1
|
He W, Xi Q, Cui H, Zhang P, Huang R, Wang T, Wang D. Forsythiaside B ameliorates coagulopathies in a rat model of sepsis through inhibition of the formation of PAD4-dependent neutrophil extracellular traps. Front Pharmacol 2022; 13:1022985. [PMID: 36408247 PMCID: PMC9666896 DOI: 10.3389/fphar.2022.1022985] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 10/20/2022] [Indexed: 01/24/2023] Open
Abstract
Forsythiaside B (FTB) is one of the main components of Forsythia suspensa (Thunb.) Vahl and exerts anti-inflammatory and anti-oxidative effects. However, its mechanism of action as a treatment for sepsis remains unclear. In this study, we developed a rat model of sepsis using cecal ligation and puncture (CLP) to investigate the effects of FTB on sepsis-associated coagulopathies. Using rats with sepsis, we investigated the effects of FTB on neutrophil extracellular trap (NETs) formation and peptidylarginine deiminase 4 (PAD4) expression in neutrophils. NET (DNase1) and PAD4 (Cl-amidine) inhibitors were used to further investigate whether FTB mitigates sepsis-associated coagulopathies by inhibiting PAD4-dependent NETs production. Our results showed that treatment with FTB increased the survival rate, ameliorated the CLP-induced inflammatory response and multiple organ dysfunction, and reduced CLP-induced pathological changes. FTB also alleviated the associated coagulopathies. Additionally, we demonstrated that treatment with FTB inhibited NETs formation and downregulated PAD4 expression in peripheral neutrophils. The effects of FTB on coagulopathies were similar to those of monotherapy with NET or PAD4 inhibitors. In conclusion, our study confirmed that FTB can alleviate coagulopathies in rats with sepsis. The underlying mechanism of FTB's effect consists in inhibition of PAD4-dependent NETs formation.
Collapse
Affiliation(s)
- Wenju He
- Department of Integration of Traditional Chinese and Western Medicine, First Central Hospital Affiliated to Nankai University, Tianjin First Central Hospital, Tianjin, China
| | - Qiang Xi
- Department of Practice and Education, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Huantian Cui
- Shandong Provincial Key Laboratory of Animal Cell and Developmental Biology, School of Life Sciences, Shandong University, Qingdao, China
| | - Pingping Zhang
- Department of Integration of Traditional Chinese and Western Medicine, First Central Hospital Affiliated to Nankai University, Tianjin First Central Hospital, Tianjin, China
| | - Rui Huang
- Department of Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Taihuan Wang
- Department of Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Dongqiang Wang
- Department of Integration of Traditional Chinese and Western Medicine, First Central Hospital Affiliated to Nankai University, Tianjin First Central Hospital, Tianjin, China,*Correspondence: Dongqiang Wang,
| |
Collapse
|
2
|
Lopes-Pires ME, Frade-Guanaes JO, Quinlan GJ. Clotting Dysfunction in Sepsis: A Role for ROS and Potential for Therapeutic Intervention. Antioxidants (Basel) 2021; 11:88. [PMID: 35052592 PMCID: PMC8773140 DOI: 10.3390/antiox11010088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 12/24/2021] [Accepted: 12/27/2021] [Indexed: 11/17/2022] Open
Abstract
Sepsis is regarded as one of the main causes of death among the critically ill. Pathogen infection results in a host-mediated pro-inflammatory response to fight infection; as part of this response, significant endogenous reactive oxygen (ROS) and nitrogen species (RNS) production occurs, instigated by a variety of sources, including activated inflammatory cells, such as neutrophils, platelets, and cells from the vascular endothelium. Inflammation can become an inappropriate self-sustaining and expansive process, resulting in sepsis. Patients with sepsis often exhibit loss of aspects of normal vascular homeostatic control, resulting in abnormal coagulation events and the development of disseminated intravascular coagulation. Diagnosis and treatment of sepsis remain a significant challenge for healthcare providers globally. Targeting the drivers of excessive oxidative/nitrosative stress using antioxidant treatments might be a therapeutic option. This review focuses on the association between excessive oxidative/nitrosative stress, a common feature in sepsis, and loss of homeostatic control at the level of the vasculature. The literature relating to potential antioxidants is also described.
Collapse
Affiliation(s)
- Maria Elisa Lopes-Pires
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London W12 0NN, UK;
| | | | - Gregory J. Quinlan
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London W12 0NN, UK;
| |
Collapse
|
3
|
Kramer M, Drexler M, Herman A, Kalimian T, Klassov Y, Nasser LA. Use of Intraoperative Tranexamic Acid and Wound Complications in Spine Surgery: A Retrospective Cohort Study. Asian Spine J 2020; 14:639-646. [PMID: 32213794 PMCID: PMC7595816 DOI: 10.31616/asj.2019.0235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 11/13/2019] [Indexed: 11/29/2022] Open
Abstract
Study Design A retrospective cohort study. Purpose This study aims to examine the effect of tranexamic acid (TXA) on postoperative wound healing in spine surgery. Overview of Literature TXA (Cyklokapron, Hexakapron) is a widely used anti-fibrinolytic drug that is shown to be effective in mitigating hemorrhage during and after surgery by competitively blocking plasminogen in fibrinolytic cascade. Plasminogen also plays a role in inflammatory and infectious diseases. The modulation of this role by TXA may influence the development of postoperative infectious complications. Methods We collected and reviewed the charts of 110 patients who underwent spine surgery at our academic center. We used multivariate regression analysis to assess the factors affecting surgical site infection (SSI). Results Of the 110 patients included in this study, 21 patients (19%) were categorized as having postoperative wound complications, 16 patients (14%) had deep or superficial wound infection, and five patients (4%) had wound dehiscence. Patients with a higher surgical invasiveness index score, longer surgeries, and older patients were found to be at risk for wound complications. TXA was determined not to be a direct risk factor for wound healing complications and SSIs. Conclusions We found no risk of wound healing complications and SSI directly attributable to preoperative and intraoperative treatment with TXA in spine surgeries.
Collapse
Affiliation(s)
- Moti Kramer
- Department of Orthopedics, Assuta Ashdod University Medical Center, Ashdod, Israel
| | - Michael Drexler
- Department of Orthopedics, Assuta Ashdod University Medical Center, Ashdod, Israel
| | - Amir Herman
- Department of Orthopedics, Assuta Ashdod University Medical Center, Ashdod, Israel
| | - Tal Kalimian
- Department of Orthopedics, Assuta Ashdod University Medical Center, Ashdod, Israel
| | - Yuri Klassov
- Department of Orthopedics, Soroka University Medical Center, Beer Sheva, Israel
| | - Layalee Abu Nasser
- Department of Orthopedics, Soroka University Medical Center, Beer Sheva, Israel
| |
Collapse
|
4
|
Hypofibrinolysis induced by tranexamic acid does not influence inflammation and mortality in a polymicrobial sepsis model. PLoS One 2019; 14:e0226871. [PMID: 31891611 PMCID: PMC6938370 DOI: 10.1371/journal.pone.0226871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 12/08/2019] [Indexed: 01/08/2023] Open
Abstract
The biological relevance of fibrinolysis to the host response to sepsis is illustrated by pathogens such as S. pyogenes and Y. pestis, whose virulence factors are proteins that challenge the balance between pro- and anti-fibrinolytic factors of the host, and by the consistent finding of hypofibrinolysis in the early stages of sepsis. Whether this hypofibrinolytic response is beneficial or detrimental to the host, by containing the spread of pathogens while at the same time limiting the access of immune cell to infectious foci, is still a matter of debate. Tranexamic acid (TnxAc) is an antifibrinolytic agent that is being increasingly used to prevent and control bleeding in conditions such as elective orthopedic surgery, trauma, and post-partum-hemorrhage, which are frequently followed by infection and sepsis. Here we used a model of polymicrobial sepsis to evaluate whether hypofibrinolysis induced by TnxAc influenced survival, tissue injury and pathogen spread. Mice were treated with two doses of TnxAc bid for 48h, and then sepsis was induced by cecal ligation and puncture. Despite the induction of hypofibrinolysis by TnxAc, no difference could be observed in survival, tissue injury (measured by biochemical and histological parameters), cytokine levels or pathogen spread. Our results contribute with a new piece of data to the understanding of the complex interplay between fibrinolysis and innate immunity. While our results do not support the use of TnxAc in sepsis, they also address the thrombotic safety of TnxAc, a low cost and widely used agent to prevent bleeding.
