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Yao Y, Zhao X, Wang M, Zhou F, Li C, Le X, Zhang S. Association between the use of statins and in-hospital mortality risk in patients with sepsis-induced coagulopathy during ICU stays: a study based on medical information mart for intensive care database. BMC Infect Dis 2024; 24:738. [PMID: 39061029 PMCID: PMC11282707 DOI: 10.1186/s12879-024-09636-y] [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: 03/12/2024] [Accepted: 07/19/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND The objective of this study was to explore the correlation between statin administration in the intensive care unit (ICU) setting and the in-hospital mortality risk of patients suffering from sepsis-induced coagulopathy (SIC). METHODS Utilizing a retrospective cohort study design, this investigation collected data from the Medical Information Mart for Intensive Care (MIMIC)-IV spanning 2008 to 2019. The diagnosis of SIC was established based on a SIC score of 4 or above. Statin usage during the ICU period was extracted from the prescription records based on the keywords of statin medications. The primary endpoint analyzed was the in-hospital mortality within the ICU, characterized by any death occurring during the ICU admission. RESULTS During the follow-up, which had a median duration of approximately 7.28 days, 18.19% of the 4,777 SIC patients died in the ICU. Statin was linked with a decrease in the risk of in-hospital mortality for SIC patients in the ICU [hazard ratio (HR): 0.73, 95% confidence interval (CI): 0.60-0.89, P = 0.002]. Relative to rosuvastatin, the use of atorvastatin (HR: 0.54, 95% CI: 0.34-0.85, P = 0.008) or simvastatin (HR: 0.55, 95% CI: 0.33-0.92, P = 0.024), as well as combinations of multiple statins (HR: 0.36, 95% CI: 0.15-0.86, P = 0.022), was associated with a reduction in ICU in-hospital mortality risk. Subgroup analysis also suggested that the use of atorvastatin, simvastatin, or a combination of statins had an advantage over rosuvastatin in reducing ICU in-hospital mortality in SIC patients older than 65 years of age or SIC patients with respiratory failure or cardiogenic shock (all P < 0.05). CONCLUSION The present study supports the potential benefits of statin use in mortality in SIC patients during ICU stays. The study encourages clinicians to consider the benefits of statins and supports the ongoing exploration of statins for enhanced outcomes in critical care settings.
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Affiliation(s)
- Yan Yao
- Intensive Care Unit, Hangzhou Xixi Hospital Affiliated to Zhejiang Chinese Medical University, 2 Hengbu Street, Liuhe Road, Xihu District, Hangzhou city, 310023, Zhejiang province, P.R. China
| | - Xi Zhao
- Intensive Care Unit, Hangzhou Xixi Hospital Affiliated to Zhejiang Chinese Medical University, 2 Hengbu Street, Liuhe Road, Xihu District, Hangzhou city, 310023, Zhejiang province, P.R. China
| | - Mengjue Wang
- Intensive Care Unit, Hangzhou Xixi Hospital Affiliated to Zhejiang Chinese Medical University, 2 Hengbu Street, Liuhe Road, Xihu District, Hangzhou city, 310023, Zhejiang province, P.R. China
| | - Fanfan Zhou
- Intensive Care Unit, Hangzhou Xixi Hospital Affiliated to Zhejiang Chinese Medical University, 2 Hengbu Street, Liuhe Road, Xihu District, Hangzhou city, 310023, Zhejiang province, P.R. China
| | - Chengfeng Li
- Department of Emergency, Hangzhou Xixi Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, China
| | - Xudong Le
- Department of Emergency, Hangzhou Xixi Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, China
| | - Siquan Zhang
- Intensive Care Unit, Hangzhou Xixi Hospital Affiliated to Zhejiang Chinese Medical University, 2 Hengbu Street, Liuhe Road, Xihu District, Hangzhou city, 310023, Zhejiang province, P.R. China.
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Li Y, Zhang L, Wang Y, Gao M, Zhang C, Zhang Y, Zhang D. Development and Validation of a Nomogram for Predicting Sepsis-Induced Coagulopathy in Septic Patients: Mixed Retrospective and Prospective Cohort Study. Thromb Haemost 2024. [PMID: 38959956 DOI: 10.1055/a-2359-2563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
BACKGROUND Sepsis-induced coagulopathy (SIC) is a common cause of poor prognosis in critically ill patients in the intensive care unit (ICU). However, currently there are no tools specifically designed for predicting the occurrence of SIC in septic patients earlier. This study aimed to develop a predictive nomogram incorporating clinical markers and scoring systems to individually predict the probability of SIC in septic patients. METHODS Patients consecutively recruited in the stage between January 2022 and April 2023 constituted the development cohort for retrospective analysis to internally test the nomogram, and patients in the stage between May 2023 to November 2023 constituted the validation cohort for prospective analysis to externally validate the nomogram. Univariate logistic regression analysis of the development cohort was performed firstly, and then multivariate logistic regression analysis was performed using backward stepwise method to determine the best-fitting model and obtain the nomogram from it. The nomogram was validated in an independent external validation cohort, involving discrimination and calibration. A decision curve analysis was also performed to evaluate the net benefit of the insertion decision with this nomogram. RESULTS A total of 548 and 245 patients, 55.1 and 49.4% with SIC occurrence, were included in the development and validation cohorts, respectively. Predictors contained in the prediction nomogram included shock, platelets, and international normalized ratio (INR). Patients with shock (odds ratio [OR]: 4.499; 95% confidence interval [CI]: 2.730-7.414; p < 0.001), higher INR (OR: 349.384; 95% CI: 62.337-1958.221; p < 0.001), and lower platelet (OR: 0.985; 95% CI: 0.982-0.988; p < 0.001) had higher probabilities of SIC. The development model showed good discrimination, with an area under the receiver operating characteristic curve (AUROC) of 0.879 (95% CI: 0.850-0.908) and good calibration. Application of the nomogram in the validation cohort also gave good discrimination with an AUROC of 0.872 (95% CI: 0.826-0.917) and good calibration. The decision curve analysis of the nomogram provided better net benefit than the alternate options (intervention or no intervention). CONCLUSION By incorporating shock, platelets, and INR in the model, this useful nomogram could be accessibly utilized to predict SIC occurrence in septic patients. However, external validation is still required for further generalizability improvement of this nomogram.
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Affiliation(s)
- Yuting Li
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Liying Zhang
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Youquan Wang
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Meng Gao
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Chaoyang Zhang
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yuhan Zhang
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Dong Zhang
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, Jilin, China
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Ushio N, Yamakawa K, Mochizuki K, Hisamune R, Umemura Y, Takasu A. Efficacy of unfractionated heparin in patients with moderate sepsis-induced coagulopathy: An observational study. Thromb Res 2024; 241:109095. [PMID: 39024902 DOI: 10.1016/j.thromres.2024.109095] [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: 05/08/2024] [Revised: 06/22/2024] [Accepted: 07/05/2024] [Indexed: 07/20/2024]
Abstract
INTRODUCTION The 2021 Surviving Sepsis Campaign guidelines recommend low-molecular-weight heparin for the prevention of venous thromboembolism in sepsis. However, observational studies suggest that anticoagulants as a whole may benefit severely ill sepsis patients with coagulopathy, but the optimal targets of unfractionated heparin remain unclear. This study investigated which sepsis patients could most benefit from unfractionated heparin. MATERIALS AND METHODS In this retrospective observational study, we identified adult sepsis patients requiring urgent hospitalization from 2006 to 2019 using a large-scale Japanese medical database. Patients were divided into two groups: those receiving unfractionated heparin within 72 h of admission and those who did not. We compared in-hospital mortality, major bleeding complications, and thromboembolic events between these groups using a multivariate logistic regression model adjusted for patient and treatment variables. Additionally, we assessed the association between heparin administration and in-hospital mortality across various subgroups. RESULTS Among 30,342 sepsis patients, 2520 received early heparin administration, and 27,822 did not. Multivariate logistic regression revealed a significant association between heparin and reduced in-hospital mortality (adjusted OR: 0.735, 95 % CI: 0.596-0.903) but no significant association with major bleeding and thromboembolic risk (adjusted OR: 1.137, 1.243; 95 % CI: 0.926-1.391, 0.853-1.788, respectively). Subgroup analyses suggested significant survival benefits associated with heparin only in the sepsis patients with moderate coagulopathy and sepsis-induced coagulopathy scores of 3 or 4 (adjusted OR: 0.452, 0.625; 95 % CI: 0.265-0.751, 0.410-0.940, respectively). CONCLUSIONS Early heparin administration upon admission is associated with lower in-hospital mortality, especially in moderate sepsis-induced coagulopathy, and no significant increase in complications.
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Affiliation(s)
- Noritaka Ushio
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Japan.
| | - Kazuma Yamakawa
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Japan.
| | - Katsunori Mochizuki
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Japan.
| | - Ryo Hisamune
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Japan.
| | - Yutaka Umemura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan.
| | - Akira Takasu
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Japan.
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4
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Wang Z, Dong S, Qin Y. The Relationship Between Acute Kidney Injury in Sepsis Patients and Coagulation Dysfunction and Prognosis. Open Access Emerg Med 2024; 16:145-157. [PMID: 38979546 PMCID: PMC11228537 DOI: 10.2147/oaem.s453632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 06/11/2024] [Indexed: 07/10/2024] Open
Abstract
Purpose The aim of this study was to investigate the relationship between ARF and coagulopathy in patients with sepsis and to explore the prognostic value of these conditions. Patients and Methods The data of 271 patients with sepsis-associated coagulopathy admitted from June 2021 to June 2022 were reviewed. The patients were divided into a survival group and a nonsurviving group according to patient prognosis. Independent sample t tests were utilized to compare laboratory parameters within 24 hours of admission, as well as the APACHE II and SOFA scores, between the two patient groups. According to the sepsis-associated coagulation dysfunction (SAC) grading criteria for grading, Spearman correlation analysis was used to study the relationship between blood creatinine and SAC grading and assignment scores, and receiver operating characteristic (ROC) curves and Cox's proportional risk regression model were used to explore the factors affecting the prognosis of SAC patients. Results Spearman correlation analysis revealed strong associations between serum creatinine (Scr) concentration, SAC classification, and SAC score, with coefficients above 0.7. SAC classification outcomes varied significantly with severity: mild severity had a 77.6% survival rate versus 22.4% mortality; moderate severity had 21.5% survival versus 78.5% mortality; and severe cases had a 0.7% survival rate versus 99.3% mortality (P<0.01 for all). Multivariate analysis revealed significant predictors of outcome, including multiple organ dysfunction syndrome (MODS), with an OR of 2.070 (P=0.019); the SOFA score (OR=1.200, P<0.01); the international normalized ratio (INR) (OR=0.72, P=0.013); and the Scr level (OR=0.995, P<0.01). The areas under the ROC curves for the SOFA score, APACHE II score, and SAC classification were >0.8, all P < 0.05. Conclusion In patients with sepsis, SAC grade 3 or a SAC score of 4 or higher is associated with poorer prognosis, and the interaction of acute kidney injury exacerbates the degree of SAC, consequently affecting prognosis.
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Affiliation(s)
- Zhenyi Wang
- Department of Emergency, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, People's Republic of China
| | - Shimin Dong
- Department of Emergency, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, People's Republic of China
| | - Yanjun Qin
- Department of Emergency, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, People's Republic of China
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5
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Helms J, Iba T, Angles-Cano E. Harnessing the power of hemostasis testing in intensive care unit. Intensive Care Med 2024; 50:1146-1148. [PMID: 38695927 DOI: 10.1007/s00134-024-07430-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/02/2024] [Indexed: 07/14/2024]
Affiliation(s)
- Julie Helms
- Faculté de Médecine, Service de Médecine Intensive-Réanimation, Université de Strasbourg (UNISTRA), Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, 1, Place de L'Hôpital, 67091, Strasbourg Cedex, France.
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France.
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Eduardo Angles-Cano
- Université Paris Cité-INSERM U-1140, Innovative Therapies in Haemostasis, 75006, Paris, France
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Scarlatescu E, Iba T, Maier CL, Moore H, Othman M, Connors JM, Levy JH. Deranged Balance of Hemostasis and Fibrinolysis in Disseminated Intravascular Coagulation: Assessment and Relevance in Different Clinical Settings. Anesthesiology 2024:141586. [PMID: 38861325 DOI: 10.1097/aln.0000000000005023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
The disruption of hemostasis/fibrinolysis balance leads to disseminated intravascular coagulation, manifested clinically by bleeding or thrombosis, and multiorgan failure. This study reviews hemostatic assessment and therapeutic strategies that restore this balance in critically ill patients.
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Affiliation(s)
- Ecaterina Scarlatescu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania; and Department of Anaesthesia and Intensive Care, Fundeni Clinical Institute, Bucharest, Romania
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Hunter Moore
- Department of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada; School of Baccalaureate Nursing, St. Lawrence College, Kingston, Ontario, Canada; and Clinical Pathology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Jean Marie Connors
- Hematology Division Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina
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7
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Iba T, Levy JH, Maier CL, Connors JM, Levi M. Four years into the pandemic, managing COVID-19 patients with acute coagulopathy: what have we learned? J Thromb Haemost 2024; 22:1541-1549. [PMID: 38428590 DOI: 10.1016/j.jtha.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/14/2024] [Accepted: 02/20/2024] [Indexed: 03/03/2024]
Abstract
Coagulopathy alongside micro- and macrovascular thrombotic events were frequent characteristics of patients presenting with acute COVID-19 during the initial stages of the pandemic. However, over the past 4 years, the incidence and manifestations of COVID-19-associated coagulopathy have changed due to immunity from natural infection and vaccination and the appearance of new SARS-CoV-2 variants. Diagnostic criteria and management strategies based on early experience and studies for COVID-19-associated coagulopathy thus require reevaluation. As many other infectious disease states are also associated with hemostatic dysfunction, the coagulopathy associated with COVID-19 may be compounded, especially throughout the winter months, in patients with diverse etiologies of COVID-19 and other infections. This commentary examines what we have learned about COVID-19-associated coagulopathy throughout the pandemic and how we might best prepare to mitigate the hemostatic consequences of emerging infection agents.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jean M Connors
- Hematology Division Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marcel Levi
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands; Department of Medicine, University College London Hospitals NHS Foundation Trust, Cardio-metabolic Programme-National Institute for Health and Care Research University College London Hospitals/University College London Biomedical Research Center, London, United Kingdom
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8
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Duan J, Ye T, Yang Y, Zhou Y, Yang S, Wang Y. A case report of sepsis associated coagulopathy after percutaneous nephrostomy. BMC Urol 2024; 24:113. [PMID: 38807082 PMCID: PMC11131197 DOI: 10.1186/s12894-024-01476-x] [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: 10/25/2023] [Accepted: 04/03/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Hemorrhage is a common complication of nephrostomy and percutaneous nephrolithotripsy, and it is caused by surgical factors. Here we report a rare case of hemorrhage caused by sepsis-related coagulation dysfunction. CASE PRESENTATION A 72-years-old male patient with bilateral ureteral calculi accompanied by hydronephrosis and renal insufficiency developed sepsis and hemorrhage on the third day after bilateral nephrostomy. After vascular injury was excluded by DSA, the hemorrhage was considered to be sepsis-associated coagulopathy(SAC/SIC), finally the patient recovered well after active symptomatic treatment. CONCLUSIONS In patients with sepsis and hemorrhage, SAC/SIC cannot be excluded even if coagulation function is slightly abnormal after surgical factors are excluded. For urologists who may encounter similar cases in their general urology practice, it is important to be aware of these unusual causes of hemorrhage.
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Affiliation(s)
- Juan Duan
- Department of urology, 920thhospital of Joint Logistics Support Force, Kunming, PLA, China
| | - Tao Ye
- Department of urology, 920thhospital of Joint Logistics Support Force, Kunming, PLA, China
| | - Yueyue Yang
- Department of urology, 920thhospital of Joint Logistics Support Force, Kunming, PLA, China
| | - Yiping Zhou
- Department of urology, 920thhospital of Joint Logistics Support Force, Kunming, PLA, China
| | - Shengyu Yang
- Department of urology, 920thhospital of Joint Logistics Support Force, Kunming, PLA, China
| | - Yueli Wang
- Department of urology, 920thhospital of Joint Logistics Support Force, Kunming, PLA, China.
