A Proposal of the Modification of Japanese Society on Thrombosis and Hemostasis (JSTH) Disseminated Intravascular Coagulation (DIC) Diagnostic Criteria for Sepsis-Associated DIC

A Narrative Review of Scoring Methods in Disseminated Intravascular Coagulation: Evaluating Diagnostic Accuracy and Clinical Utility

Disseminated intravascular coagulation (DIC) is a critical, life-threatening disorder characterized by widespread activation of the coagulation cascade, leading to microthrombi formation, consumption of clotting factors and platelets, and a paradoxically increased risk of bleeding. Accurate and timely diagnosis is crucial for effective management and improved patient outcomes. This narrative review aims to evaluate the diagnostic accuracy and clinical utility of various scoring systems used to assess DIC. We examine prominent systems, including the International Society on Thrombosis and Haemostasis (ISTH) scoring system, the Japanese Association for Acute Medicine (JAAM) DIC criteria, and other regional or institutional criteria such as the Chinese DIC scoring system (CDSS). The review compares these systems based on their criteria, sensitivity, specificity, and accuracy across different patient populations and discusses their strengths and limitations. Additionally, we explore the impact of these scoring systems on patient management and therapeutic decisions, identify challenges and limitations, and highlight emerging trends and future directions in DIC diagnosis. By providing a comprehensive analysis, this review aims to enhance understanding of DIC scoring methods and inform clinical practice to improve patient care.

A case report of sepsis associated coagulopathy after percutaneous nephrostomy

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.

Designing the Diagnostic Criteria for Disseminated Intravascular Coagulation (DIC)

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.

Development of early prediction model of in-hospital cardiac arrest based on laboratory parameters

BACKGROUND

In-hospital cardiac arrest (IHCA) is an acute disease with a high fatality rate that burdens individuals, society, and the economy. This study aimed to develop a machine learning (ML) model using routine laboratory parameters to predict the risk of IHCA in rescue-treated patients.

METHODS

This retrospective cohort study examined all rescue-treated patients hospitalized at the First Medical Center of the PLA General Hospital in Beijing, China, from January 2016 to December 2020. Five machine learning algorithms, including support vector machine, random forest, extra trees classifier (ETC), decision tree, and logistic regression algorithms, were trained to develop models for predicting IHCA. We included blood counts, biochemical markers, and coagulation markers in the model development. We validated model performance using fivefold cross-validation and used the SHapley Additive exPlanation (SHAP) for model interpretation.

RESULTS

A total of 11,308 participants were included in the study, of which 7779 patients remained. Among these patients, 1796 (23.09%) cases of IHCA occurred. Among five machine learning models for predicting IHCA, the ETC algorithm exhibited better performance, with an AUC of 0.920, compared with the other four machine learning models in the fivefold cross-validation. The SHAP showed that the top ten factors accounting for cardiac arrest in rescue-treated patients are prothrombin activity, platelets, hemoglobin, N-terminal pro-brain natriuretic peptide, neutrophils, prothrombin time, serum albumin, sodium, activated partial thromboplastin time, and potassium.

CONCLUSIONS

We developed a reliable machine learning-derived model that integrates readily available laboratory parameters to predict IHCA in patients treated with rescue therapy.

Decoding Sepsis-Induced Disseminated Intravascular Coagulation: A Comprehensive Review of Existing and Emerging Therapies

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.

Sepsis-Induced Coagulopathy: An Update on Pathophysiology, Biomarkers, and Current Guidelines

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.

Prognostic Accuracy of the Different Scoring Systems for Assessing Coagulopathy in Sepsis: A Retrospective Study

There is no gold standard for the diagnosis of coagulation dysfunction in sepsis, and the use of the current scoring systems is still controversial. The purpose of this study was to assess the performance of sepsis-induced coagulopathy (SIC), the Japanese Association for Acute Medicine Disseminated Intravascular Coagulation (JAAM DIC), and the International Society on Thrombosis and Haemostasis overt DIC (ISTH overt-DIC). The relationship between each scoring system and 28-day all-cause mortality was examined. Among 452 patients (mean age, 65 [48,76] years), 306 [66.7%] were men, the median SOFA score was 6 [4,9], and the median APACHE II score was 15 [11,22]. A total of 132 patients (29.2%) died within 28 days. Both the diagnosis of SIC (AUROC, 0.779 [95% CI, 0.728-0.830], P < 0.001) and ISTH overt-DIC (AUROC, 0.782 [95% CI, 0.732-0.833], P < 0.001) performed equally well in the discrimination of 28-day all-cause mortality (between-group difference: SIC versus ISTH overt-DIC, -0.003 [95% CI, -0.025-0.018], P = 0.766). However, the SIC demonstrated greater calibration for 28-day all-cause mortality than ISTH overt-DIC (the coincidence of the calibration curve of the former is higher than that of the latter). The diagnosis of JAAM DIC was not independently associated with 28-day all-cause mortality in sepsis (RR, 1.115, [95% CI 0.660-1.182], P = 0.684). The SIC scoring system demonstrated superior prognostic prediction ability in comparison with the others and is the most appropriate standard for diagnosing coagulopathy in sepsis.

