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Schizas N, Nazou G, Antonopoulos C, Angouras DC. Disseminated Intravascular Coagulation Post Endovascular Aortic Repair. Vasc Endovascular Surg 2023; 57:738-748. [PMID: 36946180 DOI: 10.1177/15385744231165231] [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] [Indexed: 03/23/2023]
Abstract
BACKGROUND Disseminated Intravascular Coagulation (DIC) after Endo-Vascular Aneurysm Repair (EVAR) is a highly uncommon clinical entity. With only a few case-reports available, its management strategy still remains enigmatic. OBJECTIVES The purpose of this study was to retrieve, synthesize, and appraise all existing data for DIC after EVAR. MATERIALS AND METHODS All published articles regarding DIC post-EVAR were identified from 3 major databases and analyzed. Clinical parameters, predisposing factors, along with mortality and morbidly were assessed. RESULTS The total number of publications included in the review was 15 describing 17 cases. DIC presented with a broad spectrum of clinical manifestations, while the time of diagnosis varied significantly. Endoleak was the main causative factor, with an incidence reaching 71%. The mortality of DIC after EVAR reached 29%, regardless of the therapeutic approach chosen. DIC was treated effectively in 47% of the patients (8/17), with better outcomes among patients who received conservative therapy or among those who were submitted to endovascular interventions. CONCLUSIONS DIC after EVAR, although rare, is a potentially lethal clinical condition which requires prompt diagnosis and urgent medical consideration. Treatment of endoleak may help in quick restoration of normal parameters.
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Affiliation(s)
- Nikolaos Schizas
- Department of Cardiac Surgery, Medical School, National and Kapodistrian University of Athens, Greece
| | - Georgia Nazou
- Anesthesiology Department, Evangelismos Athens General Hospital, Greece
| | - Constantine Antonopoulos
- Department of Vascular Surgery, Medical School, National and Kapodistrian University of Athens, Greece
| | - Dimitrios C Angouras
- Department of Cardiac Surgery, Medical School, National and Kapodistrian University of Athens, Greece
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Jiang M, Wan JH, Tu Y, Shen Y, Kong FC, Zhang ZL. Angioimmunoblastic T-cell lymphoma induced hemophagocytic lymphohistiocytosis and disseminated intravascular coagulopathy: A case report. World J Clin Cases 2023; 11:1086-1093. [PMID: 36874426 PMCID: PMC9979290 DOI: 10.12998/wjcc.v11.i5.1086] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 11/25/2022] [Accepted: 01/28/2023] [Indexed: 02/14/2023] Open
Abstract
BACKGROUND Angioimmunoblastic T-cell lymphoma (AITL) is a subtype of peripheral T-cell lymphoma, with heterogenous clinical manifestations and poor prognosis. Here, we report a case of AITL induced hemophagocytic lymphohistiocytosis (HLH) and disseminated intravascular coagulopathy (DIC).
CASE SUMMARY An 83-year-old man presented with fever and purpura of both lower limbs for one month. Groin lymph node puncture and flow cytometry indicated a diagnosis of AITL. Bone marrow examination and other laboratory related indexes indicated DIC and HLH. The patient rapidly succumbed to gastrointestinal bleeding and septic shock.
CONCLUSION This is the first reported case of AITL induced HLH and DIC. AITL is more aggressive in older adults. In addition to male gender, mediastinal lymphadenopathy, anaemia, and sustained high level of neutrophil-to-lymphocyte ratio may indicate a greater risk of death. Early diagnosis, early detection of severe complications, and prompt and effective treatment are vital.
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Affiliation(s)
- Mei Jiang
- Clinical Laboratory, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Jing-Hua Wan
- Clinical Laboratory, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Yi Tu
- Department of Pathology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Yan Shen
- Department of Anesthesia, Medical College of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Fan-Cong Kong
- Department of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Zhang-Lin Zhang
- Department of Transfusion, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
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Solanki D, Lal D, Sunny A, Han X, Iyanar S, Halder A, Mullangi S, Desai M, Khan U, Theli A, Devani H, Kumar P, Patel AA, Lekkala M. Temporal Trends, Predictors, and Outcomes of Disseminated Intravascular Coagulation in Hospitalizations With Sepsis. Cureus 2022; 14:e27477. [PMID: 36060388 PMCID: PMC9421097 DOI: 10.7759/cureus.27477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2022] [Indexed: 11/20/2022] Open
Abstract
Background This retrospective study was conducted to analyze the temporal trends, predictors, and impact of disseminated intravascular coagulation (DIC) on outcomes among septicemic patients using a nationally representative database. Methods We derived data from the National Inpatient Sample (NIS) for the years 2008-2017 for adult hospitalizations due to sepsis. The primary outcomes were in-hospital mortality and discharge to facility. The Cochran-Armitage test and multivariable survey logistic regression models were used to analyze the data. Results Out of 12,820,000 hospitalizations due to sepsis, 153,181 (1.18%) were complicated by DIC. The incidence of DIC decreased from 2008 to 2017. In multivariable regression analysis, demographics and comorbidities were associated with higher odds of DIC. During the study period, in-hospital mortality among patients with sepsis decreased, but the attributable risk percent of in-hospital mortality due to DIC increased. We observed similar trends for discharge to facility; however, the adjusted odds of discharge to facility due to DIC remained stable over the study period. Conclusion Although the incidence of sepsis complicated by DIC decreased, the attributable in-hospital mortality rate due to DIC increased during the study period. We identified several predictors associated with the development of DIC in sepsis, some of which are potentially modifiable.