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Yamakawa K, Umemura Y, Mochizuki K, Matsuoka T, Wada T, Hayakawa M, Iba T, Ohtomo Y, Okamoto K, Mayumi T, Ikeda T, Ishikura H, Ogura H, Kushimoto S, Saitoh D, Gando S. Proposal and Validation of a Clinically Relevant Modification of the Japanese Association for Acute Medicine Disseminated Intravascular Coagulation Diagnostic Criteria for Sepsis. Thromb Haemost 2024. [PMID: 38729189 DOI: 10.1055/s-0044-1786808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
BACKGROUND Japanese Association for Acute Medicine (JAAM) disseminated intravascular coagulation (DIC) criteria were launched nearly 20 years ago. Following the revised conceptual definition of sepsis and subsequent omission of systemic inflammatory response syndrome (SIRS) score from the latest sepsis diagnostic criteria, we omitted the SIRS score and proposed a modified version of JAAM DIC criteria, the JAAM-2 DIC criteria. OBJECTIVES To validate and compare performance between new JAAM-2 DIC criteria and conventional JAAM DIC criteria for sepsis. METHODS We used three datasets containing adult sepsis patients from a multicenter nationwide Japanese cohort study (J-septic DIC, FORECAST, and SPICE-ICU registries). JAAM-2 DIC criteria omitted the SIRS score and set the cutoff value at ≥3 points. Receiver operating characteristic (ROC) analyses were performed between the two DIC criteria to evaluate prognostic value. Associations between in-hospital mortality and anticoagulant therapy according to DIC status were analyzed using propensity score weighting to compare significance of the criteria in determining introduction of anticoagulants against sepsis. RESULTS Final study cohorts of the datasets included 2,154, 1,065, and 608 sepsis patients, respectively. ROC analysis revealed that curves for both JAAM and JAAM-2 DIC criteria as predictors of in-hospital mortality were almost consistent. Survival curves for the anticoagulant and control groups in the propensity score-weighted prediction model diagnosed using the two criteria were also almost entirely consistent. CONCLUSION JAAM-2 DIC criteria were equivalent to JAAM DIC criteria regarding prognostic and diagnostic values for initiating anticoagulation. The newly proposed JAAM-2 DIC criteria could be potentially alternative criteria for sepsis management.
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Affiliation(s)
- Kazuma Yamakawa
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Yutaka Umemura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Katsunori Mochizuki
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
- Department of Emergency and Critical Care Medicine, Azumino Red Cross Hospital, Nagano, Japan
| | - Tadashi Matsuoka
- Department of Emergency and Critical Care Medicine, Keio University, Tokyo, Japan
| | - Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Mineji Hayakawa
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | | | - Kohji Okamoto
- Department of Surgery, Kitakyushu City Yahata Hospital, Kitakyushu, Japan
| | - Toshihiko Mayumi
- Department of Intensive Care Unit, Japan Community Healthcare Organization Chukyo Hospital, Nagoya, Japan
| | - Toshiaki Ikeda
- Division of Critical Care and Emergency Medicine, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Hiroyasu Ishikura
- Department of Emergency and Critical Care Medicine, Fukuoka University, Fukuoka, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Daizoh Saitoh
- Graduate School of Emergency Medical System, Kokushikan University, Tama, Japan
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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10
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Fowler CA, Roddy M, Havlicek E, Sochet AA. Vitamin K Prescribing Trends Among Critically Ill Children Hospitalized for Sepsis: A Multicenter Observational Cohort Study. J Intensive Care Med 2024:8850666241252419. [PMID: 38711324 DOI: 10.1177/08850666241252419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Objective: Vitamin K (VK) is commonly prescribed for pediatric sepsis-induced coagulopathy without trial-derived evidence to support its use for this indication. The purpose of this study was to characterize national prescribing trends for VK in this population. Patients and Methods: This is a multicenter retrospective cohort study using the Pediatric Health Information System registry including children 0 to 17 years of age hospitalized for sepsis in the pediatric intensive care unit from January 2016 through December 2022. The primary outcome was overall, annual, and center-specific VK prescribing rates. Descriptive data included demographics, length of stay, and rates of VK deficiency, hepatic insufficiency, red blood cell (RBC) transfusion, venous thromboembolism (VTE), and mortality. VK prescribing trends were assessed using Joinpoint regression. Descriptive statistics employed included Wilcoxon rank-sum, student's t, and chi-square tests. Results: Of the 31 221 encounters studied, 4539 (14.6%) were prescribed VK (median center-specific rate: 14.2%; interquartile range [IQR]: 8.8-21%) with a linear annual trend decreasing from 17.3% in 2016 to 13.3% in 2022 (-0.6%/year, r2 = .661). Those prescribed VK had greater rates of hepatic dysfunction (20.5% vs 3.1%), RBC transfusion (26.5% vs 11.2%), VTE (12.5% vs 4.6%), mortality (17.1% vs 4.4%), and median length of stay (16 [IQR: 8-33] vs 8 [4-15] days) (all P < .001). VK deficiency was diagnosed in 0.2% of encounters. Conclusions: In this multicenter retrospective cohort, VK prescribing was common among critically ill children diagnosed with sepsis. Phased trials are needed to demonstrate clinical efficacy and safety for VK in this population.
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Affiliation(s)
- Corey A Fowler
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Meghan Roddy
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Elizabeth Havlicek
- Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Anthony A Sochet
- Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa, FL, USA
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
- Department of Medicine, Division of Pediatric Critical Care Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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11
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Ichikawa S, Araki S, Shimizu D, Kusuhara K, Shirahata A, Ochiai M, Ibara S. A survey of the current status of neonatal disseminated intravascular coagulation in neonatal intensive care units in Kyushu, Japan. Pediatr Neonatol 2024; 65:237-241. [PMID: 37957048 DOI: 10.1016/j.pedneo.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/08/2023] [Accepted: 04/26/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Neonatal disseminated intravascular coagulation (DIC) is a rare disease with a poor outcome. However, data on the incidence, treatment, and outcome of neonatal DIC are scarce. Thus, this study investigated the status of neonatal DIC in Japan. METHODS We sent a retrospective questionnaire-based survey regarding the status of diagnosis and treatment of neonatal DIC from January 1, 2016, to December 31, 2018, to 30 hospitals in Kyushu with a neonatal-perinatal medicine division. The data collected by the questionnaire survey included information about the patients diagnosed with neonatal DIC. RESULTS Among the 13,582 neonates surveyed, 120 (0.9 %) were diagnosed with DIC. Of them, clinical data were available for 105 cases. There were 11 deaths (mortality rate: 10.4 %), with the most common underlying condition being infection (n = 9), followed by neonatal asphyxia and hematologic disease (both, n = 1). Compared with the survival group, the death group had more infections, as well as a higher rate of bleeding symptoms and organ dysfunction. CONCLUSIONS Neonatal DIC associated with infectious diseases has a poor outcome. Therefore, it is necessary to formulate diagnostic and treatment guidelines for early intervention in such cases.
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Affiliation(s)
- Shun Ichikawa
- Department of Pediatrics, Hospital of the University of Occupational and Environmental Health, Kitakyushu, Japan.
| | - Shunsuke Araki
- Department of Pediatrics, Hospital of the University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Daisuke Shimizu
- Department of Pediatrics, Hospital of the University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Koichi Kusuhara
- Department of Pediatrics, Hospital of the University of Occupational and Environmental Health, Kitakyushu, Japan
| | | | - Masayuki Ochiai
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Satoshi Ibara
- Department of Neonatology, Perinatal Medical Center, Kagoshima City Hospital, Kagoshima, Japan
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12
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Lin C, Wang J, Cai K, Luo Y, Wu W, Lin S, Lin Z, Feng S. Elevated Activated Partial Thromboplastin Time as a Predictor of 28-Day Mortality in Sepsis-Associated Acute Kidney Injury: A Retrospective Cohort Analysis. Int J Gen Med 2024; 17:1739-1753. [PMID: 38706747 PMCID: PMC11069355 DOI: 10.2147/ijgm.s459583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 04/21/2024] [Indexed: 05/07/2024] Open
Abstract
Purpose To address the critical mortality rates among sepsis-associated acute kidney injury (SA-AKI) patients, early prognosis is vital. This study investigates the relationship between coagulation indices and the 28-day mortality rate in patients with SA-AKI. Patients and Methods This study was a retrospective cohort analysis including patients with SA-AKI admitted to the First Hospital of Fujian Medical University as a training cohort (n = 119) and patients admitted to the Third People's Hospital of Fujian University of Traditional Chinese Medicine as a validation cohort (n = 51). We examined the relationship between coagulation indices and 28-day mortality in SA-AKI, the cumulative mortality at different activated partial thromboplastin time (APTT) levels, and the nonlinear relationship between APTT and 28-day mortality. Receiver operating characteristic curves were plotted, and the area under the curve was calculated to assess the predictive power of APTT. Finally, subgroup analyses were performed to assess the robustness of the association. Results Overall, 119 participants with a mean±standard deviation age of 70.47±15.20 years were included in the training cohort: 54 died, 65 survived. According to univariate and multivariate COX regression analyses, APACHE II score, CRP level, Lac level, and APTT level were independent risk factors for 28-day adverse prognosis. After controlling for some variables, an elevated baseline APTT (≥ 37.7 s) was associated with an elevated risk of 28-day mortality (HR, 1.017; 95% CI, 1.001-1.032), and Kaplan-Meier analyses further confirmed the increased mortality in the group with a higher APTT. The same results were shown when the validation cohort was analyzed (HR, 1.024; 95% CI, 0.958-1.096). Subgroup analyses showed the stability of the association between APTT and poor prognosis in SA-AKI. Conclusion In essence, APTT elevation is synonymous with increased 28-day mortality rates, indicating a poor prognosis in SA-AKI scenarios.
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Affiliation(s)
- Chen Lin
- Department of Emergency, The Third Affiliated People’s Hospital, Fujian University of Traditional Chinese Medicine, Fuzhou, 350108, People’s Republic of China
| | - Jing Wang
- Department of Emergency, The First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, People’s Republic of China
| | - Kexin Cai
- Department of Emergency, The First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, People’s Republic of China
| | - Yuqing Luo
- Department of Emergency, The First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, People’s Republic of China
| | - Wensi Wu
- Department of Emergency, The Third Affiliated People’s Hospital, Fujian University of Traditional Chinese Medicine, Fuzhou, 350108, People’s Republic of China
| | - Siming Lin
- Department of Emergency, The First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, People’s Republic of China
| | - Zhihong Lin
- Department of Emergency, The First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, People’s Republic of China
| | - Shaodan Feng
- Department of Emergency, The First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, People’s Republic of China
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13
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Liu X, Niu H, Peng J. Improving predictions: Enhancing in-hospital mortality forecast for ICU patients with sepsis-induced coagulopathy using a stacking ensemble model. Medicine (Baltimore) 2024; 103:e37634. [PMID: 38579092 PMCID: PMC10994494 DOI: 10.1097/md.0000000000037634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/26/2024] [Indexed: 04/07/2024] Open
Abstract
The incidence of sepsis-induced coagulopathy (SIC) is high, leading to increased mortality rates and prolonged hospitalization and intensive care unit (ICU) stays. Early identification of SIC patients at risk of in-hospital mortality can improve patient prognosis. The objective of this study is to develop and validate machine learning (ML) models to dynamically predict in-hospital mortality risk in SIC patients. A ML model is established based on the Medical Information Mart for Intensive Care IV (MIMIC-IV) database to predict in-hospital mortality in SIC patients. Utilizing univariate feature selection for feature screening. The optimal model was determined by calculating the area under the curve (AUC) with a 95% confidence interval (CI). The optimal model was interpreted using Shapley Additive Explanation (SHAP) values. Among the 3112 SIC patients included in MIMIC-IV, a total of 757 (25%) patients experienced mortality during their ICU stay. Univariate feature selection helps us to pick out the 20 most critical variables from the original feature. Among the 10 developed machine learning models, the stacking ensemble model exhibited the highest AUC (0.795, 95% CI: 0.763-0.827). Anion gap and age emerged as the most significant features for predicting the mortality risk in SIC. In this study, an ML model was constructed that exhibited excellent performance in predicting in-hospital mortality risk in SIC patients. Specifically, the stacking ensemble model demonstrated superior predictive ability.
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Affiliation(s)
- Xuhui Liu
- Youjiang Medical University for Nationalities, Baise, China
- Baise People’s Hospital, Baise, China
| | - Hao Niu
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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14
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Williams B, Zou L, Pittet JF, Chao W. Sepsis-Induced Coagulopathy: A Comprehensive Narrative Review of Pathophysiology, Clinical Presentation, Diagnosis, and Management Strategies. Anesth Analg 2024; 138:696-711. [PMID: 38324297 PMCID: PMC10916756 DOI: 10.1213/ane.0000000000006888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 02/08/2024]
Abstract
Physiological hemostasis is a balance between pro- and anticoagulant pathways, and in sepsis, this equilibrium is disturbed, resulting in systemic thrombin generation, impaired anticoagulant activity, and suppression of fibrinolysis, a condition termed sepsis-induced coagulopathy (SIC). SIC is a common complication, being present in 24% of patients with sepsis and 66% of patients with septic shock, and is often associated with poor clinical outcomes and high mortality. 1 , 2 Recent preclinical and clinical studies have generated new insights into the molecular pathogenesis of SIC. In this article, we analyze the complex pathophysiology of SIC with a focus on the role of procoagulant innate immune signaling in hemostatic activation--tissue factor production, thrombin generation, endotheliopathy, and impaired antithrombotic functions. We also review clinical presentations of SIC, the diagnostic scoring system and laboratory tests, the current standard of care, and clinical trials evaluating the efficacies of anticoagulant therapies.
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Affiliation(s)
- Brittney Williams
- From the Division of Cardiothoracic Anesthesia, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
- Translational Research Program, Department of Anesthesiology & Center for Shock, Trauma and Anesthesiology Research (STAR), University of Maryland School of Medicine, Baltimore, Maryland
| | - Lin Zou
- Translational Research Program, Department of Anesthesiology & Center for Shock, Trauma and Anesthesiology Research (STAR), University of Maryland School of Medicine, Baltimore, Maryland
| | - Jean-Francois Pittet
- Division of Critical Care, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Wei Chao
- Translational Research Program, Department of Anesthesiology & Center for Shock, Trauma and Anesthesiology Research (STAR), University of Maryland School of Medicine, Baltimore, Maryland
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15
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Bai H, Shen L, Zhang H, Tang N. Clinical value of TAT, PIC and t-PAIC as predictive markers for severe sepsis in pediatric patients. Front Pediatr 2024; 12:1336583. [PMID: 38562140 PMCID: PMC10982468 DOI: 10.3389/fped.2024.1336583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/26/2024] [Indexed: 04/04/2024] Open
Abstract
Objective Sepsis in pediatric patients can progress to severe sepsis, and identifying biomarkers of this progression may permit timely intervention to prevent it. This study aimed to investigate the ability of thrombin-antithrombin complex (TAT), α2-plasmininhibitor-plasmin complex (PIC) and tissue-type plasminogen activator-inhibitor complex (t-PAIC) to predict severe sepsis in pediatrics early. Methods 148 eligible pediatric sepsis patients were enrolled in this study, and were then divided into those who progressed to severe sepsis (n = 50) or not (n = 98). Serum levels of TAT, PIC, and t-PAIC were analysed, and simplified pediatric critical illness score (PCIS) and DIC score were calculated on the day of pediatric sepsis diagnosis. Results Compared with sepsis patients, severe sepsis patients had higher levels of TAT, PIC and t-PAIC. Correlation analysis revealed that TAT, PIC and t-PAIC were significantly correlated with simplified PCIS and DIC score. ROC curve analysis suggested that TAT, PIC and t-PAIC could serve as biomarkers for predicting severe sepsis with the AUC up to 0.862, 0.759 and 0.851, respectively. Stratified analysis demonstrated that the patients with increased levels of TAT, PIC and t-PAIC had worse illness severity and clinical outcome. Univariate logistic regression analysis revealed that TAT, PIC and t-PAIC were all risk factors for severe sepsis, yet only TAT and t-PAIC were independent risk factors in multivariate model. Conclusions TAT, PIC and t-PAIC could serve as biomarkers for predicting severe sepsis, and correlated with illness severity in pediatrics, what's more, serum levels of TAT and t-PAIC may be independent risk factors for pediatric severe sepsis.
