injury was identified in 7%-17% of patients hospitalized with SARS-CoV-2 infection and 22%-31% in the intensive care unit setting. Available data also revealed a higher occurrence of stroke and more serious forms of peripheral arterial disease in COVID-19 patients. Hemostasis dysregulation is observed during the COVID-19 course. Lower platelet count, mildly increased prothrombin time and increased D-dimer are typical laboratory features of patients with severe SARS-CoV-2 infection, described as "COVID-19 associated coagulopathy." These alterations are correlated to poor outcomes. Moreover, patients with severe SARS-CoV-2 infection are characterized by high levels of von Willebrand factor with subsequent ADAMTS13 deficiency and impaired fibrinolysis. Platelet hyperreactivity, hypercoagulability and hypofibrinolysis during SARS-CoV-2 infection induce a pathological state named as "immuno-thromboinflammation." Finally, liver dysfunction and coagulopathy are often observed at the same time in patients with COVID-19. The hypothesis that liver dysfunction could be mediated by microvascular thrombosis has been supported by post-mortem findings and extensive vascular portal and sinusoidal thrombosis observation. Other evidence has shown a correlation between coagulation and liver damage in COVID-19, underlined by the transaminase association with coagulopathy, identified through laboratory markers such as prothrombin time, international normalized ratio, fibrinogen, D-dimer, fibrin/fibrinogen degradation products and platelet count. Other possible mechanisms like immunogenesis of COVID-19 damage or massive pericyte activation with consequent vessel wall fibrosis have been suggested.
Collapse
Affiliation(s)
- Damiano D’Ardes
- “Clinica Medica” Institute, Department of Medicine and Aging Sciences, “G. D’Annunzio” University of Chieti-Pescara, Chieti 66100, Italy
| | - Andrea Boccatonda
- Unit of Ultrasound, “G. D’Annunzio” University of Chieti-Pescara, Chieti 66100, Italy
| | - Giulio Cocco
- Unit of Ultrasound, “G. D’Annunzio” University of Chieti-Pescara, Chieti 66100, Italy
| | - Stefano Fabiani
- Unit of Ultrasound, “G. D’Annunzio” University of Chieti-Pescara, Chieti 66100, Italy
| | - Ilaria Rossi
- “Clinica Medica” Institute, Department of Medicine and Aging Sciences, “G. D’Annunzio” University of Chieti-Pescara, Chieti 66100, Italy
| | - Marco Bucci
- “Clinica Medica” Institute, Department of Medicine and Aging Sciences, “G. D’Annunzio” University of Chieti-Pescara, Chieti 66100, Italy
| | - Maria Teresa Guagnano
- “Clinica Medica” Institute, Department of Medicine and Aging Sciences, “G. D’Annunzio” University of Chieti-Pescara, Chieti 66100, Italy
| | - Cosima Schiavone
- Unit of Ultrasound, “G. D’Annunzio” University of Chieti-Pescara, Chieti 66100, Italy
| | - Francesco Cipollone
- “Clinica Medica” Institute, Department of Medicine and Aging Sciences, “G. D’Annunzio” University of Chieti-Pescara, Chieti 66100, Italy
| |
Collapse
|
18
|
Sinkovits G, Réti M, Müller V, Iványi Z, Gál J, Gopcsa L, Reményi P, Szathmáry B, Lakatos B, Szlávik J, Bobek I, Prohászka ZZ, Förhécz Z, Mező B, Csuka D, Hurler L, Kajdácsi E, Cervenak L, Kiszel P, Masszi T, Vályi-Nagy I, Prohászka Z. Associations between the von Willebrand Factor-ADAMTS13 Axis, Complement Activation, and COVID-19 Severity and Mortality. Thromb Haemost 2022; 122:240-256. [PMID: 35062036 PMCID: PMC8820843 DOI: 10.1055/s-0041-1740182] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background
Endothelial and complement activation were both associated with immunothrombosis, a key determinant of COVID-19 severity, but their interrelation has not yet been investigated.
Objectives
We aimed to determine von Willebrand factor (VWF) antigen (VWF:Ag) concentration, VWF collagen binding activity (VWF:CBA), a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) activity (ADAMTS13:Ac), and their ratios in hospitalized COVID-19 patients, and to investigate how these parameters and their constellation with complement activation relate to disease severity and in-hospital mortality in COVID-19.
Methods
Samples of 102 hospitalized patients with polymerase chain reaction-confirmed severe acute respiratory syndrome coronavirus 2 positivity were included in our observational cohort study. Patients were stratified according to the peak severity of COVID-19 disease in agreement with the World Health Organization ordinal scale. Twenty-six convalescent plasma donors with previous COVID-19 disease formed the control group. VWF:Ag concentration and VWF:CBA were determined by enzyme-linked immunosorbent assay (ELISA); ADAMTS13:Ac was determined by fluorescence resonance energy transfer. Complement C3 and C3a were measured by turbidimetry and ELISA, respectively. Clinical covariates and markers of inflammation were extracted from hospital records.
Results
VWF:Ag and VWF:CBA were elevated in all groups of hospitalized COVID-19 patients and increased in parallel with disease severity. ADAMTS13:Ac was decreased in patients with severe COVID-19, with the lowest values in nonsurvivors. High (> 300%) VWF:Ag concentrations or decreased (< 67%) ADAMTS13:Ac were associated with higher risk of severe COVID-19 disease or in-hospital mortality. The concomitant presence of decreased ADAMTS13:Ac and increased C3a/C3 ratio—indicating complement overactivation and consumption—was a strong independent predictor of in-hospital mortality.
Conclusion
Our results suggest that an interaction between the VWF-ADAMTS13 axis and complement overactivation and consumption plays an important role in the pathogenesis of COVID-19.
Collapse
Affiliation(s)
- György Sinkovits
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Marienn Réti
- Department of Haematology and Stem Cell Transplantation, Central Hospital of Southern Pest, Institute of Haematology and Infectious Diseases, Budapest, Hungary
| | - Veronika Müller
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Zsolt Iványi
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - János Gál
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - László Gopcsa
- Department of Haematology and Stem Cell Transplantation, Central Hospital of Southern Pest, Institute of Haematology and Infectious Diseases, Budapest, Hungary
| | - Péter Reményi
- Department of Haematology and Stem Cell Transplantation, Central Hospital of Southern Pest, Institute of Haematology and Infectious Diseases, Budapest, Hungary
| | - Beáta Szathmáry
- Department of Infectology, Central Hospital of Southern Pest, Institute of Haematology and Infectious Diseases, Budapest, Hungary
| | - Botond Lakatos
- Department of Infectology, Central Hospital of Southern Pest, Institute of Haematology and Infectious Diseases, Budapest, Hungary
| | - János Szlávik
- Department of Infectology, Central Hospital of Southern Pest, Institute of Haematology and Infectious Diseases, Budapest, Hungary
| | - Ilona Bobek
- Department of Anaesthesiology and Intensive Therapy, Central Hospital of Southern Pest, Institute of Haematology and Infectious Diseases, Budapest, Hungary
| | - Zita Z Prohászka
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Zsolt Förhécz
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Blanka Mező
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary.,Research Group for Immunology and Haematology, Semmelweis University - Eötvös Loránd Research Network (Office for Supported Research Groups), Budapest, Hungary
| | - Dorottya Csuka
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Lisa Hurler
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Erika Kajdácsi
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - László Cervenak
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Petra Kiszel
- Research Group for Immunology and Haematology, Semmelweis University - Eötvös Loránd Research Network (Office for Supported Research Groups), Budapest, Hungary
| | - Tamás Masszi
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - István Vályi-Nagy
- Department of Haematology and Stem Cell Transplantation, Central Hospital of Southern Pest, Institute of Haematology and Infectious Diseases, Budapest, Hungary
| | - Zoltán Prohászka
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary.,Research Group for Immunology and Haematology, Semmelweis University - Eötvös Loránd Research Network (Office for Supported Research Groups), Budapest, Hungary
| |
Collapse
|
19
|
Hadique S, Badami V, Sangani R, Forte M, Alexander T, Goswami A, Garrison A, Wen S. Coagulation Studies Are Not Predictive of Hematological Complications of COVID-19 Infection. TH OPEN 2022; 6:e1-e9. [PMID: 35059556 PMCID: PMC8763459 DOI: 10.1055/s-0041-1742225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/19/2021] [Indexed: 01/08/2023] Open
Abstract
Objectives Thrombotic and bleeding complications are common in COVID-19 disease. In a prospective study, we performed a comprehensive panel of tests to predict the risk of bleeding and thrombosis in patients admitted with hypoxic respiratory failure due to severe COVID-19 infection. Methods We performed a single center (step down and intensive care unit [ICU] at a quaternary care academic hospital) prospective study. Sequentially enrolled adult (≥18 years) patients were admitted with acute hypoxic respiratory failure due to COVID-19 between June 2020 and November 2020. Several laboratory markers of coagulopathy were tested after informed and written consent. Results Thirty-three patients were enrolled. In addition to platelet counts, prothrombin time, and activated partial thromboplastin time, a series of protocol laboratories were collected within 24 hours of admission. These included Protein C, Protein S, Antithrombin III, ADAMTS13, fibrinogen, ferritin, haptoglobin, and peripheral Giemsa smear. Patients were then monitored for the development of hematological (thrombotic and bleeding) events and followed for 30 days after discharge. Twenty-four patients (73%) required ICU admissions. At least one laboratory abnormality was detected in 100% of study patients. Nine patients (27%) suffered from significant hematological events, and four patients had a clinically significant bleeding event requiring transfusion. No significant association was observed between abnormalities of coagulation parameters and the incidence of hematologic events. However, a higher SOFA score (10.89 ± 3.48 vs. 6.92 ± 4.10, p = 0.016) and CKD (5/9 [22.2%] vs. 2/24 [12.5%] p = 0.009) at baseline were associated with the development of hematologic events. 33.3% of patients died at 30 days. Mortality was similar in those with and without hematological events. Reduced ADAMTS13 level was significantly associated with mortality. Conclusion Routine extensive testing of coagulation parameters did not predict the risk of bleeding and thrombosis in COVID-19 patients. Thrombotic and bleeding events in COVID-19 patients are not associated with a higher risk of mortality. Interestingly, renal dysfunction and a high SOFA score were found to be associated with increased risk of hematological events.
