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Scarlatescu E, Kim PY, Marchenko SP, Tomescu DR. Validation of the time to attain maximal clot amplitude after reaching maximal clot formation velocity parameter as a measure of fibrinolysis using rotational thromboelastometry and its application in the assessment of fibrinolytic resistance in septic patients: a prospective observational study: communication from the ISTH SSC Subcommittee on Fibrinolysis. J Thromb Haemost 2024; 22:1223-1235. [PMID: 38104723 DOI: 10.1016/j.jtha.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/12/2023] [Accepted: 12/04/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND In sepsis, fibrinolysis resistance correlates with worse outcomes. Practically, rotational thromboelastometry (ROTEM) is used to report residual clot amplitude relative to maximum amplitude at specified times after clot formation clot lysis indices (CLIs). However, healthy individuals can exhibit similar CLIs, thus making it challenging to solely diagnose the low fibrinolytic state. Furthermore, CLI does not include the kinetics of clot formation, which can affect overall fibrinolysis. Therefore, a more nuanced analysis, such as time to attain maximal clot amplitude after reaching maximal clot formation velocity (t-AUCi), is needed to better identify fibrinolysis resistance in sepsis. OBJECTIVES To evaluate the correlation between the degree of fibrinolytic activation and t-AUCi in healthy or septic individuals. METHODS Whole blood (n = 60) from septic or healthy donors was analyzed using tissue factor-activated (EXTEM) and nonactivated (NATEM) ROTEM assays. Lysis was initiated with tissue-type plasminogen activator, and CLI and t-AUCi were calculated. Standard coagulation tests and plasma fibrinolysis markers (D-dimer, plasmin-α2-antiplasmin complex, plasminogen activator inhibitor type 1, and plasminogen) were also measured. RESULTS t-AUCi values decreased with increasing fibrinolytic activity and correlated positively with CLI for different degrees of clot lysis both in EXTEM and NATEM. t-AUCi cutoff value of 1962.0 seconds in EXTEM predicted low fibrinolytic activity with 81.8% sensitivity and 83.7% specificity. In addition, t-AUCi is not influenced by clot retraction. CONCLUSION Whole-blood point-of-care ROTEM analyses with t-AUCi offers a more rapid and parametric evaluation of fibrinolytic potential compared with CLI, which can be used for a more rapid and accurate diagnosis of fibrinolysis resistance in sepsis.
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Affiliation(s)
- Ecaterina Scarlatescu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Department of Anesthesia and Intensive Care III, Fundeni Clinical Institute, Bucharest, Romania.
| | - Paul Y Kim
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Sergey P Marchenko
- Department of Cardiac Surgery, Pavlov First St. Petersburg Medical University, St. Petersburg, Russian Federation
| | - Dana R Tomescu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Department of Anesthesia and Intensive Care III, Fundeni Clinical Institute, Bucharest, Romania
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Marta-Enguita J, Navarro-Oviedo M, Machado FJDM, Bermejo R, Aymerich N, Herrera M, Zandio B, Pagola J, Juega J, Marta-Moreno J, Rodriguez JA, Páramo JA, Roncal C, Muñoz R, Orbe J. Role of factor XIII in ischemic stroke: a key molecule promoting thrombus stabilization and resistance to lysis. J Thromb Haemost 2024; 22:1080-1093. [PMID: 38160727 DOI: 10.1016/j.jtha.2023.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 12/14/2023] [Accepted: 12/20/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Active coagulation factor XIII (FXIII) catalyzing crosslinking of fibrin and other hemostatic factors plays a key role in clot stability and lysis. OBJECTIVES To evaluate the effect of FXIII inhibition in a mouse model of ischemic stroke (IS) and the role of activated FXIII (FXIIIa) in clot formation and lysis in patients with IS. METHODS A ferric chloride IS murine model was performed before and after administration of a FXIIIa inhibitor (FXIIIinh). Thromboelastometry in human and mice blood was used to evaluate thrombus stiffness and lysis with FXIIIinh. FXIIIa-dependent fibrin crosslinking and lysis with fibrinolytic drugs (tissue plasminogen activator and tenecteplase) were studied on fibrin plates and on thrombi and clotted plasma of patients with IS. Finally, circulating and thrombus FXIIIa were measured in 85 patients with IS. RESULTS FXIIIinh administration before stroke induction reduced infarct size, α2-antiplasmin (α2AP) crosslinking, and local microthrombosis, improving motor coordination and fibrinolysis without intracranial bleeds (24 hours). Interestingly, FXIII blockade after stroke also reduced brain damage and neurologic deficit. Thromboelastometry in human/mice blood with FXIIIinh showed delayed clot formation, reduced clot firmness, and shortened tissue plasminogen activator lysis time. FXIIIa fibrin crosslinking increased fibrin density and lysis resistance, which increased further after α2AP addition. FXIIIinh enhanced ex vivo lysis in stroke thrombi and fibrin plates. In patients with IS, thrombus FXIII and α2AP were associated with inflammatory and hemostatic components, and plasma FXIIIa correlated with thrombus α2AP and fibrin. CONCLUSION Our results suggest a key role of FXIIIa in thrombus stabilization, α2AP crosslinking, and lysis resistance, with a protective effect of FXIIIinh in an IS experimental model.
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Affiliation(s)
- Juan Marta-Enguita
- Atherothrombosis Laboratory, Cardiovascular Diseases Program, Centro de Investigacion Medica Aplicada (CIMA), Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona Spain; Neurology Department, Hospital Universitario Navarra, Pamplona, Spain; Red de Investigación Cooperativa Orientada a Resultados en Salud (RICORS)-Ictus Instituto de Salud Carlos III (ISCIII), Madrid, Spain. https://twitter.com/jmartaen
| | - Manuel Navarro-Oviedo
- Atherothrombosis Laboratory, Cardiovascular Diseases Program, Centro de Investigacion Medica Aplicada (CIMA), Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona Spain
| | - Florencio J D M Machado
- Atherothrombosis Laboratory, Cardiovascular Diseases Program, Centro de Investigacion Medica Aplicada (CIMA), Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona Spain
| | - Rebeca Bermejo
- Neurointervencionist Radiology, Hospital Universitario Navarra, Pamplona, Spain
| | - Nuria Aymerich
- Neurology Department, Hospital Universitario Navarra, Pamplona, Spain; Red de Investigación Cooperativa Orientada a Resultados en Salud (RICORS)-Ictus Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Maria Herrera
- Neurology Department, Hospital Universitario Navarra, Pamplona, Spain; Red de Investigación Cooperativa Orientada a Resultados en Salud (RICORS)-Ictus Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Beatriz Zandio
- Neurology Department, Hospital Universitario Navarra, Pamplona, Spain; Red de Investigación Cooperativa Orientada a Resultados en Salud (RICORS)-Ictus Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Jorge Pagola
- Red de Investigación Cooperativa Orientada a Resultados en Salud (RICORS)-Ictus Instituto de Salud Carlos III (ISCIII), Madrid, Spain; Stroke Unit, Vall d'Hebron Instituto de Investigación (VHIR), Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Jesús Juega
- Red de Investigación Cooperativa Orientada a Resultados en Salud (RICORS)-Ictus Instituto de Salud Carlos III (ISCIII), Madrid, Spain; Stroke Unit, Vall d'Hebron Instituto de Investigación (VHIR), Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Javier Marta-Moreno
- Red de Investigación Cooperativa Orientada a Resultados en Salud (RICORS)-Ictus Instituto de Salud Carlos III (ISCIII), Madrid, Spain; Neurology Department, Hospital Universitario Miguel Servet, IIS-Aragon, Zaragoza, Spain
| | - Jose-Antonio Rodriguez
- Atherothrombosis Laboratory, Cardiovascular Diseases Program, Centro de Investigacion Medica Aplicada (CIMA), Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), ISCIII, Madrid, Spain
| | - Jose-Antonio Páramo
- Atherothrombosis Laboratory, Cardiovascular Diseases Program, Centro de Investigacion Medica Aplicada (CIMA), Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), ISCIII, Madrid, Spain; Hematology Department, Clinica Universidad Navarra, Pamplona, Spain
| | - Carmen Roncal
- Atherothrombosis Laboratory, Cardiovascular Diseases Program, Centro de Investigacion Medica Aplicada (CIMA), Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), ISCIII, Madrid, Spain
| | - Roberto Muñoz
- Neurology Department, Hospital Universitario Navarra, Pamplona, Spain; Red de Investigación Cooperativa Orientada a Resultados en Salud (RICORS)-Ictus Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Josune Orbe
- Atherothrombosis Laboratory, Cardiovascular Diseases Program, Centro de Investigacion Medica Aplicada (CIMA), Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona Spain; Red de Investigación Cooperativa Orientada a Resultados en Salud (RICORS)-Ictus Instituto de Salud Carlos III (ISCIII), Madrid, Spain.
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Wang Y, Cheng W, Chen X, Cheng C, Zhang L, Huang W. Serum Proteomics Identified TAFI as a Potential Molecule Facilitating the Migration of Peripheral Monocytes to Damaged White Matter During Chronic Cerebral Hypoperfusion. Neurochem Res 2024; 49:597-616. [PMID: 37978153 DOI: 10.1007/s11064-023-04050-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/15/2023] [Accepted: 10/17/2023] [Indexed: 11/19/2023]
Abstract
Neuroinflammation is assumed as the critical pathophysiologic mechanism of white matter lesions (WMLs), and infiltrated peripheral monocyte-derived macrophages are implicated in the development of neuroinflammation. This study sought to explore the blood molecules that promote the migration of peripheral monocytes to the sites of WMLs. The serum protein expression profiles of patients and Sprague-Dawley rat models with WMLs were detected by data-independent acquisition (DIA) proteomics technique. Compared with corresponding control groups, we acquired 62 and 41 differentially expressed proteins (DEPs) in the serum of patients and model rats with WMLs respectively. Bioinformatics investigations demonstrated that these DEPs were linked to various Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways and Gene Ontology (GO) terms involved in neuroinflammation. Afterward, we identified thrombin-activatable fibrinolysis inhibitor (TAFI) as a shared and overexpressed protein in clinical and animal serum samples, which was further verified by enzyme-linked immunosorbent assay. Additionally, an upregulation of TAFI was also observed in the white matter of rat models, and the inhibition of TAFI impeded the migration of peripheral monocytes to the area of WMLs. In vitro experiments suggested that TAFI could enhance the migration ability of RAW264.7 cells and increase the expression of Ccr2. Our study demonstrates that neuroinflammatory signals can be detected in the peripheral blood of WMLs patients and model rats. TAFI may serve as a potential protein that promotes the migration of peripheral monocytes to WMLs regions, thereby providing a novel molecular target for further investigation into the interaction between the central and peripheral immune systems.
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Affiliation(s)
- Yuhan Wang
- Department of Neurology, Xinqiao Hospital, The Army Medical University (Third Military Medical University), Chongqing, China
| | - Wenchao Cheng
- Department of Neurology, Xinqiao Hospital, The Army Medical University (Third Military Medical University), Chongqing, China
| | - Xiuying Chen
- Department of Neurology, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing University, Chongqing, China
| | - Chang Cheng
- Department of Neurology, Xinqiao Hospital, The Army Medical University (Third Military Medical University), Chongqing, China
| | - Lan Zhang
- Department of Neurology, Xinqiao Hospital, The Army Medical University (Third Military Medical University), Chongqing, China
| | - Wen Huang
- Department of Neurology, Xinqiao Hospital, The Army Medical University (Third Military Medical University), Chongqing, China.
- Department of Neurology, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing University, Chongqing, China.
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Wada T, Gando S. Phenotypes of Disseminated Intravascular Coagulation. Thromb Haemost 2024; 124:181-191. [PMID: 37657485 PMCID: PMC10890912 DOI: 10.1055/a-2165-1142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 08/30/2023] [Indexed: 09/03/2023]
Abstract
Two phenotypes of disseminated intravascular coagulation (DIC) are systematically reviewed. DIC is classified into thrombotic and fibrinolytic phenotypes characterized by thrombosis and hemorrhage, respectively. Major pathology of DIC with thrombotic phenotype is the activation of coagulation, insufficient anticoagulation with endothelial injury, and plasminogen activator inhibitor-1-mediated inhibition of fibrinolysis, leading to microvascular fibrin thrombosis and organ dysfunction. DIC with fibrinolytic phenotype is defined as massive thrombin generation commonly observed in any type of DIC, combined with systemic pathologic hyperfibrinogenolysis caused by underlying disorder that results in severe bleeding due to excessive plasmin formation. Three major pathomechanisms of systemic hyperfibrinogenolysis have been considered: (1) acceleration of tissue-type plasminogen activator (t-PA) release from hypoxic endothelial cells and t-PA-rich storage pools, (2) enhancement of the conversion of plasminogen to plasmin due to specific proteins and receptors that are expressed on cancer cells and endothelial cells, and (3) alternative pathways of fibrinolysis. DIC with fibrinolytic phenotype can be diagnosed by DIC diagnosis followed by the recognition of systemic pathologic hyperfibrin(ogen)olysis. Low fibrinogen levels, high fibrinogen and fibrin degradation products (FDPs), and the FDP/D-dimer ratio are important for the diagnosis of systemic pathologic hyperfibrin(ogen)olysis. Currently, evidence-based treatment strategies for DIC with fibrinolytic phenotypes are lacking. Tranexamic acid appears to be one of the few methods to be effective in the treatment of systemic pathologic hyperfibrin(ogen)olysis. International cooperation for the elucidation of pathomechanisms, establishment of diagnostic criteria, and treatment strategies for DIC with fibrinolytic phenotype are urgent issues in the field of thrombosis and hemostasis.
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Affiliation(s)
- Takeshi Wada
- Department of Anesthesiology and Critical Care Medicine, Division of Acute and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Satoshi Gando
- Department of Anesthesiology and Critical Care Medicine, Division of Acute and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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Ide R, Oda T, Todo Y, Kawai K, Matsumoto M, Narumi M, Kohmura-Kobayashi Y, Furuta-Isomura N, Yaguchi C, Uchida T, Suzuki K, Kanayama N, Itoh H, Tamura N. Comparative analysis of hyperfibrinolysis with activated coagulation between amniotic fluid embolism and severe placental abruption. Sci Rep 2024; 14:272. [PMID: 38168649 PMCID: PMC10761968 DOI: 10.1038/s41598-023-50911-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 12/27/2023] [Indexed: 01/05/2024] Open
Abstract
Amniotic fluid embolism (AFE) and placental abruption (PA) are typical obstetric diseases associated with disseminated intravascular coagulation (DIC). AFE is more likely to be complicated with enhanced fibrinolysis than PA. AFE may have an additional mechanism activating fibrinolytic cascade. We aimed to compare the coagulation/fibrinolysis factors among AFE, PA, and peripartum controls. We assessed AFE cases registered in the Japanese AFE Registry, and PA cases complicated with DIC (severe PA) and peripartum controls recruited at our hospital. The following factors in plasma were compared: prothrombin fragment 1 + 2 (PF1 + 2), plasmin α2-plasmin inhibitor complex (PIC), tissue factor (TF), tissue plasminogen activator (tPA), annexin A2 (AnnA2), total thrombin activatable fibrinolysis inhibitor (TAFI) including its activated form (TAFIa), and plasminogen activator inhibitor-type 1 (PAI-1). PF1 + 2 and PIC were markedly increased in both AFE (n = 27) and severe PA (n = 12) compared to controls (n = 23), without significant difference between those disease groups; however, PIC in AFE showed a tendency to elevate relative to PF1 + 2, compared with severe PA. AFE had significantly increased tPA and decreased total TAFI levels compared with severe PA and controls, which might be associated with further plasmin production in AFE and underlie its specific fibrinolytic activation pathway.
