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Tayal D, Jain P, Goswami B. D-dimer - a multifaceted molecule. Horm Mol Biol Clin Investig 2024; 45:75-84. [PMID: 38716869 DOI: 10.1515/hmbci-2022-0093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 04/19/2024] [Indexed: 06/27/2024]
Abstract
D-dimer, a universally unique marker for fibrin degradation, is generated through the enzymatic interplay of thrombin, factor XIIIa, and plasmin. The emergence of D-dimer-containing fibrin molecules occurs in both intravascular and extravascular spaces during pivotal physiological processes like haemostasis, thrombosis, and tissue repair. Given the inherently physiological nature of fibrin formation and fibrinolysis, basal levels of D-dimer fragments are present in plasma. Beyond its role as a marker of routine physiological processes, aberrations in D-dimer levels are indicative of a spectrum of conditions, both non-pathological and pathological. The clinical utility of D-dimer has been firmly established, particularly in scenarios like venous thromboembolism (VTE), pulmonary embolism (PE), deep vein thrombosis (DVT), and disseminated intravascular coagulation (DIC). Additionally, recent applications have extended to assess the prognosis of COVID-19. While D-dimer is commonly associated with thrombotic conditions, its elevation is not confined to these conditions alone. Elevated D-dimer levels are observed across various diseases, where its significance extends beyond diagnostic indicators to prognostic implications.
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Affiliation(s)
- Devika Tayal
- Department of Biochemistry, National Institute of Tuberculosis and Respiratory Disease, New Delhi, India
| | - Prerna Jain
- Department of Biochemistry, National Institute of Tuberculosis and Respiratory Disease, New Delhi, India
| | - Binita Goswami
- Department of Biochemistry, Maulana Azad Medical College, New Delhi, India
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2
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Muse VP, Aguayo-Orozco A, Balaganeshan SB, Brunak S. Population-wide analysis of hospital laboratory tests to assess seasonal variation and temporal reference interval modification. PATTERNS (NEW YORK, N.Y.) 2023; 4:100778. [PMID: 37602220 PMCID: PMC10435957 DOI: 10.1016/j.patter.2023.100778] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 03/24/2023] [Accepted: 05/26/2023] [Indexed: 08/22/2023]
Abstract
We identified mortality-, age-, and sex-associated differences in relation to reference intervals (RIs) for laboratory tests in population-wide data from nearly 2 million hospital patients in Denmark and comprising more than 300 million measurements. A low-parameter mathematical wave-based modification method was developed to adjust for dietary and environment influences during the year. The resulting mathematical fit allowed for improved association rates between re-classified abnormal laboratory tests, patient diagnoses, and mortality. The study highlights the need for seasonally modified RIs and presents an approach that has the potential to reduce over- and underdiagnosis, affecting both physician-patient interactions and electronic health record research as a whole.
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Affiliation(s)
- Victorine P. Muse
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Alejandro Aguayo-Orozco
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Sedrah B. Balaganeshan
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Søren Brunak
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
- Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2200 Copenhagen, Denmark
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3
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Dujardin RWG, Garcia Rosenbaum G, Klercq TCJ, Thachil J, Nielsen ND, Juffermans NP. Rotational thromboelastometry in critically ill COVID-19 patients does not predict thrombosis. Res Pract Thromb Haemost 2022; 6:e12798. [PMID: 36090158 PMCID: PMC9448874 DOI: 10.1002/rth2.12798] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 07/22/2022] [Accepted: 08/03/2022] [Indexed: 12/03/2022] Open
Abstract
Background Critically ill COVID-19 patients are in a hypercoagulable state with increased risk of thrombotic complications. Rotational thromboelastometry (ROTEM) is a viscoelastic test with the potential to reflect COVID-19-associated hypercoagulability and may therefore be useful to predict thrombotic complications. Objective To investigate the potential of ROTEM profiles to predict thrombotic complications in critically ill COVID-19 patients. Patients/Methods Retrospective multicenter cohort study in 113 adult patients with confirmed COVID-19 infection admitted to the intensive care unit (ICU) of two large teaching hospitals in the United States and in the Netherlands. ROTEM profiles of the EXTEM, INTEM, and FIBTEM tracings were measured within 72 h of ICU admission. Thrombotic complications encompass both arterial and venous thromboembolic complications, diagnosed with electrocardiogram, ultrasound, or computed tomography. ROTEM profiles were compared between patients with and without thrombosis. Univariable logistic regression followed by receiver operating characteristic (ROC) curves analysis was performed to identify ROTEM parameters associated with thrombosis. Results and Conclusions Of 113 patients, 27 (23.9%) developed a thrombotic event. In the univariable analysis, EXTEM clot amplitude at 10 min (CA10) and EXTEM maximum clot formation (MCF) were associated with thrombosis with a p < 0.2 (p = 0.07 and p = 0.05, respectively). In ROC curve analysis, EXTEM CA10 had an area under the curve (AUC) of 0.58 (95% CI 0.47-0.70) and EXTEM MCF had an AUC of 0.60 (95% CI 0.49-0.71). Thereby, ROTEM profiles at ICU admission did not have the potential to differentiate between patients with a high and low risk for thrombotic complications.