Collapse
Affiliation(s)
- Sarah Hadique
- Department of Internal Medicine, Section of Pulmonary, Critical Care & Sleep Medicine, West Virginia University, Morgantown, West Virginia, United States
| | - Varun Badami
- Department of Internal Medicine, Section of Pulmonary, Critical Care & Sleep Medicine, West Virginia University, Morgantown, West Virginia, United States
| | - Rahul Sangani
- Department of Internal Medicine, Section of Pulmonary, Critical Care & Sleep Medicine, West Virginia University, Morgantown, West Virginia, United States
| | - Michael Forte
- Department of Internal Medicine, Section of Pulmonary, Critical Care & Sleep Medicine, West Virginia University, Morgantown, West Virginia, United States
| | - Talia Alexander
- Department of Epidemiology and Biostatistics, West Virginia University, Morgantown, West Virginia, United States
| | - Aarti Goswami
- Department of Pathology, Anatomy and Laboratory Medicine, West Virginia University, Morgantown, West Virginia, United States
| | - Adriana Garrison
- Department of Pathology, Anatomy and Laboratory Medicine, West Virginia University, Morgantown, West Virginia, United States
| | - Sijin Wen
- Department of Epidemiology and Biostatistics, West Virginia University, Morgantown, West Virginia, United States
| |
Collapse
|
20
|
Seth R, McKinnon TAJ, Zhang XF. Contribution of the von Willebrand factor/ADAMTS13 imbalance to COVID-19 coagulopathy. Am J Physiol Heart Circ Physiol 2022; 322:H87-H93. [PMID: 34890277 PMCID: PMC8714251 DOI: 10.1152/ajpheart.00204.2021] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The 2019 coronavirus disease (COVID-19) is the disease caused by SARS-CoV-2 infection. Although this infection has been shown to affect the respiratory system, a high incidence of thrombotic events has been observed in severe cases of COVID-19 and in a significant portion of COVID-19 nonsurvivors. Although prior literature has reported on both the coagulopathy and hypercoagulability of COVID-19, the specifics of coagulation have not been fully investigated. Observations of microthrombosis in patients with COVID-19 have brought attention to potential inflammatory endothelial injury. Von Willebrand factor (VWF) and its protease, A disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13), play an important homeostatic role in responding to endothelial injury. This report provides an overview of the literature investigating the role the VWF/ADAMTS13 axis may have in COVID-19 thrombotic events and suggests potential therapeutic strategies to prevent the progression of coagulopathy in patients with COVID-19.
Collapse
Affiliation(s)
- Ryan Seth
- Department of Bioengineering, Lehigh University, Bethlehem, Pennsylvania
| | - Thomas A J McKinnon
- Department of Immunology and Inflammation, Centre for Haematology, Imperial College London, London, United Kingdom
| | - X Frank Zhang
- Department of Bioengineering, Lehigh University, Bethlehem, Pennsylvania
| |
Collapse
|
21
|
Rostami M, Mansouritorghabeh H, Parsa-Kondelaji M. High levels of Von Willebrand factor markers in COVID-19: a systematic review and meta-analysis. Clin Exp Med 2021; 22:347-357. [PMID: 34741678 PMCID: PMC8571968 DOI: 10.1007/s10238-021-00769-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/19/2021] [Indexed: 12/23/2022]
Abstract
The SARS-CoV-2 virus has spread to all corners of the world. Thrombosis is the cause of organ failure and subsequent death in COVID-19. The pathophysiology of thrombosis in COVID-19 needs to be further explored to shed light on its downside. For this reason, this meta-analysis of Von Willebrand Factor profile (VWF: Ag, VWF: activity, VWF: RCo), ADAMTS-13, and factor VIII levels in COVID-19 was performed. To obtain data on the status of the aforementioned hemostatic factors, a systematic literature review and meta-analysis were performed on COVID-19. After reviewing the evaluation of 348 papers, 28 papers included in the meta-analysis, which was performed using STATA. The analysis showed an increase in VWF: Ag levels in COVID‐19 patients. VWF: Ac was higher in all COVID-19 patients, while it was lower in the COVID‐19 ICU patients. The pooled mean of VWF: RCO in all patients with COVID-19 was 307.94%. In subgroup analysis, VWF: RCO was significantly higher in ICU patients than in all COVID-19 patients. The pooled mean of ADAMTS-13 activity was 62.47%, and 58.42% in ICU patients. The pooled mean of factor VIII level was 275.8%, which was significantly higher in ICU patients with COVID-19 than all patients with COVID-19. Levels of VWF: Ag, VWF: activity, VWF: ristocetin, and factor VIII are increased in patients with COVID-19. The elevated levels in ICU patients with COVID-19 suggest that these markers may have prognostic value in determining the severity of COVID-19. New therapeutic programs can be developed as a result.
Collapse
Affiliation(s)
- Mehrdad Rostami
- Hematology and Blood Banking, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hassan Mansouritorghabeh
- Hematology and Blood Banking, Mashhad University of Medical Sciences, Mashhad, Iran. .,Central Diagnostic Laboratories, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran.
| | | |
Collapse
|
22
|
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
|
23
|
Swan D, Carrier M, Lisman T, Thachil J. Heparin - Messias or Verschlimmbesserung? J Thromb Haemost 2021; 19:2373-2382. [PMID: 34272818 PMCID: PMC9906358 DOI: 10.1111/jth.15464] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/02/2021] [Accepted: 07/14/2021] [Indexed: 12/11/2022]
Abstract
A heightened risk of thrombosis noted early on with the severe acute respiratory syndrome coronavirus 2 infection led to the widespread use of heparin anticoagulation in the coronavirus disease 2019 (COVID-19) pandemic. However, reports soon started appearing in the literature where an apparent failure of heparin to prevent thrombotic events was observed in hospitalized patients with this viral infection. In this review, we explore the likely mechanisms for heparin failure with particular relevance to COVID-19. We also explore the role of anti-Xa assays and global hemostatic tests in this context. The current controversy of dosing heparin in this disease is detailed with some possible mechanistic reasons for anticoagulant failure. We hope that lessons learnt from the use of heparin in COVID-19 could assist us in the appropriate use of this anticoagulant in the future.
Collapse
Affiliation(s)
- Dawn Swan
- Department of Haematology, St James' Hospital, Dublin, Ireland
| | - Marc Carrier
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jecko Thachil
- Department of Haematology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| |
Collapse
|
24
|
Alavi P, Rathod AM, Jahroudi N. Age-Associated Increase in Thrombogenicity and Its Correlation with von Willebrand Factor. J Clin Med 2021; 10:4190. [PMID: 34575297 PMCID: PMC8472522 DOI: 10.3390/jcm10184190] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/08/2021] [Accepted: 09/10/2021] [Indexed: 02/07/2023] Open
Abstract
Endothelial cells that cover the lumen of all blood vessels have the inherent capacity to express both pro and anticoagulant molecules. However, under normal physiological condition, they generally function to maintain a non-thrombogenic surface for unobstructed blood flow. In response to injury, certain stimuli, or as a result of dysfunction, endothelial cells release a highly adhesive procoagulant protein, von Willebrand factor (VWF), which plays a central role in formation of platelet aggregates and thrombus generation. Since VWF expression is highly restricted to endothelial cells, regulation of its levels is among the most important functions of endothelial cells for maintaining hemostasis. However, with aging, there is a significant increase in VWF levels, which is concomitant with a significant rise in thrombotic events. It is not yet clear why and how aging results in increased VWF levels. In this review, we have aimed to discuss the age-related increase in VWF, its potential mechanisms, and associated coagulopathies as probable consequences.
Collapse
Affiliation(s)
| | | | - Nadia Jahroudi
- Department of Medicine, University of Alberta, Edmonton, AB T6G 2S2, Canada; (P.A.); (A.M.R.)
| |
Collapse
|
25
|
Makatsariya AD, Slukhanchuk EV, Bitsadze VO, Khizroeva JK, Tretyakova MV, Shkoda AS, Elalamy I, Di Renzo GC, Rizzo G, Pyatigorskaya NV, Solopova AG, Grigoreva KN, Nakaidze IA, Mitryuk DV. The Effect of Various Types of Anticoagulant Therapy on the Reduction of Mortality in COVID-19. ANNALS OF THE RUSSIAN ACADEMY OF MEDICAL SCIENCES 2021. [DOI: 10.15690/vramn1551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Coronavirus disease 2019 (COVID-19) is a viral infection that, in severe course, leads to the development of a cytokine storm, systemic inflammatory response and coagulopathy. Unlike other sepsis-associated disseminated intravascular coagulopathy, COVID-19 induced coagulopathy is realized mainly in thrombosis. Researchers around the world are currently developing adequate diagnostic, monitoring and anticoagulant therapy approaches to safely and effectively manage patients with severe COVID-19. The need to develop laboratory monitoring is due to the fact that 20% of patients have changes in hemostasis indicators, while in patients with a severe form of the disease, they are present in 100% of cases. In case of deaths from COVID-19, there is an increase in the concentration of D-dimer and fibrinogen degradation products. Thus, the severity of hemostasis disorders has an important prognostic value. Anticoagulant therapy is included in the list of all recommendations as an effective means of reducing mortality from COVID-19. The questions of the recommended groups and doses of anticoagulant drugs are still open. The approach to the choice of an anticoagulant should be based not only on risk factors, characteristics of the course of the disease, anamnesis, but also on the wishes of the patient during long-term therapy at the post-hospital stage.