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Affiliation(s)
- Rui Ide
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Tomoaki Oda
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan.
| | - Yusuke Todo
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Kenta Kawai
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Masako Matsumoto
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Megumi Narumi
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Yukiko Kohmura-Kobayashi
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Naomi Furuta-Isomura
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Chizuko Yaguchi
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Toshiyuki Uchida
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Kazunao Suzuki
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Naohiro Kanayama
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Hiroaki Itoh
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Naoaki Tamura
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
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Favors L, Harrell K, Miles V, Hicks RC, Rippy M, Parmer H, Edwards A, Brown C, Stewart K, Day L, Wilson A, Maxwell R. Analysis of fibrinolytic shutdown in trauma patients with traumatic brain injury. Am J Surg 2024; 227:72-76. [PMID: 37802703 DOI: 10.1016/j.amjsurg.2023.09.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/01/2023] [Accepted: 09/25/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Coagulation profiles following major trauma vary depending on injury pattern and degree of shock. The physiologic mechanisms involved in coagulation function at any given time are varied and remain poorly understood. Thromboelastography (TEG) has been used evaluate coagulation profiles in the trauma population with some reports demonstrating a spectrum of fibrinolysis to fibrinolytic shutdown on initial presentation. The objective of this study was to evaluate the fibrinolytic profile of patients with TBI using thromboelastography (TEG). We hypothesized that patients with TBI would demonstrate low fibrinolytic activity. METHODS All trauma activations at an ACS-verified level 1 trauma center received a TEG analysis upon arrival from December 2019 to June 2021. A retrospective review of the results and outcomes was conducted, and TBI patients were compared to patients without TBI. Linear regression was used to evaluate the effect of patient and injury factors on fibrinolysis. Hyperfibrinolysis was defined as LY30 > 7.7%, physiologic fibrinolysis as LY30 0.6-7.7%, and fibrinolytic shutdown as LY30 < 0.6%. RESULTS A total of 1369 patients received an admission TEG analysis. Patients with TBI had a significantly higher median ISS (16 vs. 8, p < 0.001), lower median admission Glasgow Coma Scale (14 vs. 15, p < 0.001), longer intensive care unit length of stay (3 vs. 2 days, p < 0.0001), increased ventilator days (216 vs. 183, p < 0.001), higher mortality (14.6% vs. 5.1%, p < 0.001), but lower shock index (0.6 vs. 0.7, p < 0.0001) compared to those without TBI. Median LY30 was found to be decreased in the TBI group (0.1 vs. 0.2, p = 0.0006). Patients with TBI were found to have a higher rate of fibrinolytic shutdown compared those without TBI (68.7% vs. 63.5%, p = 0.054). ISS, sex, and shock index were found to be predictive of LY30 on linear regression, but TBI was not (Β: 0.09, SE: 0.277, p = 0.745). The rate of DVT/PE did not appear to be elevated in patients with TBI (0.8%) and without TBI (1.2%). CONCLUSIONS Trauma patients with and without TBI were found to have high rates of fibrinolytic shutdown. Although there was a high incidence of fibrinolytic shutdown, it did not appear to have an impact on the rate of thrombotic complications. The clinical significance of these results is unclear and differs significantly from recent reports which demonstrated that TBI is associated with a 25% rate of fibrinolytic shutdown. Further investigation is needed to better define the fibrinolytic pathway in patients with trauma and TBI to develop optimal treatment algorithms.
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Affiliation(s)
- L Favors
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA.
| | - K Harrell
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA.
| | - V Miles
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA.
| | - R C Hicks
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - M Rippy
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - H Parmer
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - A Edwards
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - C Brown
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - K Stewart
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - L Day
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - A Wilson
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - R Maxwell
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA.
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7
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Mutch NJ, Medcalf RL. The fibrinolysis renaissance. J Thromb Haemost 2023; 21:3304-3316. [PMID: 38000850 DOI: 10.1016/j.jtha.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 09/13/2023] [Accepted: 09/13/2023] [Indexed: 11/26/2023]
Abstract
Fibrinolysis is the system primarily responsible for removal of fibrin deposits and blood clots in the vasculature. The terminal enzyme in the pathway, plasmin, is formed from its circulating precursor, plasminogen. Fibrin is by far the most legendary substrate, but plasmin is notoriously prolific and is known to cleave many other proteins and participate in the activation of other proteolytic systems. Fibrinolysis is often overshadowed by the coagulation system and viewed as a simplistic poorer relation. However, the primordial plasminogen activators evolved alongside the complement system, approximately 70 million years before coagulation saw the light of day. It is highly likely that the plasminogen activation system evolved with its roots in primordial immunity. Almost all immune cells harbor at least one of a dozen plasminogen receptors that allow plasmin formation on the cell surface that in turn modulates immune cell behavior. Similarly, numerous pathogens express their own plasminogen activators or contain surface proteins that provide binding sites for host plasminogen. The fibrinolytic system has been harnessed for clinical medicine for many decades with the development of thrombolytic drugs and antifibrinolytic agents. Our refined understanding and appreciation of the fibrinolytic system and its alliance with infection and immunity and beyond are paving the way for new developments and interest in novel therapeutics and applications. One must ponder as to whether the nomenclature of the system hampered our understanding, by focusing on fibrin, rather than the complex myriad of interactions and substrates of the plasminogen activation system.
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Affiliation(s)
- Nicola J Mutch
- Aberdeen Cardiovascular & Diabetes Centre, Institute of Medical Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Foresterhill, Aberdeen, UK.
| | - Robert L Medcalf
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Wang Y, He J, Zhang X, Zhang G. Confusion in the monitoring of coagulation function in pregnant and neonate patients with severe disease: A case reports and brief literature review. Medicine (Baltimore) 2023; 102:e35997. [PMID: 37986357 PMCID: PMC10659726 DOI: 10.1097/md.0000000000035997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/17/2023] [Indexed: 11/22/2023] Open
Abstract
RATIONALE Different populations have their own unique physiological and pathological characteristics. However, in specialized maternal and child hospitals, there is currently a lack of standardized methods for assessing coagulation dysfunction, both domestically and internationally. PATIENT CONCERNS A 19-day-old neonate was transferred to neonatal intensive care unit with cyanosis, nasal bleeding for 6 hours, and a consciousness disorder for 5 hours. A 33-year-old woman presented with hydramnios and a 39 + 3week intrauterine pregnancy. All indicators before delivery were normal, but postpartum hemorrhage occurred after delivery. DIAGNOSES We retrospectively analyzed 1 neonate with pulmonary hemorrhage accompanied by thrombocytopenia and 1 pregnant patient with amniotic fluid embolism. INTERVENTIONS The new coagulation indicators, such as thrombin-antithrombin complex, plasmin-alpha 2 antiplasmin complex, thrombomodulin, and tissue plasminogen activator-plasminogen activator inhibitor-1 complex, have been indicated to be valuable. In neonates, it is necessary to continuously monitor special items combined with specific therapeutic agents, such as tranexamic acid. In cases where postpartum hemorrhage occurs with low fibrinogen levels, it is essential to effectively identify patients with severe amniotic fluid embolism from a high incidence of specimen clotting. OUTCOMES The neonate's oxygen saturation stabilized, and after 5 days of treatment with low molecular weight heparin, thrombin-antithrombin complex and plasmin-alpha 2 antiplasmin complex returned to normal levels. The pregnant began to remove the remaining thrombus, the patient's condition recovered, and she had a good prognosis. LESSONS For pregnant and neonatal critical illnesses, it is necessary to develop personalized coagulation monitoring programs that provide realistic and reasonable treatment recommendations. Such programs should consider the unique physiological and pathological characteristics of different populations to ensure effective management of critically ill patients.
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Affiliation(s)
- Yuefang Wang
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, People’s Republic of China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, People’s Republic of China
| | - Jiajing He
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, People’s Republic of China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, People’s Republic of China
| | - Xia Zhang
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, People’s Republic of China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, People’s Republic of China
| | - Ge Zhang
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, People’s Republic of China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, People’s Republic of China
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9
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Endo M, Gotoh M, Nakashima M, Kawamoto Y, Sakai S, Murakami-Murofushi K, Hashimoto K, Miyamoto Y. 2-Carba cyclic phosphatidic acid regulates blood coagulation and fibrinolysis system for repair after brain injury. Brain Res 2023; 1818:148511. [PMID: 37506965 DOI: 10.1016/j.brainres.2023.148511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 07/19/2023] [Accepted: 07/21/2023] [Indexed: 07/30/2023]
Abstract
Effective blood coagulation prevents inflammation and neuronal loss after brain injury. 2-Carba-cyclic phosphatidic acid (2ccPA), a biotherapeutic for brain injury, inhibits blood extravasation resulting from blood-brain barrier breakdown. However, the hemostasis mechanism of 2ccPA remains unclear. We determined the effects of 2ccPA-injection on blood coagulation and fibrinolysis using a needle-induced brain injury model. 2ccPA suppressed the expression of platelet degranulation-related genes. Immediately after brain injury, 2ccPA increased CD41+ platelet aggregation around the lesions and promoted fibrin aggregation. Additionally, 2ccPA supported fibrinolysis by upregulating plasminogen activator expression. These results suggest the acute effects of 2ccPA on brain hemostasis.
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Affiliation(s)
- Misaki Endo
- Graduate School of Humanities and Sciences, Ochanomizu University, Ohtsuka, Bunkyo-ku, Tokyo, Japan; Institute for Human Life Science, Ochanomizu University, Ohtsuka, Bunkyo-ku, Tokyo, Japan
| | - Mari Gotoh
- Institute for Human Life Science, Ochanomizu University, Ohtsuka, Bunkyo-ku, Tokyo, Japan
| | - Mari Nakashima
- Graduate School of Humanities and Sciences, Ochanomizu University, Ohtsuka, Bunkyo-ku, Tokyo, Japan; Institute for Human Life Science, Ochanomizu University, Ohtsuka, Bunkyo-ku, Tokyo, Japan
| | - Yuka Kawamoto
- Graduate School of Humanities and Sciences, Ochanomizu University, Ohtsuka, Bunkyo-ku, Tokyo, Japan; Institute for Human Life Science, Ochanomizu University, Ohtsuka, Bunkyo-ku, Tokyo, Japan
| | - Shiho Sakai
- Graduate School of Humanities and Sciences, Ochanomizu University, Ohtsuka, Bunkyo-ku, Tokyo, Japan; Institute for Human Life Science, Ochanomizu University, Ohtsuka, Bunkyo-ku, Tokyo, Japan
| | | | - Kei Hashimoto
- Institute for Human Life Science, Ochanomizu University, Ohtsuka, Bunkyo-ku, Tokyo, Japan; Academic Production, Ochanomizu University, Ohtsuka, Bunkyo-ku, Tokyo, Japan.
| | - Yasunori Miyamoto
- Graduate School of Humanities and Sciences, Ochanomizu University, Ohtsuka, Bunkyo-ku, Tokyo, Japan; Institute for Human Life Science, Ochanomizu University, Ohtsuka, Bunkyo-ku, Tokyo, Japan.
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10
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Rachkovska A, Krenytska D, Karbovskyy V, Raksha N, Halenova T, Vovk T, Savchuk O, Ostapchenko L. A study of fibrinolytic system components in donor groups depending on various titers of circulating anti-SARS-CoV-2 IgG in the bloodstream. Blood Coagul Fibrinolysis 2023; 34:439-445. [PMID: 37577922 DOI: 10.1097/mbc.0000000000001248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
The fibrinolytic system plays an important role in controlling blood coagulation at each stage, from thrombin generation to fibrin clot cleavage. Currently, long-term multiorgan dysfunction post-coronavirus disease 2019 (COVID-19) may include coagulation disorders. Little information is available about the potential causes of post-COVID-19 coagulopathy, but one of them may be subpopulation IgG produced by the immune system against SARS-CoV-2. This article describes the changes in the main parameters of the fibrinolytic system in donors with various titers of anti-SARS-CoV-2 IgG, which is part of a complex study of the hemostasis system in these donor groups. We determined the most significant parameters of the fibrinolytic system, such as potential activity and amount of plasminogen and tissue plasminogen activator (tPA), amount of plasminogen activator inhibitor-1 (PAI-1), inhibitory potentials of α-2-antiplasmin, α-1-antitrypsin, α-2-macroglobulin in the blood plasma of donor groups. The obtained results represent the maximum and minimum values of measurement parameters among donor groups with titers of anti-SARS-CoV-2 IgG at least 10 ± 3 Index (S/C), and their statistical differences from the reference point [donor group with titer of anti-SARS-CoV-2 IgG 0 Index (S/C)]. We established the changes in fibrinolytic parameters depending on the titers of anti-SARS-CoV-2 IgG. One conclusion can be drawn from this: anti-SARS-CoV-2 IgG population may influence coagulation in the post-COVID-19 period. Further research in-vitro and in-vivo experimental models using selected and purified IgG may confirm our previous findings.
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11
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Silva L, Divaris K, Bugge T, Moutsopoulos N. Plasmin-Mediated Fibrinolysis in Periodontitis Pathogenesis. J Dent Res 2023; 102:972-978. [PMID: 37506226 PMCID: PMC10477773 DOI: 10.1177/00220345231171837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2023] Open
Abstract
The hemostatic and inflammatory systems work hand in hand to maintain homeostasis at mucosal barrier sites. Among the factors of the hemostatic system, fibrin is well recognized for its role in mucosal homeostasis, wound healing, and inflammation. Here, we present a basic overview of the fibrinolytic system, discuss fibrin as an innate immune regulator, and provide recent work uncovering the role of fibrin-neutrophil activation as a regulator of mucosal/periodontal homeostasis. We reason that the role of fibrin in periodontitis becomes most evident in individuals with the Mendelian genetic defect, congenital plasminogen (PLG) deficiency, who are predisposed to severe periodontitis in childhood due to a defect in fibrinolysis. Consistent with plasminogen deficiency being a risk factor for periodontitis, recent genomics studies uncover genetic polymorphisms in PLG, encoding plasminogen, being significantly associated with periodontal disease, and suggesting PLG variants as candidate risk indicators for common forms of periodontitis.
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Affiliation(s)
- L.M. Silva
- Oral Immunity and Infection Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
- Proteases and Tissue Remodeling Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - K. Divaris
- Division of Pediatric and Public Health, Adams School of Dentistry, University of North Carolina–Chapel Hill, Chapel Hill, NC,USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina–Chapel Hill, Chapel Hill, NC, USA
| | - T.H. Bugge
- Proteases and Tissue Remodeling Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - N.M. Moutsopoulos
- Oral Immunity and Infection Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
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12
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Buzza MS, Pawar NR, Strong AA, Antalis TM. Intersection of Coagulation and Fibrinolysis by the Glycosylphosphatidylinositol (GPI)-Anchored Serine Protease Testisin. Int J Mol Sci 2023; 24:9306. [PMID: 37298257 PMCID: PMC10252689 DOI: 10.3390/ijms24119306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/16/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
Hemostasis is a delicate balance between coagulation and fibrinolysis that regulates the formation and removal of fibrin, respectively. Positive and negative feedback loops and crosstalk between coagulation and fibrinolytic serine proteases maintain the hemostatic balance to prevent both excessive bleeding and thrombosis. Here, we identify a novel role for the glycosylphosphatidylinositol (GPI)-anchored serine protease testisin in the regulation of pericellular hemostasis. Using in vitro cell-based fibrin generation assays, we found that the expression of catalytically active testisin on the cell surface accelerates thrombin-dependent fibrin polymerization, and intriguingly, that it subsequently promotes accelerated fibrinolysis. We find that the testisin-dependent fibrin formation is inhibited by rivaroxaban, a specific inhibitor of the central prothrombin-activating serine protease factor Xa (FXa), demonstrating that cell-surface testisin acts upstream of factor X (FX) to promote fibrin formation at the cell surface. Unexpectedly, testisin was also found to accelerate fibrinolysis by stimulating the plasmin-dependent degradation of fibrin and enhancing plasmin-dependent cell invasion through polymerized fibrin. Testisin was not a direct activator of plasminogen, but it is able to induce zymogen cleavage and the activation of pro-urokinase plasminogen activator (pro-uPA), which converts plasminogen to plasmin. These data identify a new proteolytic component that can regulate pericellular hemostatic cascades at the cell surface, which has implications for angiogenesis, cancer biology, and male fertility.
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Affiliation(s)
- Marguerite S. Buzza
- Center for Vascular and Inflammatory Diseases, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (N.R.P.); (A.A.S.); (T.M.A.)
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Research and Development Service, VA Maryland Health Care System, Baltimore, MD 21201, USA
| | - Nisha R. Pawar
- Center for Vascular and Inflammatory Diseases, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (N.R.P.); (A.A.S.); (T.M.A.)