Validation of Two Revised, Simplified Criteria for Assessing Sepsis-Associated Disseminated Intravascular Coagulation in ICU Patients with Sepsis-3: A Retrospective Study

Objective

This study aimed to validate the performance of modified Japanese Association for Acute Medicine (m-JAAM) and simplified Japanese Society on Thrombosis and Hemostasis (s-JSTH) criteria in diagnosing coagulation disorders in sepsis and examine their prognostic value compared with sepsis-induced coagulopathy (SIC) and International Society on Thrombosis and Hemostasis (ISTH) criteria.

Methods

This retrospective study included subjects diagnosed with sepsis (August 2020 to February 2021, n = 296). The m-JAAM, s-JSTH, SIC, and ISTH criteria were evaluated and compared using receiver operating characteristic (ROC) curves and areas under the curve (AUCs).

Results

There was no significant difference in AUC for predicting in-hospital 28-day mortality by m-JAAM, s-JSTH, SCI, and ISTH criteria (0.745, 0.763, 0.760, and 0.730, respectively). The proportion of patients fulfilling the m-JAAM and SIC criteria was higher than that of the s-JSTH and ISTH criteria (43.2%, 56.1% vs. 25.0%, 22.6%, P &lt; .05).

Conclusion

The m-JAAM criteria might be more suitable for early-stage disseminated intravascular coagulation of sepsis than s-JSTH criteria.

How likely is septic shock to develop in a patient with Fournier's gangrene? A risk prediction model based on a 7-year retrospective study

Background

Fournier's gangrene (FG) is a rare life-threatening form of necrotizing fasciitis. The risk factors for septic shock in patients with FG are unclear. This study aimed to identify potential risk factors and develop a prediction model for septic shock in patients with FG.

Methods

This retrospective cohort study included patients who were treated for FG between May 2013 and May 2020 at the Sixth Affiliated Hospital, Sun Yat-sen University (Guangzhou, China). The patients were divided into a septic shock group and a non-septic shock group. An L1-penalized logistic regression model was used to detect the main effect of important factors and a penalized Quadratic Discriminant Analysis method was used to identify possible interaction effects between different factors. The selected main factors and interactions were used to obtain a logistic regression model based on the Bayesian information criterion.

Results

A total of 113 patients with FG were enrolled and allocated to the septic shock group (n = 24) or non-septic shock group (n = 89). The best model selected identified by backward logistic regression based on Bayesian information criterion selected temperature, platelets, total bilirubin (TBIL) level, and pneumatosis on pelvic computed tomography/magnetic resonance images as the main linear effect and Na⁺ × TBIL as the interaction effect. The area under the ROC curve of the probability of FG with septic shock by our model was 0.84 (95% confidence interval, 0.78-0.95). The Harrell's concordance index for the nomogram was 0.864 (95% confidence interval, 0.78-0.95).

Conclusion

We have developed a prediction model for evaluation of the risk of septic shock in patients with FG that could assist clinicians in identifying critically ill patients with FG and prevent them from reaching a crisis state.

Clinical Efficacy of Soluble Thrombomodulin, Tissue Plasminogen Activator Inhibitor complex, Thrombin-Antithrombin complex,α2-Plasmininhibitor-Plasmin complex in Pediatric Sepsis

Objective

To investigated the clinical efficacy of Soluble thrombomodulin (sTM), tissue plasminogen activator inhibitor complex (t-PAI·C),thrombin-antithrombin complex (TAT),α2-plasmininhibitor-plasmin complex (PIC) in pediatric sepsis and pediatrics sepsis-induced coagulopathy (pSIC).

Methods

We prospectively collected patient data with sepsis diagnosed in the PICU of Shanghai Children's Medical Center from June 2019 to June 2021. sTM,t-PAI·C, TAT,PIC and classical coagulation laboratory tests (CCTs) were evaluated on the day of sepsis diagnosis.

Results

Fifty-nine children were enrolled, There were significant differences in t-PAI·C (P = 0.001), Plt (P < 0.001), PT (P < 0.001), INR (P < 0.001), aPTT (P < 0.001), and TT (P = 0.048) between the pSIC and non-pSIC groups, logistic regression analysis showed that Plt (P = 0.032) was an independent risk factor for pSIC. Logistic regression analysis showed that sTM (P = 0.007) and Plt (P = 0.016) were independent risk factors for the outcome in pediatrics sepsis following discharge. The AUC of sTM combined with Plt on the mortality outcome of children with sepsis at discharge was 0.889 (95%CI: 0.781,0.956). which was better than that for PRISM III (AUC, 0.723), pSOFA (AUC, 0.764), and blood Lac (AUC, 0.717) when sepsis was diagnosed in the PICU.