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Flæng S, Nygaard S, Granfeldt A, Hvas AM, Sørensen HT, Thachil J, Adelborg K. Exploring the epidemiology of disseminated intravascular coagulation: protocol for the DANish Disseminated Intravascular Coagulation (DANDIC) Cohort Study. BMJ Open 2022; 12:e062623. [PMID: 35835529 PMCID: PMC9289033 DOI: 10.1136/bmjopen-2022-062623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Since disseminated intravascular coagulation (DIC) was first described, it has been considered a serious disease of the coagulation system and a major challenge to clinicians. Currently, several important knowledge gaps remain. The DANish Disseminated Intravascular Coagulation (DANDIC) Cohort Study will aim to answer questions regarding the incidence and mortality of patients with DIC including time trends. The study will also identify prognostic factors that may guide personalised prevention and treatment. Furthermore, the study will describe treatment patterns and the safety and effectiveness of various treatment modalities. METHODS AND ANALYSIS We will establish the DANDIC Cohort using data collected in daily clinical practice from the Central Denmark Region, which covers approximately 1.3 million residents. The study period will encompass 1 January 2011 through 1 July 2021. Potential DIC cases will be identified from the hospital laboratory database, based on coagulation biomarkers, and diagnoses will be adjudicated by medical experts. The dataset will be enriched with detailed clinical data from electronic medical charts on aetiologies, bleeding, microthrombus formation, organ failure, thrombosis, treatments and comorbidities. The dataset will also take advantage of in-hospital data with longitudinal information on laboratory records, transfusions, microbiology and treatments. It will be possible to merge this dataset with other unique Danish health registries with more than 10 years of virtually complete follow-up. The project will use state-of-the-art epidemiological and biostatistical methods. ETHICS AND DISSEMINATION The project has been approved by the Danish Patient Safety Authority (31-1521-452), the Central Denmark Region (1-45-70-83-21), the Danish Data Protection Agency (1-16-02-258-21) and all the hospital chairs. Register-based studies require no ethical approval in Denmark. The results will be disseminated in international peer-reviewed journals.
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Affiliation(s)
- Simon Flæng
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Nygaard
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Asger Granfeldt
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jecko Thachil
- Department of Haematology, Manchester University NHS Foundation Trust, Manchester, Greater Manchester, UK
| | - Kasper Adelborg
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Biochemistry, Regional Hospital Gødstrup, Herning, Denmark
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Snakebite Associated Thrombotic Microangiopathy and Recommendations for Clinical Practice. Toxins (Basel) 2022; 14:toxins14010057. [PMID: 35051033 PMCID: PMC8778654 DOI: 10.3390/toxins14010057] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 01/05/2023] Open
Abstract
Snakebite is a significant and under-resourced global public health issue. Snake venoms cause a variety of potentially fatal clinical toxin syndromes, including venom-induced consumption coagulopathy (VICC) which is associated with major haemorrhage. A subset of patients with VICC develop a thrombotic microangiopathy (TMA). This article reviews recent evidence regarding snakebite-associated TMA and its epidemiology, diagnosis, outcomes, and effectiveness of interventions including antivenom and therapeutic plasma-exchange. Snakebite-associated TMA presents with microangiopathic haemolytic anaemia (evidenced by schistocytes on the blood film), thrombocytopenia in almost all cases, and a spectrum of acute kidney injury (AKI). A proportion of patients require dialysis, most survive and achieve dialysis free survival. There is no evidence that antivenom prevents TMA specifically, but early antivenom remains the mainstay of treatment for snake envenoming. There is no evidence for therapeutic plasma-exchange being effective. We propose diagnostic criteria for snakebite-associated TMA as anaemia with >1.0% schistocytes on blood film examination, together with absolute thrombocytopenia (<150 × 109/L) or a relative decrease in platelet count of >25% from baseline. Patients are at risk of long-term chronic kidney disease and long term follow up is recommended.
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Erez O, Othman M, Rabinovich A, Leron E, Gotsch F, Thachil J. DIC in Pregnancy - Pathophysiology, Clinical Characteristics, Diagnostic Scores, and Treatments. J Blood Med 2022; 13:21-44. [PMID: 35023983 PMCID: PMC8747805 DOI: 10.2147/jbm.s273047] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 09/15/2021] [Indexed: 01/04/2023] Open
Abstract
Obstetrical hemorrhage and especially DIC (disseminated intravascular coagulation) is a leading cause for maternal mortality across the globe, often secondary to underlying maternal and/or fetal complications including placental abruption, amniotic fluid embolism, HELLP syndrome (hemolysis, elevated liver enzymes and low platelets), retained stillbirth and acute fatty liver of pregnancy. Various obstetrical disorders can present with DIC as a complication; thus, increased awareness is key to diagnosing the condition. DIC patients can present to clinicians who may not be experienced in a variety of aspects of thrombosis and hemostasis. Hence, DIC diagnosis is often only entertained when the patient already developed uncontrollable bleeding or multi-organ failure, all of which represent unsalvageable scenarios. Beyond the clinical presentations, the main issue with DIC diagnosis is in relation to coagulation test abnormalities. It is widely believed that in DIC, patients will have prolonged prothrombin time (PT) and partial thromboplastin time (PTT), thrombocytopenia, low fibrinogen, and raised D-dimers. Diagnosis of DIC can be elusive during pregnancy and requires vigilance and knowledge of the physiologic changes during pregnancy. It can be facilitated by using a pregnancy specific DIC score including three components: 1) fibrinogen concentrations; 2) the PT difference - relating to the difference in PT result between the patient's plasma and the laboratory control; and 3) platelet count. At a cutoff of ≥26 points, the pregnancy specific DIC score has 88% sensitivity, 96% specificity, a positive likelihood ratio (LR) of 22, and a negative LR of 0.125. Management of DIC during pregnancy requires a prompt attention to the underlying condition leading to this complication, including the delivery of the patient, and correction of the hemostatic problem that can be guided by point of care testing adjusted for pregnancy.