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Affiliation(s)
- Huan Bai
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ling Shen
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hailong Zhang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Laboratory Medicine, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Ning Tang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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16
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Li J, Liu H, Wang N, Wang F, Shang N, Guo S, Wang G. Persistent high sepsis-induced coagulopathy and sequential organ failure assessment scores can predict the 28-day mortality of patients with sepsis: A prospective study. BMC Infect Dis 2024; 24:282. [PMID: 38438863 PMCID: PMC10913246 DOI: 10.1186/s12879-024-09154-x] [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: 05/06/2023] [Accepted: 02/19/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND The performance of the sepsis-induced coagulopathy (SIC) and sequential organ failure assessment (SOFA) scores in predicting the prognoses of patients with sepsis has been validated. This study aimed to investigate the time course of SIC and SOFA scores and their association with outcomes in patients with sepsis. METHODS This prospective study enrolled 209 patients with sepsis admitted to the emergency department. The SIC and SOFA scores of the patients were assessed on days 1, 2, and 4. Patients were categorized into survivor or non-survivor groups based on their 28-day survival. We conducted a generalized estimating equation analysis to evaluate the time course of SIC and SOFA scores and the corresponding differences between the two groups. The predictive value of SIC and SOFA scores at different time points for sepsis prognosis was evaluated. RESULTS In the non-survivor group, SIC and SOFA scores gradually increased during the first 4 days (P < 0.05). In the survivor group, the SIC and SOFA scores on day 2 were significantly higher than those on day 1 (P < 0.05); however, they decreased on day 4, dropping below the levels observed on day 1 (P < 0.05). The non-survivors showed higher SIC scores on days 2 (P < 0.05) and 4 (P < 0.001) than the survivors, whereas no significant differences were found between the two groups on day 1 (P > 0.05). The performance of SIC scores on day 4 for predicting mortality was more accurate than that on day 2, with areas under the curve of 0.749 (95% confidence interval [CI]: 0.674-0.823), and 0.601 (95% CI: 0.524-0.679), respectively. The SIC scores demonstrated comparable predictive accuracy for 28-day mortality to the SOFA scores on days 2 and 4. Cox proportional hazards models indicated that SIC on day 4 (hazard ratio [HR] = 3.736; 95% CI: 2.025-6.891) was an independent risk factor for 28-day mortality. CONCLUSIONS The time course of SIC and SOFA scores differed between surviving and non-surviving patients with sepsis, and persistent high SIC and SOFA scores can predict 28-day mortality.
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Affiliation(s)
- Junyu Li
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Capital Medical University, Beijing, China
- Department of Emergency Medicine, Capital Medical University School of Rehabilitation Medicine, Beijing Bo'Ai Hospital, China Rehabilitation Research Center , Beijing, China
| | - Huizhen Liu
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Capital Medical University, Beijing, China
- Department of Emergency Medicine, Capital Medical University School of Rehabilitation Medicine, Beijing Bo'Ai Hospital, China Rehabilitation Research Center , Beijing, China
| | - Na Wang
- Department of Emergency Medicine, Capital Medical University School of Rehabilitation Medicine, Beijing Bo'Ai Hospital, China Rehabilitation Research Center , Beijing, China
| | - Fengrong Wang
- Department of Emergency Medicine, Capital Medical University School of Rehabilitation Medicine, Beijing Bo'Ai Hospital, China Rehabilitation Research Center , Beijing, China
| | - Na Shang
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Capital Medical University, Beijing, China
| | - Shubin Guo
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Capital Medical University, Beijing, China.
| | - Guodong Wang
- Cardiovascular Department, Capital Medical University School of Rehabilitation Medicine, Beijing Bo'Ai Hospital, China Rehabilitation Research Center, Beijing, China.
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Almalki WH. NEAT1 in inflammatory infectious diseases: An integrated perspective on molecular modulation. Pathol Res Pract 2024; 254:154956. [PMID: 38218038 DOI: 10.1016/j.prp.2023.154956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/13/2023] [Accepted: 11/15/2023] [Indexed: 01/15/2024]
Abstract
The long non-coding RNA (lncRNA), NEAT1, has emerged as a central figure in the intricate network of molecular regulators in inflammatory infectious diseases (IIDs). The review initiates a comprehensive exploration of NEAT1's multifaceted roles and molecular interactions in the context of these complex diseases. The study begins by acknowledging the global health burden of IIDs, underscoring the urgency for innovative insights into their pathogenesis and therapeutic avenues. NEAT1 is introduced as a pivotal lncRNA with growing relevance in immune responses and inflammatory processes. The core of this review unravels the NEAT1 landscape, elucidating its involvement in the modulation of immune signalling pathways, regulation of inflammatory cytokines, and interactions with various immune cells during infection. It explores NEAT1's role in orchestrating immune responses and balancing host defence mechanisms with the risk of immunopathology. Furthermore, the review underscores the clinical significance of NEAT1 in infectious diseases, discussing its associations with disease severity, prognosis, and potential as a diagnostic and therapeutic target. It provides insights into ongoing research endeavours aimed at harnessing NEAT1 for innovative disease management strategies, including developing RNA-based therapeutics. Concluding on a forward-looking note, the review highlights the broader implications of NEAT1 in the context of emerging infectious diseases and the possibility for precision medicine approaches that leverage NEAT1's regulatory capacities. In summary, this review illuminates the pivotal role of NEAT1 in IIDs by navigating its complex landscape, offering profound insights into its implications for disease pathogenesis and the development of targeted therapies.
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Affiliation(s)
- Waleed Hassan Almalki
- Department of Pharmacology, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia.
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18
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Han Y, Duan J, Chen M, Huang S, Zhang B, Wang Y, Liu J, Li X, Yu W. Relationship between serum sodium level and sepsis-induced coagulopathy. Front Med (Lausanne) 2024; 10:1324369. [PMID: 38298508 PMCID: PMC10828971 DOI: 10.3389/fmed.2023.1324369] [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] [Received: 10/19/2023] [Accepted: 12/21/2023] [Indexed: 02/02/2024] Open
Abstract
Purpose A discussion about the correlation between the level of serum sodium and sepsis-induced coagulopathy (SIC). Materials and methods A retrospective analysis was conducted on sepsis patients who were admitted to the Intensive Care Unit (ICU) of Nanjing Drum Tower Hospital from January 2021 to December 2022. Based on the presence of coagulation disorders, the patients were divided into two groups: sepsis-induced coagulopathy (SIC) and non-sepsis-induced coagulopathy (non-SIC) groups. We recorded demographic characteristics and laboratory indicators at the time of ICU admission, and analyzed relationship between serum sodium level and SIC. Results One hundred and twenty-five patients with sepsis were enrolled, among which, the SIC and the non-SIC groups included 62 and 63 patients, respectively. Compared to patients in the non-SIC group, the level of serum sodium of those in the SIC was significantly higher (p < 0.001). Multi-factor logistic regression showed serum sodium level was independently associated with SIC (or = 1.127, p = 0.001). Pearson's correlation analysis indicated that the higher the serum sodium level, the significantly higher the SIC score was (r = 0.373, p < 0.001). Additionally, the mortality rate of patients with sepsis in the ICU were significantly correlated with increased serum sodium levels (p = 0.014). Conclusion An increase in serum sodium level was independently associated with an increased occurrence of SIC and also associated with the poor prognosis for patients with sepsis.
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Affiliation(s)
- Yanyu Han
- Department of Critical Care Medicine, Nanjing Drum Tower Hospital, Drum Tower Clinical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Jianfeng Duan
- Department of Critical Care Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Ming Chen
- Department of Critical Care Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Shijie Huang
- Department of Critical Care Medicine, Nanjing Drum Tower Hospital, Drum Tower Clinical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Beiyuan Zhang
- Department of Critical Care Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yan Wang
- Department of Critical Care Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Jiali Liu
- Department of Critical Care Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Xiaoyao Li
- Department of Critical Care Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Wenkui Yu
- Department of Critical Care Medicine, Nanjing Drum Tower Hospital, Drum Tower Clinical College, Nanjing University of Chinese Medicine, Nanjing, China
- Department of Critical Care Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
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Zhou S, Lu Z, Liu Y, Wang M, Zhou W, Cui X, Zhang J, Xiao W, Hua T, Zhu H, Yang M. Interpretable machine learning model for early prediction of 28-day mortality in ICU patients with sepsis-induced coagulopathy: development and validation. Eur J Med Res 2024; 29:14. [PMID: 38172962 PMCID: PMC10763177 DOI: 10.1186/s40001-023-01593-7] [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: 12/19/2022] [Accepted: 12/13/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE Sepsis-induced coagulopathy (SIC) is extremely common in individuals with sepsis, significantly associated with poor outcomes. This study attempted to develop an interpretable and generalizable machine learning (ML) model for early predicting the risk of 28-day death in patients with SIC. METHODS In this retrospective cohort study, we extracted SIC patients from the Medical Information Mart for Intensive Care III (MIMIC-III), MIMIC-IV, and eICU-CRD database according to Toshiaki Iba's scale. And the overlapping in the MIMIC-IV was excluded for this study. Afterward, only the MIMIC-III cohort was randomly divided into the training set, and the internal validation set according to the ratio of 7:3, while the MIMIC-IV and eICU-CRD databases were considered the external validation sets. The predictive factors for 28-day mortality of SIC patients were determined using recursive feature elimination combined with tenfold cross-validation (RFECV). Then, we constructed models using ML algorithms. Multiple metrics were used for evaluation of performance of the models, including the area under the receiver operating characteristic curve (AUROC), area under the precision recall curve (AUPRC), accuracy, sensitivity, specificity, negative predictive value, positive predictive value, recall, and F1 score. Finally, Shapley Additive Explanations (SHAP), Local Interpretable Model-Agnostic Explanations (LIME) were employed to provide a reasonable interpretation for the prediction results. RESULTS A total of 3280, 2798, and 1668 SIC patients were screened from MIMIC-III, MIMIC-IV, and eICU-CRD databases, respectively. Seventeen features were selected to construct ML prediction models. XGBoost had the best performance in predicting the 28-day mortality of SIC patients, with AUC of 0.828, 0.913 and 0.923, the AUPRC of 0.807, 0.796 and 0.921, the accuracy of 0.785, 0.885 and 0.891, the F1 scores were 0.63, 0.69 and 0.70 in MIMIC-III (internal validation set), MIMIC-IV, and eICU-CRD databases. The importance ranking and SHAP analyses showed that initial SOFA score, red blood cell distribution width (RDW), and age were the top three critical features in the XGBoost model. CONCLUSIONS We developed an optimal and explainable ML model to predict the risk of 28-day death of SIC patients 28-day death risk. Compared with conventional scoring systems, the XGBoost model performed better. The model established will have the potential to improve the level of clinical practice for SIC patients.
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Affiliation(s)
- Shu Zhou
- Emergency Internal Medicine, the Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, Anhui, People's Republic of China
| | - Zongqing Lu
- The 2nd Department of Intensive Care Unit, the Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, Anhui, People's Republic of China
- The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, Anhui, People's Republic of China
| | - Yu Liu
- Key Laboratory of Intelligent Computing and Signal Processing, Anhui University, Ministry of Education, Hefei, 230601, Anhui, People's Republic of China
| | - Minjie Wang
- The 2nd Department of Intensive Care Unit, the Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, Anhui, People's Republic of China
- The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, Anhui, People's Republic of China
| | - Wuming Zhou
- The 2nd Department of Intensive Care Unit, the Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, Anhui, People's Republic of China
- The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, Anhui, People's Republic of China
| | - Xuanxuan Cui
- The 2nd Department of Intensive Care Unit, the Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, Anhui, People's Republic of China
- The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, Anhui, People's Republic of China
| | - Jin Zhang
- The 2nd Department of Intensive Care Unit, the Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, Anhui, People's Republic of China
- The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, Anhui, People's Republic of China
| | - Wenyan Xiao
- The 2nd Department of Intensive Care Unit, the Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, Anhui, People's Republic of China
- The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, Anhui, People's Republic of China
| | - Tianfeng Hua
- The 2nd Department of Intensive Care Unit, the Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, Anhui, People's Republic of China
- The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, Anhui, People's Republic of China
| | - Huaqing Zhu
- Laboratory of Molecular Biology and Department of Biochemistry, Anhui Medical University, Hefei, 230022, Anhui, People's Republic of China.
| | - Min Yang
- The 2nd Department of Intensive Care Unit, the Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, Anhui, People's Republic of China.
- The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, Anhui, People's Republic of China.
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Iba T, Helms J, Levi M, Levy JH. Thromboinflammation in acute injury: infections, heatstroke, and trauma. J Thromb Haemost 2024; 22:7-22. [PMID: 37541590 DOI: 10.1016/j.jtha.2023.07.020] [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: 06/09/2023] [Revised: 07/13/2023] [Accepted: 07/23/2023] [Indexed: 08/06/2023]
Abstract
Tissue microcirculation is essential for the maintenance of organ homeostasis. Following acute infections, activation of coagulation and inflammation, which are critical interconnected responses, lead to thromboinflammation and microthrombosis, thereby contributing to multiorgan dysfunction. Sepsis is the most common underlying disease and has been extensively studied. However, the COVID-19 pandemic further illustrated the pathomechanisms of diseases in which thromboinflammation plays a critical role. During thromboinflammation, injury to monocytes, neutrophils, platelets, and endothelial cells, along with coagulation and complement activation, was further characterized. Thrombin is pivotal in orchestrating thrombosis and inflammation and has long been considered a potential therapeutic target in sepsis. Although thromboprophylaxis for venous thromboembolism with heparins is part of standard management for COVID-19, it also potentially attenuates organ dysfunction due to thrombotic sequela. In contrast, the effectiveness of anticoagulation with heparin, antithrombin, or thrombomodulin to reduce mortality has not conclusively been proven in sepsis. Nonetheless, thromboinflammation has also been reported as an important pathophysiologic mechanism in other critical illnesses, including heatstroke, trauma, and ischemia/reperfusion injury, and may provide a potential therapeutic target for future clinical studies.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Julie Helms
- Strasbourg University (UNISTRA), Strasbourg University Hospital, Medical Intensive Care Unit - NHC; INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
| | - Marcel Levi
- Department of Vascular Medicine, Amsterdam University Medical Center, The Netherlands; Department of Medicine, University College London Hospitals NHS Foundation Trust (UCLH), Cardio-metabolic Programme-National Institute for Health and Care Research UCLH/UCL Biomedical Research Centres, London, United Kingdom
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina, USA
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Zhao H, Dong Y, Wang S, Shen J, Song Z, Xue M, Shao M. Comparison between sepsis-induced coagulopathy and sepsis-associated coagulopathy criteria in identifying sepsis-associated disseminated intravascular coagulation. World J Emerg Med 2024; 15:190-196. [PMID: 38855376 PMCID: PMC11153374 DOI: 10.5847/wjem.j.1920-8642.2024.041] [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: 10/29/2023] [Accepted: 02/20/2024] [Indexed: 06/11/2024] Open
Abstract
BACKGROUND Disseminated intravascular coagulation (DIC) is associated with increased mortality in sepsis patients. In this study, we aimed to assess the clinical ability of sepsis-induced coagulopathy (SIC) and sepsis-associated coagulopathy (SAC) criteria in identifying overt-DIC and pre-DIC status in sepsis patients. METHODS Data from 419 sepsis patients were retrospectively collected from July 2018 to December 2022. The performances of the SIC and SAC were assessed to identify overt-DIC on days 1, 3, 7, or 14. The SIC status or SIC score on day 1, the SAC status or SAC score on day 1, and the sum of the SIC or SAC scores on days 1 and 3 were compared in terms of their ability to identify pre-DIC. The SIC or SAC status on day 1 was evaluated as a pre-DIC indicator for anticoagulant initiation. RESULTS On day 1, the incidences of coagulopathy according to overt-DIC, SIC and SAC criteria were 11.7%, 22.0% and 31.5%, respectively. The specificity of SIC for identifying overt-DIC was significantly higher than that of the SAC criteria from day 1 to day 14 (P<0.05). On day 1, the SIC score with a cut-off value > 3 had a significantly higher sensitivity (72.00%) and area under the curve (AUC) (0.69) in identifying pre-DIC than did the SIC or SAC status (sensitivity: SIC status 44.00%, SAC status 52.00%; AUC: SIC status 0.62, SAC status 0.61). The sum of the SIC scores on days 1 and 3 had a higher AUC value for identifying the pre-DIC state than that of SAC (0.79 vs. 0.69, P<0.001). Favorable effects of anticoagulant therapy were observed in SIC (adjusted hazard ratio [HR]=0.216, 95% confidence interval [95% CI]: 0.060-0.783, P=0.018) and SAC (adjusted HR=0.146, 95% CI: 0.041-0.513, P=0.003). CONCLUSION The SIC and SAC seem to be valuable for predicting overt-DIC. The sum of SIC scores on days 1 and 3 has the potential to help identify pre-DIC.
