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Azoulay LD, Frapard T, Larcher R, Pène F, Argaud L, Mayaux J, Jamme M, Coudroy R, Mathian A, Gibelin A, Azoulay E, Tandjaoui-Lambiotte Y, Dargent A, Beloncle FM, Raphalen JH, Bréchot N, de Prost N, Devaquet J, Contou D, Gaugain S, Trouiller P, Grangé S, Ledochowski S, Lemarie J, Faguer S, Degos V, Frere C, Quentric P, Moyon Q, Luyt CE, Combes A, Amoura Z, Pineton de Chambrun M. Hematological features and alternate diagnoses in critically ill thrombotic antiphospholipid syndrome patients. Clin Rheumatol 2024; 43:2889-2898. [PMID: 39073513 DOI: 10.1007/s10067-024-07051-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: 03/12/2024] [Revised: 05/14/2024] [Accepted: 06/26/2024] [Indexed: 07/30/2024]
Abstract
OBJECTIVES Severe thrombotic antiphospholipid syndrome (APS) frequently affects the kidney, heart, and central nervous system. The precise frequency, clinical picture, differential diagnoses, and outcome of APS-related hematological involvement are lacking, especially in patients requiring ICU admission. This study aimed to describe the hematological manifestations associated with critically ill thrombotic APS patients and catastrophic antiphospholipid syndrome. METHODS This French, national, multicenter, retrospective study, conducted, from January 2000 to September 2018, included all APS patients admitted to 24 participating centers' ICUs with any new thrombotic manifestation. The prevalence of hematological manifestations and their associated outcomes were studied. RESULTS One hundred and thirty-four patients, female 72%, median [IQR] age 45 [34-56] years, with 152 episodes were included. Anemia was present in 95% of episodes and thrombocytopenia in 93%. The lowest values for hemoglobin and platelets were 7.1 [6.3-8.8] g/dL and 38 [21-60] g/L, respectively. The lowest platelet count below 20 g/L was significantly associated with a higher in-ICU mortality rate (50%, p < 0.0001). A thrombotic microangiopathy syndrome (TMA) syndrome was seen in 16 patients (12%) and was associated with higher in-hospital mortality (p = 0.05). Median ADAMTS-13 levels were 44% [27-74]. Anti-ADAMTS13 antibodies were tested in 11 patients and found negative in all. A suspicion of heparin-induced thrombocytopenia (HIT) was raised in 66 patients but only four patients were classified as definite HIT. Disseminated intravascular coagulation (DIC) was seen in 51% of patients. CONCLUSION Thrombocytopenia is very frequent in severe APS patients and may be related to TMA, HIT, or DIC. Deciphering the mechanisms of thrombocytopenia is decisive in CAPS patients. Key Points • Thrombocytopenia is the hallmark laboratory finding in CAPS. • A complete thrombotic microangiopathy pattern is infrequent in CAPS patients. • Alternate diagnoses of CAPS, especially heparin-induced thrombocytopenia, need to be adequately investigated.
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Affiliation(s)
- Levi-Dan Azoulay
- Syndrome Des Anticorps Anti-Phospholipides Et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Paris, France
| | - Thomas Frapard
- Syndrome Des Anticorps Anti-Phospholipides Et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Paris, France
| | - Romaric Larcher
- Service de Médecine Intensive-Réanimation, Hôpital Lapeyronie, Centre Hospitalier Universitaire (CHU) de Montpellier, PhyMedExp, Université de Montpellier, INSERM, CNRS, Montpellier, France
| | - Frédéric Pène
- Service de Médecine Intensive-Réanimation, Hôpital Cochin, Hôpitaux Universitaires Paris Centre, APHP, Université Paris Descartes, Paris, France
| | - Laurent Argaud
- Service de Médecine Intensive-Réanimation, Hôpital Edouard-Herriot, Hospices Civils de Lyon, Lyon, France
| | - Julien Mayaux
- AP-HP, Hôpital La Pitié-Salpêtrière, Service de Pneumologie, Médecine Intensive Et Réanimation Médicale, Département R3S, Sorbonne Université, INSERM UMRS1158, Neurophysiologie Respiratoire Expérimentale Et Clinique, Paris, France
| | - Matthieu Jamme
- Sorbonne Université, AP-HP, Hôpital Tenon, Service d'Urgences Néphrologiques Et de Transplantation Rénale, Paris, France
| | - Remi Coudroy
- CHU de Poitiers, Service de Médecine Intensive Réanimation, Université de Poitiers, INSERM CIC 1402, IS-ALIVE Research Group, 86000, Poitiers, France
| | - Alexis Mathian
- Syndrome Des Anticorps Anti-Phospholipides Et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Paris, France
| | - Aude Gibelin
- Service de Médecine Intensive Réanimation, Hôpital Tenon, AP-HP, Faculté de Médecine Sorbonne Université, Paris, France
| | - Elie Azoulay
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Louis, AP-HP, Paris, France
| | - Yacine Tandjaoui-Lambiotte
- Pneumologie & Infectiologie, CH Saint Denis, 93200, Saint Denis, France
- INSERM UMR 1137 IAME, Paris, France
- INSERM UMR 1272 Hypoxie & Poumon, Bobigny, France
| | - Auguste Dargent
- Service de Médecine Intensive-Réanimation, CHU Dijon, INSERM UMR 1231 LabEx Lipstic, Dijon, France
| | - François-Michel Beloncle
- Département de Médecine Intensive-Réanimation Et Médecine Hyperbare, CHU d'Angers, Université d'Angers, Angers, France
| | - Jean-Herlé Raphalen
- Service d'Anesthésie Et de Réanimation, Hôpital Necker, Université Paris Descartes, AP-HP, Paris, France
| | - Nicolas Bréchot
- Service de Médecine Intensive-Réanimation, Hôpital Européen George-Pompidou, Université Paris Descartes, AP-HP, Paris, France
| | - Nicolas de Prost
- Service de Médecine Intensive-Réanimation, CHU Henri-Mondor, AP-HP, Créteil, France
| | - Jérôme Devaquet
- Service de Réanimation Polyvalente, Hôpital Foch, Suresnes, France
| | - Damien Contou
- Service de Réanimation Polyvalente, Centre Hospitalier Victor-Dupouy, Argenteuil, France
| | - Samuel Gaugain
- Département d'Anesthésie Et Réanimation, Hôpital Saint-Louis-Lariboisière, Université Paris Diderot, AP-HP, Paris, France
| | - Pierre Trouiller
- Service de Réanimation Polyvalente Et Unité de Surveillance Continue, Hôpital Antoine-Béclère, Hôpitaux Universitaires Paris-Sud, AP-HP, Clamart, France
| | - Steven Grangé
- Service de Néphrologie, Hôpital Charles-Nicolle, CHU de Rouen, Rouen, France
| | - Stanislas Ledochowski
- Service de Réanimation Polyvalente, Médipôle Lyon-Villeurbanne, Ramsay Santé, Villeurbanne, France
| | - Jérémie Lemarie
- Service de Réanimation Médicale, Hôpital Central, CHRU de Nancy, Nancy, France
| | - Stanislas Faguer
- Département de Néphrologie Et Transplantation d'Organes, Unité de Réanimation, Centre de Référence Des Maladies Rénales Rares, Hôpital Rangueil, CHU de Toulouse, Toulouse, France
| | - Vincent Degos
- Département d'Anesthésie-Réanimation, Unité d'Anesthésie-Réanimation Tête Et Cou, Sorbonne Université, Hôpital La Pitié-Salpêtrière, APHP, Paris, France
| | - Corinne Frere
- Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Service d'Hematologie Biologique Et d'Hemostase, Paris, France
| | - Paul Quentric
- Syndrome Des Anticorps Anti-Phospholipides Et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Paris, France
- Sorbonne Université, Inserm, Centre d'Immunologie Et Des Maladies Infectieuses, CIMI-Paris, Paris, France
| | - Quentin Moyon
- Syndrome Des Anticorps Anti-Phospholipides Et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Paris, France
- Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive-Réanimation, Paris, France
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme Et Nutrition (ICAN), Paris, France
| | - Charles-Edouard Luyt
- Sorbonne Université, Inserm, Centre d'Immunologie Et Des Maladies Infectieuses, CIMI-Paris, Paris, France
- Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive-Réanimation, Paris, France
| | - Alain Combes
- Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive-Réanimation, Paris, France
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme Et Nutrition (ICAN), Paris, France
| | - Zahir Amoura
- Syndrome Des Anticorps Anti-Phospholipides Et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Paris, France
- Sorbonne Université, Inserm, Centre d'Immunologie Et Des Maladies Infectieuses, CIMI-Paris, Paris, France
| | - Marc Pineton de Chambrun
- Syndrome Des Anticorps Anti-Phospholipides Et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Paris, France.
- Sorbonne Université, Inserm, Centre d'Immunologie Et Des Maladies Infectieuses, CIMI-Paris, Paris, France.
- Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive-Réanimation, Paris, France.
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme Et Nutrition (ICAN), Paris, France.
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Boire A, Burke K, Cox TR, Guise T, Jamal-Hanjani M, Janowitz T, Kaplan R, Lee R, Swanton C, Vander Heiden MG, Sahai E. Why do patients with cancer die? Nat Rev Cancer 2024; 24:578-589. [PMID: 38898221 PMCID: PMC7616303 DOI: 10.1038/s41568-024-00708-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2024] [Indexed: 06/21/2024]
Abstract
Cancer is a major cause of global mortality, both in affluent countries and increasingly in developing nations. Many patients with cancer experience reduced life expectancy and have metastatic disease at the time of death. However, the more precise causes of mortality and patient deterioration before death remain poorly understood. This scarcity of information, particularly the lack of mechanistic insights, presents a challenge for the development of novel treatment strategies to improve the quality of, and potentially extend, life for patients with late-stage cancer. In addition, earlier deployment of existing strategies to prolong quality of life is highly desirable. In this Roadmap, we review the proximal causes of mortality in patients with cancer and discuss current knowledge about the interconnections between mechanisms that contribute to mortality, before finally proposing new and improved avenues for data collection, research and the development of treatment strategies that may improve quality of life for patients.
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Affiliation(s)
- Adrienne Boire
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Katy Burke
- University College London Hospitals NHS Foundation Trust and Central and North West London NHS Foundation Trust Palliative Care Team, London, UK
| | - Thomas R Cox
- Cancer Ecosystems Program, The Garvan Institute of Medical Research and The Kinghorn Cancer Centre, Darlinghurst, New South Wales, Australia.
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, UNSW Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia.
| | - Theresa Guise
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mariam Jamal-Hanjani
- Cancer Metastasis Laboratory, University College London Cancer Institute, London, UK
- Department of Oncology, University College London Hospitals, London, UK
- Cancer Research UK Lung Centre of Excellence, University College London Cancer Institute, London, UK
| | - Tobias Janowitz
- Cold Spring Harbour Laboratory, Cold Spring Harbour, New York, NY, USA
- Northwell Health Cancer Institute, New York, NY, USA
| | - Rosandra Kaplan
- Paediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Rebecca Lee
- Tumour Cell Biology Laboratory, The Francis Crick Institute, London, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Charles Swanton
- Department of Oncology, University College London Hospitals, London, UK
- Cancer Research UK Lung Centre of Excellence, University College London Cancer Institute, London, UK
- Cancer Evolution and Genome Instability Laboratory, The Francis Crick Institute, London, UK
| | - Matthew G Vander Heiden
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
- Dana-Farber Cancer Institute, Boston, MA, USA
| | - Erik Sahai
- Tumour Cell Biology Laboratory, The Francis Crick Institute, London, UK.
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Wijnsma KL, Schijvens AM, Bouwmeester RN, Aarts LAM, van den Heuvel L(BP, Haaxma CA, van de Kar NCAJ. Mutations in Genes Encoding Subunits of the RNA Exosome as a Potential Novel Cause of Thrombotic Microangiopathy. Int J Mol Sci 2024; 25:7604. [PMID: 39062862 PMCID: PMC11277116 DOI: 10.3390/ijms25147604] [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: 05/28/2024] [Revised: 07/06/2024] [Accepted: 07/09/2024] [Indexed: 07/28/2024] Open
Abstract
Thrombotic microangiopathy (TMA) in association with RNA exosome encoding mutations has only recently been recognized. Here, we present an infant (female) with an EXOSC5 mutation (c.230_232del p.Glu77del) associated with the clinical phenotype known as CABAC syndrome (cerebellar ataxia, brain abnormalities, and cardiac conduction defects), including pontocerebellar hypoplasia, who developed renal TMA. At the age of four months, she presented with signs of septic illness, after which she developed TMA. A stool culture showed rotavirus as a potential trigger. The patient received eculizumab once, alongside supportive treatment, while awaiting diagnostic analysis of TMA, including genetic complement analysis, all of which were negative. Eculizumab was withdrawn and the patient's TMA recovered quickly. A review of the literature identified an additional four patients (age < 1 year) who developed TMA after a viral trigger in the presence of mutations in EXOSC3. The recurrence of TMA in one of these patients with an EXOSC3 mutation while on eculizumab treatment underscores the apparent lack of responsiveness to C5 inhibition. In conclusion, mutations in genes influencing the RNA exosome, like EXOSC3 and EXOSC5, characterized by neurodevelopment and neurodegenerative disorders could potentially lead to TMA in the absence of complement dysregulation. Hence, these patients were likely non-responsive to eculizumab.
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Affiliation(s)
- Kioa L. Wijnsma
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands (R.N.B.); (L.P.v.d.H.); (N.C.A.J.v.d.K.)
| | - Anne M. Schijvens
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands (R.N.B.); (L.P.v.d.H.); (N.C.A.J.v.d.K.)
| | - Romy N. Bouwmeester
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands (R.N.B.); (L.P.v.d.H.); (N.C.A.J.v.d.K.)
| | - Lonneke A. M. Aarts
- Department of Pediatrics, Amalia Children’s Hospital, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands;
| | - Lambertus (Bert) P. van den Heuvel
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands (R.N.B.); (L.P.v.d.H.); (N.C.A.J.v.d.K.)
| | - Charlotte A. Haaxma
- Department of Pediatric Neurology, Amalia Children’s Hospital, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands;
| | - Nicole C. A. J. van de Kar
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands (R.N.B.); (L.P.v.d.H.); (N.C.A.J.v.d.K.)
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Plante MM, Wang J, Alhaj Moustafa M. 73-Year-Old Man With Worsening Hematuria. Mayo Clin Proc 2024:S0025-6196(23)00523-2. [PMID: 38912987 DOI: 10.1016/j.mayocp.2023.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/10/2023] [Accepted: 10/17/2023] [Indexed: 06/25/2024]
Affiliation(s)
- Marie M Plante
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Jing Wang
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Muhamad Alhaj Moustafa
- Advisor to residents and Consultant in Hematology and Medical Oncology, Mayo Clinic, Jacksonville, FL.