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Affiliation(s)
- Romein W. G. Dujardin
- Department of Intensive CareOLVG HospitalAmsterdamThe Netherlands
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
| | - Gabriel Garcia Rosenbaum
- Department of Internal MedicineUniversity of New Mexico School of MedicineAlbuquerqueNew MexicoUSA
| | | | - Jecko Thachil
- Department of HaematologyManchester Royal InfirmaryManchesterUK
| | - Nathan D. Nielsen
- Division of Pulmonary, Critical Care and Sleep MedicineUniversity of New Mexico School of MedicineAlbuquerqueNew MexicoUSA
- Department of PathologyUniversity of New Mexico School of MedicineAlbuquerqueNew MexicoUSA
| | - Nicole P. Juffermans
- Department of Intensive CareOLVG HospitalAmsterdamThe Netherlands
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
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Li L, Zhou J, Huang L, Zhen J, Yao L, Xu L, Zhang W, Zhang G, Chen Q, Cheng B, Gong S, Cai G, Jiang R, Yan J. Prevention, treatment, and risk factors of deep vein thrombosis in critically ill patients in Zhejiang province, China: a multicenter, prospective, observational study. Ann Med 2021; 53:2234-2245. [PMID: 34797177 PMCID: PMC8805816 DOI: 10.1080/07853890.2021.2005822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/08/2021] [Indexed: 11/21/2022] Open
Abstract
PURPOSE The aim of this study is to investigate the prevention and treatment patterns of deep vein thrombosis (DVT) in critically ill patients and to explore the risk factors for DVT in people from Zhejiang Province, China. MATERIALS AND METHODS This study prospectively enrolled patients admitted in intensive care units (ICUs) of 54 hospitals from 09/16/2019 to 01/16/2020. The risk of developing DVT and subsequent prophylaxis was evaluated. The primary outcome was DVT occurrence during ICU hospitalisation. Univariate and multivariate logistic regression were performed to determine the risk factors for DVT. RESULTS A total of 940 patients were included in the study. Among 847 patients who received prophylaxis, 635 (75.0%) patients received physical prophylaxis and 199 (23.5%) patients received drug prophylaxis. Fifty-eight (6.2%) patients were diagnosed with DVT after admission to the ICU, and 36 patients were treated with anticoagulants (all patients received low molecular weight heparin [LMWH]). D-dimer levels (OR = 1.256, 95% CI: 1.132-1.990), basic prophylaxis (OR = 0.092, 95% CI: 0.016-0.536), and physical prophylaxis (OR = 0.159, 95% CI: 0.038-0.674) were independently associated with DVT in ICU patients. The short-term survival was similar between DVT and non-DVT patients. CONCLUSIONS DVT prophylaxis is widely performed in ICU patients. Prophylaxis is an independent protective factor for DVT occurrence. The most common treatment of DVT patients is LMWH, although it might increase the rate of bleeding.Key messagesThis is the only multicenter and prospective study of DVT in ICUs in China.d-dimer levels were independently associated with DVT in ICU patients.Prophylaxis was an independent protective factor for DVT occurrence in ICU.