Collapse
|
5
|
Deciphering the Role of WNT Signaling in Metabolic Syndrome–Linked Alzheimer’s Disease. Mol Neurobiol 2019; 57:302-314. [DOI: 10.1007/s12035-019-01700-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/09/2019] [Indexed: 12/22/2022]
|
6
|
Tipoe TL, Wu WKK, Chung L, Gong M, Dong M, Liu T, Roever L, Ho J, Wong MCS, Chan MTV, Tse G, Wu JCY, Wong SH. Plasminogen Activator Inhibitor 1 for Predicting Sepsis Severity and Mortality Outcomes: A Systematic Review and Meta-Analysis. Front Immunol 2018; 9:1218. [PMID: 29967603 PMCID: PMC6015919 DOI: 10.3389/fimmu.2018.01218] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/15/2018] [Indexed: 01/24/2023] Open
Abstract
Objectives Plasminogen activator inhibitor-1 (PAI-1), a crucial regulator of fibrinolysis, is increased in sepsis, but its values in predicting disease severity or mortality outcomes have been controversial. Therefore, we conducted a systematic review and meta-analysis of its predictive values in sepsis. Methods PubMed and Embase were searched until August 18, 2017 for studies that evaluated the relationships between PAI-1 levels and disease severity or mortality in sepsis. Results A total of 112 and 251 entries were retrieved from the databases, of which 18 studies were included in the final meta-analysis. A total of 4,467 patients (36% male, mean age: 62 years, mean follow-up duration: 36 days) were analyzed. PAI-1 levels were significantly higher in non-survivors than survivors [odds ratios (OR): 3.93, 95% confidence interval (CI): 2.31-6.67, P < 0.0001] and in patients with severe sepsis than in those less severe sepsis (OR: 3.26, 95% CI: 1.37-7.75, P = 0.008). Conclusion PAI-1 is a significant predictor of disease severity and all-cause mortality in sepsis. Although the predictive values of PAI-1 reached statistical significance, the clinical utility of PAI-1 in predicting outcomes will require carefully designed prospective trials.
Collapse
Affiliation(s)
- Timothy L Tipoe
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - William K K Wu
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Lilianna Chung
- Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Mengqi Gong
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Mei Dong
- Department of Clinical Research, Federal University of Uberlândia, Uberlândia, Brazil
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Leonardo Roever
- Department of Clinical Research, Federal University of Uberlândia, Uberlândia, Brazil
| | - Jeffery Ho
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Martin C S Wong
- JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Matthew T V Chan
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Gary Tse
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Justin C Y Wu
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Sunny H Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| |
Collapse
|
7
|
Abstract
The serine protease inhibitor clade E member 1 (SERPINE1) gene has been suggested to exert great influence on the development of sepsis. But there is little overlap in the results of association between SERPINE1 -675 4G/5G polymorphism and sepsis.To get a more precise estimation of this association, we conducted a meta-analysis with a relatively larger sample size including 1806 cases and 2239 controls. Odds ratio (OR) with 95% confidence interval (CI) was used to evaluate the relationship between -675 4G/5G polymorphism and sepsis susceptibility. Subgroup analyses were conducted based on ethnicity and source of controls.The results showed that there was no association of the SERPINE1 polymorphism and sepsis susceptibility (5G5G vs 4G4G: OR = 0.87, CI = 0.75-1.03; 5G5G+4G5G vs 4G4G: OR = 0.93, CI = 0.84-1.02; 5G5G vs 4G4G+4G5G: OR = 0.96, CI = 0.83-1.11; 5G vs 4G: OR = 0.94, CI = 0.86-1.01; 4G5G vs 4G4G: OR = 0.90, CI = 0.80-1.01). Nor did any subgroup analysis indicate a significant association.In conclusion, -675 4G/5G polymorphism in the SERPINE1 gene may not be associated with the risk of sepsis.
Collapse
Affiliation(s)
- Chengfang Shi
- From the Third Military Medical University of Chinese People's Liberation Army, Chongqing, China (CS); Department of Dermatology, General Hospital of Beijing Military Region, Beijing, China (CS, ZS, RY); and Department of Burns, General Hospital of Beijing Military Region, Beijing, China (LL)
| | | | | | | |
Collapse
|
8
|
Gould TJ, Vu TT, Stafford AR, Dwivedi DJ, Kim PY, Fox-Robichaud AE, Weitz JI, Liaw PC. Cell-Free DNA Modulates Clot Structure and Impairs Fibrinolysis in Sepsis. Arterioscler Thromb Vasc Biol 2015; 35:2544-53. [PMID: 26494232 DOI: 10.1161/atvbaha.115.306035] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 09/30/2015] [Indexed: 01/13/2023]
Abstract
OBJECTIVES Sepsis is characterized by systemic activation of inflammation and coagulation in response to infection. In sepsis, activated neutrophils extrude neutrophil extracellular traps composed of cell-free DNA (CFDNA) that not only trap pathogens but also provide a stimulus for clot formation. Although the effect of CFDNA on coagulation has been extensively studied, much less is known about the impact of CFDNA on fibrinolysis. To address this, we (1) investigated the relationship between CFDNA levels and fibrinolytic activity in sepsis and (2) determined the mechanisms by which CFDNA modulates fibrinolysis. APPROACH AND RESULTS Plasma was collected from healthy and septic individuals, and CFDNA was quantified. Clot lysis assays were performed in plasma and purified systems, and lysis times were determined by monitoring absorbance. Clot morphology was assessed using scanning electron microscopy. Clots formed in plasma from septic patients containing >5 µg/mL CFDNA were dense in structure and resistant to fibrinolysis, a phenomenon overcome by deoxyribonuclease addition. These effects were recapitulated in control plasma supplemented with CFDNA. In a purified system, CFDNA delayed fibrinolysis but did not alter tissue-type plasminogen activator-induced plasmin generation. Using surface plasmon resonance, CFDNA bound plasmin with a Kd value of 4.2±0.3 µmol/L, and increasing concentrations of CFDNA impaired plasmin-mediated degradation of fibrin clots via the formation of a nonproductive ternary complex between plasmin, CFDNA, and fibrin. CONCLUSIONS Our studies suggest that the increased levels of CFDNA in sepsis impair fibrinolysis by inhibiting plasmin-mediated fibrin degradation, thereby identifying CFDNA as a potential therapeutic target for sepsis treatment.