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Amando A. Strong
- Center for Vascular and Inflammatory Diseases, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (N.R.P.); (A.A.S.); (T.M.A.)
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Toni M. Antalis
- Center for Vascular and Inflammatory Diseases, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (N.R.P.); (A.A.S.); (T.M.A.)
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Research and Development Service, VA Maryland Health Care System, Baltimore, MD 21201, USA
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13
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Zheng Z, Mukhametova L, Boffa MB, Moore EE, Wolberg AS, Urano T, Kim PY. Assays to quantify fibrinolysis: strengths and limitations. Communication from the International Society on Thrombosis and Haemostasis Scientific and Standardization Committee on fibrinolysis. J Thromb Haemost 2023; 21:1043-1054. [PMID: 36759279 PMCID: PMC10109242 DOI: 10.1016/j.jtha.2023.01.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 01/04/2023] [Accepted: 01/06/2023] [Indexed: 01/15/2023]
Abstract
Fibrinolysis is a series of enzymatic reactions that degrade insoluble fibrin. Plasminogen activators convert the zymogen plasminogen to the active serine protease plasmin, which cleaves and solubilizes crosslinked fibrin clots into fibrin degradation products. The quantity and quality of fibrinolytic enzymes, their respective inhibitors, and clot structure determine overall fibrinolysis. The quantity of protein can be measured by antigen-based assays, and both quantity and quality can be assessed using functional assays. Furthermore, variations of commonly used assays have been reported, which are tailored to address the role(s) of specific fibrinolytic factors and cellular elements (eg, platelets, neutrophils, and red blood cells). Although the concentration and/or activity of a protein can be quantified, how these individual components contribute to the overall fibrinolysis outcome can be challenging to determine. This difficulty is due to temporal changes within and around the thrombi during the clot breakdown, particularly the fibrin matrix structure, and composition. Furthermore, terms such as "fibrinolytic activity/potential," "plasminogen activation," and "plasmin activity" are often used interchangeably despite having different definitions. The purpose of this review is to 1) summarize the assays measuring fibrinolysis activity and potential, 2) facilitate the interpretation of data generated by these assays, and 3) summarize the strengths and limitations of these assays.
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Affiliation(s)
- Ze Zheng
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA; Blood Research Institute, Versiti Blood Center of Wisconsin, Milwaukee, Wisconsin, USA
| | - Liliya Mukhametova
- Chemical Enzymology Department, Chemistry Faculty, Lomonosov Moscow State University, Moscow, Russia
| | - Michael B Boffa
- Department of Biochemistry and Robarts Research Institute, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Ernest E Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, Colorado, USA
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Tetsumei Urano
- Department of Medical Physiology, Hamamatsu University School of Medicine and Shizuoka Graduate University of Public Health, Hamamatsu, Japan
| | - Paul Y Kim
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada.
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14
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Cralley AL, Moore EE, Coleman JR, Vigneshwar N, Bartley M, Kissau D, Eitel A, Hom P, Mitra S, Ghasabyan A, Fragoso M, Guo Z, Deguchi H, Griffin JH, Cohen MJ, Silliman CC, Banerjee A, Hansen K, Sauaia A. Hemorrhagic shock and tissue injury provoke distinct components of trauma-induced coagulopathy in a swine model. Eur J Trauma Emerg Surg 2023; 49:1079-1089. [PMID: 36319860 PMCID: PMC10802987 DOI: 10.1007/s00068-022-02148-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/14/2022] [Indexed: 03/02/2023]
Abstract
INTRODUCTION Tissue injury (TI) and hemorrhagic shock (HS) are the major contributors to trauma-induced coagulopathy (TIC). However, the individual contributions of these insults are difficult to discern clinically because they typically coexist. TI has been reported to release procoagulants, while HS has been associated with bleeding. We developed a large animal model to isolate TI and HS and characterize their individual mechanistic pathways. We hypothesized that while TI and HS are both drivers of TIC, they provoke different pathways; specifically, TI reduces time to clotting, whereas, HS decreases clot strength stimulates hyperfibrinolysis. METHODS After induction of general anesthesia, 50 kg male, Yorkshire swine underwent isolated TI (bilateral muscle cutdown of quadriceps, bilateral femur fractures) or isolated HS (controlled bleeding to a base excess target of - 5 mmol/l) and observed for 240 min. Thrombelastography (TEG), calcium levels, thrombin activatable fibrinolysis inhibitor (TAFI), protein C, plasminogen activator inhibitor 1 (PAI-1), and plasminogen activator inhibitor 1/tissue-type plasminogen activator complex (PAI-1-tPA) were analyzed at pre-selected timepoints. Linear mixed models for repeated measures were used to compare results throughout the model. RESULTS TI resulted in elevated histone release which peaked at 120 min (p = 0.02), and this was associated with reduced time to clot formation (R time) by 240 min (p = 0.006). HS decreased clot strength at time 30 min (p = 0.003), with a significant decline in calcium (p = 0.001). At study completion, HS animals had elevated PAI-1 (p = 0.01) and PAI-1-tPA (p = 0.04), showing a trend toward hyperfibrinolysis, while TI animals had suppressed fibrinolysis. Protein C, TAFI and skeletal myosin were not different among the groups. CONCLUSION Isolated injury in animal models can help elucidate the mechanistic pathways leading to TIC. Our results suggest that isolated TI leads to early histone release and a hypercoagulable state, with suppressed fibrinolysis. In contrast, HS promotes poor clot strength and hyperfibrinolysis resulting in hypocoagulability.
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Affiliation(s)
| | - Ernest E Moore
- Department of Surgery, University of Colorado, Aurora, CO, USA
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO, USA
| | - Julia R Coleman
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | | | - Matt Bartley
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Daniel Kissau
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Andrew Eitel
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Patrick Hom
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | | | - Arsen Ghasabyan
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Miguel Fragoso
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Zihan Guo
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA, USA
| | - Hiroshi Deguchi
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA, USA
| | - John H Griffin
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA, USA
- Department of Medicine, University of California, San Diego, CA, USA
| | | | - Christopher C Silliman
- Vitalant Research Institute, Denver, CO, USA
- Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | | | - Kirk Hansen
- Department of Proteomics and Metabolomics, University of Colorado, Aurora, CO, USA
| | - Angela Sauaia
- Department of Health Systems, Management and Policy, School of Public Health, University of Colorado Denver, Aurora, CO, USA
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15
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Ilich A, Gernsheimer TB, Triulzi DJ, Herren H, Brown SP, Holle LA, Lucas AT, de Laat B, El Kassar N, Wolberg AS, May S, Key NS. Absence of hyperfibrinolysis may explain lack of efficacy of tranexamic acid in hypoproliferative thrombocytopenia. Blood Adv 2023; 7:900-908. [PMID: 36044391 PMCID: PMC10025092 DOI: 10.1182/bloodadvances.2022008255] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/29/2022] [Accepted: 08/21/2022] [Indexed: 11/20/2022] Open
Abstract
The American Trial Using Tranexamic Acid (TXA) in Thrombocytopenia (A-TREAT, NCT02578901) demonstrated no superiority of TXA over placebo in preventing World Health Organization (WHO) grade 2 or higher bleeding in patients with severe thrombocytopenia requiring supportive platelet transfusion following myeloablative therapy for hematologic disorders. In this ancillary study, we sought to determine whether this clinical outcome could be explained on the basis of correlative assays of fibrinolysis. Plasma was collected from A-TREAT participants (n = 115) before the initiation of study drug (baseline) and when TXA was at steady-state trough concentration (follow-up). Global fibrinolysis was measured by 3 assays: euglobulin clot lysis time (ECLT), plasmin generation (PG), and tissue-type plasminogen activator (tPA)-challenged clot lysis time (tPA-CLT). TXA was quantified in follow-up samples by tandem mass spectrometry. Baseline samples did not demonstrate fibrinolytic activation by ECLT or tPA-CLT. Furthermore, neither ECLT nor levels of plasminogen activator inhibitor-1, tPA, plasminogen, alpha2-antiplasmin, or plasmin-antiplasmin complexes were associated with a greater risk of WHO grade 2+ bleeding. TXA trough concentrations were highly variable (range, 0.7-10 μg/mL) and did not correlate with bleeding severity, despite the fact that plasma TXA levels correlated strongly with pharmacodynamic assessments by PG (Spearman r, -0.78) and tPA-CLT (r, 0.74). We conclude that (1) no evidence of fibrinolytic activation was observed in these patients with thrombocytopenia, (2) trough TXA concentrations varied significantly between patients receiving the same dosing schedule, and (3) tPA-CLT and PG correlated well with TXA drug levels.
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Affiliation(s)
- Anton Ilich
- Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
- UNC Blood Research Center, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Terry B. Gernsheimer
- Department of Medicine/Hematology and Seattle Cancer Care Alliance, University of Washington, Seattle, WA
| | | | - Heather Herren
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Siobhan P. Brown
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Lori A. Holle
- UNC Blood Research Center, University of North Carolina School of Medicine, Chapel Hill, NC
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Andrew T. Lucas
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC
| | - Bas de Laat
- Synapse Research Institute, Maastricht, The Netherlands
| | - Nahed El Kassar
- Division of Blood Diseases and Resources, National Heart Lung and Blood Institute, Washington, DC
| | - Alisa S. Wolberg
- UNC Blood Research Center, University of North Carolina School of Medicine, Chapel Hill, NC
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Susanne May
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Nigel S. Key
- Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
- UNC Blood Research Center, University of North Carolina School of Medicine, Chapel Hill, NC
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
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16
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Kanji R, Leader J, Memtsas V, Gorog DA. Measuring Thrombus Stability at High Shear, Together With Thrombus Formation and Endogenous Fibrinolysis: First Experience Using the Global Thrombosis Test 3 (GTT-3). Clin Appl Thromb Hemost 2023; 29:10760296231181917. [PMID: 37551011 PMCID: PMC10411283 DOI: 10.1177/10760296231181917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/12/2023] [Accepted: 05/29/2023] [Indexed: 08/09/2023] Open
Abstract
Thrombus formation in a severely stenosed artery is initiated by high shear activation of platelets, with soluble platelet agonists, such as ADP and thromboxane, playing only a secondary role in the growth and stability of the thrombus. Conventional platelet function tests, however, assess only the soluble agonist-dependent pathway of platelet aggregation. As the thrombus evolves, its stability and ability to withstand dislodgement by arterial flow will determine whether complete and persistent vessel occlusion will occur. The Global Thrombosis Test (GTT), an automated point-of-care technique, simulates the formation of thrombus in whole blood under high shear flow (shear rate >12 000 s-1) and measures the time for occlusive thrombus formation and spontaneous, endogenous thrombolysis/fibrinolysis. The latest GTT-3 model subjects the growing thrombus to upstream pressure, resembling that in a medium-sized artery, and provides an additional assessment of thrombus stability and fibrinolysis rate. It can be used in 3 programs, including a new "hypershear" mode, whereby repetitive cycles of pressure are applied to the growing thrombus, increasing shear rate to ∼22 000 s-1, such as that in patients on mechanical circulatory support. In addition to assessing the risk of arterial thrombosis, the GTT-3 could be used to assess the impact of antithrombotic medications on thrombus stability at high shear. Although current antiplatelet medications target the biochemical axis of platelet aggregation (soluble agonists) and also increase bleeding risk, novel shear-selective antiplatelet therapies may prevent thrombosis while preserving hemostasis. Future studies are needed to assess the usefulness of assessing thrombus stability on cardiovascular and pharmacological evaluation.
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Affiliation(s)
- Rahim Kanji
- Faculty of Medicine, National Heart & Lung Institute, Imperial College, London, UK
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Joshua Leader
- Faculty of Medicine, National Heart & Lung Institute, Imperial College, London, UK
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, UK
| | - Vassilios Memtsas
- Faculty of Medicine, National Heart & Lung Institute, Imperial College, London, UK
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, UK
| | - Diana A Gorog
- Faculty of Medicine, National Heart & Lung Institute, Imperial College, London, UK
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, UK
- Centre for Health Services and Clinical Research, School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, UK
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17
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Tarandovskiy ID, Buehler PW, Karnaukhova E. Sex-dependent balance between thrombin and plasmin generation in the presence of thrombomodulin. J Thromb Thrombolysis 2022; 55:566-570. [PMID: 36508084 DOI: 10.1007/s11239-022-02742-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Assessing simultaneous generation of thrombin (TG) and plasmin (PG) is an approach to evaluate the balance between coagulation and fibrinolysis with sensitivity to predict endogenous thrombin and plasmin generation. The addition of thrombomodulin (TM), provides the essential component for thrombin activation of protein C and thrombin-activatable fibrinolysis inhibitor. However, the influence of sex on the balance between TG and PG with and without TM addition has not been investigated to date. OBJECTIVES To investigate the possible sex-based differences in TG and PG in the presence and absence of TM. METHODS Simultaneous TG and PG were measured in plasma samples obtained from 17 males and 17 females upon tissue factor and tissue plasminogen activator addition. Thrombin- and plasmin-specific fluorogenic substrates Z-Gly-Gly-Arg-AMC and Boc-Glu-Lys-Lys-AMC were used in the study. Thrombin and plasmin peak height (TPH and PPH) and production rate (TPR and PPR) values were determined. To evaluate the balance between TG and PG, the ratios between TPH and PPH (TPH/PPH) and TPR and PPR (TPR/PPR) were calculated. RESULTS AND CONCLUSIONS TPH between males and females demonstrated significant difference regardless of TM addition. TPR demonstrated differences between males and females only upon TM addition, while PG parameters was not dependent on the sex of the donor. TM significantly lowered TPH/PPH in males, and enhanced TPR/PPR in females. Thus, TPH/PPH and TPR/PPR significantly differed between men and women. Our results indicate that TM may act differently in males and females by shifting the underlying TG/PG balance to fibrinolysis in males and to coagulation in females.
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Affiliation(s)
- Ivan D Tarandovskiy
- Hemostasis Branch, Center for Biologics Evaluation and Research, Food and Drug Administration, 10903 New Hampshire Avenue, 20993, Silver Spring, MD, USA.
| | - Paul W Buehler
- Department of Pathology, The Center for Blood Oxygen Transport and Hemostasis, Department of Pediatrics, University of Maryland, Baltimore, MD, USA
| | - Elena Karnaukhova
- Laboratory of Biochemistry and Vascular Biology, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
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18
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Risman RA, Abdelhamid A, Weisel JW, Bannish BE, Tutwiler V. Effects of clot contraction on clot degradation: A mathematical and experimental approach. Biophys J 2022; 121:3271-3285. [PMID: 35927957 PMCID: PMC9463642 DOI: 10.1016/j.bpj.2022.07.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 06/09/2022] [Accepted: 07/19/2022] [Indexed: 12/01/2022] Open
Abstract
Thrombosis, resulting in occlusive blood clots, blocks blood flow to downstream organs and causes life-threatening conditions such as heart attacks and strokes. The administration of tissue plasminogen activator (t-PA), which drives the enzymatic degradation (fibrinolysis) of these blood clots, is a treatment for thrombotic conditions, but the use of these therapeutics is often limited due to the time-dependent nature of treatment and their limited success. We have shown that clot contraction, which is altered in prothrombotic conditions, influences the efficacy of fibrinolysis. Clot contraction results in the volume shrinkage of blood clots, with the redistribution and densification of fibrin and platelets on the exterior of the clot and red blood cells in the interior. Understanding how these key structural changes influence fibrinolysis can lead to improved diagnostics and patient care. We used a combination of mathematical modeling and experimental methodologies to characterize the process of exogenous delivery of t-PA (external fibrinolysis). A three-dimensional (3D) stochastic, multiscale model of external fibrinolysis was used to determine how the structural changes that occur during the process of clot contraction influence the mechanism(s) of fibrinolysis. Experiments were performed based on modeling predictions using pooled human plasma and the external delivery of t-PA to initiate lysis. Analysis of fibrinolysis simulations and experiments indicate that fibrin densification makes the most significant contribution to the rate of fibrinolysis compared with the distribution of components and degree of compaction (p < 0.0001). This result suggests the possibility of a certain fibrin density threshold above which t-PA effective diffusion is limited. From a clinical perspective, this information can be used to improve on current therapeutics by optimizing timing and delivery of lysis agents.
