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Li Z, Zeng M, Wu T, Wang Z, Sun Y, Zhang Z, Wu F, Chen Z, Fu M, Meng F. Causal Effects of COVID-19 on the Risk of Thrombosis: A Two-Sample Mendel Randomization Study. Thromb Haemost 2024; 124:709-720. [PMID: 38325400 PMCID: PMC11259497 DOI: 10.1055/a-2263-8514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 11/17/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) and thrombosis are linked, but the biomolecular mechanism is unclear. We aimed to investigate the causal relationship between COVID-19 and thrombotic biomarkers. METHODS We used two-sample Mendelian randomization (MR) to assess the effect of COVID-19 on 20 thrombotic biomarkers. We estimated causality using inverse variance weighting with multiplicative random effect, and performed sensitivity analysis using weighted median, MR-Egger regression and MR Pleiotropy Residual Sum and Outlier (MR-PRESSO) methods. All the results were examined by false discovery rate (FDR) with the Benjamin and Hochberg method for this correction to minimize false positives. We used R language for the analysis. RESULTS All COVID-19 classes showed lower levels of tissue factor pathway inhibitor (TFPI) and interleukin-1 receptor type 1 (IL-1R1). COVID-19 significantly reduced TFPI (odds ratio [OR] = 0.639, 95% confidence interval [CI]: 0.435-0.938) and IL-1R1 (OR = 0.603, 95% CI = 0.417-0.872), nearly doubling the odds. We also found that COVID-19 lowered multiple coagulation factor deficiency protein 2 and increased C-C motif chemokine 3. Hospitalized COVID-19 cases had less plasminogen activator, tissue type (tPA) and P-selectin glycoprotein ligand 1 (PSGL-1), while severe cases had higher mean platelet volume (MPV) and lower platelet count. These changes in TFPI, tPA, IL-1R1, MPV, and platelet count suggested a higher risk of thrombosis. Decreased PSGL-1 indicated a lower risk of thrombosis. CONCLUSION TFPI, IL-1R, and seven other indicators provide causal clues of the pathogenesis of COVID-19 and thrombosis. This study demonstrated that COVID-19 causally influences thrombosis at the biomolecular level.
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Affiliation(s)
- Zhengran Li
- The Second Clinical Medicine School, Southern Medical University, Guangzhou, Guangdong, China
- Department of Ophthalmology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Minghui Zeng
- Institute of Scientific Research, Southern Medical University, Guangzhou, China
| | - Tong Wu
- The First Clinical Medicine School, Southern Medical University, Guangzhou, Guangdong, China
| | - Zijin Wang
- The Second Clinical Medicine School, Southern Medical University, Guangzhou, Guangdong, China
| | - Yuxin Sun
- The Second Clinical Medicine School, Southern Medical University, Guangzhou, Guangdong, China
| | - Ziran Zhang
- The Second Clinical Medicine School, Southern Medical University, Guangzhou, Guangdong, China
| | - Fanye Wu
- The Second Clinical Medicine School, Southern Medical University, Guangzhou, Guangdong, China
| | - Zejun Chen
- The Second Clinical Medicine School, Southern Medical University, Guangzhou, Guangdong, China
| | - Min Fu
- Department of Ophthalmology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Fanke Meng
- Emergency Department, Zhujiang Hospital of Southern Medical University, Guangzhou, China
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2
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Fu Y, Xue H, Wang T, Ding Y, Cui Y, Nie H. Fibrinolytic system and COVID-19: From an innovative view of epithelial ion transport. Biomed Pharmacother 2023; 163:114863. [PMID: 37172333 PMCID: PMC10169260 DOI: 10.1016/j.biopha.2023.114863] [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: 03/13/2023] [Revised: 05/05/2023] [Accepted: 05/06/2023] [Indexed: 05/14/2023] Open
Abstract
Lifeways of worldwide people have changed dramatically amid the coronavirus disease 2019 (COVID-19) pandemic, and public health is at stake currently. In the early stage of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, fibrinolytic system is mostly inhibited, which is responsible for the development of hypofibrinolysis, promoting disseminated intravascular coagulation, hyaline membrane formation, and pulmonary edema. Whereas the common feature and risk factor at advanced stage is a large amount of fibrin degradation products, including D-dimer, the characteristic of hyperfibrinolysis. Plasmin can cleave both SARS-CoV-2 spike protein and γ subunit of epithelial sodium channel (ENaC), a critical element to edematous fluid clearance. In this review, we aim to sort out the role of fibrinolytic system in the pathogenesis of COVID-19, as well as provide the possible guidance in current treating methods. In addition, the abnormal regulation of ENaC in the occurrence of SARS-CoV-2 mediated hypofibrinolysis and hyperfibrinolysis are summarized, with the view of proposing an innovative view of epithelial ion transport in preventing the dysfunction of fibrinolytic system during the progress of COVID-19.
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Affiliation(s)
- Yunmei Fu
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang 110122, China
| | - Hao Xue
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang 110122, China
| | - Tingyu Wang
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang 110122, China
| | - Yan Ding
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang 110122, China
| | - Yong Cui
- Department of Anesthesiology, the First Hospital of China Medical University, Shenyang 110001, China.
| | - Hongguang Nie
- Department of Stem Cells and Regenerative Medicine, College of Basic Medical Science, China Medical University, Shenyang 110122, China.
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3
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Amini S, Rezabakhsh A, Hashemi J, Saghafi F, Azizi H, Sureda A, Habtemariam S, Khayat Kashani HR, Hesari Z, Sahebnasagh A. Pharmacotherapy consideration of thrombolytic medications in COVID-19-associated ARDS. J Intensive Care 2022; 10:38. [PMID: 35908022 PMCID: PMC9338522 DOI: 10.1186/s40560-022-00625-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 06/22/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND In late 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which is responsible for coronavirus disease (COVID-19), was identified as the new pathogen to lead pneumonia in Wuhan, China, which has spread all over the world and developed into a pandemic. Despite the over 1 year of pandemic, due to the lack of an effective treatment plan, the morbidity and mortality of COVID-19 remains high. Efforts are underway to find the optimal management for this viral disease. MAIN BODY SARS-CoV-2 could simultaneously affect multiple organs with variable degrees of severity, from mild to critical disease. Overproduction of pro-inflammatory mediators, exacerbated cellular and humoral immune responses, and coagulopathy such as Pulmonary Intravascular Coagulopathy (PIC) contributes to cell injuries. Considering the pathophysiology of the disease and multiple microthrombi developments in COVID-19, thrombolytic medications seem to play a role in the management of the disease. Beyond the anticoagulation, the exact role of thrombolytic medications in the management of patients with COVID-19-associated acute respiratory distress syndrome (ARDS) is not explicit. This review focuses on current progress in underlying mechanisms of COVID-19-associated pulmonary intravascular coagulopathy, the historical use of thrombolytic drugs in the management of ARDS, and pharmacotherapy considerations of thrombolytic therapy, their possible benefits, and pitfalls in COVID-19-associated ARDS. CONCLUSIONS Inhaled or intravenous administration of thrombolytics appears to be a salvage therapy for severe ARDS associated with COVID-19 by prompt attenuation of lung injury. Considering the pathogenesis of COVID-19-related ARDS and mechanism of action of thrombolytic agents, thrombolytics appear attractive options in stable patients without contraindications.