Conclusions

The t-PAI·C increased in children with pSIC. The prediction of sepsis outcome using sTM combined with Plt was better than with PRISM III, pSOFA, or Lac.Further research is still needed in the future to explore the clinical value of sTM, TAT, PIC, and t-PAI·C in diagnosis and outcome of pediatrics sepsis and pSIC.

The Cause–Effect Dilemma of Hematologic Changes in COVID-19: One Year after the Start of the Pandemic

COVID-19 is a systemic infection that leads to multisystem affection, including hematological changes. On the other hand, the patients who have certain hematological diseases are more susceptible to COVID-19 infection. The aim of this review is to examine the wide spectrum of hematological changes that are reported to occur due to COVID-19 infection. Most of the studies over the past year mainly show that most of these changes are mainly non-specific, but are of prognostic value. On the other hand, the susceptibility of hematological patients to COVID-19 infection and complications remains questionable. Patients with certain hematological diseases (including malignancy) and those who are treated by aggressive immunosuppressive therapy have shown higher rates of COVID-19 infection and complications. On the other hand, for most of the patients suffering from other chronic hematological conditions, no evidence has shown a greater risk of infection, compared to the general population.

Association between COVID-19 Diagnosis and Coronary Artery Thrombosis: A Narrative Review

Coronavirus disease 2019 is characterized by its severe respiratory effects. Data early on indicated an increased risk of mortality in patients with cardiovascular comorbidities. Early reports highlighted the multisystem inflammatory syndrome, cytokine storm, and thromboembolic events as part of the disease processes. The aim of this review is to assess the association between COVID-19 and its thrombotic complications, specifically related to the cardiovascular system. The role of neutrophil extracellular traps (NETs) is explored in the pathogenesis of the disease. The structure and anatomy of the virus are pivotal to its virulence in comparison to other α and β Coronaviridae (HCoV-229E, HCoV-OC43, HCoV-229E, HCoV-NL63, HCoV-OC43, and HCoV-HKU1). In particular, the host interaction and response may explain the variability of severity in patients. Angio tensin-converting enzyme 2 (ACE2) activation may be implicated in the cardiovascular and throm bogenic potential of the disease. The virus may also have direct effects on the endothelial lining affecting hemostasis and resulting in thrombosis through several mechanisms. Dipyridamole may have a therapeutic benefit in NET suppression. Therapeutic avenues should be concentrated on the different pathophysiological steps involving the virus and the host.

Clinical Significance of Pro-inflammatory Cytokines and Their Correlation with Disease Severity and Blood Coagulation in Septic Patients with Bacterial Co-infection

PURPOSE

To evaluate the clinical significance of pro-inflammatory cytokines for disease severity and coagulation in septic patients with bacterial co-infection.

METHODS

A total of 92 patients with sepsis admitted to intensive care unit (ICU) from January 2017 to August 2020 were enrolled and their clinical data were retrospectively analyzed. Forty-seven patients (51.1%) had a single infection by Klebsiella pneumoniae or Acinetobacter baumannii (single-infection group), and 45 patients (48.9%) were infected by both species (co-infection group). We compared the clinical characteristics and disease severity among the 92 patients. Disease severity was defined as ICU stay time and 30-day mortality. Plasma concentrations of pro-inflammatory cytokines and their correlation with disease severity and blood coagulation were analyzed.

RESULTS

The 30-day mortality in the co-infection group (35.5%) was significantly higher than in the single-infection group (19.1%). The levels of IL-6 and TNF-α in the co-infection group were higher than in the single-infection group. Moreover, high levels of IL-6, IL-8, and TNF-α were positively correlated with disease severity (Spearman P value < 0.05). High levels of IL-6 and TNF-α were negatively correlated with the platelet count (Spearman P value < 0.05) and positively correlated with prothrombin time, and plasma levels of fibrin degradation product and D-dimer levels (Spearman P value < 0.05 for all).

CONCLUSION

Septic patients with bacterial co-infection had increased plasma levels of pro-inflammatory cytokines. Furthermore, a positive correlation between high levels of pro-inflammatory cytokines and increased disease severity and depressed blood coagulation function for septic patients with co-infection was identified.

[Treatment of sepsis-induced coagulopathy : Results of a Germany-wide survey in intensive care units]

BACKGROUND

In the context of sepsis and septic shock, coagulopathy often occurs due to the close relationship between coagulation and inflammation. Sepsis-induced coagulopathy (SIC) is the most severe and potentially fatal form. Anticoagulants used in prophylactic or therapeutic doses are discussed to potentially exert beneficial effects in patients with sepsis and/or SIC; however, due to the lack of evidence recent guidelines are limited to recommendations for drug prophylaxis of venous thromboembolism (VTE), while treatment of SIC has not been addressed.

METHODS

In order to determine the status quo of VTE prophylaxis as well as treatment of SIC in German intensive care units (ICU), we conducted a Germany-wide online survey among heads of ICUs from October 2019 to May 2020. In April 2020, the survey was supplemented by an additional block of questions on VTE prophylaxis and SIC treatment in coronavirus disease 2019 (COVID-19) patients.