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Affiliation(s)
| | | | - John W Weisel
- University of Pennsylvania, Philadelphia, Pennsylvania
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19
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de Vries JJ, Visser C, Geers L, Slotman JA, van Kleef ND, Maas C, Bax HI, Miedema JR, van Gorp ECM, Goeijenbier M, van den Akker JPC, Endeman H, Rijken DC, Kruip MJHA, de Maat MPM. Altered fibrin network structure and fibrinolysis in intensive care unit patients with COVID-19, not entirely explaining the increased risk of thrombosis. J Thromb Haemost 2022; 20:1412-1420. [PMID: 35316570 PMCID: PMC9115158 DOI: 10.1111/jth.15708] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/11/2022] [Accepted: 03/16/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus 2 infection is associated with an increased incidence of thrombosis. OBJECTIVES By studying the fibrin network structure of coronavirus disease 2019 (COVID-19) patients, we aimed to unravel pathophysiological mechanisms that contribute to this increased risk of thrombosis. This may contribute to optimal prevention and treatment of COVID-19 related thrombosis. PATIENTS/METHODS In this case-control study, we collected plasma samples from intensive care unit (ICU) patients with COVID-19, with and without confirmed thrombosis, between April and December 2020. Additionally, we collected plasma from COVID-19 patients admitted to general wards without thrombosis, from ICU patients with pneumococcal infection, and from healthy controls. Fibrin fiber diameters and fibrin network density were quantified in plasma clots imaged with stimulated emission depletion microscopy and confocal microscopy. Finally, we determined the sensitivity to fibrinolysis. RESULTS COVID-19 ICU patients (n = 37) and ICU patients with pneumococcal disease (n = 7) showed significantly higher fibrin densities and longer plasma clot lysis times than healthy controls (n = 7). No differences were observed between COVID-19 ICU patients with and without thrombosis, or ICU patients with pneumococcal infection. At a second time point, after diagnosis of thrombosis or at a similar time point in patients without thrombosis, we observed thicker fibers and longer lysis times in COVID-19 ICU patients with thrombosis (n = 19) than in COVID-19 ICU patients without thrombosis (n = 18). CONCLUSIONS Our results suggest that severe COVID-19 is associated with a changed fibrin network structure and decreased susceptibility to fibrinolysis. Because these changes were not exclusive to COVID-19 patients, they may not explain the increased thrombosis risk.
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Affiliation(s)
- Judith J de Vries
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Chantal Visser
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Lotte Geers
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Johan A Slotman
- Erasmus Optical Imaging Centre, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nadine D van Kleef
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Coen Maas
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hannelore I Bax
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Internal Medicine, Section of Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jelle R Miedema
- Department of Pulmonary Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Eric C M van Gorp
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Viroscience, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marco Goeijenbier
- Department of Viroscience, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Johannes P C van den Akker
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dingeman C Rijken
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Moniek P M de Maat
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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20
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Morton AP, Hadley JB, Ghasabyan A, Kelher MR, Moore EE, Bevers S, Dzieciatkowska M, Hansen KC, Cohen MS, Banerjee A, Silliman CC. The α-globin chain of hemoglobin potentiates tissue plasminogen activator induced hyperfibrinolysis in vitro. J Trauma Acute Care Surg 2022; 92:159-166. [PMID: 34538821 PMCID: PMC8692352 DOI: 10.1097/ta.0000000000003410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Severe injury predisposes patients to trauma-induced coagulopathy, which may be subdivided by the state of fibrinolysis. Systemic hyperfibrinolysis (HF) occurs in approximately 25% of these patients with mortality as high as 70%. Severe injury also causes the release of numerous intracellular proteins, which may affect coagulation, one of which is hemoglobin, and hemoglobin substitutes induce HF in vitro. We hypothesize that the α-globin chain of hemoglobin potentiates HF in vitro by augmenting plasmin activity. METHODS Proteomic analysis was completed on a pilot study of 30 injured patients before blood component resuscitation, stratified by their state of fibrinolysis, plus 10 healthy controls. Different concentrations of intact hemoglobin A, the α- and β-globin chains, or normal saline (controls) were added to whole blood, and tissue plasminogen activator (tPA)-challenged thrombelastography was used to assess the degree of fibrinolysis. Interactions with plasminogen (PLG) were evaluated using surface plasmon resonance. Tissue plasminogen activator-induced plasmin activity was evaluated in the presence of the α-globin chain. RESULTS Only the α- and β-globin chains increased in HF patients (p < 0.01). The α-globin chain but not hemoglobin A or the β-globin chain decreased the reaction time and significantly increased lysis time 30 on citrated native thrombelastographies (p < 0.05). The PLG and α-globin chain had interaction kinetics similar to tPA:PLG, and the α-globin chain increased tPA-induced plasmin activity. CONCLUSIONS The α-globin chain caused HF in vitro by binding to PLG and augmenting plasmin activity and may represent a circulating "moonlighting" mediator released by the tissue damage and hemorrhagic shock inherent to severe injury. LEVEL OF EVIDENCE Prognostic, level III.
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Affiliation(s)
- Alexander P Morton
- Department of Surgery, School of Medicine University of Colorado Denver, Aurora, CO
- Department of Surgery, Denver Health Medical Center, Vitalant Mountain Division, Denver, CO
| | - Jamie B Hadley
- Department of Surgery, School of Medicine University of Colorado Denver, Aurora, CO
| | - Arsen Ghasabyan
- Department of Surgery, School of Medicine University of Colorado Denver, Aurora, CO
- Department of Surgery, Denver Health Medical Center, Vitalant Mountain Division, Denver, CO
| | - Marguerite R. Kelher
- Department of Surgery, School of Medicine University of Colorado Denver, Aurora, CO
- Department of Surgery, Denver Health Medical Center, Vitalant Mountain Division, Denver, CO
| | - Ernest E Moore
- Department of Surgery, School of Medicine University of Colorado Denver, Aurora, CO
- Department of Surgery, Denver Health Medical Center, Vitalant Mountain Division, Denver, CO
| | - Shaun Bevers
- Department of Biochemistry and Molecular Genetics, School of Medicine University of Colorado Denver, Aurora, CO
| | - Monika Dzieciatkowska
- Department of Biochemistry and Molecular Genetics, School of Medicine University of Colorado Denver, Aurora, CO
| | - Kirk C Hansen
- Department of Biochemistry and Molecular Genetics, School of Medicine University of Colorado Denver, Aurora, CO
| | - Mitchell S Cohen
- Department of Surgery, School of Medicine University of Colorado Denver, Aurora, CO
| | - Anirban Banerjee
- Department of Surgery, School of Medicine University of Colorado Denver, Aurora, CO
| | - Christopher C Silliman
- Department of Surgery, School of Medicine University of Colorado Denver, Aurora, CO
- Department of Pediatrics, School of Medicine University of Colorado Denver, Aurora, CO
- Vitalant Research Institute, Vitalant Mountain Division, Denver, CO
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21
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Nagelkirk PR, Soave K, Altherr C, Del Pozzi A. Regular Resistance Training Enhances Fibrinolytic Potential but Does Not Affect Coagulation. Med Sci Sports Exerc 2021; 53:2318-2323. [PMID: 34115732 DOI: 10.1249/mss.0000000000002724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE This study aimed to identify effects of an 8-wk, whole-body RT program on coagulation and fibrinolysis. METHODS Sixteen healthy women and men (23 ± 5 yr) completed an RT program three times per week for 8 wk. Exercises included 2-3 sets of 8-12 repetitions performed at approximately 60%-80% of a one repetition maximum. Strength, body composition, and body circumferences were assessed before and after training. Plasma samples were obtained before and after training, and analyzed for active tissue plasminogen activator (tPA activity), total tissue plasminogen activator (tPA antigen), active plasminogen activator inhibitor-1 (PAI-1 activity), total plasminogen activator inhibitor-1 (PAI-1 antigen), fibrinogen, and coagulation factors VII (FVII) and VIII (FVIII). RESULTS Significant increases in lean mass, arm and thigh circumferences, maximal chest press (PRE: 57.8 ± 37.5 kg, POST: 73.3 ± 43.2 kg), and leg press (PRE: 189.5 ± 96.0 kg, POST: 256.7 ± 97.9 kg) were observed (P < 0.05 for all). PAI-1 activity (PRE: 20.3 ± 32.5 IU·mL-1, POST 9.5 ± 20.9 IU·mL-1) and PAI-1 antigen decreased (PRE: 10.2 ± 9.0 ng·dL-1, POST: 7.2 ± 5.7 ng·dL-1; both, P < 0.05). No change in tPA activity or tPA antigen occurred. Fibrinogen, FVII, and FVIII did not change after training. CONCLUSIONS Inhibition of fibrinolysis was decreased after training, and coagulation was unaffected. These results suggest that regular RT may beneficially influence the risk of a thrombotic event. More research is warranted to understand the mechanisms through which RT affects hemostasis.
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Affiliation(s)
- Paul R Nagelkirk
- Integrative Exercise Physiology Laboratory, Ball State University, Muncie, IN
| | - Kayla Soave
- Integrative Exercise Physiology Laboratory, Ball State University, Muncie, IN
| | | | - Andrew Del Pozzi
- Integrative Exercise Physiology Laboratory, Ball State University, Muncie, IN
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22
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Grobbelaar L, Venter C, Vlok M, Ngoepe M, Laubscher G, Lourens P, Steenkamp J, Kell D, Pretorius E. SARS-CoV-2 spike protein S1 induces fibrin(ogen) resistant to fibrinolysis: implications for microclot formation in COVID-19. Biosci Rep 2021; 41:BSR20210611. [PMID: 34328172 PMCID: PMC8380922 DOI: 10.1042/bsr20210611] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 07/13/2021] [Accepted: 07/29/2021] [Indexed: 11/17/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2)-induced infection, the cause of coronavirus disease 2019 (COVID-19), is characterized by unprecedented clinical pathologies. One of the most important pathologies, is hypercoagulation and microclots in the lungs of patients. Here we study the effect of isolated SARS-CoV-2 spike protein S1 subunit as potential inflammagen sui generis. Using scanning electron and fluorescence microscopy as well as mass spectrometry, we investigate the potential of this inflammagen to interact with platelets and fibrin(ogen) directly to cause blood hypercoagulation. Using platelet-poor plasma (PPP), we show that spike protein may interfere with blood flow. Mass spectrometry also showed that when spike protein S1 is added to healthy PPP, it results in structural changes to β and γ fibrin(ogen), complement 3, and prothrombin. These proteins were substantially resistant to trypsinization, in the presence of spike protein S1. Here we suggest that, in part, the presence of spike protein in circulation may contribute to the hypercoagulation in COVID-19 positive patients and may cause substantial impairment of fibrinolysis. Such lytic impairment may result in the persistent large microclots we have noted here and previously in plasma samples of COVID-19 patients. This observation may have important clinical relevance in the treatment of hypercoagulability in COVID-19 patients.
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Affiliation(s)
- Lize M. Grobbelaar
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch, Private Bag X1, Matieland 7602, South Africa
| | - Chantelle Venter
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch, Private Bag X1, Matieland 7602, South Africa
| | - Mare Vlok
- Central Analytical Facility: Mass Spectrometry Stellenbosch University, Tygerberg Campus, Room 6054, Clinical Building, Francie van Zijl Drive, Tygerberg, Cape Town 7505, South Africa
| | - Malebogo Ngoepe
- Department of Mechanical Engineering, Faculty of Engineering and the Built Environment, University of Cape Town, Cape Town, Rondebosch 7701, South Africa
- Stellenbosch Institute for Advanced Study, Wallenberg Research Centre, Stellenbosch University, Stellenbosch, South Africa
| | | | | | - Janami Steenkamp
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch, Private Bag X1, Matieland 7602, South Africa
- PathCare Laboratories, PathCare Business Centre, PathCare Park, Neels Bothma Street, N1 City 7460, South Africa
| | - Douglas B. Kell
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch, Private Bag X1, Matieland 7602, South Africa
- Department of Biochemistry and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool L69 7ZB, U.K
- The Novo Nordisk Foundation Centre for Biosustainability, Technical University of Denmark, Kemitorvet 200, Kgs Lyngby 2800, Denmark
| | - Etheresia Pretorius
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch, Private Bag X1, Matieland 7602, South Africa
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Abstract
To study the dynamic changes in perinatal coagulation function in patients with preeclampsia (PE).The general data and coagulation indexes of 290 PE patients during the perinatal period (prenatal and 1 and 3 days postpartum) and 256 healthy pregnant women in the third trimester of pregnancy were investigated, and the data were analyzed.Compared with healthy pregnant women, prothrombin time (PT), fibrinogen (FIB), platelet count (PLT), mean platelet volume (MPV), thrombocytocrit (PCT), maximum amplitude (MA), and coagulation index (CI) of PE patients decreased, and activated partial thrombin time (APTT), thrombin time (TT), D-dimer (DD), platelet distribution width (PDW) and K values increased before delivery (P < .05). APTT and FIB in PE patients were lower in the day 1 postpartum group than in the prenatal and postpartum day 3 groups, and TT, DD, and fibrin degradation products (FDP) were higher (P < .05). PCT and MPV were highest in the prenatal group (P < .05).Compared with that of healthy pregnant women, the coagulation function of PE patients is in a relatively low-coagulation and high-fibrinolysis state on postpartum day 1, which increases the risk of postpartum hemorrhage and other adverse outcomes.
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Affiliation(s)
- Chang Xu
- Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
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24
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Belvedere R, Morretta E, Pessolano E, Novizio N, Tosco A, Porta A, Whiteford J, Perretti M, Filippelli A, Monti MC, Petrella A. Mesoglycan exerts its fibrinolytic effect through the activation of annexin A2. J Cell Physiol 2021; 236:4926-4943. [PMID: 33284486 DOI: 10.1002/jcp.30207] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 12/12/2022]
Abstract
Mesoglycan is a drug based on a mixture of glycosaminoglycans mainly used for the treatment of blood vessel diseases acting as antithrombotic and profibrinolytic drugs. Besides the numerous clinical studies, there is no information about its function on the fibrinolytic cascade. Here, we have elucidated the mechanism of action by which mesoglycan induces the activation of plasmin from endothelial cells. Surprisingly, by a proteomic analysis, we found that, following mesoglycan treatment, these cells show a notable amount of annexin A2 (ANXA2) at the plasma membrane. This protein has been widely associated with fibrinolysis and appears able to move to the membrane when phosphorylated. In our model, this translocation has proven to enhance cell migration, invasion, and angiogenesis. Furthermore, the interaction of mesoglycan with syndecan 4 (SDC4), a coreceptor belonging to the class of heparan sulfate proteoglycans, represents the upstream event of the ANXA2 behavior. Indeed, the activation of SDC4 triggers the motility of endothelial cells culminating in angiogenesis. Interestingly, mesoglycan can induce the release of plasmin in endothelial cell supernatants only in the presence of ANXA2. This evaluation suggests that mesoglycan triggers the formation of a chain mechanism starting from the activation of SDC4, and the related cascade of events, including src complex and PKCα activation, promoting the phosphorylation of ANXA2 and its translocation to plasma membrane. This indicates a connection among mesoglycan, SDC4-(PKCα-src), and ANXA2 which, in turn, links the tissue plasminogen activator bringing it closer to plasminogen. This latter is so cleaved to release the plasmin and degrade fibrin sleeves.