Collapse
Affiliation(s)
- Travis J Gould
- From the Department of Medical Sciences (T.J.G., T.T.V.), Thrombosis and Atherosclerosis Research Institute (T.J.G., T.T.V., A.R.S., D.J.D., P.Y.K., A.E.F.-R., J.I.W., P.C.L.), and Department of Medicine (A.R.S., P.Y.K., A.E.F.-R., J.I.W., P.C.L.), McMaster University, Hamilton, Ontario, Canada
| | - Trang T Vu
- From the Department of Medical Sciences (T.J.G., T.T.V.), Thrombosis and Atherosclerosis Research Institute (T.J.G., T.T.V., A.R.S., D.J.D., P.Y.K., A.E.F.-R., J.I.W., P.C.L.), and Department of Medicine (A.R.S., P.Y.K., A.E.F.-R., J.I.W., P.C.L.), McMaster University, Hamilton, Ontario, Canada
| | - Alan R Stafford
- From the Department of Medical Sciences (T.J.G., T.T.V.), Thrombosis and Atherosclerosis Research Institute (T.J.G., T.T.V., A.R.S., D.J.D., P.Y.K., A.E.F.-R., J.I.W., P.C.L.), and Department of Medicine (A.R.S., P.Y.K., A.E.F.-R., J.I.W., P.C.L.), McMaster University, Hamilton, Ontario, Canada
| | - Dhruva J Dwivedi
- From the Department of Medical Sciences (T.J.G., T.T.V.), Thrombosis and Atherosclerosis Research Institute (T.J.G., T.T.V., A.R.S., D.J.D., P.Y.K., A.E.F.-R., J.I.W., P.C.L.), and Department of Medicine (A.R.S., P.Y.K., A.E.F.-R., J.I.W., P.C.L.), McMaster University, Hamilton, Ontario, Canada
| | - Paul Y Kim
- From the Department of Medical Sciences (T.J.G., T.T.V.), Thrombosis and Atherosclerosis Research Institute (T.J.G., T.T.V., A.R.S., D.J.D., P.Y.K., A.E.F.-R., J.I.W., P.C.L.), and Department of Medicine (A.R.S., P.Y.K., A.E.F.-R., J.I.W., P.C.L.), McMaster University, Hamilton, Ontario, Canada
| | - Alison E Fox-Robichaud
- From the Department of Medical Sciences (T.J.G., T.T.V.), Thrombosis and Atherosclerosis Research Institute (T.J.G., T.T.V., A.R.S., D.J.D., P.Y.K., A.E.F.-R., J.I.W., P.C.L.), and Department of Medicine (A.R.S., P.Y.K., A.E.F.-R., J.I.W., P.C.L.), McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey I Weitz
- From the Department of Medical Sciences (T.J.G., T.T.V.), Thrombosis and Atherosclerosis Research Institute (T.J.G., T.T.V., A.R.S., D.J.D., P.Y.K., A.E.F.-R., J.I.W., P.C.L.), and Department of Medicine (A.R.S., P.Y.K., A.E.F.-R., J.I.W., P.C.L.), McMaster University, Hamilton, Ontario, Canada
| | - Patricia C Liaw
- From the Department of Medical Sciences (T.J.G., T.T.V.), Thrombosis and Atherosclerosis Research Institute (T.J.G., T.T.V., A.R.S., D.J.D., P.Y.K., A.E.F.-R., J.I.W., P.C.L.), and Department of Medicine (A.R.S., P.Y.K., A.E.F.-R., J.I.W., P.C.L.), McMaster University, Hamilton, Ontario, Canada.
| |
Collapse
|
9
|
Peetermans M, Vanassche T, Liesenborghs L, Lijnen RH, Verhamme P. Bacterial pathogens activate plasminogen to breach tissue barriers and escape from innate immunity. Crit Rev Microbiol 2015; 42:866-82. [PMID: 26485450 DOI: 10.3109/1040841x.2015.1080214] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Both coagulation and fibrinolysis are tightly connected with the innate immune system. Infection and inflammation cause profound alterations in the otherwise well-controlled balance between coagulation and fibrinolysis. Many pathogenic bacteria directly exploit the host's hemostatic system to increase their virulence. Here, we review the capacity of bacteria to activate plasminogen. The resulting proteolytic activity allows them to breach tissue barriers and evade innate immune defense, thus promoting bacterial spreading. Yersinia pestis, streptococci of group A, C and G and Staphylococcus aureus produce a specific bacterial plasminogen activator. Moreover, surface plasminogen receptors play an established role in pneumococcal, borrelial and group B streptococcal infections. This review summarizes the mechanisms of bacterial activation of host plasminogen and the role of the fibrinolytic system in infections caused by these pathogens.
Collapse
Affiliation(s)
- Marijke Peetermans
- a Center for Molecular and Vascular Biology, KU Leuven , Leuven , Belgium
| | - Thomas Vanassche
- a Center for Molecular and Vascular Biology, KU Leuven , Leuven , Belgium
| | | | - Roger H Lijnen
- a Center for Molecular and Vascular Biology, KU Leuven , Leuven , Belgium
| | - Peter Verhamme
- a Center for Molecular and Vascular Biology, KU Leuven , Leuven , Belgium
| |
Collapse
|
10
|
Panigada M, Zacchetti L, L’Acqua C, Cressoni M, Anzoletti MB, Bader R, Protti A, Consonni D, D’Angelo A, Gattinoni L. Assessment of Fibrinolysis in Sepsis Patients with Urokinase Modified Thromboelastography. PLoS One 2015; 10:e0136463. [PMID: 26308340 PMCID: PMC4550424 DOI: 10.1371/journal.pone.0136463] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 08/03/2015] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Impairment of fibrinolysis during sepsis is associated with worse outcome. Early identification of this condition could be of interest. The aim of this study was to evaluate whether a modified point-of-care viscoelastic hemostatic assay can detect sepsis-induced impairment of fibrinolysis and to correlate impaired fibrinolysis with morbidity and mortality. METHODS This single center observational prospective pilot study was performed in an adult Intensive Care Unit (ICU) of a tertiary academic hospital. Forty consecutive patients admitted to the ICU with severe sepsis or septic shock were included. Forty healthy individuals served as controls. We modified conventional kaolin activated thromboelastography (TEG) adding urokinase to improve assessment of fibrinolysis in real time (UK-TEG). TEG, UK-TEG, plasminogen activator inhibitor (PAI)-1, thrombin-activatable fibrinolysis inhibitor (TAFI), d-dimer, DIC scores and morbidity (rated with the SOFA score) were measured upon ICU admission. Logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (95% CIs) of mortality at ICU discharge. RESULTS UK-TEG revealed a greater impairment of fibrinolysis in sepsis patients compared to healthy individuals confirmed by PAI-1. TAFI was not different between sepsis patients and healthy individuals. 18/40 sepsis patients had fibrinolysis impaired according to UK-TEG and showed higher SOFA score (8 (6-13) vs 5 (4-7), p = 0.03), higher mortality (39% vs 5%, p = 0.01) and greater markers of cellular damage (lactate levels, LDH and bilirubin). Mortality at ICU discharge was predicted by the degree of fibrinolysis impairment measured by UK-TEG Ly30 (%) parameter (OR 0.95, 95% CI 0.93-0.98, p = 0.003). CONCLUSIONS Sepsis-induced impairment of fibrinolysis detected at UK-TEG was associated with increased markers of cellular damage, morbidity and mortality.