Collapse
|
26
|
Mobayen G, Dhutia A, Clarke C, Prendecki M, McAdoo S, Keniyopoullos R, Malik T, Laffan M, Willicombe M, McKinnon T. Severe COVID-19 is associated with endothelial activation and abnormal glycosylation of von Willebrand factor in patients undergoing hemodialysis. Res Pract Thromb Haemost 2021; 5:e12582. [PMID: 34532629 PMCID: PMC8435526 DOI: 10.1002/rth2.12582] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 07/19/2021] [Accepted: 07/27/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND A major clinical feature of severe coronavirus diease 2019 (COVID-19) is microvascular thrombosis linked to endothelial cell activation. Consistent with this, a number of studies have shown that patients with severe COVID-19 have highly elevated plasma levels of von Willebrand Factor (VWF) that may contribute to the prothrombotic phenotype. In the current study, we investigated the extent of endothelial activation in patients receiving hemodialysis who had either mild or severe COVID-19. METHODS Plasma VWF, ADAMTS-13, angiopoietin-2 (Ang2), and syndecan-1 levels were determined by ELISA. The sialic acid content of VWF was investigated using a modified ELISA to measure elderberry bark lectin, specific for sialic acid residues, binding to VWF. RESULTS Patients receiving hemodialysis with severe COVID-19 had significantly higher plasma levels of VWF and lower ADAMTS-13. VWF levels peaked and were sustained during the first 10 days after positive confirmation of infection. While Ang2 trended toward being higher in severely ill patients, this did not reach significance; however, severely ill patients had significantly higher soluble syndecan-1 levels, with high levels related to risk of death. Finally, higher VWF levels in severely ill patients were correlated with lower VWF sialic acid content. CONCLUSIONS Severe COVID-19 in patients undergoing hemodialysis is associated with both acute and sustained activation of the endothelium, leading to alteration of the VWF/ADAMTS-13 axis. Lower VWF sialic acid content represents altered VWF processing and further confirms the disturbance caused to the endothelium in COVID-19.
Collapse
Affiliation(s)
- Golzar Mobayen
- Department of Immunology and InflammationCentre for HaematologyCommonwealth BuildingHammersmith CampusImperial College of Science Technology and MedicineLondonUK
| | - Amrita Dhutia
- Department of Immunology and InflammationCentre for Inflammatory DiseaseCommonwealth BuildingHammersmith CampusImperial College of Science Technology and MedicineLondonUK
| | - Candice Clarke
- Department of Immunology and InflammationCentre for Inflammatory DiseaseCommonwealth BuildingHammersmith CampusImperial College of Science Technology and MedicineLondonUK
| | - Maria Prendecki
- Department of Immunology and InflammationCentre for Inflammatory DiseaseCommonwealth BuildingHammersmith CampusImperial College of Science Technology and MedicineLondonUK
| | - Stephen McAdoo
- Department of Immunology and InflammationCentre for Inflammatory DiseaseCommonwealth BuildingHammersmith CampusImperial College of Science Technology and MedicineLondonUK
| | - Renos Keniyopoullos
- Department of Immunology and InflammationCentre for HaematologyCommonwealth BuildingHammersmith CampusImperial College of Science Technology and MedicineLondonUK
| | - Talat Malik
- Department of Immunology and InflammationCentre for Inflammatory DiseaseCommonwealth BuildingHammersmith CampusImperial College of Science Technology and MedicineLondonUK
| | - Michael Laffan
- Department of Immunology and InflammationCentre for HaematologyCommonwealth BuildingHammersmith CampusImperial College of Science Technology and MedicineLondonUK
| | - Michelle Willicombe
- Department of Immunology and InflammationCentre for Inflammatory DiseaseCommonwealth BuildingHammersmith CampusImperial College of Science Technology and MedicineLondonUK
| | - Thomas McKinnon
- Department of Immunology and InflammationCentre for HaematologyCommonwealth BuildingHammersmith CampusImperial College of Science Technology and MedicineLondonUK
| |
Collapse
|
27
|
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
|
28
|
Bhogal P, Makalanda L, Hassan AE, Fiorella D, Andersson T, Ahmad M, Bäzner H, Jaffer O, Henkes H. COVID-19 and Delayed Cerebral Ischemia-More in Common Than First Meets the Eye. J Clin Med 2021; 10:2646. [PMID: 34208470 PMCID: PMC8233948 DOI: 10.3390/jcm10122646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/06/2021] [Accepted: 06/09/2021] [Indexed: 01/22/2023] Open
Abstract
Since the arrival of the global COVID-19 pandemic scientists around the world have been working to understand the pathological mechanisms resulting from infection. There has gradually been an understanding that COVID-19 triggers a widespread endotheliopathy and that this can result in a widespread thrombosis and in particular a microthrombosis. The mechanisms involved in the microthrombosis are not confined to infection and there is evidence that patients with aneurysmal sub-arachnoid haemorrhage (SAH) also suffer from an endotheliopathy and microthrombosis. In this article we attempt to shed light on similarities in the underlying processes involved in both diseases and suggest potential treatment options.
Collapse
Affiliation(s)
- Pervinder Bhogal
- Department of Interventional Neuroradiology, The Royal London Hospital, Barts NHS Trust, Whitechapel Road, Whitechapel, London E1 1BB, UK;
| | - Levansri Makalanda
- Department of Interventional Neuroradiology, The Royal London Hospital, Barts NHS Trust, Whitechapel Road, Whitechapel, London E1 1BB, UK;
| | - Ameer E. Hassan
- Departments of Neurology and Radiology, University of Texas Rio Grande Valley, Harlingen, TX 78550, USA;
| | - Dave Fiorella
- Department of Neurosurgery, Stony Brook University Hospital, Stony Brook, NY 11794, USA;
| | - Tommy Andersson
- Department of Interventional Neuroradiology, The Karolinska University Hospital, 171 76 Stockholm, Sweden;
| | | | - Hansjörg Bäzner
- Department of Neurology, Klinikum Stuttgart, 70174 Stuttgart, Germany;
| | - Ounali Jaffer
- Department of Interventional Radiology, The Royal London Hospital, Barts NHS Trust, Whitechapel Road, Whitechapel, London E1 1BB, UK;
| | - Hans Henkes
- Department of Neuroradiology, Klinikum Stuttgart, 70174 Stuttgart, Germany;
| |
Collapse
|
29
|
Bhogal P, Paul G, Collins G, Jaffer O. Letter in response to: circulating von Willebrand factor and high molecular weight multimers as markers of endothelial injury predict COVID-19 in-hospital mortality. Angiogenesis 2021; 24:413-415. [PMID: 34101095 PMCID: PMC8186348 DOI: 10.1007/s10456-021-09790-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/03/2021] [Indexed: 12/25/2022]
Affiliation(s)
- P Bhogal
- Department of Interventional Neuroradiology, The Royal London Hospital, Barts NHS Trust, Whitechapel Road, London, E1 1BB, UK.
| | - G Paul
- Department, of Gastroenterology, Hepatology, Pneumology and Infectious Diseases, Katharinenhospital, Klinikum Stuttgart, Krigesbergstraße 60, 70174, Stuttgart, Germany
| | - G Collins
- Department of Cardiology, St. Bartholomew's Hospital, Barts NHS Trust, London, UK
| | - O Jaffer
- Department of Interventional Radiology, The Royal London Hospital, Barts NHS Trust, London, UK
| |
Collapse
|
30
|
Chang JC. COVID-19 Sepsis: Pathogenesis and Endothelial Molecular Mechanisms Based on "Two-Path Unifying Theory" of Hemostasis and Endotheliopathy-Associated Vascular Microthrombotic Disease, and Proposed Therapeutic Approach with Antimicrothrombotic Therapy. Vasc Health Risk Manag 2021; 17:273-298. [PMID: 34103921 PMCID: PMC8179800 DOI: 10.2147/vhrm.s299357] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 03/24/2021] [Indexed: 12/15/2022] Open
Abstract
COVID-19 sepsis is characterized by acute respiratory distress syndrome (ARDS) as a consequence of pulmonary tropism of the virus and endothelial heterogeneity of the host. ARDS is a phenotype among patients with multiorgan dysfunction syndrome (MODS) due to disseminated vascular microthrombotic disease (VMTD). In response to the viral septicemia, the host activates the complement system which produces terminal complement complex C5b-9 to neutralize pathogen. C5b-9 causes pore formation on the membrane of host endothelial cells (ECs) if CD59 is underexpressed. Also, viral S protein attraction to endothelial ACE2 receptor damages ECs. Both affect ECs and provoke endotheliopathy. Disseminated endotheliopathy activates two molecular pathways: inflammatory and microthrombotic. The former releases inflammatory cytokines from ECs, which lead to inflammation. The latter initiates endothelial exocytosis of unusually large von Willebrand factor (ULVWF) multimers and FVIII from Weibel-Palade bodies. If ADAMTS13 is insufficient, ULVWF multimers activate intravascular hemostasis of ULVWF path. In activated ULVWF path, ULVWF multimers anchored to damaged endothelial cells recruit circulating platelets and trigger microthrombogenesis. This process produces "microthrombi strings" composed of platelet-ULVWF complexes, leading to endotheliopathy-associated VMTD (EA-VMTD). In COVID-19, microthrombosis initially affects the lungs per tropism causing ARDS, but EA-VMTD may orchestrate more complex clinical phenotypes, including thrombotic thrombocytopenic purpura (TTP)-like syndrome, hepatic coagulopathy, MODS and combined micro-macrothrombotic syndrome. In this pandemic, ARDS and pulmonary thromboembolism (PTE) have often coexisted. The analysis based on two hemostatic theories supports ARDS caused by activated ULVWF path is EA-VMTD and PTE caused by activated ULVWF and TF paths is macrothrombosis. The thrombotic disorder of COVID-19 sepsis is consistent with the notion that ARDS is virus-induced disseminated EA-VMTD and PTE is in-hospital vascular injury-related macrothrombosis which is not directly related to viral pathogenesis. The pathogenesis-based therapeutic approach is discussed for the treatment of EA-VMTD with antimicrothrombotic regimen and the potential need of anticoagulation therapy for coinciding macrothrombosis in comprehensive COVID-19 care.