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Dobson GP, Letson HL, Morris JL. Revolution in sepsis: a symptoms-based to a systems-based approach? J Biomed Sci 2024; 31:57. [PMID: 38811967 PMCID: PMC11138085 DOI: 10.1186/s12929-024-01043-4] [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: 04/02/2024] [Accepted: 05/17/2024] [Indexed: 05/31/2024] Open
Abstract
Severe infection and sepsis are medical emergencies. High morbidity and mortality are linked to CNS dysfunction, excessive inflammation, immune compromise, coagulopathy and multiple organ dysfunction. Males appear to have a higher risk of mortality than females. Currently, there are few or no effective drug therapies to protect the brain, maintain the blood brain barrier, resolve excessive inflammation and reduce secondary injury in other vital organs. We propose a major reason for lack of progress is a consequence of the treat-as-you-go, single-nodal target approach, rather than a more integrated, systems-based approach. A new revolution is required to better understand how the body responds to an infection, identify new markers to detect its progression and discover new system-acting drugs to treat it. In this review, we present a brief history of sepsis followed by its pathophysiology from a systems' perspective and future opportunities. We argue that targeting the body's early immune-driven CNS-response may improve patient outcomes. If the barrage of PAMPs and DAMPs can be reduced early, we propose the multiple CNS-organ circuits (or axes) will be preserved and secondary injury will be reduced. We have been developing a systems-based, small-volume, fluid therapy comprising adenosine, lidocaine and magnesium (ALM) to treat sepsis and endotoxemia. Our early studies indicate that ALM therapy shifts the CNS from sympathetic to parasympathetic dominance, maintains cardiovascular-endothelial glycocalyx coupling, reduces inflammation, corrects coagulopathy, and maintains tissue O2 supply. Future research will investigate the potential translation to humans.
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Affiliation(s)
- Geoffrey P Dobson
- Heart, Sepsis and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville, QLD, 4811, Australia.
| | - Hayley L Letson
- Heart, Sepsis and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville, QLD, 4811, Australia
| | - Jodie L Morris
- Heart, Sepsis and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville, QLD, 4811, Australia
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Wolff L, Khzouri T. Coagulation intravasculaire disséminée : mise au point. Rev Med Interne 2024; 45:271-278. [PMID: 38575440 DOI: 10.1016/j.revmed.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 02/27/2024] [Accepted: 03/07/2024] [Indexed: 04/06/2024]
Affiliation(s)
- L Wolff
- Service de réanimation polyvalente du groupe hospitalier intercommunal Le Raincy Montfermeil, 10, rue du Général Leclerc, 93370 Montfermeil, France.
| | - T Khzouri
- Service de réanimation polyvalente du groupe hospitalier intercommunal Le Raincy Montfermeil, 10, rue du Général Leclerc, 93370 Montfermeil, France.
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King HL, Benedetti GB, Keller JJ, DeLoughery TG, Shatzel JJ, Martens KL. Dermatologic manifestations of hematologic disorders. Ann Hematol 2024:10.1007/s00277-024-05761-5. [PMID: 38662204 DOI: 10.1007/s00277-024-05761-5] [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: 02/13/2024] [Accepted: 04/14/2024] [Indexed: 04/26/2024]
Abstract
Distinguishing key morphologic features and understanding the pathophysiology of common cutaneous manifestations of hematologic disorders is essential to ensure prompt and appropriate treatment. In fact, classic cutaneous signs may provide the first clue to the diagnosis of an underlying hematologic disease. Disorders of coagulation, vascular abnormalities, or cutaneous infiltration and deposition are responsible for the underlying pathophysiology of cutaneous manifestations in the majority of cases. Hematologists often feel ill-equipped in identifying morphologic changes in the skin. Thus, the purpose of this review is to provide a comprehensive overview of classic cutaneous manifestations and diagnostic considerations of the associated hematologic conditions. Though there is a specific focus on non-malignant disorders, those straddling the spectrum of malignancy are also discussed. In many disease states, the skin may serve as an important marker of an emerging hematologic disorder, so close collaboration and multidisciplinary input remain essential to provide optimal and timely care for these patients.
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Affiliation(s)
- Hannah L King
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | | | - Jesse J Keller
- Department of Dermatology, Oregon Health & Science University, Portland, OR, USA
| | - Thomas G DeLoughery
- Division of Hematology and Medical Oncology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road Mail Code: OC14HO, 97239, Portland, OR, USA
| | - Joseph J Shatzel
- Division of Hematology and Medical Oncology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road Mail Code: OC14HO, 97239, Portland, OR, USA
| | - Kylee L Martens
- Division of Hematology and Medical Oncology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road Mail Code: OC14HO, 97239, Portland, OR, USA.
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Maier CL, Brohi K, Curry N, Juffermans NP, Mora Miquel L, Neal MD, Shaz BH, Vlaar APJ, Helms J. Contemporary management of major haemorrhage in critical care. Intensive Care Med 2024; 50:319-331. [PMID: 38189930 DOI: 10.1007/s00134-023-07303-5] [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: 09/08/2023] [Accepted: 12/05/2023] [Indexed: 01/09/2024]
Abstract
Haemorrhagic shock is frequent in critical care settings and responsible for a high mortality rate due to multiple organ dysfunction and coagulopathy. The management of critically ill patients with bleeding and shock is complex, and treatment of these patients must be rapid and definitive. The administration of large volumes of blood components leads to major physiological alterations which must be mitigated during and after bleeding. Early recognition of bleeding and coagulopathy, understanding the underlying pathophysiology related to specific disease states, and the development of individualised management protocols are important for optimal outcomes. This review describes the contemporary understanding of the pathophysiology of various types of coagulopathic bleeding; the diagnosis and management of critically ill bleeding patients, including major haemorrhage protocols and post-transfusion management; and finally highlights recent areas of opportunity to better understand optimal management strategies for managing bleeding in the intensive care unit (ICU).
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Affiliation(s)
- Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, USA
| | - Karim Brohi
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
| | - Nicola Curry
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Clinical and Laboratory Sciences, Radcliffe Department of Medicine, Oxford University, Oxford, UK
| | - Nicole P Juffermans
- Department of Intensive Care and Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Lidia Mora Miquel
- Department of Anaesthesiology, Intensive Care and Pain Clinic, Vall d'Hebron Trauma, Rehabilitation and Burns Hospital, Autonomous University of Barcelona, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Matthew D Neal
- Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Beth H Shaz
- Department of Pathology, Duke University School of Medicine, Durham, NC, USA
| | | | - Julie Helms
- Service de Médecine Intensive-Réanimation, Department of Intensive Care, Nouvel Hôpital Civil, Université de Strasbourg (UNISTRA), 1, Place de L'Hôpital, 67091, Strasbourg Cedex, France.
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Alana NB, Ciurylo WA, Hurlock N. HMG-CoA reductase inhibitors and the attenuation of risk for disseminated intravascular coagulation in patients with sepsis. J Thromb Thrombolysis 2024; 57:260-268. [PMID: 37945940 DOI: 10.1007/s11239-023-02910-x] [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] [Accepted: 10/22/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Disseminated Intravascular Coagulation (DIC) is a syndrome of dysregulated coagulation. Patients with sepsis are at increased risk for DIC. HMG-CoA Reductase Inhibitors (Statins) are primarily used as lipid-lowering agents; however, studies have suggested statins may possess anti-inflammatory, antithrombotic, anticoagulant, and endothelial stabilizing properties. These mechanisms may oppose those that underlie the pathogenesis of septic DIC. METHODS To evaluate whether statins may be protective against the development of DIC, we conducted a multi-center, retrospective case-control study where 86,638 critically ill patients admitted to the ICU with sepsis, severe sepsis or septic shock were identified during a 3-year period. Patients who developed DIC during their hospitalization were identified and stratified by whether they received a statin or not during their hospitalization. Odds ratios for development of DIC was calculated by composite of any statin, as well as low, moderate, and high intensity statins. RESULTS 2236 patients would develop DIC compared to 84,402 who did not. The use of any statin was associated with a reduced likelihood for developing DIC (odds ratio [OR], 0.69; 95% CI, 0.61-0.78). This was observed with use of both moderate (OR, 0.64; 95% CI, 0.53-0.77) and high (OR, 0.72; 95% CI, 0.61-0.84) but not low intensity statins (OR, 0.84; 95% CI, 0.53-1.32). CONCLUSIONS The use of moderate and high intensity statins was associated with a significantly reduced odds of developing DIC in critically ill patients with sepsis. This present study may be the first to suggest that statin medications may independently reduce the frequency of DIC in critically ill patients with severe sepsis or septic shock. More research is needed to investigate the potential for this class of medication to be protective against DIC.
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Affiliation(s)
- Nicholas B Alana
- Portsmouth Regional Hospital Internal Medicine Residency Program, HCA Healthcare/Tufts University School of Medicine, 333 Borthwick Ave. Portsmouth, New Hampshire, 03801, USA.
| | - William A Ciurylo
- Portsmouth Regional Hospital Internal Medicine Residency Program, HCA Healthcare/Tufts University School of Medicine, 333 Borthwick Ave. Portsmouth, New Hampshire, 03801, USA
| | - Natalie Hurlock
- HCA Healthcare, 2000 Health Park Drive, Brentwood, TN, 37027, UK
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10
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Retter A, Hunt BJ. Consumptive coagulopathy in the ICU. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:754-760. [PMID: 38066939 PMCID: PMC10727004 DOI: 10.1182/hematology.2023000502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
A consumptive coagulopathy describes a situation where there is a loss of hemostatic factors, which leads to an increased risk of bleeding. Some recent studies have used the term interchangeably with disseminated intravascular coagulation (DIC), but we have reverted to the older definition, which covers a broader range of issues where there is loss of hemostatic factors due to multiple causes, which includes systemic activation of coagulation as seen in DIC. Therefore, the term consumptive coagulopathy covers conditions from the hemostatic effects of major hemorrhage to the use of extracorporeal circuits to true DIC. We review the current understanding of the pathophysiology, diagnosis, and management of common consumptive coagulopathy in critical care patients, focusing on recent advances and controversies. Particular emphasis is given to DIC because it is a common and often life-threatening condition in critical care patients and is characterized by the simultaneous occurrence of widespread microvascular thrombosis and bleeding. Second, we focus on the effect of modern medical technology, such as extracorporeal membrane oxygenation, on hemostasis.
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Affiliation(s)
- Andrew Retter
- Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Beverley J Hunt
- Kings Healthcare Partners and Thrombosis & Haemophilia Centre, GSTT, London, UK
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11
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Wang Z, Tenzing N, Xu Q, Liu H, Ye Y, Wen Y, Wuren T, Cui S. Apoptosis is one cause of thrombocytopenia in patients with high-altitude polycythemia. Platelets 2023; 34:2157381. [PMID: 36597012 DOI: 10.1080/09537104.2022.2157381] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
High-altitude polycythemia (HAPC) can occur in individuals who are intolerant to high-altitude hypoxia. In patients with HAPC, erythrocytosis is often accompanied by a decrease in platelet count. Chronic hypoxia can increase the incidence of arteriovenous thrombosis and the risk of bleeding during antithrombotic treatment due to thrombocytopenia; therefore, understanding the cause of thrombocytopenia can reduce the risk of treatment-related bleeding. In this study, we examined platelet production and apoptosis to understand the cause of thrombocytopenia in patients with HAPC. The classification of myeloid-derived megakaryocytes (MKs) in HAPC patients was mainly granular MKs rather than mature MKs, suggesting impaired differentiation and maturation. However, the total number of MKs and newly generated reticulated platelets in the peripheral blood increased, indicating sufficient platelet generation in HAPC thrombocytopenia. Increased platelet apoptosis may be one of the causes of thrombocytopenia. Platelet activation and GP1bα pathway activation induced by thrombin and von Willebrand factor can lead to platelet apoptosis. Platelet production was not reduced in patients with HAPC, whereas platelet apoptosis was associated with thrombocytopenia. These findings provide a rationale for considering the bleeding risk in HAPC patient while treating thrombotic diseases.
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Affiliation(s)
- Zhuoya Wang
- Research Center for High Altitude Medicine, Qinghai University, Xining, China.,Department of Qinghai University, Key Laboratory of Application and Foundation for High Altitude Medicine Research in Qinghai Province, Xining, China.,Gerontology Department, Qinghai University Affiliated Hospital, Xining, China
| | - Noryung Tenzing
- Gerontology Department, Qinghai University Affiliated Hospital, Xining, China
| | - Qiying Xu
- Research Center for High Altitude Medicine, Qinghai University, Xining, China.,Department of Qinghai University, Key Laboratory of Application and Foundation for High Altitude Medicine Research in Qinghai Province, Xining, China.,Gerontology Department, Qinghai University Affiliated Hospital, Xining, China
| | - Huifang Liu
- Research Center for High Altitude Medicine, Qinghai University, Xining, China.,Department of Qinghai University, Key Laboratory of Application and Foundation for High Altitude Medicine Research in Qinghai Province, Xining, China.,Gerontology Department, Qinghai University Affiliated Hospital, Xining, China
| | - Yi Ye
- Research Center for High Altitude Medicine, Qinghai University, Xining, China.,Department of Qinghai University, Key Laboratory of Application and Foundation for High Altitude Medicine Research in Qinghai Province, Xining, China
| | - Yi Wen
- Department of General Surgery & Pancreatic Injury and Repair Key Laboratory of Sichuan Province, The General Hospital of Western Theater Command (Chengdu Military General Hospital), Chengdu, China
| | - Tana Wuren
- Research Center for High Altitude Medicine, Qinghai University, Xining, China.,Department of Qinghai University, Key Laboratory of Application and Foundation for High Altitude Medicine Research in Qinghai Province, Xining, China
| | - Sen Cui
- Gerontology Department, Qinghai University Affiliated Hospital, Xining, China
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12
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Haering D, Meador H, Lynch E, Lauria M, Garchar E, Braude D. Management of Postpartum Hemorrhage in Critical Care Transport. Air Med J 2023; 42:488-495. [PMID: 37996188 DOI: 10.1016/j.amj.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 08/01/2023] [Accepted: 08/22/2023] [Indexed: 11/25/2023]
Abstract
Postpartum hemorrhage is a relatively common and highly morbid complication of the postpartum period that often requires management by specialized providers at tertiary care facilities. Critical care transport teams may be tasked with transporting postpartum patients who are already experiencing postpartum hemorrhage, but they should also be aware that other peripartum patients may be at risk for developing postpartum hemorrhage while in the process of transport. As such, it is imperative that transport providers understand the signs, symptoms, causes, and complications of postpartum hemorrhage as well as the options for intervention and treatment. This article reviews the current clinical evidence regarding resuscitation and medical management strategies that transport teams should be familiar with as well as more advanced and invasive management techniques they may encounter and be expected to monitor during transport, such as balloon tamponade and aortic balloon occlusion.