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Affiliation(s)
- Li Li
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, Zhejiang, China
| | - Jia Zhou
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, Zhejiang, China
| | - Liquan Huang
- Department of Critical Care Medicine, Zhejiang Provincial Hospital of Chinese Medicine, Hangzhou, Zhejiang, China
| | - Junhai Zhen
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, Zhejiang, China
| | - Lina Yao
- Department of Critical Care Medicine, Ningbo Yinzhou People’s Hospital, Yinzhou, Zhejiang, China
| | - Lingen Xu
- Department of Critical Care Medicine, Xinchang Hospital of Traditional Chinese Medicine, Xinchang, Zhejiang, China
| | - Weimin Zhang
- Department of Critical Care Medicine, Dongyang People's Hospital, Dongyang, Zhejiang, China
| | - Gensheng Zhang
- Department of Critical Care Medicine, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Qijiang Chen
- Department of Critical Care Medicine, Ninghai First Hospital, Ninghai, Zhejiang, China
| | - Bihuan Cheng
- Department of Critical Care Medicine, The 2 School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Shijin Gong
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, Zhejiang, China
| | - Guolong Cai
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, Zhejiang, China
| | - Ronglin Jiang
- Department of Critical Care Medicine, Zhejiang Provincial Hospital of Chinese Medicine, Hangzhou, Zhejiang, China
| | - Jing Yan
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, Zhejiang, China
| | - (Zhejiang Provincial Critical Care Clinical Research Group)
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, Zhejiang, China
- Department of Critical Care Medicine, Zhejiang Provincial Hospital of Chinese Medicine, Hangzhou, Zhejiang, China
- Department of Critical Care Medicine, Ningbo Yinzhou People’s Hospital, Yinzhou, Zhejiang, China
- Department of Critical Care Medicine, Xinchang Hospital of Traditional Chinese Medicine, Xinchang, Zhejiang, China
- Department of Critical Care Medicine, Dongyang People's Hospital, Dongyang, Zhejiang, China
- Department of Critical Care Medicine, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Department of Critical Care Medicine, Ninghai First Hospital, Ninghai, Zhejiang, China
- Department of Critical Care Medicine, The 2 School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China
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Das B, Bhatia SY, Pal PM. Evaluation of the Role of Routine Laboratory Biomarkers in COVID-19 Patients: Perspective from a Tertiary Care Hospital in India. Indian J Clin Biochem 2021; 36:473-484. [PMID: 33907355 PMCID: PMC8062949 DOI: 10.1007/s12291-021-00978-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 02/17/2021] [Indexed: 01/08/2023]
Abstract
To evaluate the role of routine laboratory biomarkers like C Reactive Protein (CRP), Lactate Dehydrogenase (LDH), Interleukin 6 (IL6), Ferritin, Creatinine, Procalcitonin (PCT), Aspartate aminotransferase (AST), Alanine aminotransferase (ALT), Serum Albumin, Total Bilirubin (T Bil), High Sensitive Troponin I (hs troponin I), N Terminal-pro B-type Natriuretic Peptide (NT proBNP), Blood Urea Nitrogen (BUN) and Blood Gases in COVID 19 patients who are admitted with SARS CoV-2 positive test results by real-time reverse transcriptase polymerase chain reaction (rRT PCR) in Kokilaben Dhirubhai Ambani Hospital & Medical Research Institute, Mumbai, India. 100 individuals detected with COVID-19 belonging to the age group 12-83 years (median age 62 years) within the period of 1st March 2020 to 10th July 2020 were studied. The case group consisted of 72 males and 28 females. 40 healthy adults without any history or clinical evidence suggestive of COVID-19 and without any comorbidities, like diabetes, hypertension chronic lung disease, cardiac disease, cancer, and immune-compromised individuals were considered as a control group for the study. Routine laboratory findings of these 100 patients were used to evaluate the abnormalities found in COVID-19 patients. Statistical analysis was carried out on the data after determining whether the data had a normal/log-normal distribution and their significance was determined by calculating the p-value. The percentage of patients showing a decrease or increase from the normal value was calculated. Trend analysis was carried out for the 100 patients considered in the case group. Among them, 6 patients were used as representatives to show the trend in these biomarkers during the course of hospital stay. These 5 severe cases consisted of 2 adult males, 2 adult females, and 1 adolescent girl. This selection is to demonstrate the representation of COVID-19 infection in adult males and females and pediatric multisystem inflammatory syndrome associated with COVID-19 in the younger age group. One mild case (adult male) was also selected in the case study. We found a significant increase in mean values of AST, ALT, Total Billirubin, Creatinine, CRP, PCT, LDH, IL6, Ferritin, Lactate, hsTroponin I, NT Pro BNP and decrease in mean values of Albumin, SO2, and PO2 in COVID 19 cases than control. We applied Receiver Operating Curve (ROC) curve to discriminate case population more precisely than the control population. Therefore, Routine laboratory biomarkers appear to play a significant role in COVID-19 patients.