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Affiliation(s)
- Shahideh Amini
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Aysa Rezabakhsh
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Javad Hashemi
- Department of Pathobiology and Laboratory Sciences, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Fatemeh Saghafi
- Department of Clinical Pharmacy, Faculty of Pharmacy and Pharmaceutical Sciences Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Hossein Azizi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Antoni Sureda
- Research Group On Community Nutrition and Oxidative Stress, University of the Balearic Islands, Palma, Spain.,CIBEROBN (Physiopathology of Obesity and Nutrition CB12/03/30038), Instituto de Salud Carlos III, Madrid, Spain
| | - Solomon Habtemariam
- Pharmacognosy Research Laboratories and Herbal Analysis Services, University of Greenwich, Central Avenue, Chatham-Maritime, Kent, ME4 4TB, UK
| | | | - Zahra Hesari
- Laboratory Sciences Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | - Adeleh Sahebnasagh
- Clinical Research Center, Department of Internal Medicine, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran.
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4
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Coagulopathy and Fibrinolytic Pathophysiology in COVID-19 and SARS-CoV-2 Vaccination. Int J Mol Sci 2022; 23:ijms23063338. [PMID: 35328761 PMCID: PMC8955234 DOI: 10.3390/ijms23063338] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 03/03/2022] [Accepted: 03/15/2022] [Indexed: 02/06/2023] Open
Abstract
Coronavirus Disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is frequently complicated by thrombosis. In some cases of severe COVID-19, fibrinolysis may be markedly enhanced within a few days, resulting in fatal bleeding. In the treatment of COVID-19, attention should be paid to both coagulation activation and fibrinolytic activation. Various thromboses are known to occur after vaccination with SARS-CoV-2 vaccines. Vaccine-induced immune thrombotic thrombocytopenia (VITT) can occur after adenovirus-vectored vaccination, and is characterized by the detection of anti-platelet factor 4 antibodies by enzyme-linked immunosorbent assay and thrombosis in unusual locations such as cerebral venous sinuses and visceral veins. Treatment comprises high-dose immunoglobulin, argatroban, and fondaparinux. Some VITT cases show marked decreases in fibrinogen and platelets and marked increases in D-dimer, suggesting the presence of enhanced-fibrinolytic-type disseminated intravascular coagulation with a high risk of bleeding. In the treatment of VITT, evaluation of both coagulation activation and fibrinolytic activation is important, adjusting treatments accordingly to improve outcomes.
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5
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Khandelwal G, Ray A, Sethi S, Harikrishnan HK, Khandelwal C, Sadasivam B. COVID-19 and thrombotic complications-the role of anticoagulants, antiplatelets and thrombolytics. J Family Med Prim Care 2021; 10:3561-3567. [PMID: 34934647 PMCID: PMC8653484 DOI: 10.4103/jfmpc.jfmpc_1297_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/13/2020] [Accepted: 07/09/2021] [Indexed: 01/08/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is a global pandemic the world is dealing with currently. Clinical evidences suggest that the patients are predisposed to both venous and arterial thrombotic complications. This is because of severe inflammatory responses, injury to endothelium and activation of platelets leading to increased coagulation. Additionally, individuals who are already receiving antithrombotic drug therapy for various cardiovascular diseases and complications might contract the disease in which case, attention should be given to the choice and duration of the therapy besides close monitoring of biochemical blood parameters. Herein, we review the incidences of thrombotic complications and their outcomes in COVID-19 patients as reported till date, while understanding the prophylactic and therapeutic roles of anticoagulants, antiplatelets and thrombolytics in the management of this severe viral respiratory illness.
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Affiliation(s)
- Gaurav Khandelwal
- Department of Cardiology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Avik Ray
- Department of Pharmacology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Samdish Sethi
- Department of Medicine, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - H K Harikrishnan
- Department of Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Chaitanya Khandelwal
- Department of Medicine, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Balakrishnan Sadasivam
- Department of Pharmacology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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6
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Cioni P, Gabellieri E, Campanini B, Bettati S, Raboni S. Use of Exogenous Enzymes in Human Therapy: Approved Drugs and Potential Applications. Curr Med Chem 2021; 29:411-452. [PMID: 34259137 DOI: 10.2174/0929867328666210713094722] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/05/2021] [Accepted: 03/17/2021] [Indexed: 11/22/2022]
Abstract
The development of safe and efficacious enzyme-based human therapies has increased greatly in the last decades, thanks to remarkable advances in the understanding of the molecular mechanisms responsible for different diseases, and the characterization of the catalytic activity of relevant exogenous enzymes that may play a remedial effect in the treatment of such pathologies. Several enzyme-based biotherapeutics have been approved by FDA (the U.S. Food and Drug Administration) and EMA (the European Medicines Agency) and many are undergoing clinical trials. Apart from enzyme replacement therapy in human genetic diseases, which is not discussed in this review, approved enzymes for human therapy find applications in several fields, from cancer therapy to thrombolysis and the treatment, e.g., of clotting disorders, cystic fibrosis, lactose intolerance and collagen-based disorders. The majority of therapeutic enzymes are of microbial origin, the most convenient source due to fast, simple and cost-effective production and manipulation. The use of microbial recombinant enzymes has broadened prospects for human therapy but some hurdles such as high immunogenicity, protein instability, short half-life and low substrate affinity, still need to be tackled. Alternative sources of enzymes, with reduced side effects and improved activity, as well as genetic modification of the enzymes and novel delivery systems are constantly searched. Chemical modification strategies, targeted- and/or nanocarrier-mediated delivery, directed evolution and site-specific mutagenesis, fusion proteins generated by genetic manipulation are the most explored tools to reduce toxicity and improve bioavailability and cellular targeting. This review provides a description of exogenous enzymes that are presently employed for the therapeutic management of human diseases with their current FDA/EMA-approved status, along with those already experimented at the clinical level and potential promising candidates.