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Affiliation(s)
- Huixin Zhao
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yiming Dong
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Sijia Wang
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Jiayuan Shen
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Zhenju Song
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Mingming Xue
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Mian Shao
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
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22
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Zhang Y, Wang L, Kuang X, Tang D, Zhang P. Diagnostic and Prognostic Value of C1q in Sepsis-Induced Coagulopathy. Clin Appl Thromb Hemost 2024; 30:10760296241257517. [PMID: 38778544 PMCID: PMC11113060 DOI: 10.1177/10760296241257517] [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: 03/19/2024] [Revised: 04/27/2024] [Accepted: 05/10/2024] [Indexed: 05/25/2024] Open
Abstract
Early identification of biomarkers that can predict the onset of sepsis-induced coagulopathy (SIC) in septic patients is clinically important. This study endeavors to examine the diagnostic and prognostic utility of serum C1q in the context of SIC. Clinical data from 279 patients diagnosed with sepsis at the Departments of Intensive Care, Respiratory Intensive Care, and Infectious Diseases at the Renmin Hospital of Wuhan University were gathered spanning from January 2022 to January 2024. These patients were categorized into two groups: the SIC group comprising 108 cases and the non-SIC group consisting of 171 cases, based on the presence of SIC. Within the SIC group, patients were further subdivided into a survival group (43 cases) and non-survival group (65 cases). The concentration of serum C1q in the SIC group was significantly lower than that in the non-SIC group. Furthermore, A significant correlation was observed between serum C1q levels and both SIC score and coagulation indices. C1q demonstrated superior diagnostic and prognostic performance for SIC patients, as indicated by a higher area under the curve (AUC). Notably, when combined with CRP, PCT, and SOFA score, C1q displayed the most robust diagnostic efficacy for SIC. Moreover, the combination of C1q with the SOFA score heightened predictive value concerning the 28-day mortality of SIC patients.
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Affiliation(s)
- Ye Zhang
- Department of Clinical Laboratory, Institute of Translational Medicine, Renmin Hospital of Wuhan University, Wuhan, PR China
| | - Li Wang
- Department of Clinical Laboratory, Institute of Translational Medicine, Renmin Hospital of Wuhan University, Wuhan, PR China
| | - Xiandong Kuang
- Department of Clinical Laboratory, Institute of Translational Medicine, Renmin Hospital of Wuhan University, Wuhan, PR China
| | - Dongling Tang
- Department of Clinical Laboratory, Institute of Translational Medicine, Renmin Hospital of Wuhan University, Wuhan, PR China
| | - Pingan Zhang
- Department of Clinical Laboratory, Institute of Translational Medicine, Renmin Hospital of Wuhan University, Wuhan, PR China
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23
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Khaleq MAA. Effect of Enoxaparin on D-dimer levels in hospitalized Corona Virus patients with a comparison of its level in patients with comorbid conditions. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2024; 77:828-833. [PMID: 38865643 DOI: 10.36740/wlek202404131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
OBJECTIVE Aim: The main goal is to assess the levels of comorbid diseases and examine the changes in D-dimer in hospitalized patients before and following SC enoxaparin medication. PATIENTS AND METHODS Material and Methods: At the Al-Yarmouk Teaching Hospital in Baghdad, Iraq, from October 2022 to May 2023, 86 patients who were hospitalized and had severe to critical COVID-19 infections provided data for a retrospective analysis. RESULTS Results: The medical records of all COVID-19 patients who were hospitalized and whose D-dimer level was greater than 0.5 mg/l and who were given enoxaparin (40 mg subcutaneously) were reviewed with the requisite authorization from the relevant authorities. The D-dimer level was assessed following therapy on the day of admission and day five after commencing enoxaparin. An examination of 86 case records revealed that persons with COVID-19 had significantly decreased D-dimer levels after taking subcutaneous enoxaparin (p-value<0.0001). The comorbidities (diabetes mellitus, hypertension) of patients who received the drug were compared. CONCLUSION Conclusions: Enoxaparin and other anticoagulants were utilized to treat the coagulopathy brought on by COVID-19. Low molecular weight heparin enoxaparin has demonstrated positive outcomes in the management of VTE. A decrease in D-dimer level is anticipated when COVID-19 patients are treated with subcutaneous enoxaparin, partly because decreased coagulation results in lower fibrin formation.
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24
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Wu MA, Del GIovane C, Colombo R, Dolci G, Arquati M, Vicini R, Russo U, Ruggiero D, Coluccio V, Taino A, Franceschini E, Facchinetti P, Mighali P, Trombetta L, Tonelli F, Gabiati C, Cogliati C, D'Amico R, Marietta M. Low-molecular-weight heparin for the prevention of clinical worsening in severe non-critically ill COVID-19 patients: a joint analysis of two randomized controlled trials. Intern Emerg Med 2024; 19:71-79. [PMID: 37794281 DOI: 10.1007/s11739-023-03439-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/14/2023] [Indexed: 10/06/2023]
Abstract
Coronavirus disease 2019 (COVID-19) carries a high risk of vascular thrombosis. However, whether a specific anticoagulation intensity strategy may prevent clinical worsening in severe COVID-19 patients is still debated. We conducted a joint analysis of two randomized controlled trials, COVID-19 HD (NCT044082359) and EMOS-COVID (NCT04646655), to assess the efficacy and safety of two anticoagulant regimens in hospitalized severe COVID-19 patients. Subjects with COVID-19-associated respiratory compromise and/or coagulopathy were randomly assigned to low (4000 IU qd) or high (70 IU Kg-1 every 12 h) enoxaparin dose. The primary efficacy endpoint was clinical worsening within 30 days, defined as the occurrence of at least one of the following events, whichever came first: in-hospital death, evidence of arterial or venous thromboembolism, acute myocardial infarction, need for either continuous positive airway pressure (CPAP) or non-invasive ventilation (NIV) in patients receiving standard oxygen therapy or none at randomization, and need for mechanical ventilation in any patient. The safety endpoint was major bleeding. We estimated the relative risk (RR) and its 95% confidence interval (CI) for the outcomes. Among 283 patients included in the study (144 in the low-dose and 139 in the high-dose group), 118 (41.7%) were on NIV or CPAP at randomization. 23/139 (16.5%) patients in the high-dose group reached the primary endpoint compared to 33/144 (22.9%) in the low-dose group (RR 0.72, 95% CI 0.45-1.17). No major bleeding was observed. No significant differences were found in the clinical worsening of hospitalized COVID-19 patients treated with high versus low doses of enoxaparin.
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Affiliation(s)
- Maddalena Alessandra Wu
- Division of Internal Medicine, Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy.
| | - Cinzia Del GIovane
- Department of Medical and Surgical Sciences for Children and Adults, University-Hospital of Modena and Reggio Emilia, Modena, Italy
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Unità di Supporto Statistico Metodologico per la Ricerca Clinica Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Riccardo Colombo
- Division of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Giovanni Dolci
- Infectious Diseases Unit, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Roberto Vicini
- Unità di Supporto Statistico Metodologico per la Ricerca Clinica Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Umberto Russo
- Division of Haematology, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Diego Ruggiero
- Division of Cardiology, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Valeria Coluccio
- Hematology Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Alba Taino
- Division of Internal Medicine, Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Erica Franceschini
- Infectious Diseases Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Pietro Facchinetti
- Division of Internal Medicine, Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Pasquale Mighali
- Servizio Formazione, Ricerca e Innovazione, Azienda Ospedaliero-Universitaria di Modena, Ospedale Policlinico, Modena, Italy
| | - Lucia Trombetta
- Division of Internal Medicine, Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Francesca Tonelli
- Division of Internal Medicine, Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Claudia Gabiati
- Division of Internal Medicine, Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, Fatebenefratelli Hospital, University of Milan, Milan, Italy
| | - Chiara Cogliati
- Division of Internal Medicine, Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Roberto D'Amico
- Department of Medical and Surgical Sciences for Children and Adults, University-Hospital of Modena and Reggio Emilia, Modena, Italy
- Unità di Supporto Statistico Metodologico per la Ricerca Clinica Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Marco Marietta
- Hematology Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
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THACHIL JECKO, IBA TOSHIAKI. Designing the Diagnostic Criteria for Disseminated Intravascular Coagulation (DIC). JUNTENDO IJI ZASSHI = JUNTENDO MEDICAL JOURNAL 2023; 69:463-465. [PMID: 38855069 PMCID: PMC11153069 DOI: 10.14789/jmj.jmj23-0038-p] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 12/13/2023] [Indexed: 06/11/2024]
Abstract
Disseminated intravascular coagulation (DIC) is a common and critical complication in various diseases. There are several diagnostic criteria, such as the International Society on Thrombosis and Haemostasis (ISTH) criteria, the Japanese Society on Thrombosis and Hemostasis (JSTH) criteria, and the Japanese Association for Acute Medicine (JAAM) criteria. Due to the strengths and drawbacks inherent in each diagnostic criterion, it has the potential to cause confusion in clinical settings. It is possible to increase the specificity by making a complex criterion but simple and easy-to-use criteria are demanded in practice. To establish pragmatic criteria using readily available biomarkers, the ISTH focused on DIC arising from sepsis and released sepsis-induced coagulopathy criteria (SIC). A similar approach will aid in constructing a practical diagnostic criterion tailored to each specific background.
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Affiliation(s)
| | - TOSHIAKI IBA
- Corresponding author: Toshiaki Iba(ORCID: 0000-0002-0255-4088), Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan, TEL: +81-3-3813-3111 (X: 3813) E-mail:
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26
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曹 锐, 刘 开, 胡 丹, 齐 共. [Value of the expression levels of complement-3a receptor 1 and neutrophil extracellular traps in predicting sepsis-induced coagulopathy]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2023; 25:1259-1264. [PMID: 38112144 PMCID: PMC10731964 DOI: 10.7499/j.issn.1008-8830.2307109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/06/2023] [Indexed: 12/20/2023]
Abstract
OBJECTIVES To investigate the clinical value of complement-3a receptor 1 (C3aR1) and neutrophil extracellular traps (NETs) in predicting sepsis-induced coagulopathy (SIC). METHODS A prospective study was conducted among 78 children with sepsis who attended Xuzhou Children's Hospital Affiliated to Xuzhou Medical University from June 2022 to June 2023. According to the presence or absence of SIC, they were divided into two groups: SIC (n=36) and non-SIC (n=42) . The two groups were compared in terms of clinical data and the levels of C3aR1 and NETs. The factors associated with the occurrence of SIC were analyzed. The receiver operating characteristic (ROC) curve was used to evaluate the performance of C3aR1 and NETs in predicting SIC. RESULTS Compared with the non-SIC group, the SIC group had significantly higher levels of C-reactive protein, interleukin-6 (IL-6), interleukin-10, C3aR1, and NETs (P<0.05). The multivaiate logistic regression analysis showed that the increases in C3aR1, NETs, and IL-6 were closely associated with the occurrence of SIC (P<0.05). The ROC curve analysis showed that C3aR1 combined with NETs had an area under the curve (AUC) of 0.913 in predicting SIC (P<0.05), which was significantly higher than the AUC of C3aR1 or IL-6 (P<0.05), while there was no significant difference in AUC between C3aR1 combined with NETs and NETs alone (P>0.05). CONCLUSIONS There are significant increases in the expression levels of C3aR1 and NETs in the peripheral blood of children with SIC, and the expression levels of C3aR1 and NETs have a high clinical value in predicting SIC.
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27
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Iba T, Maier CL, Tanigawa T, Levy JH. Risk stratification utilizing sequential organ failure assessment (SOFA) score, antithrombin activity, and demographic data in sepsis-associated disseminated intravascular coagulation (DIC). Sci Rep 2023; 13:22502. [PMID: 38110515 PMCID: PMC10728127 DOI: 10.1038/s41598-023-49855-y] [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: 09/21/2023] [Accepted: 12/12/2023] [Indexed: 12/20/2023] Open
Abstract
Disseminated intravascular coagulation (DIC) is a frequent complication in patients with sepsis and is associated with increased mortality. Anticoagulant therapy may be appropriate for certain patients with DIC, particularly those with increased disease severity and deficiency in the physiologic anticoagulant antithrombin. We retrospectively analyzed post-marketing survey data from 1562 patients with sepsis-associated DIC and antithrombin activity of 70% or less. All the patients were treated with antithrombin concentrates. Baseline sequential organ failure assessment (SOFA) score, DIC score, and antithrombin activity were assessed. Cox multivariate regression analysis, Kaplan-Meier curve analysis, and receiver operating characteristic (ROC) curve analysis were performed to evaluate the performance of variables used to assess mortality. Furthermore, a decision tree was constructed to classify the risk of 28-day mortality. COX multivariate regression analysis demonstrated a significant association of age, sex, baseline SOFA score, baseline antithrombin activity, and the presence of pneumonia or skin/soft tissue infection with increased mortality. The area under the curve of SOFA score or antithrombin activity for mortality was 0.700 and 0.614, respectively. Kaplan-Meier analysis demonstrated that mortality was significantly higher in patients with SOFA score ≥ 12 and antithrombin activity < 47%. The decision tree analysis accurately classified the risk of death into high (> 40%), medium (40%-20%), and low (< 20%) categories in 86.1% of the cohort. Twenty eight-day mortality can be strongly predicted using baseline SOFA score, antithrombin activity, infection site, age, and sex as variables in the clinical decision tree for patients with sepsis-associated disseminated intravascular coagulation (DIC).
