Elevated Plasma Levels of Fibrin Degradation Productsby Granulocyte-Derived Elastase in Patients with Disseminated Intravascular Coagulation

Plasma levels of granulocyte-derived elastase (GE-XDP), D-dimer, and soluble fibrin (SF) were examined in 177 patients with disseminated intravascular coagulation (DIC) of various etiologies. Plasma levels of GE-XDP and D-dimer, but not SF, were significantly high in patients with sepsis and solid cancer. The ratio of GE-XDP/D-dimer was significantly high in patients with trauma, burn, and sepsis, suggesting that fibrinolysis due to GE-XDP may be dominant in DIC. Plasma levels of GE-XDP and D-dimer, but not SF, were significantly high in patients with overt DIC and correlated with DIC score. Plasma levels of GE-XDP, but not SF, correlated significantly with D-dimer. Plasma levels of D-dimer, but not SF, correlated significantly with plasmin plasmin inhibitor complex (PPIC). Plasma levels of GEXDP and D-dimer, but not SF, were significantly high in nonsurvivors. Plasma levels of GE-XDP, but not SF, correlated significantly with sepsis-related organ failure assessment (SOFA) score. These results suggest that GE-XDP is a potentially useful marker for the diagnosis of overt-DIC and as a predictor of organ failure-related outcome.

Linear relationship between ADAMTS13 activity and platelet dynamics even before severe thrombocytopenia

Von Willebrand factor (VWF) cleaving metalloprotease, ADAMTS13, known for its causative relation to thrombotic thrombocytopenic purpura (TTP), also decreases to variable degree in other clinical conditions associated with thrombocytopenia, indicating a possible contribution of moderate deficiency of ADAMTS13 to platelet dynamics. We measured ADAMTS13 activity along with VWF activity, collagen binding activity (VWF:CB), and thrombin/antithrombin complex (TAT) in plasma drawn from patients with consumptive coagulopathy, in whom the platelet count was closely followed. ADAMTS13 activity was significantly but variably decreased in the patients, and VWF activity and VWF:CB were markedly increased as expected. The platelet count itself was not correlated with ADAMTS13 activity, VWF activity, or VWF:CB. However, the rate of decline of log-scaled platelet count (DeltaLnPLT/day) correlated well with ADAMTS13 activity and VWF:CB. ADADMTS13 activity showed inverse correlation with VWF:CB. Moreover, the correlation between ADAMTS13 and DeltaLnPLT/day was preserved even after VWF:CB was controlled. Multiple regression analysis showed that ADAMTS13 activity was the sole factor explaining DeltaLnPLT/day among ADAMTS13, VWF:CB, TAT, prothrombin time, d-dimer, and fibrinogen. TAT level and d-dimer as indicators of systemic fibrinolytic activity did not correlate with ADAMTS13 activity. In conclusion, we found that the decrease of ADADMTS13 activity in consumptive coagulopathy has stronger relationship to platelet dynamics than has generally been recognized.

Temporal changes in factors associated with neutrophil elastase and coagulation in intensive care patients with a biphasic waveform and disseminated intravascular coagulation

Summary. The biphasic waveform is an early marker of disseminated intravascular coagulation (DIC). Neutrophil elastase (NE) cleaves coagulation factors; thus, elevated elastase levels or its dysregulation by alpha-1-protease inhibitor (Alpha1PI) may be linked to DIC. Time courses over a period were determined for factors associated with NE and coagulation in 14 Intensive Care Unit patients with a biphasic waveform who developed DIC. The data were analyzed using a random coefficient linear regression model to predict the variables' mean values on day 0 and their mean rates of change over the period in which the biphasic waveform appeared. The biphasic waveform was normal on day 0, maximized on day 1, and approached normal again by day 4. Alpha1PI/NE complex levels were 2.5-fold greater than normal for the entire period. The A1PI activity, antigen, and specific activity levels were normal on day 0 and increased thereafter by 21.0, 10.5, and 8.9% of normal per day, respectively. Factor II, V, VII, IX, and X activity levels were, respectively, 57, 46, 46, 77, and 46% of normal on day 0, whereas factor VIII and fibrinogen levels were normal. All coagulation factor levels trended upward with time but not significantly. The prothrombin time, but not the activated partial thromboplastin time, was prolonged, and the platelet counts and hematocrits were below normal on day 0 and remained so thereafter. We conclude that events associated with neutrophil activation, elastase release, and perturbations of coagulation precede both the appearance of the biphasic waveform and the diagnosis of DIC in these patients.