RESULTS

A total of 67 senior doctors took part in the survey. The majority (n = 50; 74.6%) of the responses were from ICU under the direction of an anesthesiologist and/or a department of anesthesiology. Most of the participants worked either at a university hospital (n = 31; 47.8%) or an academic teaching hospital (n = 27; 40.3%). The survey results show a pronounced heterogeneity in clinical practice with respect to the prophylaxis of VTE as well as SIC treatment. In an exemplary case of pneumogenic sepsis, low molecular weight heparins (LMWH) were by far the most frequently mentioned group of medications (n = 51; 76.1% of the responding ITS). In the majority of cases (n = 43; 64.2%), anti-FXa activity is not monitored with the use of LMWH in prophylaxis doses. Unfractionated heparin (UFH) was listed as a strategy for VTE prophylaxis in 37.3% of the responses (n = 25). In an exemplary case of abdominal sepsis 54.5% of the participants (n = 36; multiple answers possible) stated the use of UFH or LMWH and UFH with dosage controlled by PTT is used on two participating ICUs. The anti-FXa activity under prophylactic anticoagulation with LMWH is monitored in 7 participating clinics (10.6%) in abdominal sepsis. Systematic screening for sepsis-associated coagulation disorders does not take place in most hospitals and patterns in the use of anticoagulants show significant variability between ICUs. In the case of COVID-19 patients, it is particularly noticeable that in three quarters of the participating ICUs the practice of drug-based VTE prophylaxis and SIC treatment does not differ from that of non-COVID-19 patients.

CONCLUSION

The heterogeneity of answers collected in the survey suggests that a systematic approach to this topic via clinical trials is urgently needed to underline individualized patient care with the necessary evidence.

An evaluation of the Japanese Society on Thrombosis and Hemostasis criteria for disseminated intravascular coagulation as a predictor of prognosis in patients with infection

INTRODUCTION

A criterion for disseminated intravascular coagulation (DIC) that reflects the status of controlled coagulopathy would be useful for determining when to stop treatment. Use of the DIC criteria of the Japanese Society on Thrombosis and Hemostasis (JSTH) for predicting the outcome during recombinant soluble thrombomodulin (thrombomodulin alfa, TM-α) treatment was evaluated.

METHODS

A retrospective, multicenter survey was conducted in 798 medical facilities in Japan. Of the 4342 patients who underwent TM-α treatment, 193 with infection-associated DIC were investigated.

RESULTS

The 28-day mortality rate increased with the increase in JSTH DIC scores at the end of TM-α treatment, with a Cramer's coefficient of association of 0.431. A reduced platelet count (odds ratio [OR]: 0.847, P < .001), prolonged prothrombin time ratio (OR: 5.681, P < .001), decreased fibrinogen level (OR: 0.995, P < .001), higher level of fibrinogen and fibrin degradation products (OR: 1.009, P = .026), and lower antithrombin activity (OR: 0.973, P < .001) were correlated with 28-day mortality. On multivariate analysis, the JSTH DIC score at the completion of TM-α therapy was a predictor of mortality (OR: 1.591, 95% CI: 1.219-2.077).

CONCLUSION

The JSTH DIC score at the end of anticoagulation therapy may be a reliable tool for predicting the outcome in patients with infection-associated DIC.

Incidence and impact of disseminated intravascular coagulation in COVID-19 a systematic review and meta-analysis

OBJECTIVES

Coronavirus disease 2019 (COVID-19) is a novel infectious disease, with significant morbidity and mortality. This meta-analysis is to evaluate the prevalence of disseminated intravascular coagulation (DIC) in COVID-19 patients and to determine the association of DIC with the severity and prognosis of COVID-19.

METHODS

We searched the PubMed, EMBASE, and China National Knowledge Infrastructure (CNKI) database until August 12, 2020. The meta-analysis was performed using Stata 16.0 software.

RESULTS

14 studies were included in our meta-analysis. The pooled analysis revealed that the incidence of COVID-19 patients developing DIC was 3% (95%: 1%-5%, P < 0.001). In addition, deaths were more likely to be associated with DIC (Log OR = 2.46, 95% CI: 0.94-3.99, P < 0.001) with statistical significance.

CONCLUSIONS

DIC is associated with the severity and poor prognosis of COVID-19 patients. Therefore, attention should be paid to coagulation dysfunction in COVID-19 patients. Monitoring of coagulation indicators may improve the prognosis of COVID-19 inpatients.

Consumptive coagulopathy is associated with a disturbed host response in patients with sepsis

BACKGROUND

A prolonged prothrombin time (PT) is a common feature in sepsis indicating consumptive coagulopathy.

OBJECTIVES

To determine the association between a prolonged PT and aberrations in other host response mechanisms in sepsis.

