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Parente Filho SLA, Lima LMB, Dantas GLDA, Silva DDA, Rolim VDM, Oliveira Filho AMPD, Melo ITVE, Silva Junior GBD, Daher EDF. Prognostic factors among critically ill patients with community-acquired acute bacterial meningitis and acute kidney injury. Rev Bras Ter Intensiva 2018; 30:153-159. [PMID: 29995079 PMCID: PMC6031427 DOI: 10.5935/0103-507x.20180030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 01/10/2018] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To investigate prognostic factors among critically ill patients with community-acquired bacterial meningitis and acute kidney injury. METHODS A retrospective study including patients admitted to a tertiary infectious disease hospital in Fortaleza, Brazil diagnosed with community-acquired bacterial meningitis complicated with acute kidney injury. Factors associated with death, mechanical ventilation and use of vasopressors were investigated. RESULTS Forty-one patients were included, with a mean age of 41.6 ± 15.5 years; 56% were males. Mean time between intensive care unit admission and acute kidney injury diagnosis was 5.8 ± 10.6 days. Overall mortality was 53.7%. According to KDIGO criteria, 10 patients were classified as stage 1 (24.4%), 18 as stage 2 (43.9%) and 13 as stage 3 (31.7%). KDIGO 3 significantly increased mortality (OR = 6.67; 95%CI = 1.23 - 36.23; p = 0.028). Thrombocytopenia was not associated with higher mortality, but it was a risk factor for KDIGO 3 (OR = 5.67; 95%CI = 1.25 - 25.61; p = 0.024) and for mechanical ventilation (OR = 6.25; 95%CI = 1.33 - 29.37; p = 0.02). Patients who needed mechanical ventilation by 48 hours from acute kidney injury diagnosis had higher urea (44.6 versus 74mg/dL, p = 0.039) and sodium (138.6 versus 144.1mEq/L; p = 0.036). CONCLUSION Mortality among critically ill patients with community-acquired bacterial meningitis and acute kidney injury is high. Acute kidney injury severity was associated with even higher mortality. Thrombocytopenia was associated with severer acute kidney injury. Higher urea was an earlier predictor of severer acute kidney injury than was creatinine.
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Affiliation(s)
- Sérgio Luiz Arruda Parente Filho
- Programa de Pós-Graduação em Ciências Médicas, Departamento de Medicina Clínica, Hospital Universitário Walter Cantídio, Faculdade de Medicina, Universidade Federal do Ceará - Fortaleza (CE), Brasil
| | - Livia Maria Barbosa Lima
- Programa de Pós-Graduação em Ciências Médicas, Departamento de Medicina Clínica, Hospital Universitário Walter Cantídio, Faculdade de Medicina, Universidade Federal do Ceará - Fortaleza (CE), Brasil
| | - Gilberto Loiola de Alencar Dantas
- Programa de Pós-Graduação em Ciências Médicas, Departamento de Medicina Clínica, Hospital Universitário Walter Cantídio, Faculdade de Medicina, Universidade Federal do Ceará - Fortaleza (CE), Brasil
| | - Débora de Almeida Silva
- Programa de Pós-Graduação em Ciências Médicas, Departamento de Medicina Clínica, Hospital Universitário Walter Cantídio, Faculdade de Medicina, Universidade Federal do Ceará - Fortaleza (CE), Brasil
| | - Victor de Matos Rolim
- Programa de Pós-Graduação em Ciências Médicas, Departamento de Medicina Clínica, Hospital Universitário Walter Cantídio, Faculdade de Medicina, Universidade Federal do Ceará - Fortaleza (CE), Brasil
| | - Antônio Mendes Ponte de Oliveira Filho
- Programa de Pós-Graduação em Ciências Médicas, Departamento de Medicina Clínica, Hospital Universitário Walter Cantídio, Faculdade de Medicina, Universidade Federal do Ceará - Fortaleza (CE), Brasil
| | - Iamê Tavares Vale E Melo
- Programa de Pós-Graduação em Ciências Médicas, Departamento de Medicina Clínica, Hospital Universitário Walter Cantídio, Faculdade de Medicina, Universidade Federal do Ceará - Fortaleza (CE), Brasil