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Affiliation(s)
- Patrizia Cioni
- Institute of Biophysics, National Research Council, Via Moruzzi 1, 56124 Pisa. Italy
| | - Edi Gabellieri
- Institute of Biophysics, National Research Council, Via Moruzzi 1, 56124 Pisa. Italy
| | - Barbara Campanini
- Department of Food and Drug, University of Parma, Parco Area delle Scienze 23/A, 43124 Parma. Italy
| | - Stefano Bettati
- Institute of Biophysics, National Research Council, Via Moruzzi 1, 56124 Pisa. Italy
| | - Samanta Raboni
- Institute of Biophysics, National Research Council, Via Moruzzi 1, 56124 Pisa. Italy
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7
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Xu K, Wei Y, Giunta S, Zhou M, Xia S. Do inflammaging and coagul-aging play a role as conditions contributing to the co-occurrence of the severe hyper-inflammatory state and deadly coagulopathy during COVID-19 in older people? Exp Gerontol 2021; 151:111423. [PMID: 34048906 PMCID: PMC8149167 DOI: 10.1016/j.exger.2021.111423] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 05/22/2021] [Accepted: 05/24/2021] [Indexed: 12/19/2022]
Abstract
The coronavirus disease 2019 (COVID-19) is a new infectious respiratory disease, which has caused a pandemic that has become the world's leading public health emergency, threatening people of all ages worldwide, especially the elderly. Complications of COVID-19 are closely related to an upregulation of the inflammatory response revealed by the pro-inflammatory profile of plasma cytokines (to the point of causing a cytokine storm), which is also a contributing cause of the associated coagulation disorders with venous and arterial thromboembolisms, causing multiple organ dysfunction and failure. In severe fulminant cases of COVID-19, there is an activation of coagulation and consumption of clotting factors leading to a deadly disseminated intravascular coagulation (DIC). It is well established that human immune response changes with age, and also that the pro-inflammatory profile of plasma cytokines is upregulated in both healthy and diseased elderly people. In fact, normal aging is known to be associated with a subclinical, sterile, low-grade, systemic pro-inflammatory state linked to the chronic activation of the innate immune system, a phenomenon known as “inflammaging”. Inflammaging may play a role as a condition contributing to the co-occurrence of the severe hyper-inflammatory state (cytokine storm) during COVID-19, and also in other severe infections (sepsis) in older people. Moreover, we must consider the impact of inflammation on coagulation due to the crosstalk between inflammation and coagulation. The systemic inflammatory state and coagulation disorders are closely related, a phenomenon that here we call “coagul-aging” (Giunta S.). In this review, we discuss the various degrees of inflammation in older adults after being infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the adverse effects of aging on the inflammatory response and coagulation system. It is important to note that although there is no gender difference in susceptibility to COVID-19 infection, however, due to differences in angiotensin-converting enzyme 2 (ACE2) expression, innate immunity, and comorbidities, older men exhibit more severe disease and higher mortality than older women. There are currently no FDA-approved specific antiviral drugs that can be used against the virus. Therapies used in patients with COVID-19 consist of remdesivir, dexamethasone, low-molecular-weight heparin, in addition to monoclonal antibodies against the spike protein of SARS-CoV-2 in the early phase of the disease. Future pharmacological research should also consider targeting the possible role of the underlying scenario of inflammaging in healthy older people to prevent or mitigate disease complications. It is worth mentioning that some specific cytokine antagonists and traditional Chinese medicine preparations can reduce the elderly's inflammatory state.
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Affiliation(s)
- Kangqiao Xu
- Department of Geriatrics, Shanghai Institute of Geriatrics, Huadong Hospital, Fudan University, Shanghai, PR China.
| | - Yaqin Wei
- Department of Geriatrics, Shanghai Institute of Geriatrics, Huadong Hospital, Fudan University, Shanghai, PR China; School of Clinical Medicine, Bengbu Medical College, Bengbu, PR China
| | - Sergio Giunta
- Casa di Cura Prof. Nobili-GHC Garofalo Health Care, Bologna, Italy
| | - Min Zhou
- Department of Respiratory Diseases, Jinshan Branch of the Sixth People's Hospital of Shanghai, Shanghai Jiaotong University, Shanghai, PR China.
| | - Shijin Xia
- Department of Geriatrics, Shanghai Institute of Geriatrics, Huadong Hospital, Fudan University, Shanghai, PR China.
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8
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Lanspa MJ, Peltan ID. Do the Right Thing. Chest 2021; 158:442-443. [PMID: 32768058 PMCID: PMC7399662 DOI: 10.1016/j.chest.2020.05.550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 05/10/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Michael J Lanspa
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center; and the Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, University of Utah, Murray, UT.
| | - Ithan D Peltan
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center; and the Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, University of Utah, Murray, UT
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9
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Li X, Zhong X, Wang Y, Zeng X, Luo T, Liu Q. Clinical determinants of the severity of COVID-19: A systematic review and meta-analysis. PLoS One 2021; 16:e0250602. [PMID: 33939733 PMCID: PMC8092779 DOI: 10.1371/journal.pone.0250602] [Citation(s) in RCA: 99] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 04/11/2021] [Indexed: 01/08/2023] Open
Abstract
Objective We aimed to systematically identify the possible risk factors responsible for severe cases. Methods We searched PubMed, Embase, Web of science and Cochrane Library for epidemiological studies of confirmed COVID-19, which include information about clinical characteristics and severity of patients’ disease. We analyzed the potential associations between clinical characteristics and severe cases. Results We identified a total of 41 eligible studies including 21060 patients with COVID-19. Severe cases were potentially associated with advanced age (Standard Mean Difference (SMD) = 1.73, 95% CI: 1.34–2.12), male gender (Odds Ratio (OR) = 1.51, 95% CI:1.33–1.71), obesity (OR = 1.89, 95% CI: 1.44–2.46), history of smoking (OR = 1.40, 95% CI:1.06–1.85), hypertension (OR = 2.42, 95% CI: 2.03–2.88), diabetes (OR = 2.40, 95% CI: 1.98–2.91), coronary heart disease (OR: 2.87, 95% CI: 2.22–3.71), chronic kidney disease (CKD) (OR = 2.97, 95% CI: 1.63–5.41), cerebrovascular disease (OR = 2.47, 95% CI: 1.54–3.97), chronic obstructive pulmonary disease (COPD) (OR = 2.88, 95% CI: 1.89–4.38), malignancy (OR = 2.60, 95% CI: 2.00–3.40), and chronic liver disease (OR = 1.51, 95% CI: 1.06–2.17). Acute respiratory distress syndrome (ARDS) (OR = 39.59, 95% CI: 19.99–78.41), shock (OR = 21.50, 95% CI: 10.49–44.06) and acute kidney injury (AKI) (OR = 8.84, 95% CI: 4.34–18.00) were most likely to prevent recovery. In summary, patients with severe conditions had a higher rate of comorbidities and complications than patients with non-severe conditions. Conclusion Patients who were male, with advanced age, obesity, a history of smoking, hypertension, diabetes, malignancy, coronary heart disease, hypertension, chronic liver disease, COPD, or CKD are more likely to develop severe COVID-19 symptoms. ARDS, shock and AKI were thought to be the main hinderances to recovery.