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Affiliation(s)
- Offer Erez
- Maternity Department “D”, Division of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Faculty of Health Sciences Ben Gurion University of the Negev, Beer Sheva, Israel
- Department of Obstetrics and Gynecology, Hutzel Women’s Hospital, Wayne State University, Detroit, MI, USA
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen’s University, Kingston, ON, Canada
| | - Anat Rabinovich
- Thrombosis and Hemostasis Unit, Hematology Institute, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Elad Leron
- Division of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Faculty of Health Sciences Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Francesca Gotsch
- Department of Obstetrics and Gynecology, Azienda Ospedaliera Universitaria Integrata, AOUI Verona, University of Verona, Verona, Italy
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
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Nasreen S, Calzavara AJ, Sundaram ME, MacDonald SE, Righolt CH, Pai M, Field TS, Zhou LW, Wilson SE, Kwong JC. Background incidence rates of hospitalisations and emergency department visits for thromboembolic and coagulation disorders in Ontario, Canada for COVID-19 vaccine safety assessment: a population-based retrospective observational study. BMJ Open 2021; 11:e052019. [PMID: 34921078 PMCID: PMC8685534 DOI: 10.1136/bmjopen-2021-052019] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE The objective of this study was to estimate background rates of selected thromboembolic and coagulation disorders in Ontario, Canada. DESIGN Population-based retrospective observational study using linked health administrative databases. Records of hospitalisations and emergency department visits were searched to identify cases using International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Canada diagnostic codes. PARTICIPANTS All Ontario residents. PRIMARY OUTCOME MEASURES Incidence rates of ischaemic stroke, intracerebral haemorrhage, subarachnoid haemorrhage, deep vein thrombosis, pulmonary embolism, idiopathic thrombocytopaenia, disseminated intravascular coagulation and cerebral venous thrombosis during five prepandemic years (2015-2019) and 2020. RESULTS The average annual population was 14 million with 51% female. The mean annual rates per 100 000 population during 2015-2019 were 127.1 (95% CI 126.2 to 127.9) for ischaemic stroke, 22.0 (95% CI 21.6 to 22.3) for intracerebral haemorrhage, 9.4 (95% CI 9.2 to 9.7) for subarachnoid haemorrhage, 86.8 (95% CI 86.1 to 87.5) for deep vein thrombosis, 63.7 (95% CI 63.1 to 64.3) for pulmonary embolism, 6.1 (95% CI 5.9 to 6.3) for idiopathic thrombocytopaenia, 1.6 (95% CI 1.5 to 1.7) for disseminated intravascular coagulation, and 1.5 (95% CI 1.4 to 1.6) for cerebral venous thrombosis. Rates were lower in 2020 than during the prepandemic years for ischaemic stroke, deep vein thrombosis and idiopathic thrombocytopaenia. Rates were generally consistent over time, except for pulmonary embolism, which increased from 57.1 to 68.5 per 100 000 between 2015 and 2019. Rates were higher for females than males for subarachnoid haemorrhage, pulmonary embolism and cerebral venous thrombosis, and vice versa for ischaemic stroke and intracerebral haemorrhage. Rates increased with age for most of these conditions, but idiopathic thrombocytopaenia demonstrated a bimodal distribution with incidence peaks at 0-19 years and ≥60 years. CONCLUSIONS Our estimated background rates help contextualise observed events of these potential adverse events of special interest and to detect potential safety signals related to COVID-19 vaccines.
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Affiliation(s)
- Sharifa Nasreen
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | | | - Maria E Sundaram
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Shannon E MacDonald
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Christiaan H Righolt
- Vaccine and Drug Evaluation Centre, Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Menaka Pai
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Thalia S Field
- Division of Neurology, The University of British Columbia, Vancouver, Columbia, Canada
| | - Lily W Zhou
- Division of Neurology, The University of British Columbia, Vancouver, Columbia, Canada
- Stanford Stroke Center, Palo Alto, California, USA
| | - Sarah E Wilson
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Immunization and vaccine-preventable diseases, Public Health Ontario, Toronto, Ontario, Canada
| | - Jeffrey C Kwong
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
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Iwasaki Y, Ohbe H, Shigemi D, Fushimi K, Yasunaga H. Effect of antithrombin III among patients with disseminated intravascular coagulation in obstetrics: a nationwide observational study in Japan. BJOG 2021; 129:805-811. [PMID: 34545675 DOI: 10.1111/1471-0528.16938] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 08/11/2021] [Accepted: 09/12/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Pregnant women may develop disseminated intravascular coagulation (DIC), possibly resulting in massive maternal haemorrhage and perinatal death. The Japan guideline recommends use of antithrombin III (ATIII) for DIC in obstetrics; however, its effect remains uncertain. The present study aimed to investigate the effect of ATIII for DIC in obstetrics, using a national inpatient database in Japan. DESIGN Nationwide observational study. SETTING Japan. POPULATION We used the Diagnosis Procedure Combination inpatient database to identify patients who delivered at hospital and were diagnosed with DIC from July 2010 to March 2018. METHODS Propensity score matching analyses were performed to compare in-hospital maternal mortality and hysterectomy during hospitalisation between users and non-users of ATIII on the day of delivery. MAIN OUTCOME MEASURES In-hospital mortality, hysterectomy. RESULTS A total of 9920 patients were enrolled, including 4329 patients (44%) who used ATIII and 5511 patients (56%) who did not use ATIII. One-to-one propensity score matching created 3290 pairs. In-hospital maternal mortality did not differ significantly between the propensity-matched groups (0.3% in the ATIII group versus 0.5% in the control group; odds ratio 0.73; 95% CI 0.35-1.54). A significantly lower proportion of patients in the ATIII group, compared with those in the control group, underwent hysterectomy during hospitalisation (5.3% versus 8.7%; absolute risk difference -2.9%; 95% CI -4.2 to -1.6%). CONCLUSIONS Although the present study did not show a mortality-reducing effect of ATIII for patients with DIC in obstetrics, it may have clinical benefit in terms of reducing the number of patients undergoing hysterectomy. TWEETABLE ABSTRACT This study did not show mortality-reducing effect of antithrombin III for patients with DIC in obstetrics.
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Affiliation(s)
- Y Iwasaki
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - H Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - D Shigemi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - K Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - H Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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Emleek EMQ, Khalil AA. Disseminated Intravascular Coagulopathy in Critically Ill Patients in Amman, Jordan. Biol Res Nurs 2021; 23:689-697. [PMID: 34030507 DOI: 10.1177/10998004211017241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The disseminated intravascular coagulation (DIC) is under-recognized in critically ill patients. The International Society of Thrombosis and Haemostasis (ISTH; DIC) provides a useful scoring system for accurate DIC identification. The study investigated the period prevalence of ISTH DIC from 2015 to 2017 in critically ill patients. METHODS In this multi-center, retrospective observational study, we included all patients identified with a DIC code or medically diagnosed with DIC during all admissions. Based on ISTH DIC scores ≥ 5, patients were classified with overt DIC. RESULTS A total of 220 patients were included in this study. The period prevalence of DIC was 4.45%. The point prevalence of DIC has increased from 3.49% to 5.58% from 2015 to 2017 (27.7% female; median age 61.6 years). Based on the ISTH-Overt DIC criteria, 45.2% of the sample had sepsis. Overt DIC patients had significantly lower baseline hemoglobin (HB; t = 2.137, df = 193, p = 0.034), platelet count (t = 3.591, df = 193, p < 0.001) and elevated serum creatinine level (M = 2.1, SD = 1.5, t = 2.203, df = 193, p = 0.029) compared to non-Overt DIC. There was a statistically significant elevation in FDPs among Overt DIC compared to non-Overt DIC (χ2 = 30.381, df = 1, p < 0.001). Overt DIC patients had significantly prolonged PT (U = 2,298, z = 5.7, p < 0.001), PTT (U = 2,334, z = 2.0, p = 0.045) and INR (U = 2,541, z = 5.1, p < 0.001) compared to those with non-Overt DIC. CONCLUSION The ISTH overt-DIC score can be used in critically ill patients regardless of the underlying disease. Efforts are required to predict and identify overt DIC using a valid scoring system on admission and follow-up of adult patients admitted to ICU.