| | - Geraldo Bezerra da Silva Junior
- Programa de Pós-Graduação em Saúde Pública, Centro de Ciências da Saúde, Faculdade de Medicina, Universidade de Fortaleza - Fortaleza (CE), Brasil
| | - Elizabeth De Francesco Daher
- Programa de Pós-Graduação em Ciências Médicas, Departamento de Medicina Clínica, Hospital Universitário Walter Cantídio, Faculdade de Medicina, Universidade Federal do Ceará - Fortaleza (CE), Brasil
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Abstract
Adjunctive therapies have been proposed for use in at least 5 inflammation pathobiology phenotypes in pediatric sepsis-induced multiple organ failure. This article discusses host-pathogen interaction prototypes to facilitate understanding of the rationale for personalized therapy in these phenotypes. The article discusses the literature on adjunctive antiinflammatory and immune modulation therapies that, in addition to traditional organ support and infection source control, might be part of a personalized precision medicine approach to the reversal of each of these inflammatory pathobiology phenotypes.
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Sins JWR, Schimmel M, Luken BM, Nur E, Zeerleder SS, van Tuijn CFJ, Brandjes DPM, Kopatz WF, Urbanus RT, Meijers JCM, Biemond BJ, Fijnvandraat K. Dynamics of von Willebrand factor reactivity in sickle cell disease during vaso-occlusive crisis and steady state. J Thromb Haemost 2017; 15:1392-1402. [PMID: 28457019 DOI: 10.1111/jth.13728] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Indexed: 02/02/2023]
Abstract
Essentials The role of von Willebrand Factor (VWF) in the pathophysiology of sickle cell disease is unclear. We assessed markers of VWF during admission for vaso-occlusive crisis (VOC) and steady state. VWF reactivity was higher during VOC and was associated with inflammation and neutrophil activation. Hyper-adhesive VWF may promote VOC in sickle cell disease. SUMMARY Background Endothelial activation plays a central role in the pathophysiology of vaso-occlusion in sickle cell disease (SCD), facilitating adhesive interactions with circulating blood cells. Upon activation, various adhesive molecules are expressed, including von Willebrand factor (VWF). Increased VWF levels have been observed in patients with SCD during steady state. However, the role of VWF in the pathogenesis of SCD vaso-occlusion is unclear. Objectives To longitudinally assess the quantity and reactivity of VWF and its regulating protease ADAMTS-13 during vaso-occlusive crisis (VOC). Methods In this observational study, we obtained sequential blood samples in adult SCD patients during VOC. Results VWF reactivity was significantly higher during VOC (active VWF, VWF glycoprotein Ib-binding activity, and high molecular weight multimers), whereas platelet count and levels of ADAMTS-13 antigen and ADAMTS-13 activity were concomitantly lower than during steady state. Levels of VWF antigen, VWF propeptide (VWF:pp) and ADAMTS-13 specific activity did not change during VOC. VWF reactivity correlated strongly with markers of inflammation and neutrophil activation, and was inversely correlated with the platelet count. In patients who developed acute chest syndrome, levels of VWF, VWF:pp and active, hyperadhesive VWF were significantly higher, whereas ADAMTS-13 activity was lower, than in patients without this complication. Conclusions We provide the first evidence that VOC in SCD is associated with increased reactivity of VWF, without a pronounced ADAMTS-13 deficiency. This hyper-reactivity may be explained by resistance of VWF to proteolysis, secondary to processes such as inflammation and oxidative stress. Hyperadhesive VWF, scavenging blood cells in the microcirculation, may thereby amplify and sustain VOC in SCD.