Collapse
Affiliation(s)
- Jae C Chang
- Department of Medicine, University of California Irvine School of Medicine, Irvine, CA, USA
| |
Collapse
|
31
|
Doevelaar AAN, Bachmann M, Hölzer B, Seibert FS, Rohn BJ, Bauer F, Witzke O, Dittmer U, Bachmann M, Yilmaz S, Dittmer R, Schneppenheim S, Babel N, Budde U, Westhoff TH. von Willebrand Factor Multimer Formation Contributes to Immunothrombosis in Coronavirus Disease 2019. Crit Care Med 2021; 49:e512-e520. [PMID: 33591004 DOI: 10.1097/ccm.0000000000004918] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Prevention and therapy of immunothrombosis remain crucial challenges in the management of coronavirus disease 2019, since the underlying mechanisms are incompletely understood. We hypothesized that endothelial damage may lead to substantially increased concentrations of von Willebrand factor with subsequent relative deficiency of a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13). DESIGN Prospective controlled cross-over trial. SETTING Blood samples of patients with confirmed coronavirus disease 2019 and healthy controls were obtained in three German hospitals and analyzed in a German hemostaseologic laboratory. PATIENTS Seventy-five patients with confirmed coronavirus disease 2019 of mild to critical severity and 30 healthy controls. MEASUREMENTS AND MAIN RESULTS von Willebrand factor antigen, ADAMTS13, and von Willebrand factor multimer formation were analyzed. von Willebrand factor antigen was 4.1 times higher in COVID-19 patients compared with healthy controls (p < 0.0001), whereas ADAMTS13 activities were not significantly different (p = 0.18). The ADAMTS13/von Willebrand factor antigen ratio was significantly lower in COVID-19 than in the control group (24.4 ± 20.5 vs 82.0 ± 30.7; p < 0.0001). Fourteen patients (18.7%) undercut a critical ratio of 10 as described in thrombotic thrombocytopenic purpura. Gel analysis of multimers resembled a thrombotic thrombocytopenic purpura pattern with loss of the largest multimers in 75% and a smeary triplet pattern in 39% of the patients. The ADAMTS13/von Willebrand factor antigen ratio decreased continuously from mild to critical disease (analysis of variance p = 0.026). Furthermore, it differed significantly between surviving patients and those who died from COVID-19 (p = 0.001) yielding an area under the curve of 0.232 in receiver operating characteristic curve curve analysis. CONCLUSION COVID-19 is associated with a substantial increase in von Willebrand factor levels, which can exceed the ADAMTS13 processing capacity resulting in the formation of large von Willebrand factor multimers indistinguishable from thrombotic thrombocytopenic purpura. The ADAMTS13/von Willebrand factor antigen ratio is an independent predictor of severity of disease and mortality. These findings provide a rationale to consider plasma exchange as a therapeutic option in COVID-19 and to include von Willebrand factor and ADAMTS13 in the diagnostic workup.
Collapse
Affiliation(s)
- Adrian A N Doevelaar
- Medical Department I, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Martin Bachmann
- Department of Intensive Care and Ventilatory Medicine, Asklepios Klinikum Hamburg Harburg, Hamburg, Germany
| | - Bodo Hölzer
- Medical Department I, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Felix S Seibert
- Medical Department I, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Benjamin J Rohn
- Medical Department I, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Frederic Bauer
- Medical Department I, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Oliver Witzke
- Department of Infectiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ulf Dittmer
- Department of Virology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Michael Bachmann
- Department of Microbiology and Molecular Genetics, Michigan State University, East Lansing, MI
| | - Serap Yilmaz
- Department of Intensive Care and Ventilatory Medicine, Asklepios Klinikum Hamburg Harburg, Hamburg, Germany
| | - Rita Dittmer
- Department of Hemostaseology, MEDILYS Laborgesellschaft mbH, Hamburg, Germany
| | - Sonja Schneppenheim
- Department of Hemostaseology, MEDILYS Laborgesellschaft mbH, Hamburg, Germany
| | - Nina Babel
- Medical Department I, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Ulrich Budde
- Department of Hemostaseology, MEDILYS Laborgesellschaft mbH, Hamburg, Germany
| | - Timm H Westhoff
- Medical Department I, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| |
Collapse
|
32
|
Abstract
Thrombotic thrombocytopenic purpura (TTP) which can cause significant mortality is a thrombotic microangiopathy due to deficiency of VWF cleaving protease ADAMTS13 and as per medical literature there are examples that TTP can be caused by COVID 19 infection. A 35 years old female after admission with right sided weakness and slurring of speech was found to be COVID positive and diagnosed as a case of TTP. Patient had absent ADAMTS13 level on day 1. Treatment was started with therapeutic plasma exchange (TPE) later injection Vincristine and Rituximab was given after 4th TPE as it was suspected as refractory case. Finally patient received 16 TPE procedures with cryo poor plasma as exchange fluid and gradually her platelet count started to maintain normal and she was discharged. Specific management and such association of this type of cases need to be studied more judiciously.
Collapse
|
33
|
Favaloro EJ, Henry BM, Lippi G. Increased VWF and Decreased ADAMTS-13 in COVID-19: Creating a Milieu for (Micro)Thrombosis. Semin Thromb Hemost 2021; 47:400-418. [PMID: 33893632 DOI: 10.1055/s-0041-1727282] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
von Willebrand factor (VWF) is a large adhesive multimeric protein involved in hemostasis. The larger the size (or number of VWF multimers), the greater the functionality of the protein. A deficiency or defect of VWF can lead to von Willebrand disease (VWD) and cause bleeding. Conversely, an increase in VWF may create an environment that promotes thrombosis. ADAMS-13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13), sometimes called VWF-cleaving protease, is primarily responsible for controlling the size of VWF. The most severe deficiency (<10% of normal levels) of ADAMTS-13 arises in thrombotic thrombocytopenic purpura, a condition characterized by the presence of ultralarge VWF and clinically resulting in enhanced risk of thrombosis. However, ADAMTS-13 deficiency may result from other pathological processes. Of relevance is the recent finding that COVID-19 (coronavirus disease 2019) is associated with both increased levels and activity of VWF as well as generally decreased (or occasionally normal) activity levels of ADAMTS-13. Thus, in COVID-19 there is an alteration in the VWF/ADAMTS-13 axis, most often described by increased VWF/ADAMTS-13 ratio (or reduced ADAMTS-13/VWF ratio). COVID-19 is also associated with high prothrombotic risk. Thus, the imbalance of VWF and ADAMTS-13 in COVID-19 may be providing a milieu that promotes (micro)thrombosis, in a clinical picture resembling a secondary thrombotic microangiopathy in some patients. This review therefore assesses the literature on VWF, ADAMTS-13, and COVID-19. Whenever reported in COVID-19, VWF has always been identified as raised (compared with normal reference ranges or control populations). Reports have included VWF level (i.e., VWF antigen) and in some cases one or more VWF "activity" (e.g., collagen binding; platelet glycoprotein Ib [GPIb] binding, using ristocetin cofactor or more modern versions including VWF:GPIbR [recombinant] and VWF:GPIbM [mutant]). Whenever reported, ADAMTS-13 has been reported as "normal" or reduced; however, it should be recognized that "normal" levels may still identify a relative reduction in individual cases. Some reports also discuss the raised VWF/ADAMTS-13 (or reduced ADAMTS-13/VWF) ratio, but very few provide actual numerical data.
Collapse
Affiliation(s)
- Emmanuel J Favaloro
- Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia.,School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, New South Wales, Australia
| | - Brandon Michael Henry
- Cardiac Intensive Care Unit, The Heart Institute, Cincinnati Children's Hospital Medical Center, Ohio
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| |
Collapse
|
34
|
Marco A, Marco P. Von Willebrand factor and ADAMTS13 activity as clinical severity markers in patients with COVID-19. J Thromb Thrombolysis 2021; 52:497-503. [PMID: 33866481 PMCID: PMC8053027 DOI: 10.1007/s11239-021-02457-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2021] [Indexed: 12/22/2022]
Abstract
The coronavirus disease 2019 (COVID-19) increases thrombotic risk. The mechanisms that lead to this prothrombotic state are not well established. The main aim was to evaluate the von Willebrand factor (VWF) antigen and plasma ADAMTS13 activity as endothelial injury markers in COVID-19. We present a prospective study in COVID-19 patients recruited in our institution. VWF antigen, ADAMTS13 activity, D-dimer, and fibrinogen were measured during the first week once COVID-19 was diagnosed. Fifty COVID-19 inpatients [44% in the intensive care unit (ICU)] and 102 COVID-19 outpatients were enrolled. Thirty age and gender matched non-COVID-19 ward inpatients and 30 non-COVID-19 healthy individuals were recruited. The COVID-19 inpatients had higher D-dimer, fibrinogen, and VWF antigen levels and a lower ADAMTS13 activity compared with the COVID-19 outpatients (p < 0.05). ICU patients had higher D-dimer and VWF antigen levels compared with the ward patients and the lowest ADAMTS13 activity (p < 0.05). An imbalance in VWF antigen/ADAMTS13 ratio was observed in COVID-19, reaching the highest in ICU patients. In contrast to other ward non-COVID-19 inpatients, a significative reduction in ADAMTS13 activity was observed in all COVID-19 patients. There is an increase in VWF antigen and an ADAMTS13 activity reduction in COVID-19 related to disease severity and could predict poor clinical outcomes. The ADAMTS13 activity reduction could be a marker associated with COVID-19 compared to other non-critical medical conditions.
Collapse
Affiliation(s)
- A Marco
- Thrombosis and Hemostasis Department, Hematology Service, University General Hospital in Alicante, Alicante, Spain.