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Affiliation(s)
- Eman Mahmoud Qasim Emleek
- Department of Bone Marrow Transplantation, The King Hussein Cancer Center (KHCC), University of Jordan, Amman, Jordan
| | - Amani Anwar Khalil
- Clinical Nursing Department, School of Nursing, 54658The University of Jordan, Amman, Jordan
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Adelborg K, Larsen JB, Hvas AM. Disseminated intravascular coagulation: epidemiology, biomarkers, and management. Br J Haematol 2021; 192:803-818. [PMID: 33555051 DOI: 10.1111/bjh.17172] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Disseminated intravascular coagulation (DIC) is a systemic activation of the coagulation system, which results in microvascular thrombosis and, simultaneously, potentially life-threatening haemorrhage attributed to consumption of platelets and coagulation factors. Underlying conditions, e.g. infection, cancer, or obstetrical complications are responsible for the initiation and propagation of the DIC process. This review provides insights into the epidemiology of DIC and the current understanding of its pathophysiology. It details the use of diagnostic biomarkers, current diagnostic recommendations from international medical societies, and it provides an overview of emerging diagnostic and prognostic biomarkers. Last, it provides guidance on management. It is concluded that timely and accurate diagnosis of DIC and its underlying condition is essential for the prognosis. Treatment should primarily focus on the underlying cause of DIC and supportive treatment should be individualised according to the underlying aetiology, patient's symptoms and laboratory records.
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Affiliation(s)
- Kasper Adelborg
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Denmark
| | - Julie B Larsen
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Denmark
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Moreno G, Carbonell R, Bodí M, Rodríguez A. [Systematic review of the prognostic utility of D-dimer, disseminated intravascular coagulation, and anticoagulant therapy in COVID-19 critically ill patients]. Med Intensiva 2021; 45:42-55. [PMID: 32646669 PMCID: PMC7298463 DOI: 10.1016/j.medin.2020.06.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/02/2020] [Accepted: 06/03/2020] [Indexed: 12/17/2022]
Abstract
During the new pandemic caused by SARS-CoV-2, there is short knowledge regarding the management of different disease areas, such as coagulopathy and interpretation of D-dimer levels, its association with disseminated intravascular coagulation (DIC) and controversy about the benefit of anticoagulation. Thus, a systematic review has been performed to define the role of D-dimer in the disease, the prevalence of DIC and the usefulness of anticoagulant treatment in these patients. A literature search was performed to analyze the studies of COVID-19 patients. Four recommendations were drawn based on expert opinion and scientific knowledge, according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. The present review suggests the presence of higher levels of D-dimer in those with worse prognosis, there may be an overdiagnosis of DIC in the course of the disease and there is no evidence on the benefit of starting anticoagulant treatment based only on isolated laboratory data.
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Affiliation(s)
- G Moreno
- Servicio de Medicina Intensiva, Hospital Universitari Joan XXIII, URV/IISPV, Tarragona, España.
| | - R Carbonell
- Servicio de Medicina Intensiva, Hospital Universitari Joan XXIII, URV/IISPV, Tarragona, España
| | - M Bodí
- Servicio de Medicina Intensiva, Hospital Universitari Joan XXIII, URV/IISPV, Tarragona, España
| | - A Rodríguez
- Servicio de Medicina Intensiva, Hospital Universitari Joan XXIII, URV/IISPV, Tarragona, España
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12
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Moreno G, Carbonell R, Bodí M, Rodríguez A. Systematic review of the prognostic utility of D-dimer, disseminated intravascular coagulation, and anticoagulant therapy in COVID-19 critically ill patients. MEDICINA INTENSIVA (ENGLISH EDITION) 2021. [PMCID: PMC7833662 DOI: 10.1016/j.medine.2020.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
During the new pandemic caused by SARS-CoV-2, there is short knowledge regarding the management of different disease areas, such as coagulopathy and interpretation of D-dimer levels, its association with disseminated intravascular coagulation (DIC) and controversy about the benefit of anticoagulation. Thus, a systematic review has been performed to define the role of D-dimer in the disease, the prevalence of DIC and the usefulness of anticoagulant treatment in these patients. A literature search was performed to analyze the studies of COVID-19 patients. Four recommendations were drawn based on expert opinion and scientific knowledge, according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. The present review suggests the presence of higher levels of D-dimer in those with worse prognosis, there may be an overdiagnosis of DIC in the course of the disease and there is no evidence on the benefit of starting anticoagulant treatment based only on isolated laboratory data.
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Jackson Chornenki NL, Dwivedi DJ, Kwong AC, Zamir N, Fox-Robichaud AE, Liaw PC. Identification of hemostatic markers that define the pre-DIC state: A multi-center observational study. J Thromb Haemost 2020; 18:2524-2531. [PMID: 32573898 DOI: 10.1111/jth.14973] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/05/2020] [Accepted: 06/08/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND A limitation of diagnostic scoring systems for disseminated intravascular coagulation (DIC) is that once DIC is identified, it may be in a state of irreversible deterioration. OBJECTIVES To identify hemostatic markers that can identify the pre-DIC state. METHODS This was a multi-center observational study of 357 septic patients. The incidence of DIC was determined using the International Society on Thrombosis and Haemostasis (ISTH) DIC Score. Markers of interest include components of the DIC score: protein C (PC), antithrombin (AT), and citrullinated histones (H3Cit), which is a marker of NETosis. RESULTS Out of 357 sepsis patients, 236 patients did not develop DIC (without-DIC), 79 patients had DIC on Day 1 (overt-DIC), and 42 patients developed DIC after Day 1 (pre-DIC). Compared to without-DIC patients, pre-DIC patients had decreased platelet count, increased international normalized ratio (INR), decreased PC and AT, and increased H3Cit. In contrast, D-dimer and fibrinogen levels did not differ between pre-DIC and without-DIC patients. Using receiver operating characteristics (ROC) analysis, we found that platelet count and INR in combination with PC and AT could discriminate pre-DIC from without-DIC. The area under the curve in the ROC analysis was 0.83 (95% confidence interval, 0.76 to 0.89). CONCLUSION Our study suggests that platelets and INR in combination with PC and AT can identify the pre-DIC state in septic patients. In contrast, D-dimer increased and fibrinogen decreased in the late (ie, overt) stages of DIC. Our data also suggest that NETosis contributes to the onset of DIC in sepsis.