Collapse
Affiliation(s)
- Mauro Panigada
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
- * E-mail:
| | - Lucia Zacchetti
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Camilla L’Acqua
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Cressoni
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Boscolo Anzoletti
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Rossella Bader
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandro Protti
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Dario Consonni
- Epidemiology Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Armando D’Angelo
- Coagulation Service and Thrombosis Research Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Luciano Gattinoni
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
11
|
Raeven P, Drechsler S, Weixelbaumer KM, Bastelica D, Peiretti F, Klotz A, Jafarmadar M, Redl H, Bahrami S, Alessi MC, Declerck PJ, Osuchowski MF. Systemic inhibition and liver-specific over-expression of PAI-1 failed to improve survival in all-inclusive populations or homogenous cohorts of CLP mice. J Thromb Haemost 2014; 12:958-69. [PMID: 24655755 DOI: 10.1111/jth.12565] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 03/11/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND The role of plasminogen activator inhibitor type-1 (PAI-1) in abdominal sepsis remains elusive. OBJECTIVES To study the influence of inhibition and over-expression of PAI-1 upon survival in cecal ligation and puncture (CLP) sepsis. METHODS (i) Mice underwent moderate CLP and received 10 mg kg(-1) of either monoclonal anti-PAI-1 (MA-MP6H6) or control (MA-Control) antibody intravenously at 0, 18 or 30 h post-CLP. The 30-h treatment group was additionally stratified into mice predicted to survive (P-SUR) or die (P-DIE) based on IL 6 measured at 24 h post-CLP. (ii) PAI-1 expression was induced with pLIVE.PAI-1 plasmid administered 72 h pre-CLP. Blood was sampled for 5 days and survival was monitored for 28 days. RESULTS MA-MP6H6 effectively neutralized active PAI-1 and fully restored fibrinolysis while PAI-1 over-expression was liver-specific and correlated with PAI-1 increase in the blood. Without stratification, MA-MP6H6 co-/post-treatment conferred no survival benefit. Prospective stratification (IL-6 cut-off: 14 ng mL(-1) ) suggested increased mortality by MA-MP6H6 treatment in P-SUR that reached 30% difference (vs. MA-Control; P < 0.05) after a retrospective cut-off readjustment to 3.3 ng mL(-1) for better P-SUR homogeneity. Subsequent prospective anti-PAI-1 treatment in P-SUR mice with 3.3 ng mL(-1) cut-off demonstrated a negative but statistically insignificant effect: mortality was higher by 17% after MA-MP6H6 vs. MA-Control. Over-expression of PAI 1 did not alter post-CLP survival. Neither PAI-1 inhibition nor over-expression meaningfully modified inflammatory response and/or organ function. CONCLUSIONS Restoration of fibrinolysis in early abdominal sepsis was not beneficial and it may prove detrimental in subjects with the lowest risk of death, while preemptive PAI-1 up-regulation at the current magnitude was not protective.
Collapse
Affiliation(s)
- P Raeven
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology in the Trauma Research Center of the AUVA, Vienna, Austria; Department of Anesthesiology, University Medical Center, Regensburg, Germany
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Kager LM, Weehuizen TA, Wiersinga WJ, Roelofs JJTH, Meijers JCM, Dondorp AM, van 't Veer C, van der Poll T. Endogenous α2-antiplasmin is protective during severe gram-negative sepsis (melioidosis). Am J Respir Crit Care Med 2013; 188:967-75. [PMID: 23992406 DOI: 10.1164/rccm.201307-1344oc] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE α2-Antiplasmin (A2AP) is a major inhibitor of fibrinolysis by virtue of its capacity to inhibit plasmin. Although the fibrinolytic system is strongly affected by infection, the functional role of A2AP in the host response to sepsis is unknown. OBJECTIVES To study the role of A2AP in melioidosis, a common form of community-acquired sepsis in Southeast Asia and Northern Australia caused by the gram-negative bacterium Burkholderia pseudomallei. METHODS In a single-center observational study A2AP was measured in patients with culture-proven septic melioidosis. Wild-type and A2AP-deficient (A2AP(-/-)) mice were intranasally infected with B. pseudomallei to induce severe pneumosepsis (melioidosis). Parameters of inflammation and coagulation were measured, and survival studies were performed. MEASUREMENTS AND MAIN RESULTS Patients with melioidosis showed elevated A2AP plasma levels. Likewise, A2AP levels in plasma and lung homogenates were elevated in mice infected with B. pseudomallei. A2AP-deficient (A2AP(-/-)) mice had a strongly disturbed host response during experimental melioidosis as reflected by enhanced bacterial growth at the primary site of infection accompanied by increased dissemination to distant organs. In addition, A2AP(-/-) mice showed more severe lung pathology and injury together with an increased accumulation of neutrophils and higher cytokine levels in lung tissue. A2AP deficiency further was associated with exaggerated systemic inflammation and coagulation, increased distant organ injury, and enhanced lethality. CONCLUSIONS This study is the first to identify A2AP as a protective mediator during gram-negative (pneumo)sepsis by limiting bacterial growth, inflammation, tissue injury, and coagulation.
Collapse
|
13
|
Zaki MES, Fouda M, Sharaf eldeen OA, Zaghloul MHED. Extracellular accumulation of bioactive substances; Interleukin-1β (IL-1β) and plasminogen activator inhibitor-1 (PAI-1) in stored blood units and relation to bacterial contamination. Hematology 2013; 11:301-5. [PMID: 17178672 DOI: 10.1080/10245330600702745] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Bacterial contamination of blood and its cellular components remains an unresolved problem in transfusion medicine and is considered to be the most common microbiological cause of transfusion associated morbidity and mortality. The present work was designed to explore the levels of two bioactive compounds interleukin-1 beta (IL-1beta) and plasminogen activator inhibitor-1 (PAI-1) in stored blood units and their relation to bacterial contamination of these units. This study was conducted on 112 blood units obtained from blood bank of Mansoura University Children Hospital. Sequential blood samples were obtained both immediately at donation and after 10 days for measurement of IL-1beta and PAI-1 and for bacterial culture by BACTEC 9050 system. There was statistically significant increase in both IL-1 beta and PAI-1 (P = 0.0001) after 10 days of blood units storage. Bacteriological culture revealed no growth in 68% and positive growth in 32% of blood units. The commonest isolated organism was Staphylococcus aureus (15%) followed by Staphylococcus epidermedis (13%) then Yersinia sp. and Enterobacter sp. (2%) for each. From the present study we could conclude that stored blood units contain platelets and WBCs derived bioactive substances PAI-1 and IL-1beta which increase with the duration of blood storage. Furthermore, the extended duration of storage carries the danger of blood contamination by bacteria. Automated blood culture system seems to be helpful in identification of bacterial contamination of blood units. We recommend fresh blood transfusion as early as possible and the practice of Leucofiltration to avoid blood transfusion complications.