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Affiliation(s)
- Barnali Das
- Department of Biochemistry & Immunology, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, Maharashtra India
| | - Seema Y. Bhatia
- Department of Biochemistry & Immunology, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, Maharashtra India
| | - Poonam M. Pal
- Department of Biochemistry & Immunology, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, Maharashtra India
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Jiang RM, Pourzanjani AA, Cohen MJ, Petzold L. Associations of longitudinal D-Dimer and Factor II on early trauma survival risk. BMC Bioinformatics 2021; 22:122. [PMID: 33714270 PMCID: PMC7955634 DOI: 10.1186/s12859-021-04065-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Trauma-induced coagulopathy (TIC) is a disorder that occurs in one-third of severely injured trauma patients, manifesting as increased bleeding and a 4X risk of mortality. Understanding the mechanisms driving TIC, clinical risk factors are essential to mitigating this coagulopathic bleeding and is therefore essential for saving lives. In this retrospective, single hospital study of 891 trauma patients, we investigate and quantify how two prominently described phenotypes of TIC, consumptive coagulopathy and hyperfibrinolysis, affect survival odds in the first 25 h, when deaths from TIC are most prevalent. METHODS We employ a joint survival model to estimate the longitudinal trajectories of the protein Factor II (% activity) and the log of the protein fragment D-Dimer ([Formula: see text]g/ml), representative biomarkers of consumptive coagulopathy and hyperfibrinolysis respectively, and tie them together with patient outcomes. Joint models have recently gained popularity in medical studies due to the necessity to simultaneously track continuously measured biomarkers as a disease evolves, as well as to associate them with patient outcomes. In this work, we estimate and analyze our joint model using Bayesian methods to obtain uncertainties and distributions over associations and trajectories. RESULTS We find that a unit increase in log D-Dimer increases the risk of mortality by 2.22 [1.57, 3.28] fold while a unit increase in Factor II only marginally decreases the risk of mortality by 0.94 [0.91,0.96] fold. This suggests that, while managing consumptive coagulopathy and hyperfibrinolysis both seem to affect survival odds, the effect of hyperfibrinolysis is much greater and more sensitive. Furthermore, we find that the longitudinal trajectories, controlling for many fixed covariates, trend differently for different patients. Thus, a more personalized approach is necessary when considering treatment and risk prediction under these phenotypes. CONCLUSION This study reinforces the finding that hyperfibrinolysis is linked with poor patient outcomes regardless of factor consumption levels. Furthermore, it quantifies the degree to which measured D-Dimer levels correlate with increased risk. The single hospital, retrospective nature can be understood to specify the results to this particular hospital's patients and protocol in treating trauma patients. Expanding to a multi-hospital setting would result in better estimates about the underlying nature of consumptive coagulopathy and hyperfibrinolysis with survival, regardless of protocol. Individual trajectories obtained with these estimates can be used to provide personalized dynamic risk prediction when making decisions regarding management of blood factors.
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Affiliation(s)
- Richard M. Jiang
- Department of Computer Science, University of California, Santa Barbara, Santa Barbara, USA
| | - Arya A. Pourzanjani
- Department of Computer Science, University of California, Santa Barbara, Santa Barbara, USA
- Now at Foresite Capital, San Francisco, USA
| | | | - Linda Petzold
- Department of Computer Science, University of California, Santa Barbara, Santa Barbara, USA
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Kamel MH, Yin W, Zavaro C, Francis JM, Chitalia VC. Hyperthrombotic Milieu in COVID-19 Patients. Cells 2020; 9:E2392. [PMID: 33142844 PMCID: PMC7694011 DOI: 10.3390/cells9112392] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 10/23/2020] [Accepted: 10/25/2020] [Indexed: 02/06/2023] Open
Abstract
COVID-19 infection has protean systemic manifestations. Experience from previous coronavirus outbreaks, including the current SARS-CoV-2, has shown an augmented risk of thrombosis of both macrovasculature and microvasculature. The former involves both arterial and venous beds manifesting as stroke, acute coronary syndrome and venous thromboembolic events. The microvascular thrombosis is an underappreciated complication of SARS-CoV-2 infection with profound implications on the development of multisystem organ failure. The telltale signs of perpetual on-going coagulation and fibrinolytic cascades underscore the presence of diffuse endothelial damage in the patients with COVID-19. These parameters serve as strong predictors of mortality. While summarizing the alterations of various components of thrombosis in patients with COVID-19, this review points to the emerging evidence that implicates the prominent role of the extrinsic coagulation cascade in COVID-19-related coagulopathy. These mechanisms are triggered by widespread endothelial cell damage (endotheliopathy), the dominant driver of macro- and micro-vascular thrombosis in these patients. We also summarize other mediators of thrombosis, clinically relevant nuances such as the occurrence of thromboembolic events despite thromboprophylaxis (breakthrough thrombosis), current understanding of systemic anticoagulation therapy and its risk-benefit ratio. We conclude by emphasizing a need to probe COVID-19-specific mechanisms of thrombosis to develop better risk markers and safer therapeutic targets.