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Affiliation(s)
- Donald Haering
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM.
| | - Hallie Meador
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM
| | - Elizabeth Lynch
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM
| | - Michael Lauria
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM
| | - Elizabeth Garchar
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, NM
| | - Darren Braude
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM
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13
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Howick V JF, Harmon DM, McBane RD. 44-Year-Old Woman With Cough and Shortness of Breath. Mayo Clin Proc 2023; 98:1557-1563. [PMID: 37793730 DOI: 10.1016/j.mayocp.2023.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/28/2023] [Accepted: 02/02/2023] [Indexed: 10/06/2023]
Affiliation(s)
- James F Howick V
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - David M Harmon
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Robert D McBane
- Advisor to residents and Consultant in Vascular Cardiology, Mayo Clinic, Rochester, MN.
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14
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Lien TS, Sun DS, Wu WS, Chang HH. Simulation of Hemorrhage Pathogenesis in Mice through Dual Stimulation with Dengue Envelope Protein Domain III-Coated Nanoparticles and Antiplatelet Antibody. Int J Mol Sci 2023; 24:ijms24119270. [PMID: 37298220 DOI: 10.3390/ijms24119270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 05/22/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
Dengue hemorrhagic fever (DHF) is a severe form of dengue virus (DENV) infection that can lead to abnormal immune responses, endothelial vascular dysfunction, and hemorrhage pathogenesis. The virion-associated envelope protein domain III (EIII) is thought to play a role in the virulence of DENV by damaging endothelial cells. However, it is unclear whether EIII-coated nanoparticles simulating DENV virus particles could cause a more severe pathogenesis than soluble EIII alone. This study aimed to investigate whether EIII-coated silica nanoparticles (EIII-SNPs) could elicit greater cytotoxicity in endothelial cells and hemorrhage pathogenesis in mice compared to EIII or silica nanoparticles alone. The main methods included in vitro assays to assess cytotoxicity and in vivo experiments to examine hemorrhage pathogenesis in mice. EIII-SNPs induced greater endothelial cytotoxicity in vitro than EIII or silica nanoparticles alone. Two-hit combined treatment with EIII-SNPs and antiplatelet antibodies to simulate DHF hemorrhage pathogenesis during secondary DENV infections resulted in higher endothelial cytotoxicity than either treatment alone. In mouse experiments, two-hit combined treatment with EIII-SNPs and antiplatelet antibodies resulted in more severe hemorrhage pathogenesis compared to single treatments of EIII, EIII-SNPs, or antiplatelet antibodies alone. These findings suggest that EIII-coated nanoparticles are more cytotoxic than soluble EIII and could be used to develop a tentative dengue two-hit hemorrhage pathogenesis model in mice. Additionally, our results indicated that EIII-containing DENV particles could potentially exacerbate hemorrhage pathogenesis in DHF patients who have antiplatelet antibodies, highlighting the need for further research on the potential role of EIII in DHF pathogenesis.
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Affiliation(s)
- Te-Sheng Lien
- Department of Molecular Biology and Human Genetics, Tzu-Chi University, Hualien 970, Taiwan
| | - Der-Shan Sun
- Department of Molecular Biology and Human Genetics, Tzu-Chi University, Hualien 970, Taiwan
| | - Wen-Sheng Wu
- Division of General Surgery, Department of Surgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970, Taiwan
| | - Hsin-Hou Chang
- Department of Molecular Biology and Human Genetics, Tzu-Chi University, Hualien 970, Taiwan
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15
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Hakobyan N, Ilerhunmwuwa N, Wasifuddin M, Tasnim A, Boris A. COVID-19-Associated Disseminated Intravascular Coagulopathy Presenting As Inferior ST-Segment Elevation Myocardial Infarction. Cureus 2023; 15:e39308. [PMID: 37346198 PMCID: PMC10281741 DOI: 10.7759/cureus.39308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2023] [Indexed: 06/23/2023] Open
Abstract
Disseminated intravascular coagulopathy (DIC) is infrequently associated with COVID-19 infection. COVID-19 infection can predispose to thrombotic events through inflammation and microvascular injury. DIC is rarely associated with coronary artery disease, especially myocardial infarction (MI). In this case report, we present an uncommon case of a patient with concurrent DIC and MI in the setting of COVID-19 infection. A 73-year-old male patient with no known cardiovascular risk factor presented with syncope. Assessment in the field by emergency medical service (EMS) showed the patient had a third-degree atrioventricular block and a heart rate of 40 beats per minute. He was given atropine and transcutaneously paced. Upon admission, he was found to have an inferior wall ST-elevation myocardial infarction (STEMI) and tested positive for COVID-19. Cardiac catheterization was performed urgently and revealed triple vessel disease. Attempts to revascularize the vessels were unsuccessful. He subsequently developed cardiogenic shock. He was started on multiple pressor support. Laboratory workup was suggestive of DIC, and he later developed multiorgan failure. Continuous renal replacement therapy was initiated but failed due to persistent thrombosis of the dialysis access. Despite all measures, the patient developed cardiac arrest and passed away on the third day of hospitalization. Our understanding of COVID-19 and its complications has grown exponentially since the beginning of the pandemic. The pro-inflammatory state induced by the disease creates a hypercoagulable state that may result in thrombotic complications, including MI. In severe cases, a consumptive coagulopathy may develop, leading to DIC. This unique case report seeks to highlight the importance of staying vigilant about the potential complications of MI and DIC induced by COVID-19 so that prompt diagnosis can be made to reduce morbidity and mortality in these patients.
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Affiliation(s)
- Narek Hakobyan
- Internal Medicine, Brookdale University Hospital Medical Center, Brooklyn, USA
| | | | - Mustafa Wasifuddin
- Internal Medicine, Brookdale University Hospital Medical Center, Brooklyn, USA
| | - Anika Tasnim
- Internal Medicine, Brookdale University Hospital Medical Center, Brooklyn, USA
| | - Avezbakiyev Boris
- Hematology/Oncology, Brookdale University Hospital Medical Center, Brooklyn, USA
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16
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Lee AI, Heidari P, Fenves AZ, Bardia A, Ta R. Case 8-2023: A 71-Year-Old Woman with Refractory Hemolytic Anemia. N Engl J Med 2023; 388:1032-1041. [PMID: 36920760 PMCID: PMC10133839 DOI: 10.1056/nejmcpc2211370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Affiliation(s)
- Alfred I Lee
- From the Department of Medicine, Yale School of Medicine, New Haven, CT (A.I.L.); and the Departments of Radiology (P.H.), Medicine (A.Z.F., A.B.), and Pathology (R.T.), Massachusetts General Hospital, and the Departments of Radiology (P.H.), Medicine (A.Z.F., A.B.), and Pathology (R.T.), Harvard Medical School - both in Boston
| | - Pedram Heidari
- From the Department of Medicine, Yale School of Medicine, New Haven, CT (A.I.L.); and the Departments of Radiology (P.H.), Medicine (A.Z.F., A.B.), and Pathology (R.T.), Massachusetts General Hospital, and the Departments of Radiology (P.H.), Medicine (A.Z.F., A.B.), and Pathology (R.T.), Harvard Medical School - both in Boston
| | - Andrew Z Fenves
- From the Department of Medicine, Yale School of Medicine, New Haven, CT (A.I.L.); and the Departments of Radiology (P.H.), Medicine (A.Z.F., A.B.), and Pathology (R.T.), Massachusetts General Hospital, and the Departments of Radiology (P.H.), Medicine (A.Z.F., A.B.), and Pathology (R.T.), Harvard Medical School - both in Boston
| | - Aditya Bardia
- From the Department of Medicine, Yale School of Medicine, New Haven, CT (A.I.L.); and the Departments of Radiology (P.H.), Medicine (A.Z.F., A.B.), and Pathology (R.T.), Massachusetts General Hospital, and the Departments of Radiology (P.H.), Medicine (A.Z.F., A.B.), and Pathology (R.T.), Harvard Medical School - both in Boston
| | - Robert Ta
- From the Department of Medicine, Yale School of Medicine, New Haven, CT (A.I.L.); and the Departments of Radiology (P.H.), Medicine (A.Z.F., A.B.), and Pathology (R.T.), Massachusetts General Hospital, and the Departments of Radiology (P.H.), Medicine (A.Z.F., A.B.), and Pathology (R.T.), Harvard Medical School - both in Boston
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17
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Jacobs JW, Filkins L, Booth GS, Adkins BD. They come in threes: Marburg virus, emerging infectious diseases, and the blood supply. Transfus Apher Sci 2023; 62:103528. [PMID: 36038475 PMCID: PMC9417361 DOI: 10.1016/j.transci.2022.103528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 08/10/2022] [Accepted: 08/24/2022] [Indexed: 11/24/2022]
Affiliation(s)
- Jeremy W. Jacobs
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, USA,Correspondence to: 55 Park Street, New Haven, CT 06511, USA
| | - Laura Filkins
- Department of Pathology, University of Texas Southwestern, Dallas, TX, USA
| | - Garrett S. Booth
- Department of Pathology, Microbiology & Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brian D. Adkins
- Department of Pathology, University of Texas Southwestern, Dallas, TX, USA
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18
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Garraud O, Hamzeh-Cognasse H, Chalayer E, Duchez AC, Tardy B, Oriol P, Haddad A, Guyotat D, Cognasse F. Platelet transfusion in adults: An update. Transfus Clin Biol 2023; 30:147-165. [PMID: 36031180 DOI: 10.1016/j.tracli.2022.08.147] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Many patients worldwide receive platelet components (PCs) through the transfusion of diverse types of blood components. PC transfusions are essential for the treatment of central thrombocytopenia of diverse causes, and such treatment is beneficial in patients at risk of severe bleeding. PC transfusions account for almost 10% of all the blood components supplied by blood services, but they are associated with about 3.25 times as many severe reactions (attributable to transfusion) than red blood cell transfusions after stringent in-process leukoreduction to less than 106 residual cells per blood component. PCs are not homogeneous, due to the considerable differences between donors. Furthermore, the modes of PC collection and preparation, the safety precautions taken to limit either the most common (allergic-type reactions and febrile non-hemolytic reactions) or the most severe (bacterial contamination, pulmonary lesions) adverse reactions, and storage and conservation methods can all result in so-called PC "storage lesions". Some storage lesions affect PC quality, with implications for patient outcome. Good transfusion practices should result in higher levels of platelet recovery and efficacy, and lower complication rates. These practices include a matching of tissue ABH antigens whenever possible, and of platelet HLA (and, to a lesser extent, HPA) antigens in immunization situations. This review provides an overview of all the available information relating to platelet transfusion, from donor and donation to bedside transfusion, and considers the impact of the measures applied to increase transfusion efficacy while improving safety and preventing transfusion inefficacy and refractoriness. It also considers alternatives to platelet component (PC) transfusion.
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Affiliation(s)
- O Garraud
- SAINBIOSE, INSERM, U1059, University of Lyon, Saint-Étienne, France.
| | | | - E Chalayer
- SAINBIOSE, INSERM, U1059, University of Lyon, Saint-Étienne, France; Saint-Etienne University Hospital, Department of Hematology and Cellular Therapy, Saint-Étienne, France
| | - A C Duchez
- SAINBIOSE, INSERM, U1059, University of Lyon, Saint-Étienne, France; Établissement Français du Sang Auvergne-Rhône-Alpes, Saint-Étienne, France
| | - B Tardy
- SAINBIOSE, INSERM, U1059, University of Lyon, Saint-Étienne, France; CHU de Saint-Etienne, INSERM and CIC EC 1408, Clinical Epidemiology, Saint-Étienne, France
| | - P Oriol
- CHU de Saint-Etienne, INSERM and CIC EC 1408, Clinical Epidemiology, Saint-Étienne, France
| | - A Haddad
- SAINBIOSE, INSERM, U1059, University of Lyon, Saint-Étienne, France; Sacré-Cœur Hospital, Beirut, Lebanon; Lebanese American University, Beirut, Lebanon
| | - D Guyotat
- Saint-Etienne University Hospital, Department of Hematology and Cellular Therapy, Saint-Étienne, France
| | - F Cognasse
- SAINBIOSE, INSERM, U1059, University of Lyon, Saint-Étienne, France; Établissement Français du Sang Auvergne-Rhône-Alpes, Saint-Étienne, France
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19
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Suzuki N, Suzuki N, Kawaguchi Y, Okamoto S, Kanematsu T, Katsumi A, Suzuki A, Tamura S, Kojima T, Kiyoi H, Matsushita T. The usefulness of tranexamic acid for bleeding symptoms of chronic consumptive coagulopathy complicated by aortic disease: a single-institute, retrospective study of 14 patients. Thromb J 2023; 21:10. [PMID: 36698142 PMCID: PMC9878879 DOI: 10.1186/s12959-022-00429-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 11/04/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Tranexamic acid (TXA) is an antifibrinolytic drug that blocks lysine-binding sites on the profibrinolytic enzyme plasminogen. Aortic diseases with chronic consumption coagulopathy may lead to disseminated intravascular coagulation (DIC) and cause fatal bleeding. Although the use of antifibrinolytic agents in DIC is generally not recommended due to enhanced fibrin deposition risking thrombotic symptoms, the efficacy of TXA has been reported in several cases of DIC with aortic diseases. However, the efficacy and safety of TXA for bleeding symptoms of chronic consumption coagulopathy with aortic diseases have not been studied in detail. METHODS We evaluated the efficacy of TXA in 14 patients with chronic consumptive coagulopathy due to aortic disease complicated by bleeding symptoms. Changes in coagulation and fibrinolysis parameters from baseline were analyzed with Wilcoxon matched-pairs signed-rank tests, excluding missing values. Kaplan-Meier curves were used to analyze overall survival. RESULTS Median age was 78.5 years (range, 66-89 years) and median observation period was 448 days (range, 0-2282 days). Twelve patients had chronic renal failure and 1 patient had chronic liver failure. Before starting treatment, median Japanese Ministry of Health and Welfare DIC diagnostic criteria score was 8 (range, 4-11) and median platelet count was 64 × 109/L (range, 25-97 × 109/L). Twelve patients underwent evaluation of bleeding symptoms after introduction of TXA, and 10 of those 12 patients showed improved bleeding tendencies within 30 days (median, 5.0 days). One patient with chronic liver failure showed worsening of bleeding symptoms. Although only one patient was initiated TXA in combination with anticoagulants, no significant worsening of thrombotic events was observed within 30 days. CONCLUSIONS TXA therapy appears effective against chronic consumptive coagulopathy with bleeding due to aortic disease, with few side effects.