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Affiliation(s)
- J W R Sins
- Department of Hematology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- Department of Pediatric Hematology, Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - M Schimmel
- Department of Hematology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - B M Luken
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - E Nur
- Department of Hematology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - S S Zeerleder
- Department of Hematology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - C F J van Tuijn
- Department of Hematology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - D P M Brandjes
- Department of Internal Medicine, Slotervaart Hospital, Amsterdam, the Netherlands
| | - W F Kopatz
- Department of Experimental Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - R T Urbanus
- Department of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - J C M Meijers
- Department of Experimental Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- Department of Plasma Proteins, Sanquin Research, Amsterdam, the Netherlands
| | - B J Biemond
- Department of Hematology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - K Fijnvandraat
- Department of Pediatric Hematology, Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- Department of Plasma Proteins, Sanquin Research, Amsterdam, the Netherlands
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Abstract
von Willebrand factor (VWF) is a large multimeric glycoprotein that mediates the attachment of platelets to damaged endothelium and also serves as the carrier protein for coagulation factor VIII (FVIII), protecting it from proteolytic degradation. Quantitative or qualitative defects in VWF result in von Willebrand disease (VWD), a common inherited bleeding disorder. VWF is synthesized with a very large propeptide (VWFpp) that is critical for intracellular processing of VWF. VWFpp actively participates in the process of VWF multimerization and is essential for trafficking of VWF to the regulated storage pathway. Mutations identified within VWFpp in VWD patients are associated with altered VWF structure and function. The assay of plasma VWFpp has clinical utility in assessing acute and chronic vascular perturbation associated with diseases such as thrombotic thrombocytopenic purpura, sepsis, and diabetes among others. VWFpp assay also has clear utility in the diagnosis of VWD subtypes, particularly in discriminating true type 3 subjects from type 1C (reduced plasma survival of VWF), which is clinically important and has implications for therapeutic treatment.
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Djamiatun K, van der Ven AJAM, de Groot PG, Faradz SMH, Hapsari D, Dolmans WMV, Sebastian S, Fijnheer R, de Mast Q. Severe dengue is associated with consumption of von Willebrand factor and its cleaving enzyme ADAMTS-13. PLoS Negl Trop Dis 2012; 6:e1628. [PMID: 22563509 PMCID: PMC3341341 DOI: 10.1371/journal.pntd.0001628] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Accepted: 03/08/2012] [Indexed: 12/27/2022] Open
Abstract
Background Thrombocytopenia, bleeding and plasma leakage are cardinal features of severe dengue. Endothelial cell activation with exocytosis of Weibel-Palade bodies (WPBs) may play an etiological role in this condition. Methods and Principal Findings In a cohort of 73 Indonesian children with dengue hemorrhagic fever (DHF), of which 30 with dengue shock syndrome (DSS), we measured plasma levels of the WPB constituents von Willebrand factor antigen (VWF:Ag), VWF propeptide and osteoprotegerin (OPG), together with activity levels of the VWF-cleaving enzyme ADAMTS-13 and the amount of VWF in a platelet binding conformation (VWF activation factor). Compared with healthy controls (n = 17), children with DHF/DSS had significantly higher levels of VWF:Ag, VWF propeptide and OPG and decreased ADAMTS-13 activity. The VWF activation factor was also significantly higher in DHF/DSS and highest in children who died. There were significant differences in the kinetics of the various WPB constituents: VWF propeptide and OPG levels decreased toward discharge, while VWF:Ag levels were lower than expected at enrollment with plasma levels increasing toward discharge. Moreover, VWF propeptide levels correlated better with markers of disease severity (platelet count, liver enzymes, serum albumin and pleural effusion index) than corresponding VWF levels. Together, these findings suggest that there is consumption of VWF in DHF/DSS. In 4 out of 15 selected children with low ADAMTS-13 levels on admission, we found a remarkable reduction in the large and intermediate VWF multimers in the discharge blood samples, consistent with an acquired von Willebrand disease. Conclusion These findings