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-Ku, Tokyo, 113-8421, Japan.
| | - Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Tomoki Tanigawa
- Medical Affairs Section, Research & Development Division, Japan Blood Products Organization, Tokyo, Japan
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
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28
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Iba T, Helms J, Neal MD, Levy JH. Mechanisms and management of the coagulopathy of trauma and sepsis: trauma-induced coagulopathy, sepsis-induced coagulopathy, and disseminated intravascular coagulation. J Thromb Haemost 2023; 21:3360-3370. [PMID: 37722532 PMCID: PMC10873124 DOI: 10.1016/j.jtha.2023.05.028] [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: 01/18/2023] [Revised: 04/18/2023] [Accepted: 05/12/2023] [Indexed: 09/20/2023]
Abstract
Disseminated intravascular coagulation can occur due to different causes but commonly following sepsis. Trauma-induced coagulopathy (TIC) occurs on hospital arrival in approximately 25% of seriously injured patients who initially presents with impaired hemostasis and a bleeding phenotype that can later progress to a prothrombotic phase. Following traumatic injury, ineffective hemostasis is driven by massive blood loss, tissue damage, and hyperfibrinolysis. This initial impaired hemostasis continues until surgical or other management strategies not only to stop the causes of hemorrhage but also progresses to a prothrombotic and hypofibrinolytic state, also termed fibrinolytic shutdown. Prothrombotic progression is also promoted by inflammatory mediator release, endothelial injury, and platelet dysregulation, which is commonly seen in sepsis with increased mortality. Unlike TIC, the early phase of sepsis is frequently complicated by multiorgan dysfunction described as sepsis-induced coagulopathy (SIC) that lacks a hemorrhagic phase. The phenotypes of SIC and TIC are different, especially in their initial presentations; however, patients who survive TIC may also develop subsequent infections and potentially sepsis and SIC. Although the pathophysiology of SIC and TIC are different, endothelial injury, dysregulated fibrinolysis, and coagulation abnormalities are common. Management includes treatment of the underlying cause, tissue injury vs infection is critical, and supportive therapies, such as hemostatic resuscitation and circulatory support are essential, and adjunct therapies are recommended in guidelines. Based on clinical studies and certain guidelines, additional therapies include tranexamic acid in the limited timing of initial traumatic injury and anticoagulants, such as antithrombin and recombinant thrombomodulin in disseminated intravascular coagulation.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Julie Helms
- Strasbourg University (UNISTRA); Strasbourg University Hospital, Medical Intensive Care Unit - NHC; INSERM (French National Institute of Health and Medical Research), Strasbourg, France
| | - Matthew D Neal
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina, USA. https://twitter.com/JerroldLevy
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Ajanel A, Middleton EA. Alterations in the megakaryocyte transcriptome impacts platelet function in sepsis and COVID-19 infection. Thromb Res 2023; 231:247-254. [PMID: 37258336 PMCID: PMC10198739 DOI: 10.1016/j.thromres.2023.05.015] [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: 01/04/2023] [Revised: 04/04/2023] [Accepted: 05/16/2023] [Indexed: 06/02/2023]
Abstract
Platelets and their parent cell, the megakaryocyte (MK), are increasingly recognized for their roles during infection and inflammation. The MK residing in the bone marrow or arising from precursors trafficked to other organs for development go on to form platelets through thrombopoiesis. Infection, by direct and indirect mechanisms, can alter the transcriptional profile of MKs. The altered environment, whether mediated by inflammatory cytokines or other signaling mechanisms results in an altered platelet transcriptome. Platelets released into the circulation, in turn, interact with each other, circulating leukocytes and endothelial cells and contribute to the clearance of pathogens or the potentiation of pathophysiology through such mechanisms as immunothrombosis. In this article we hope to identify key contributions that explore the impact of an altered transcriptomic landscape during severe, systemic response to infection broadly defined as sepsis, and viral infections, including SARS-CoV2. We include current publications that outline the role of MKs from bone-marrow and extra-medullary sites as well as the circulating platelet. The underlying diseases result in thrombotic complications that exacerbate organ dysfunction and mortality. Understanding the impact of platelets on the pathophysiology of disease may drive therapeutic advances to improve the morbidity and mortality of these deadly afflictions.
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Affiliation(s)
- Abigail Ajanel
- Molecular Medicine Program, University of Utah, Salt Lake City, UT 84112, USA; Department of Pathology, University of Utah, Salt Lake City, UT 84112, USA
| | - Elizabeth A Middleton
- Molecular Medicine Program, University of Utah, Salt Lake City, UT 84112, USA; Department of Internal Medicine, University of Utah, Salt Lake City, UT 84112, USA.
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WANG L, FENG J, ZHAN D, WANG J, ZHOU D. Protective effects of tanshinone ⅡA on sepsis-induced multiple organ dysfunction: a literature review. J TRADIT CHIN MED 2023; 43:1040-1046. [PMID: 37679993 PMCID: PMC10465841 DOI: 10.19852/j.cnki.jtcm.20230727.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 09/21/2022] [Indexed: 09/09/2023]
Abstract
TanshinoneⅡA (TanⅡA) is a noteworthy lipophilic diterpene compound derived from the dried roots of the Traditional Chinese Medicine Danshen () that has various pharmacological properties, including anti-inflammatory, antibacterial, and antioxidative effects. Sepsis is a life-threatening organ dysfunction induced by a dysregulated host response to infection. Recently, increasing attention has been paid to sepsis-induced dysfunction of the intestine, car-diovascular system, lungs, kidneys, liver, and other organs. Experimental studies have shown that TanⅡA has therapeutic potential for sepsis-induced organ dysfunction owing to its anti-inflammatory, anti-apoptotic and regulatory effects on multiple signalling pathways. The purpose of this article is to evaluate the potential multiorgan protective effects of TanⅡA in sepsis.
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Affiliation(s)
- Lili WANG
- Emergency Department and Intensive Care Unit, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Ju FENG
- Emergency Department and Intensive Care Unit, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Daqian ZHAN
- Emergency Department and Intensive Care Unit, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Junshuai WANG
- Emergency Department and Intensive Care Unit, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Daixing ZHOU
- Emergency Department and Intensive Care Unit, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
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Li H, Fan S, Lu D, Zhou J. A New Scoring System for Predicting Mortality in Hematological Malignancies with Sepsis: A Derivation and Validation Study. Cancer Manag Res 2023; 15:1073-1083. [PMID: 37794881 PMCID: PMC10546994 DOI: 10.2147/cmar.s428930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/22/2023] [Indexed: 10/06/2023] Open
Abstract
Objective This study aimed to derive and validate a prognostic scoring system to identify patients with hematological malignancies (HMs) and sepsis who have a high mortality rate. Methods Cohorts for derivation and validation were created from all data. Using univariate and multivariate analysis, the independent variables connected to 28-day mortality in the derivation cohort were found. A receiver operating characteristic (ROC) curve was used to compare the predictive power and determine their cutoff points. These risk variables were given a score weighted by risk prediction function, and a new scoring system was also developed. The area under the ROC curve (AUROC) and sensitivity and specificity for mortality of the risk category of the new scoring system were compared with Sequential Organ Failure Assessment (SOFA) score. Results 90 (45.22%) of the 199 patients passed away within 28 days. Ninety-nine patients made up the derivation cohort, with 47 (47.47%) fatalities. Ages in the non-survival group were higher (61.47 ± 14.53 vs 55.13 ± 15.66) than in the survival group. As independent predictors of death, multivariable analysis identified SOFA score (OR 1.442, 95% CI 1.035, 2.009), age (OR 1.242, 95% CI 1.026, 1.503), and prothrombin time (PT) (OR 1.213, 95% CI 1.030, 1.430). The AUROC with 95% CI of the new scoring system and its sensitivity and specificity to mortality were virtually all superior to SOFA score in both derivation and validation cohorts: AUROC (0.757 vs 0.716), Sensitivity (75 vs 67.3%), and Specificity (68.1% vs 63.8%) are the Derivation cohort; Validation cohort: Sensitivity (91.2% vs 84.2%), AUROC (0.792 vs 0.733), and Specificity (58.1% vs 58.1%). The model was correctly calibrated, according to the Hosmer-Lemeshow test. Conclusion The new scoring system was more accurate in predicting 28-day mortality among patients with HMs and sepsis than the SOFA score.
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Affiliation(s)
- Haitao Li
- Harbin Medical University, Harbin, 150001, People’s Republic of China
| | - Shengjin Fan
- Department of Hematology, First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People’s Republic of China
| | - Dongxue Lu
- Department of Hematology, First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People’s Republic of China
| | - Jin Zhou
- Harbin Medical University, Harbin, 150001, People’s Republic of China
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Harahap AT, Irawan C, Susilo A, Harimurti K, Gathmyr D, Shatri H, Lubis AM, Nainggolan L, Abdullah M. The role of IL-6, ferritin, and coagulopathy in Covid-19 clinical progression. F1000Res 2023; 11:1285. [PMID: 37841828 PMCID: PMC10576189 DOI: 10.12688/f1000research.125115.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2023] [Indexed: 10/17/2023] Open
Abstract
Background In COVID-19, the release of pro-inflammatory mediators in the cytokine storm, primarily interleukin-6 (IL-6), has been hypothesized to induce pulmonary intravascular coagulation. However, the relationship between IL-6 and coagulopathy remains unclear in COVID-19 progression. We aimed to investigate the correlation of IL-6 with D-dimer, fibrinogen, prothrombin time (PT), and ferritin. Furthermore, we also analyzed the effect of those parameters on the worsening of COVID-19 patients. Methods A prospective cohort study was conducted in moderate and severe COVID-19 patients from June 2020 to January 2021. A serial evaluation of IL-6, D-dimer, fibrinogen, ferritin, and PT was performed and correlated with the patient's condition at admission and on the 14th day. The outcomes (improvement, worsening, or discharged patients) were recorded during the study. Results Of 374 patients, 73 study subjects (61 severe and 12 moderate COVID-19) were included in this study. A total of 35 out of 61 severe and one out of 12 moderate illness subjects had experienced worsening. Spearman-rank correlation of IL-6 with with ferritin, D-dimer, fibrinogen, and PT was 0.08 ( p=0.5), -0.13 ( p=0.27), 0.01 ( p=0.91), and 0.03 ( p=0.77), respectively. In ROC analysis, D-dimer (74,77%) and IL-6 (71,32%) were the highest among other variables (>60%). Conclusions In COVID-19 patients, there was a correlation between elevated IL-6 and D-dimer levels with disease deterioration. There was no correlation between elevated IL-6 levels with ferritin, D-dimer, fibrinogen, and PT levels. Therefore, changes in IL-6 and D-dimer can predict worsening in moderate and severe COVID-19 patients.
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Affiliation(s)
- Alvin Tagor Harahap
- Department of Internal Medicine, Pertamina Central Hospital, Jakarta, 12120, Indonesia
| | - Cosphiadi Irawan
- Hematology and Medical Oncology Division, Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Jakarta, 10430, Indonesia
| | - Adityo Susilo
- Tropical and Infectious Diseases Division, Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Jakarta, 10430, Indonesia
| | - Kuntjoro Harimurti
- Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Jakarta, 10430, Indonesia
| | - Dewi Gathmyr
- Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Jakarta, 10430, Indonesia
| | - Hamzah Shatri
- Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Jakarta, 10430, Indonesia
| | - Anna Mira Lubis
- Hematology and Medical Oncology Division, Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Jakarta, 10430, Indonesia
| | - Leonard Nainggolan
- Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Jakarta, 10430, Indonesia
| | - Murdani Abdullah
- Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Jakarta, 10430, Indonesia
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Unar A, Bertolino L, Patauner F, Gallo R, Durante-Mangoni E. Decoding Sepsis-Induced Disseminated Intravascular Coagulation: A Comprehensive Review of Existing and Emerging Therapies. J Clin Med 2023; 12:6128. [PMID: 37834771 PMCID: PMC10573475 DOI: 10.3390/jcm12196128] [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: 07/31/2023] [Revised: 09/09/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023] Open
Abstract
Disseminated intravascular coagulation (DIC) is a recurrent complication of sepsis. Since DIC not only promotes organ dysfunction but also represents a strong prognostic factor, it is important to diagnose DIC as early as possible. When coagulation is activated, fibrinolysis is inhibited, blood thinners are consumed, and a condition is created that promotes blood clotting, making it more difficult for the body to remove fibrin or prevent it from being deposited in the blood vessels. This leads to microvascular thrombosis, which plays a role in organ dysfunction. Despite efforts to understand the underlying mechanisms of sepsis-induced DIC, healthcare providers worldwide still face challenges in effectively treating this condition. In this review, we provide an in-depth analysis of the available strategies for sepsis-induced DIC, considering their effectiveness, limitations, and potential for future advances. Corticosteroids (CS), recombinant thrombomodulin (rTM), vitamin C, fibrinolytic therapy, and platelet transfusion are among the treatments discussed in the review. In addition, we are specifically addressing immunomodulatory therapy (IMT) by investigating treatments such as granulocyte colony-stimulating factor (G-CSF), granulocyte-macrophage colony-stimulating factor (GM-CSF), interferon gamma (IFN-γ), and mesenchymal stem cell therapy (MSC). Finally, we also examined how these therapies might affect COVID-19 cases, which often present with sepsis-induced DIC. The review suggests that targeted experiments with randomization are needed to verify the effectiveness of these treatments and to discover novel approaches to treat sepsis-induced DIC. By increasing our knowledge of sepsis-induced DIC, we can develop targeted treatments that have the potential to save lives and improve outcomes.
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Affiliation(s)
- Ahsanullah Unar
- Department of Precision Medicine, University of Campania ‘L. Vanvitelli’, 80138 Naples, Italy; (A.U.); (L.B.); (F.P.); (R.G.)
| | - Lorenzo Bertolino
- Department of Precision Medicine, University of Campania ‘L. Vanvitelli’, 80138 Naples, Italy; (A.U.); (L.B.); (F.P.); (R.G.)
| | - Fabian Patauner
- Department of Precision Medicine, University of Campania ‘L. Vanvitelli’, 80138 Naples, Italy; (A.U.); (L.B.); (F.P.); (R.G.)
| | - Raffaella Gallo
- Department of Precision Medicine, University of Campania ‘L. Vanvitelli’, 80138 Naples, Italy; (A.U.); (L.B.); (F.P.); (R.G.)
| | - Emanuele Durante-Mangoni
- Department of Precision Medicine, University of Campania ‘L. Vanvitelli’, 80138 Naples, Italy; (A.U.); (L.B.); (F.P.); (R.G.)
- Unit of Infectious and Transplant Medicine, AORN Ospedali dei Colli-Monaldi Hospital, 80131 Naples, Italy
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Ortega-Martorell S, Olier I, Johnston BW, Welters ID. Sepsis-induced coagulopathy is associated with new episodes of atrial fibrillation in patients admitted to critical care in sinus rhythm. Front Med (Lausanne) 2023; 10:1230854. [PMID: 37780563 PMCID: PMC10540306 DOI: 10.3389/fmed.2023.1230854] [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] [Received: 05/29/2023] [Accepted: 08/29/2023] [Indexed: 10/03/2023] Open
Abstract
Background Sepsis is a life-threatening disease commonly complicated by activation of coagulation and immune pathways. Sepsis-induced coagulopathy (SIC) is associated with micro- and macrothrombosis, but its relation to other cardiovascular complications remains less clear. In this study we explored associations between SIC and the occurrence of atrial fibrillation (AF) in patients admitted to the Intensive Care Unit (ICU) in sinus rhythm. We also aimed to identify predictive factors for the development of AF in patients with and without SIC. Methods Data were extracted from the publicly available AmsterdamUMCdb database. Patients with sepsis and documented sinus rhythm on admission to ICU were included. Patients were stratified into those who fulfilled the criteria for SIC and those who did not. Following univariate analysis, logistic regression models were developed to describe the association between routinely documented demographics and blood results and the development of at least one episode of AF. Machine learning methods (gradient boosting machines and random forest) were applied to define the predictive importance of factors contributing to the development of AF. Results Age was the strongest predictor for the development of AF in patients with and without SIC. Routine coagulation tests activated Partial Thromboplastin Time (aPTT) and International Normalized Ratio (INR) and C-reactive protein (CRP) as a marker of inflammation were also associated with AF occurrence in SIC-positive and SIC-negative patients. Cardiorespiratory parameters (oxygen requirements and heart rate) showed predictive potential. Conclusion Higher INR, elevated CRP, increased heart rate and more severe respiratory failure are risk factors for occurrence of AF in critical illness, suggesting an association between cardiac, respiratory and immune and coagulation pathways. However, age was the most dominant factor to predict the first episodes of AF in patients admitted in sinus rhythm with and without SIC.
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Affiliation(s)
- Sandra Ortega-Martorell
- School of Computer Science and Mathematics, Liverpool John Moores University, Liverpool, United Kingdom
- Liverpool Centre for Cardiovascular Science, Liverpool, United Kingdom
| | - Ivan Olier
- School of Computer Science and Mathematics, Liverpool John Moores University, Liverpool, United Kingdom
- Liverpool Centre for Cardiovascular Science, Liverpool, United Kingdom
| | - Brian W. Johnston
- Liverpool Centre for Cardiovascular Science, Liverpool, United Kingdom
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Ingeborg D. Welters
- Liverpool Centre for Cardiovascular Science, Liverpool, United Kingdom
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
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Unar A, Bertolino L, Patauner F, Gallo R, Durante-Mangoni E. Pathophysiology of Disseminated Intravascular Coagulation in Sepsis: A Clinically Focused Overview. Cells 2023; 12:2120. [PMID: 37681852 PMCID: PMC10486945 DOI: 10.3390/cells12172120] [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: 07/20/2023] [Revised: 08/07/2023] [Accepted: 08/12/2023] [Indexed: 09/09/2023] Open
Abstract
Sepsis is a major global health problem that results from a dysregulated and uncontrolled host response to infection, causing organ failure. Despite effective anti-infective therapy and supportive treatments, the mortality rate of sepsis remains high. Approximately 30-80% of patients with sepsis may develop disseminated intravascular coagulation (DIC), which can double the mortality rate. There is currently no definitive treatment approach for sepsis, with etiologic treatment being the cornerstone of therapy for sepsis-associated DIC. Early detection, diagnosis, and treatment are critical factors that impact the prognosis of sepsis-related DIC. Over the past several decades, researchers have made continuous efforts to better understand the mechanisms of DIC in sepsis, as well as improve its quantitative diagnosis and treatment. This article aims to provide a comprehensive overview of the current understanding of sepsis-related DIC, focusing on common causes and diagnoses, with the goal of guiding healthcare providers in the care of patients with sepsis.