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Affiliation(s)
- Nicholas L Jackson Chornenki
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Thrombosis and Atherosclerosis Research Institute (TaARI), Hamilton, ON, Canada
| | - Dhruva J Dwivedi
- Thrombosis and Atherosclerosis Research Institute (TaARI), Hamilton, ON, Canada
| | - Andrew C Kwong
- Thrombosis and Atherosclerosis Research Institute (TaARI), Hamilton, ON, Canada
| | - Nasim Zamir
- Thrombosis and Atherosclerosis Research Institute (TaARI), Hamilton, ON, Canada
| | - Alison E Fox-Robichaud
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Thrombosis and Atherosclerosis Research Institute (TaARI), Hamilton, ON, Canada
| | - Patricia C Liaw
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Thrombosis and Atherosclerosis Research Institute (TaARI), Hamilton, ON, Canada
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Yamakawa K, Ohbe H, Taniguchi K, Matsui H, Fushimi K, Yasunaga H. Time Trends of the Outcomes and Treatment Options for Disseminated Intravascular Coagulation: A Nationwide Observational Study in Japan. JMA J 2020; 3:313-320. [PMID: 33225103 PMCID: PMC7677444 DOI: 10.31662/jmaj.2020-0013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/05/2020] [Indexed: 11/09/2022] Open
Abstract
Introduction Existing evidence on the mortality time trends of patients with disseminated intravascular coagulation (DIC) is limited, and whether the mortality trend or quality of care of DIC patients has improved remains unknown. This study aimed to investigate the temporal trend in mortality, patient outcomes, and treatment preferences of several anticoagulants in Japan. Methods This retrospective observational study used the Japanese Diagnosis Procedure Combination inpatient database, which contains data from more than 1200 acute-care hospitals in Japan. We identified all adult patients that were diagnosed with DIC from July 2010 to March 2018 and sorted them into one of five predefined underlying conditions: sepsis, solid cancer, leukemia, trauma, or obstetric. The data collected as general outcomes were the 28-day mortality and major bleeding events. We also evaluated anticoagulant use for DIC treatment. Results A total of 325,327 DIC patients were included in this study. Regarding the baseline characteristics, an increase in median age, worsened comorbid conditions, and higher illness severity were observed over time. The underlying conditions for DIC were largely unchanged. Over the study period, the 28-day mortality for overall DIC patients decreased from 41.8% (95% CI 41.2%-42.3%) to 36.1% (95% CI 35.6%-36.6%), which is a 14% decrease over the 8-year period (P trend < 0.001). The downward trend in mortality was more evident in patients with sepsis and leukemia (15% and 14% decreases, respectively), whereas no clinically meaningful change in mortality occurred in trauma and obstetrics patients. Over time, major bleeding events modestly increased, and the length of hospital stay decreased. The temporal trend in the treatment preferences of anticoagulants for DIC patients clearly changed over time. Conclusions The overall 28-day mortality for DIC patients clearly decreased from 2010 to 2017. The downward trend in mortality might have resulted from the advances made in the fundamental treatment of underlying diseases and from the changes in anti-DIC strategies.
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Affiliation(s)
- Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kohei Taniguchi
- Translational Research Program, Osaka Medical College, Osaka, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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15
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Ikezoe T. Advances in the diagnosis and treatment of disseminated intravascular coagulation in haematological malignancies. Int J Hematol 2020; 113:34-44. [PMID: 32902759 DOI: 10.1007/s12185-020-02992-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/22/2020] [Accepted: 08/28/2020] [Indexed: 11/26/2022]
Abstract
Haematological malignancies, including acute leukaemia and non-Hodgkin lymphoma, are one of the underlying diseases that frequently cause disseminated intravascular coagulation (DIC), an acquired thrombotic disorder. Concomitant DIC is associated with the severity of the underlying disease and poor prognosis. The Japanese Society on Thrombosis and Hemostasis released the new DIC diagnostic criteria in 2017. This criteria include coagulation markers such as soluble fibrin and the thrombin-antithrombin complex to more accurately evaluate the hypercoagulable state in patients. Among several groups of anticoagulants available, recombinant human soluble thrombomodulin is most frequently used to treat DIC caused by haematological malignancies in Japan. DIC is remitted in parallel with the improvement of the underlying haematological diseases; thus, there is room for debate regarding whether the treatment of DIC would improve the prognosis of patients. Haematopoietic stem cell transplantation as well as the recently introduced chimeric antigen receptor (CAR)-T-cell therapy are innovative therapies to produce a cure in a subset of patients with haematological malignancies. However, coagulopathy frequently occurs after these therapies, which limits the success of the treatment. For example, DIC is noted in approximately 50% of patients after CAT-T-cell therapy in conjunction with cytokine release syndrome. Hematopoietic stem cell transplantation (HSCT) causes endotheliitis, which triggers coagulopathy and the development of potentially lethal complications, such as sinusoidal obstruction syndrome/veno-occlusive disease and transplant-associated thrombotic microangiopathy. This review article describes the pathogenesis, clinical manifestation, diagnosis, and treatment of DIC caused by haematological malignancies, CAR-T-cell therapy, and HSCT.
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Affiliation(s)
- Takayuki Ikezoe
- Department of Haematology, Fukushima Medical University, Fukushima, 960-1295, Japan.
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16
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Kalpatthi R, Kiss JE. Thrombotic Thrombocytopenic Purpura, Heparin-Induced Thrombocytopenia, and Disseminated Intravascular Coagulation. Crit Care Clin 2020; 36:357-377. [PMID: 32172818 DOI: 10.1016/j.ccc.2019.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Hemostatic abnormalities are common among critically ill patients and are associated with a high risk of bleeding. The abnormalities range from isolated thrombocytopenia or prolongation of global coagulation assays to complex disease states, such as thrombotic microangiopathic syndromes, and can be associated with a wide range of conditions, including trauma, surgery, acute disease processes, cardiopulmonary bypass, and exposure to drugs and blood products. Prompt identification of underlying causes is important because treatment strategies vary. Moreover, prompt initiation of both supportive and specific treatments is vital to decrease the morbidity and mortality in the intensive care unit.