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Affiliation(s)
- Naruko Suzuki
- grid.27476.300000 0001 0943 978XDepartment of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobuaki Suzuki
- grid.437848.40000 0004 0569 8970Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Yuka Kawaguchi
- grid.27476.300000 0001 0943 978XDepartment of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shuichi Okamoto
- grid.437848.40000 0004 0569 8970Department of Clinical Laboratory, Nagoya University Hospital, Nagoya, Japan
| | - Takeshi Kanematsu
- grid.437848.40000 0004 0569 8970Department of Clinical Laboratory, Nagoya University Hospital, Nagoya, Japan
| | - Akira Katsumi
- grid.419257.c0000 0004 1791 9005Department of Hematology, National Center of Geriatrics and Gerontology, Obu, Japan
| | - Atsuo Suzuki
- grid.437848.40000 0004 0569 8970Department of Medical Technique, Nagoya University Hospital, Nagoya, Japan
| | - Shogo Tamura
- grid.27476.300000 0001 0943 978XDepartment of Integrated Health Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan ,grid.39158.360000 0001 2173 7691Present address: Department of Medical Laboratory Science, Hokkaido University Graduate School of Health Science, Sapporo, Japan
| | | | - Hitoshi Kiyoi
- grid.27476.300000 0001 0943 978XDepartment of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tadashi Matsushita
- grid.437848.40000 0004 0569 8970Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
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20
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Lu Y, Li D, Huang Y, Sun Y, Zhou H, Ye F, Yang H, Xu T, Quan S, Pan J. Pretreatment with Eupatilin Attenuates Inflammation and Coagulation in Sepsis by Suppressing JAK2/STAT3 Signaling Pathway. J Inflamm Res 2023; 16:1027-1042. [PMID: 36926276 PMCID: PMC10013575 DOI: 10.2147/jir.s393850] [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: 10/25/2022] [Accepted: 02/24/2023] [Indexed: 03/12/2023] Open
Abstract
Purpose Sepsis is an aggressive and life-threatening organ dysfunction induced by infection. Excessive inflammation and coagulation contribute to the negative outcomes for sepsis, resulting in high morbidity and mortality. In this study, we explored whether Eupatilin could alleviate lung injury, reduce inflammation and coagulation during sepsis. Methods We constructed an in vitro sepsis model by stimulating RAW264.7 cells with 1 μg/mL lipopolysaccharide (LPS) for 6 hours. The cells were divided into control group, LPS group, LPS+ Eupatilin (Eup) group, and Eup group to detect their cell activity and inflammatory cytokines and coagulation factor levels. Cells in LPS+Eup and Eup group were pretreated with Eupatilin (10μM) for 2 hours. In vivo, mice were divided into sham operation group, cecal ligation and puncture (CLP) group and Eup group. Mice in the CLP and Eup groups were pretreated with Eupatilin (10mg/kg) for 2 hours by gavage. Lung tissue and plasma were collected and inflammatory cytokines, coagulation factors and signaling were measured. Results In vitro, tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6, and tissue factor (TF) expression in LPS-stimulated RAW264.7 cells was downregulated by Eupatilin (10μM). Furthermore, Eupatilin inhibited phosphorylation of the JAK2/STAT3 signaling pathway and suppressed p-STAT3 nuclear translocation. In vivo, Eupatilin increased the survival rate of the mice. In septic mice, plasma concentrations of TNF-α, IL-1β and IL-6, as well as TF, plasminogen activator inhibitor 1 (PAI-1), D-dimer, thrombin-antithrombin complex (TAT) and fibrinogen were improved by Eupatilin. Moreover, Eupatilin alleviated lung injury by improving the expression of inflammatory cytokines and TF, fibrin deposition and macrophage infiltration in lung tissue. Conclusion Our results revealed that Eupatilin may modulate inflammation and coagulation indicators as well as improve lung injury in sepsis via the JAK2/STAT3 signaling pathway.
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Affiliation(s)
- Yilun Lu
- Department of Intensive Care Unit, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China.,Key Laboratory of Intelligent Treatment and Life Support for Critical Diseases of Zhejiang Province, Wenzhou, People's Republic of China.,Wenzhou Key Laboratory of Critical Care and Artificial Intelligence, Wenzhou, People's Republic of China
| | - Ding Li
- Department of Intensive Care Unit, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China.,Key Laboratory of Intelligent Treatment and Life Support for Critical Diseases of Zhejiang Province, Wenzhou, People's Republic of China.,Wenzhou Key Laboratory of Critical Care and Artificial Intelligence, Wenzhou, People's Republic of China
| | - Yueyue Huang
- Department of Intensive Care Unit, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China.,Key Laboratory of Intelligent Treatment and Life Support for Critical Diseases of Zhejiang Province, Wenzhou, People's Republic of China.,Wenzhou Key Laboratory of Critical Care and Artificial Intelligence, Wenzhou, People's Republic of China
| | - Yuanyuan Sun
- Department of Intensive Care Unit, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China.,Key Laboratory of Intelligent Treatment and Life Support for Critical Diseases of Zhejiang Province, Wenzhou, People's Republic of China.,Wenzhou Key Laboratory of Critical Care and Artificial Intelligence, Wenzhou, People's Republic of China
| | - Hongmin Zhou
- Department of Intensive Care Unit, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China.,Key Laboratory of Intelligent Treatment and Life Support for Critical Diseases of Zhejiang Province, Wenzhou, People's Republic of China.,Wenzhou Key Laboratory of Critical Care and Artificial Intelligence, Wenzhou, People's Republic of China
| | - Fanrong Ye
- Department of Intensive Care Unit, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China.,Key Laboratory of Intelligent Treatment and Life Support for Critical Diseases of Zhejiang Province, Wenzhou, People's Republic of China.,Wenzhou Key Laboratory of Critical Care and Artificial Intelligence, Wenzhou, People's Republic of China
| | - Hongjing Yang
- Department of Intensive Care Unit, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China.,Key Laboratory of Intelligent Treatment and Life Support for Critical Diseases of Zhejiang Province, Wenzhou, People's Republic of China.,Wenzhou Key Laboratory of Critical Care and Artificial Intelligence, Wenzhou, People's Republic of China
| | - Tingting Xu
- Department of Intensive Care Unit, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China.,Key Laboratory of Intelligent Treatment and Life Support for Critical Diseases of Zhejiang Province, Wenzhou, People's Republic of China.,Wenzhou Key Laboratory of Critical Care and Artificial Intelligence, Wenzhou, People's Republic of China
| | - Shichao Quan
- Wenzhou Key Laboratory of Critical Care and Artificial Intelligence, Wenzhou, People's Republic of China.,Collaborative Innovation Center for Intelligence Medical Education, Wenzhou, People's Republic of China.,Zhejiang Engineering Research Center for Hospital Emergency and Process Digitization, Wenzhou, People's Republic of China.,Department of General Medicine, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Jingye Pan
- Department of Intensive Care Unit, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China.,Key Laboratory of Intelligent Treatment and Life Support for Critical Diseases of Zhejiang Province, Wenzhou, People's Republic of China.,Wenzhou Key Laboratory of Critical Care and Artificial Intelligence, Wenzhou, People's Republic of China.,Collaborative Innovation Center for Intelligence Medical Education, Wenzhou, People's Republic of China.,Zhejiang Engineering Research Center for Hospital Emergency and Process Digitization, Wenzhou, People's Republic of China
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21
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Lemiale V, Mabrouki A, Miry L, Mokart D, Pène F, Kouatchet A, Mayaux J, Bruneel F, Perez P, Meert AP, Moreau AS, Benoit D, Darmon M, Zafrani L, Clere-Jehl R. Sepsis-associated coagulopathy in onco-hematology patients presenting with thrombocytopenia: a multicentric observational study. Leuk Lymphoma 2023; 64:197-204. [PMID: 36305707 DOI: 10.1080/10428194.2022.2136971] [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: 11/07/2022]
Abstract
Coagulation disorders increase mortality rate during septic shock, but the impact of concomitant hematological malignancies remains unknown. The study assessed coagulation disorders in onco-hematological patients with thrombocytopenia (<100 G/L) admitted to ICU for septic shock. Among 146 included patients, 50 patients had lymphoma and 49 patients had acute leukemia. ICU mortality rate was 43.8% (n = 64). Median increase in prothrombin time (PT) at day(d) 1 was 4.7 s (IQR 3.2-7.9) in ICU survivors vs. 6.4 s (IQR 4.5-13.7; p < 0.01) in non-survivors. Fibrinogen kinetics (increase in fibrinogen levels between d1 and d2) was +0.55 (-0.22-1.55) vs. +0.10 g/L (-0.40-0.50; p = 0.03) in surviving and non-surviving patients, respectively. PT increase ≥6 s at d1 (OR 5.5; 95% CI 1.1-6.0; p = 0.03) and mechanical ventilation (OR 7.4; 95% CI 3.3-17.7; p < 0.001) were independently associated with ICU mortality. This study provides information and new ways to identify hematological patients with high-risk mortality.
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Affiliation(s)
- Virginie Lemiale
- Department of Medical Intensive Care Unit, Saint-Louis Teaching Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Asma Mabrouki
- Department of Medical Intensive Care Unit, Saint-Louis Teaching Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Loïc Miry
- Neuro-Intensive Care Unit, Rothschild Foundation Hospital, France
| | - Djamel Mokart
- Medical and Surgical Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France
| | - Frédéric Pène
- Service de Médecine Intensive-réanimation, Hôpital Cochin, AP-HP, Centre & Université Paris Cité, Paris, France
| | - Achille Kouatchet
- Medical Intensive Care Unit, Angers University Hospital, Angers, France
| | - Julien Mayaux
- Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Fabrice Bruneel
- Department of Critical Care, Versailles Hospital, Le Chesnay, France
| | - Pierre Perez
- Medical Intensive Care Unit, Hôpital Brabois, Vandoeuvre Les Nancy, France
| | - Anne-Pascale Meert
- Soins intensifs et urgences oncologiques, Service de Médecine interne, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Bruxelles, Belgique
| | - Anne-Sophie Moreau
- Pôle de médecine intensive réanimation, Hôpital Roger Salengro, CHU Lille, Lille cedex, France
| | - Dominique Benoit
- Medical Unit, Department of Intensive Care, Ghent University Hospitalc, Ghent, Belgium
| | - Michael Darmon
- Department of Medical Intensive Care Unit, Saint-Louis Teaching Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Lara Zafrani
- Department of Medical Intensive Care Unit, Saint-Louis Teaching Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,INSERM U976, Human Immunology, Pathophysiology and Immunotherapy, Saint-Louis Teaching Hospital, Paris University, Paris, France
| | - Raphaël Clere-Jehl
- Department of Medical Intensive Care Unit, Saint-Louis Teaching Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Laboratoire d'ImmunoRhumatologie Moléculaire, INSERM (French National Institute of Health and Medical Research), UMR_S1109, Centre de Recherche d'Immunologie et d'Hématologie, Faculté de Médecine, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg Cedex, France
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22
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Lin Y, Huang L, Tu Y, Huang B, Zhang S, Chen Y, Li W. Case report of Salmonella derby septicemia complicated with co-occurrence of disseminated intravascular coagulation and thrombotic microangiopathy. BMC Infect Dis 2022; 22:914. [PMID: 36476209 PMCID: PMC9730593 DOI: 10.1186/s12879-022-07913-2] [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: 07/13/2022] [Accepted: 12/01/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Both disseminated intravascular coagulation and thrombotic microangiopathy are complications of sepsis as Salmonella septicemia, respectively. They are related and have similar clinical characteristics as thrombopenia and organ dysfunctions. They rarely co-occur in some specific cases, which requires a clear distinction. CASE PRESENTATION A 22-year-old woman had just undergone intracranial surgery and suffered from Salmonella derby septicemia with multiorgan involvement in the hospital. Laboratory workup demonstrated coagulation disorder, hemolytic anemia, thrombocytopenia, and acute kidney injury, leading to the co-occurrence of disseminated intravascular coagulation and secondary thrombotic microangiopathy. She received antibiotics, plasma exchange therapy, dialysis, mechanical ventilation, fluids, and vasopressors and gained full recovery without complications. CONCLUSION Disseminated intravascular coagulation and secondary thrombotic microangiopathy can co-occur in Salmonella derby septicemia. They should be treated cautiously in diagnosis and differential diagnosis. Thrombotic microangiopathy should not be missed just because of the diagnosis of disseminated intravascular coagulation. Proper and timely identification of thrombotic microangiopathy with a diagnostic algorithm is essential for appropriate treatment and better outcomes.
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Affiliation(s)
- Yingxin Lin
- grid.440601.70000 0004 1798 0578Department of Intensive Care, Peking University Shenzhen Hospital, Shenzhen, China
| | - Lei Huang
- grid.440601.70000 0004 1798 0578Department of Intensive Care, Peking University Shenzhen Hospital, Shenzhen, China
| | - Yunliang Tu
- grid.440601.70000 0004 1798 0578Department of Intensive Care, Peking University Shenzhen Hospital, Shenzhen, China
| | - Bin Huang
- grid.440601.70000 0004 1798 0578Department of Intensive Care, Peking University Shenzhen Hospital, Shenzhen, China
| | - Sheng Zhang
- grid.440601.70000 0004 1798 0578Department of Intensive Care, Peking University Shenzhen Hospital, Shenzhen, China
| | - Yingqun Chen
- grid.440601.70000 0004 1798 0578Department of Intensive Care, Peking University Shenzhen Hospital, Shenzhen, China
| | - Weijia Li
- grid.440601.70000 0004 1798 0578Department of Intensive Care, Peking University Shenzhen Hospital, Shenzhen, China
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23
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Lin Y, Shao Y, Liu Y, Yang R, Liao S, Yang S, Xu M, He J. Efficacy and safety of nafamostat mesilate anticoagulation in blood purification treatment of critically ill patients: a systematic review and meta-analysis. Ren Fail 2022; 44:1263-1279. [PMID: 35930302 PMCID: PMC9359194 DOI: 10.1080/0886022x.2022.2105233] [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] [Indexed: 01/08/2023] Open
Abstract
Background Nafamostat mesilate (NM), a broad-spectrum and potent serine protease inhibitor, can be used as an anticoagulant during extracorporeal circulation, as well as a promising drug effective against coronavirus disease 2019 (COVID-19). We conducted a systematic meta-analysis to evaluate the safety and efficacy of NM administration in critically ill patients who underwent blood purification therapy (BPT). Methods The Cochrane Library, Web of Science and PubMed were comprehensively searched from inception to August 20, 2021, for potential studies. Results Four randomized controlled trials (RCTs) and seven observational studies with 2723 patients met the inclusion criteria. The meta-analysis demonstrated that conventional therapy (CT) significantly increased hospital mortality compared with NM administration (RR = 1.25, p = 0.0007). In subgroup analyses, the in-hospital mortality of the NM group was significantly lower than that of the anticoagulant-free (NA) group (RR = 1.31, p = 0.002). The CT interventions markedly elevated the risk ratio of bleeding complications by 45% (RR = 1.45, p = 0.010) compared with NM interventions. In another subgroup analysis, NM used exhibited a significantly lower risk of bleeding complications than those of the low-molecular-weight heparin (LMWH) used (RR = 4.58, p = 0.020). The filter lifespan was decreased significantly (MD = −10.59, p < 0.0001) in the NA groups compared with the NM groups. Due to the poor quality of the included RCTs, these results should be interpreted with caution. Conclusion Given the better survival outcomes, lower risk of bleeding, NM anticoagulation seems to be a safe and efficient approach for BPT patients and could yield a favorable filter lifespan. More multi-center RCTs with large samples are required for further validation of this study.