- Biomedical Research Institute in Alicante, Alicante, Spain.
| | - P Marco
- Thrombosis and Hemostasis Department, Hematology Service, University General Hospital in Alicante, Alicante, Spain
- Biomedical Research Institute in Alicante, Alicante, Spain
- Clinical Medicine Department, Miguel Hernández University, Alicante, Spain
| |
Collapse
|
35
|
COVID-19: imbalance of multiple systems during infection and importance of therapeutic choice and dosing of cardiac and anti-coagulant therapies. Mol Biol Rep 2021; 48:2917-2928. [PMID: 33837899 PMCID: PMC8035598 DOI: 10.1007/s11033-021-06333-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 04/01/2021] [Indexed: 12/26/2022]
Abstract
The renin-angiotensin-aldosterone system and its metabolites play an important role in homeostasis of body, especially the cardiovascular system. In this study, we discuss the imbalance of multiple systems during the infection and the importance of therapeutic choice, dosing, and laboratory monitoring of cardiac and anti-coagulant therapies in COVID-19 patients. The crosstalk between angiotensin, kinin-kallikrein system, as well as inflammatory and coagulation systems plays an essential role in COVID-19. Cardiac complications and coagulopathies imply the crosstalks between the mentioned systems. We believe that the blockage of bradykinin can be a good option in the management of COVID-19 and CVD in patients and that supportive treatment of respiratory and cardiologic complications is needed in COVID-19 patients. Ninety-one percent of COVID-19 patients who were admitted to hospital with a prolonged aPTT were positive for lupus anticoagulant, which increases the risk of thrombosis and prolonged aPTT. Therefore, the question that is posed at this juncture is whether it is safe to use the prophylactic dose of heparin particularly in those with elevated D-dimer levels. It should be noted that timing is of high importance in anti-coagulant therapy; therefore, we should consider the level of D-dimer, fibrinogen, drug-drug interactions, and risk factors during thromboprophylaxis administration. Fibrinogen is an independent predictor of resistance to heparin and should be considered before thromboprophylaxis. Alteplase and Futhan might be a good choice to assess the condition of heparin resistance. Finally, the treatment option, dosing, and laboratory monitoring of anticoagulant therapy are critical decisions in COVID-19 patients.
Collapse
|
36
|
Sweeney JM, Barouqa M, Krause GJ, Gonzalez-Lugo JD, Rahman S, Gil MR. Low ADAMTS13 Activity Correlates with Increased Mortality in COVID-19 Patients. TH OPEN 2021; 5:e89-e103. [PMID: 33709050 PMCID: PMC7943318 DOI: 10.1055/s-0041-1723784] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 12/29/2020] [Indexed: 01/08/2023] Open
Abstract
The causes of coagulopathy associated with coronavirus disease 2019 (COVID-19) are poorly understood. We aimed to investigate the relationship between von Willebrand factor (VWF) biomarkers, intravascular hemolysis, coagulation, and organ damage in COVID-19 patients and study their association with disease severity and mortality. We conducted a retrospective study of 181 hospitalized COVID-19 patients randomly selected with balanced distribution of survivors and nonsurvivors. Patients who died had significantly lower ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) activity, significantly elevated lactate dehydrogenase levels, significantly increased shistocyte/RBC fragment counts, and significantly elevated VWF antigen and activity levels compared with patients discharged alive. These biomarkers correlate with markedly elevated D-dimers. Additionally, only 30% of patients who had an ADAMTS13 activity level of less than 43% on admission survived, yet 60% of patients survived who had an ADAMTS13 activity level of greater than 43% on admission. In conclusion, COVID-19 may present with low ADAMTS13 activity in a subset of hospitalized patients. Presence of schistocytes/RBC fragment and elevated D-dimer on admission may warrant a work-up for ADAMTS13 activity and VWF antigen and activity levels. These findings indicate the need for future investigation to study the relationship between endothelial and coagulation activation and the efficacy of treatments aimed at prevention and/or amelioration of microangiopathy in COVID-19.
Collapse
Affiliation(s)
- Joseph M Sweeney
- Department Physiology and Biophysics, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Mohammad Barouqa
- Department of Pathology Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Gregory J Krause
- Department of Developmental and Molecular Biology, Albert Einstein College of Medicine, Bronx, New York, United States.,Institute of Aging Studies, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Jesus D Gonzalez-Lugo
- Division of Hematology, Department of Medical Oncology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, United States
| | - Shafia Rahman
- Division of Hematology, Department of Medical Oncology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, United States
| | - Morayma Reyes Gil
- Department of Pathology Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, United States
| |
Collapse
|
37
|
Invited commentary to: ADAMTS13 deficiency is associated with abnormal distribution of von Willebrand factor multimers in patients with COVID-19 by Tiffany Pascreau et al. Letter to the Editors-in-Chief, Thrombosis Research. Thromb Res 2021; 204:141-142. [PMID: 33678420 PMCID: PMC7927580 DOI: 10.1016/j.thromres.2021.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 11/23/2022]
|
38
|
Mattioli M, Benfaremo D, Mancini M, Mucci L, Mainquà P, Polenta A, Baldini PM, Fulgenzi F, Dennetta D, Bedetta S, Gasperoni L, Caraffa A, Frausini G. Safety of intermediate dose of low molecular weight heparin in COVID-19 patients. J Thromb Thrombolysis 2021; 51:286-292. [PMID: 32794132 PMCID: PMC7426007 DOI: 10.1007/s11239-020-02243-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Coagulopathy represents one of the most important determinants of morbidity and mortality in coronavirus disease-19 (COVID-19). Whether standard thromboprophylaxis is sufficient or higher doses are needed, especially in severe patients, is unknown. To evaluate the safety of intermediate dose regimens of low-weight molecular heparin (LWMH) in COVID-19 patients with pneumonia, particularly in older patients. We retrospectively evaluated 105 hospitalized patients (61 M, 44 F; mean age 73.7 years) treated with subcutaneous enoxaparin: 80 mg/day in normal weight and mild-to-moderate impair or normal renal function; 40 mg/day in severe chronic renal failure or low bodyweight (< 45 kg); 100 mg/day if bodyweight was higher than 100 kg. All the patients had radiologically confirmed pneumonia and 63.8% had severe COVID-19. None of the patients had fatal haemorrhage; two (1.9%) patients had a major bleeding event (one spontaneous hematoma and one gastrointestinal bleeding). Only 6.7% of patients needed transfusions of red blood cells. One thrombotic event (pulmonary embolism) was observed. When compared to younger patients, patients older than 85 years had a higher mortality (40% vs 13.3%), but not an increased risk of bleeding or need for blood transfusion. The use of an intermediate dose of LWMH appears to be feasible and data suggest safety in COVID-19 patients, although further studies are needed.
Collapse
Affiliation(s)
- Massimo Mattioli
- UOC Pronto Soccorso e Medicina d'Urgenza, Azienda Ospedaliera "Ospedali Riuniti Marche Nord", Piazzale Cinelli, 61121, 4 Pesaro, Italy.
| | - Devis Benfaremo
- Dipartimento di Scienze Cliniche e Molecolari, Università Politecnica delle Marche, Ancona, Italy
| | - Mauro Mancini
- Internal Pharmacy Department, Azienda Ospedaliera "Ospedali Riuniti Marche Nord", Pesaro, Italy
| | - Luciano Mucci
- UOC Medicina Interna, Azienda Ospedaliera "Ospedali Riuniti Marche Nord", Pesaro, Italy
| | - Paola Mainquà
- UOC Geriatria, Azienda Ospedaliera "Ospedali Riuniti Marche Nord", Pesaro, Italy
| | - Antonio Polenta
- UOC Malattie Infettive, Azienda Ospedaliera "Ospedali Riuniti Marche Nord", Pesaro, Italy
| | | | - Francesca Fulgenzi
- UOC Pronto Soccorso e Medicina d'Urgenza, Azienda Ospedaliera "Ospedali Riuniti Marche Nord", Piazzale Cinelli, 61121, 4 Pesaro, Italy
| | - Donatella Dennetta
- UO Pneumologia, Azienda Ospedaliera "Ospedali Riuniti Marche Nord", Pesaro, Italy
| | - Samuele Bedetta
- UOC Medicina Interna, Azienda Ospedaliera "Ospedali Riuniti Marche Nord", Pesaro, Italy
| | - Lorenzo Gasperoni
- Internal Pharmacy Department, Azienda Ospedaliera "Ospedali Riuniti Marche Nord", Pesaro, Italy
| | - Alessandro Caraffa
- Internal Pharmacy Department, Azienda Ospedaliera "Ospedali Riuniti Marche Nord", Pesaro, Italy
| | - Gabriele Frausini
- UOC Medicina Interna, Azienda Ospedaliera "Ospedali Riuniti Marche Nord", Pesaro, Italy
| |
Collapse
|
39
|
Turecek PL, Peck RC, Rangarajan S, Reilly-Stitt C, Laffan MA, Kazmi R, James I, Dushianthan A, Schrenk G, Gritsch H, Ewenstein BM, Mellgard B, Erdlenbruch W, Jain N, Binder NB, Mumford AD. Recombinant ADAMTS13 reduces abnormally up-regulated von Willebrand factor in plasma from patients with severe COVID-19. Thromb Res 2021; 201:100-112. [PMID: 33662796 PMCID: PMC7890348 DOI: 10.1016/j.thromres.2021.02.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/14/2021] [Accepted: 02/08/2021] [Indexed: 12/14/2022]
Abstract
Thrombosis affecting the pulmonary and systemic vasculature is common during severe COVID-19 and causes adverse outcomes. Although thrombosis likely results from inflammatory activation of vascular cells, the mediators of thrombosis remain unconfirmed. In a cross-sectional cohort of 36 severe COVID-19 patients, we show that markedly increased plasma von Willebrand factor (VWF) levels were accompanied by a partial reduction in the VWF regulatory protease ADAMTS13. In all patients we find this VWF/ADAMTS13 imbalance to be associated with persistence of ultra-high-molecular-weight (UHMW) VWF multimers that are highly thrombogenic in some disease settings. Incubation of plasma samples from patients with severe COVID-19 with recombinant ADAMTS13 (rADAMTS13) substantially reduced the abnormally high VWF activity, reduced overall multimer size and depleted UHMW VWF multimers in a time and concentration dependent manner. Our data implicate disruption of normal VWF/ADAMTS13 homeostasis in the pathogenesis of severe COVID-19 and indicate that this can be reversed ex vivo by correction of low plasma ADAMTS13 levels. These findings suggest a potential therapeutic role for rADAMTS13 in helping restore haemostatic balance in COVID-19 patients.