Neutrophil elastase may play a key role in developing symptomatic disseminated intravascular coagulation and multiple organ failure in patients with head injury

OBJECTIVE

To study the mechanism associated with the development of symptomatic disseminated intravascular coagulation (DIC) after head injury.

METHODS

Plasma parameters were analyzed in patients with symptomatic (group A, n = 10) and asymptomatic DIC (group B, n = 15) induced by head injury, and in patients in whom DIC was caused by sepsis (group C, n = 10).

RESULTS

Levels of fibrinogen, alpha2PI-plasmin complex and platelets in group A (58.1 mg/dL, 22.4 microg/mL, 16.0 x 10(4)/ mm3) and group B (98.3, 22.1, 16.6 x 10(4)) were comparable, but differed significantly from those in group C (297.4, 2.4, 6.3 x 10(4)). Significant differences were observed between groups A and B in both neutrophil-elastase (1,528 vs. 293 microg/ml) and D-dimer (42.1 vs. 17.6 microg/mL).

CONCLUSION

Neutrophil elastase may be implicated in the development of symptomatic DIC after head injury, whose characteristics include "enhanced fibrinolysis with minimal platelet loss."

Elastase mediated fibrinolysis in acute promyelocytic leukemia

The bleeding syndrome of acute promyelocytic leukemia (APL) is complex and consists of disseminated intravascular coagulation (DIC) and hyperfibrinolysis. Elastase, derived from malignant promyelocytes, is believed to mediate the fibrinogeno- and fibrinolysis by aspecific proteolysis. In this study we measured the role of elastase in fifteen patients with APL by using an assay for elastase degraded fibrin(ogen) and the results were compared with those obtained in patients with sepsis induced DIC. High levels of elastase were observed in sepsis and APL. The levels of fibrinogen and fibrin degradation products were significantly higher in APL patients compared to patients with sepsis induced DIC. Nevertheless, the level of elastase degraded fibrin(ogen) was higher in the sepsis group (635.3 ng/ml, compared to 144.3 ng/ml in APL; p <0.0001). So, the enormous increase in fibrin and fibrinogen degradation products in APL cannot be explained by elastase activity. This study suggests a minor role for elastase mediated proteolysis in the hemorrhagic diathesis in APL patients.

Soluble thrombomodulin increases in patients with disseminated intravascular coagulation and in those with multiple organ dysfunction syndrome after trauma: role of neutrophil elastase

OBJECTIVE

Our goal was to investigate the role of soluble thrombomodulin (TM) and neutrophil elastase in patients with trauma.

DESIGN

This study is a prospective case-control study.

MATERIALS AND METHODS

Forty-seven trauma victims, 14 with disseminated intravascular coagulation (DIC), 5 with multiple organ dysfunction syndrome (MODS), and 28 control patients without DIC or MODS were the participants. Soluble TM and neutrophil elastase (elastase-alpha1-proteinase inhibitor complex) were measured on the day of the injury, and on the first, third, and fifth days after admission. The results of these measurements and demographic data were compared among the groups, and correlations between the soluble TM and the neutrophil elastase were examined. The DIC patients were classified into subgroups of survivors (n = 5) and nonsurvivors (n = 9), and the changes of the soluble TM between the subgroups were then studied.

MEASUREMENTS AND MAIN RESULTS

A high incidence of DIC patients encountered MODS complications (12 of 14, 86%). The DIC patients had higher Injury Severity Scores (ISSs) than the other patients. The levels of soluble TM and neutrophil elastase significantly increased on the day of admission in the patients with DIC and also in those with MODS (p < 0.05 vs. control patients) and continued to show markedly high values until the fifth day of admission in the patients with DIC. In the DIC patients, the levels of soluble TM were higher in the nonsurvivors than in the survivors (p < 0.05 on the third and the fifth days of admission). In all patients, there was weak but statistically significant correlation between peak levels of soluble TM and ISS (r2 = 0.125, p < 0.025). Comparison of the levels of soluble TM and neutrophil elastase in the patients with DIC or MODS demonstrated an excellent correlation (r2 = 0.718 and r2 = 0.714, respectively).