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Affiliation(s)
- Mohamed Hassan Kamel
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA; (M.H.K.); (W.Y.); (C.Z.); (J.M.F.)
| | - Wenqing Yin
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA; (M.H.K.); (W.Y.); (C.Z.); (J.M.F.)
| | - Chris Zavaro
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA; (M.H.K.); (W.Y.); (C.Z.); (J.M.F.)
| | - Jean M. Francis
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA; (M.H.K.); (W.Y.); (C.Z.); (J.M.F.)
| | - Vipul C. Chitalia
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA; (M.H.K.); (W.Y.); (C.Z.); (J.M.F.)
- Veterans Affairs Boston Healthcare System, Boston, MA 02132, USA
- Institute of Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
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Levi M, Vincent JL, Tanaka K, Radford AH, Kayanoki T, Fineberg DA, Hoppensteadt D, Fareed J. Effect of a Recombinant Human Soluble Thrombomodulin on Baseline Coagulation Biomarker Levels and Mortality Outcome in Patients With Sepsis-Associated Coagulopathy. Crit Care Med 2020; 48:1140-1147. [PMID: 32697484 PMCID: PMC7365672 DOI: 10.1097/ccm.0000000000004426] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To assess the effects of recombinant human soluble thrombomodulin treatment on 28-day all-cause mortality in subgroups categorized by baseline coagulation biomarker levels (prothrombin fragment 1.2, thrombin-antithrombin complex, D-dimer) in patients with sepsis-associated coagulopathy in the Sepsis Coagulopathy Asahi Recombinant LE Thrombomodulin trial (SCARLET) (NCT01598831). DESIGN Post hoc, subgroup analysis of a randomized, double-blind, placebo-controlled, multinational, multicenter phase 3 study. SETTING ICUs at 159 sites in 26 countries. PATIENTS Eight-hundred adults with sepsis-associated coagulopathy defined as international normalized ratio greater than 1.40 and platelet count between 30 × 10/L and 150 × 10/L or greater than 30% decrease within 24 hours with concomitant cardiovascular and/or respiratory failure. INTERVENTIONS Patients randomized and treated with recombinant human soluble thrombomodulin (0.06 mg/kg/d; n = 395) or equivalent placebo (n = 405) for 6 days. MEASUREMENTS AND MAIN RESULTS Recombinant human soluble thrombomodulin did not significantly reduce 28-day all-cause mortality in the Sepsis Coagulopathy Asahi Recombinant LE Thrombomodulin trial: absolute risk reduction was 2.55% (p = 0.32) in patients with sepsis-associated coagulopathy. In this post hoc analysis, mortality steadily increased with increasing baseline prothrombin fragment 1.2 and thrombin-antithrombin complex levels in the placebo group; for those values exceeding the upper limit of normal, the mortality increases in the recombinant human soluble thrombomodulin group were lower or negligible with increasing baseline prothrombin fragment 1.2 and thrombin-antithrombin complex. Consequently, absolute risk reductions were greater in subgroups with higher baseline prothrombin fragment 1.2 or thrombin-antithrombin complex. Absolute risk reductions were also greater in subgroups with baseline coagulation biomarker levels at or above median of the entire study population, ranging from 4.2% (95% CI, -5.0% to 13.4%) to 5.5% (95% CI, -4.0% to 14.9%). CONCLUSIONS Compared with patients receiving placebo, patients treated with recombinant human soluble thrombomodulin having higher baseline thrombin generation biomarker levels had lower mortality. Further research regarding the predictive role of coagulation biomarkers for recombinant human soluble thrombomodulin treatment response in sepsis-associated coagulopathy is warranted to evaluate clinical relevance.