METHODS

Patients admitted to the intensive care unit with sepsis were divided in quartiles according to the highest PT value measured within 24 h after admission. The host response was evaluated by measuring 19 plasma biomarkers reflecting pathways implicated in sepsis pathogenesis and by blood leukocyte gene expression profiling.

MEASUREMENTS AND MAIN RESULTS

Of 1524 admissions for sepsis, 386 (25.3%) involved patients with a normal PT (≤12.7 s); the remaining quartiles entailed 379 (24.9%) patients with a slightly prolonged PT (12.8 ≤ PT ≤ 15.0 s), 383 (25.1%) with an intermediately prolonged PT (15.1 ≤ PT ≤ 17.2 s), and 376 (24.7%) with an extremely prolonged PT (≥17.3 s). While patients with an extremely prolonged PT showed an increased crude mortality up to 1 year after admission, none of the prolonged PT groups was independently associated with 30-day adjusted mortality. Comparison of the host response between patients with a normal PT or an extremely prolonged PT matched for baseline characteristics including severity of disease showed that an extremely prolonged PT was associated with impaired anticoagulant mechanisms, a more disturbed endothelial barrier integrity and increased systemic inflammation, and blood leukocyte transcriptomes indicating more prominent metabolic reprogramming and protein catabolism.

CONCLUSION

A prolonged PT is associated with stronger anomalies in pathways implicated in the pathogenesis of sepsis, suggesting that activation of coagulation impacts other host response mechanisms.

Disseminated intravascular coagulation: epidemiology, biomarkers, and management

Disseminated intravascular coagulation (DIC) is a systemic activation of the coagulation system, which results in microvascular thrombosis and, simultaneously, potentially life-threatening haemorrhage attributed to consumption of platelets and coagulation factors. Underlying conditions, e.g. infection, cancer, or obstetrical complications are responsible for the initiation and propagation of the DIC process. This review provides insights into the epidemiology of DIC and the current understanding of its pathophysiology. It details the use of diagnostic biomarkers, current diagnostic recommendations from international medical societies, and it provides an overview of emerging diagnostic and prognostic biomarkers. Last, it provides guidance on management. It is concluded that timely and accurate diagnosis of DIC and its underlying condition is essential for the prognosis. Treatment should primarily focus on the underlying cause of DIC and supportive treatment should be individualised according to the underlying aetiology, patient's symptoms and laboratory records.

Plasma tissue plasminogen activator and plasminogen activator inhibitor-1 in hospitalized COVID-19 patients

Patients with coronavirus disease-19 (COVID-19) are at high risk for thrombotic arterial and venous occlusions. However, bleeding complications have also been observed in some patients. Understanding the balance between coagulation and fibrinolysis will help inform optimal approaches to thrombosis prophylaxis and potential utility of fibrinolytic-targeted therapies. 118 hospitalized COVID-19 patients and 30 healthy controls were included in the study. We measured plasma antigen levels of tissue-type plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) and performed spontaneous clot-lysis assays. We found markedly elevated tPA and PAI-1 levels in patients hospitalized with COVID-19. Both factors demonstrated strong correlations with neutrophil counts and markers of neutrophil activation. High levels of tPA and PAI-1 were associated with worse respiratory status. High levels of tPA, in particular, were strongly correlated with mortality and a significant enhancement in spontaneous ex vivo clot-lysis. While both tPA and PAI-1 are elevated among COVID-19 patients, extremely high levels of tPA enhance spontaneous fibrinolysis and are significantly associated with mortality in some patients. These data indicate that fibrinolytic homeostasis in COVID-19 is complex with a subset of patients expressing a balance of factors that may favor fibrinolysis. Further study of tPA as a biomarker is warranted.

Plasma tissue plasminogen activator and plasminogen activator inhibitor-1 in hospitalized COVID-19 patients

Patients with coronavirus disease-19 ( COVID-19 ) are at high risk for thrombotic arterial and venous occlusions. However, bleeding complications have also been observed in some patients. Understanding the balance between coagulation and fibrinolysis will help inform optimal approaches to thrombosis prophylaxis and potential utility of fibrinolytic-targeted therapies. 118 hospitalized COVID-19 patients and 30 healthy controls were included in the study. We measured plasma antigen levels of tissue-type plasminogen activator (tPA ) and plasminogen activator inhibitor-1 ( PAI-1 ) and performed spontaneous clot-lysis assays. We found markedly elevated tPA and PAI-1 levels in patients hospitalized with COVID-19. Both factors demonstrated strong correlations with neutrophil counts and markers of neutrophil activation. High levels of tPA and PAI-1 were associated with worse respiratory status. High levels of tPA, in particular, were strongly correlated with mortality and a significant enhancement in spontaneous ex vivo clot-lysis. While both tPA and PAI-1 are elevated among COVID-19 patients, extremely high levels of tPA enhance spontaneous fibrinolysis and are significantly associated with mortality in some patients. These data indicate that fibrinolytic homeostasis in COVID-19 is complex with a subset of patients expressing a balance of factors that may favor fibrinolysis. Further study of tPA as a biomarker is warranted.