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Affiliation(s)
- Ahsanullah Unar
- Department of Precision Medicine, University of Campania ‘L. Vanvitelli’, 80138 Naples, Italy; (A.U.); (L.B.); (F.P.); (R.G.)
| | - Lorenzo Bertolino
- Department of Precision Medicine, University of Campania ‘L. Vanvitelli’, 80138 Naples, Italy; (A.U.); (L.B.); (F.P.); (R.G.)
| | - Fabian Patauner
- Department of Precision Medicine, University of Campania ‘L. Vanvitelli’, 80138 Naples, Italy; (A.U.); (L.B.); (F.P.); (R.G.)
| | - Raffaella Gallo
- Department of Precision Medicine, University of Campania ‘L. Vanvitelli’, 80138 Naples, Italy; (A.U.); (L.B.); (F.P.); (R.G.)
| | - Emanuele Durante-Mangoni
- Department of Precision Medicine, University of Campania ‘L. Vanvitelli’, 80138 Naples, Italy; (A.U.); (L.B.); (F.P.); (R.G.)
- Unit of Infectious and Transplant Medicine, AORN Ospedali dei Colli-Monaldi Hospital, 80131 Naples, Italy
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Zhang Z, Yan T, Ren D, Zhou J, Liu L, Li J, Fu S, Ni T, Xu W, Yang Y, Chen T, He Y, Zhao Y, Liu J. Low-molecular-weight heparin therapy reduces 28-day mortality in patients with sepsis-3 by improving inflammation and coagulopathy. Front Med (Lausanne) 2023; 10:1157775. [PMID: 37359014 PMCID: PMC10289000 DOI: 10.3389/fmed.2023.1157775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 05/02/2023] [Indexed: 06/28/2023] Open
Abstract
Background and aim Sepsis is a syndromic response to infection and is associated with high mortality, thus imposing a significant global burden of disease. Although low-molecular-weight heparin (LMWH) has been recommended to prevent venous thromboembolism, its anticoagulant and anti-inflammatory effects in sepsis remain controversial. Owing to the modification of the Sepsis-3 definition and diagnostic criteria, further evaluation of the efficacy and benefit population of LMWH is required. Methods We performed a retrospective cohort study to assess whether LMWH improved the inflammation, coagulopathy, and clinical outcomes against Sepsis-3 and to identify the target patients. All patients diagnosed with sepsis at the First Affiliated Hospital of Xi'an Jiaotong University (the largest general hospital in northwest China) from January 2016 to December 2020 were recruited and re-evaluated using Sepsis-3 criteria. Results After 1:1 propensity score matching, 88 pairs of patients were categorized into the treatment and control groups based on subcutaneous LMWH administration. Compared with the control group, a significantly lower 28-day mortality was observed in the LMWH group (26.1 vs. 42.0%, p = 0.026) with a comparable incidence of major bleeding events (6.8 vs. 8.0%, p = 0.773). Cox regression analysis showed that LMWH administration was the independent protective factor for septic patients (aHR, 0.48; 95% CI, 0.29-0.81; p = 0.006). Correspondingly, the LMWH treatment group showed a significant improvement in inflammation and coagulopathy. Further subgroup analysis showed that LMWH therapy was associated with favorable outcomes in patients younger than 60 years and diagnosed with sepsis-induced coagulopathy (SIC), ISTH overt DIC, non-septic shock, or non-diabetics and in patients included in the moderate-risk group (APACHE II score 20-35 or SOFA score 8-12). Conclusion Our study results showed that LMWH improves 28-day mortality by improving inflammatory response and coagulopathy in patients meeting Sepsis-3 criteria. The SIC and ISTH overt DIC scoring systems can better identify septic patients who are likely to benefit more from LMWH administration.
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Affiliation(s)
- Ze Zhang
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Taotao Yan
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Danfeng Ren
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Jingwen Zhou
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Liangru Liu
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Juan Li
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Shan Fu
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Tianzhi Ni
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Weicheng Xu
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
| | - Yuan Yang
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Institution of Hepatology, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Tianyan Chen
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Institution of Hepatology, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Yingli He
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Institution of Hepatology, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Yingren Zhao
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
- Institution of Hepatology, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Jinfeng Liu
- The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
- Shaanxi Clinical Medical Research Center of Infectious Diseases, Xi'an, China
- Institution of Hepatology, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
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Minici R, Fontana F, Venturini M, Guzzardi G, Siciliano A, Piacentino F, Serra R, Coppola A, Guerriero P, Apollonio B, Santoro R, Team MGJRR, Brunese L, Laganà D. Transcatheter Arterial Embolization (TAE) in the Management of Bleeding in the COVID-19 Patient. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1062. [PMID: 37374266 PMCID: PMC10305036 DOI: 10.3390/medicina59061062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/24/2023] [Accepted: 05/30/2023] [Indexed: 06/29/2023]
Abstract
Background and Objectives: Increasing attention is being paid to the coagulation disorders associated with SARS-CoV-2 infection. Bleeding accounts for 3-6% of COVID-19 patient deaths, and is often a forgotten part of the disease. The bleeding risk is enhanced by several factors, including spontaneous heparin-induced thrombocytopenia, thrombocytopenia, the hyperfibrinolytic state, the consumption of coagulation factors, and thromboprophylaxis with anticoagulants. This study aims to assess the efficacy and safety of TAE in the management of bleeding in COVID-19 patients. Materials and Methods: This multicenter retrospective study analyzes data from COVID-19 patients subjected to transcatheter arterial embolization for the management of bleeding from February 2020 to January 2023. Results: Transcatheter arterial embolization was performed in 73 COVID-19 patients for acute non-neurovascular bleeding during the study interval (February 2020-January 2023). Coagulopathy was observed in forty-four (60.3%) patients. The primary cause of bleeding was spontaneous soft tissue hematoma (63%). A 100% technical success rate was recorded; six cases of rebleeding resulted in a 91.8% clinical success rate. No cases of non-target embolization were observed. Complications were recorded in 13 (17.8%) patients. The efficacy and safety endpoints did not differ significantly between the coagulopathy and non-coagulopathy groups. Conclusions: Transcatheter Arterial Embolization (TAE) is an effective, safe and potentially life-saving option for the management of acute non-neurovascular bleeding in COVID-19 patients. This approach is effective and safe even in the subgroup of COVID-19 patients with coagulopathy.
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Affiliation(s)
- Roberto Minici
- Radiology Unit, Dulbecco University Hospital, 88100 Catanzaro, Italy; (R.M.); (A.S.)
| | - Federico Fontana
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy; (M.V.); (F.P.); (A.C.)
- School of Medicine and Surgery, Insubria University, 21100 Varese, Italy
| | - Massimo Venturini
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy; (M.V.); (F.P.); (A.C.)
- School of Medicine and Surgery, Insubria University, 21100 Varese, Italy
| | - Giuseppe Guzzardi
- Radiology Unit, Maggiore della Carità University Hospital, 28100 Novara, Italy;
| | - Agostino Siciliano
- Radiology Unit, Dulbecco University Hospital, 88100 Catanzaro, Italy; (R.M.); (A.S.)
| | - Filippo Piacentino
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy; (M.V.); (F.P.); (A.C.)
| | - Raffaele Serra
- Vascular Surgery Unit, Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Dulbecco University Hospital, 88100 Catanzaro, Italy;
| | - Andrea Coppola
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy; (M.V.); (F.P.); (A.C.)
| | - Pasquale Guerriero
- Radiology Unit, Santobono-Pausilipon Hospital, 80129 Naples, Italy;
- Department of Medicine and Health Sciences, University of Molise, 86100 Campobasso, Italy;
| | | | - Rita Santoro
- Haemophilia and Thrombosis Center, Dulbecco University Hospital, 88100 Catanzaro, Italy;
| | - MGJR Research Team
- Magna Graecia Junior Radiologists Research Team, 88100 Catanzaro, Italy;
| | - Luca Brunese
- Department of Medicine and Health Sciences, University of Molise, 86100 Campobasso, Italy;
- Scientific Committee of the Italian National Institute of Health (Istituto Superiore di Sanità, ISS), 00161 Rome, Italy
| | - Domenico Laganà
- Radiology Unit, Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, Dulbecco University Hospital, 88100 Catanzaro, Italy
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Iba T, Helms J, Connors JM, Levy JH. The pathophysiology, diagnosis, and management of sepsis-associated disseminated intravascular coagulation. J Intensive Care 2023; 11:24. [PMID: 37221630 DOI: 10.1186/s40560-023-00672-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 05/18/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND The International Society on Thrombosis and Haemostasis (ISTH) released overt disseminated intravascular coagulation (DIC) diagnostic criteria in 2001. Since then, DIC has been understood as the end-stage consumptive coagulopathy and not the therapeutic target. However, DIC is not merely a decompensated coagulation disorder, but also includes early stages with systemic activation in coagulation. Thus, the ISTH has recently released sepsis-induced coagulopathy (SIC) criteria that can diagnose compensated-phase of coagulopathy with readily available biomarkers. MAIN BODY DIC is a laboratory-based diagnosis due to various critical conditions, although sepsis is the most common underlying disease. The pathophysiology of sepsis-associated DIC is multifactorial, and in addition to coagulation activation with suppressed fibrinolysis, multiple inflammatory responses are initiated by activated leukocytes, platelets, and vascular endothelial cells as part of thromboinflammation. Although overt DIC diagnostic criteria were established by ISTH to diagnose the advanced stage of DIC, additional criteria that can detect an earlier stage of DIC were needed for potential therapeutic considerations. Accordingly, the ISTH introduced SIC criteria in 2019 that are easy to use and require only platelet count, prothrombin time-international normalized ratio, and Sequential Organ Failure Assessment Score. SIC score can be used to evaluate disease severity and determine the timing of potential therapeutic interventions. One of the major disadvantages in treating sepsis-associated DIC is the lack of availability of specific therapeutic approaches beyond treating the underlying infection. Clinical trials to date have failed because included patients who were not coagulopathic. Nevertheless, in addition to infection control, anticoagulant therapy will be the choice for sepsis-associated DIC. Therefore, the efficacy of heparin, antithrombin, and recombinant thrombomodulin has to be proven in future clinical studies. CONCLUSION It is necessary to develop a novel therapeutic strategy against sepsis-associated DIC and improve the outcomes. Consequently, we recommend screening and monitoring DIC using SIC scoring system.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-Ku, Tokyo, 113-8421, Japan.
| | - Julie Helms
- Université de Strasbourg (UNISTRA), Faculté de 1Médecine, Hôpitaux Universitaires de Strasbourg, Service de Médecine Intensive-Réanimation, Nouvel Hôpital Civil, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
| | - Jean Marie Connors
- Hematology Division Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
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Dechamps M, De Poortere J, Octave M, Ginion A, Robaux V, Pirotton L, Bodart J, Gruson D, Van Dievoet MA, Douxfils J, Haguet H, Morimont L, Derive M, Jolly L, Bertrand L, Laterre PF, Horman S, Beauloye C. Dexamethasone Modulates the Cytokine Response but Not COVID-19-Induced Coagulopathy in Critically Ill. Int J Mol Sci 2023; 24:ijms24087278. [PMID: 37108440 PMCID: PMC10138864 DOI: 10.3390/ijms24087278] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 03/29/2023] [Accepted: 04/05/2023] [Indexed: 04/29/2023] Open
Abstract
Severe forms of coronavirus 2019 (COVID-19) disease are caused by an exaggerated systemic inflammatory response and subsequent inflammation-related coagulopathy. Anti-inflammatory treatment with low dose dexamethasone has been shown to reduce mortality in COVID-19 patients requiring oxygen therapy. However, the mechanisms of action of corticosteroids have not been extensively studied in critically ill patients in the context of COVID-19. Plasma biomarkers of inflammatory and immune responses, endothelial and platelet activation, neutrophil extracellular trap formation, and coagulopathy were compared between patients treated or not by systemic dexamethasone for severe forms of COVID-19. Dexamethasone treatment significantly reduced the inflammatory and lymphoid immune response in critical COVID-19 patients but had little effect on the myeloid immune response and no effect on endothelial activation, platelet activation, neutrophil extracellular trap formation, and coagulopathy. The benefits of low dose dexamethasone on outcome in critical COVID-19 can be partially explained by a modulation of the inflammatory response but not by reduction of coagulopathy. Future studies should explore the impact of combining dexamethasone with other immunomodulatory or anticoagulant drugs in severe COVID-19.
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Affiliation(s)
- Mélanie Dechamps
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCLouvain), 1200 Brussels, Belgium
- Department of Cardiovascular Intensive Care, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Julien De Poortere
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCLouvain), 1200 Brussels, Belgium
| | - Marie Octave
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCLouvain), 1200 Brussels, Belgium
| | - Audrey Ginion
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCLouvain), 1200 Brussels, Belgium
| | - Valentine Robaux
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCLouvain), 1200 Brussels, Belgium
| | - Laurence Pirotton
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCLouvain), 1200 Brussels, Belgium
| | - Julie Bodart
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCLouvain), 1200 Brussels, Belgium
| | - Damien Gruson
- Department of Clinical Biology, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | | | - Jonathan Douxfils
- Department of Pharmacy, Namur Research Institute for Life Sciences (Narilis), 5000 Namur, Belgium
- Qualiblood, s.a., 5000 Namur, Belgium
| | - Hélène Haguet
- Department of Pharmacy, Namur Research Institute for Life Sciences (Narilis), 5000 Namur, Belgium
- Qualiblood, s.a., 5000 Namur, Belgium
| | - Laure Morimont
- Department of Pharmacy, Namur Research Institute for Life Sciences (Narilis), 5000 Namur, Belgium
- Qualiblood, s.a., 5000 Namur, Belgium
| | - Marc Derive
- Inotrem s.a., 54500 Vandoeuvre-les-Nancy, France
| | - Lucie Jolly
- Inotrem s.a., 54500 Vandoeuvre-les-Nancy, France
| | - Luc Bertrand
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCLouvain), 1200 Brussels, Belgium
- Walloon Excellence in Life Sciences and Biotechnology (WELBIO) Department, WEL Research Institute, 1300 Wavre, Belgium
| | - Pierre-François Laterre
- Department of Intensive Care, Centre Hospitalier Regional Mons-Hainaut, 7000 Mons, Belgium
- Critical Care Coordinating Center (4Cs), 1200 Brussels, Belgium
| | - Sandrine Horman
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCLouvain), 1200 Brussels, Belgium
| | - Christophe Beauloye
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCLouvain), 1200 Brussels, Belgium
- Department of Cardiology, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
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Sutanto H, Soegiarto G. Risk of Thrombosis during and after a SARS-CoV-2 Infection: Pathogenesis, Diagnostic Approach, and Management. Hematol Rep 2023; 15:225-243. [PMID: 37092518 PMCID: PMC10123679 DOI: 10.3390/hematolrep15020024] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/07/2023] [Accepted: 03/24/2023] [Indexed: 04/05/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) increases the risk of thromboembolic events, especially in patients with severe infections requiring intensive care and cardiorespiratory support. COVID-19 patients with thromboembolic complications have a higher risk of death, and if they survive, these complications are expected to negatively affect these patients’ quality of life. Moreover, recent data reported that the risk of thromboembolism remains high months after a COVID-19 infection. Therefore, understanding the pathogenesis of thrombosis in the setting of COVID-19 may facilitate the early prevention and treatment of COVID-19-associated thromboembolism to reduce concomitant morbidity, mortality, and disability. This review will first discuss the clinical characteristics of COVID-19 infections, particularly with regard to the underlying pathophysiology. Then, the pathogenesis of COVID-19-associated thrombosis at the molecular and cellular levels will be comprehensively reviewed. Next, the clinical manifestations of venous and arterial thromboembolism in COVID-19 as well as the potential benefits of several laboratory markers of thrombosis will be further discussed. Lastly, the preventive and therapeutic management of thromboembolism during and after COVID-19 will also be explained.