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Affiliation(s)
- Marcel Levi
- Department of Medicine and Cardiometabolic Programme - NIHR UCLH/UCL BRC, University College London Hospitals NHS Trust, London, United Kingdom
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Schefold JC, Gerber JL, Angehrn MC, Müller M, Messmer AS, Leichtle AB, Fiedler GM, Exadaktylos AK, Pfortmueller CA. Renal Function-Adjusted D-Dimer Levels in Critically Ill Patients With Suspected Thromboembolism. Crit Care Med 2020; 48:e270-e276. [PMID: 32205616 DOI: 10.1097/ccm.0000000000004204] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Diagnosing thromboembolic disease typically includes D-dimer testing and use of clinical scores in patients with low to intermediate pretest probability. However, renal dysfunction is often observed in patients with thromboembolic disease and was previously shown to be associated with increased D-dimer levels. We seek to validate previously suggested estimated glomerular filtration rate-adjusted D-dimer cutoff levels. Furthermore, we strive to explore whether the type of renal dysfunction affects estimated glomerular filtration rate-adjusted D-dimer test characteristics. DESIGN Single-center retrospective data analysis from electronic healthcare records of all emergency department patients admitted for suspected thromboembolic disease. SETTING Tertiary care academic hospital. SUBJECTS Exclusion criteria were as follows: age less than 16 years old, patients with active bleeding, and/or incomplete records. INTERVENTIONS Test characteristics of previously suggested that estimated glomerular filtration rate-adjusted D-dimer cutoff levels (> 333 µg/L [estimated glomerular filtration rate, > 60 mL/min/1.73 m], > 1,306 µg/L [30-60 mL/min/1.73 m], and > 1,663 µg/L [< 30 mL/min/1.73 m]) were validated and compared with the conventional D-dimer cutoff level of 500 µg/L. MAIN RESULTS A total of 14,477 patients were included in the final analysis, with 467 patients (3.5%) diagnosed with thromboembolic disease. Renal dysfunction was observed in 1,364 (9.4%) of the total population. When adjusted D-dimer levels were applied, test characteristics remained stable: negative predictive value (> 99%), sensitivity (91.2% vs 93.4%), and specificity (42.7% vs 50.7%) when compared with the conventional D-dimer cutoff level to rule out thromboembolic disease (< 500 µg/L). Comparable characteristics were also observed when adjusted D-dimer cutoff levels were applied in patients with acute kidney injury (negative predictive value, 98.8%; sensitivity, 95.8%; specificity, 39.2%) and/or "acute on chronic" renal dysfunction (negative predictive value, 98.0%; sensitivity, 92.9%; specificity, 48.5%). CONCLUSIONS D-Dimer cutoff levels adjusted for renal dysfunction appear feasible and safe assessing thromboembolic disease in critically ill patients. Furthermore, adjusted D-dimer cutoff levels seem reliable in patients with acute kidney injury and "acute on chronic" renal dysfunction. In patients with estimated glomerular filtration rate less than 60 mL/min/1.73 m, the false-positive rate can be reduced when estimated glomerular filtration rate-adjusted D-dimer cutoff levels are applied.
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Affiliation(s)
- Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Joël L Gerber
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michelle C Angehrn
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Health Economics and Clinical Epidemiology, University Hospital of Cologne, Cologne, Germany
| | - Anna S Messmer
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alexander B Leichtle
- Insel Data Coordination Lab (IDCL), Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Georg M Fiedler
- Center for Laboratory Medicine, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Aristomenis K Exadaktylos
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Carmen A Pfortmueller
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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High mobility group box protein 1 neutralization therapy in ovine bacteremia: Lessons learned from an ovine septic shock model incorporating intensive care support. Exp Ther Med 2019; 18:3271-3280. [PMID: 31602200 PMCID: PMC6777221 DOI: 10.3892/etm.2019.7961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 02/19/2019] [Indexed: 12/12/2022] Open
Abstract
Sepsis is a highly complex and often fatal syndrome which varies widely in its clinical manifestations, and therapies that target the underlying uncontrolled immune status in sepsis are needed. The failure of preclinical approaches to provide significant sepsis survival benefit in the clinic is often attributed to inappropriate animal disease models. It has been demonstrated that high mobility group box protein 1 (HMGB1) blockade can reduce inflammation, mortality and morbidity in experimental sepsis without promoting immunosuppression. Within this study, we explored the use of ovine anti-HMGB1 antibodies in a model of ovine septic shock incorporating intensive care supports (OSSICS). Results: Septic sheep exhibited elevated levels of HMGB1 within 12 h after the induction of sepsis. In this study, sepsis was induced in six anaesthetized adult Border Leicester × Merino ewes via intravenous instillation of E. coli and sheep monitored according to intensive care unit standard protocols for 26 h, with the requirement for noradrenaline as the primary endpoint. Septic sheep exhibited a hyperdynamic circulation, renal dysfunction, deranged coagulation profile and severe metabolic acidosis. Sheep were assigned a severity of illness score, which increased over time. While a therapeutic effect of intravenous anti-HMGB1 antibody could not be observed in this model due to limited animal numbers, a reduced bacterial dose induced a septic syndrome of much lower severity. With modifications including a reduced bacterial dose, a longer timeframe and broad spectrum antibiotics, the OSSICS model may become a robust tool for preclinical assessment of sepsis therapeutics.