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Affiliation(s)
- Ram Kalpatthi
- Division of Pediatric Hematology Oncology, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Suite 501A, Pittsburgh, PA 15224, USA
| | - Joseph E Kiss
- Division of Hematology Oncology, Department of Medicine, Clinical Apheresis and Blood Services, Vitalant Northeast Division, University of Pittsburgh School of Medicine, 3636 Boulevard of the Allies, Pittsburgh, PA 15213, USA.
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Abstract
The evaluation and management of thrombocytopenia is a daily challenge for clinicians in the intensive care unit (ICU). Thrombocytopenia is incredibly common, present in upwards of 60% of ICU patients. Additionally, thrombocytopenia in the critically ill is rarely caused by a single etiology. Several causes of thrombocytopenia in the ICU including heparin-induced thrombocytopenia (HIT) and thrombotic thrombocytopenic purpura demand urgent recognition and intervention. This chapter provides a general overview of thrombocytopenia in the ICU and highlights important diagnostic and management considerations for some of the most common etiologies.
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Affiliation(s)
- Robert C. Hyzy
- Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI USA
| | - Jakob McSparron
- Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI USA
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18
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Affiliation(s)
- Marie Scully
- Department of Haematology University College London HospitalLondonUK
- Cardiometabolic Programme‐NIHR UCLH/UCL BRC LondonUK
| | - Marcel Levi
- Cardiometabolic Programme‐NIHR UCLH/UCL BRC LondonUK
- Department of Medicine UCLH London UK
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Padungmaneesub W, Reungrongrat S, Manowong S, Fanhchaksai K, Panyasit N, Natesirinilkul R. Biomarkers of disseminated intravascular coagulation in pediatric intensive care unit in Thailand. Int J Lab Hematol 2018; 41:32-38. [PMID: 30208259 DOI: 10.1111/ijlh.12917] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 07/16/2018] [Accepted: 07/25/2018] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Disseminated intravascular coagulation (DIC) is a systemic activation of hemostatic system caused by several causes. Biomarkers including antithrombin (AT), protein C (PC), and thrombomodulin (TM) were reported as the additional markers for DIC in adults. This study aimed to determine the association between biomarkers among patients with overt DIC (ODIC) and nonovert DIC (NDIC) in children in PICU. METHODS We enrolled 103 subjects, aged 1 month-18 years, who were admitted to PICU at Chiang Mai University (CMU) Hospital >24 hours with underlying conditions predisposing to DIC were enrolled. Biomarkers were tested after 24 hours of admission. Subject who had NDIC on the 1st investigations would have other tests on days 3-5 of admission. RESULTS The incidence of ODIC by the International Society on Thrombosis and Hemostasis (ISTH) DIC score was found 24%. The bleeding, thrombosis, and death were significantly higher in ODIC group (P < 0.05). Mean levels of AT and PC in ODIC group were significantly different from NDIC one (66.9% vs 79.9%, P < 0.001 and 46.1% vs 59.2%, P = 0.004, respectively) while mean level of TM was not different between two groups. Adding AT to DIC score was better than the original score for predict mortality [area under curve (AUC) = 0.662 vs AUC = 0.65] and bleeding (AUC = 0.751 vs AUC = 0.732). CONCLUSIONS ODIC is prevalent among critically ill children. Adverse outcomes were more commonly found in children with ODIC. AT and PC levels after 24 hours of PICU admission seem to be the useful biomarkers for ODIC in PICU.
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Affiliation(s)
| | - Sanit Reungrongrat
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Suphara Manowong
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kanda Fanhchaksai
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Noppamas Panyasit
- Hematology Laboratory, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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20
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How I treat disseminated intravascular coagulation. Blood 2018; 131:845-854. [DOI: 10.1182/blood-2017-10-804096] [Citation(s) in RCA: 134] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 12/17/2017] [Indexed: 12/31/2022] Open
Abstract
Abstract
Disseminated intravascular coagulation (DIC) is a condition characterized by systemic activation of coagulation, potentially leading to thrombotic obstruction of small and midsize vessels, thereby contributing to organ dysfunction. At the same time, ongoing consumption of platelets and coagulation proteins results in thrombocytopenia and low concentrations of clotting factors, which may cause profuse hemorrhagic complications. DIC is always secondary to an underlying condition, such as severe infections, solid or hematologic malignancies, trauma, or obstetric calamities. A reliable diagnosis of DIC can be made through simple scoring algorithms based on readily available routine hemostatic parameters. The cornerstone of supportive treatment of this coagulopathy is management of the underlying condition. Additionally, administration of heparin may be useful, and restoration of physiological anticoagulants has been suggested, but has not been proven successful in improving clinically relevant outcomes so far. In patients with major bleeding or at risk for hemorrhagic complications, administration of platelet concentrates, plasma, or coagulation factor concentrates should be considered.