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Affiliation(s)
| | - Elva Morretta
- Department of Pharmacy, University of Salerno, Fisciano (SA), Italy
| | - Emanuela Pessolano
- Department of Pharmacy, University of Salerno, Fisciano (SA), Italy
- The William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Nunzia Novizio
- Department of Pharmacy, University of Salerno, Fisciano (SA), Italy
| | - Alessandra Tosco
- Department of Pharmacy, University of Salerno, Fisciano (SA), Italy
| | - Amalia Porta
- Department of Pharmacy, University of Salerno, Fisciano (SA), Italy
| | - James Whiteford
- The William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mauro Perretti
- The William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Amelia Filippelli
- Department of Medicine, Surgery, and Dentistry, University of Salerno, Baronissi (SA), Italy
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25
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Wang Y, Xie J, Pei F. Plasma D-dimer and FDP are promising biomarkers to predict perioperative fibrinolysis and bleeding following primary total joint arthroplasty: A STROBE compliant article. Medicine (Baltimore) 2021; 100:e26058. [PMID: 34011123 PMCID: PMC8136990 DOI: 10.1097/md.0000000000026058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 04/30/2021] [Indexed: 02/05/2023] Open
Abstract
Perioperative bleeding is associated with postoperative hyperfibrinolysis caused by surgical trauma in the setting of total hip and knee arthroplasty (THA/ TKA). The study aimed to clarify the dynamics of postoperative fibrinolytic activity and the values of fibrin degeneration products and thromboelastography (TEG) to guide precisive antifibrinolytic therapy.Forty three patients undergoing primary unilateral THAs and 40 TKAs were included to the prospective observational cohort study. Venous blood sample at different time points (preoperative, intraoperative, postoperative 6 hours, 12 hours, 24 hours, 48 hours) were drawn to test D-dimer, fibrin (-ogen) degradation products (FDP) and TEG.The TEG parameters associated with coagulation (R, K, α, MA, and CI) and fibrinolysis (estimate percent lysis and Ly30) were all in normal range although had a higher level than preoperative time (P < .05). The postoperative levels of D-dimer and FDP were higher than preoperative level (P < .05). The dynamics of D-dimer and FDP presented a bimodal pattern, which peaked at 6 hours postoperatively, then remained and decreased until 24 hours, but would rebound at 48 hours postoperatively with smaller amplitude. Moreover, FDP6h (P = .028), D-Dimer6h (P = .044), FDP12h (P = .009), D-dimer12h (P = .007), and FDP48h (P = .016) were all correlated with total blood loss on POD3.FDP and D-dimer were effective and practical markers for prediction of acute postoperative fibrinolytic activity, which peaked at 6 hours after end of surgery and would maintain for at least 24 hours.
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Affiliation(s)
- Yan Wang
- Core Facility of West China Hospital
| | - Jinwei Xie
- Department of Orthopaedic Surgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Fuxing Pei
- Department of Orthopaedic Surgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
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Mazzeffi MA, Chow JH, Tanaka K. COVID-19 Associated Hypercoagulability: Manifestations, Mechanisms, and Management. Shock 2021; 55:465-471. [PMID: 32890309 PMCID: PMC7959868 DOI: 10.1097/shk.0000000000001660] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/17/2020] [Accepted: 08/24/2020] [Indexed: 12/15/2022]
Abstract
ABSTRACT Patients with severe coronavirus disease-2019 (COVID-19) frequently have hypercoagulability caused by the immune response to the severe acute respiratory syndrome coronavirus-2 infection. The pathophysiology of COVID-19 associated hypercoagulability is not fully understood, but characteristic changes include: increased fibrinogen concentration, increased Factor VIII activity, increased circulating von Willebrand factor, and exhausted fibrinolysis. Anticoagulant therapy improves outcomes in mechanically ventilated patients with COVID-19 and viscoelastic coagulation testing offers an opportunity to tailor anticoagulant therapy based on an individual patient's coagulation status. In this narrative review, we summarize clinical manifestations of COVID-19, mechanisms, monitoring considerations, and anticoagulant therapy. We also review unique considerations for COVID-19 patients who are on extracorporeal membrane oxygenation.
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Affiliation(s)
- Michael A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
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27
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Gitto S, Romanelli RG, Cellai AP, Lami D, Vizzutti F, Abbate R, Margheri F, Fibbi G, Del Rosso M, Laffi G. Altered clot formation and lysis are associated with increased fibrinolytic activity in ascites in patients with advanced cirrhosis. Intern Emerg Med 2021; 16:339-347. [PMID: 32445164 DOI: 10.1007/s11739-020-02375-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 05/12/2020] [Indexed: 11/26/2022]
Abstract
Analysis of coagulation disorders and assessment of rebalanced hemostasis with the use of traditional coagulation assays is challenging in cirrhotic patients. Therefore, alternative tests are under investigation for the evaluation of coagulopathy in this specific setting. Aim of this study was to analyze the modifications of clot structure and function in cirrhotic patients with different degrees of severity. Cirrhotic patients referred to our Unit were consecutively enrolled. Global test measurements, including clot and lysis assays, clot lysis time, and determination of other fibrinolytic parameters, were performed. Analyses of clot formation, morphology, and lysis were performed with a turbidimetric clotting and lysis assay (EuroCLOT). Lysis of a tissue factor-induced clot by exogenous tissue plasminogen activator was analyzed by studying the modifications of turbidity during clot formation and the following lysis. We evaluated coagulative and fibrinolytic parameters in both plasma and ascites. Urokinase plasminogen activator (uPA) and gelatinase activity in ascites were also measured. We analyzed data from 33 cirrhotic patients (11 in Child-Pugh class A; 22 in class B or C and with ascites) and 21 healthy subjects (HS). In class B/C patients prolonged latency time, a decline in clotting absorbance, and decreased fibrin formation were observed in comparison with class A and HS. Generated curves and Thrombin-Activatable Fibrinolysis Inhibitor (TAFI) progressively declined from HS to class C patients, whereas levels of plasminogen activator inhibitor-1 and tissue plasminogen activator increased. D-dimer levels were markedly increased in ascites, together with significantly smaller levels of TAFI, αlfa2-antiplasmin, and plasminogen. Caseinolytic activity was also present. Class C patients showed smaller amount of uPA and significantly lower levels of matrix metallopeptidases (MMP)2 in ascites in comparison with Class B subjects. Clot formation and lysis are altered in cirrhosis and fibrinolysis is activated in ascites. Ascitic levels of uPA and MMP2 are reduced and inversely related to the severity of liver disease.
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Affiliation(s)
- Stefano Gitto
- Dipartimento Medicina Clinica e Sperimentale (DMSC)-Liver Unit, University of Florence, School of Medicine-Azienda Ospedaliero Universitaria Careggi (AOUC), Largo Brambilla, 3 and Viale Morgagni, 50, 50134, Florence, Italy
| | - Roberto Giulio Romanelli
- Dipartimento Medicina Clinica e Sperimentale (DMSC)-Liver Unit, University of Florence, School of Medicine-Azienda Ospedaliero Universitaria Careggi (AOUC), Largo Brambilla, 3 and Viale Morgagni, 50, 50134, Florence, Italy
| | - Anna Paola Cellai
- Dipartimento Oncologia-Thrombosis Center, University of Florence, School of Medicine-Azienda Ospedaliero Universitaria Careggi (AOUC), Largo Brambilla, 3 and Viale Morgagni, 50, 50134, Florence, Italy
| | - Donatella Lami
- Sezione Malattie Aterotrombotiche-Dipartimento Area Critica Medico/Chirurgica, University of Florence, School of Medicine-Azienda Ospedaliero Universitaria Careggi (AOUC), Largo Brambilla, 3 and Viale Morgagni, 50, 50134, Florence, Italy
| | - Francesco Vizzutti
- Dipartimento Medicina Clinica e Sperimentale (DMSC)-Liver Unit, University of Florence, School of Medicine-Azienda Ospedaliero Universitaria Careggi (AOUC), Largo Brambilla, 3 and Viale Morgagni, 50, 50134, Florence, Italy
| | - Rosanna Abbate
- Sezione Malattie Aterotrombotiche-Dipartimento Area Critica Medico/Chirurgica, University of Florence, School of Medicine-Azienda Ospedaliero Universitaria Careggi (AOUC), Largo Brambilla, 3 and Viale Morgagni, 50, 50134, Florence, Italy
| | - Francesca Margheri
- Dipartimento Scienze Biomediche Sperimentali e Cliniche "Mario Serio", University of Florence, School of Medicine-Azienda Ospedaliero Universitaria Careggi (AOUC), Largo Brambilla, 3 and Viale Morgagni, 50, 50134, Florence, Italy
| | - Gabriella Fibbi
- Dipartimento Scienze Biomediche Sperimentali e Cliniche "Mario Serio", University of Florence, School of Medicine-Azienda Ospedaliero Universitaria Careggi (AOUC), Largo Brambilla, 3 and Viale Morgagni, 50, 50134, Florence, Italy
| | - Mario Del Rosso
- Dipartimento Scienze Biomediche Sperimentali e Cliniche "Mario Serio", University of Florence, School of Medicine-Azienda Ospedaliero Universitaria Careggi (AOUC), Largo Brambilla, 3 and Viale Morgagni, 50, 50134, Florence, Italy
| | - Giacomo Laffi
- Dipartimento Medicina Clinica e Sperimentale (DMSC)-Liver Unit, University of Florence, School of Medicine-Azienda Ospedaliero Universitaria Careggi (AOUC), Largo Brambilla, 3 and Viale Morgagni, 50, 50134, Florence, Italy.
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Claesen K, Mertens JC, Leenaerts D, Hendriks D. Carboxypeptidase U (CPU, TAFIa, CPB2) in Thromboembolic Disease: What Do We Know Three Decades after Its Discovery? Int J Mol Sci 2021; 22:ijms22020883. [PMID: 33477318 PMCID: PMC7830380 DOI: 10.3390/ijms22020883] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 02/01/2023] Open
Abstract
Procarboxypeptidase U (proCPU, TAFI, proCPB2) is a basic carboxypeptidase zymogen that is converted by thrombin(-thrombomodulin) or plasmin into the active carboxypeptidase U (CPU, TAFIa, CPB2), a potent attenuator of fibrinolysis. As CPU forms a molecular link between coagulation and fibrinolysis, the development of CPU inhibitors as profibrinolytic agents constitutes an attractive new concept to improve endogenous fibrinolysis or to increase the efficacy of thrombolytic therapy in thromboembolic diseases. Furthermore, extensive research has been conducted on the in vivo role of CPU in (the acute phase of) thromboembolic disease, as well as on the hypothesis that high proCPU levels and the Thr/Ile325 polymorphism may cause a thrombotic predisposition. In this paper, an overview is given of the methods available for measuring proCPU, CPU, and inactivated CPU (CPUi), together with a summary of the clinical data generated so far, ranging from the current knowledge on proCPU concentrations and polymorphisms as potential thromboembolic risk factors to the positioning of different CPU forms (proCPU, CPU, and CPUi) as diagnostic markers for thromboembolic disease, and the potential benefit of pharmacological inhibition of the CPU pathway.
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Corrêa TD, Cordioli RL, Campos Guerra JC, Caldin da Silva B, dos Reis Rodrigues R, de Souza GM, Midega TD, Campos NS, Carneiro BV, Campos FND, Guimarães HP, de Matos GFJ, de Aranda VF, Rolim Ferraz LJ. Coagulation profile of COVID-19 patients admitted to the ICU: An exploratory study. PLoS One 2020; 15:e0243604. [PMID: 33320874 PMCID: PMC7737963 DOI: 10.1371/journal.pone.0243604] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 11/20/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Coagulation abnormalities in COVID-19 patients have not been addressed in depth. OBJECTIVE To perform a longitudinal evaluation of coagulation profile of patients admitted to the ICU with COVID-19. METHODS Conventional coagulation tests, rotational thromboelastometry (ROTEM), platelet function, fibrinolysis, antithrombin, protein C and S were measured at days 0, 1, 3, 7 and 14. Based on median total maximum SOFA score, patients were divided in two groups: SOFA ≤ 10 and SOFA > 10. RESULTS Thirty patients were studied. Some conventional coagulation tests, as aPTT, PT and INR remained unchanged during the study period, while alterations on others coagulation laboratory tests were detected. Fibrinogen levels were increased in both groups. ROTEM maximum clot firmness increased in both groups from Day 0 to Day 14. Moreover, ROTEM-FIBTEM maximum clot firmness was high in both groups, with a slight decrease from day 0 to day 14 in group SOFA ≤ 10 and a slight increase during the same period in group SOFA > 10. Fibrinolysis was low and decreased over time in all groups, with the most pronounced decrease observed in INTEM maximum lysis in group SOFA > 10. Also, D-dimer plasma levels were higher than normal reference range in both groups and free protein S plasma levels were low in both groups at baseline and increased over time, Finally, patients in group SOFA > 10 had lower plasminogen levels and Protein C than patients with SOFA <10, which may represent less fibrinolysis activity during a state of hypercoagulability. CONCLUSION COVID-19 patients have a pronounced hypercoagulability state, characterized by impaired endogenous anticoagulation and decreased fibrinolysis. The magnitude of coagulation abnormalities seems to correlate with the severity of organ dysfunction. The hypercoagulability state of COVID-19 patients was not only detected by ROTEM but it much more complex, where changes were observed on the fibrinolytic and endogenous anticoagulation system.
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Affiliation(s)
- Thiago Domingos Corrêa
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Ricardo Luiz Cordioli
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Bruno Caldin da Silva
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | - Thais Dias Midega
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | | | - Hélio Penna Guimarães
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Kruse JM, Magomedov A, Kurreck A, Münch FH, Koerner R, Kamhieh-Milz J, Kahl A, Gotthardt I, Piper SK, Eckardt KU, Dörner T, Zickler D. Thromboembolic complications in critically ill COVID-19 patients are associated with impaired fibrinolysis. Crit Care 2020; 24:676. [PMID: 33287877 PMCID: PMC7719734 DOI: 10.1186/s13054-020-03401-8] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 11/20/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND There is emerging evidence for enhanced blood coagulation in coronavirus 2019 (COVID-19) patients, with thromboembolic complications contributing to morbidity and mortality. The mechanisms underlying this prothrombotic state remain enigmatic. Further data to guide anticoagulation strategies are urgently required. METHODS We used viscoelastic rotational thromboelastometry (ROTEM) in a single-center cohort of 40 critically ill COVID-19 patients. RESULTS Clear signs of a hypercoagulable state due to severe hypofibrinolysis were found. Maximum lysis, especially following stimulation of the extrinsic coagulation system, was inversely associated with an enhanced risk of thromboembolic complications. Combining values for maximum lysis with D-dimer concentrations revealed high sensitivity and specificity of thromboembolic risk prediction. CONCLUSIONS The study identifies a reduction in fibrinolysis as an important mechanism in COVID-19-associated coagulopathy. The combination of ROTEM and D-dimer concentrations may prove valuable in identifying patients requiring higher intensity anticoagulation.
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Affiliation(s)
- Jan Matthias Kruse
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Abakar Magomedov
- Department of Hepatology and Gastroenterology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Annika Kurreck
- Department of Hematology and Oncology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Frédéric H Münch
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Roland Koerner
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Julian Kamhieh-Milz
- Institute for Transfusion Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Wimedko GmbH, Berlin, Germany
| | - Andreas Kahl
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Inka Gotthardt
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Sophie K Piper
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Thomas Dörner
- Department of Rheumatology Und Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Deutsches Rheumaforschungszentrum (DRFZ), Berlin, Germany
| | - Daniel Zickler
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
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Yagi K, Tao Y, Hara K, Kanda E, Hirai S, Takai H, Kinoshita K, Mimani Y, Miyazaki Y, Oyama N, Yagita Y, Matsubara S, Uno M. Increased plasma plasmin-α2-plasmin inhibitor complex levels correlate with postoperative rebleeding after endoscopic surgery for spontaneous intracerebral hemorrhage. Acta Neurochir (Wien) 2020; 162:3129-3136. [PMID: 31781996 DOI: 10.1007/s00701-019-04154-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 11/18/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Postoperative rebleeding (PR) is one of the most severe complications of endoscopic surgery, often performed to remove spontaneous intracerebral hemorrhage (sICH). However, the risk factors for PR remain unclear. OBJECTIVE This study retrospectively investigated whether increased preoperative plasma plasmin-α2-plasmin inhibitor complex (PIC) levels, indicating activation of fibrinolysis, are associated with PR. METHODS A total of 101 patients underwent endoscopic surgery to evacuate sICH at our institution from January 2010 to June 2019, and 79 patients who underwent examinations of plasma PIC levels at admission with available radiographical data were included. Correlations between PR and increased plasma PIC levels were retrospectively evaluated. RESULTS PR occurred in eight patients (10.1%), and high PIC levels (≥ 4 or 6 μg/ml) were significantly associated with PR. The sensitivities employing high PIC levels of ≥ 4 μg/ml and ≥ 6 μg/ml were both 0.63, and the specificities using the same PIC levels were 0.86 and 0.92, respectively. Multivariable analyses showed that high plasma PIC levels of ≥ 4 μg/ml (odds ratio (OR), 12.77; 95% confidence interval (CI), 1.65-98.77; p = 0.02) or ≥ 6 μg/ml (OR, 18.33; 95% CI, 2.32-144.82; p = 0.006) were independent predictors of PR. CONCLUSIONS This study found that increased plasma PIC levels were associated with PR following the endoscopic evacuation of sICHs, indicating that increased plasma PIC levels could be potentially used to predict PR. Further studies are needed to establish new surgical strategies and adjuvant treatments to improve surgical outcomes in patients with sICH prone to PR.