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Affiliation(s)
- Henry Sutanto
- Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia
- Department of Internal Medicine, Dr. Soetomo Teaching Hospital, Surabaya 60286, Indonesia
| | - Gatot Soegiarto
- Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia
- Department of Internal Medicine, Dr. Soetomo Teaching Hospital, Surabaya 60286, Indonesia
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia
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Schupp T, Weidner K, Rusnak J, Jawhar S, Forner J, Dulatahu F, Brück LM, Lübke J, Hoffmann U, Bertsch T, Behnes M, Akin I. Fibrinogen reflects severity and predicts outcomes in patients with sepsis and septic shock. Blood Coagul Fibrinolysis 2023; 34:161-170. [PMID: 36966770 DOI: 10.1097/mbc.0000000000001197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
The study investigates the diagnostic and prognostic value of fibrinogen and the albumin-to-fibrinogen-ratio (AFR) in patients with sepsis and septic shock. Limited data regarding the prognostic value of fibrinogen and AFR during the course of sepsis or septic shock are available. Consecutive patients with sepsis and septic shock from 2019 to 2021 were included monocentrically. Blood samples were retrieved from the day of disease onset (day 1), as well as on day 2 and 3. Firstly, the diagnostic value of fibrinogen and the AFR for the diagnosis of a septic shock was tested. Secondly, the prognostic value of fibrinogen and AFR was tested with regard to the 30-day all-cause mortality. Statistical analyses included univariable t-tests, Spearman's correlations, C-statistics, Kaplan-Meier and multivariable Cox regression analyses. Ninety-one patients with sepsis and septic shock were included. With an area under the curve (AUC) of 0.653-0.801, fibrinogen discriminated patients with septic shock from those with sepsis. In the septic shock group, fibrinogen levels were shown to decrease from day 1 to 3 (median decrease 41%). In line, fibrinogen was a reliable predictor for 30-day all-cause mortality (AUC 0.661-0.744), whereas fibrinogen levels less than 3.6 g/l were associated with an increased risk of 30-day all-cause mortality (78 vs. 53%; log rank P = 0.004; hazard ratio = 2.073; 95% confidence interval 1.233-3.486; P = 0.006), which was still observed after multivariable adjustment. In contrast, the AFR was no longer associated with the risk of mortality after multivariable adjustment. Fibrinogen was a reliable diagnostic and prognostic tool for the diagnosis of septic shock as well as for 30-day all-cause mortality and superior compared with the AFR in patients admitted with sepsis or septic shock.
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Affiliation(s)
- Tobias Schupp
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim
| | - Kathrin Weidner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim
| | - Jonas Rusnak
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim
| | - Schanas Jawhar
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim
| | - Jan Forner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim
| | - Floriana Dulatahu
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim
| | - Lea Marie Brück
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim
| | - Johannes Lübke
- Third Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim
| | - Ursula Hoffmann
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Nuremberg General Hospital, Paracelsus Medical University, Nuremberg, Germany
| | - Michael Behnes
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim
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Labbé V, Contou D, Heming N, Megarbane B, Razazi K, Boissier F, Ait-Oufella H, Turpin M, Carreira S, Robert A, Monchi M, Souweine B, Preau S, Doyen D, Vivier E, Zucman N, Dres M, Fejjal M, Noel-Savina E, Bachir M, Jaffal K, Timsit JF, Picos SA, Mariotte E, Martis N, Juguet W, Melica G, Rondeau P, Audureau E, Mekontso Dessap A. Effects of Standard-Dose Prophylactic, High-Dose Prophylactic, and Therapeutic Anticoagulation in Patients With Hypoxemic COVID-19 Pneumonia: The ANTICOVID Randomized Clinical Trial. JAMA Intern Med 2023:2802821. [PMID: 36946232 PMCID: PMC10034664 DOI: 10.1001/jamainternmed.2023.0456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
Importance Given the high risk of thrombosis and anticoagulation-related bleeding in patients with hypoxemic COVID-19 pneumonia, identifying the lowest effective dose of anticoagulation therapy for these patients is imperative. Objectives To determine whether therapeutic anticoagulation (TA) or high-dose prophylactic anticoagulation (HD-PA) decreases mortality and/or disease duration compared with standard-dose prophylactic anticoagulation (SD-PA), and whether TA outperforms HD-PA; and to compare the net clinical outcomes among the 3 strategies. Design, Settings, and Participants The ANTICOVID randomized clinical open-label trial included patients with hypoxemic COVID-19 pneumonia requiring supplemental oxygen and having no initial thrombosis on chest computer tomography with pulmonary angiogram at 23 health centers in France from April 14 to December 13, 2021. Of 339 patients randomized, 334 were included in the primary analysis-114 patients in the SD-PA group, 110 in the HD-PA, and 110 in the TA. At randomization, 90% of the patients were in the intensive care unit. Data analyses were performed from April 13, 2022, to January 3, 2023. Interventions Patients were randomly assigned (1:1:1) to receive either SD-PA, HD-PA, or TA with low-molecular-weight or unfractionated heparin for 14 days. Main Outcomes and Measures A hierarchical criterion of all-cause mortality followed by time to clinical improvement at day 28. Main secondary outcome was net clinical outcome at day 28 (composite of thrombosis, major bleeding, and all-cause death). Results Among the study population of 334 individuals (mean [SD] age, 58.3 [13.0] years; 226 [67.7%] men and 108 [32.3%] women), use of HD-PA and SD-PA had similar probabilities of favorable outcome (47.3% [95% CI, 39.9% to 54.8%] vs 52.7% [95% CI, 45.2% to 60.1%]; P = .48), as did TA compared with SD-PA (50.9% [95% CI, 43.4% to 58.3%] vs 49.1% [95% CI, 41.7% to 56.6%]; P = .82) and TA compared with HD-PA (53.5% [95% CI 45.8% to 60.9%] vs 46.5% [95% CI, 39.1% to 54.2%]; P = .37). Net clinical outcome was met in 29.8% of patients receiving SD-PA (20.2% thrombosis, 2.6% bleeding, 14.0% death), 16.4% receiving HD-PA (5.5% thrombosis, 3.6% bleeding, 11.8% death), and 20.0% receiving TA (5.5% thrombosis, 3.6% bleeding, 12.7% death). Moreover, HD-PA and TA use significantly reduced thrombosis compared with SD-PA (absolute difference, -14.7 [95% CI -6.2 to -23.2] and -14.7 [95% CI -6.2 to -23.2], respectively). Use of HD-PA significantly reduced net clinical outcome compared with SD-PA (absolute difference, -13.5; 95% CI -2.6 to -24.3). Conclusions and Relevance This randomized clinical trial found that compared with SD-PA, neither HD-PA nor TA use improved the primary hierarchical outcome of all-cause mortality or time to clinical improvement in patients with hypoxemic COVID-19 pneumonia; however, HD-PA resulted in significantly better net clinical outcome by decreasing the risk of de novo thrombosis. Trial Registration ClinicalTrials.gov Identifier: NCT04808882.
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Affiliation(s)
- Vincent Labbé
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire Tenon, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
- Service des Soins Intensifs, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Bruxelles, Belgium
- Université Paris Est Créteil, Institut Mondor de Recherche Biomédicale, Groupe de Recherche Clinique CARMAS (Cardiovascular and Respiratory Manifestations of Acute lung injury and Sepsis), Créteil, France
| | - Damien Contou
- Service de Réanimation Polyvalente, Centre Hospitalier Victor Dupouy, Argenteuil, France
| | - Nicholas Heming
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire Raymond Poincaré, Assistance Publique-Hôpitaux de Paris, Université Versailles Saint Quentin-Université Paris Saclay, Garches, France
- Laboratoire d'infection et inflammation, Unité 1173, Faculté de Médecine Simone Veil, Institut national de la santé et de la recherche médicale, Université Versailles Saint Quentin - Université Paris Saclay, Garches, France
| | - Bruno Megarbane
- Service de Réanimation Médicale et Toxicologique, Centre Hospitalier Universitaire Lariboisière, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
- Unité Mixte de Recherche en Santé 1144, Institut national de la santé et de la recherche médicale, Université Paris Cité, Paris, France
| | - Keyvan Razazi
- Université Paris Est Créteil, Institut Mondor de Recherche Biomédicale, Groupe de Recherche Clinique CARMAS (Cardiovascular and Respiratory Manifestations of Acute lung injury and Sepsis), Créteil, France
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
| | - Florence Boissier
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Université de Poitiers, Poitiers, France
- Centre d'Investigation Clinique 1402 (Investigations of Sleep, Acute Lung Injury, & Ventilation group), Institut national de la santé et de la recherche médicale, Université de Poitiers, Poitiers, France
| | - Hafid Ait-Oufella
- Service de Médecine Intensive Réanimation, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Matthieu Turpin
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire Tenon, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Serge Carreira
- Service d'Anesthésie-Réanimation polyvalente, Hôpital Saint Camille, Bry-sur-Marne, France
| | - Alexandre Robert
- Service de Médecine Intensive Réanimation, Hôpital Simone Veil, Centre Hospitalier de Cannes, Cannes, France
- Centre Méditerranéen de Médecine Moléculaire, Institut national de la santé et de la recherche médicale, Université Côte d'Azur, Nice, France
| | - Mehran Monchi
- Service de Médecine Intensive Réanimation, Groupe Hospitalier Sud Ile de France, Melun, France
| | - Bertrand Souweine
- Service de Médecine Intensive Réanimation, Hôpital Universitaire Gabriel-Montpied, Clermont-Ferrand, France
| | - Sebastien Preau
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire Lille, Université de Lille, Lille, France
- Unité 1167, Institut Pasteur de Lille, Institut national de la santé et de la recherche médicale, Université de Lille, Lille, France
| | - Denis Doyen
- Service de Médecine Intensive Réanimation, Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, Nice, France
- Unité de Recherche Clinique Côte d'Azur, Université Côte d'Azur, Nice, France
| | - Emmanuel Vivier
- Service de Réanimation Polyvalente, Centre Hospitalier Saint Joseph-Saint Luc, Lyon, France
| | - Noémie Zucman
- Service de Médecine Intensive Réanimation, Departement Médico-Universitaire ESPRIT, Centre Hospitalier Universitaire Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes, France
- Unité de Formation et de Recherche de Médecine, Université Paris Cité, Paris, France
| | - Martin Dres
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Mohamed Fejjal
- Service de Médecine Intensive Réanimation, Centre Hospitalier Léon Binet, Provins, France
| | - Elise Noel-Savina
- Service de Pneumologie et de Soins Intensifs Respiratoires, Hôpital Larrey, Toulouse, France
| | - Marwa Bachir
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire Tenon, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Karim Jaffal
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire Raymond Poincaré, Assistance Publique-Hôpitaux de Paris, Garches, France
| | - Jean-François Timsit
- Service de Médecine Intensive et Réanimation Infectieuse, Centre Hospitalier Universitaire Bichat, Assistance Publique-Hôpitaux de Paris, Université de Paris-Cité, Paris, France
- Infection, Anti-microbien, Modélisation, Evolution, Institut National de la Santé et de la Recherche Médicale, Unité 1137, Université de Paris-Cité, Paris, France
| | - Santiago Alberto Picos
- Service de Médecine Intensive Réanimation, Centre Hospitalier La Dracénie De Draguignan, Draguignan, France
| | - Eric Mariotte
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Universitaire Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Nihal Martis
- Service de Médecine Interne, Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, Nice, France
| | - William Juguet
- Service de Réanimation Médico-Chirurgicale, Centre Hospitalier Universitaire Avicenne, Assistance Publique-Hôpitaux de Paris, Université Sorbonne Paris Nord, Bobigny, France
| | - Giovanna Melica
- Service des Maladies Infectieuses et Tropicales, Hôpitaux Universitaires Henri-Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
| | - Paul Rondeau
- Service de Médecine Interne, Hôpital Saint Camille, Bry-sur-Marne, France
| | - Etienne Audureau
- Unité de Recherche Clinique Henri Mondor, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
- Institut Mondor de Recherche Biomédicale, Unité 955, Institut National de la Santé et de la Recherche Médicale, Université Paris Est Créteil, Créteil, France
| | - Armand Mekontso Dessap
- Université Paris Est Créteil, Institut Mondor de Recherche Biomédicale, Groupe de Recherche Clinique CARMAS (Cardiovascular and Respiratory Manifestations of Acute lung injury and Sepsis), Créteil, France
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
- Université Paris Est Créteil, Institut Mondor de recherche biomédicale, Institut national de la santé et de la recherche médicale, Créteil, France
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Wada T, Yamakawa K, Kabata D, Abe T, Fujishima S, Kushimoto S, Mayumi T, Ogura H, Saitoh D, Shiraishi A, Otomo Y, Gando S. Sepsis-related coagulopathy treatment based on the disseminated intravascular coagulation diagnostic criteria: a post-hoc analysis of a prospective multicenter observational study. J Intensive Care 2023; 11:8. [PMID: 36872342 PMCID: PMC9985865 DOI: 10.1186/s40560-023-00656-5] [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: 12/06/2022] [Accepted: 02/23/2023] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND The development of disseminated intravascular coagulation (DIC) in patients with sepsis has been repeatedly confirmed as a factor associated with poor prognosis. Anticoagulant therapy has been expected to improve sepsis patient outcomes, whereas no randomized controlled trials have demonstrated the survival benefit of anticoagulant therapies in non-specific overall sepsis. Patient selection based on the component of "high disease severity" in addition to "sepsis with DIC" has recently proved important in identifying appropriate targets for anticoagulant therapy. The aims of this study were to characterize "severe" sepsis DIC patients and to identify the patient population benefiting from anticoagulant therapy. METHODS This retrospective sub-analysis of a prospective multicenter study included 1,178 adult patients with severe sepsis from 59 intensive care units in Japan from January 2016 to March 2017. We examined the association of patient outcomes, including organ dysfunction and in-hospital mortality, with the DIC score and prothrombin time-international normalized ratio (PT-INR), one of the components of the DIC score, using multivariable regression models including the cross-product term between these indicators. Multivariate Cox proportional hazard regression analysis with non-linear restricted cubic spline including a three-way interaction term (anticoagulant therapy × the DIC score × PT-INR) was also performed. Anticoagulant therapy was defined as the administration of antithrombin, recombinant human thrombomodulin, or their combination. RESULTS In total, we analyzed 1013 patients. The regression model showed that organ dysfunction and in-hospital mortality deteriorated with higher PT-INR values in the range of < 1.5 and that this trend was more pronounced with higher DIC scores. Three-way interaction analysis demonstrated that anticoagulant therapy was associated with better survival outcome in patients with a high DIC score and high PT-INR. Furthermore, we identified a DIC score ≥ 5 and PT-INR ≥ 1.5 as the clinical threshold for identification of optimal targets for anticoagulant therapy. CONCLUSIONS The combined use of the DIC score and PT-INR helps in selecting the optimal patient population for anticoagulant therapy in sepsis-induced DIC. The results obtained from this study will provide valuable information regarding the study design of randomized controlled trials examining the effects of anticoagulant therapy for sepsis. TRIAL REGISTRATION UMIN-CTR, UMIN000019742. Registered on November 16, 2015.