CONCLUSIONS

Soluble TM as a novel endothelial cell injury marker increases in patients with DIC and also in those with MODS after trauma. Neutrophil elastase may be involved in the pathogenesis of the injury. Soluble TM is a marker of the severity of injury and is a good predictor of MODS.

Plasma levels of granulocyte elastase-alpha 1-proteinase inhibitor complex in patients with disseminated intravascular coagulation: pathophysiologic implications

To investigate the role of neutrophil activation in the pathophysiology and sequelae of disseminated intravascular coagulation (DIC), we measured plasma levels of granulocyte elastase-alpha 1-proteinase inhibitor complex (GEPIC) in 41 patients with DIC and 27 patients with similar underlying conditions but without DIC. Mean GEPIC levels were significantly higher in patients with DIC (421.0 +/- 45.6 ng/ml) than in patients without DIC (246.1 +/- 41.9 ng/ml, P < 0.01). Significant differences were also noted in DIC patients with or without infection (474.7 +/- 61.2 ng/ml vs. 302.4 +/- 48.9 ng/ml, P < 0.04), with or without organ dysfunction (546.6 +/- 72.7 ng/ml vs. 305.6 +/- 42 ng/ml, P < 0.01), and with or without respiratory failure (640.0 +/- 91.2 ng/ml vs. 328.1 +/- 55.1 ng/ml, P < 0.01). No significant difference was found in mean GEPIC levels in DIC patients with or without renal failure, heart failure, hepatic failure, or gastrointestinal bleeding. The frequency of respiratory failure correlated with rising plasma levels of GEPIC. Mortality was higher in patients with GEPIC levels > 500 ng/ml (53.8%) than in patients with GEPIC levels < 500 ng/ml (28.6%). This correlation was particularly strong in patients with DIC, infection, and respiratory failure. Based on these data, we suggest that neutrophil activation, triggered by the coagulation cascade and perhaps augmented by endotoxin or cytokine release with infection, significantly contributes to respiratory failure and mortality in patients with DIC.

Factors relating to coagulation, fibrinolysis and hepatic damage after liver resection

A survey of the blood of twenty-two patients who had undergone hepatic resection was performed. Serum levels of alpha-2 plasmin inhibitor-plasmin complex initially decreased from 1.58 +/- 0.31 microgram/ml on the preoperative day (PREOP), to 0.92 +/- 0.14 mu/ml on the first postoperative day (POD 1), and then increased to 3.13 +/- 0.92 micrograms/ml on the seventh postoperative day (POD 7) (mean +/- SE)). Thrombin-anti-thrombin III complex (14.2 +/- 4.3 ng/ml on PREOP and 26.0 +/- 4.1 ng/ml on POD 7 (mean +/- SE)) and D-dimer (335 +/- 96 ng/ml on PREOP and 1859 +/- 258 ng/ml on POD 7 (mean +/- SE)) increased in the early postoperative stage. The level of 6-keto-prostaglandin F1 alpha increased after the operations (from 13.2 +/- 1.8 pg/ml on PREOP to 37.8 +/- 12.8 pg/ml on POD 7 (mean +/- SE)). The level of thromboxane B-2 decreased at first, and then gradually increased and returned to its preoperative level on POD 7 (144.7 +/- 43.8 pg/ml on PREOP, 57.6 +/- 27.5 pg/ml on POD 1 and 152.5 +/- 58.4 pg/ml on POD 7 (mean +/- SE)). Superoxide dismutase activity increased at first, and then gradually decreased, postoperatively (2.8 +/- 0.5 NU/ml on PREOP, 4.8 +/- 0.8 NU/ml on POD 1 and 2.6 +/- 0.3 NU/ml on POD 7 (mean +/- SE)). That is, biodefensive reactions which protect patients against the shift to disseminated intravascular coagulation (DIC) were inferred with by the increase in antiplatelet aggregation, despite the activation of coagulation and fibrinolytic mechanisms after hepatic resection.