Collapse
Affiliation(s)
- Maysaa El Sayed Zaki
- Department of Clinical Pathology, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
| | | | | | | |
Collapse
|
14
|
Florova G, Karandashova S, Declerck PJ, Idell S, Komissarov AA. Remarkable stabilization of plasminogen activator inhibitor 1 in a "molecular sandwich" complex. Biochemistry 2013; 52:4697-709. [PMID: 23734661 DOI: 10.1021/bi400470s] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Plasminogen activator inhibitor 1 (PAI-1) levels are elevated in a number of life-threatening conditions and often correlate with unfavorable outcomes. Spontaneous inactivation due to active to latent transition limits PAI-1 activity in vivo. While endogenous vitronectin (Vn) stabilizes PAI-1 by 1.5-2.0-fold, further stabilization occurs in a "molecular sandwich" complex (MSC) in which a ligand that restricts the exposed reactive center loop is bound to PAI-1/Vn. The effects of S195A two-chain urokinase (tcuPA) and Vn on inactivation of wild-type (wt) glycosylated (Gl-PAI-1), nonglycosylated (rPAI-1), and nonglycosylated Q123K PAI-1 (lacks Vn binding) forms were studied. S195A tcuPA decreased the rate constant (kL) for spontaneous inactivation at 37 °C for rPAI-1, Q123K, and Gl-PAI-1 by 6.7-, 3.4-, and 7.8-fold, respectively, and both S195A tcuPA and Vn by 66.7-, 5.5-, and 103.3-fold, respectively. Analysis of the temperature dependences of kL revealed a synergistic increase in the Gibbs free activation energy for spontaneous inactivation of wt Gl-PAI-1 and rPAI-1 in MSC from 99.8 and 96.1 to 111.3 and 107.0 kJ/mol, respectively, due to an increase in the activation enthalpy and a decrease in the activation entropy. Anti-PAI-1 monoclonal antibodies (mAbs) competing with proteinase also stabilize PAI-1/Vn. The rate of inhibition of target proteinases by MSCs, with a stoichiometry close to unity, was limited by the dissociation (k = 10(-4) to 10(-3) s(-1)) of S195A tcuPA or mAb. The stabilization of PAI-1 in MSCs in vivo may potentiate uncontrolled thrombosis or extravascular fibrin deposition, suggesting a new paradigm for using PAI-1 inhibitors and novel potential targets for therapy.
Collapse
Affiliation(s)
- Galina Florova
- Texas Lung Injury Institute, University of Texas Health Science Center at Tyler , 11937 U.S. Highway 271, Tyler, Texas 75708-3154, United States
| | | | | | | | | |
Collapse
|
15
|
Zakynthinos S, Papanikolaou S, Mentzelopoulos S, Konstandelou E, Psachoulia C, Mavrommatis A. Procollagen type III aminoterminal propeptide as biomarker of host response in severe sepsis. J Crit Care 2013; 28:577-85. [PMID: 23683562 DOI: 10.1016/j.jcrc.2013.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 03/04/2013] [Accepted: 04/02/2013] [Indexed: 01/31/2023]
Abstract
PURPOSE The purpose of this study is to test the hypothesis that procollagen type III aminoterminal propeptide (PIIINP) is early elevated in septic episodes and can indicate the acute organ dysfunction/failure characterizing severe sepsis. MATERIALS AND METHODS This prospective study included 107 consecutive septic patients (44 with sepsis, 13 with severe sepsis, and 50 with septic shock) and 45 controls. After blood sampling (within 48 hours after onset of septic episodes), serum was assayed. Patients were followed up, and their disease severity was daily evaluated. RESULTS Procollagen type III aminoterminal propeptide (median [range]) increased in patients with sepsis (9.4 [2.2-42.4] ng/mL) compared with controls (3.6 [1.9-4.9] ng/mL; P<.001), exhibiting further significant increase in patients with severe sepsis and septic shock (19.5 [6.0-52.4] and 20.2 [1.8-89.2] ng/mL, respectively; P<.01-.001 vs sepsis). Among biomarkers of host response severity, PIIINP was the sole that was independently associated with severe sepsis/septic shock (P=.01). The area under the receiver operating characteristic curve for PIIINP to predict which patients with sepsis would eventually develop severe sepsis/septic shock was 0.87; the cutoff of 12 ng/mL had sensitivity 82% and specificity 89%. CONCLUSIONS Increased serum PIIINP can signify severe sepsis/septic shock and predict which patients with sepsis will eventually develop severe sepsis/septic shock, thus representing a biomarker of risk stratification of patients with sepsis.
Collapse
Affiliation(s)
- Spyros Zakynthinos
- First Department of Critical Care Medicine and Pulmonary Services, Medical School of Athens University, Evaggelismos Hospital, GR-10675, Athens, Greece.
| | | | | | | | | | | |
Collapse
|
16
|
Cornet AD, Hofstra JJ, Vlaar AP, Tuinman PR, Levi M, Girbes AR, Schultz MJ, Groeneveld AB, Beishuizen A. Activated protein C attenuates pulmonary coagulopathy in patients with acute respiratory distress syndrome. J Thromb Haemost 2013; 11:894-901. [PMID: 23433188 PMCID: PMC9906436 DOI: 10.1111/jth.12179] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Accepted: 02/15/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Acute respiratory distress syndrome (ARDS) frequently complicates critical illness. We hypothesized that an infusion of recombinant human activated protein C (rh-APC), a natural anticoagulant, would attenuate pulmonary coagulopathy and injury. METHODS In this sub study of a multicenter open-label randomized controlled trial of patients with ARDS, we compared an intravenous (i.v.) infusion of rh-APC (24 mcg kg(-1) h(-1) for 96 h) with placebo. Patients with sepsis or septic shock were excluded. RESULTS In 27 patients serial non-directed bronchoalveolar lavage fluid (NBLF) samples were obtained: 16 patients were treated with rh-APC and 11 patients with placebo. The rh-APC infusion was associated with higher APC levels in plasma during the infusion period of 4 days (P = 0.001), as well as higher APC levels in NBLF up to day 5 after the start of the infusion (P = 0.028). An infusion of rh-APC was associated with lower levels of thrombin-antithrombin complexes (P = 0.009) and soluble tissue factor (P = 0.011) in NBLF, compared with treatment with placebo. An infusion of rh-APC affected fibrinolysis, as plasminogen activator activity levels in NBLF were higher in the patients treated with rh-APC (P = 0.01), presumably as a result of lower NBLF levels of plasminogen activator inhibitor 1, (P = 0.01). The rh-APC infusion decreased the lung injury score (P = 0.005) and simplified the acute physiology score (P = 0.013) on day 5, when compared with baseline. The rh-APC infusion was not associated with bleeding complications. CONCLUSION An infusion of rh-APC in patients with ARDS attenuates pulmonary coagulopathy and injury.