Collapse
Affiliation(s)
| | - Rachel C Peck
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
| | - Savita Rangarajan
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; K J Somaiya Superspecialty Hospital and Research Centre, Mumbai, India
| | | | - Michael A Laffan
- Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Rashid Kazmi
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Izabela James
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | | | - Gerald Schrenk
- Baxalta Innovations GmbH, a Takeda company, Vienna, Austria
| | | | | | | | | | - Nisha Jain
- Baxalta US Inc., a Takeda company, Cambridge, MA, USA
| | - Nikolaus B Binder
- Technoclone Herstellung von Diagnostika und Arzneimitteln GmbH, Vienna, Austria
| | - Andrew D Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom; University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom.
| |
Collapse
|
40
|
Flores-Pliego A, Miranda J, Vega-Torreblanca S, Valdespino-Vázquez Y, Helguera-Repetto C, Espejel-Nuñez A, Borboa-Olivares H, Espino y Sosa S, Mateu-Rogell P, León-Juárez M, Ramírez-Santes V, Cardona-Pérez A, Villegas-Mota I, Torres-Torres J, Juárez-Reyes Á, Rizo-Pica T, González RO, González-Mariscal L, Estrada-Gutierrez G. Molecular Insights into the Thrombotic and Microvascular Injury in Placental Endothelium of Women with Mild or Severe COVID-19. Cells 2021; 10:cells10020364. [PMID: 33578631 PMCID: PMC7916402 DOI: 10.3390/cells10020364] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/30/2021] [Accepted: 02/03/2021] [Indexed: 02/07/2023] Open
Abstract
Clinical manifestations of coronavirus disease 2019 (COVID-19) in pregnant women are diverse, and little is known of the impact of the disease on placental physiology. Severe acute respiratory syndrome coronavirus (SARS-CoV-2) has been detected in the human placenta, and its binding receptor ACE2 is present in a variety of placental cells, including endothelium. Here, we analyze the impact of COVID-19 in placental endothelium, studying by immunofluorescence the expression of von Willebrand factor (vWf), claudin-5, and vascular endothelial (VE) cadherin in the decidua and chorionic villi of placentas from women with mild and severe COVID-19 in comparison to healthy controls. Our results indicate that: (1) vWf expression increases in the endothelium of decidua and chorionic villi of placentas derived from women with COVID-19, being higher in severe cases; (2) Claudin-5 and VE-cadherin expression decrease in the decidua and chorionic villus of placentas from women with severe COVID-19 but not in those with mild disease. Placental histological analysis reveals thrombosis, infarcts, and vascular wall remodeling, confirming the deleterious effect of COVID-19 on placental vessels. Together, these results suggest that placentas from women with COVID-19 have a condition of leaky endothelium and thrombosis, which is sensitive to disease severity.
Collapse
Affiliation(s)
- Arturo Flores-Pliego
- Department of Immunobiochemistry, Instituto Nacional de Perinatología, Ciudad de México 11000, Mexico; (A.F.-P.); (C.H.-R.); (A.E.-N.); (M.L.-J.)
| | - Jael Miranda
- Department of Physiology, Biophysics and Neuroscience, Center for Research and Advanced Studies (Cinvestav), Ciudad de México 07360, Mexico; (J.M.); (S.V.-T.)
| | - Sara Vega-Torreblanca
- Department of Physiology, Biophysics and Neuroscience, Center for Research and Advanced Studies (Cinvestav), Ciudad de México 07360, Mexico; (J.M.); (S.V.-T.)
| | | | - Cecilia Helguera-Repetto
- Department of Immunobiochemistry, Instituto Nacional de Perinatología, Ciudad de México 11000, Mexico; (A.F.-P.); (C.H.-R.); (A.E.-N.); (M.L.-J.)
| | - Aurora Espejel-Nuñez
- Department of Immunobiochemistry, Instituto Nacional de Perinatología, Ciudad de México 11000, Mexico; (A.F.-P.); (C.H.-R.); (A.E.-N.); (M.L.-J.)
| | - Héctor Borboa-Olivares
- Community Interventions Research Branch, Instituto Nacional de Perinatología, Ciudad de México 11000, Mexico;
| | - Salvador Espino y Sosa
- Clinical Research Branch, Instituto Nacional de Perinatología, Ciudad de México 11000, Mexico; (S.E.yS.); (P.M.-R.)
| | - Paloma Mateu-Rogell
- Clinical Research Branch, Instituto Nacional de Perinatología, Ciudad de México 11000, Mexico; (S.E.yS.); (P.M.-R.)
| | - Moisés León-Juárez
- Department of Immunobiochemistry, Instituto Nacional de Perinatología, Ciudad de México 11000, Mexico; (A.F.-P.); (C.H.-R.); (A.E.-N.); (M.L.-J.)
| | - Victor Ramírez-Santes
- Department of Obstetrics, Instituto Nacional de Perinatología, Ciudad de México 11000, Mexico;
| | - Arturo Cardona-Pérez
- General Direction, Instituto Nacional de Perinatología, Ciudad de México 11000, Mexico;
| | - Isabel Villegas-Mota
- Department of Epidemiology, Instituto Nacional de Perinatología, Ciudad de México 11000, Mexico;
| | - Johnatan Torres-Torres
- Hospital General de México Dr Eduardo Liceaga, Ciudad de México 06720, Mexico; (J.T.-T.); (Á.J.-R.); (T.R.-P.)
| | - Ángeles Juárez-Reyes
- Hospital General de México Dr Eduardo Liceaga, Ciudad de México 06720, Mexico; (J.T.-T.); (Á.J.-R.); (T.R.-P.)
| | - Thelma Rizo-Pica
- Hospital General de México Dr Eduardo Liceaga, Ciudad de México 06720, Mexico; (J.T.-T.); (Á.J.-R.); (T.R.-P.)
| | - Rosa O. González
- Department of Mathematics, Autonomous Metropolitan University-Iztapalapa (UAM-I), Ciudad de México 14387, Mexico;
| | - Lorenza González-Mariscal
- Department of Physiology, Biophysics and Neuroscience, Center for Research and Advanced Studies (Cinvestav), Ciudad de México 07360, Mexico; (J.M.); (S.V.-T.)
- Correspondence: (L.G.-M.); (G.E.-G.); Tel.: +5255-5-747-3800 (ext. 3966) (L.G.-M.); +5255-5-520-9900 (ext. 160) (G.E.-G.)
| | - Guadalupe Estrada-Gutierrez
- Research Division, Instituto Nacional de Perinatología, Ciudad de México 11000, Mexico
- Correspondence: (L.G.-M.); (G.E.-G.); Tel.: +5255-5-747-3800 (ext. 3966) (L.G.-M.); +5255-5-520-9900 (ext. 160) (G.E.-G.)
| |
Collapse
|
41
|
No Evidence for Classic Thrombotic Microangiopathy in COVID-19. J Clin Med 2021; 10:jcm10040671. [PMID: 33572417 PMCID: PMC7916239 DOI: 10.3390/jcm10040671] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/27/2021] [Accepted: 02/02/2021] [Indexed: 01/08/2023] Open
Abstract
Background: Coronavirus disease-2019 (COVID-19) triggers systemic infection with involvement of the respiratory tract. There are some patients developing haemostatic abnormalities during their infection with a considerably increased risk of death. Materials and Methods: Patients (n = 85) with SARS-CoV-2 infection attending the University Medical Center, Mainz, from 3 March to 15 May 2020 were retrospectively included in this study. Data regarding demography, clinical features, treatment and laboratory parameters were analyzed. Twenty patients were excluded for assessment of disseminated intravascular coagulation (DIC) and thrombotic microangiopathy (TMA) due to lack of laboratory data. Results: COVID-19 patients (n = 65) were investigated, 19 with uncomplicated, 29 with complicated, and 17 with critical course; nine (13.8%) died. Seven patients showed overt DIC according to the ISTH criteria. The fibrinogen levels dropped significantly in these patients, although not below 100 mg/dl. Hallmarks of TMA, such as thrombocytopenia and microangiopathic haemolytic anaemia, were not detected in any of our COVID-19 patients. ADAMTS13 activity was mildly to moderately reduced in 4/22 patients, all having strongly elevated procalcitonin levels. Conclusion: DIC occurred in 7/65 COVID-19 patients but fibrinogen and platelet consumption were compensated in almost all. ADAMTS13 assays excluded TTP and hallmarks of classic TMA were absent in all investigated patients. We hypothesize that the lacking erythrocyte fragmentation and only mild platelet consumption in severe COVID-19 are due to a microangiopathy predominantly localized to the alveolar microcirculation with a low blood pressure gradient.
Collapse
|
42
|
de Carranza M, Salazar DE, Troya J, Alcázar R, Peña C, Aragón E, Domínguez M, Torres J, Muñoz-Rivas N. Aortic thrombus in patients with severe COVID-19: review of three cases. J Thromb Thrombolysis 2021; 51:237-242. [PMID: 32648092 PMCID: PMC7344037 DOI: 10.1007/s11239-020-02219-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Coronavirus disease 2019 (COVID-19) could predispose to both venous and arterial thromboembolism, in an exaggerated immune response to the virus, especially in severe patients. Even though aortic clots are a rare entity, the pro-coagulant nature of COVID-19 is associated with thrombosis in atypical locations and should be considered in patients with severe abnormalities in coagulation parameters. We describe a series of three cases of aortic thrombi diagnosed by computerized tomography (CT) angiography in patients with confirmed SARS-CoV-2 infection.