Polymorphonuclear leucocyte elastase in Plasmodium falciparum malaria

Sixty-one patients with falciparum malaria were studied prospectively to determine the plasma concentrations of the lysosomal proteinase, polymorphonuclear leucocyte elastase (PMN-elastase) and their relationship to disease severity. The patients were divided into 3 groups; severe (parasitaemia > 5%) or vital organ dysfunction (n = 23), moderate (parasitaemia 1%-5% without complications) (n = 15), and mild (parasitaemia < 1%) (n = 23). The mean plasma PMN-elastase level in 10 healthy Thai volunteers was 49.5 (SD = 21.6) ng/ml (range 33-65 ng/ml). Plasma PMN-elastase concentrations on admission were elevated (> 2 x SD above normal) in all patients with severe malaria and were above 100 ng/ml in 86.6% and 65% of the moderately severe and mild patients respectively. PMN-elastase levels during the first 3 hospital days were significantly higher in severe malaria compared with the other 2 groups (P = < 0.001-0.013). The levels decreased as the patients became afebrile and aparasitaemic. Admission plasma concentrations of PMN-elastase correlated directly with bilirubin (rs = 0.50, P < 0.001), serum glutamic oxalacetic transaminase (rs = 0.54, P0.001), parasite count (rs = 0.62, P < 0.001), blood urea nitrogen (rs = 0.54, P < 0.001) and inversely with antithrombin III activity (rs = 0.54, P < 0.001) and the platelet count (rs = 0.58, P < 0.001). Polymorphonuclear leucocyte activation may contribute to the pathogenesis of severe malaria.

Change in the acid protease activity in plasma of patients with disseminated intravascular coagulation

Lysosomal protease was determined in the serum of patients with disseminated intravascular coagulation (DIC) to clarify whether the platelet count is an appropriate diagnostic index which allows the early initiation of treatment. The platelet count and the serum level of cathepsin D, a lysosomal protease, were determined in 60 patients diagnosed to have DIC. The cathepsin D activity could not be detected in the sera of healthy individuals with a platelet count of 100,000 or above, but was detectable in the serum of DIC patients with a platelet count of 100,000, and this activity increased as the platelet count decreased to 70,000 and 50,000, and was about 5 times higher at a platelet count of 30,000 than at 70,000. In DIC patients, the decrease in the platelet count was correlated with the increase in the serum lysosomal protease activity. The appearance of cathepsin D activity in the serum of DIC patients is considered to reflect the release of lysosomal enzyme activities from damaged organs, and the treatment for DIC must be initiated before the platelet count decrease below 100,000, and cathepsin D activity then appears in the serum. At a platelet count of 30,000 or less, DIC becomes established, and no therapeutic effects can be expected because of the associated multiple organ failure.

Plasma active renin, inactive renin and kallikrein in patients with disseminated intravascular coagulation

To investigate the role plasma kallikrein plays in the in vivo activation of inactive renin, we measured plasma active renin, inactive renin, kallikrein and prekallikrein levels in 10 patients with disseminated intravascular coagulation (DIC), with 16 normal persons as controls. The plasma active renin concentration was expressed by the angiotensin I generation rate after the addition of sheep renin substrate. Plasma inactive renin was activated by trypsin. The plasma total kallikrein level was measured by an assay of kallikrein activity on synthetic substrate S-2302 after the addition of a prekallikrein activator. Plasma kallikrein was assayed by its activity on S-2302 without addition of the activator. The prekallikrein level was obtained by subtracting the kallikrein activity from the total kallikrein activity. A significant decrease in the plasma prekallikrein concentration was observed in DIC patients, as compared to that of controls (p less than 0.01). There was no significant difference in plasma levels of kallikrein, inactive renin, and the proportion of active renin between DIC patients and normal controls, but the active renin level was higher in DIC patients. There was no significant correlation between the level of plasma kallikrein and the proportion of active renin in either normal controls or DIC patients. These results are compatible with, but do not prove, the theory that plasma kallikrein plays a role in the in vivo activation of inactive renin.