Collapse
Affiliation(s)
- A D Cornet
- Department of Intensive Care Medicine, VU University Medical Center Amsterdam, Amsterdam, The Netherlands.
| | | | | | | | | | | | | | | | | |
Collapse
|
17
|
A non-lethal traumatic/hemorrhagic insult strongly modulates the compartment-specific PAI-1 response in the subsequent polymicrobial sepsis. PLoS One 2013; 8:e55467. [PMID: 23408987 PMCID: PMC3568129 DOI: 10.1371/journal.pone.0055467] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Accepted: 12/23/2012] [Indexed: 12/29/2022] Open
Abstract
Introduction Plasminogen activator inhibitor 1 (PAI-1) is a key factor in trauma- and sepsis-induced coagulopathy. We examined how trauma-hemorrhage (TH) modulates PAI-1 responses in subsequent cecal ligation and puncture (CLP)-induced sepsis, and the association of PAI-1 with septic outcomes. Methods Mice underwent TH and CLP 48 h later in three separate experiments. In experiment 1, mice were sacrificed pre- and post-CLP to characterize the trajectory of PAI-1 in plasma (protein) and tissues (mRNA). Post-CLP dynamics in TH-CLP (this study) and CLP-Only mice (prior study) were then compared for modulatory effects of TH. In experiment 2, to relate PAI-1 changes to outcome, mice underwent TH-CLP and were sampled daily and followed for 14 days to compare non-survivors (DEAD) and survivors (SUR). In experiment 3, plasma and tissue PAI-1 expression were compared between mice predicted to die (P-DIE) and to live (P-LIVE). Results In experiment 1, an early post-TH rise of circulating PAI-1 was contrasted by a delayed (post-TH) decrease of PAI-1 mRNA in organs. In the post-CLP phase, profiles of circulating PAI-1 were similar between TH-CLP and CLP-Only mice. Conversely, PAI-1 mRNA declined in the liver and heart of TH-CLP mice versus CLP-Only. In experiment 2, there were no DEAD/SUR differences in circulating PAI-1 prior to CLP. Post-CLP, circulating PAI-1 in DEAD was 2–4-fold higher than in SUR. PAI-1 increase heralded septic deaths up to 48 h prior but DEAD/SUR thrombomodulin (endothelial injury marker) levels were identical. In experiment 3, levels of circulating PAI-1 and its hepatic gene expression were higher in P-DIE versus P-LIVE mice and those increases closely correlated with liver dysfunction. Conclusions Trauma modulated septic PAI-1 responses in a compartment-specific fashion. Only post-CLP increases in circulating PAI-1 predicted septic outcomes. In posttraumatic sepsis, pre-lethal release of PAI-1 was mostly of hepatic origin and was independent of endothelial injury.
Collapse
|
18
|
Sulfatide attenuates experimental Staphylococcus aureus sepsis through a CD1d-dependent pathway. Infect Immun 2013; 81:1114-20. [PMID: 23340309 DOI: 10.1128/iai.01334-12] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Natural killer T (NKT) lymphocytes are implicated in the early response to microbial infection. Further, sulfatide, a myelin self-glycosphingolipid, activates a type II NKT cell subset and can modulate disease in murine models. We examined the role of NKT cells and the effect of sulfatide treatment in a murine model of Staphylococcus aureus sepsis. The lack of CD1d-restricted NKT cells did not alter survival after a lethal inoculum of S. aureus. In contrast, sulfatide treatment significantly improved the survival rate of mice with S. aureus sepsis, accompanied by decreased levels of tumor necrosis factor alpha and interleukin-6 in the blood. The protective effect of sulfatide treatment depended on CD1d but not on type I NKT cells, suggesting that activation of type II NKT cells by sulfatide has beneficial effects on the outcome of S. aureus sepsis in this model.
Collapse
|
19
|
Endogenous tissue-type plasminogen activator impairs host defense during severe experimental Gram-negative sepsis (melioidosis)*. Crit Care Med 2012; 40:2168-75. [PMID: 22564963 DOI: 10.1097/ccm.0b013e31824ea05e] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Melioidosis is a frequent cause of severe sepsis in Southeast Asia caused by the gram-negative bacterium Burkholderia pseudomallei. Patients with melioidosis have elevated circulating levels of tissue-type plasminogen activator, an important regulator of fibrinolysis. In this study, we aimed to investigate the role of tissue-type plasminogen activator during melioidosis. DESIGN Animal study. SETTING University research laboratory. SUBJECTS Wild-type and tissue-type plasminogen activator-deficient C57BL/6 mice. INTERVENTIONS Mice were intranasally infected with viable Burkholderia pseudomallei and killed after 24, 48, or 72 hrs for harvesting of lungs, liver, and blood. Additionally, survival studies were performed. MEASUREMENTS AND MAIN RESULTS Experimentally induced melioidosis was associated with elevated levels of tissue-type plasminogen activator in lungs of infected wild-type mice. During infection with Burkholderia pseudomallei, tissue-type plasminogen activator-deficient mice were protected when compared to wild-type mice as demonstrated by a strongly decreased mortality (62% vs. 100% amongst wild-type mice, p < .0001), together with decreased pulmonary bacterial loads, less severe histopathological scores, and decreased fibrinolysis. These results were accompanied with an early increase in cytokine levels in tissue-type plasminogen activator-deficient mice. CONCLUSIONS During severe gram-negative sepsis caused by Burkholderia pseudomallei, endogenous tissue-type plasminogen activator has harmful effects with respect to survival and pulmonary bacterial growth. These effects are related to tissue-type plasminogen activator-associated plasmin-induced fibrinolysis and/or a tissue-type plasminogen activator-associated decrease in proinflammatory cytokine production.
Collapse
|
20
|
Raeven P, Feichtinger GA, Weixelbaumer KM, Atzenhofer S, Redl H, Van Griensven M, Bahrami S, Osuchowski MF. Compartment-specific expression of plasminogen activator inhibitor-1 correlates with severity/outcome of murine polymicrobial sepsis. Thromb Res 2012; 129:e238-45. [DOI: 10.1016/j.thromres.2012.02.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 01/24/2012] [Accepted: 02/05/2012] [Indexed: 01/28/2023]
|
21
|
Komissarov AA, Florova G, Idell S. Effects of extracellular DNA on plasminogen activation and fibrinolysis. J Biol Chem 2011; 286:41949-41962. [PMID: 21976662 DOI: 10.1074/jbc.m111.301218] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The increased levels of extracellular DNA found in a number of disorders involving dysregulation of the fibrinolytic system may affect interactions between fibrinolytic enzymes and inhibitors. Double-stranded (ds) DNA and oligonucleotides bind tissue-(tPA) and urokinase (uPA)-type plasminogen activators, plasmin, and plasminogen with submicromolar affinity. The binding of enzymes to DNA was detected by EMSA, steady-state, and stopped-flow fluorimetry. The interaction of dsDNA/oligonucleotides with tPA and uPA includes a fast bimolecular step, followed by two monomolecular steps, likely indicating slow conformational changes in the enzyme. DNA (0.1-5.0 μg/ml), but not RNA, potentiates the activation of Glu- and Lys-plasminogen by tPA and uPA by 480- and 70-fold and 10.7- and 17-fold, respectively, via a template mechanism similar to that known for fibrin. However, unlike fibrin, dsDNA/oligonucleotides moderately affect the reaction between plasmin and α(2)-antiplasmin and accelerate the inactivation of tPA and two chain uPA by plasminogen activator inhibitor-1 (PAI-1), which is potentiated by vitronectin. dsDNA (0.1-1.0 μg/ml) does not affect the rate of fibrinolysis by plasmin but increases by 4-5-fold the rate of fibrinolysis by Glu-plasminogen/plasminogen activator. The presence of α(2)-antiplasmin abolishes the potentiation of fibrinolysis by dsDNA. At higher concentrations (1.0-20 μg/ml), dsDNA competes for plasmin with fibrin and decreases the rate of fibrinolysis. dsDNA/oligonucleotides incorporated into a fibrin film also inhibit fibrinolysis. Thus, extracellular DNA at physiological concentrations may potentiate fibrinolysis by stimulating fibrin-independent plasminogen activation. Conversely, DNA could inhibit fibrinolysis by increasing the susceptibility of fibrinolytic enzymes to serpins.