Prothrombotic autoantibodies in serum from patients hospitalized with COVID-19

Patients with COVID-19 are at high risk for thrombotic arterial and venous occlusions. Lung histopathology often reveals fibrin-based blockages in the small blood vessels of patients who succumb to the disease. Antiphospholipid syndrome is an acquired and potentially life-threatening thrombophilia in which patients develop pathogenic autoantibodies targeting phospholipids and phospholipid-binding proteins (aPL antibodies). Case series have recently detected aPL antibodies in patients with COVID-19. Here, we measured eight types of aPL antibodies in serum samples from 172 patients hospitalized with COVID-19. These aPL antibodies included anticardiolipin IgG, IgM, and IgA; anti-β2 glycoprotein I IgG, IgM, and IgA; and anti-phosphatidylserine/prothrombin (aPS/PT) IgG and IgM. We detected aPS/PT IgG in 24% of serum samples, anticardiolipin IgM in 23% of samples, and aPS/PT IgM in 18% of samples. Antiphospholipid autoantibodies were present in 52% of serum samples using the manufacturer's threshold and in 30% using a more stringent cutoff (≥40 ELISA-specific units). Higher titers of aPL antibodies were associated with neutrophil hyperactivity, including the release of neutrophil extracellular traps (NETs), higher platelet counts, more severe respiratory disease, and lower clinical estimated glomerular filtration rate. Similar to IgG from patients with antiphospholipid syndrome, IgG fractions isolated from patients with COVID-19 promoted NET release from neutrophils isolated from healthy individuals. Furthermore, injection of IgG purified from COVID-19 patient serum into mice accelerated venous thrombosis in two mouse models. These findings suggest that half of patients hospitalized with COVID-19 become at least transiently positive for aPL antibodies and that these autoantibodies are potentially pathogenic.

COVID-19-associated coagulopathy: An exploration of mechanisms

An ongoing global pandemic of viral pneumonia (coronavirus disease [COVID-19]), due to the virus SARS-CoV-2, has infected millions of people and remains a threat to many more. Most critically ill patients have respiratory failure and there is an international effort to understand mechanisms and predictors of disease severity. Coagulopathy, characterized by elevations in D-dimer and fibrin(ogen) degradation products (FDPs), is associated with critical illness and mortality in patients with COVID-19. Furthermore, increasing reports of microvascular and macrovascular thrombi suggest that hemostatic imbalances may contribute to the pathophysiology of SARS-CoV-2 infection. We review the laboratory and clinical findings of patients with COVID-19-associated coagulopathy, and prior studies of hemostasis in other viral infections and acute respiratory distress syndrome. We hypothesize that an imbalance between coagulation and inflammation may result in a hypercoagulable state. Although thrombosis initiated by the innate immune system is hypothesized to limit SARS-CoV-2 dissemination, aberrant activation of this system can cause endothelial injury resulting in loss of thromboprotective mechanisms, excess thrombin generation, and dysregulation of fibrinolysis and thrombosis. The role various components including neutrophils, neutrophil extracellular traps, activated platelets, microparticles, clotting factors, inflammatory cytokines, and complement play in this process remains an area of active investigation and ongoing clinical trials target these different pathways in COVID-19.

Prothrombotic antiphospholipid antibodies in COVID-19

Patients with coronavirus disease 19 (COVID-19) are at high risk for thrombotic arterial and venous occlusions. At the same time, lung histopathology often reveals fibrin-based occlusion in the small vessels of patients who succumb to the disease. Antiphospholipid syndrome (APS) is an acquired and potentially life-threatening thrombophilia in which patients develop pathogenic autoantibodies (aPL) targeting phospholipids and phospholipid-binding proteins. Case series have recently detected aPL in patients with COVID-19. Here, we measured eight types of aPL [anticardiolipin IgG/IgM/IgA, anti-beta-2 glycoprotein I IgG/IgM/IgA, and anti- phosphatidylserine/prothrombin (aPS/PT) IgG/IgM] in the sera of 172 patients hospitalized with COVID-19. We detected aPS/PT IgG in 24%, anticardiolipin IgM in 23%, and aPS/PT IgM in 18%. Any aPL was present in 52% of patients using the manufacturer's threshold and in 30% using a more stringent cutoff (≥40 units). Higher levels of aPL were associated with neutrophil hyperactivity (including the release of neutrophil extracellular traps/NETs), higher platelet count, more severe respiratory disease, and lower glomerular filtration rate. Similar to patients with longstanding APS, IgG fractions isolated from patients with COVID-19 promoted NET release from control neutrophils. Furthermore, injection of these COVID-19 IgG fractions into mice accelerated venous thrombosis. Taken together, these studies suggest that a significant percentage of patients with COVID-19 become at least transiently positive for aPL and that these aPL are potentially pathogenic.