Collapse
Affiliation(s)
- María de Carranza
- Department of Internal Medicine, Hospital Universitario Infanta Leonor, Infanta Leonor, University Hospital, Avenida Gran Vía Este 80, 28031, Madrid, Spain.
| | | | - Jesús Troya
- Department of Internal Medicine, Hospital Universitario Infanta Leonor, Infanta Leonor, University Hospital, Avenida Gran Vía Este 80, 28031, Madrid, Spain
| | - Roberto Alcázar
- Department of Nephrology, Infanta Leonor University Hospital, Madrid, Spain
| | - Cristina Peña
- Department of Internal Medicine, Hospital Universitario Infanta Leonor, Infanta Leonor, University Hospital, Avenida Gran Vía Este 80, 28031, Madrid, Spain
| | - Esther Aragón
- Department of Neurology, Infanta Leonor University Hospital, Madrid, Spain
| | - Marta Domínguez
- Department of Cardiology, Infanta Leonor University Hospital, Madrid, Spain
| | - Juan Torres
- Department of Internal Medicine, Hospital Universitario Infanta Leonor, Infanta Leonor, University Hospital, Avenida Gran Vía Este 80, 28031, Madrid, Spain
| | - Nuria Muñoz-Rivas
- Department of Internal Medicine, Hospital Universitario Infanta Leonor, Infanta Leonor, University Hospital, Avenida Gran Vía Este 80, 28031, Madrid, Spain
| |
Collapse
|
43
|
Mancini I, Baronciani L, Artoni A, Colpani P, Biganzoli M, Cozzi G, Novembrino C, Boscolo Anzoletti M, De Zan V, Pagliari MT, Gualtierotti R, Aliberti S, Panigada M, Grasselli G, Blasi F, Peyvandi F. The ADAMTS13-von Willebrand factor axis in COVID-19 patients. J Thromb Haemost 2021; 19:513-521. [PMID: 33230904 PMCID: PMC7753796 DOI: 10.1111/jth.15191] [Citation(s) in RCA: 152] [Impact Index Per Article: 50.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/27/2020] [Accepted: 11/13/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Severe coronavirus disease 2019 (COVID-19) is characterized by an increased risk of thromboembolic events, with evidence of microthrombosis in the lungs of deceased patients. OBJECTIVES To investigate the mechanism of microthrombosis in COVID-19 progression. PATIENTS/METHODS We assessed von Willebrand factor (VWF) antigen (VWF:Ag), VWF ristocetin-cofactor (VWF:RCo), VWF multimers, VWF propeptide (VWFpp), and ADAMTS13 activity in a cross-sectional study of 50 patients stratified according to their admission to three different intensity of care units: low (requiring high-flow nasal cannula oxygenation, n = 14), intermediate (requiring continuous positive airway pressure devices, n = 17), and high (requiring mechanical ventilation, n = 19). RESULTS Median VWF:Ag, VWF:RCo, and VWFpp levels were markedly elevated in COVID-19 patients and increased with intensity of care, with VWF:Ag being 268, 386, and 476 IU/dL; VWF:RCo 216, 334, and 388 IU/dL; and VWFpp 156, 172, and 192 IU/dL in patients at low, intermediate, and high intensity of care, respectively. Conversely, the high-to-low molecular-weight VWF multimers ratios progressively decreased with increasing intensity of care, as well as median ADAMTS13 activity levels, which ranged from 82 IU/dL for patients at low intensity of care to 62 and 55 IU/dL for those at intermediate and high intensity of care. CONCLUSIONS We found a significant alteration of the VWF-ADAMTS13 axis in COVID-19 patients, with an elevated VWF:Ag to ADAMTS13 activity ratio that was strongly associated with disease severity. Such an imbalance enhances the hypercoagulable state of COVID-19 patients and their risk of microthrombosis.
Collapse
Affiliation(s)
- Ilaria Mancini
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Luciano Baronciani
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, and Fondazione Luigi Villa, Milan, Italy
| | - Andrea Artoni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, and Fondazione Luigi Villa, Milan, Italy
| | - Paola Colpani
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, and Fondazione Luigi Villa, Milan, Italy
| | - Marina Biganzoli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, and Fondazione Luigi Villa, Milan, Italy
| | - Giovanna Cozzi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, and Fondazione Luigi Villa, Milan, Italy
| | - Cristina Novembrino
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, and Fondazione Luigi Villa, Milan, Italy
| | - Massimo Boscolo Anzoletti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, and Fondazione Luigi Villa, Milan, Italy
| | - Valentina De Zan
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Maria Teresa Pagliari
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, and Fondazione Luigi Villa, Milan, Italy
| | - Roberta Gualtierotti
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, and Fondazione Luigi Villa, Milan, Italy
| | - Stefano Aliberti
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, UOC Pneumologia, Milan, Italy
| | - Mauro Panigada
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, UOC Anestesia e Terapia Intensiva Adulti, Milan, Italy
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, UOC Anestesia e Terapia Intensiva Adulti, Milan, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, UOC Pneumologia, Milan, Italy
| | - Flora Peyvandi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, and Fondazione Luigi Villa, Milan, Italy
| |
Collapse
|
44
|
Rodríguez Rodríguez M, Castro Quismondo N, Zafra Torres D, Gil Alos D, Ayala R, Martinez-Lopez J. Increased von Willebrand factor antigen and low ADAMTS13 activity are related to poor prognosis in covid-19 patients. Int J Lab Hematol 2021; 43:O152-O155. [PMID: 33502080 PMCID: PMC8014254 DOI: 10.1111/ijlh.13476] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/08/2021] [Accepted: 01/09/2021] [Indexed: 01/03/2023]
Affiliation(s)
| | | | - Denis Zafra Torres
- Department of Hematology, Hospital Universitario "12 de Octubre", Madrid, Spain
| | - Daniel Gil Alos
- Department of Hematology, Hospital Universitario "12 de Octubre", Madrid, Spain
| | - Rosa Ayala
- Department of Hematology, Hospital Universitario "12 de Octubre", Madrid, Spain.,Hematological Malignancies Clinical Research Unit, CNIO, Madrid, Spain.,Complutense University, Madrid, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Joaquín Martinez-Lopez
- Department of Hematology, Hospital Universitario "12 de Octubre", Madrid, Spain.,Hematological Malignancies Clinical Research Unit, CNIO, Madrid, Spain.,Complutense University, Madrid, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain
| |
Collapse
|
45
|
Voicu S, Ketfi C, Stépanian A, Chousterman BG, Mohamedi N, Siguret V, Mebazaa A, Mégarbane B, Bonnin P. Pathophysiological Processes Underlying the High Prevalence of Deep Vein Thrombosis in Critically Ill COVID-19 Patients. Front Physiol 2021; 11:608788. [PMID: 33488398 PMCID: PMC7820906 DOI: 10.3389/fphys.2020.608788] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/27/2020] [Indexed: 12/12/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) predisposes to deep vein thrombosis (DVT) and pulmonary embolism (PE) particularly in mechanically ventilated adults with severe pneumonia. The extremely high prevalence of DVT in the COVID-19 patients hospitalized in the intensive care unit (ICU) has been established between 25 and 84% based on studies including systematic duplex ultrasound of the lower limbs when prophylactic anticoagulation was systematically administrated. DVT prevalence has been shown to be markedly higher than in mechanically ventilated influenza patients (6-8%). Unusually high inflammatory and prothrombotic phenotype represents a striking feature of COVID-19 patients, as reflected by markedly elevated reactive protein C, fibrinogen, interleukin 6, von Willebrand factor, and factor VIII. Moreover, in critically ill patients, venous stasis has been associated with the prothrombotic phenotype attributed to COVID-19, which increases the risk of thrombosis. Venous stasis results among others from immobilization under muscular paralysis, mechanical ventilation with high positive end-expiratory pressure, and pulmonary microvascular network injuries or occlusions. Venous return to the heart is subsequently decreased with increase in central and peripheral venous pressures, marked proximal and distal veins dilation, and drops in venous blood flow velocities, leading to a spontaneous contrast "sludge pattern" in veins considered as prothrombotic. Together with endothelial lesions and hypercoagulability status, venous stasis completes the Virchow triad and considerably increases the prevalence of DVT and PE in critically ill COVID-19 patients, therefore raising questions regarding the optimal doses for thromboprophylaxis during ICU stay.
Collapse
Affiliation(s)
- Sebastian Voicu
- Department of Medical and Toxicological Critical Care, Hôpital Lariboisière, APHP, Faculté de Santé, Université de Paris, Paris, France
- INSERM UMRS 1144, Université de Paris, Paris, France
| | - Chahinez Ketfi
- Department of Clinical Physiology, Hôpital Lariboisière, APHP, Faculté de Santé, Université de Paris, Paris, France
| | - Alain Stépanian
- Laboratory of Biological Hematology, Hôpital Lariboisière, APHP, Faculté de Santé, Université de Paris, Paris, France
- EA3518, Université de Paris, Paris, France
| | - Benjamin G. Chousterman
- Department of Anesthesia and Critical Care, Faculté de Santé, Hôpital Lariboisière, APHP, FHU PROMICE, Paris, France
- Université de Paris, Paris, France
- INSERM UMR-S 942 – MASCOT, Université de Paris, Paris, France
| | - Nassim Mohamedi
- Department of Clinical Physiology, Hôpital Lariboisière, APHP, Faculté de Santé, Université de Paris, Paris, France
| | - Virginie Siguret
- Laboratory of Biological Hematology, Hôpital Lariboisière, APHP, Faculté de Santé, Université de Paris, Paris, France
- INSERM UMR-S 1140, Université de Paris, Paris, France
| | - Alexandre Mebazaa
- Department of Anesthesia and Critical Care, Faculté de Santé, Hôpital Lariboisière, APHP, FHU PROMICE, Paris, France
- Université de Paris, Paris, France
- INSERM UMR-S 942 – MASCOT, Université de Paris, Paris, France
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Hôpital Lariboisière, APHP, Faculté de Santé, Université de Paris, Paris, France
- INSERM UMRS 1144, Université de Paris, Paris, France
| | - Philippe Bonnin
- Department of Clinical Physiology, Hôpital Lariboisière, APHP, Faculté de Santé, Université de Paris, Paris, France
- INSERM U1148, LVTS, Université de Paris, Paris, France
| |
Collapse
|
46
|
Valga F, Vega-Díaz N, Macía M, Rodríguez-Pérez JC. A new inflammatory-microthrombotic syndrome as an explanation for thrombotic complications in patients with COVID-19. REVISTA ESPAÑOLA DE CARDIOLOGÍA (ENGLISH EDITION) 2021; 74:115-116. [PMID: 33069615 PMCID: PMC7531278 DOI: 10.1016/j.rec.2020.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 08/18/2020] [Indexed: 11/01/2022]
|
47
|
Lippi G, Sanchis-Gomar F, Favaloro EJ, Lavie CJ, Henry BM. Coronavirus Disease 2019-Associated Coagulopathy. Mayo Clin Proc 2021; 96:203-217. [PMID: 33413819 PMCID: PMC7604017 DOI: 10.1016/j.mayocp.2020.10.031] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 10/09/2020] [Accepted: 10/27/2020] [Indexed: 02/07/2023]
Abstract
Patients with the severe form of coronavirus disease 2019 (COVID-19) have been frequently found to suffer from both arterial and venous thrombotic events due to the perpetuation of a hypercoagulable state. This phenomenon, termed COVID-19-associated coagulopathy, is now considered a major component of the pathophysiology of this novel infectious disease, leading to widespread thrombosis. While at first, the vascular insults may be limited to the pulmonary microvasculature, as the disease progresses, systemic involvement occurs, culminating in distant organ thrombosis and multiorgan dysfunction syndrome. In this review article, we discuss recent insights into the pathophysiologic mechanisms of COVID-19-associated coagulopathy and review the clinical, histopathologic, and laboratory evidence, which leads us to conclude that COVID-19 is both a pulmonary and vascular disorder.