Collapse
Affiliation(s)
- Andrey A Komissarov
- Texas Lung Injury Institute, University of Texas Health Science Center at Tyler, Tyler, Texas 75708-3154.
| | - Galina Florova
- Texas Lung Injury Institute, University of Texas Health Science Center at Tyler, Tyler, Texas 75708-3154
| | - Steven Idell
- Texas Lung Injury Institute, University of Texas Health Science Center at Tyler, Tyler, Texas 75708-3154
| |
Collapse
|
22
|
Fei Y, Wang W, Kwiecinski J, Josefsson E, Pullerits R, Jonsson IM, Magnusson M, Jin T. The combination of a tumor necrosis factor inhibitor and antibiotic alleviates staphylococcal arthritis and sepsis in mice. J Infect Dis 2011; 204:348-57. [PMID: 21742832 DOI: 10.1093/infdis/jir266] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Despite advances in medical practices, in recent decades permanent reductions in joint function have not been achieved, and the high mortality rate of patients with staphylococcal septic arthritis has not substantially improved. METHODS We evaluated the effects of a combined tumor necrosis factor (TNF) inhibitor and antibiotic therapy on the course of Staphylococcus aureus arthritis and sepsis in mice. RESULTS Treatment with the combination of a TNF inhibitor and an antibiotic resulted in a quicker relief of clinical arthritis in mice with septic arthritis, compared with an antibiotic monotherapy. Both histopathologically verified synovitis and the extent of joint destruction were reduced by this combined treatment. Importantly, anti-TNF treatment significantly improved the survival rate of mice with S. aureus sepsis and staphylococcal enterotoxin shock syndrome; this effect might be the result of a partial restoration of the hemostatic balance between coagulation and fibrinolysis. Finally, we demonstrated that anti-TNF treatment downregulates high-mobility group protein B1 in staphylococcal enterotoxin shock syndrome. CONCLUSIONS Thus, simultaneous systemic TNF inhibition and antibiotic therapy has beneficial effects on the outcome of S. aureus arthritis and sepsis in a mouse model, suggesting that the combination of a TNF inhibitor and antibiotics represents a novel therapeutic strategy for the treatment of staphylococcal infections.
Collapse
Affiliation(s)
- Ying Fei
- Department of Rheumatology and Inflammation Research, Institute of Clinical Sciences, Gothenburg University, Göteborg, Sweden
| | | | | | | | | | | | | | | |
Collapse
|
23
|
Kłak M, Anäkkälä N, Wang W, Lange S, Jonsson IM, Tarkowski A, Jin T. Tranexamic acid, an inhibitor of plasminogen activation, aggravates staphylococcal septic arthritis and sepsis. ACTA ACUST UNITED AC 2010; 42:351-8. [PMID: 20100112 DOI: 10.3109/00365540903510690] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Haemostatic balance shifts towards pro-coagulation during infection. Plasminogen, a key molecule of fibrinolysis, may play an important role in the pathogenesis of staphylococcal infections. In the present study, we assessed the impact of inhibition of plasminogen activation by tranexamic acid on the course of staphylococcal sepsis and septic arthritis in mice. We found significantly down-regulated plasmin activity and increased D-dimer levels in the blood from the mice with staphylococcal sepsis. Treatment with tranexamic acid significantly increased the severity and mortality of staphylococcal infection. In addition, tranexamic acid reduced the survival rate in a murine model for staphylococcal enterotoxin A-induced death. The aggravation of diseases by tranexamic acid was due neither to the pro-inflammatory cytokine network, nor to impairment of bacterial clearance. Modulation of fibrinolysis, either by supplement of fibrinolytic molecules (tissue plasminogen activator or plasmin) or by fibrinogen depletion, did not reduce the mortality of staphylococcal sepsis. In conclusion, we report that treatment with tranexamic acid led to distinct aggravation of staphylococcal septic arthritis and sepsis in mice, suggesting the clinical importance of fibrinolytic balance in staphylococcal infection.
Collapse
Affiliation(s)
- Marcin Kłak
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg Hospital, Göteborg, Sweden
| | | | | | | | | | | | | |
Collapse
|
24
|
de Kruif MD, Limper M, Sierhuis K, Wagenaar JFP, Spek CA, Garlanda C, Cotena A, Mantovani A, ten Cate H, Reitsma PH, van Gorp ECM. PTX3 predicts severe disease in febrile patients at the emergency department. J Infect 2009; 60:122-7. [PMID: 19961874 DOI: 10.1016/j.jinf.2009.11.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2009] [Revised: 10/29/2009] [Accepted: 11/25/2009] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The long pentraxin PTX3 is a promising marker of disease severity in severely ill patients. In order to identify patients warranting critical care as quickly as possible, we investigated the value of PTX3 as a biomarker for disease severity in patients presenting with fever at the emergency department. METHODS Levels of PTX3 were measured in 211 febrile patients at the emergency and the levels were linked to markers of disease severity including admittance to a special care unit, bloodstream infection and congestive heart failure. RESULTS In comparison to median baseline levels of 2.30 ng/ml (interquartile range 1.66-3.67 ng/ml), levels of PTX3 were significantly elevated in patients admitted to the intensive-/medium care unit (median value 44.4 ng/ml, interquartile range 13.6-105.9 ng/ml) and in patients referred to the ward (median value 14.2 ng/ml, interquartile range 7.01-25.1 ng/ml). In addition, PTX3 was associated with duration of hospital stay and acute congestive heart failure. The levels were predictive for bloodstream infection (AUC=0.71; 95% CI 0.62-0.81). CONCLUSIONS PTX3 may be a useful marker for differentiation of patients with severe disease in patients presenting with fever to the emergency department.
Collapse
Affiliation(s)
- Martijn D de Kruif
- Department of Internal Medicine, Slotervaart Hospital, Louwesweg 6, 1066 EC, Amsterdam, The Netherlands.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
The wnt pathway: a macrophage effector molecule that triggers inflammation. Curr Atheroscler Rep 2009; 11:236-42. [PMID: 19361356 DOI: 10.1007/s11883-009-0036-4] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Wnt proteins are members of the highly conserved wingless family of proteins responsible for cell differentiation and development and for neoplastic and degenerative processes. Recently, Toll-like receptor-mediated Wnt signaling was found to be associated with innate immunity in Drosophila. Upregulation of Wnt5A in human macrophages upon microbial challenge indicated a similar mechanism. Toll-like receptor-mediated Wnt5A expression is a key process for sustained inflammatory macrophage activation through autocrine and paracrine signaling. Downregulation of Wnt5A expression and subsequent attenuation of inflammatory macrophage responses by activated protein C supports the link between inflammation and coagulation, another highly conserved biologic system. Direct evidence for the relevance of Wnt5A in severe systemic inflammation is provided by the finding of higher Wnt5A levels in patients with sepsis than in healthy individuals. The fact that Wnt5A signaling can be modulated by anti-inflammatory mediators makes this effector molecule an attractive target for therapeutic intervention in inflammatory diseases.