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Affiliation(s)
- Xinyang Li
- School of Stomatology, Wuhan University, Wuhan, Hubei, China
| | - Xianrui Zhong
- Department of Computer Science, University of Illinois at Urbana-Champaign, Champaign, Illinois, United States of America
| | - Yongbo Wang
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xiantao Zeng
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Ting Luo
- School of Stomatology, Wuhan University, Wuhan, Hubei, China
| | - Qing Liu
- Department of Epidemiology and Health Statistics, School of Health Sciences, Wuhan University, Wuhan, Hubei, China
- * E-mail:
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10
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Meizoso JP, Moore HB, Moore EE. Fibrinolysis Shutdown in COVID-19: Clinical Manifestations, Molecular Mechanisms, and Therapeutic Implications. J Am Coll Surg 2021; 232:995-1003. [PMID: 33766727 PMCID: PMC7982779 DOI: 10.1016/j.jamcollsurg.2021.02.019] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 02/06/2023]
Abstract
The COVID-19 pandemic has introduced a global public health threat unparalleled in our history. The most severe cases are marked by ARDS attributed to microvascular thrombosis. Hypercoagulability, resulting in a profoundly prothrombotic state, is a distinct feature of COVID-19 and is accentuated by a high incidence of fibrinolysis shutdown. The aims of this review were to describe the manifestations of fibrinolysis shutdown in COVID-19 and its associated outcomes, review the molecular mechanisms of dysregulated fibrinolysis associated with COVID-19, and discuss potential implications and therapeutic targets for patients with severe COVID-19.
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Affiliation(s)
- Jonathan P Meizoso
- Ernest E Moore Shock Trauma Center, Denver Health Medical Center, University of Colorado, Denver, CO.
| | - Hunter B Moore
- Division of Transplant Surgery, University of Colorado, Denver, CO
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center, Denver Health Medical Center, University of Colorado, Denver, CO
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11
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Kwaan HC, Lindholm PF. The Central Role of Fibrinolytic Response in COVID-19-A Hematologist's Perspective. Int J Mol Sci 2021; 22:1283. [PMID: 33525440 PMCID: PMC7919196 DOI: 10.3390/ijms22031283] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 01/26/2021] [Accepted: 01/26/2021] [Indexed: 01/08/2023] Open
Abstract
The novel coronavirus disease (COVID-19) has many characteristics common to those in two other coronavirus acute respiratory diseases, severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). They are all highly contagious and have severe pulmonary complications. Clinically, patients with COVID-19 run a rapidly progressive course of an acute respiratory tract infection with fever, sore throat, cough, headache and fatigue, complicated by severe pneumonia often leading to acute respiratory distress syndrome (ARDS). The infection also involves other organs throughout the body. In all three viral illnesses, the fibrinolytic system plays an active role in each phase of the pathogenesis. During transmission, the renin-aldosterone-angiotensin-system (RAAS) is involved with the spike protein of SARS-CoV-2, attaching to its natural receptor angiotensin-converting enzyme 2 (ACE 2) in host cells. Both tissue plasminogen activator (tPA) and plasminogen activator inhibitor 1 (PAI-1) are closely linked to the RAAS. In lesions in the lung, kidney and other organs, the two plasminogen activators urokinase-type plasminogen activator (uPA) and tissue plasminogen activator (tPA), along with their inhibitor, plasminogen activator 1 (PAI-1), are involved. The altered fibrinolytic balance enables the development of a hypercoagulable state. In this article, evidence for the central role of fibrinolysis is reviewed, and the possible drug targets at multiple sites in the fibrinolytic pathways are discussed.
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Affiliation(s)
- Hau C. Kwaan
- Division of Hematology/Oncology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Paul F. Lindholm
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA;
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12
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Henry BM, Cheruiyot I, Benoit JL, Lippi G, Prohászka Z, Favaloro EJ, Benoit SW. Circulating Levels of Tissue Plasminogen Activator and Plasminogen Activator Inhibitor-1 Are Independent Predictors of Coronavirus Disease 2019 Severity: A Prospective, Observational Study. Semin Thromb Hemost 2021; 47:451-455. [PMID: 33482678 DOI: 10.1055/s-0040-1722308] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Brandon Michael Henry
- Cardiac Intensive Care Unit, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Justin L Benoit
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, Department of Neuroscience, Biomedicine and Movement, University of Verona, Verona, Italy
| | - Zoltán Prohászka
- Department of Medicine and Hematology, Research Laboratory, Semmelweis University, Budapest, Hungary
| | - Emmanuel J Favaloro
- Haematology, Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead, NSW, Australia
| | - Stefanie W Benoit
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Ohio
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13
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Mazilu L, Katsiki N, Nikolouzakis TK, Aslanidis MI, Lazopoulos G, Kouretas D, Tsatsakis A, Suceveanu AI, Stoian AP, Parepa IR, Voinea F, Suceveanu AP, Arsene AL, Velescu BȘ, Vesa C, Nitipir C. Thrombosis and Haemostasis challenges in COVID-19 - Therapeutic perspectives of heparin and tissue-type plasminogen activator and potential toxicological reactions-a mini review. Food Chem Toxicol 2021; 148:111974. [PMID: 33421462 PMCID: PMC7837001 DOI: 10.1016/j.fct.2021.111974] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/19/2020] [Accepted: 01/02/2021] [Indexed: 12/20/2022]
Abstract
The coronavirus disease (COVID)-19 pandemic is a major challenge for the health systems worldwide. Acute respiratory distress syndrome (ARDS), is one of the most common complications of the COVID-19 infection. The activation of the coagulation system plays an important role in the pathogenesis of ARDS. The development of lung coagulopathy involves thrombin generation and fibrinolysis inhibition. Unfractionated heparin and its recently introduced counterpart low molecular weight heparin (LMWH), are widely used anticoagulants with a variety of clinical indications allowing for limited and manageable physio-toxicologic side effects while the use of protamine sulfate, heparin's effective antidote, has made their use even safer. Tissue-type plasminogen activator (tPA) is approved as intravenous thrombolytic treatment. The present narrative review discusses the use of heparin and tPA in the treatment of COVID-19-induced ARDS and their related potential physio-toxicologic side effects. The article is a quick review of articles on anticoagulation in COVID infection and the potential toxicologic reactions associated with these drugs.