Collapse
Key Words
- ace2, angiotensin-converting enzyme 2
- ards, acute respiratory distress syndrome
- cc, coronavirus 2019–associated coagulopathy
- covid-19, coronavirus disease 2019
- dic, disseminated intravascular coagulation
- dvt, deep vein thrombosis
- icu, intensive care unit
- il, interleukin
- ly30, lysis at 30 minutes
- no, nitric oxide
- pai-1, plasminogen activator inhibitor 1
- pe, pulmonary embolism
- sars-cov-2, severe acute respiratory syndrome coronavirus 2
- tf, tissue factor
- tma, thrombotic microangiopathy
- tpa, tissue plasminogen activator
- vte, venous thromboembolism
- vwf, von willebrand factor
Collapse
Affiliation(s)
- Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Fabian Sanchis-Gomar
- Department of Physiology, Faculty of Medicine, University of Valencia and INCLIVA Biomedical Research Institute, Valencia, Spain.
| | - Emmanuel J Favaloro
- Haematology, Sydney Centers for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School - The University of Queensland School of Medicine, New Orleans, LA, USA
| | - Brandon M Henry
- Cardiac Intensive Care Unit, The Heart Institute, Cincinnati Children's Hospital Medical Center, Ohio, USA
| |
Collapse
|
48
|
Argañaraz GA, Palmeira JDF, Argañaraz ER. Phosphatidylserine inside out: a possible underlying mechanism in the inflammation and coagulation abnormalities of COVID-19. Cell Commun Signal 2020; 18:190. [PMID: 33357215 PMCID: PMC7765775 DOI: 10.1186/s12964-020-00687-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 11/23/2020] [Indexed: 12/22/2022] Open
Abstract
The rapid ability of SARS-CoV-2 to spread among humans, along with the clinical complications of coronavirus disease 2019-COVID-19, have represented a significant challenge to the health management systems worldwide. The acute inflammation and coagulation abnormalities appear as the main causes for thousands of deaths worldwide. The intense inflammatory response could be involved with the formation of thrombi. For instance, the presence of uncleaved large multimers of von Willebrand (vWF), due to low ADAMTS13 activity in plasma could be explained by the inhibitory action of pro-inflammatory molecules such as IL-1β and C reactive protein. In addition, the damage to endothelial cells after viral infection and/or activation of endothelium by pro-inflammatory cytokines, such as IL-1β, IL-6, IFN-γ, IL-8, and TNF-α induces platelets and monocyte aggregation in the vascular wall and expression of tissue factor (TF). The TF expression may culminate in the formation of thrombi, and activation of cascade by the extrinsic pathway by association with factor VII. In this scenario, the phosphatidylserine-PtdSer exposure on the outer leaflet of the cell membrane as consequence of viral infection emerges as another possible underlying mechanism to acute immune inflammatory response and activation of coagulation cascade. The PtdSer exposure may be an important mechanism related to ADAM17-mediated ACE2, TNF-α, EGFR and IL-6R shedding, and the activation of TF on the surface of infected endothelial cells. In this review, we address the underlying mechanisms involved in the pathophysiology of inflammation and coagulation abnormalities. Moreover, we introduce key biochemical and pathophysiological concepts that support the possible participation of PtdSer exposure on the outer side of the SARS-CoV-2 infected cells membrane, in the pathophysiology of COVID-19. Video Abstract.
Collapse
Affiliation(s)
- Gustavo A. Argañaraz
- Laboratory of Molecular Neurovirology, Faculty of Health Science, University of Brasília, Brasília, 70910-900 Brazil
| | - Julys da Fonseca Palmeira
- Laboratory of Molecular Neurovirology, Faculty of Health Science, University of Brasília, Brasília, 70910-900 Brazil
| | - Enrique R. Argañaraz
- Laboratory of Molecular Neurovirology, Faculty of Health Science, University of Brasília, Brasília, 70910-900 Brazil
| |
Collapse
|
49
|
Delrue M, Siguret V, Neuwirth M, Joly B, Beranger N, Sène D, Chousterman BG, Voicu S, Bonnin P, Mégarbane B, Stépanian A. von Willebrand factor/ADAMTS13 axis and venous thromboembolism in moderate-to-severe COVID-19 patients. Br J Haematol 2020; 192:1097-1100. [PMID: 33368196 DOI: 10.1111/bjh.17216] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/09/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Maxime Delrue
- Department of Hematology, Lariboisière Hospital, Paris University, Paris, France.,EA 3518, Paris University, Paris, France
| | - Virginie Siguret
- Department of Hematology, Lariboisière Hospital, Paris University, Paris, France.,INSERM, UMRS 1140, Paris University, Paris, France
| | - Marie Neuwirth
- Department of Hematology, Lariboisière Hospital, Paris University, Paris, France.,INSERM, UMRS 1140, Paris University, Paris, France
| | - Bérangère Joly
- Department of Hematology, Lariboisière Hospital, Paris University, Paris, France.,EA 3518, Paris University, Paris, France
| | - Nicolas Beranger
- Department of Hematology, Lariboisière Hospital, Paris University, Paris, France.,EA 3518, Paris University, Paris, France
| | - Damien Sène
- Department of Internal Medicine, Lariboisière Hospital, Paris University, Paris, France
| | - Benjamin G Chousterman
- Department of Anesthesiology and Critical Care, Lariboisière Hospital, Paris University, Paris, France.,INSERM, UMRS 942, Université de Paris, Paris, France
| | - Sebastian Voicu
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, Paris University, Paris, France.,INSERM, UMRS 1144, Paris University, Paris, France
| | - Philippe Bonnin
- Department of Clinical Physiology, Lariboisière Hospital, Paris University, Paris, France.,INSERM U1265, INSERM, Université de Paris, Paris, France.,INSERM U1148-Laboratory for Vascular and Translational Science, Université de Paris, Paris, France
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, Paris University, Paris, France.,INSERM, UMRS 1144, Paris University, Paris, France
| | - Alain Stépanian
- Department of Hematology, Lariboisière Hospital, Paris University, Paris, France.,EA 3518, Paris University, Paris, France
| |
Collapse
|
50
|
Henry BM, Benoit SW, de Oliveira MHS, Lippi G, Favaloro EJ, Benoit JL. ADAMTS13 activity to von Willebrand factor antigen ratio predicts acute kidney injury in patients with COVID-19: Evidence of SARS-CoV-2 induced secondary thrombotic microangiopathy. Int J Lab Hematol 2020; 43 Suppl 1:129-136. [PMID: 33270980 PMCID: PMC7753610 DOI: 10.1111/ijlh.13415] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/21/2020] [Accepted: 11/10/2020] [Indexed: 12/18/2022]
Abstract
Introduction Severe COVID‐19 is often compounded by a prothrombotic state that is associated with poor outcomes. In this investigation, we aimed to evaluate ADAMTS13 activity, von Willebrand factor level (VWF:Ag), and the corresponding ADAMTS13 activity/VWF:Ag ratio, in patients with COVID‐19 and for associations with disease progression and acute kidney injury (AKI). Methods Patients presenting to the emergency department (ED) with COVID‐19 were enrolled in this prospective, observational study. ADAMTS13 activity and VWF:Ag were measured at index ED visit. The primary endpoint was severe AKI defined by KDIGO stage 2 + 3 criteria, while the secondary endpoint was peak 30‐day COVID‐19 severity. Results A total of 52 adult COVID‐19 patients were enrolled. Overall, we observed that 23.1% of the cohort had a relative deficiency in ADAMTS13 activity, while 80.8% had elevated VWF:Ag. The ADAMTS13 activity/VWF:Ag ratio was significantly lower in patients with severe AKI (P = .002) and those who developed the severe form of COVID‐19 (P = .020). The ADAMTS13 activity/VWF:Ag ratio was negatively correlated with age (P < .001) and LDH (P < .001), while positively correlated with hemoglobin (P = .041). After controlling for confounders, a one‐unit increase in ADAMTS13/VWF:Ag ratio was associated with 20% decreased odds of severe AKI. Conclusion A low ADAMTS13 activity:VWF:Ag ratio at ED presentation is associated with progression to severe COVID‐19 disease and severe AKI, with a pattern suggestive of a secondary microangiopathy. Further interventional studies should be conducted to assess the restoration of ADAMTS13:VWF:Ag ratio in hospitalized patients with COVID‐19.
Collapse
Affiliation(s)
- Brandon Michael Henry
- Cardiac Intensive Care Unit, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Stefanie W Benoit
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | | | - Giuseppe Lippi
- Section of Clinical Biochemistry, Department of Neuroscience, Biomedicine and Movement, University of Verona, Verona, Italy
| | - Emmanuel J Favaloro
- Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Justin L Benoit
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA
| |
Collapse
|