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Affiliation(s)
- Kenji Yagi
- Department of Neurosurgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan.
| | - Yoshifumi Tao
- Department of Neurosurgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Keijirou Hara
- Department of Neurosurgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Eiichiro Kanda
- Medical Science, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Satoshi Hirai
- Department of Neurosurgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Hiroki Takai
- Department of Neurosurgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Keita Kinoshita
- Department of Neurosurgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Yukari Mimani
- Department of Neurosurgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Yuko Miyazaki
- Department of Neurosurgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Naoki Oyama
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Yoshiki Yagita
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Shunji Matsubara
- Department of Neurosurgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Masaaki Uno
- Department of Neurosurgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
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Gue YX, Kanji R, Wellsted DM, Srinivasan M, Wyatt S, Gorog DA. Rationale and design of "Can Very Low Dose Rivaroxaban (VLDR) in addition to dual antiplatelet therapy improve thrombotic status in acute coronary syndrome (VaLiDate-R)" study : A randomised trial modulating endogenous fibrinolysis in patients with acute coronary syndrome. J Thromb Thrombolysis 2020; 49:192-198. [PMID: 31872349 PMCID: PMC6969858 DOI: 10.1007/s11239-019-02014-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Impaired endogenous fibrinolysis is novel biomarker that can identify patients with ACS at increased cardiovascular risk. The addition of Very Low Dose Rivaroxaban (VLDR) to dual antiplatelet therapy has been shown to reduce cardiovascular events but at a cost of increased bleeding and is therefore not suitable for all-comers. Targeted additional pharmacotherapy with VLDR to improve endogenous fibrinolysis may improve outcomes in high-risk patients, whilst avoiding unnecessary bleeding in low-risk individuals. The VaLiDate-R study (ClinicalTrials.gov Identifier: NCT03775746, EudraCT: 2018-003299-11) is an investigator-initiated, randomised, open-label, single centre trial comparing the effect of 3 antithrombotic regimens on endogenous fibrinolysis in 150 patients with ACS. Subjects whose screening blood test shows impaired fibrinolytic status (lysis time > 2000s), will be randomised to one of 3 treatment arms in a 1:1:1 ratio: clopidogrel 75 mg daily (Group 1); clopidogrel 75 mg daily plus rivaroxaban 2.5 mg twice daily (Group 2); ticagrelor 90 mg twice daily (Group 3), in addition to aspirin 75 mg daily. Rivaroxaban will be given for 30 days. Fibrinolytic status will be assessed during admission and at 2, 4 and 8 weeks. The primary outcome measure is the change in fibrinolysis time from admission to 4 weeks follow-up, using the Global Thrombosis Test. If VLDR can improve endogenous fibrinolysis in ACS, future large-scale studies would be required to assess whether targeted use of VLDR in patients with ACS and impaired fibrinolysis can translate into improved clinical outcomes, with reduction in major adverse cardiovascular events in this high-risk cohort.
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Affiliation(s)
- Ying X Gue
- Department of Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
- Cardiology Department, East and North Hertfordshire NHS Trust, Hertfordshire, UK
| | - Rahim Kanji
- Cardiology Department, East and North Hertfordshire NHS Trust, Hertfordshire, UK
- National Heart and Lung Institute, Imperial College, Dovehouse Street, London, SW3 6LY, UK
| | - David M Wellsted
- Department of Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | | | - Solange Wyatt
- Department of Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | - Diana A Gorog
- Department of Postgraduate Medicine, University of Hertfordshire, Hatfield, UK.
- Cardiology Department, East and North Hertfordshire NHS Trust, Hertfordshire, UK.
- National Heart and Lung Institute, Imperial College, Dovehouse Street, London, SW3 6LY, UK.
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Abstract
The overflow of studies in the recent literature on COVID-19 often gives provisional or contradictory results and therefore deserves pauses of reflection and reconsideration. In fact, knowledges of pathophysiology of this new disease are still in development and hence originate discussions and interpretations. Regarding the role of blood coagulation and fibrinolysis, these mechanisms should be considered as crucial especially in severe cases. It is proposed to consider two distinct phenotypes of thrombotic manifestations: the current "thromboembolic type" also occurring in other kinds of sepsis, and the diffuse micro-thrombotic type, prevailing in the lungs but sometimes extending to other organs. Both types can induce severe disease and are potentially lethal. The micro-thrombotic pattern, more specific for COVID-19, results from a massive activation of coagulation strictly coupled with a hyper-intense inflammatory and immune reaction. This results in widespread occlusive thrombotic micro-angiopathy with destruction of alveoli and obstructive neoangiogenesis. The involvement of fibrinolysis, often neglected, confers a double faceted process of activation/inhibition, finally conducive to a fibrinolytic shutdown that reinforces persistence of micro-thrombi. Considering these peculiar mechanisms, it seems evident that both prophylactic and therapeutic effects of current anti-thrombotic drugs cannot be taken for granted and need therefore new specific and rigorous controlled trials.
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Cone SJ, Fuquay AT, Litofsky JM, Dement TC, Carolan CA, Hudson NE. Inherent fibrin fiber tension propels mechanisms of network clearance during fibrinolysis. Acta Biomater 2020; 107:164-177. [PMID: 32105833 PMCID: PMC7160043 DOI: 10.1016/j.actbio.2020.02.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 02/13/2020] [Accepted: 02/18/2020] [Indexed: 11/21/2022]
Abstract
Proper wound healing necessitates both coagulation (the formation of a blood clot) and fibrinolysis (the dissolution of a blood clot). A thrombus resistant to clot dissolution can obstruct blood flow, leading to vascular pathologies. This study seeks to understand the mechanisms by which individual fibrin fibers, the main structural component of blood clots, are cleared from a local volume during fibrinolysis. We observed 2-D fibrin networks during lysis by plasmin, recording the clearance of each individual fiber. We found that, in addition to transverse cleavage of fibers, there were multiple other pathways by which clot dissolution occurred, including fiber bundling, buckling, and collapsing. These processes are all influenced by the concentration of plasmin utilized in lysis. The network fiber density influenced the kinetics and distribution of these pathways. Individual cleavage events often resulted in large morphological changes in network structure, suggesting that the inherent tension in fibers played a role in fiber clearance. Using images before and after a cleavage event to measure fiber lengths, we estimated that fibers are strained ~23% beyond their equilibrium length during polymerization. To understand the role of fiber tension in fibrinolysis we modeled network clearance under differing amounts of fiber polymerized strain (prestrain). The comparison of experimental and model data indicated that fibrin tension enables 35% more network clearance due to network rearrangements after individual cleavage events than would occur if fibers polymerized in a non-tensed state. Our results highlight many characteristics and mechanisms of fibrin breakdown, which have implications on future fibrin studies, our understanding of the fibrinolytic process, and the development of thrombolytic therapies. STATEMENT OF SIGNIFICANCE: Fibrin fibers serve as the main structural element of blood clots. They polymerize under tension and have remarkable extensibility and elasticity. After the cessation of wound healing, fibrin must be cleared from the vasculature by the enzyme plasmin in order to resume normal blood flow: a process called fibrinolysis. In this study we investigate the mechanisms that regulate the clearance of individual fibrin fibers during fibrinolysis. We show that the inherent tension in fibers enhances the action of plasmin because every fiber cleavage event results in a redistribution of the network tension. This network re-equilibration causes fibers to buckle, bundle, and even collapse, leading to a more rapid fiber clearance than plasmin alone could provide.
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Affiliation(s)
- Sean J Cone
- Department of Physics, East Carolina University; 1000 E 5(th) St, Greenville, NC 27858, United States
| | - Andrew T Fuquay
- Medical Physics Graduate Program, Duke University; DUMC 2729, 2424 Erwin Rd Suite 101, Durham, NC 27705, USA
| | - Justin M Litofsky
- Department of Physics, East Carolina University; 1000 E 5(th) St, Greenville, NC 27858, United States
| | - Taylor C Dement
- Department of Physics, East Carolina University; 1000 E 5(th) St, Greenville, NC 27858, United States
| | - Christopher A Carolan
- Department of Mathematics, East Carolina University; 1000 E 5(th) St, Greenville, NC 27858, United States
| | - Nathan E Hudson
- Department of Physics, East Carolina University; 1000 E 5(th) St, Greenville, NC 27858, United States.
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35
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Garrigue D, Prunet B, Pottecher J. Routine use of viscoelastic tests for severe trauma management: The bright side. Anaesth Crit Care Pain Med 2019; 38:445-447. [PMID: 31369837 DOI: 10.1016/j.accpm.2019.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 07/17/2019] [Accepted: 07/20/2019] [Indexed: 06/10/2023]
Affiliation(s)
| | - Bertrand Prunet
- Bureau de médecine d'urgence, brigade de sapeurs-pompiers de Paris, 1, Place J. Renard, 75017 Paris, France; Service de santé des armées, chaire d'anesthésie-réanimation-urgence, école du Val-de-Grâce, 75005 Paris, France.
| | - Julien Pottecher
- Unités de réanimation chirurgicale et de surveillance continue, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France; EA 3072 « mitochondrie, stress oxydant et protection musculaire », Fédération de médecine translationnelle de Strasbourg (FMTS), faculté de médecine, université de Strasbourg, 67000 Strasbourg, France.
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36
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Moore HB, Moore EE, Neal MD, Sheppard FR, Kornblith LZ, Draxler DF, Walsh M, Medcalf RL, Cohen MJ, Cotton BA, Thomas SG, Leeper CM, Gaines BA, Sauaia A. Fibrinolysis Shutdown in Trauma: Historical Review and Clinical Implications. Anesth Analg 2019; 129:762-773. [PMID: 31425218 PMCID: PMC7340109 DOI: 10.1213/ane.0000000000004234] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Despite over a half-century of recognizing fibrinolytic abnormalities after trauma, we remain in our infancy in understanding the underlying mechanisms causing these changes, resulting in ineffective treatment strategies. With the increased utilization of viscoelastic hemostatic assays (VHAs) to measure fibrinolysis in trauma, more questions than answers are emerging. Although it seems certain that low fibrinolytic activity measured by VHA is common after injury and associated with increased mortality, we now recognize subphenotypes within this population and that specific cohorts arise depending on the specific time from injury when samples are collected. Future studies should focus on these subtleties and distinctions, as hypofibrinolysis, acute shutdown, and persistent shutdown appear to represent distinct, unique clinical phenotypes, with different pathophysiology, and warranting different treatment strategies.
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Affiliation(s)
- Hunter B. Moore
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Ernest E. Moore
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | - Matthew D. Neal
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Lucy Z. Kornblith
- Department of Surgery, San Francisco General Hospital, University of California San Francisco, San Francisco, California
| | - Dominik F. Draxler
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
| | - Mark Walsh
- Department of Surgery, Memorial Hospital Trauma Center, Springfield, Illinois
- Department of Emergency Medicine, Memorial Hospital Trauma Center, Springfield, Illinois
| | - Robert L. Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
| | - Mitch J. Cohen
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | - Bryan A. Cotton
- Department of Surgery, Center for Translational Injury Research, The McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Scott G. Thomas
- Department of Surgery, Memorial Hospital Trauma Center, Springfield, Illinois
- Department of Emergency Medicine, Memorial Hospital Trauma Center, Springfield, Illinois
| | - Christine M. Leeper
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Barbara A. Gaines
- Department of Surgery, Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Angela Sauaia
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
- Division of Health Systems, Management, and Policy, University of Colorado School of Public Health, Aurora, Colorado
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Wieczór R, Wieczór AM, Kulwas A, Rość D. Type 2 Diabetes and Cardiovascular Factors Contrasted with Fibrinolysis Disorders in the Blood of Patients with Peripheral Arterial Disease. ACTA ACUST UNITED AC 2019; 55:medicina55070395. [PMID: 31336615 PMCID: PMC6681256 DOI: 10.3390/medicina55070395] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 07/19/2019] [Accepted: 07/19/2019] [Indexed: 11/18/2022]
Abstract
Background and objectives: Both in the pathogenesis of type 2 diabetes (DM 2) and Peripheral Arterial Disease (PAD), a vital role is played by endothelial dysfunction. Metabolic disorders found in DM 2 (hyperglycemia, insulin resistance), endothelial dysfunction, and increased inflammation lead to intensified atherothrombosis. The fibrinolysis system comprises a natural compensatory mechanism in case of hypercoagulability. The aim of this study was to assess concentrations of selected fibrinolysis parameters in the blood of patients with symptomatic PAD, including in particular concurrent DM 2 and other cardiovascular factors. Materials and Methods: In the group of 80 patients with PAD (27 F/53 M) and 30 healthy volunteers (10 F/20 M), the following parameters were measured: Concentrations of fibrinogen, tissue-Plasminogen Activator (t-PA Ag), Plasminogen Activator Inhibitor-1 (PAI-1 Ag), D-dimer, and platelet (PLT) count. Results: In the blood of patients with PAD and concomitant DM 2 significantly higher concentrations of fibrinogen were found in comparison with patients with PAD and without diabetes (p = 0.044). No significant impact was observed in individuals with atherosclerotic complications (manifested by coronary artery disease, atherosclerosis of cerebral arteries) and selected cardiovascular risk factors (smoking, LDL and triglyceride concentrations, BP values) on the levels of t-PA, PAI-1, D-dimer, and PLT count. It was found that t-PA Ag and PAI-1 Ag values tended to rise along with a BMI increase in the subgroups of subjects (with normal body mass, overweight, and obesity), but no statistically significant differences were observed. However, two significant positive correlations were reported between t-PA Ag and BMI, as well as between PAI-1 Ag and BMI. Conclusions: Type 2 diabetes in peripheral arterial disease affects the concentration of fibrinogen causing its increase, which is connected with the inflammation and prothrombotic process in the course of both conditions. The concurrence of atherosclerosis of coronary or cerebral arteries, smoking, LDL and TG concentrations, and BP value do not have a significant impact on the levels of analyzed fibrinolysis parameters. A positive correlation between BMI and t-PA Ag and PAI-1 Ag concentrations needs to be supported in further studies on a larger number of overweight and obese patients.
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Affiliation(s)
- Radosław Wieczór
- Department of Pathophysiology, Faculty of Pharmacy, Nicolaus Copernicus University in Toruń, Ludwik Rydygier Collegium Medicum in Bydgoszcz, 85-094 Bydgoszcz, Poland.