Prevalence and Impact of Coagulation Dysfunction in COVID-19 in China: A Meta-Analysis

Background  The aim of this meta-analysis is to assess the prevalence of coagulation dysfunction in Chinese COVID-19 patients and to determine the association of coagulopathy with the severity and prognosis of COVID-19.

Methods  A meta-analysis of the prevalence of different abnormal coagulation indicators in COVID-19 patients in China was performed. The difference of coagulation indicators and the incidence of DIC were compared between severe cases and nonsevere cases as well as nonsurvivors and survivors, respectively.

Results  A total of 22 Chinese studies involving 4,889 confirmed COVID-19 inpatients were included. The average D-dimer value of COVID-19 patients is 0.67 µg/mL (95% confidence interval [CI]: 0.56–0.78), and 29.3% (95% CI: 20.1–38.5%) of patients showed elevated D-dimer values. Severe patients had significantly higher D-dimer levels and prolonged prothrombin time (PT) compared with nonsevere patients. Nonsurvivors had significantly higher D-dimer levels, prolonged PT, and decreased platelet count compared with survivors. In total, 6.2% (95% CI: 2.6–9.9%) COVID-19 patients were complicated by disseminated intravascular coagulation (DIC), in which the log risk ratio in nonsurvivors was 3.267 (95% CI: 2.191–4.342, Z  = 5.95, p  < 0.05) compared with that in survivors.

Conclusion  The prevalence of coagulopathy in Chinese COVID-19 inpatients is high, and both the abnormal coagulation indicators and DIC are closely associated with the severity and poor prognosis of these COVID-19 patients. Therefore, attention should be paid to coagulation dysfunction in COVID-19 patients. Closely monitoring of coagulation indicators and application of appropriate anticoagulation may improve the prognosis of COVID-19 inpatients in China.

Characteristics Behaviors of Coagulation and Fibrinolysis Markers in Acquired Thrombotic Thrombocytopenic Purpura

INTRODUCTIONS

Patients with acquired thrombotic thrombocytopenic purpura (TTP) show no severe abnormalities in coagulation or fibrinolysis. However, the exact extent of the abnormalities is unclear.

MATERIALS AND METHODS

This study analyzed 138 patients with acquired TTP and 46 patients with septic disseminated intravascular coagulation (DIC) who were included in a Japanese registry. Complete blood cell counts and 8 coagulation or fibrinolysis parameters were compared between the 2 groups.

RESULTS

Platelet counts in the acquired TTP group were significantly lower than those in the septic DIC group (P < .001). The international normalized ratio of prothrombin time and the activated partial thromboplastin time in the septic DIC group were significantly higher and longer, respectively, than those in the acquired TTP group (P < .01). The antithrombin (AT) values were significantly lower in the septic DIC group than in the acquired TTP group (P < .001), the latter of which were almost normal. Although both groups revealed elevations of fibrinogen degradation product (FDP) and D-dimer, these levels were significantly higher in the septic DIC group than in the acquired TTP group (P < .001). Of 138 patients with acquired TTP, 25 (18.1%) were diagnosed with septic DIC by the diagnostic criteria of the Japanese Ministry Health, Labour and Welfare, and 78 (56.5%) by those of the Japanese Association of Acute Medicine. Receiver operating characteristic curve analysis showed that acquired TTP could be diagnosed based on severe thrombocytopenia (<20 × 10⁹/L), normal AT level (>87%), and mildly elevated FDP (<23 µg/mL).

CONCLUSIONS

Our results indicate that 3 routine laboratory tests could differentiate between acquired TTP and septic DIC.

Diagnosis of sepsis-induced disseminated intravascular coagulation and coagulopathy

Disseminated intravascular coagulation (DIC) is a frequent complication in sepsis. Once patients develop DIC, the mortality rate increases significantly. Moreover, recent studies have suggested that coagulation disorder plays a significant role in the development of organ dysfunction in sepsis. Thus, the early detection of DIC is vital in sepsis care, and the Japanese Association for Acute Medicine established a set of original diagnostic criteria in 2006 (JAAM DIC). Since then, the usefulness of the JAAM DIC has been repeatedly reported, and these criteria have been widely adopted in emergency and critical care settings in Japan. Different criteria have also been released by the International Society on Thrombosis and Haemostasis (ISTH overt-DIC), and the latter criteria are presently considered to be the international standard. Compared with the JAAM DIC, the ISTH overt-DIC criteria are stricter and the timing of diagnosis is later. This discrepancy is because of conceptual differences. As many physicians think sepsis-associated DIC is the target of anticoagulant therapies in Japan, the JAAM DIC criteria were designed to allow the early initiation of treatment. As other countries do not provide DIC-specific treatments, early diagnosis is not necessary, and this situation has led to a significant gap. However, as overt-DIC is a late-phase coagulation disorder, a need for early detection has been advocated, and members of the ISTH have recently proposed the category of sepsis-induced coagulopathy. In this review, we introduce the strengths and weaknesses of the major criteria including JAAM-DIC, ISTH overt-DIC, sepsis-induced coagulopathy, and Japanese Society on Thrombosis and Haemostasis-DIC.