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Wang B, Wu S, Wang T, Ma Z, Liu K. Bone Marrow-Derived Mesenchymal Stem Cells-Mediated Protection Against Organ Dysfunction in Disseminated Intravascular Coagulation Is Associated With Peripheral Immune Responses. J Cell Biochem 2017; 118:3184-3192. [PMID: 28252221 DOI: 10.1002/jcb.25964] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 02/28/2017] [Indexed: 02/06/2023]
Abstract
Disseminated intravascular coagulation (DIC) is a fatal thrombohemorrhagic disorder. Bone marrow-derived mesenchymal stem cells (BMSCs) are multipotent stem cells that have tremendous therapeutic effect. Our aim was to explore whether the immune mechanisms were associated with BMSCs-afforded protection against DIC. We generated a rat model of DIC by lipopolysaccharide (LPS, 3 mg/kg) injection via the tail vein. In the treatment group, rats were pre-treated with 1 × l03 , 1 × l04 , 1 × l05 , and 1 × l06 allogeneic BMSCs before LPS injection. Blood sample was withdrawn from the abdominal aorta at 0 (before), 4, and 8 h after LPS injection and used for biochemical analyses. After experiments, the mice were sacrificed and their organs were harvested and observed by H&E and PTAH staining. Continuous infusion of LPS into the rats gradually impaired the hemostatic parameters and damaged organ functions. However, pre-treatment with BMSCs dose-dependently improved the hemostatic parameters. Meanwhile, the treatment significantly suppressed the fibrin microthrombi formation and alleviated liver, heart, lung, and renal injuries. Flow cytometry analysis demonstrated that BMSCs pre-treatment inhibited LPS-induced upregulation of CD3+ CD8+ T cells and CD3+ /CD161a+ NKT cells in the peripheral blood. BMSCs pre-treatment reversed the upregualtion of the B-cell population and the percentage of CD43+ /CD172a+ monocytes in the DIC models. Finally, BMSCs pre-treatment decreased the levels of tumor necrosis factor-α (TNF-α), interferon-γ (IFN-γ), interleukin-1β (IL-1β), and interleukin-6 (IL-6) and increased the levels of interleukin-10 (IL-10) in LPS-induced DIC models. Pre-treatment with BMSCs can reduce coagulation and alleviate organ dysfunction via peripheral immune responses in LPS-induced DIC rat model. J. Cell. Biochem. 118: 3184-3192, 2017. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Biao Wang
- Department of Cardiovascular Surgery, Qilu Hospital, Shandong, University, Jinan, Shandong, 250012, China
| | - Shuming Wu
- Department of Cardiovascular Surgery, Qilu Hospital, Shandong, University, Jinan, Shandong, 250012, China
| | - Tao Wang
- Department of Cardiovascular Surgery, Qilu Hospital, Shandong, University, Jinan, Shandong, 250012, China
| | - Zengshan Ma
- Department of Cardiovascular Surgery, Qilu Hospital, Shandong, University, Jinan, Shandong, 250012, China
| | - Kai Liu
- Department of Cardiovascular Surgery, Qilu Hospital, Shandong, University, Jinan, Shandong, 250012, China
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Abstract
OBJECTIVES To provide a review of the definition, pathophysiology, differential diagnosis, and treatment of disseminated intravascular coagulation (DIC). METHODS A case scenario and a review of the literature related to the pertinent facts concerning DIC are provided. RESULTS DIC is a systemic pathophysiologic process and not a single disease entity, resulting from an overwhelming activation of coagulation that consumes platelets and coagulation factors and causes microvascular fibrin thrombi, which can result in multiorgan dysfunction syndrome from tissue ischemia. Some conditions associated with acute DIC include septic shock, exsanguinating trauma, burns, or acute promyelocytic leukemia. CONCLUSIONS The massive tissue factor stimulus results in excess intravascular thrombin, which overcomes the anticoagulant systems and leads to thrombosis. Because of consumption of coagulation factors and platelets, DIC also has a hemorrhagic phase. Treatment of the bleeding patient with DIC is supportive with the use of blood components.
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Affiliation(s)
| | - Dennis J Williams
- Pathology and Laboratory MedicineUniversity of Kentucky Medical Center, Lexington
| | - Leonard I Boral
- Pathology and Laboratory MedicineUniversity of Kentucky Medical Center, Lexington
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Abstract
Disseminated intravascular coagulation (DIC) is an acquired syndrome characterized by widespread intravascular activation of coagulation that can be caused by infectious insults (such as sepsis) and non-infectious insults (such as trauma). The main pathophysiological mechanisms of DIC are inflammatory cytokine-initiated activation of tissue factor-dependent coagulation, insufficient control of anticoagulant pathways and plasminogen activator inhibitor 1-mediated suppression of fibrinolysis. Together, these changes give rise to endothelial dysfunction and microvascular thrombosis, which can cause organ dysfunction and seriously affect patient prognosis. Recent observations have pointed to an important role for extracellular DNA and DNA-binding proteins, such as histones, in the pathogenesis of DIC. The International Society on Thrombosis and Haemostasis (ISTH) established a DIC diagnostic scoring system consisting of global haemostatic test parameters. This scoring system has now been well validated in diverse clinical settings. The theoretical cornerstone of DIC management is the specific and vigorous treatment of the underlying conditions, and DIC should be simultaneously managed to improve patient outcomes. The ISTH guidance for the treatment of DIC recommends treatment strategies that are based on current evidence. In this Primer, we provide an updated overview of the pathophysiology, diagnosis and management of DIC and discuss the future directions of basic and clinical research in this field.
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Nakamura K, Inokuchi R, Hiruma T, Ohshima K, Sonoo T, Tokunaga K, Doi K, Nakajima S. Recombinant thrombomodulin for secondary thrombotic thrombocytopenic purpura. Medicine (Baltimore) 2016; 95:e3712. [PMID: 27310951 PMCID: PMC4998437 DOI: 10.1097/md.0000000000003712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
In the pathogenesis of thrombotic thrombocytopenic purpura (TTP), reductions in the enzyme activity of ADAMTS13, which cuts ultralarge von Willebrand multimers, generates shear stress on the microvascular endothelium, leading to platelet aggregation and the formation of a thrombus. ADAMTS13 activity is markedly decreased in typical TTP, but is only mildly reduced in secondary TTP, which concomitantly develops with primary disease. The latter develops with septic disseminated intravascular coagulation (DIC) and often causes organ failure. Recombinant thrombomodulin (rTM) is a drug that is used to treat DIC and may also remit TTP because it improves vascular endothelial dysfunction. Therefore, we herein investigated the efficacy of rTM in patients treated for the pathology of secondary TTP. Patients who were admitted to the Emergency and Critical Care Center of our hospital and met the following conditions were extracted and retrospectively analyzed: hemolytic anemia accompanied by fragmented red blood cells (Hb < 12 g/dL or lower); thrombocytopenia (<100 × 10/μL); and ADAMTS13 activity <50%. Sixteen patients were included and accompanied by Kidney Disease: Improving Global Outcomes (KDIGO) stage 2 or more severe nephropathy and DIC. Eleven and 5 patients treated with and without rTM (the rTM and non-rTM treatment groups, respectively) were compared, and no significant difference was noted in their basic characteristics, such as background disease and severity. No significant difference was observed in survival rates; however, the platelet count, which is an important outcome of treatments for TTP, significantly increased in the rTM treatment group: 3.3 ± 2.6→11.3 ± 14.6 versus 3.5 ± 3.7→5.7 ± 3.9 (×1000/μL) (P = 0.034). Thrombotic thrombocytopenic purpura originally requires invasive treatments and its prognosis is not favorable. Blood thrombomodulin levels also markedly increase due to vascular endothelial dysfunction, whereas rTM alleviates vascular endothelial dysfunction in TTP patients with high blood TM levels, suggesting the importance of administering rTM. Thus, rTM may be effective for secondary TTP and may be adopted as adjuvant therapy.