- Clinic of Vascular and Internal Medicine, Dr Jan Biziel University Hospital No. 2 in Bydgoszcz, 85-168 Bydgoszcz, Poland.
| | - Anna Maria Wieczór
- Department of Pathophysiology, Faculty of Pharmacy, Nicolaus Copernicus University in Toruń, Ludwik Rydygier Collegium Medicum in Bydgoszcz, 85-094 Bydgoszcz, Poland
| | - Arleta Kulwas
- Department of Pathophysiology, Faculty of Pharmacy, Nicolaus Copernicus University in Toruń, Ludwik Rydygier Collegium Medicum in Bydgoszcz, 85-094 Bydgoszcz, Poland
| | - Danuta Rość
- Department of Pathophysiology, Faculty of Pharmacy, Nicolaus Copernicus University in Toruń, Ludwik Rydygier Collegium Medicum in Bydgoszcz, 85-094 Bydgoszcz, Poland
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Mertens JC, Claesen K, Leenaerts D, Sim Y, Lambeir AM, Hendriks D. Inhibition of the procarboxypeptidase U (proCPU, TAFI, proCPB2) system due to hemolysis. J Thromb Haemost 2019; 17:878-884. [PMID: 30887647 DOI: 10.1111/jth.14432] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 03/11/2019] [Indexed: 11/30/2022]
Abstract
Essentials Hemolytic influence on the (pro)carboxypeptidase U ((pro)CPU) system is not known. In the current manuscript, this was assessed by spiking pooled normal plasma with hemolysate. CPU activity, proCPU levels, and clot lysis times showed a dose-dependent hemolytic bias. The observed bias in the several CPU related parameters is due to inhibition of CPU activity. INTRODUCTION Spurious hemolysis of samples is the leading cause of interference in coagulation testing and was described to interfere in fibrinolysis assays. The influence of hemolysis on the procarboxypeptidase U (proCPU) system is not known. METHODS By means of spiking of hemolysate in pooled normal plasma, the effect of hemolysis on CPU, proCPU, and functional clot lysis assays was assessed. The influence of hemolysis on CPU generation during in vitro clot lysis was also evaluated. Cutoffs corresponding to maximal acceptable bias were determined. RESULTS AND DISCUSSION When active CPU was added to pooled plasma, a severe decrease in activity - up to 97.2% inhibition - was seen with increasing plasma concentrations of oxyhemoglobin (oxyHb) and the 10% cutoff value was found to be 0.3 g/L oxyHb. Using an activity-based assay, proCPU levels appeared to decrease gradually with increased hemolysis (maximal reduction of 19.5%) with a 10% cutoff value of 4.2 g/L oxyHb. The relative clot lysis time (CLT) showed a maximal negative bias of 68.5%. The reduction in CLT paralleled a significant reduction of the first CPU activity peak during clot lysis. The cutoff value for the CLT was 0.4 g/L oxyHb. In presence of thrombomodulin (TM), CLT+TM was not affected up to 8.0 g/L oxyHb. CONCLUSION These data indicate a clear inhibition of the CPU system because of hemolysis resulting in an increase of lysis in functional fibrinolysis assays. We were able to quantify the inhibitory effect and to propose cutoff values for every parameter.
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Affiliation(s)
- Joachim C Mertens
- Laboratory of Medical Biochemistry, Department of Pharmaceutical Sciences, University of Antwerp, Antwerp, Belgium
| | - Karen Claesen
- Laboratory of Medical Biochemistry, Department of Pharmaceutical Sciences, University of Antwerp, Antwerp, Belgium
| | - Dorien Leenaerts
- Laboratory of Medical Biochemistry, Department of Pharmaceutical Sciences, University of Antwerp, Antwerp, Belgium
| | - Yani Sim
- Laboratory of Medical Biochemistry, Department of Pharmaceutical Sciences, University of Antwerp, Antwerp, Belgium
| | - Anne-Marie Lambeir
- Laboratory of Medical Biochemistry, Department of Pharmaceutical Sciences, University of Antwerp, Antwerp, Belgium
| | - Dirk Hendriks
- Laboratory of Medical Biochemistry, Department of Pharmaceutical Sciences, University of Antwerp, Antwerp, Belgium
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Harbaum L, Ghataorhe P, Wharton J, Jiménez B, Howard LSG, Gibbs JSR, Nicholson JK, Rhodes CJ, Wilkins MR. Reduced plasma levels of small HDL particles transporting fibrinolytic proteins in pulmonary arterial hypertension. Thorax 2019; 74:380-389. [PMID: 30478197 PMCID: PMC6475111 DOI: 10.1136/thoraxjnl-2018-212144] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 10/28/2018] [Accepted: 11/12/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND Aberrant lipoprotein metabolism has been implicated in experimental pulmonary hypertension, but the relevance to patients with pulmonary arterial hypertension (PAH) is inconclusive. OBJECTIVE To investigate the relationship between circulating lipoprotein subclasses and survival in patients with PAH. METHODS Using nuclear magnetic resonance spectroscopy, 105 discrete lipoproteins were measured in plasma samples from two cohorts of patients with idiopathic or heritable PAH. Data from 1124 plasma proteins were used to identify proteins linked to lipoprotein subclasses. The physical presence of proteins was confirmed in plasma lipoprotein subfractions separated by ultracentrifugation. RESULTS Plasma levels of three lipoproteins from the small high-density lipoprotein (HDL) subclass, termed HDL-4, were inversely related to survival in both the discovery (n=127) and validation (n=77) cohorts, independent of exercise capacity, comorbidities, treatment, N-terminal probrain natriuretic peptide, C reactive protein and the principal lipoprotein classes. The small HDL subclass rich in apolipoprotein A-2 content (HDL-4-Apo A-2) exhibited the most significant association with survival. None of the other lipoprotein classes, including principal lipoprotein classes HDL and low-density lipoprotein cholesterol, were prognostic. Three out of nine proteins identified to associate with HDL-4-Apo A-2 are involved in the regulation of fibrinolysis, namely, the plasmin regulator, alpha-2-antiplasmin, and two major components of the kallikrein-kinin pathway (coagulation factor XI and prekallikrein), and their physical presence in the HDL-4 subfraction was confirmed. CONCLUSION Reduced plasma levels of small HDL particles transporting fibrinolytic proteins are associated with poor outcomes in patients with idiopathic and heritable PAH.
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Affiliation(s)
- Lars Harbaum
- Department of Medicine, Imperial College London, London, UK
| | | | - John Wharton
- Department of Medicine, Imperial College London, London, UK
| | - Beatriz Jiménez
- Imperial Clinical Phenome Centre, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Luke S G Howard
- National Heart and Lung Institute, Imperial College London, London, UK
- National Pulmonary Hypertension Service, Imperial College Healthcare Trust NHS, London, UK
| | - J Simon R Gibbs
- National Heart and Lung Institute, Imperial College London, London, UK
- National Pulmonary Hypertension Service, Imperial College Healthcare Trust NHS, London, UK
| | - Jeremy K Nicholson
- Division of Computational Systems Medicine, Department of Surgery and Cancer, and Centre for Digestive and Gut Health, Imperial College London, London, UK
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Barbosa CJDG, de Souza Barreiros R, Franci A, Arantes FBB, de Mendonça Furtado RH, Strunz CMC, da Rocha TRF, Baracioli LM, Ramires JAF, Kalil-Filho R, Nicolau JC. Platelet function, coagulation and fibrinolysis in patients with previous coronary and cerebrovascular ischemic events. Clinics (Sao Paulo) 2019; 74:e1222. [PMID: 31576918 PMCID: PMC6751368 DOI: 10.6061/clinics/2019/e1222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 07/17/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Ischemic stroke (IS) or transient ischemic attack (TIA) history is present in 4-17% of patients with coronary artery disease (CAD). This subgroup of patients is at high risk for both ischemic and bleeding events. The aim of this study was to determine the role of platelet aggregability, coagulation and endogenous fibrinolysis in patients with CAD and previous IS or TIA. METHODS A prospective case-control study that included 140 stable CAD patients divided into two groups: the CASE group (those with a previous IS/TIA, n=70) and the CONTROL group (those without a previous IS/TIA, n=70). Platelet aggregability (VerifyNow Aspirin® and VerifyNow P2Y12®), coagulation (fibrinogen and thromboelastography by Reorox®) and endogenous fibrinolysis (D dimer and plasminogen activator inhibitor-1) were evaluated. RESULTS Patients in the CASE group presented significantly higher systolic blood pressure levels (135.84±16.09 vs 123.68±16.11, p<0.01), significantly more previous CABG (25.71% vs 10%, p=0.015) and significantly higher calcium channel blocker usage (42.86% vs 24.29%, p=0.02) than those in the control group. In the adjusted models, low triglyceride values, low hemoglobin values and higher systolic blood pressure were significantly associated with previous IS/TIA (CASE group). Most importantly, platelet aggregability, coagulation and fibrinolysis tests were not independently associated with previous cerebrovascular ischemic events (CASE group). CONCLUSION Platelet aggregability, coagulation and endogenous fibrinolysis showed similar results among CAD patients with and without previous IS/TIA. Therefore, it remains necessary to identify other targets to explain the higher bleeding risk presented by these patients.
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Affiliation(s)
- Carlos José Dornas Gonçalves Barbosa
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Hospital do Coracao do Brasil, Rede D'Or Sao Luiz, Brasilia, DF, BR
- Corresponding author. E-mail:
| | - Renata de Souza Barreiros
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - André Franci
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | | - Remo Holanda de Mendonça Furtado
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Célia Maria Cassaro Strunz
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | | - Luciano Moreira Baracioli
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - José Antônio Franchini Ramires
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Roberto Kalil-Filho
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - José Carlos Nicolau
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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Garin A, Bavozet F. Metropolitan W135 meningococcal compressive pericarditis treated with intrapericardial fibrinolysis. BMJ Case Rep 2018; 2018:bcr-2018-225080. [PMID: 30333198 PMCID: PMC6202986 DOI: 10.1136/bcr-2018-225080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2018] [Indexed: 11/03/2022] Open
Abstract
Meningococcal pericarditis is a rare but severe form of acute purulent pericarditis. It is a classic complication of Neisseria meningitidis of serotype W135, usually occurring in pilgrims to Mecca and their household contacts. This severe form of meningococcaemia is difficult to diagnose and evolves frequently and gradually towards a tamponade, requiring emergency drainage. We report a case of meningococcal pericarditis caused by N. meningitidis W135 in an immunocompetent patient, without any other organ involvement especially meningeal, requiring pericardium drainage in emergency and then intrapericardial fibrinolysis.
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Affiliation(s)
- Aude Garin
- Department of Intensive Care, Centre Hospitalier Victor Jousselin, Dreux, France
| | - Florent Bavozet
- Department of Intensive Care, Centre Hospitalier Victor Jousselin, Dreux, France
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Oladosu-olayiwola O, Olawumi H, Babatunde A, Ijaiya M, Durotoye I, Biliaminu S, Ibraheem R. Fibrinolytic proteins of normal pregnancy and pre-eclamptic patients in North West Nigeria. Afr Health Sci 2018; 18:576-583. [PMID: 30602990 PMCID: PMC6307030 DOI: 10.4314/ahs.v18i3.15] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The hypercoagulability of pregnancy is exaggerated in pre-eclamptic state because of endothelial activation with resultant production of some endothelial derived proteins that are said to be inhibitors of fibrinolysis. This study compares these proteins like tPA, PAI-1 and D-dimers in normal pregnant women and the pre-eclamptic women. METHODOLOGY This was a comparative cross-sectional study. Eighty-five pre-eclamptic women were recruited as subjects and eighty five age, trimester and parity matched normotensive pregnant women as controls. Levels of PT, aPTT, tPA, PAI-1, D-dimer protein were determined in blood samples of subjects and controls. Urinalysis was performed with dipstick method on their urine samples. Data generated was analysed using the IBM®SPSS 20.0 (2011) soft ware packages and the level of significance was a p-value <0.05. RESULTS The mean age of the respondents was 29.9±5.2 years. The median(25th-75th percentile) values of D-dimer, tPA, and PAI-1 of subjects were 730 (305.000-1560.000ng/ml), 0.11 (0.065-0,300ng/ml) and 3.65 (2.970-4,400ng/ml) respectively which were significantly higher than the corresponding values in the controls of 520 (24.000-1030.000ng/ml), 0.05 (0.040-0.090ng/ml and 2.650 (2.125-3.400ng/ml) respectively, p<0.05 each. CONCLUSION The abnormal levels of PAI-1, D-dimer and tPA imply that they contribute to the exaggerated hypercoagulabilty state in pre-eclampsia thus, measuring their levels can help in the management of the condition.
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Affiliation(s)
| | | | | | - Munirdeen Ijaiya
- University of Ilorin / University of Ilorin teaching hospital., Obstetrics & Gynaecology
| | | | - Sikiru Biliaminu
- University of Ilorin Teaching Hospital, Chemical Pathology and Immunology
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Varjú I, Farkas VJ, Kőhidai L, Szabó L, Farkas ÁZ, Polgár L, Chinopoulos C, Kolev K. Functional cyclophilin D moderates platelet adhesion, but enhances the lytic resistance of fibrin. Sci Rep 2018; 8:5366. [PMID: 29599453 PMCID: PMC5876378 DOI: 10.1038/s41598-018-23725-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 03/20/2018] [Indexed: 01/11/2023] Open
Abstract
In the course of thrombosis, platelets are exposed to a variety of activating stimuli classified as 'strong' (e.g. thrombin and collagen) or 'mild' (e.g. ADP). In response, activated platelets adhere to injured vasculature, aggregate, and stabilise the three-dimensional fibrin scaffold of the expanding thrombus. Since 'strong' stimuli also induce opening of the mitochondrial permeability transition pore (MPTP) in platelets, the MPTP-enhancer Cyclophilin D (CypD) has been suggested as a critical pharmacological target to influence thrombosis. However, it is poorly understood what role CypD plays in the platelet response to 'mild' stimuli which act independently of MPTP. Furthermore, it is unknown how CypD influences platelet-driven clot stabilisation against enzymatic breakdown (fibrinolysis). Here we show that treatment of human platelets with Cyclosporine A (a cyclophilin-inhibitor) boosts ADP-induced adhesion and aggregation, while genetic ablation of CypD in murine platelets enhances adhesion but not aggregation. We also report that platelets lacking CypD preserve their integrity in a fibrin environment, and lose their ability to render clots resistant against fibrinolysis. Our results indicate that CypD has opposing haemostatic roles depending on the stimulus and stage of platelet activation, warranting a careful design of any antithrombotic strategy targeting CypD.
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Affiliation(s)
- Imre Varjú
- Department of Medical Biochemistry, Semmelweis University, Budapest, 1094, Hungary
- Program in Cellular and Molecular Medicine, Boston Children's Hospital, Harvard Medical School, Boston, 02115, USA
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, 10032, USA
| | | | - László Kőhidai
- Department of Genetics, Cell- and Immunobiology, Semmelweis University, Budapest, 1089, Hungary
| | - László Szabó
- Department of Functional and Structural Materials, Institute of Materials and Environmental Chemistry, Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, 1117, Hungary
| | - Ádám Zoltán Farkas
- Department of Medical Biochemistry, Semmelweis University, Budapest, 1094, Hungary
| | - Lívia Polgár
- Department of Genetics, Cell- and Immunobiology, Semmelweis University, Budapest, 1089, Hungary
| | - Christos Chinopoulos
- Department of Medical Biochemistry, Semmelweis University, Budapest, 1094, Hungary
- MTA-SE Lendület Neurobiochemistry Research Group, Budapest, 1094, Hungary
| | - Krasimir Kolev
- Department of Medical Biochemistry, Semmelweis University, Budapest, 1094, Hungary.
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Abstract
Fibrinolysis is a physiologic component of hemostasis that functions to limit clot formation. However, after trauma or surgery, excessive fibrinolysis may contribute to coagulopathy, bleeding, and inflammatory responses. Antifibrinolytic agents are increasingly used to reduce bleeding, allogeneic blood administration, and adverse clinical outcomes. Tranexamic acid is the agent most extensively studied and used in most countries. This review will explore the role of fibrinolysis as a pathologic mechanism, review the different pharmacologic agents used to inhibit fibrinolysis, and focus on the role of tranexamic acid as a therapeutic agent to reduce bleeding in patients after surgery and trauma.
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Affiliation(s)
- Jerrold H. Levy
- Division of Cardiothoracic Anesthesiology and Critical Care, Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Andreas Koster
- Institute of Anesthesiology, Heart and Diabetes Center NRW, Bad Oeynhausen, Ruhr-University Bochum, Germany
| | - Quintin J. Quinones
- Division of Cardiothoracic Anesthesiology and Critical Care, Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | | | - Nigel S. Key
- Department of Medicine, Division of Hematology/Oncology, University of North Carolina, Chapel Hill, NC
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Miyashima Y, Iwamuro M, Shibata M, Miyabe Y, Kawai Y, Kaihara M, Mitogawa T, Harada M. Prediction of Disseminated Intravascular Coagulation by Liver Function Tests in Patients with Japanese Spotted Fever. Intern Med 2018; 57:197-202. [PMID: 29021432 PMCID: PMC5820036 DOI: 10.2169/internalmedicine.8420-16] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 04/10/2017] [Indexed: 11/25/2022] Open
Abstract
Objective Cases of Japanese spotted fever (JSF) are sometimes complicated by disseminated intravascular coagulation (DIC) with an abnormal liver function, resulting in unfavorable outcomes. The aim of the present study was to clarify the correlation between liver function test results and DIC scores. Methods Twenty patients diagnosed with JSF between April 2010 and April 2014 were enrolled. Age, gender, disturbance of consciousness, body temperature, pulse rate, presence of diffuse erythema, eschar and swelling of lymph nodes, laboratory test results at the time of initial presentation such as blood cell count, C-reactive protein, liver function, renal function and blood coagulation and fibrinolysis, maximum Japanese Association for Acute Medicine (JAAM) DIC score during the course of JSF, treatment and the prognosis were retrospectively reviewed. Results The median age of the patients (8 men, 12 women) was 68.3 years. There were significant differences in the alkaline phosphatase (ALP) and rothrombin time international normalized ratio (PT-INR) between the DIC and non-DIC groups using Mann-Whitney's U test. A multiple logistic regression analysis showed that the ALP and blood urea nitrogen (BUN) levels at the time of initial presentation were independent predictors of the occurrence of DIC. Conclusion We should pay special attention to JSF patients showing high levels of ALP at the initial presentation, since such patients may have a higher likelihood of developing DIC over the course of JSF and unfavorable outcomes than those with lower levels.