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Affiliation(s)
- Yao Lin
- Jieyang Medical Research Center, Jieyang People's Hospital, Jieyang, China
| | - Yiming Shao
- The Intensive Care Unit, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Yuchun Liu
- Jieyang Medical Research Center, Jieyang People's Hospital, Jieyang, China
| | - Ruoxuan Yang
- Jieyang Medical Research Center, Jieyang People's Hospital, Jieyang, China
| | - Shuanglin Liao
- The Intensive Care Unit, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Shuai Yang
- The Intensive Care Unit, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Mingwei Xu
- Jieyang Medical Research Center, Jieyang People's Hospital, Jieyang, China
| | - Junbing He
- Jieyang Medical Research Center, Jieyang People's Hospital, Jieyang, China
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24
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Eden G, Schmidt JJ, Büttner S, Kümpers P, Hafer C, Rovas A, Koch BF, Schmidt BMW, Kielstein JT. Safety and efficacy of the Seraph® 100 Microbind® Affinity Blood Filter to remove bacteria from the blood stream: results of the first in human study. Crit Care 2022; 26:181. [PMID: 35715801 PMCID: PMC9205040 DOI: 10.1186/s13054-022-04044-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 06/02/2022] [Indexed: 11/10/2022] Open
Abstract
Background Bacterial burden as well as duration of bacteremia influence the outcome of patients with bloodstream infections. Promptly decreasing bacterial load in the blood by using extracorporeal devices in addition to anti-infective therapy has recently been explored. Preclinical studies with the Seraph® 100 Microbind® Affinity Blood Filter (Seraph® 100), which consists of heparin that is covalently bound to polymer beads, have demonstrated an effective binding of bacteria and viruses. Pathogens adhere to the heparin coated polymer beads in the adsorber as they would normally do to heparan sulfate on cell surfaces. Using this biomimetic principle, the Seraph® 100 could help to decrease bacterial burden in vivo.
Methods This first in human, prospective, multicenter, non-randomized interventional study included patients with blood culture positive bloodstream infection and the need for kidney replacement therapy as an adjunctive treatment for bloodstream infections. We performed a single four-hour hemoperfusion treatment with the Seraph® 100 in conjunction with a dialysis procedure. Post procedure follow up was 14 days. Results Fifteen hemodialysis patients (3F/12 M, age 74.0 [68.0–78.5] years, dialysis vintage 28.0 [11.0–45.0] months) were enrolled. Seraph® 100 treatment started 66.4 [45.7–80.6] hours after the initial positive blood culture was drawn. During the treatment with the Seraph® 100 with a median blood flow of 285 [225–300] ml/min no device or treatment related adverse events were reported. Blood pressure and heart rate remained stable while peripheral oxygen saturation improved during the treatment from 98.0 [92.5–98.0] to 99.0 [98.0–99.5] %; p = 0.0184. Four patients still had positive blood culture at the start of Seraph® 100 treatment. In one patient blood cultures turned negative during treatment. The time to positivity (TTP) was increased between inflow and outflow blood cultures by 36 [− 7.2 to 96.3] minutes. However, overall TTP increase was not statistical significant. Conclusions Seraph® 100 treatment was well tolerated. Adding Seraph® 100 to antibiotics early in the course of bacteremia might result in a faster resolution of bloodstream infections, which has to be evaluated in further studies. Trail registration: ClinicalTrials.gov Identifier: NCT02914132, first posted September 26, 2016. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04044-7.
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25
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Arad-Cohen N, Zeller B, Abrahamsson J, Fernandez Navarro JM, Cheuk D, Palmu S, Costa V, De Moerloose B, Hasle H, Jahnukainen K, Pronk CJ, Gísli Jónsson Ó, Kovalova Z, Lausen B, Munthe-Kaas M, Noren-Nyström U, Palle J, Pasauliene R, Saks K, Kaspers GJ. Supportive care in pediatric acute myeloid leukemia:Expert-based recommendations of the NOPHO-DB-SHIP consortium. Expert Rev Anticancer Ther 2022; 22:1183-1196. [PMID: 36191604 DOI: 10.1080/14737140.2022.2131544] [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: 01/12/2023]
Abstract
INTRODUCTION Pediatric acute myeloid leukemia (AML) is the second most common type of pediatric leukemia. Patients with AML are at high risk for several complications such as infections, typhlitis, and acute and long-term cardiotoxicity. Despite this knowledge, there are no definite supportive care guidelines as to what the best approach is to manage or prevent these complications. AREA COVERED The NOPHO-DB-SHIP (Nordic-Dutch-Belgian-Spain-Hong-Kong-Israel-Portugal) consortium, in preparation for a new trial in pediatric AML patients, had dedicated meetings for supportive care. In this review, the authors discuss the available data and outline recommendations for the management of children and adolescents with AML with an emphasis on hyperleukocytosis, tumor lysis syndrome, coagulation abnormalities and bleeding, infection, typhlitis, malnutrition, cardiotoxicity, and fertility preservation. EXPERT OPINION Improved supportive care has significantly contributed to increased cure rates. Recommendations on supportive care are an essential part of treatment for this highly susceptible population and will further improve their outcome.
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Affiliation(s)
- Nira Arad-Cohen
- Department of Pediatric Hemato-Oncology, Rambam Health Care Campus, Haifa, Israel
| | - Bernward Zeller
- Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Jonas Abrahamsson
- Department of Paediatrics, Queen Silvia Children's Hospital, Institution for Clinical Sciences, Gothenburg, Sweden
| | | | - Daniel Cheuk
- Department of Pediatrics, Queen Mary Hospital, Hong Kong Pediatric Hematology & Oncology Study Group (HKPHOSG), Hong Kong
| | - Sauli Palmu
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Vitor Costa
- Departament of Paediatrics, Instituto Português de Oncologia, FG-Porto, Portugal
| | | | - Henrik Hasle
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Kirsi Jahnukainen
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | | | - Zhanna Kovalova
- Department of Paediatrics, Children's Clinical University Hospital, Riga, Latvia
| | - Birgitte Lausen
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Monica Munthe-Kaas
- Pediatric Department, Women and Children's Division, Oslo University Hospital, Oslo, Norway
| | | | - Josefine Palle
- Department of Woman's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Ramune Pasauliene
- Center of Oncology and Hematology, BMT unit, Vilnius University Children's Hospital, Vilnius, Lithuania
| | - Kadri Saks
- Department of Paediatrics, SA Tallinna Lastehaigla, Tallinn, Estonia
| | - Gertjan Jl Kaspers
- Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, The Netherlands
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26
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Wiedermann CJ. Antithrombin as Therapeutic Intervention against Sepsis-Induced Coagulopathy and Disseminated Intravascular Coagulation: Lessons Learned from COVID-19-Associated Coagulopathy. Int J Mol Sci 2022; 23:ijms232012474. [PMID: 36293332 PMCID: PMC9604230 DOI: 10.3390/ijms232012474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 10/15/2022] [Accepted: 10/17/2022] [Indexed: 12/04/2022] Open
Abstract
Recent research has contributed significantly to our understanding of the pathogenesis of acute disseminated intravascular coagulation. COVID-19 can be considered as a new underlying condition of disseminated intravascular coagulation. In this narrative review, current evidence is presented regarding biomarker differences between sepsis-induced and COVID-19-associated coagulopathies, supporting the importance of acquired antithrombin deficiency in the early differential diagnosis of septic coagulopathy and its potential impact on treatment with endogenous anticoagulants. Establishing new scoring systems for septic coagulopathy in combination with endogenous anticoagulant biomarker activities may allow for the identification of those in the heterogeneous population of sepsis patients who are more likely to benefit from targeted specific treatment interventions.
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Affiliation(s)
- Christian J. Wiedermann
- Institute of General Practice, Claudiana—College of Health Professions, 39100 Bolzano, Italy;
- Department of Public Health, Medical Decision Making and HTA, University of Health Sciences, Medical Informatics and Technology—Tyrol, 6060 Hall in Tyrol, Austria
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27
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Graf J, Pérez R, López R. Increased respiratory dead space could associate with coagulation activation and poor outcomes in COVID-19 ARDS. J Crit Care 2022; 71:154095. [PMID: 35724445 PMCID: PMC9212801 DOI: 10.1016/j.jcrc.2022.154095] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/17/2022] [Accepted: 06/04/2022] [Indexed: 01/08/2023]
Abstract
PURPOSE To determine whether VDPhys/VT is associated with coagulation activation and outcomes. MATERIALS AND METHODS We enrolled patients with COVID-19 pneumonia who were supported by invasive mechanical ventilation and were monitored using volumetric capnography. Measurements were performed during the first 24 h of mechanical ventilation. The primary endpoint was the likelihood of being discharge alive on day 28. RESULTS Sixty patients were enrolled, of which 25 (42%) had high VDPhys/VT (>57%). Patients with high vs. low VDPhys/VT had higher APACHE II (10[8-13] vs. 8[6-9] points, p = 0.002), lower static compliance of the respiratory system (35[24-46] mL/cmH2O vs. 42[37-45] mL/cmH2O, p = 0.005), and higher D-dimer levels (1246[1050-1594] ng FEU/mL vs. 792[538-1159] ng FEU/mL, p = 0.001), without differences in P/F ratio (157[112-226] vs. 168[136-226], p = 0.719). Additionally, D-dimer levels correlated with VDPhys/VT (r = 0.530, p < 0.001), but not with the P/F ratio (r = -0.103, p = 0.433). Patients with high VDPhys/VT were less likely to be discharged alive on day 28 (32% vs. 71%, aHR = 3.393[1.161-9.915], p = 0.026). CONCLUSIONS In critically ill COVID-19 patients, increased VDPhys/VT was associated with high D-dimer levels and a lower likelihood of being discharged alive. Dichotomic VDPhys/VT could help identify a high-risk subgroup of patients neglected by the P/F ratio.
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Affiliation(s)
- Jerónimo Graf
- Departamento de Paciente Crítico, Clínica Alemana de Santiago, Avenida Vitacura 5951, Vitacura, Santiago Zip Code 7650568, Chile,Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Av. Plaza 680, San Carlos de Apoquindo, Las Condes, Santiago Zip Code 7550000, Chile
| | - Rodrigo Pérez
- Departamento de Paciente Crítico, Clínica Alemana de Santiago, Avenida Vitacura 5951, Vitacura, Santiago Zip Code 7650568, Chile,Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Av. Plaza 680, San Carlos de Apoquindo, Las Condes, Santiago Zip Code 7550000, Chile
| | - René López
- Departamento de Paciente Crítico, Clínica Alemana de Santiago, Avenida Vitacura 5951, Vitacura, Santiago Zip Code 7650568, Chile; Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Av. Plaza 680, San Carlos de Apoquindo, Las Condes, Santiago Zip Code 7550000, Chile.
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28
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Voigtländer M, Langer F. [Cancer-associated coagulation disorders]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2022; 73:809-819. [PMID: 36102956 DOI: 10.1007/s00105-022-05056-8] [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: 06/15/2023]
Abstract
Diagnosis and treatment of paraneoplastic coagulation disorders are a challenge in daily practice. While prophylactic anticoagulation to prevent venous thromboembolism (VTE) is standard of care in all surgical and acutely ill medical cancer patients, particularly careful evaluation of risks and benefits using validated risk assessment models is required during outpatient chemotherapy. Low-molecular-weight heparin and direct oral factor Xa inhibitors are available to treat established cancer-associated VTE, adhering to algorithms for bleeding risk stratification. In patients with overt disseminated intravascular coagulation, therapeutic measures should strictly follow clinical symptoms. An acquired von Willebrand syndrome may evoke a severe bleeding tendency in patients with myeloproliferative neoplasms or plasma cell dyscrasias. In 15% of cases, acquired hemophilia A, due to the formation of inhibitory autoantibodies against coagulation factor VIII, is associated with malignancy.
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Affiliation(s)
- Minna Voigtländer
- Zentrum für Onkologie - Universitäres Cancer Center Hamburg (UCCH), II. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Florian Langer
- Zentrum für Onkologie - Universitäres Cancer Center Hamburg (UCCH), II. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
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Louw S, Jacobson BF, Mayne ES. Distinguishing and overlapping laboratory results of thrombotic microangiopathies in HIV infection: Can scoring systems assist? J Clin Apher 2022; 37:460-467. [PMID: 36054148 PMCID: PMC9804888 DOI: 10.1002/jca.22003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 07/09/2022] [Accepted: 07/30/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Patients with Human Immunodeficiency Virus (HIV) infection are at risk of thrombotic microangiopathies (TMAs) notably thrombotic thrombocytopenic purpura (TTP) and disseminated intravascular coagulation (DIC). Overlap between laboratory results exists resulting in diagnostic ambiguity. METHODS Routine laboratory results of 71 patients with HIV-associated TTP (HIV-TTP) and 81 with DIC with concomitant HIV infection (HIV-DIC) admitted between 2015 and 2021 to academic hospitals in Johannesburg, South Africa were retrospectively reviewed. Both the PLASMIC and the International Society of Thrombosis and Haemostasis (ISTH) DIC scores were calculated. RESULTS Patients with HIV-TTP had significantly (P < .001) increased schistocytes and features of hemolysis including elevated lactate dehydrogenase (LDH)/upper-limit-of-normal ratio (median of 9 (interquartile range [IQR] 5-12) vs 3 (IQR 2-5)) but unexpectedly lower fibrinogen (median 2.8 (IQR 2.2-3.4) vs 4 g/L (IQR 2.5-9.2)) and higher D-dimer (median 4.8 (IQR 2.4-8.1) vs 3.6 g/L (IQR 1.7-6.2)) levels vs the HIV-DIC cohort. Patients with HIV-DIC were more immunocompromised with frequent secondary infections, higher platelet and hemoglobin levels, more deranged coagulation parameters and less hemolysis. Overlap in scoring systems was however observed. CONCLUSION The laboratory parameter overlap between HIV-DIC and HIV-TTP might reflect a shared pathogenesis including endothelial dysfunction and inflammation and further research is required. Fibrinogen in DIC may be elevated as an acute phase reactant and D-dimers may reflect the extensive hemostatic activation in HIV-TTP. Inclusion of additional parameters in TMA scoring systems such the LDH/upper-limit-of-normal ratio, schistocytes count and wider access to ADAMTS-13 testing may enhance diagnostic accuracy and ensure appropriate utilization of plasma.