Activation and complexation of protein C and cleavage and decrease of protein S in plasma of patients with intravascular coagulation

Activated protein C (APC) is inhibited by two major plasma inhibitors (PCIs). To find evidence for in vivo complexation of APC, immunoblotting studies were performed on plasmas of 85 patients with suspected disseminated intravascular coagulation (DIC). Samples from 62 of these patients contained 5% to 35% of protein C antigen in APC:inhibitor complexes, indicating that protein C activation and inhibition had occurred. In 24 normal plasmas, no detectable APC:PCI complexes were observed (less than 5%). Patients with higher levels of complexes had more abnormal coagulation test data for DIC. The major band of APC complexes detected by anti-protein C antibodies did not react with antibodies to the heparin-dependent protein C inhibitor (PCI-1) previously described. Rather, APC was complexed with another recently described plasma protein C inhibitor, PCI-2. Immunoblotting studies for protein S, the cofactor for APC, revealed that the majority of the DIC patient plasmas contained a higher than normal proportion of protein S in cleaved form, suggesting that protein S may have been proteolytically inactivated. Protein S total antigen levels were also found to be low in DIC patients, excluding those with malignancy. These studies support the hypothesis that the protein C pathway is activated during DIC.

[Serum endotoxin level in the course of open peritonitis treatment]

In 27 patients with severe diffuse purulent or fecal peritonitis planned relaparotomies with peritoneal lavage or continuous dorsoventral lavage with open abdomen were performed after surgical treatment of the primary infection. During the course of the lavage treatment serum endotoxin was measured daily. The endotoxin-induced liberation of lysosomal proteases was studied by determining the elastase from polymorphonuclear leucocytes. 16 surviving patients showed decreasing endotoxin levels and decreasing elastase concentrations during the course of abdominal lavages. Planned peritoneal lavage and continuous dorso-ventral lavage seem to have the same potency in eliminating endotoxin from the infected peritoneal cavity. In letal courses endotoxinemia either persisted at high levels or even progressed inspite of lavage treatment.

Detection of circulating T-activating enzyme in the serum of a patient having hemolytic-uremic syndrome and disseminated intravascular coagulation

A three-and-a-half-year old boy suffering from streptococcal pneumonia developed hemolytic-uremic syndrome and disseminated intravascular coagulation (DIC). His red blood cells (RBC) were shown to be T- and Tk-activated; serial testing showed his mature RBCs as well as neocytes remained T-activated at 40 days. Anti-T was detected in his serum, with only one of two T-activated RBC samples. T-activating enzyme was shown to be present in his serum.

Serial studies of protein C and its plasma inhibitor in patients with disseminated intravascular coagulation

This study was undertaken to determine the levels of protein C antigen and activity and protein C inhibitor in sequential plasma samples of disseminated intravascular coagulation (DIC) patients. Our normal range for both protein C antigen and activity is 70 to 130 U/dL, and protein C inhibitor is 65 to 135 U/dL. A decreased level of protein C activity was found in 96% of the plasma samples from individuals with DIC; the protein C antigen was decreased in 73%. The inhibitor of protein C was decreased in all samples. Analysis of serial samples from patients with DIC reveals that protein C activity and antigen and protein C inhibitor decrease progressively during the initial stages of DIC and remain at a low level for 24 to 48 hours before gradually returning toward normal in nonfatal cases. The protein C activity decreases in parallel with protein C inhibitor and is lower than protein C antigen. In a fatal case of DIC, protein C activity and protein C inhibitor rapidly decreased to undetectable levels; however, protein C antigen was gradually decreasing but still detectable at time of death. In DIC, a discrepancy initially occurs between the activity and antigen of protein C, suggesting a complex with the inhibitor or other inactive forms of protein C. Protein C appears to play a major role in the control of DIC.