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Alhabibi AM, Eldewi DM, Wahab MAA, Farouk N, El-Hagrasy HA, Saleh OI. Platelet-derived growth factor-beta as a new marker of deep venous thrombosis. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2019; 24:48. [PMID: 31160915 PMCID: PMC6540930 DOI: 10.4103/jrms.jrms_965_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 01/16/2019] [Accepted: 02/28/2019] [Indexed: 12/15/2022]
Abstract
Background: Deep venous thrombosis (DVT) is associated with significant morbidity and mortality. Thus, there is a great need to demonstrate a more efficient biomarker that would confirm the diagnosis of DVT. Our work aimed to evaluate the role of platelet-derived growth factor-beta (PDGF-B) as a new marker of DVT and its correlation with other radiological and laboratory tools used for the diagnosis. Materials and Methods: A case–control study enrolled forty patients selected from our university hospital between April 2018 and August 2018, who divided into two groups: Group I (n = 20) consisted of patients diagnosed with acute venous thrombosis and Group II (n = 20) consisted of patients diagnosed with chronic venous thrombosis. Twenty samples were collected from age- and gender-matched apparently healthy controls to be used as a control. Venous duplex ultrasonography, routine laboratory investigations, D-dimer (DD), and protein expression of PDGF-B were performed on all patients. Results: There was a highly significant increase in a protein expression of PDFG-B in all cases of acute and chronic venous thrombosis compared to the control group with P < 0.001; furthermore, it was more specific than DD for the detection of DVT (specificity 95% and 90%, respectively). Conclusion: Our study submits a novel association of PDGF-B plasma levels with DVT, and PDGF-B is considered to be a more specific indicator for DVT than is DD.
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Affiliation(s)
- Alshaymaa M Alhabibi
- Department of Clinical Pathology, Faculty of Medicine (For Girls), Al-Azhar University, Cairo, Egypt
| | - Dalia Mahmoud Eldewi
- Department of Clinical Pathology, Faculty of Medicine (For Girls), Al-Azhar University, Cairo, Egypt
| | - Maisa A Abdel Wahab
- Department of Vascular Surgery, Faculty of Medicine (For Girls), Al-Azhar University, Cairo, Egypt
| | - Nehal Farouk
- Department of Vascular Surgery, Faculty of Medicine (For Girls), Al-Azhar University, Cairo, Egypt
| | - Hanan A El-Hagrasy
- Department of Clinical Pathology, Faculty of Medicine (For Girls), Al-Azhar University, Cairo, Egypt
| | - Ola I Saleh
- Department of Radio-Diagnosis, Faculty of Medicine (For Girls), Al-Azhar University, Cairo, Egypt
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Abstract
Advanced therapies are available for both deep venous thrombosis and pulmonary embolism when anticoagulation alone is not sufficient to improve clinical outcomes. In some cases, clinical deterioration ensues despite anticoagulation, and this requires unique techniques that can ameliorate the clinical course. Such advancements are described in this upcoming article.
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Takechi D, Kuroda N, Dote H, Kim E, Yonekawa O, Watanabe T, Urano T, Homma Y. Better documentation in electronic medical records would lead to an increased use of lower extremity venous ultrasound in the inpatient setting: a retrospective study. Acute Med Surg 2017; 4:385-393. [PMID: 29123898 PMCID: PMC5649297 DOI: 10.1002/ams2.289] [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: 02/01/2017] [Accepted: 04/20/2017] [Indexed: 11/12/2022] Open
Abstract
Aim We hypothesized that the quality of the assessment of abnormal laboratory data in the emergency department (ED) could affect the hospital-attending physicians' decision-making after a patient's hospitalization. To test this hypothesis, we investigated how patients with a positive D-dimer result were reported by ED physicians in electronic medical records, and measured whether lower extremity venous ultrasonography examination was undertaken during hospitalization by the hospital-attending physicians. Methods In an urban tertiary acute care general hospital in Japan, between January 2012 and December 2013, we included patients hospitalized after a positive D-dimer measurement (≥1.0 μg/mL) that was taken in the emergency department. We retrospectively measured the quality of ED physician assessments. Then we examined whether that affected the decisions of attending physicians to order lower extremity venous ultrasonography examinations during hospitalization. The exposure variable was the quality of the ED physicians' assessment of patients with positive D-dimer results. The outcome was whether a lower extremity venous ultrasonography examination was ordered by the attending physician during hospitalization. Results When assessments were described by ED physicians for patients with positive D-dimer results, the attending physicians frequently ordered lower extremity venous ultrasonography (odds ratio, 10.74; 95% confidence interval, 5.92-19.50), even if the assessments only contained "copied and pasted" laboratory data (odds ratio, 1.68; 95% confidence interval, 2.10-2.40). Conclusions Better documentation by ED physicians, regarding patients with positive D-dimer results, strongly affected the decisions made by attending physicians to order lower extremity venous ultrasonography examination.