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Affiliation(s)
- Susan Louw
- Department of Molecular Medicine and Haematology, Faculty of Health SciencesUniversity of the Witwatersrand (Wits) and National Health Laboratory Service (NHLS)JohannesburgSouth Africa
| | - Barry Frank Jacobson
- Department of Molecular Medicine and Haematology, Faculty of Health SciencesUniversity of the Witwatersrand (Wits) and National Health Laboratory Service (NHLS)JohannesburgSouth Africa
| | - Elizabeth Sarah Mayne
- Division of Immunology, Department of Pathology, Faculty of Health SciencesUniversity of the Cape Town (UCT) and National Health Laboratory Service (NHLS)Cape TownSouth Africa
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Zhang Y, Deng X, Zhang J, Zhang L, Akram Z, Zhang B, Sun S. A Potential Driver of Disseminated Intravascular Coagulation in Heat Stroke Mice: Neutrophil Extracellular Traps. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12448. [PMID: 36231751 PMCID: PMC9566744 DOI: 10.3390/ijerph191912448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 09/25/2022] [Accepted: 09/26/2022] [Indexed: 06/16/2023]
Abstract
AIMS Disseminated intravascular coagulation (DIC) is a common complication of heat stroke (HS) patients, and it is one of the important reasons leading to multiple organ failure and even death. The association between neutrophil extracellular traps (NETs) and DIC is unclear in HS mice. METHODS AND RESULTS Here, HS was induced by the combination of hyperthermia (HT) and lipopolysaccharide (LPS). The DIC was evaluated by measuring prothrombin time (PT), D-dimer, thrombomodulin (TM), fibrinogen (FIB), and platelet (PLT). The expression of citrullinated-histone (CitH3) was analyzed by Western blotting. The formation of NETs was observed by immunofluorescence microscopy. The risk of HS-induced DIC was increased when HT was combined with LPS. The markers of NETs were significantly higher than those in the control group, and the NETs derived from HS promoted the development of DIC. DNase I improved coagulation dysfunction via the clearance of NETs caused by neutrophil aggregation. CONCLUSIONS Degradation of NETs reduced the risk of developing DIC, and thus the survival rate of mice was improved. These results indicate that NETs may hold potential alternative therapeutic strategies for the treatment of DIC in HS patients.
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Affiliation(s)
- Yuling Zhang
- Key Laboratory of Xinjiang Phytomedicine Resource and Utilization, Ministry of Education, Shihezi University, Shihezi 832000, China
- Key Laboratory for Green Processing of Chemical Engineering of Xinjiang Bingtuan, School of Chemistry and Chemical Engineering, Shihezi University, Shihezi 832000, China
| | - Xiling Deng
- Key Laboratory of Xinjiang Phytomedicine Resource and Utilization, Ministry of Education, Shihezi University, Shihezi 832000, China
| | - Jing Zhang
- Key Laboratory of Xinjiang Phytomedicine Resource and Utilization, Ministry of Education, Shihezi University, Shihezi 832000, China
- Key Laboratory for Green Processing of Chemical Engineering of Xinjiang Bingtuan, School of Chemistry and Chemical Engineering, Shihezi University, Shihezi 832000, China
| | - Liang Zhang
- Key Laboratory of Xinjiang Phytomedicine Resource and Utilization, Ministry of Education, Shihezi University, Shihezi 832000, China
| | - Zubair Akram
- Key Laboratory for Green Processing of Chemical Engineering of Xinjiang Bingtuan, School of Chemistry and Chemical Engineering, Shihezi University, Shihezi 832000, China
| | - Bo Zhang
- Key Laboratory of Xinjiang Phytomedicine Resource and Utilization, Ministry of Education, Shihezi University, Shihezi 832000, China
| | - Shiguo Sun
- Key Laboratory of Xinjiang Phytomedicine Resource and Utilization, Ministry of Education, Shihezi University, Shihezi 832000, China
- College of Chemistry and Pharmaceutical Engineering, Hebei University of Science and Technology, Shijiazhuang 050000, China
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31
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Assessment of COVID -19 associated coagulopathy and multiple hemostatic markers: a single center study in Egypt. Infection 2022; 51:655-664. [PMID: 36138306 PMCID: PMC9510359 DOI: 10.1007/s15010-022-01917-5] [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: 04/01/2022] [Accepted: 08/26/2022] [Indexed: 11/25/2022]
Abstract
Background Coagulopathy is still a serious pattern of coronavirus-19 disease. We aimed to evaluate COVID-19-associated coagulopathy and multiple hemostatic markers in Egyptian patients. In addition, to assess coagulation acute phase reactants and its effect on the outcome. Methods The study included 106 COVID-19 patients, and 51 controls. All patients were positive for COVID-19 infection by nasopharyngeal swab for detection of viral RNA by real-time PCR. In addition to baseline data and radiological findings, the coagulation profile was done with special attention to Fibrinogen, d-dimer, Factor VIII, von Willebrand factor (VWF), Protein C, Protein S, Antithrombin III (ATIII) and Lupus anticoagulant (LA)-1 and 2. Results The results showed significantly higher VWF, d-dimer, and LA1 (screening) and LA2 (confirmation) in patients than a control group. Significantly higher d-dimer FVIII, VWF and LA1-2 were detected in the severe group. ATIII had high diagnostic accuracy in severity prediction. We found a significantly higher international randomized ratio (INR) and VWF among patients with thrombotic events. For prediction of thrombosis; VWF at cutoff > 257.7 has 83.3% sensitivity and 83.3% specificity. Conclusion Patients with COVID-19 infection are vulnerable to different forms of coagulopathy. This could be associated with poor outcomes. d-Dimer is a chief tool in diagnosis, severity evaluation but not thrombosis prediction. Early screening for this complication and its proper management would improve the outcome.
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Wifi MN, Morad MA, El Sheemy R, Abdeen N, Afify S, Abdalgaber M, Abdellatef A, Zaghloul M, Alboraie M, El-Kassas M. Hemostatic system and COVID-19 crosstalk: A review of the available evidence. World J Methodol 2022; 12:331-349. [PMID: 36186748 PMCID: PMC9516549 DOI: 10.5662/wjm.v12.i5.331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 03/17/2022] [Accepted: 07/22/2022] [Indexed: 02/08/2023] Open
Abstract
Since the discovery of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its resultant coronavirus disease 2019 (COVID-19) pandemic, respiratory manifestations have been the mainstay of clinical diagnosis, laboratory evaluations, and radiological investigations. As time passed, other pathological aspects of SARS-CoV-2 have been revealed. Various hemostatic abnormalities have been reported since the rise of the pandemic, which was sometimes superficial, transient, or fatal. Mild thrombocytopenia, thrombocytosis, venous, arterial thromboembolism, and disseminated intravascular coagulation are among the many hemostatic events associated with COVID-19. Venous thromboembolism necessitating therapeutic doses of anticoagulants is more frequently seen in severe cases of COVID-19, especially in patients admitted to intensive care units. Hemorrhagic complications rarely arise in COVID-19 patients either due to a hemostatic imbalance resulting from severe disease or as a complication of over anticoagulation. Although the pathogenesis of coagulation disturbance in SARS-CoV-2 infection is not yet understood, professional societies recommend prophylactic antithrombotic therapy in severe cases, especially in the presence of abnormal coagulation indices. The review article discusses the various available evidence on coagulation disorders, management strategies, outcomes, and prognosis associated with COVID-19 coagulopathy, which raises awareness about the importance of anticoagulation therapy for COVID-19 patients to guard against possible thromboembolic events.
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Affiliation(s)
- Mohamed-Naguib Wifi
- Department of Internal Medicine, Hepatogastro- enterology Unit, Kasr Al-Ainy School of Medicine, Cairo University, Cairo 11451, Egypt
| | - Mohamed Abdelkader Morad
- Clinical Hematology Unit, Department of Internal Medicine, Kasr Al-Ainy, Faculty of Medicine, Cairo University, Cairo 11451, Egypt
| | - Reem El Sheemy
- Department of Tropical Medicine, Minia Faculty of Medicine, Minia University, Minia 61511, Egypt
| | - Nermeen Abdeen
- Department of Tropical Medicine, Faculty of Medicine, Alexandria University, Alexandria 21523, Egypt
| | - Shimaa Afify
- Department of Gastroenterology, National Hepatology and Tropical Medicine, National Hepatology and Tropical Medicine Research Institute, Cairo 11451, Egypt
| | - Mohammad Abdalgaber
- Department of Gastroenterology and Hepatology, Police Authority Hospital, Agoza, Giza 12511, Egypt
| | - Abeer Abdellatef
- Department of Internal Medicine, Hepatogastro- enterology Unit, Kasr Al-Ainy School of Medicine, Cairo University, Cairo 11451, Egypt
| | - Mariam Zaghloul
- Department of Hepatology, Gastroenterology and Infectious Diseases, Faculty of Medicine, Kafrelsheikh University, Kafrelsheikh 33511, Egypt
| | - Mohamed Alboraie
- Department of Internal Medicine, Al-Azhar University, Cairo 11884, Egypt
| | - Mohamed El-Kassas
- Department of Endemic Medicine, Faculty of Medicine, Helwan University, Helwan 11731, Egypt
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Xu X, Feng Y, Jia Y, Zhang X, Li L, Bai X, Jiao L. Prognostic value of von Willebrand factor and ADAMTS13 in patients with COVID-19: A systematic review and meta-analysis. Thromb Res 2022; 218:83-98. [PMID: 36027630 PMCID: PMC9385270 DOI: 10.1016/j.thromres.2022.08.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/14/2022] [Accepted: 08/15/2022] [Indexed: 11/17/2022]
Abstract
Background Endotheliopathy and coagulopathy appear to be the main causes for critical illness and death in patients with coronavirus disease 2019 (COVID-19). The adhesive ligand von Willebrand factor (VWF) has been involved in immunothrombosis responding to endothelial injury. Here, we reviewed the current literature and performed meta-analyses on the relationship between both VWF and its cleaving protease ADAMTS13 (a disintegrin and metalloproteinase with thrombospondin type 1 motif, member 13) with the prognosis of COVID-19. Methods We searched MEDLINE, Cochrane Library, Web of Science, and EMBASE databases from inception to 4 March 2022 for studies analyzing the relationship between VWF-related variables and composite clinical outcomes of patients with COVID-19. The VWF-related variables analyzed included VWF antigen (VWF:Ag), VWF ristocetin cofactor (VWF:Rco), ADAMTS13 activity (ADAMTS13:Ac), the ratio of VWF:Ag to ADAMTS13:Ac, and coagulation factor VIII (FVIII). The unfavorable outcomes were defined as mortality, intensive care unit (ICU) admission, and severe disease course. We used random or fixed effects models to create summary estimates of risk. Risk of bias was assessed based on the principle of the Newcastle-Ottawa Scale. Results A total of 3764 patients from 40 studies were included. The estimated pooled means indicated increased plasma levels of VWF:Ag, VWF:Rco, and VWF:Ag/ADAMTS13:Ac ratio, and decreased plasma levels of ADAMTS13:Ac in COVID-19 patients with unfavorable outcomes when compared to those with favorable outcomes (composite outcomes or subgroup analyses of non-survivor versus survivor, ICU versus non-ICU, and severe versus non-severe). In addition, FVIII were higher in COVID-19 patients with unfavorable outcomes. Subgroup analyses indicated that FVIII was higher in patients admitting to ICU, while there was no significant difference between non-survivors and survivors. Conclusions The imbalance of the VWF-ADAMTS13 axis (massive quantitative and qualitative increases of VWF with relative deficiency of ADAMTS13) is associated with poor prognosis of patients with COVID-19.
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Affiliation(s)
- Xin Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, China; China International Neuroscience Institute (China-INI), 45 Changchun Street, Beijing, China.
| | - Yao Feng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, China; China International Neuroscience Institute (China-INI), 45 Changchun Street, Beijing, China
| | - Yitong Jia
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, China
| | - Xiao Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, China; China International Neuroscience Institute (China-INI), 45 Changchun Street, Beijing, China
| | - Long Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, China; China International Neuroscience Institute (China-INI), 45 Changchun Street, Beijing, China
| | - Xuesong Bai
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, China; China International Neuroscience Institute (China-INI), 45 Changchun Street, Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, China; China International Neuroscience Institute (China-INI), 45 Changchun Street, Beijing, China; Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, China..
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Mori H, Kataoka Y, Harada-Shirado K, Kawano N, Hayakawa M, Seki Y, Uchiyama T, Yamakawa K, Ishikura H, Irie Y, Nishio K, Yada N, Okamoto K, Yamada S, Ikezoe T. Prognostic value of serum high mobility group box 1 protein and histone H3 levels in patients with disseminated intravascular coagulation: a multicenter prospective cohort study. Thromb J 2022; 20:33. [PMID: 35698137 PMCID: PMC9190102 DOI: 10.1186/s12959-022-00390-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 05/12/2022] [Indexed: 12/01/2022] Open
Abstract
Background We compared the prognostic value of serum high mobility group box 1 protein (HMGB1) and histone H3 levels with the International Society on Thrombosis and Haemostasis (ISTH) disseminated intravascular coagulation (DIC) scores for 28-day in-hospital mortality in patients with DIC caused by various underlying diseases. Methods We conducted a multicenter prospective cohort study including two hematology departments, four emergency departments, and one general medicine department in Japan, between August 2017 and July 2021. We included patients diagnosed with DIC by the ISTH DIC scoring system. Results Overall, 104 patients were included: 50 with hematopoietic disorders, 41 with infections, and 13 with the other diseases. The 28-day in-hospital mortality rate was 21%. The receiver operator characteristic (ROC) curve showed that a DIC score of 6 points, serum HMGB1 level of 8 ng/mL, and serum histone H3 level of 2 ng/mL were the optimal cutoff points. The odds ratios of more than these optimal cutoff points of the DIC score, serum HMGB1, and histone H3 levels were 1.58 (95% confidence interval [CI]: 0.60 to 4.17, p = 0.36), 5.47 (95% CI: 1.70 to 17.6, p = 0.004), and 9.07 (95% CI: 2.00 to 41.3, p = 0.004), respectively. The area under the ROC curve of HMGB1 (0.74, 95% CI: 0.63 to 0.85) was better than that of the ISTH DIC scores (0.55, 95% CI: 0.43 to 0.67, p = 0.03), whereas that of histone H3 was not (0.71, 95% CI: 0.60 to 0.82, p = 0.07). Calibration and net reclassification plots of HMGB1 identified some high-risk patients, whereas the ISTH DIC scores and histone H3 did not. The category-free net reclassification improvement of HMGB1 was 0.45 (95% CI: 0.01 to 0.90, p = 0.04) and that of histone H3 was 0.37 (95% CI: − 0.05 to 0.78, p = 0.08). Conclusions Serum HMGB1 levels have a prognostic value for mortality in patients with DIC. This finding may help physicians develop treatment strategies. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-022-00390-2.