A case of postpartum hemolytic uremic syndrome with severe elevations of liver enzymes

An unusual case of multifocused postpartum thrombotic microangiopathy was encountered in a woman with pregnancy-induced hypertension, which presented clinical features different from those generally seen in postpartum hemolytic uremic syndrome or thrombotic thrombocytopenic purpura. These changes included acute disseminated intravascular coagulation, severe elevations of liver enzymes, severe renal dysfunction, and hemolytic anemia. The patient was treated successfully with heparin, gabexate mesilate, furosemide, fresh whole blood, and large doses of corticosteroid with antibiotics, and she recovered completely without sequelae. The hypothetical pathogenesis of the complex symptoms of this catastrophic clinical condition is proposed.

Immunoreactive trypsin in the adult respiratory distress syndrome

With the purpose of studying the role of proteinases in the development of ARDS, plasma levels of immunoreactive trypsin (IRT) and amylase were measured in 43 intensive care patients at risk of developing ARDS (22 polytrauma, seven abdominal surgery, four burns, two DIC and eight pancreatitis). Twenty four of these 43 patients developed ARDS and 31 presented abnormal IRT values (above 70 micrograms/L). Twenty-one of these 31 patients had ARDS; a significant correlation thus appeared between ARDS and abnormal IRT values. In nine patients, IRT values were higher than 800 micrograms/L and remained high for 3 to 4 days. A statistically significant correlation also appeared between abnormal IRT and septic phenomena: 20 patients with high IRT values presented septic problems. When IRT values were high, amylase values were often also abnormal: 12 of 23 patients with high IRT had abnormal amylase levels (the eight patients with documented pancreatitis were excluded); no other clinical signs or symptoms of pancreatitis were present in these patients. IRT could be one of the mediators of ARDS in septic patients. It is not clear that the pancreas is the origin of IRT in all cases.

[Fluctuations in pulmonary fibrin decomposing activities (plasmin and non-plasmin activities) in an endotoxin DIC model in rats]

Non-plasmin fibrinolysis enzyme was extracted from the lung and spleen of conventional rats (Thrombos. Haemostas., 1979), although the enzyme was not found in germfree rats, suggesting the possibility that the enzyme may participate in the defence mechanism of the body. The present study was made in an attempt to determine the behavior of non-plasmin fibrinolysis enzyme of the lung tissue in the DIC model of conventional rats induced by a single injection of bacterial endotoxin. The plasminogen-activator activity of the lung tissue, and the fibrinogen level, platelet count, urea nitrogen and plasminogen-activator activity in the blood were also measured. Examination of the lung tissue in the DIC rats indicated a remarkable increase in non-plasmin fibrinolysis activity and a disappearance of plasminogen-activator activity. Inhibitor studies using t-AMCHA and DFP demonstrated that the increased non-plasmin fibrinolysis activity was not derived from activated plasmin, but from serine protease. The disappearance of plasminogen-activator activity in the lung and increase of plasminogen-activator activity in the blood suggested a release of the activator from the lung into the blood due to the endotoxin injection.

Cathodic isozyme of serum creatine kinase in a case of stomach cancer complicated by disseminated intravascular coagulation

A rare isozyme of serum creatine kinase (CK) migrating cathodic to CK-MM on electrophoresis was found in a 30-year-old male with stomach cancer complicated by disseminated intravascular coagulation leading to massive upper gastrointestinal bleeding and marked anemia. Serum CK activity rose to a maximum of 374 U/l without detectable CK-MB isoenzyme. The patient was also characterized by a marked increase in serum lactate dehydrogenase (all isozymes elevated) and by preferential leakage of mitochondrial aspartate aminotransferase and glutamate dehydrogenase, indicating the presence of extensive tissue damage involving mitochondria. Skeletal muscle mitochondria were considered the most likely source of the additional CK isozyme.

Creatine kinase isoenzymes in cerebrospinal fluid in a case of brain damage

We present a case of a 11/2-year-old boy with toxic enteritis, consecutive consumption coagulopathy, and sever brain damage. During the acute phase we found high activity of the BB isoenzyme of creatine kinase in cerebrospinal fluid, but not in the serum. Isoenzyme MM could also be found in the spinal fluid (37.9% of the total activity). We conclude that analysis for creatine kinase isoenzymes in spinal fluid is of clinical importance.