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Affiliation(s)
- Laura Mazilu
- Oncology Department, Clinical Emergency Hospital, Faculty of Medicine, "Ovidius" University, Constanța, Romania
| | - Niki Katsiki
- First Department of Internal Medicine, Diabetes Center, Division of Endocrinology and Metabolism, AHEPA University Hospital, Thessaloniki, Greece
| | | | | | - George Lazopoulos
- Department of Cardiothoracic Surgery, University General Hospital of Heraklion, Medical School, University of Crete, Greece
| | - Dimitrios Kouretas
- Department of Forensic Sciences and Toxicology, Faculty of Medicine, University of Crete, Greece
| | - Aristidis Tsatsakis
- Department of Biochemistry and Biotechnology, University of Thessaly, Larisa, 41500, Greece
| | - Andra-Iulia Suceveanu
- Gastroenterology Department, Clinical Emergency Hospital, Faculty of Medicine, "Ovidius" University, Constanța, Romania
| | - Anca-Pantea Stoian
- Department of Diabetes, Nutrition and Metabolic Diseases, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.
| | - Irinel-Raluca Parepa
- Cardiology Department, Clinical Emergency Hospital, Faculty of Medicine, "Ovidius" University, Constanța, Romania
| | - Felix Voinea
- Urology Department, Clinical Emergency Hospital, Faculty of Medicine, "Ovidius" University, Constanța, Romania
| | - Adrian Paul Suceveanu
- Internal Medicine Department, Clinical Emergency Hospital, Faculty of Medicine, "Ovidius" University, Constanța, Romania
| | - Andreea Letiția Arsene
- Faculty of Pharmacy, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Bruno Ștefan Velescu
- Faculty of Pharmacy, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Cosmin Vesa
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, Oradea, Romania
| | - Cornelia Nitipir
- Oncology Department, Elias Emergency Hospital, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
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14
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Ehrlich H, McKenney M, Elkbuli A. The Need for Chemo-Thromboprophylaxis Protocols in Critically Ill COVID-19 Patients. Am Surg 2020; 87:698-699. [PMID: 33283541 DOI: 10.1177/0003134820973351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Haley Ehrlich
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA.,Department of Surgery, University of South FL, Tampa, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
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15
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Feng X, Xie X, Song S, Chen W, Bian H, Rui F, Zhu Q, Ren W, Qin C, Qi J. Current directions, conceptions and viewpoints on 2019-nCoV (Review). Exp Ther Med 2020; 21:70. [PMID: 33365070 PMCID: PMC7716651 DOI: 10.3892/etm.2020.9502] [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: 04/27/2020] [Accepted: 10/30/2020] [Indexed: 11/06/2022] Open
Abstract
On December 31, 2019, the first case of a novel coronavirus infection was reported in Wuhan, China. The ongoing outbreak of the 2019 novel coronavirus (2019-nCoV) has caused immense global concern. According to the recommendations of the International Health Regulations Emergency Committee and the facts and cases that 215 other countries have also reported to date, the World Health Organization Director-General announced that the outbreak of 2019-nCoV constitutes a public health emergency of international concern and a severe threat to the human health worldwide. To date, the prevalence of the virus has continued in waves and is increasing globally. The present review briefly introduces the epidemiology of 2019-nCoV, as well as viral structural characteristics, and receptors and cells that may act after entering the body, laboratory examinations, imaging and pathological features, clinical manifestations, complications, treatment and management.
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Affiliation(s)
- Xiao Feng
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong 250021, P.R. China
| | - Xiaoyu Xie
- Department of Gastroenterology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250021, P.R. China
| | - Shouyang Song
- Department of Gastroenterology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250021, P.R. China
| | - Wenjun Chen
- Department of Gastroenterology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250021, P.R. China.,Department of Gastroenterology, The Affiliated Weihai Second Municipal Hospital of Qingdao University, Weihai, Shandong 264200, P.R. China
| | - Hongjun Bian
- Department of Emergency Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong 250021, P.R. China
| | - Fajuan Rui
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong 250021, P.R. China
| | - Qiang Zhu
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong 250021, P.R. China.,Department of Gastroenterology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250021, P.R. China
| | - Wanhua Ren
- Department of Infectious Disease, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong 250021, P.R. China
| | - Chengyong Qin
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong 250021, P.R. China.,Department of Gastroenterology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250021, P.R. China
| | - Jianni Qi
- Central Laboratory, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong 250021, P.R. China.,Department of Central Laboratory, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250021, P.R. China
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16
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COVID-19-associated coagulopathy and disseminated intravascular coagulation. Int J Hematol 2020; 113:45-57. [PMID: 33161508 PMCID: PMC7648664 DOI: 10.1007/s12185-020-03029-y] [Citation(s) in RCA: 231] [Impact Index Per Article: 57.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 10/15/2020] [Accepted: 10/22/2020] [Indexed: 01/08/2023]
Abstract
The pathology of coronavirus disease 2019 (COVID-19) is exacerbated by the progression of thrombosis, and disseminated intravascular coagulation (DIC), and cytokine storms. The most frequently reported coagulation/fibrinolytic abnormality in COVID-19 is the increase in d-dimer, and its relationship with prognosis has been discussed. However, limits exist to the utility of evaluation by d-dimer alone. In addition, since the coagulation/fibrinolytic condition sometimes fluctuates within a short period of time, regular examinations in recognition of the significance of the examination are desirable. The pathophysiology of disseminated intravascular coagulation (DIC) associated with COVID-19 is very different from that of septic DIC, and both thrombotic and hemorrhagic pathologies should be noted. COVID-19 thrombosis includes macro- and microthrombosis, with diagnosis of the latter depending on markers of coagulation and fibrinolysis. Treatment of COVID-19 is classified into antiviral treatment, cytokine storm treatment, and thrombosis treatment. Rather than providing uniform treatment, the treatment method most suitable for the severity and stage should be selected. Combination therapy with heparin and nafamostat is expected to develop in the future. Fibrinolytic therapy and adsorption therapy require further study
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17
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Dobesh PP, Trujillo TC. Coagulopathy, Venous Thromboembolism, and Anticoagulation in Patients with COVID-19. Pharmacotherapy 2020; 40:1130-1151. [PMID: 33006163 PMCID: PMC7537066 DOI: 10.1002/phar.2465] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/11/2020] [Accepted: 09/12/2020] [Indexed: 01/08/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) has led to a worldwide pandemic, and patients with the infection are referred to as having COVID‐19. Although COVID‐19 is commonly considered a respiratory disease, there is clearly a thrombotic potential that was not expected. The pathophysiology of the disease and subsequent coagulopathy produce an inflammatory, hypercoagulable, and hypofibrinolytic state. Several observational studies have demonstrated surprisingly high rates of venous thromboembolism (VTE) in both general ward and intensive care patients with COVID‐19. Many of these observational studies demonstrate high rates of VTE despite patients being on standard, or even higher intensity, pharmacologic VTE prophylaxis. Fibrinolytic therapy has also been used in patients with acute respiratory distress syndrome. Unfortunately, high quality randomized controlled trials are lacking. A literature search was performed to provide the most up‐to‐date information on the pathophysiology, coagulopathy, risk of VTE, and prevention and treatment of VTE in patients with COVID‐19. These topics are reviewed in detail, along with practical issues of anticoagulant selection and duration. Although many international organizations have produced guidelines or consensus statements, they do not all cover the same issues regarding anticoagulant therapy for patients with COVID‐19, and they do not all agree. These statements and the most recent literature are combined into a list of clinical considerations that clinicians can use for the prevention and treatment of VTE in patients with COVID‐19.