A pilot study to introduce a local external quality assurance scheme for D-dimers in the National Health Laboratory Service, in South Africa

INTRODUCTION

Laboratory quality assurance (QA) includes internal quality control (IQC), external quality assurance (EQA) and quality improvement (QI). EQA identifies quality deviations and training needs. D-dimers are breakdown products of thrombus and results guide various clinical decisions.

METHODS

The National Health Laboratory Service (NHLS) in South Africa performs the pathology tests for more than 80% of the population. The NHLS Quality Assurance Department distributed 301 questionnaires to laboratories enquiring about D-dimer testing. Two levels of STAGO^® and Siemens^® commercial D-dimer assay control material were distributed for analysis and returned results analysed.

RESULTS

A total of 64 (21.2%) completed questionnaires were returned and 26 (40.6%) laboratories were performing D-dimers with 25 (97%) subscribing to an EQA scheme. All laboratories reported results in D-dimer units with a negative result cut-off of ≤0.25 mg/L but various testing platforms were in use. All returned interpretations of analyses on the blinded control material were correct. The results were also within the respective reference ranges of the controls apart from three outliers. One laboratory obtained a result on STAGO^® pathological control that was above the cut-off of the control reference range but the reason for this error could not be identified. Another obtained results on the STAGO^® and on the Siemens^® normal controls that were both below the cut-off of the control reference range due to transcription errors.

CONCLUSION

The study demonstrated the feasibility of a local EQA scheme for D-dimers based on commercial control material that could mitigate against the cost of international EQA scheme participation.

Newly Proposed Sepsis-Induced Coagulopathy Precedes International Society on Thrombosis and Haemostasis Overt-Disseminated Intravascular Coagulation and Predicts High Mortality

BACKGROUND

Disseminated intravascular coagulation (DIC) has been recognized as an urgent and critical condition in patients with sepsis. Therefore, unfamiliar and time-consuming tests or a complex scoring system are not suitable for diagnosis. Sepsis-induced coagulopathy (SIC), a newly proposed category delineated by a few global coagulation tests, has been established as an early warning sign for DIC. The purpose of this study was to elucidate the characteristics of SIC, especially in relation to the score of the International Society on Thrombosis and Haemostasis (ISTH) for overt DIC.

METHOD

A data set for 332 patients with sepsis who were suspected to have DIC, antithrombin activity <70%, and treated with antithrombin substitution was utilized to examine the relationship between SIC and overt DIC. The performance of SIC calculated at baseline (ie, before treatment) as well as on days 2, 4, or 7 was analyzed in terms of its ability to predict 28-day mortality and overt DIC.

RESULTS

At baseline, 149 (98.7%) of 151 patients with overt DIC according to the ISTH definition were diagnosed as having SIC. Of the 49, 46 (93.9%) patients who developed overt DIC between days 2 and 4 had received a prior diagnosis of SIC. The sensitivity of baseline SIC for the prediction of death was significantly higher than that of overt DIC (86.8% vs 64.5%, P < .001). The sensitivity of SIC on days 2, 4, and 7 was significantly higher than those of overt DIC (96.1%, 92.3%, and 84.4% vs 67.1%, 57.7%, and 50.0%, P < .001, .001, and .001, respectively), although the specificity of SIC was lower at all time points.

Pathogenic factors associated with development of disseminated intravascular coagulopathy (DIC) in a tertiary academic hospital in South Africa

Introduction

Disseminated intravascular coagulopathy (DIC) is a thrombotic microangiopathy arising from consumption of both coagulation factors and platelets. DIC is triggered by a number of clinical conditions including severe infection, trauma and obstetric complications. Early diagnosis and treatment of the underlying condition is paramount. A high clinical index of suspicion is needed to ensure that patients at risk of developing DIC are appropriately investigated.

Methods

In order to establish the clinical conditions most frequently associated with DIC, we reviewed all DIC screens received at a tertiary hospital in Johannesburg, South Africa over a 1 year period.

Results

The commonest clinical condition associated with DIC in our population was infection with 84% of patients infected with an identified pathogen. The most frequently diagnosed pathogen was HIV followed by Mycobacterium tuberculosis and other bacterial infections. In the majority of cases, bacteria were isolated from blood cultures. In 47 patients, HIV was the only pathogen which could be isolated. A relative risk ratio of 2.73 and an odds ratio of 29.97 was attributed to HIV for development of a DIC. A malignancy was present in 51 of the patients of which approximately 60% had co-existing infection. No cause could be attributed in 30 patients.

Conclusion

Infection was identified in the majority of the patients diagnosed with DIC in this study. HIV showed the highest relative risk ratio of all pathogens although previous studies have not suggested that HIV was strongly associated with DIC. In almost half of the HIV infected patients, there was no other pathogen isolated despite extensive investigation. This suggests that HIV has a strong association with the development of DIC, warranting further research into the relationship between HIV and disseminated microvascular thrombosis.