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Affiliation(s)
- Hirotaka Mori
- Department of Hematology, Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1295, Japan.,Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan
| | - Yuki Kataoka
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan.,Department of Internal Medicine, Kyoto Min-Iren Asukai Hospital, 89 Tanaka Asukai-cho, Kyoto, 606-8226, Japan.,Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Sakyo-ku, Kyoto, 606-8501, Japan.,Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine/Public Health, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Kayo Harada-Shirado
- Department of Hematology, Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Noriaki Kawano
- Department of Hematology, Miyazaki Prefectural Miyazaki Hospital, 5-30 Kita Takamatsu-machi, Miyazaki, 880-8510, Japan
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, Kita-ku, Sapporo, Hokkaido, N14W5060-8648, Japan
| | - Yoshinobu Seki
- Department of Hematology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, 4132 Urasa, Minamiuonuma-shi, Niigata, 949-7302, Japan
| | - Toshimasa Uchiyama
- Department of Laboratory Medicine, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho, Takasaki, Gunma, 370-0829, Japan
| | - Kazuma Yamakawa
- Department of Emergency Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Hiroyasu Ishikura
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Yuhei Irie
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Kenji Nishio
- Department of General Medicine, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Noritaka Yada
- Department of General Medicine, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Kohji Okamoto
- Department of Surgery, Kitakyushu City Yahata Hospital, 2-6-2 Ogura Yahatahigashi-ku, Kitakyushu, Fukuoka, 805-8534, Japan
| | - Shingo Yamada
- Shino-Test Corporation, R&D Center, Sagamihara, 252-0331, Japan
| | - Takayuki Ikezoe
- Department of Hematology, Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1295, Japan.
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Arslan FD, Başok BI, Terzioğlu M, Altan TK, Karaca Y, Senger SS, Çolak A. Evaluation of D-dimer levels measured by different analytical methods in COVID-19 patients. Blood Coagul Fibrinolysis 2022; 33:209-215. [PMID: 35239616 DOI: 10.1097/mbc.0000000000001129] [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: 11/26/2022]
Abstract
Clinicians experience some challenges due to the lack of standardization of test, although D-dimer is a prognostic marker for COVID-19. We compared the clinical and analytical performances of D-dimer results obtained from different devices, kits and methods in patients with a diagnosis of COVID-19. Thirty-nine patients with a diagnosis of COVID-19 and 24 healthy individuals were included in the study. D-dimer levels were measured with Innovance D-DIMER kit (immunoturbidimetric method) on Sysmex CS-2500 and BCS XP and VIDAS D-Dimer Exclusion II kit (enzyme-linked fluorescence method) on mini VIDAS. The studies of precision, method comparison and clinic performance were performed. The variation coefficients in all systems were within the acceptable imprecision (7.8%). Bias%(12.5%) between BCS XP and Sysmex CS-2500 was lower than the acceptable Bias%(15.5%). Bias% values (19.2% and 33.3%, respectively) between Mini VIDAS with BCS XP and Sysmex CS-2500 were higher than the acceptable Bias%. The correlation coefficients among all systems were 0.89-0.98. For 500 ng/ml FEU, there was almost perfect agreement between BCS XP and Sysmex CS-2500, a moderate agreement between Mini VIDAS and BCS XP and Sysmex CS-2500. The cut-off values for distinguishing between individuals with and withoutCOVID-19 were Mini VIDAS, Sysmex CS-2500 and BCS XP 529, 380 and 390 ng/ml FEU, respectively. The immunoturbidimetric method can be used as an alternative to the enzyme-linked fluorescent method because of satisfactory agreement at the different thresholds proposed for venous thromboembolism. However, it is recommended to follow up COVID-19 with the D-dimer results obtained by the same assay system.
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Affiliation(s)
- Fatma Demet Arslan
- Department of Medical Biochemistry, University of Bakircay, School of Medicine
| | | | | | | | | | - Suheyla Serin Senger
- Department of Infectious Diseases and Clinical Microbiology, University of Health Sciences, Tepecik Training and Research Hospital, Izmir, Turkey
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Thrombotic thrombocytopenic purpura (TTP) in Human immunodeficiency virus (HIV) infected patients: New twists on an old disease. AIDS 2022; 36:1345-1354. [PMID: 35608117 DOI: 10.1097/qad.0000000000003257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Investigate the presence of inflammation, endothelial dysfunction and complement activation in patients with HIV-associated thrombotic thrombocytopenic purpura (HIV-TTP) to support the hypothesis that these processes probably contribute to the development of this thrombotic microangiopathy. DESIGN A prospective, investigational cohort study of 35 consecutive patients diagnosed with HIV-associated TTP presenting to three academic, tertiary care hospitals in Johannesburg, South Africa over 2 years. METHODS The patients with HIV-TTP received therapeutic plasma therapy and supportive treatment. Demographic data, the results of routine investigations and patient outcomes were recorded. Peripheral blood samples were collected prior to and on completion of plasma therapy and the following additional parameters were assessed at both time points: activity of the von Willebrand factor (VWF) cleaving protease, a-disintegrin-and-metalloproteinase-with-thrombospondin-motifs 13 (ADAMTS-13) and the presence of ADAMTS-13 autoantibodies, levels of pro-inflammatory cytokines, interleukin-6 and tumour necrosis factor-alpha, and two endothelial cell adhesion molecules. Complement activation was assessed by sequential measurement of C3 and C4 as well as levels of the complement inhibitor, factor H. RESULTS The inflammatory and endothelial activation markers were significantly (P < 0.001) elevated in the cohort of patients prior to plasma therapy compared with levels on discharge. Complement was activated and normalized with therapy. The ADAMTS-13 levels were reduced with significant auto-antibodies to this protease at presentation. CONCLUSION Inflammation in HIV mediates endothelial damage and complement activation. This study proposes that these processes are probably contributory to the development of HIV-TTP, which can therefore be characterized in part as a complementopathy, resembling TTP-like syndrome.
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Versluis J, Pandey M, Flamand Y, Haydu JE, Belizaire R, Faber M, Vedula RS, Charles A, Copson KM, Shimony S, Rozental A, Bendapudi PK, Wolach O, Griffiths EA, Thompson JE, Stone RM, DeAngelo DJ, Neuberg D, Luskin MR, Wang ES, Lindsley RC. Prediction of life-threatening and disabling bleeding in patients with AML receiving intensive induction chemotherapy. Blood Adv 2022; 6:2835-2846. [PMID: 35081257 PMCID: PMC9092400 DOI: 10.1182/bloodadvances.2021006166] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/11/2022] [Indexed: 11/20/2022] Open
Abstract
Bleeding in patients with acute myeloid leukemia (AML) receiving intensive induction chemotherapy is multifactorial and contributes to early death. We sought to define the incidence and risk factors of grade 4 bleeding to support strategies for risk mitigation. Bleeding events were retrospectively assessed between day-14 and day +60 of induction treatment according to the World Health Organization (WHO) bleeding assessment scale, which includes grade 4 bleeding as fatal, life-threatening, retinal with visual impairment, or involving the central nervous system. Predictors were considered pretreatment or prior to grade 4 bleeding. Using multivariable competing-risk regression analysis with grade 4 bleeding as the primary outcome, we identified risk factors in the development cohort (n = 341), which were tested in an independent cohort (n = 143). Grade 4 bleeding occurred in 5.9% and 9.8% of patients in the development and validation cohort, respectively. Risk factors that were independently associated with grade 4 bleeding included baseline platelet count ≤40 × 109/L compared with >40 × 109/L, and baseline international normalized ratio of prothrombin time (PT-INR) >1.5 or 1.3 > 1.5 compared with ≤1.3. These variables were allocated points, which allowed for stratification of patients with low- and high-risk for grade 4 bleeding. Cumulative incidence of grade 4 bleeding at day+60 was significantly higher among patients with high- vs low-risk (development: 31 ± 7% vs 2 ± 1%; P < .001; validation: 25 ± 9% vs 7 ± 2%; P = .008). In both cohorts, high bleeding risk was associated with disseminated intravascular coagulation (DIC) and proliferative disease. We developed and validated a simple risk model for grade 4 bleeding, which enables the development of rational risk mitigation strategies to improve early mortality of intensive induction treatment.
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Affiliation(s)
- Jurjen Versluis
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Manu Pandey
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Yael Flamand
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - J. Erika Haydu
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Roger Belizaire
- Division of Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Mark Faber
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Rahul S. Vedula
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Anne Charles
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Kevin M. Copson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Shai Shimony
- Institute of Hematology, Davidoff Cancer Centre, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel
- Sackler Medical School, Tel Aviv University, Tel Aviv, Israel; and
| | - Alon Rozental
- Institute of Hematology, Davidoff Cancer Centre, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel
- Sackler Medical School, Tel Aviv University, Tel Aviv, Israel; and
| | - Pavan K. Bendapudi
- Division of Hematology and Blood Transfusion Service, Massachusetts General Hospital, Boston, MA
| | - Ofir Wolach
- Institute of Hematology, Davidoff Cancer Centre, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel
- Sackler Medical School, Tel Aviv University, Tel Aviv, Israel; and
| | | | - James E. Thompson
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Richard M. Stone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Daniel J. DeAngelo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Donna Neuberg
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Marlise R. Luskin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Eunice S. Wang
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - R. Coleman Lindsley
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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Spring J, Munshi L. Hematology Emergencies in Critically Ill Adults. Chest 2022; 161:1285-1296. [DOI: 10.1016/j.chest.2021.12.650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/14/2021] [Accepted: 12/23/2021] [Indexed: 10/19/2022] Open
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Arslan E. COVID-19: A Cause of HELLP Syndrome? A Case Report. Int J Womens Health 2022; 14:617-623. [PMID: 35506047 PMCID: PMC9057225 DOI: 10.2147/ijwh.s362877] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/21/2022] [Indexed: 12/17/2022] Open
Abstract
Purpose There are still many unexplained points about how COVID-19 affects pregnant women and what kind of clinical and laboratory findings it reveals. These findings can become clinical conun drums when there is significant overlap with known and serious syndromes in pregnancy. The aim of this study is to report a case with a laboratory-proven diagnosis of COVID-19 and HELLP syndrome hypothesis. Case Presentation A 30-year-old multigravida (g3p2, repeated cesarean section) 32-week pregnant patient reported to the emergency service with complaints of chills, cough and shortness of breath that started 6 days ago. Following comprehensive screening tests for the differential diagnosis of lymphopenia, high liver enzymes, low platelets, abnormal coagulation panel, high D-dimer, high total bilirubin, high LDH and HELLP syndrome in the laboratory examinations of the patient, the patient's laboratory findings were evaluated as compatible with HELLP syndrome. Emergency cesarean section was performed on the patient because of maternal hypoxemia. The finalization of the microbiological diagnosis of COVID-19 resulted to start conventional COVID-19 treatment. The fetus was also confirmed to be positive for COVID-19, and the newborn died on the 5th postnatal day. Unfortunately, our mother patient died on the 10th day of her hospitalization. Conclusion This report describes a case of multigravida, 30 years old, who presented with respiratory tract infection symptoms and hypothesized HELLP syndrome, who later tested positive for the novel coronavirus. The distinction between these two etiologies and onset times is extremely difficult. However, given the sequence of events in this case, it is reasonable to consider that COVID-19 may be an etiological factor associated with the pathophysiology of HELLP, despite the lack of conclusive evidence.
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Affiliation(s)
- Ebubekir Arslan
- Mogadishu Somalia Turkish Training and Research Hospital, Mogadishu, 2526, Somalia
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Sridharan M, D Navitskas S, M Kock E, E Houghton D, M Heikal N, Chen D, K Pruthi R. Evaluation of soluble fibrin monomer complex in patients in SARS-CoV-2 COVID-19 infection-associated coagulopathy. Eur J Haematol 2022; 108:319-326. [PMID: 34921683 DOI: 10.1111/ejh.13738] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 11/29/2022]
Abstract
Hospitalized patients with COVID-19 infection frequently have coagulopathy resembling disseminated intravascular coagulation (DIC). An elevation of D-dimer level is associated with a poor prognosis; however, the role of other fibrin degradation products, such as soluble fibrin monomers (SFMC), is not known. The objective of the study was to investigate the frequency and prognostic role of elevated SFMC in patients with COVID-19. In this retrospective cohort study, patients hospitalized between April 1, 2020 and December 14, 2020 at Mayo Clinic with COVID-19 infection who underwent DIC panel testing were identified. Results of laboratory tests and outcomes (thrombosis and death) within 40 days of testing were obtained via medical record review. Of 108 patients, D-dimer was elevated in 82 (75.9%) patients. Of those with elevated D-dimer, SFMC was elevated in 19/82 (23%) patients. There were 16 thrombotic events and 16 deaths during the 40-day follow-up. The incidence of overt-DIC was 4.6%. In univariate analysis, D-dimer ≥5 x highest upper limit normal (ULN) and elevated SFMC were each associated with higher 40-day mortality. However, when used in combination with D-dimer ≥5 x highest ULN, an elevated SFMC provided no further mortality predictive value. Compared to 75.9% of patients with elevated D-dimers, of those tested, only 23% had elevated SFMC. These results support the hypothesis that elevated D-dimer in COVID-19 infection is a direct consequence of endothelial damage and not overt-DIC.
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Affiliation(s)
- Meera Sridharan
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Serena D Navitskas
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth M Kock
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Damon E Houghton
- Division of Cardiovascular Disease, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nahla M Heikal
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Dong Chen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Rajiv K Pruthi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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Maiorano S, Gulden-Sala W, Gerber B, Ghilardi G. Anti-PD-L1 monoclonal antibody for the management of chronic disseminated intravascular coagulation secondary to a urothelial carcinoma: a case report. J Med Case Rep 2022; 16:113. [PMID: 35307010 PMCID: PMC8935767 DOI: 10.1186/s13256-022-03338-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 02/18/2022] [Indexed: 01/23/2023] Open
Abstract
Background Thrombocytopenia is often considered a risk factor for bleeding, but conversely may be associated with an increased thrombotic risk in several clinical situations. Here we present a patient with arterial thrombosis and chronic disseminated intravascular coagulation caused by metastatic urothelial carcinoma. As the treatment for a disseminated intravascular coagulation caused by a neoplasia is the treatment of the underlying disease itself, our case highlights a new therapeutic approach—immunotherapy—in a patient prone to hematological complications due to conventional chemotherapy. Clinical case A 74-year-old Caucasian male patient with a history of urothelial carcinoma of the bladder and moderate thrombocytopenia had multiple arterial thrombotic events despite antiplatelet therapy and anticoagulation. A diagnosis of chronic disseminated intravascular coagulation in the setting of a metastatic bladder urothelial carcinoma was made. The patient was treated with an anti-PD-L1 monoclonal antibody, and achieved a rapid response with subsequent reversal of the disseminated intravascular coagulation. Conclusion Unexplained arterial or venous thrombosis despite adequate thromboprophylaxis should be investigated, especially in the setting of thrombocytopenia. Chronic disseminated intravascular coagulation is a possible, life-threatening reason for this clinical picture, and should prompt rapid identification of the underlying disease. To the best of our knowledge, this is the second case of chronic disseminated intravascular coagulation due to neoplastic disease treated with immunotherapy.