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Affiliation(s)
- Paul P Dobesh
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Toby C Trujillo
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
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18
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Görlinger K, Dirkmann D, Gandhi A, Simioni P. COVID-19-Associated Coagulopathy and Inflammatory Response: What Do We Know Already and What Are the Knowledge Gaps? Anesth Analg 2020; 131:1324-1333. [PMID: 33079850 PMCID: PMC7389937 DOI: 10.1213/ane.0000000000005147] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Patients with coronavirus disease 2019 (COVID-19) frequently experience a coagulopathy associated with a high incidence of thrombotic events leading to poor outcomes. Here, biomarkers of coagulation (such as D-dimer, fibrinogen, platelet count), inflammation (such as interleukin-6), and immunity (such as lymphocyte count) as well as clinical scoring systems (such as sequential organ failure assessment [SOFA], International Society on Thrombosis and Hemostasis disseminated intravascular coagulation [ISTH DIC], and sepsis-induced coagulopathy [SIC] score) can be helpful in predicting clinical course, need for hospital resources (such as intensive care unit [ICU] beds, intubation and ventilator therapy, and extracorporeal membrane oxygenation [ECMO]) and patient's outcome in patients with COVID-19. However, therapeutic options are actually limited to unspecific supportive therapy. Whether viscoelastic testing can provide additional value in predicting clinical course, need for hospital resources and patient's outcome or in guiding anticoagulation in COVID-19-associated coagulopathy is still incompletely understood and currently under investigation (eg, in the rotational thromboelastometry analysis and standard coagulation tests in hospitalized patients with COVID-19 [ROHOCO] study). This article summarizes what we know already about COVID-19-associated coagulopathy and-perhaps even more importantly-characterizes important knowledge gaps.
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Affiliation(s)
- Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany, and Medical Director, Tem Innovations GmbH, Martin-Kollar-Strasse 15, 81829 Munich, Germany, mobile: +49 1726596069, e-mail:
| | - Daniel Dirkmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany, mobile: +49 201 723 84423,
| | - Ajay Gandhi
- Clinical Affairs, Instrumentation Laboratory India Private Limited, New Delhi, India, 1471-76, Agrawal Millennium Tower II, Plot Number E-4, Netaji Subhash Place, Pitampura, New Delhi, India 110034, mobile: +91 9826870517, e-mail:
| | - Paolo Simioni
- General Internal Medicine and Thrombotic and Haemorrhagic Diseases Units, Department of Medicine, Padova University Hospital, Via Ospedale Civile 105, 35100 Padova, Italy, phone: +39 0498212667, e-mail:
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19
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Conzelmann C, Müller JA, Perkhofer L, Sparrer KM, Zelikin AN, Münch J, Kleger A. Inhaled and systemic heparin as a repurposed direct antiviral drug for prevention and treatment of COVID-19. Clin Med (Lond) 2020; 20:e218-e221. [PMID: 32863274 PMCID: PMC7687307 DOI: 10.7861/clinmed.2020-0351] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Here, we advocate a highly favourable opportunity for the treatment of COVID-19 disease by repurposing a long-serving medical agent with an excellent history of clinical use, namely heparin. Heparin is best known as an anticoagulant, but it also exhibits direct antiviral activity against many enveloped viruses and has anti-inflammatory activity. The high incidence of thromboembolic events in COVID-19 patients suggests that coagulopathy plays an important role in the SARS-CoV-2 pathogenesis. This already makes heparin a unique, potentially curative agent that can be used immediately to help resolve the ongoing crisis associated with SARS-CoV-2 infection and COVID-19 disease. We demonstrate here in vitro that heparin does indeed inhibit SARS-CoV-2 infection. The three concurrent modes of activity of heparin (antiviral, anticoagulant and anti-inflammatory) against SARS-CoV-2/COVID-19 form a unique therapeutic combination. Thus, repurposing of heparin to fight SARS-CoV-2 and COVID-19 appears to be a powerful, readily available measure to address the current pandemic.
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Affiliation(s)
- Carina Conzelmann
- Institute of Molecular Virology, Ulm University Medical Centre, Ulm, Germany
- *equal contributions
| | - Janis A Müller
- Institute of Molecular Virology, Ulm University Medical Centre, Ulm, Germany
- *equal contributions
| | - Lukas Perkhofer
- Department of Internal Medicine, Ulm University Hospital, Ulm, Germany
| | | | - Alexander N Zelikin
- Department of Chemistry and iNano Interdisciplinary Nanoscience Centre, Aarhus University, Aarhus, Denmark
- #equal contribution and joint supervision
| | - Jan Münch
- Institute of Molecular Virology, Ulm University Medical Centre, Ulm, Germany
| | - Alexander Kleger
- Department of Internal Medicine, Ulm University Hospital, Ulm, Germany
- #equal contribution and joint supervision
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20
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Abstract
CONTEXT.— The coronavirus disease 2019 (COVID-19) is a highly contagious respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Coagulation dysfunction is a hallmark in patients with COVID-19. Fulminant thrombotic complications emerge as critical issues in patients with severe COVID-19. OBJECTIVE.— To present a review of the literature and discuss the mechanisms of COVID-19 underlying coagulation activation and the implications for anticoagulant and thrombolytic treatment in the management of COVID-19. DATA SOURCES.— We performed a systemic review of scientific papers on the topic of COVID-19, available online via the PubMed NCBI, medRxiv, and Preprints as of May 15, 2020. We also shared our experience on the management of thrombotic events in patients with COVID-19. CONCLUSIONS.— COVID-19-associated coagulopathy ranges from mild laboratory alterations to disseminated intravascular coagulation (DIC) with a predominant phenotype of thrombotic/multiple organ failure. Characteristically, high D-dimer levels on admission and/or continuously increasing concentrations of D-dimer are associated with disease progression and poor overall survival. SARS-CoV-2 infection triggers the immune-hemostatic response. Drastic inflammatory responses including, but not limited to, cytokine storm, vasculopathy, and NETosis may contribute to an overwhelming activation of coagulation. Hypercoagulability and systemic thrombotic complications necessitate anticoagulant and thrombolytic interventions, which provide opportunities to prevent or reduce "excessive" thrombin generation while preserving "adaptive" hemostasis and bring additional benefit via their anti-inflammatory effect in the setting of COVID-19.