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Affiliation(s)
- Yuichi Miyashima
- Department of Gastroenterology, Onomichi Municipal Hospital, Japan
- Third Department of Internal Medicine, University of Occupational and Environmental Health, Japan
| | - Masaya Iwamuro
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
| | - Michihiko Shibata
- Third Department of Internal Medicine, University of Occupational and Environmental Health, Japan
| | - Yoshio Miyabe
- Department of Gastroenterology, Onomichi Municipal Hospital, Japan
| | - Yoshinari Kawai
- Department of Gastroenterology, Onomichi Municipal Hospital, Japan
| | - Masanobu Kaihara
- Department of Internal Medicine, Onomichi Municipal Hospital, Japan
| | | | - Masaru Harada
- Third Department of Internal Medicine, University of Occupational and Environmental Health, Japan
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Huebner BR, Moore EE, Moore HB, Gonzalez E, Kelher MR, Sauaia A, Banerjee A, Silliman CC. Thrombin stimulates increased plasminogen activator inhibitor-1 release from liver compared to lung endothelium. J Surg Res 2018; 225:1-5. [PMID: 29605018 DOI: 10.1016/j.jss.2017.12.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 11/05/2017] [Accepted: 12/13/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Plasminogen activator inhibitor-1 (PAI-1) is a major regulator of the fibrinolytic system, covalently binding to tissue plasminogen activator and blocking its activity. Fibrinolysis shutdown is evident in the majority of severely injured patients in the first 24 h and is thought to be due to PAI-1. The source of this PAI-1 is thought to be predominantly endothelial cells, but there are known organ-specific differences, with higher levels thought to be in the liver. Thrombin generation is also elevated in injured patients and is a potent stimulus for PAI-1 release in human umbilical endothelial cells. We hypothesize that thrombin induces liver endothelial cells to release increased amounts of PAI-1, versus pulmonary endothelium, consisting of both stored PAI-1 and a larger contribution from de novo PAI-1 synthesis. METHODS Human liver sinusoidal endothelial cells (LSECs) and human microvascular lung endothelial cells (HMVECs) were stimulated in vitro ± thrombin (1 and 5 IU/mL) for 15-240 min, the supernatants were collected, and PAI-1 was measured by enzyme-linked immunosorbent assays. To elucidate the PAI-1 contribution from storage versus de novo synthesis, cycloheximide (10 μg/mL) was added before thrombin in separate experiments. RESULTS While both LSECs and HMVECs rapidly stimulated PAI-1 release, LSECs released more PAI-1 than HMVECs in response to high-dose thrombin, whereas low-dose thrombin did not provoke immediate release. LSECs continued to release PAI-1 over the ensuing 240 min, whereas HMVECs did not. Cycloheximide did not inhibit early PAI-1 release from LSECs but did at the later time points (30-240 min). CONCLUSIONS Thrombin elicits increased amounts of PAI-1 release from liver endothelium compared with lung, with a small presynthesized stored contribution and a later, larger increase in PAI-1 release via de novo synthesis. This study suggests that the liver may be an important therapeutic target for inhibition of the hypercoagulable surgical patient and the associated complications that result.
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Affiliation(s)
| | - Ernest E Moore
- Department of Surgery, University of Colorado, Aurora, Colorado; Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | - Hunter B Moore
- Department of Surgery, University of Colorado, Aurora, Colorado
| | | | | | - Angela Sauaia
- Department of Surgery, University of Colorado, Aurora, Colorado; Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | | | - Christopher C Silliman
- Bonfils Blood Center, Denver, Colorado; Department of Pediatrics, University of Colorado, Aurora, Colorado
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Morton AP, Moore EE, Moore HB, Gonzalez E, Chapman MP, Peltz E, Banerjee A, Silliman C. Hemoglobin-based oxygen carriers promote systemic hyperfibrinolysis that is both dependent and independent of plasmin. J Surg Res 2017; 213:166-170. [PMID: 28601310 PMCID: PMC5467451 DOI: 10.1016/j.jss.2015.04.077] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Revised: 04/14/2015] [Accepted: 04/21/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND Hyperfibrinolysis plays an integral role in the genesis of trauma-induced coagulopathy. Recent data demonstrate that red blood cell lysis promotes fibrinolysis; however, the mechanism is unclear. Hemoglobin-based oxygen carriers (HBOCs) have been developed for resuscitation and have been associated with coagulopathy. We hypothesize that replacement of whole blood (WB) using an HBOC results in a coagulopathy because of the presence of free hemoglobin. MATERIALS AND METHODS WB was sampled from healthy donors (n = 6). The clotting profile of each citrated sample was evaluated using native thromboelastography. Serial titrations were performed using both HBOC (PolyHeme) and normal saline (NS; 5%, 25%, and 50%) and evaluated both with and without a 75-ng/mL tissue plasminogen activator (tPA) challenge. Tranexamic acid (TXA) was added to inhibit plasmin-dependent fibrinolysis. Fibrinolysis was measured and recorded as lysis at 30 min (LY30), the percentage of clot LY30 after maximal clot strength. Dilution of WB with NS or HBOC was correlated using LY30 via Spearman rho coefficients. Groups were also compared using a Friedman test and post hoc analysis with a Bonferroni adjustment. RESULTS tPA-provoked fibrinolysis was enhanced by both HBOC (median LY30 at 5%, 25%, and 50% titrations: 11%, 21%, and 44%, respectively; Spearman = 0.94; P < 0.001) and NS (11%, 28%, and 58%, respectively; Spearman = 0.790; P < 0.001). However, HBOC also enhanced fibrinolysis without the addition of tPA (1%, 4%, 5%; Spearman = 0.735; P = 0.001) and NS did not (1%, 2%, 1%; r = 0.300; P = 0.186. Moreover, addition of TXA did not alter or inhibit this fibrinolysis (WB versus 50% HBOC: 1.8% versus 5.7%, P = 0.04). There was no significant difference in fibrinolysis of HBOC with or without TXA (50% HBOC versus 50% HBOC + TXA: 5.6% versus 5.7%, P = 0.92). In addition, the increased fibrinolysis seen with NS was reversed when TXA was present (WB versus 50% NS: 1.8% versus 1.7%, P = 1.0). CONCLUSIONS HBOCs enhance fibrinolysis both with and without addition of tPA; moreover, this mechanism is independent of plasmin as the phenomenon persists in the presence of TXA. Our findings indicate the hemoglobin molecule or its components stimulate fibrinolysis by both tPA-dependent and innate mechanisms.
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Affiliation(s)
- Alexander P Morton
- Department of Surgery-Trauma Research Center, University of Colorado, Denver, Colorado.
| | - Ernest E Moore
- Department of Surgery-Trauma Research Center, University of Colorado, Denver, Colorado; Department of Surgery-Denver Health Medical Center, Denver, Colorado
| | - Hunter B Moore
- Department of Surgery-Trauma Research Center, University of Colorado, Denver, Colorado
| | - Eduardo Gonzalez
- Department of Surgery-Trauma Research Center, University of Colorado, Denver, Colorado
| | - Michael P Chapman
- Department of Surgery-Trauma Research Center, University of Colorado, Denver, Colorado
| | - Erik Peltz
- Department of Surgery-Trauma Research Center, University of Colorado, Denver, Colorado
| | - Anirban Banerjee
- Department of Surgery-Trauma Research Center, University of Colorado, Denver, Colorado
| | - Christopher Silliman
- Department of Surgery-Trauma Research Center, University of Colorado, Denver, Colorado; Bonfils Blood Center, Denver, Colorado
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Chukwuemeka CP, Cupp J, Sanders JR. Using a Radial Diffusion Method to Investigate the Role of Plasmin Degradation of Fibrin in a Physical Model of an Early-phase Wound. Wounds 2017; 29:115-121. [PMID: 28135202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Fibrin clot formation, which acts to stabilize a wound following injury, is among the key early aspects of dermal wound healing. This preliminary matrix is eventually degraded via a process known as fibrinolysis and replaced with a collagen-rich matrix that continues to be remodeled to minimize scarring. Disruptions in these carefully coordinated events lead to certain undesirable conditions such as fibrosis and the formation of abnormal scars that are associated with excess amounts of collagen. The hypothesis proposed herein is that the presence of collagen (and potentially other molecules) in an early-phase model of healing alters fibrinolysis and that this effect can be attenuated with mediators of the process. MATERIALS AND METHODS Laboratory in vitro experiments were conducted using agarose-fibrin gel systems with and without collagen to study fibrinolysis caused by plasmin (a serine protease that degrades fibrin) and the effects of aprotinin (a serine protease inhibitor) and bromelain (an extract from pineapple) on fibrin clot breakdown. The extent of fibrinolysis was monitored at various times (0.5, 1, 2, 4, 8, 12, 24, 48, and 72 hours) by measuring the size of rings of fibrinolysis following the diffusion of plasmin. The data obtained at 0.5, 12, and 24-hour time points were considered (because there was no difference found in the data collected for closer intermediates nor for the longer times beyond 24 hours) and were compared using the nonparametric Mann-Whitney U statistical significance test. RESULTS The results obtained showed aprotinin significantly inhibited fibrinolysis in systems containing collagen, while bromelain improved fibrinolysis. In general, the presence of increasing amounts of collagen in the system decreased the extent of fibrinolysis. CONCLUSIONS These findings support the notion that early-phase deposition of collagen contributes to disrupted fibrinolysis, which could lead to impaired healing as well as potentially facilitate control of fibrinolysis.
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Affiliation(s)
| | - Jann Cupp
- Tennessee Technological University, Cookeville, TN
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Idell RD, Florova G, Komissarov AA, Shetty S, Girard RBS, Idell S. The fibrinolytic system: A new target for treatment of depression with psychedelics. Med Hypotheses 2017; 100:46-53. [PMID: 28236848 DOI: 10.1016/j.mehy.2017.01.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 11/10/2016] [Accepted: 01/21/2017] [Indexed: 12/28/2022]
Abstract
Current understanding of the neurobiology of depression has grown over the past few years beyond the traditional monoamine theory of depression to include chronic stress, inflammation and disrupted synaptic plasticity. Tissue plasminogen activator (tPA) is a key factor that not only promotes fibrinolysis via the activation of plasminogen, but also contributes to regulation of synaptic plasticity and neurogenesis through plasmin-mediated activation of a probrain derived neurotrophic factor (BDNF) to mature BDNF. ProBDNF activation could potentially be supressed by competition with fibrin for plasmin and tPA. High affinity binding of plasmin and tPA to fibrin could result in a decrease of proBDNF activation during brain inflammation leading to fibrosis further perpetuating depressed mood. There is a paucity of data explaining the possible role of the fibrinolytic system or aberrant extravascular fibrin deposition in depression. We propose that within the brain, an imbalance between tPA and urokinase plasminogen activator (uPA) and plasminogen activator inhibitor-1 (PAI-1) and neuroserpin favors the inhibitors, resulting in changes in neurogenesis, synaptic plasticity, and neuroinflammation that result in depressive behavior. Our hypothesis is that peripheral inflammation mediates neuroinflammation, and that cytokines such as tumor necrosis factor alpha (TNF-α) can inhibit the fibrinolytic system by up- regulating PAI-1 and potentially neuroserpin. We propose that the decrement of the activity of tPA and uPA occurs with downregulation of uPA in part involving the binding and clearance from the surface of neural cells of uPA/PAI-1 complexes by the urokinase receptor uPAR. We infer that current antidepressants and ketamine mitigate depressive symptoms by restoring the balance of the fibrinolytic system with increased activity of tPA and uPA with down-regulated intracerebral expression of their inhibitors. We lastly hypothesize that psychedelic 5-ht2a receptor agonists, such as psilocybin, can improve mood through anti- inflammatory and pro-fibrinolytic effects that include blockade of TNF-α activity leading to decreased PAI-1 activity and increased clearance. The process involves disinhibition of tPA and uPA with subsequent increased cleavage of proBDNF which promotes neurogenesis, decreased neuroinflammation, decreased fibrin deposition, normalized glial-neuronal cross-talk, and optimally functioning neuro-circuits involved in mood. We propose that psilocybin can alleviate deleterious changes in the brain caused by chronic stress leading to restoration of homeostatic brain fibrinolytic capacity leading to euthymia.
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Affiliation(s)
- R D Idell
- Department of Behavioral Health, Child and Adolescent Psychiatry, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, United States.
| | - G Florova
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, United States
| | - A A Komissarov
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, United States
| | - S Shetty
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, United States
| | - R B S Girard
- Biotechnology Graduate Program, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, United States
| | - S Idell
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, United States
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Le A, Zhang L, Liu W, Li X, Ren J, Ning A. A case control study on the structural equation model of the mechanism of coagulation and fibrinolysis imbalance in chronic schistosomiasis. Medicine (Baltimore) 2017; 96:e6116. [PMID: 28207534 PMCID: PMC5319523 DOI: 10.1097/md.0000000000006116] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
A structural equation model was used for verification with chronic schistosomiasis to investigate the coagulation-anticoagulation system imbalance and to deduce the mechanism of D-dimer (D-D) level elevation in patients with advanced schistosome hepatic disease. We detected the plasma levels of tissue-type fiber plasminogen activator (tPA), urokinase type plasminogen activator (uPA), plasmin-antiplasmin complex (PAP), plasminogen (PLG), antithrombin (AT), plasminogen activator inhibitor 1 (PAI1), D-D, factor VIII: C (FVIII:C), antithrombin-III (AT-III), PLG, protein S (PS), and protein C (PC) in the healthy people as control (69), patients with chronic schistosomiasis (150) or advanced chronic schistosomiasis (90). FVIII, PAP, D-D, tPA, and uPA plasma levels were significantly higher in the chronic group than in the control group and were also significantly higher in the advanced group. However, AT-III, PC, PS, AT, PLG, and PAI1 plasma levels in the advanced and chronic groups were significantly lower than those in the control group. With progression of disease in patients with schistosomiasis japonica, a hypercoagulable state is induced by the coagulation-anticoagulation imbalance, eventually leading to patients with high levels of D-D. Furthermore, we established a structural equation model path of a "chronic schistosomiasis disease stage-(coagulation-anticoagulation-fibrinolysis)-D-D." By using analysis of moment structures (AMOS), it was shown that the chronic schistosomiasis stage was positively related to factor VIII and had negative correlation with AT-III; a good positive correlation with PAP, tPA, and uPA; and a good negative correlation with PLG and PAI1. In addition, our results show that the path coefficient of anticoagulation-fibrinolysis system to the chronic stage of schistosomiasis or D-D levels was significantly higher than that of the coagulation system. In conclusion, the coagulation and fibrinolysis imbalance in patients with chronic schistosomiasis, especially with advanced schistosomiasis, is due to the progression of disease stages.
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Affiliation(s)
| | - Lunli Zhang
- Department of Infectious Diseases, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi
| | - Wei Liu
- Departments of Blood Transfusion
| | - Xiaopeng Li
- Department of Infectious Diseases, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi
| | - Jianwei Ren
- Health Department of the PLA General Staff Headquarters of the Security Council, Beijing
| | - An Ning
- Jiangxi Institute of Parasitology, Nanchang, Jiangxi, P.R. China
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