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Affiliation(s)
- Daisuke Takechi
- Department of General Internal Medicine Seirei Hamamatsu General Hospital Hamamatsu Shizuoka Japan
| | - Naoto Kuroda
- Department of General Internal Medicine Seirei Hamamatsu General Hospital Hamamatsu Shizuoka Japan
| | - Hisashi Dote
- Department of Emergency & Critical Care Medicine Seirei Hamamatsu General Hospital Hamamatsu Shizuoka Japan
| | - Euido Kim
- Department of General Internal Medicine Seirei Hamamatsu General Hospital Hamamatsu Shizuoka Japan
| | - Osamu Yonekawa
- Department of Laboratory MedicineSeirei Hamamatsu General Hospital Hamamatsu Shizuoka Japan
| | - Takuya Watanabe
- Department of General Internal Medicine Seirei Hamamatsu General Hospital Hamamatsu Shizuoka Japan
| | - Tetsumei Urano
- Department of Physiology Hamamatsu University School of Medicine Hamamatsu Shizuoka Japan
| | - Yoichiro Homma
- Department of General Internal Medicine Seirei Hamamatsu General Hospital Hamamatsu Shizuoka Japan
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Minet C, Potton L, Bonadona A, Hamidfar-Roy R, Somohano CA, Lugosi M, Cartier JC, Ferretti G, Schwebel C, Timsit JF. Venous thromboembolism in the ICU: main characteristics, diagnosis and thromboprophylaxis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:287. [PMID: 26283414 PMCID: PMC4539929 DOI: 10.1186/s13054-015-1003-9] [Citation(s) in RCA: 144] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep venous thrombosis (DVT), is a common and severe complication of critical illness. Although well documented in the general population, the prevalence of PE is less known in the ICU, where it is more difficult to diagnose and to treat. Critically ill patients are at high risk of VTE because they combine both general risk factors together with specific ICU risk factors of VTE, like sedation, immobilization, vasopressors or central venous catheter. Compression ultrasonography and computed tomography (CT) scan are the primary tools to diagnose DVT and PE, respectively, in the ICU. CT scan, as well as transesophageal echography, are good for evaluating the severity of PE. Thromboprophylaxis is needed in all ICU patients, mainly with low molecular weight heparin, such as fragmine, which can be used even in cases of non-severe renal failure. Mechanical thromboprophylaxis has to be used if anticoagulation is not possible. Nevertheless, VTE can occur despite well-conducted thromboprophylaxis.
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Affiliation(s)
- Clémence Minet
- UJF-Grenoble I, University Hospital Albert Michallon, Medical Intensive Care Unit, Grenoble, F-38041, France.
| | - Leila Potton
- UJF-Grenoble I, University Hospital Albert Michallon, Medical Intensive Care Unit, Grenoble, F-38041, France
| | - Agnès Bonadona
- UJF-Grenoble I, University Hospital Albert Michallon, Medical Intensive Care Unit, Grenoble, F-38041, France
| | - Rébecca Hamidfar-Roy
- UJF-Grenoble I, University Hospital Albert Michallon, Medical Intensive Care Unit, Grenoble, F-38041, France
| | - Claire Ara Somohano
- UJF-Grenoble I, University Hospital Albert Michallon, Medical Intensive Care Unit, Grenoble, F-38041, France
| | - Maxime Lugosi
- UJF-Grenoble I, University Hospital Albert Michallon, Medical Intensive Care Unit, Grenoble, F-38041, France
| | - Jean-Charles Cartier
- UJF-Grenoble I, University Hospital Albert Michallon, Medical Intensive Care Unit, Grenoble, F-38041, France
| | - Gilbert Ferretti
- Department of Radiology, UJF-Grenoble I, University Hospital Albert Michallon, Grenoble, F-38041, France.,UJF-Grenoble I, University Hospital Albert Michallon, U823 Institut Albert Bonniot, Team 11: Outcome of mechanically ventilated patients and airway cancers, Grenoble, F-38041, France
| | - Carole Schwebel
- UJF-Grenoble I, University Hospital Albert Michallon, Medical Intensive Care Unit, Grenoble, F-38041, France
| | - Jean-François Timsit
- UJF-Grenoble I, University Hospital Albert Michallon, Medical Intensive Care Unit, Grenoble, F-38041, France.,UJF-Grenoble I, University Hospital Albert Michallon, U823 Institut Albert Bonniot, Team 11: Outcome of mechanically ventilated patients and airway cancers, Grenoble, F-38041, France
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