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Affiliation(s)
- Yang Fei
- From the Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Fei, Tang)
| | - Ning Tang
- From the Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Fei, Tang)
| | - Hefei Liu
- the Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City (Liu, Cao)
| | - Wenjing Cao
- the Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City (Liu, Cao)
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21
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Asakura H, Ogawa H. Perspective on fibrinolytic therapy in COVID-19: the potential of inhalation therapy against suppressed-fibrinolytic-type DIC. J Intensive Care 2020; 8:71. [PMID: 32959003 PMCID: PMC7499019 DOI: 10.1186/s40560-020-00491-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 09/10/2020] [Indexed: 01/08/2023] Open
Abstract
A high rate of thrombotic complications, such as pulmonary embolism, has been linked to mortality in COVID-19, and appropriate treatment of thrombosis is important for lifesaving. Although heparin is frequently used to treat thrombotic pathology in COVID-19, pulmonary embolism is still seen in severe cases. Although systemic fibrinolytic therapy is a focus of attention because a thrombotic pathology is the cause of death in severe COVID-19, it should be kept in mind that fibrinolytic therapy might be harmful at advanced stage of COVID-19 where the status of disseminated intravascular coagulation (DIC) has been transmitted from suppressed-fibrinolytic to enhanced-fibrinolytic in disease progression of COVID-19. In this respect, inhalation therapy with fibrinolytic substances might be a safe and promising treatment.
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Affiliation(s)
- Hidesaku Asakura
- Department of Hematology, Kanazawa University Hospital, Takaramachi 13-1, Kanazawa, Ishikawa 920-8640 Japan
| | - Haruhiko Ogawa
- Department of Environmental and Preventive Medicine, Kanazawa University, Takaramachi 13-1, Kanazawa, Ishikawa 920-8640 Japan
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22
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Zeng J, Xie MH, Yang J, Chao SW, Xu EL. Clinical efficacy of tocilizumab treatment in severe and critical COVID-19 patients. World J Clin Cases 2020; 8:3763-3773. [PMID: 32953852 PMCID: PMC7479568 DOI: 10.12998/wjcc.v8.i17.3763] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/08/2020] [Accepted: 08/05/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The main pathophysiological basis of coronavirus disease 2019 (COVID-19) causing respiratory failure is a cytokine storm and interleukin-6 (IL-6) is an important component of the COVID-19 cytokine storm. As a specific antagonist of IL-6, tocilizumab may block the cytokine storm of COVID-19. The Diagnosis and Treatment Guidelines of New Coronavirus Pneumonia (7th Edition) includes tocilizumab as a recommended drug for immunotherapy in severe and critical COVID-19 patients. However, the specific clinical efficacy of tocilizumab in the treatment of COVID-19 patients is worth studying.
AIM To determine the clinical efficacy of tocilizumab in inhibiting the cytokine storm in COVID-19.
METHODS In total, 19 severe and critical COVID-19 patients were enrolled in this study, and were treated with tocilizumab in Optical Valley Campus of Hubei Maternal and Child Health Care Hospital from February 20 to March 31, 2020. The imaging manifestations and clinical data before and after treatment were analyzed retrospectively, including routine peripheral venous blood tests, routine blood biochemical tests, coagulation test, C-reactive protein (CRP), IL-6, and arterial blood gas analysis.
RESULTS Of the 19 patients in this group, 13 (68.4%) had significantly improved symptoms of COVID-19 (5 patients were discharged directly and 8 patients were transferred after improvement) following treatment. One case was invalid, 1 case was exacerbated, and 4 deaths (21.1%) were observed (all critical cases). The lymphocyte count, CRP, lactic acid, oxygenation index, fibrinogen (FIB) and IL-6 levels were significantly different in the improved group.
CONCLUSION Tocilizumab treatment is effective against IL-6 in COVID-19 patients, but it does not completely inhibit the inflammation and cytokine storm in all patients with COVID-19.In the clinical treatment of COVID-19 patients, attention should be paid to the timing of drug administration and other adjuvant treatments.
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Affiliation(s)
- Jia Zeng
- Department of Aviation Disease, Naval Medical Center of PLA, Shanghai 200052, China
- No. 1 Department of Infection, Optical Valley Campus of Hubei Maternal and Child Health Care Hospital, Wuhan 430073, Hubei Province, China
| | - Ming-Hui Xie
- No. 1 Department of Infection, Optical Valley Campus of Hubei Maternal and Child Health Care Hospital, Wuhan 430073, Hubei Province, China
- Department of Interventional Therapy, First Affiliated Hospital, the Second Military Medical University, Shanghai 200433, China
| | - Jing Yang
- No. 1 Department of Infection, Optical Valley Campus of Hubei Maternal and Child Health Care Hospital, Wuhan 430073, Hubei Province, China
- Department of Nephrology, Naval Medical Center of PLA, Shanghai 200052, China
| | - Sheng-Wu Chao
- No. 1 Department of Infection, Optical Valley Campus of Hubei Maternal and Child Health Care Hospital, Wuhan 430073, Hubei Province, China
- Department of Cardiovascular Medicine, Naval Medical Center of PLA, Shanghai 200052, China
| | - Er-Li Xu
- Department of Aviation Disease, Naval Medical Center of PLA, Shanghai 200052, China
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23
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SARS-CoV-2 and cancer: Are they really partners in crime? Cancer Treat Rev 2020; 89:102068. [PMID: 32731090 PMCID: PMC7351667 DOI: 10.1016/j.ctrv.2020.102068] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 12/15/2022]
Abstract
The outbreak of the SARS-CoV-2 pandemic has overwhelmed health care systems in many countries. The clinical presentation of the SARS-CoV-2 varies between a subclinical or flu-like syndrome to that of severe pneumonia with multi-organ failure and death. Initial reports have suggested that cancer patients may have a higher susceptibility to get infected by the SARS-CoV-2 virus but current evidence remains poor as it is biased by important confounders. Patients with ongoing or recent cancer treatment for advanced active disease, metastatic solid tumors and hematological malignancies are at higher risk of developing severe COVID-19 respiratory disease that requires hospitalization and have a poorer disease outcome compared to individuals without cancer. However it is not clear whether these are independent risk factors, or mainly driven by male gender, age, obesity, performance status, uncontrolled diabetes, cardiovascular disease and various other medical conditions. These often have a greater influence on the probability to die due to SARS-CoV-2 then cancer. Delayed diagnosis and suboptimal cancer management due to the pandemic results in disease upstaging and has considerable impact cancer on specific death rates. Surgery during the peak of the pandemic seems to increase mortality, but there is no convincing evidence that adjuvant systemic cancer therapy and radiotherapy are contraindicated, implicating that cancer treatment can be provided safely after individual risk/benefit assessment and some adaptive measures. Underlying immunosuppression, elevated cytokine levels, altered expression of the angiotensin converting enzyme (ACE-2) and TMPRSS2, and a prothrombotic status may fuel the effects of a SARS-CoV-2 in some cancer patients, but have the potential to be used as biomarkers for severe disease and therapeutic targets. The rapidly expanding literature on COVID-19 should be interpreted with care as it is often hampered by methodological and statistical flaws.