suggest that severe dengue is associated with exocytosis of WPBs with increased circulating levels of VWF:Ag, VWF propeptide and OPG. High circulating levels of VWF in its active conformation, together with low ADAMTS-13 activity levels, are likely to contribute to the thrombocytopenia and complications of dengue. During the convalescence phase, qualitative defects in VWF with loss of larger VWF multimers may develop. Severe dengue infections are characterized by thrombocytopenia, clinical bleeding and plasma leakage. Activation of the endothelium, the inner lining of blood vessels, leads to the secretion of storage granules called Weibel Palade bodies (WPBs). We demonstrated that severe dengue in Indonesian children is associated with a strong increase in plasma levels of the WPB constituents von Willebrand factor (VWF), VWF propeptide and osteoprotegerin (OPG). An increased amount of the hemostatic protein VWF was in a hyperreactive, platelet binding conformation, and this was most pronounced in the children who died. VWF levels at enrollment were lower than expected from concurrent VWF propeptide and OPG levels and VWF levels did not correlate well with markers of disease severity. Together, this suggests that VWF is being consumed during severe dengue. Circulating levels of the VWF-cleaving enzyme ADAMTS-13 were reduced. VWF is a multimeric protein and a subset of children had a decrease in large and intermediate VWF multimers at discharge. In conclusion, severe dengue is associated with exocytosis of WPBs with consumption of VWF and low ADAMTS-13 activity levels. This may contribute to the thrombocytopenia and complications of dengue.
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Affiliation(s)
- Kis Djamiatun
- Department of Parasitology, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Andre J. A. M. van der Ven
- Department of General Internal Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Philip G. de Groot
- Laboratory for Thrombosis and Haemostasis, Department of Clinical Chemistry and Haematology, University Medical Centre, Utrecht, The Netherlands
| | - Sultana M. H. Faradz
- Division of Human Genetics, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - D. Hapsari
- Department of Pediatrics, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Wil M. V. Dolmans
- Department of General Internal Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Silvie Sebastian
- Laboratory for Thrombosis and Haemostasis, Department of Clinical Chemistry and Haematology, University Medical Centre, Utrecht, The Netherlands
| | - Rob Fijnheer
- Laboratory for Thrombosis and Haemostasis, Department of Clinical Chemistry and Haematology, University Medical Centre, Utrecht, The Netherlands
| | - Quirijn de Mast
- Department of General Internal Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
- * E-mail:
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Hollestelle MJ, Lai KW, van Deuren M, Lenting PJ, de Groot PG, Sprong T, Bovenschen N. Cleavage of von Willebrand factor by granzyme M destroys its factor VIII binding capacity. PLoS One 2011; 6:e24216. [PMID: 21909423 PMCID: PMC3164717 DOI: 10.1371/journal.pone.0024216] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Accepted: 08/03/2011] [Indexed: 12/27/2022] Open
Abstract
Von Willebrand factor (VWF) is a pro-hemostatic multimeric plasma protein that promotes platelet aggregation and stabilizes coagulation factor VIII (FVIII) in plasma. The metalloproteinase ADAMTS13 regulates the platelet aggregation function of VWF via proteolysis. Severe deficiency of ADAMTS13 is associated with thrombotic thrombocytopenic purpura, but does not always correlate with its clinical course. Therefore, other proteases could also be important in regulating VWF activity. In the present study, we demonstrate that VWF is cleaved by the cytotoxic lymphocyte granule component granzyme M (GrM). GrM cleaved both denaturated and soluble plasma-derived VWF after Leu at position 276 in the D3 domain. GrM is unique in that it did not affect the multimeric size and pro-hemostatic platelet aggregation ability of VWF, but instead destroyed the binding of VWF to FVIII in vitro. In meningococcal sepsis patients, we found increased plasma GrM levels that positively correlated with an increased plasma VWF/FVIII ratio in vivo. We conclude that, next to its intracellular role in triggering apoptosis, GrM also exists extracellularly in plasma where it could play a physiological role in controlling blood coagulation by determining plasma FVIII levels via proteolytic processing of its carrier VWF.
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Affiliation(s)
- Martine J Hollestelle
- Department of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht, The Netherlands.
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