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Affiliation(s)
- Kensuke Nakamura
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki
| | - Ryota Inokuchi
- Department of Emergency and General Medicine, JR General Hospital, Sibuya-ku, Tokyo
| | - Takahiro Hiruma
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Kazuma Ohshima
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki
| | - Tomohiro Sonoo
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Kurato Tokunaga
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Susumu Nakajima
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
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Iba T, Thachil J. Present and future of anticoagulant therapy using antithrombin and thrombomodulin for sepsis-associated disseminated intravascular coagulation: a perspective from Japan. Int J Hematol 2015; 103:253-61. [PMID: 26588929 DOI: 10.1007/s12185-015-1904-z] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 11/04/2015] [Accepted: 11/08/2015] [Indexed: 02/07/2023]
Abstract
In sepsis, the coagulation system is often systemically activated in combination with the simultaneous impairment of fibrinolysis and anticoagulant systems. Since this hypercoagulable state often leads to disseminated intravascular coagulation (DIC), an independent predictor of mortality in critically ill patients, the appropriate management of DIC itself is a crucial part of treatment strategies for severe sepsis. In this context, the Japanese Association of Acute Medicine (JAAM) scoring system for DIC has been proposed as a valid test for diagnosing DIC; this system is also expected to aid in devising specifically tailored management strategies. Anticoagulant therapy is commonly given to septic patients with DIC as part of the standard care in Japan. More recently, antithrombin concentrate and recombinant thrombomodulin have become the two major anticoagulant agents of choice. In relation to the use of antithrombin, recent studies have indicated that the recovery of antithrombin activity to within the normal range (>70%) is necessary if supplementation therapy is to provide a favorable outcome. Recombinant thrombomodulin is slightly more controversial, with favorable results being greater among severe cases of DIC. In the present review, we summarize recent clinical advances in anticoagulant therapy for sepsis-associated DIC.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK.
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Yatabe T, Nakamura R, Kumagai N, Iiyama T, Yamashita K, Yokoyama M. Administration of recombinant thrombomodulin before progression of disease causing disseminated intravascular coagulation might be better compared with administration after progression of disease. J Intensive Care 2014. [DOI: 10.1186/s40560-014-0049-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Wu Z, Li JN, Bai ZQ, Lin X. Antagonism by salvianolic acid B of lipopolysaccharide-induced disseminated intravascular coagulation in rabbits. Clin Exp Pharmacol Physiol 2014; 41:502-8. [DOI: 10.1111/1440-1681.12242] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 03/25/2014] [Accepted: 04/02/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Zheng Wu
- Department of Developmental and Regenerative Biology; Ji-nan University; Guangzhou China
| | - Jian-nan Li
- Department of Parmacology; Medical College; Ji-nan University; Guangzhou China
| | - Zhi-quan Bai
- Department of Physiology; Medical College; Ji-nan University; Guangzhou China
| | - Xi Lin
- Department of Parmacology; Medical College; Ji-nan University; Guangzhou China
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Murata A, Okamoto K, Mayumi T, Muramatsu K, Matsuda S. The recent time trend of outcomes of disseminated intravascular coagulation in Japan: an observational study based on a national administrative database. J Thromb Thrombolysis 2014; 38:364-71. [PMID: 24823684 DOI: 10.1007/s11239-014-1068-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Martin R, Esper A, Martin GS. Hematologic Complications. NON-PULMONARY COMPLICATIONS OF CRITICAL CARE 2014. [PMCID: PMC7121187 DOI: 10.1007/978-1-4939-0873-8_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Critically ill patients are at high risk of developing various hematologic complications that may be present on admission or occur during their stay in the Intensive Care Unit (ICU). Often times the etiology of specific hematologic abnormalities is unclear and the diagnosis may be challenging due to the complexity of critically ill patients. This chapter will focus on diagnosis and management of the most commonly encountered hematologic problems in the critically ill such as anemia, neutropenia, thrombocytopenia, coagulopathy and thrombotic complications, with specific focus on diagnosis and management of these conditions.
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Singh B, Parsaik AK, Mielke MM, Roberts RO, Scanlon PD, Geda YE, Pankratz VS, Christianson T, Yawn BP, Petersen RC. Chronic obstructive pulmonary disease and association with mild cognitive impairment: the Mayo Clinic Study of Aging. Mayo Clin Proc 2013; 88:1222-30. [PMID: 24182702 PMCID: PMC3875365 DOI: 10.1016/j.mayocp.2013.08.012] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Revised: 08/02/2013] [Accepted: 08/13/2013] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To investigate the association of chronic obstructive pulmonary disease (COPD) with mild cognitive impairment (MCI) and MCI subtype: amnestic MCI and nonamnestic MCI, in a population-based study of elderly patients. PATIENTS AND METHODS Participants included 1927 individuals aged 70 to 89 years enrolled in the population-based Mayo Clinic Study of Aging. Participants were evaluated by using a nurse assessment, neurological evaluation, and neuropsychological testing, and the diagnosis of MCI was made by a consensus panel according to the standardized criteria. Chronic obstructive pulmonary disease was identified by the review of medical records. The study was conducted from October 1, 2004, through July 31, 2007. The associations of COPD and disease duration with MCI and its subtypes were evaluated by using logistic regression models adjusted for potential covariates. RESULTS Of 1927 participants, 288 had COPD (men vs women: 18% vs 12%; P<.001). As compared with patients without COPD, patients with COPD had a higher prevalence of MCI (27% vs 15%; P<.001). The odds ratio (OR) for MCI was almost 2 times higher in patients with COPD than in those without (OR, 1.87; 95% CI, 1.34-2.61), with a similar effect in men and women. The OR for MCI increased from 1.60 (95% CI, 0.97-2.57) in patients with a COPD duration of 5 years or less to 2.10 (95% CI, 1.38-3.14) in patients with a COPD duration of more than 5 years. CONCLUSION This population-based study suggests that COPD is associated with increased odds of having MCI and its subtypes. There was a dose-response relationship with the duration of COPD after controlling for the potential covariates.
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Affiliation(s)
- Balwinder Singh
- Department of Neurology, Mayo Clinic, Rochester, MN; Department of Clinical Neuroscience, University of North Dakota School of Medicine and Health Sciences, Fargo, ND.
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