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24
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Thrombosis in Coronavirus disease 2019 (COVID-19) through the prism of Virchow's triad. Clin Rheumatol 2020; 39:2529-2543. [PMID: 32654082 PMCID: PMC7353835 DOI: 10.1007/s10067-020-05275-1] [Citation(s) in RCA: 143] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 06/26/2020] [Accepted: 06/30/2020] [Indexed: 02/07/2023]
Abstract
The pathogenesis of Coronavirus disease 2019 (COVID-19) is gradually being comprehended. A high number of thrombotic episodes are reported, along with the mortality benefits of heparin. COVID-19 can be viewed as a prothrombotic disease. We overviewed the available evidence to explore this possibility. We identified various histopathology reports and clinical case series reporting thromboses in COVID-19. Also, multiple coagulation markers support this. COVID-19 can be regarded as a risk factor for thrombosis. Applying the principles of Virchow's triad, we described abnormalities in the vascular endothelium, altered blood flow, and platelet function abnormalities that lead to venous and arterial thromboses in COVID-19. Endothelial dysfunction, activation of the renin-angiotensin-aldosterone system (RAAS) with the release of procoagulant plasminogen activator inhibitor (PAI-1), and hyperimmune response with activated platelets seem to be significant contributors to thrombogenesis in COVID-19. Stratifying risk of COVID-19 thromboses should be based on age, presence of comorbidities, D-dimer, CT scoring, and various blood cell ratios. Isolated heparin therapy may not be sufficient to combat thrombosis in this disease. There is an urgent need to explore newer avenues like activated protein C, PAI-1 antagonists, and tissue plasminogen activators (tPA). These should be augmented with therapies targeting RAAS, antiplatelet drugs, repurposed antiinflammatory, and antirheumatic drugs. Key Points • Venous and arterial thromboses in COVID-19 can be viewed through the prism of Virchow's triad. • Endothelial dysfunction, platelet activation, hyperviscosity, and blood flow abnormalities due to hypoxia, immune reactions, and hypercoagulability lead to thrombogenesis in COVID-19. • There is an urgent need to stratify COVID-19 patients at risk for thrombosis using age, comorbidities, D-dimer, and CT scoring. • Patients with COVID-19 at high risk for thrombosis should be put on high dose heparin therapy.
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25
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Wright FL, Vogler TO, Moore EE, Moore HB, Wohlauer MV, Urban S, Nydam TL, Moore PK, McIntyre RC. Fibrinolysis Shutdown Correlation with Thromboembolic Events in Severe COVID-19 Infection. J Am Coll Surg 2020; 231:193-203.e1. [PMID: 32422349 PMCID: PMC7227511 DOI: 10.1016/j.jamcollsurg.2020.05.007] [Citation(s) in RCA: 281] [Impact Index Per Article: 70.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/07/2020] [Accepted: 05/08/2020] [Indexed: 01/08/2023]
Abstract
Background COVID-19 predisposes patients to a prothrombotic state with demonstrated microvascular involvement. The degree of hypercoagulability appears to correlate with outcomes; however, optimal criteria to assess for the highest-risk patients for thrombotic events remain unclear; we hypothesized that deranged thromboelastography measurements of coagulation would correlate with thromboembolic events. Study Design Patients admitted to an ICU with COVID-19 diagnoses who had thromboelastography analyses performed were studied. Conventional coagulation assays, d-dimer levels, and viscoelastic measurements were analyzed using a receiver operating characteristic curve to predict thromboembolic outcomes and new-onset renal failure. Results Forty-four patients with COVID-19 were included in the analysis. Derangements in coagulation laboratory values, including elevated d-dimer, fibrinogen, prothrombin time, and partial thromboplastin time, were confirmed; viscoelastic measurements showed an elevated maximum amplitude and low lysis of clot at 30 minutes. A complete lack of lysis of clot at 30 minutes was seen in 57% of patients and predicted venous thromboembolic events with an area under the receiver operating characteristic curve of 0.742 (p = 0.021). A d-dimer cutoff of 2,600 ng/mL predicted need for dialysis with an area under the receiver operating characteristic curve of 0.779 (p = 0.005). Overall, patients with no lysis of clot at 30 minutes and a d-dimer > 2,600 ng/mL had a venous thromboembolic event rate of 50% compared with 0% for patients with neither risk factor (p = 0.008), and had a hemodialysis rate of 80% compared with 14% (p = 0.004). Conclusions Fibrinolysis shutdown, as evidenced by elevated d-dimer and complete failure of clot lysis at 30 minutes on thromboelastography predicts thromboembolic events and need for hemodialysis in critically ill patients with COVID-19. Additional clinical trials are required to ascertain the need for early therapeutic anticoagulation or fibrinolytic therapy to address this state of fibrinolysis shutdown.
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Affiliation(s)
| | | | - Ernest E Moore
- Departments of Surgery; Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO
| | | | | | - Shane Urban
- University of Colorado Anschutz Medical Campus, UCHealth, University of Colorado Hospital, Aurora
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Kichloo A, Dettloff K, Aljadah M, Albosta M, Jamal S, Singh J, Wani F, Kumar A, Vallabhaneni S, Khan MZ. COVID-19 and Hypercoagulability: A Review. Clin Appl Thromb Hemost 2020; 26:1076029620962853. [PMID: 33074732 PMCID: PMC7592310 DOI: 10.1177/1076029620962853] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 09/04/2020] [Accepted: 09/09/2020] [Indexed: 01/08/2023] Open
Abstract
Thrombotic complications of the novel coronavirus (COVID-19) are a concerning aspect of the disease, due to the high incidence in critically ill patients and poor clinical outcomes. COVID-19 predisposes patients to a hypercoagulable state, however, the pathophysiology behind the thrombotic complications seen in this disease is not well understood. Several mechanisms have been proposed and the pathogenesis likely involves a host immune response contributing to vascular endothelial cell injury, inflammation, activation of the coagulation cascade via tissue factor expression, and shutdown of fibrinolysis. Treatments targeting these pathways may need to be considered to improve clinical outcomes and decrease overall mortality due to thrombotic complications. In this review, we will discuss the proposed pathophysiologic mechanisms for thrombotic complications in COVID-19, as well as treatment strategies for these complications based on the current literature available.
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Affiliation(s)
- Asim Kichloo
- St. Mary’s of Saginaw Hospital, Saginaw, MI, USA
- Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Kirk Dettloff
- Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Michael Aljadah
- Medical College of Wisconsin Affiliated Hospitals, Milwaukee, WI, USA
| | - Michael Albosta
- Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Shakeel Jamal
- St. Mary’s of Saginaw Hospital, Saginaw, MI, USA
- Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Jagmeet Singh
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Farah Wani
- Samaritan Medical Center, Watertown, NY, USA
| | - Akshay Kumar
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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