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Association between COVID-19 Diagnosis and Coronary Artery Thrombosis: A Narrative Review. Biomedicines 2022; 10:biomedicines10030702. [PMID: 35327504 PMCID: PMC8945192 DOI: 10.3390/biomedicines10030702] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/13/2022] [Accepted: 03/16/2022] [Indexed: 01/08/2023] Open
Abstract
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.
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Swan D, Thachil J. Management of haemostatic complications of chimaeric antigen receptor T-cell therapy. Br J Haematol 2022; 197:250-259. [PMID: 35146749 DOI: 10.1111/bjh.18045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 01/03/2022] [Accepted: 01/04/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Dawn Swan
- Department of Haematology, St James' Hospital, Dublin, Republic of Ireland
| | - Jecko Thachil
- Department of Haematology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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Marvi TK, Stubblefield WB, Tillman BF, Tenforde MW, Patel MM, Lindsell CJ, Self WH, Grijalva CG, Rice TW. Serial Thromboelastography and the Development of Venous Thromboembolism in Critically Ill Patients With COVID-19. Crit Care Explor 2022; 4:e0618. [PMID: 35072082 PMCID: PMC8769106 DOI: 10.1097/cce.0000000000000618] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
To test the hypothesis that relatively lower clot strength on thromboelastography maximum amplitude (MA) is associated with development of venous thromboembolism (VTE) in critically ill patients with COVID-19. DESIGN Prospective, observational cohort study. SETTING Tertiary care, academic medical center in Nashville, TN. PATIENTS Patients with acute respiratory failure from COVID-19 pneumonia admitted to the adult medical ICU without known VTE at enrollment. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Ninety-eight consecutive critically ill adults with laboratory-confirmed COVID-19 were enrolled. Thromboelastography parameters and conventional coagulation parameters were measured on days 0 (within 48 hr of ICU admission), 3, 5, and 7 after enrollment. The primary outcome was diagnosis of VTE with confirmed deep venous thrombosis and/or pulmonary embolism by clinical imaging or autopsy. Twenty-six patients developed a VTE. Multivariable regression controlling for antiplatelet exposure and anticoagulation dose with death as a competing risk found that lower MA was associated with increased risk of VTE. Each 1 mm increase in enrollment and peak MA was associated with an 8% and 14% decrease in the risk of VTE, respectively (enrollment MA: subdistribution hazard ratio [SHR], 0.92; 95% CI, 0.87-0.97; p = 0.003 and peak MA: SHR, 0.86; 95% CI, 0.81-0.91; p < 0.001). Lower enrollment platelet counts and fibrinogen levels were also associated with increased risk of VTE (p = 0.002 and p = 0.01, respectively). Platelet count and fibrinogen level were positively associated with MA (multivariable model: adjusted R 2 = 0.51; p < 0.001). CONCLUSIONS When controlling for the competing risk of death, lower enrollment and peak MA were associated with increased risk of VTE. Lower platelet counts and fibrinogen levels at enrollment were associated with increased risk of VTE. The association of diminished MA, platelet counts, and fibrinogen with VTE may suggest a relative consumptive coagulopathy in critically ill patients with COVID-19.
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Affiliation(s)
- Tanya K Marvi
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | | | - Benjamin F Tillman
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Mark W Tenforde
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA
| | - Manish M Patel
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, Nashville, TN
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
| | - Todd W Rice
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, Nashville, TN
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
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Coagulopatía en la infección por el virus SARS-CoV-2 (COVID-19): de los mecanismos fisiopatológicos al diagnóstico y tratamiento. ACTA COLOMBIANA DE CUIDADO INTENSIVO 2022. [PMCID: PMC7659516 DOI: 10.1016/j.acci.2020.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
La presencia de coagulopatía en pacientes con infección por COVID-19 se asocia con un mayor riesgo de muerte. Además, la relevancia de dichas anomalías de la coagulación se ha convertido en un factor determinante en el desenlace de los pacientes más enfermos, a medida que una proporción sustancial de pacientes con manifestaciones clínicas graves desarrollan complicaciones tromboembólicas venosas y arteriales, muchas veces no diagnosticadas sino hasta hallazgos post mortem. La evidencia disponible derivada de observaciones clínicas y series de autopsias distingue la coagulopatía asociada a COVID-19 de la microangiopatía trombótica y la coagulación intravascular diseminada (CID) (coagulopatía inducida por sepsis). Se pueden observar posibles superposiciones en pacientes críticos en los que el colapso circulatorio, la falla orgánica multisistémica, la hipoxemia refractaria y el síndrome de dificultad respiratoria aguda causan una combinación de CID de bajo grado y microangiopatía trombótica pulmonar localizada, que podría tener un impacto sustancial en la disfunción orgánica en los pacientes más gravemente afectados.
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Abstract
Fibrinogen plays a fundamental role in coagulation through its support for platelet aggregation and its conversion to fibrin. Fibrin stabilizes clots and serves as a scaffold and immune effector before being broken down by the fibrinolytic system. Given its importance, abnormalities in fibrin(ogen) and fibrinolysis result in a variety of disorders with hemorrhagic and thrombotic manifestations. This review summarizes (i) the basic elements of fibrin(ogen) and its role in coagulation and the fibrinolytic system; (ii) the laboratory evaluation for fibrin(ogen) disorders, including the use of global fibrinolysis assays; and (iii) the management of congenital and acquired disorders of fibrinogen and fibrinolysis.
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Affiliation(s)
- Jori E May
- Division of Hematology/Oncology, University of Alabama at Birmingham, 1720 2nd Avenue South, NP 2503, Birmingham, AL 35294, USA
| | - Alisa S Wolberg
- UNC Department of Pathology and Laboratory Medicine, UNC Blood Research Center, 8018A Mary Ellen Jones Building, CB7035, Chapel Hill, NC 27599-7035, USA
| | - Ming Yeong Lim
- Department of Internal Medicine, Division of Hematology and Hematologic Malignancies, University of Utah, 2000 Circle Hope Drive, Room 4126, Salt Lake City, UT 84112, USA.
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Incidence and risk factors associated with bleeding and thrombosis following chimeric antigen receptor T-cell therapy. Blood Adv 2021; 5:4465-4475. [PMID: 34521106 PMCID: PMC8579267 DOI: 10.1182/bloodadvances.2021004716] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/22/2021] [Indexed: 01/16/2023] Open
Abstract
Clinically significant bleeding occurred in 9% of patients after CAR T therapy and was associated with features of systemic coagulopathy. Low baseline platelets and possibly high-grade ICANS are risk factors for bleeding and require close monitoring for bleeding up to 1 month.
Bleeding and thrombotic events are an emerging toxicity associated with chimeric antigen receptor (CAR) therapies. To determine their incidence, we retrospectively analyzed consecutive adult patients (N = 127) with large B-cell lymphoma (LBCL) or B-cell acute lymphoblastic leukemia (B-ALL) treated from 2017 through 2020 with axicabtagene ciloleucel (axi-cel; n = 89) or a bispecific CD19/CD22 CAR (n = 38). Twelve (9.4%) and 8 (6.3%) patients developed bleeding and thrombosis within the first 3 months, respectively. In the axi-cel subgroup, these occurred in 11.2% and 6.7%, respectively. Bleeding occurred between days 8 and 30 (median, 17.5) and thrombosis between days 2 and 91 (median, 29). Bleeding sites included genitourinary, soft tissue, intracranial, gastrointestinal, and pulmonary and were associated with features of consumptive coagulopathy. On univariate analysis, patients with bleeding were older, had lower baseline platelets (86 × 103/μL vs 178 × 103/μL; P < .01), lower platelet and fibrinogen nadirs , and elevated lactate dehydrogenase. Immune effector cell (IEC)–associated neurotoxicity syndrome (ICANS) grade ≥3 was associated with increased bleeding (50% vs 15%; P = .01), thrombosis (50% vs 16%; P = .04), prothrombin time prolongation, hypofibrinogenemia, and elevated D-dimer. Low pretreatment platelet counts were associated with bleeding in a multivariate logistic regression model. Patients with thrombocytopenia or severe ICANS are at increased risk of bleeding and should be closely monitored, particularly within the first month after CAR therapy. Future studies in larger cohorts should assess risk factors for systemic coagulopathies in CAR T therapy, including their association with neurotoxicity.
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Singh S, Pandey R, Tomar S, Varshney R, Sharma D, Gangenahalli G. A brief molecular insight of COVID-19: epidemiology, clinical manifestation, molecular mechanism, cellular tropism and immuno-pathogenesis. Mol Cell Biochem 2021; 476:3987-4002. [PMID: 34195882 PMCID: PMC8244678 DOI: 10.1007/s11010-021-04217-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 06/23/2021] [Indexed: 02/06/2023]
Abstract
In December 2019, the emergence and expansion of novel and infectious respiratory virus SARS-CoV-2 originated from Wuhan, China caused an unprecedented threat to the public health and became a global pandemic. SARS-CoV-2 is an enveloped, positive sense and single stranded RNA virus belonging to genera betacoronavirus, of Coronaviridae family. The viral genome sequencing studies revealed 75-80% similarity with SARS-CoV. SARS-CoV-2 mainly affects the lower respiratory system and may progress to pneumonia and Acute Respiratory Distress Syndrome (ARDS). Apart from life-threatening situations and burden on the global healthcare system, the COVID-19 pandemic has imposed several challenges on the worldwide economics and livelihood. The novel pathogen is highly virulent, rapidly mutating and has a tendency to cross the species boundaries such as from bats to humans through the evolution and natural selection from intermediate host. In this review we tried to summarize the overall picture of SARS-CoV-2 including origin/ emergence, epidemiology, pathogenesis, genome organization, comparative analysis with other CoVs, infection and replication mechanism along with cellular tropism and immunopathogenesis which will provide a brief panoramic view about the virus and disease.
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Affiliation(s)
- Sweta Singh
- Division of Stem Cell and Gene Therapy, Institute of Nuclear Medicine and Allied Sciences, Brig. S. K. Mazumdar Road, Delhi, 110054, India
| | - Rakesh Pandey
- Division of Stem Cell and Gene Therapy, Institute of Nuclear Medicine and Allied Sciences, Brig. S. K. Mazumdar Road, Delhi, 110054, India
| | - Sarika Tomar
- Division of Stem Cell and Gene Therapy, Institute of Nuclear Medicine and Allied Sciences, Brig. S. K. Mazumdar Road, Delhi, 110054, India
| | - Raunak Varshney
- Division of Cyclotron and Radiopharmaceutical Sciences, Institute of Nuclear Medicine and Allied Sciences, Brig. S. K. Mazumdar Road, Delhi, 110054, India
| | - Darshika Sharma
- Division of Stem Cell and Gene Therapy, Institute of Nuclear Medicine and Allied Sciences, Brig. S. K. Mazumdar Road, Delhi, 110054, India
- Meerut Institute of Engineering and Technology, Meerut, India
| | - Gurudutta Gangenahalli
- Division of Stem Cell and Gene Therapy, Institute of Nuclear Medicine and Allied Sciences, Brig. S. K. Mazumdar Road, Delhi, 110054, India.
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Ullah I, Sohail A, Shah MUFA, Khurshid M, Diwan MN, Qadir A, Irfan M. Central Retinal Vein Occlusion in patients with COVID-19 infection: A systematic review. Ann Med Surg (Lond) 2021; 71:102898. [PMID: 34659743 PMCID: PMC8500694 DOI: 10.1016/j.amsu.2021.102898] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 12/12/2022] Open
Abstract
This systematic review summarizes the evidence on patients diagnosed with central retinal vein occlusion (CRVO) secondary to COVID-19. We searched PubMed and Google Scholar from its inception till June 2021. From an initial 55 publications, 10 studies provided specific information on COVID-19 patients with CRVO. Studies described 10 patients, 60% were male and the mean age was 39.3 ± 11.6 years. Blurred vision (40%) and decreased vision (50%) were the most common presenting complain. Symptom onset ranged from 5 days to 6 weeks after initial complaint of fever. Laboratory results showed elevated inflammatory markers and D-dimers in 60% of patients included in our review. Common treatment options were intravitreal anti-VEGF injections, steroids, and anticoagulants. Traditional co-morbidities like diabetes mellites, hypertension, and morbid obesity (hyperlipidemia) were observed in only 3/10 patients. The prognosis was excellent as all patients saw improvement in their condition. Our findings highlight the importance of identifying CRVO as an important complication of COVID-19 infection. Thus, physicians should not overlook the likelihood of CRVO in patients with COVID-19 infection and offer prompt treatment.
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Affiliation(s)
- Irfan Ullah
- Kabir Medical College, Gandhara University, Peshawar, 25000, Pakistan
| | - Aruba Sohail
- Dow University of Health Science, Karachi, Pakistan
| | | | | | | | - Abdul Qadir
- Internal Medicine, Khyber Medical College, Peshawar, Pakistan
| | - Muhammad Irfan
- Internal Medicine, Hayatabad Medical Complex, Peshawar, Pakistan
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Cellular and molecular mechanisms in COVID-19 coagulopathy: role of inflammation and endotheliopathy. J Thromb Thrombolysis 2021; 53:282-290. [PMID: 34687400 PMCID: PMC8536904 DOI: 10.1007/s11239-021-02583-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2021] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Coronavirus 2 (CoV-2) infection or coronavirus disease 2019 (COVID-19) is frequently associated with microvascular thrombosis.The microthrombosis in COVID-19 is the result of the interplay between inflammation and endotheliopathy. Elevated interleukin-6 (IL-6) characterizes COVID-19 inflammation resulting in endotheliopathy and coagulopathy marked by elevated D-dimer (DD). Aim of this study is to identify and to describe the coagulation changes in 100 moderate COVID-19 patients having lung involvement and to determine the association of coagulopathy with the severity and prognosis. METHODS Inflammation, endothelial and coagulation molecules were measured in moderate and mild disease. RESULTS IL-6 and tumor necrosis factor-α (TNF-α) and tissue factor (TF), von Willebrand factor (VWF), and tissue factor pathway inhibitor (TFPI) significantly increased in moderate disease as well as D-dimer, thrombin antithrombin complex (TAT), Fibrinogen (Fib), platelet factor-4 (PF4), β-thromboglobulin (β-TG), P-selectin, and platelet adhesion. Shortened clotting time (CT) and clot formation time (CFT), high maximum clot firmness (MCF) and low LY at 30 min were present in 100% of moderate COVID-19 patients compared with mild COVID-19 patients. CONCLUSIONS These findings demonstrate that moderate COVID-19 has a profound inflammation associated with severee ndotheliopathy and intense coagulation activation uncontrolled by TFPI. Attention should be paid to coagulopathy in COVID-19. Closely monitoring of coagulation and application of appropriate anticoagulation may improve the prognosis of moderate COVID-19 and to prevent the progression to severe COVID-19 disease.
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