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Affiliation(s)
- Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, N15, W7, Kita-Ku, Sapporo, Japan.
| | - Kazuma Yamakawa
- Department of Emergency Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Daijiro Kabata
- Department of Medical Statistics, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan.,Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Toshihiko Mayumi
- Department of Trauma, Critical Care Medicine and Burn Center, Community Healthcare Organization, Chukyo Hospital, Nagoya, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Japan
| | | | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, N15, W7, Kita-Ku, Sapporo, Japan.,Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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Iba T, Levy JH, Thachil J, Susen S, Levi M, Scarlatescu E. Communication from the Scientific Standardization Committees of the International Society on Thrombosis and Haemostasis on vascular endothelium-related biomarkers in disseminated intravascular coagulation. J Thromb Haemost 2023; 21:691-699. [PMID: 36696178 DOI: 10.1016/j.jtha.2022.11.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/21/2022] [Accepted: 11/06/2022] [Indexed: 01/26/2023]
Abstract
Disseminated intravascular coagulation (DIC) is not a disease criterion but a pathomechanistic process that accompanies various underlying diseases. According to the International Society on Thrombosis and Haemostasis definition, endothelial injury is an essential component in addition to systemic coagulation activation. Despite this definition, current diagnostic criteria for DIC do not include biomarkers for vascular endothelial injury. Endothelial cells are critical for hemostatic regulation because they produce various antithrombotic substances and express anticoagulant factors at the same time as facilitating coagulation, inflammatory reactions, platelet aggregation, and fibrinolysis with acute injury. Endothelial cells also exhibit various receptors, adhesion molecules, and the critical role of glycocalyx that regulates cellular interactions in thromboinflammation. For clinicians, biomarkers suitable for assessing endothelial injury are not readily available. Although we still do not have ideal biomarkers, antithrombin activity and von Willebrand factor can be candidates for the endothelium-related markers because those reflect the severity and are available in most clinical settings. Further, the dysfunction of endothelial cell in DIC arising from various underlying diseases is likely highly variable. For example, the involvement of endothelial dysfunction is significant in sepsis-induced coagulopathy, while moderate in trauma-induced coagulopathy, and variable in hematologic malignancy-associated coagulopathy. Because of the complexity of disease status associated with DIC, further research searching clinically available endothelium-related biomarkers is expected to establish individualized diagnostic criteria and potential therapeutic approaches.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| | - Sophie Susen
- Department of Hematology and Transfusion, Lille University Hospital, Lille, France
| | - Marcel Levi
- Department of Vascular Medicine, Amsterdam University Medical Center, the Netherlands and Department of Medicine, University College London Hospitals NHS Foundation Trust, and Cardio-metabolic Programme-NIHR UCLH/UCL BRC London, UK
| | - Ecaterina Scarlatescu
- University of Medicine and Pharmacy "Carol Davila," Bucharest and Department of Anaesthesia and Intensive Care, Fundeni Clinical Institute, Bucharest, Romania
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Sepsis-Induced Coagulopathy Phenotype Induced by Oxidized High-Density Lipoprotein Associated with Increased Mortality in Septic-Shock Patients. Antioxidants (Basel) 2023; 12:antiox12030543. [PMID: 36978791 PMCID: PMC10045333 DOI: 10.3390/antiox12030543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/08/2023] [Accepted: 02/15/2023] [Indexed: 02/25/2023] Open
Abstract
Sepsis syndrome is a highly lethal uncontrolled response to an infection, which is characterized by sepsis-induced coagulopathy (SIC). High-density lipoprotein (HDL) exhibits antithrombotic activity, regulating coagulation in vascular endothelial cells. Sepsis induces the release of several proinflammatory molecules, including reactive oxygen species, which lead to an increase in oxidative stress in blood vessels. Thus, circulating lipoproteins, such as HDL, are oxidized to oxHDL, which promotes hemostatic dysfunction, acquiring prothrombotic properties linked to the severity of organ failure in septic-shock patients (SSP). However, a rigorous and comprehensive investigation demonstrating that oxHDL is associated with a coagulopathy-associated deleterious outcome of SSP, has not been reported. Thus, we investigated the participation of plasma oxHDL in coagulopathy-associated sepsis pathogenesis and elucidated the underlying molecular mechanism. A prospective study was conducted on 42 patients admitted to intensive care units, (26 SSP and 16 non-SSP) and 39 healthy volunteers. We found that an increased plasma oxHDL level in SSP was associated with a prothrombotic phenotype, increased mortality and elevated risk of death, which predicts mortality in SSP. The underlying mechanism indicates that oxHDL triggers an endothelial protein expression reprogramming of coagulation factors and procoagulant adhesion proteins, to produce a prothrombotic environment, mainly mediated by the endothelial LOX-1 receptor. Our study demonstrates that an increased plasma oxHDL level is associated with coagulopathy in SSP through a mechanism involving the endothelial LOX-1 receptor and endothelial protein expression regulation. Therefore, the plasma oxHDL level plays a role in the molecular mechanism associated with increased mortality in SSP.
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Frank CS, Larsen JB. Prognostic Impact of the International Society on Thrombosis and Hemostasis Disseminated Intravascular Coagulation Score in Sepsis: A Systematic Review. Semin Thromb Hemost 2023. [PMID: 36731487 DOI: 10.1055/s-0043-1761216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The International Society on Thrombosis and Haemostasis (ISTH) diagnostic criteria for disseminated intravascular coagulation (DIC) are widely used for DIC diagnosis. However, the prognostic value of the score may vary between different patient populations and settings. This systematic review investigated the association between the ISTH DIC score and mortality in sepsis patients. A literature search was conducted in PubMed and Embase. Inclusion criteria were studies including adult and pediatric patients hospitalized with sepsis, using any sepsis definition, and investigating the association between mortality and the ISTH DIC score. The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. In total, 42 studies were included. A positive association between the ISTH DIC score and mortality was consistently reported, with odds ratios of death in DIC versus non-DIC patients ranging from 1.125 (95% confidence interval [CI]: 0.838-1.511) to 21.008 (95% CI: 1.408-313.405) in adults and from 1.378 (95% CI: 1.004-1.893) to 2.99 (95% CI: 0.54-16.6) in pediatric populations. However, the DIC score only had a low-moderate positive predictive value for mortality, as area under receiver-operator characteristics ranged from 0.602 (95% CI: 0.575-0.630) to 0.815 (95% CI: 0.676-0.954) in adults. Of note, only few studies adjusted for potential confounders such as age, gender, and comorbidity. The ISTH DIC score is consistently associated with sepsis-related mortality but is not a strong positive predictor for mortality. Nevertheless, the score may still have a prognostic value and its use in sepsis is encouraged.
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Affiliation(s)
- Christian Sandberg Frank
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Julie Brogaard Larsen
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Nygaard S, Hvas CL, Hvas AM, Adelborg K. In vitro Effect of Dalteparin and Argatroban on Hemostasis in Critically Ill Sepsis Patients with New-Onset Thrombocytopenia. TH OPEN : COMPANION JOURNAL TO THROMBOSIS AND HAEMOSTASIS 2023; 7:e42-e55. [PMID: 36751302 PMCID: PMC9886503 DOI: 10.1055/a-2000-6576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022]
Abstract
Thrombocytopenia is common among critically ill sepsis patients, while they also hold an increased risk for thromboembolic events. Thus, the choice of anticoagulant prophylaxis for this patient population is challenging. We investigated the in vitro effect of low-molecular-weight heparin (dalteparin) and direct thrombin inhibitor (argatroban) on the hemostasis in blood from sepsis patients with new-onset thrombocytopenia. Thrombocytopenia was defined as a platelet count drop of ≥30% and/or from >100 × 10 9 /L to 30 to 100 × 10 9 /L within 24 hours prior to inclusion. We included five healthy individuals and ten patients. Analyses of thrombin generation (Calibrated Automated Thrombogram), thrombin-antithrombin (TAT) complex levels, prothrombin fragment 1+2 (F1+2), and rotational thromboelastometry (ROTEM) were performed. Based on dose-response relationships investigated in healthy blood, patient samples were spiked with prophylactic (0.25 IU/mL) and therapeutic (0.75 IU/mL) dalteparin and low (0.25 µg/mL) and high (0.50 µg/mL) argatroban concentrations, each with a sample without anticoagulant. In patients, the endogenous thrombin potential was markedly lower in therapeutic dalteparin samples than in samples without anticoagulant [median (range): 29 (0-388) vs. 795 (98-2121) nM × min]. In high argatroban concentration samples, thrombin lag time was longer than in samples without anticoagulant [median (range): 15.5 (10.5-20.2) versus 5.3 (2.8-7.3) min]. Dalteparin and argatroban both increased clotting time but did not affect maximum clot firmness in the ROTEM INTEM assay. Six patients had elevated TAT and eight patients had elevated F1 + 2. In conclusion, dalteparin mainly affected the amount of thrombin generated and argatroban delayed clot initiation in critically ill sepsis patients with new-onset thrombocytopenia. Neither anticoagulant affected clot strength.
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Affiliation(s)
- Søren Nygaard
- Department of Clinical Biochemistry, Thrombosis and Hemostasis Research Unit, Aarhus University Hospital, Aarhus, Denmark,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Christine L. Hvas
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark,Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | | | - Kasper Adelborg
- Department of Clinical Biochemistry, Thrombosis and Hemostasis Research Unit, Aarhus University Hospital, Aarhus, Denmark,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark,Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark,Department of Clinical Biochemistry, Gødstrup Regional Hospital, Herning, Denmark,Address for correspondence Kasper Adelborg, MD, PhD Department of Clinical BiochemistryThrombosis and Hemostasis Research Unit, Palle Juul-Jensens Boulevard 99, Aarhus University Hospital, 8200 Aarhus NDenmark
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Sepsis-Induced Coagulopathy: An Update on Pathophysiology, Biomarkers, and Current Guidelines. Life (Basel) 2023; 13:life13020350. [PMID: 36836706 PMCID: PMC9961497 DOI: 10.3390/life13020350] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/16/2023] [Accepted: 01/20/2023] [Indexed: 02/03/2023] Open
Abstract
Significant cross talk occurs between inflammation and coagulation. Thus, coagulopathy is common in sepsis, potentially aggravating the prognosis. Initially, septic patients tend to exhibit a prothrombotic state through extrinsic pathway activation, cytokine-induced coagulation amplification, anticoagulant pathways suppression, and fibrinolysis impairment. In late sepsis stages, with the establishment of disseminated intravascular coagulation (DIC), hypocoagulability ensues. Traditional laboratory findings of sepsis, including thrombocytopenia, increased prothrombin time (PT) and fibrin degradation products (FDPs), and decreased fibrinogen, only present late in the course of sepsis. A recently introduced definition of sepsis-induced coagulopathy (SIC) aims to identify patients at an earlier stage when changes to coagulation status are still reversible. Nonconventional assays, such as the measurement of anticoagulant proteins and nuclear material levels, and viscoelastic studies, have shown promising sensitivity and specificity in detecting patients at risk for DIC, allowing for timely therapeutic interventions. This review outlines current insights into the pathophysiological mechanisms and diagnostic options of SIC.
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Schmoch T, Möhnle P, Weigand MA, Briegel J, Bauer M, Bloos F, Meybohm P, Keh D, Löffler M, Elke G, Brenner T, Bogatsch H. The prevalence of sepsis-induced coagulopathy in patients with sepsis - a secondary analysis of two German multicenter randomized controlled trials. Ann Intensive Care 2023; 13:3. [PMID: 36635426 PMCID: PMC9837358 DOI: 10.1186/s13613-022-01093-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 12/05/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Sepsis and septic shock are frequently accompanied by coagulopathy. Since the sepsis-induced coagulopathy (SIC) score was first described, subsequent studies from Asia revealed a SIC prevalence of 40-60%. In Europe, however, SIC prevalence in patients fulfilling sepsis criteria according to the third international consensus definition (SEPSIS-3) has not yet been evaluated. METHODS The Critical Care Trials Group of the German Sepsis Competence Network (SepNet) conducted a secondary analysis of two randomized controlled trials. Only patients fulfilling sepsis criteria according SEPSIS-3 were included in this secondary analysis. In a two step approach, SIC prevalence was determined in 267 patients with sepsis but not septic shock (at the time of inclusion) from the "Effect of Hydrocortisone on Development of Shock Among Patients With Severe Sepsis" (HYPRESS) trial. Then, we estimated SIC prevalence in 1,018 patients from the "Effect of Sodium Selenite Administration and Procalcitonin-Guided Therapy on Mortality in Patients With Severe Sepsis or Septic Shock" (SISPCT) trial using a simplified SIC score based on the platelet-SIC-subscore (PSSC). Study aims were to assess (i) the prevalence of SIC in patients with SEPSIS-3, (ii) the association of SIC with 90-day mortality and morbidity, (iii) the time when patients become SIC positive during the course of sepsis, and (iv) the value of the PSSC for predicting SIC. RESULTS In the HYPRESS trial, SIC prevalence was 22.1% (95% confidence interval [CI] 17.5-27.5%). The estimated SIC prevalence in the SISPCT trial was 24.2% (95% CI 21.6-26.9%). In the HYPRESS trial, SIC was associated with significantly higher 90-day mortality (13.9% vs. 26.8%, p = 0.027) and morbidity. Logistic regression analysis adjusted for age, sex, treatment arm, and (SIC-adapted) SOFA score confirmed the negative association of SIC with survival (p = 0.011). In the SISPCT trial, increased PSSCs were associated with higher 90-day mortality (PSSC 0: 34.4%, PSSC 1: 40.5%, PSSC 2: 53.3%; p < 0.001). In both trials, SIC was already present at sepsis diagnosis or occurred during the following 4 days. CONCLUSIONS SIC is a clinically relevant complication of sepsis. Although it might be less frequent than previously reported, its occurrence is associated with higher morbidity and mortality and should be interpreted as an early warning sign.
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Affiliation(s)
- Thomas Schmoch
- grid.414194.d0000 0004 0613 2450Department of Anesthesiology and Intensive Care Medicine, Hôpitaux Robert Schuman – Hôpital Kirchberg, 9, Rue Edward Steichen, 2540 Luxembourg City, Luxembourg ,grid.5718.b0000 0001 2187 5445Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Patrick Möhnle
- grid.411095.80000 0004 0477 2585Department of Transfusion Medicine, Cell Therapeutics and Hemostasis, Department of Anesthesiology, Klinikum Der Ludwig-Maximilians-Universität, Munich, Germany
| | - Markus A. Weigand
- grid.5253.10000 0001 0328 4908Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Josef Briegel
- grid.411095.80000 0004 0477 2585Department of Anesthesiology, Klinikum Der Ludwig-Maximilians-Universität, Munich, Germany
| | - Michael Bauer
- grid.275559.90000 0000 8517 6224Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - Frank Bloos
- grid.275559.90000 0000 8517 6224Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany ,grid.275559.90000 0000 8517 6224Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Patrick Meybohm
- grid.411760.50000 0001 1378 7891Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Würzburg, Germany
| | - Didier Keh
- grid.6363.00000 0001 2218 4662Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Markus Löffler
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE) and Clinical Trial Centre Leipzig, Leipzig, Germany
| | - Gunnar Elke
- grid.412468.d0000 0004 0646 2097Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Thorsten Brenner
- grid.5718.b0000 0001 2187 5445Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Holger Bogatsch
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE) and Clinical Trial Centre Leipzig, Leipzig, Germany
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Management Strategies in Septic Coagulopathy: A Review of the Current Literature. Healthcare (Basel) 2023; 11:healthcare11020227. [PMID: 36673595 PMCID: PMC9858837 DOI: 10.3390/healthcare11020227] [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] [Received: 11/27/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 01/14/2023] Open
Abstract
One of the 'organs' that can be affected by sepsis is the coagulation system. Coagulopathy in sepsis may take the form of sepsis-induced coagulopathy (SIC) or sepsis-associated disseminated intravascular coagulation (DIC). It is important to identify SIC early, as at this stage of coagulopathy anticoagulants may be of the greatest benefit. The most recent diagnostic scoring systems for septic coagulopathy come from the International Society on Thrombosis and Hemostasis and the Japanese Association for Acute Medicine. Recommendations regarding the management of septic coagulopathy differ between organizations. Moreover, septic coagulopathy is an area of intense research in recent years. Therefore we searched three databases to review the most recent management strategies in septic coagulopathy. The mainstream management strategies in septic coagulopathy include the causal treatment of sepsis, unfractionated heparin, low-molecular-weight heparin, antithrombin, and recombinant human thrombomodulin. The last two have been associated with the highest survival benefit. Nevertheless, the indiscriminate use of these anticoagulants should be avoided due to the lack of mortality benefit and increased risk of bleeding. The early diagnosis of SIC and monitoring of coagulation status during sepsis is crucial for the timely management and selection of the most suitable treatment at a time. New directions in septic coagulopathy include new diagnostic biomarkers, dynamic diagnostic models, genetic markers for SIC management, and new therapeutic agents. These new research avenues may potentially result in timelier SIC diagnosis and improved management of all stages of septic coagulopathy by making it more effective, safe, and personalized.
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