Collapse
|
26
|
Abstract
OBJECTIVE To investigate whether tight glycemic control, in patients with sepsis, may restore a normal fibrinolysis by lowering plasminogen activator inhibitor (PAI)-1 levels. DESIGN Prospective randomized clinical trial. SETTING Three Italian university hospital intensive care units. PATIENTS Ninety patients with severe sepsis/septic shock. INTERVENTIONS Patients were randomized to receive either tight glycemic control (treatment group, target glycemia, 80-110 mg/dL) or conventional glycemic control (control group, target glycemia, 180-200 mg/dL). MEASUREMENTS Inflammation, coagulation, and fibrinolysis markers were assessed, along with Sepsis-related Organ Failure Assessment scores, >28 days. MAIN RESULTS In the whole population, at enrolment, inflammation and coagulation were activated in >80 of 90 patients, whereas fibrinolysis, as assessed by PAI-1 activity and concentration, was impaired in only 34 patients. The extent of the inflammatory reaction or of the coagulation activation was unrelated to outcome. In contrast, 90-day mortality rate of the 34 patients in whom fibrinolysis was definitely inhibited at study entry was twice that of the 56 patients in whom fibrinolysis was intact (44% vs. 21%, p = 0.02). After randomization, during the study, daily glycemia averaged 112 +/- 23 mg/dL in the treatment group and 159 +/- 31 mg/dL in controls (p < 0.001), with total daily administered insulin 57 +/- 59 IU and 36 +/- 44 IU, respectively (p < 0.001). A small, but significant, enhancement of fibrinolysis could be observed in the treatment group, as indicated by the time course of PAI-1 activity (p < 0.001), PAI-1 concentration (p = 0.004), and plasmin-antiplasmin complexes (p < 0.001). Morbidity, rated with the Sepsis-related Organ Failure Assessment score, became significantly lower (p = 0.03) in the treatment group. CONCLUSIONS Fibrinolysis inhibition, in severe sepsis/septic shock, seems to have a relevant pathogenetic role. In this context, tight glycemic control seems to reduce, with time, the fibrinolytic impairment and morbidity.
Collapse
|
27
|
Fong IW. New Concepts and Emerging Issues in Sepsis. EMERGING ISSUES AND CONTROVERSIES IN INFECTIOUS DISEASE 2009. [PMCID: PMC7122214 DOI: 10.1007/978-0-387-84841-9_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- I. W. Fong
- Professor of Medicine University of Toronto, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8 Canada
| |
Collapse
|
28
|
Schouten M, Wiersinga WJ, Levi M, van der Poll T. Inflammation, endothelium, and coagulation in sepsis. J Leukoc Biol 2008; 83:536-45. [PMID: 18032692 DOI: 10.1189/jlb.0607373] [Citation(s) in RCA: 431] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Sepsis is a systemic response to infection, and symptoms are produced by host defense systems rather than by the invading pathogens. Amongst the most prominent features of sepsis, contributing significantly to its outcome, is activation of coagulation with concurrent down-regulation of anticoagulant systems and fibrinolysis. Inflammation-induced coagulation on its turn contributes to inflammation. Another important feature of sepsis, associated with key symptoms such as hypovolemia and hypotension, is endothelial dysfunction. Under normal conditions, the endothelium provides for an anticoagulant surface, a property that is lost in sepsis. In this review, data about the interplay between inflammation and coagulation in sepsis are summarized with a special focus on the influence of the endothelium on inflammation-induced coagulation and vice versa. Possible procoagulant properties of the endothelium are described, such as expression of tissue factor (TF) and von Willebrand factor and interaction with platelets. Possible procoagulant roles of microparticles, circulating endothelial cells and endothelial apoptosis, are also discussed. Moreover, the important roles of the endothelium in down-regulating the anticoagulants TF pathway inhibitor, antithrombin, and the protein C (PC) system and inhibition of fibrinolysis are discussed. The influence of coagulation on its turn on inflammation and the endothelium is described with a special focus on protease-activated receptors (PARs). We conclude that the relationship between endothelium and coagulation in sepsis is tight and that further research is needed, for example, to better understand the role of activated PC signaling via PAR-1, the role of the endothelial PC receptor herein, and the role of the glycocalyx.
Collapse
Affiliation(s)
- Marcel Schouten
- Center for Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | | | | | | |
Collapse
|
29
|
Redirection of the reaction between activated protein C and a serpin to the substrate pathway. Thromb Res 2008; 122:397-404. [DOI: 10.1016/j.thromres.2007.10.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2007] [Revised: 09/13/2007] [Accepted: 10/23/2007] [Indexed: 11/19/2022]
|
30
|
|
31
|
Wiersinga WJ, Meijers JCM, Levi M, Van 't Veer C, Day NP, Peacock SJ, van der Poll T. Activation of coagulation with concurrent impairment of anticoagulant mechanisms correlates with a poor outcome in severe melioidosis. J Thromb Haemost 2008; 6:32-9. [PMID: 17944999 DOI: 10.1111/j.1538-7836.2007.02796.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Melioidosis, which is caused by infection with the Gram-negative bacterium Burkholderia pseudomallei, is an important cause of sepsis in South-East Asia with a mortality of up to 40%. Knowledge of the involvement of coagulation and fibrinolysis in the pathogenesis of melioidosis is highly limited. OBJECTIVE To define the involvement of the coagulation and fibrinolytic systems in patients with severe melioidosis. METHODS Parameters of coagulation and fibrinolysis were measured in 34 patients with culture proven septic melioidosis and 32 healthy controls. RESULTS Patients demonstrated strong activation of the coagulation system, as reflected by high plasma levels of soluble tissue factor, the prothrombin fragment F(1+2) and thrombin-antithrombin complexes (TATc), and consumption of coagulation factors resulting in a prolonged prothrombin time and activated partial thromboplastin time. Concurrently, anticoagulant pathways were downregulated in patients: protein C, protein S, and antithrombin levels were all decreased when compared to controls. Patients also demonstrated evidence of activation and inhibition of fibrinolysis, as reflected by elevated concentrations of tissue-type plasminogen activator (tPA), plasminogen activator inhibitor type 1, plasmin-alpha2-antiplasmin complexes (PAPc) and D-dimer. High TATc/PAPc ratios in patients pointed to a predominance of the prothrombotic pathway in melioidosis. Furthermore, soluble thrombomodulin levels were increased. The extent of coagulation activation correlated with mortality; patients who went on to die had higher TATc, F(1+2), tPA and PAPc and lower protein C and antithrombin levels on admission than patients who survived. CONCLUSIONS The coagulation system is strongly activated during melioidosis. A high degree of activation of the coagulation system is an indicator of poor outcome in patients with melioidosis.
Collapse
Affiliation(s)
- W J Wiersinga
- Center for Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | | | | | | | | | | | | |
Collapse
|
32
|
Poggi M, Paulmyer-Lacroix O, Verdier M, Peiretti F, Bastelica D, Boucraut J, Lijnen HR, Juhan-Vague I, Alessi MC. Chronic plasminogen activator inhibitor-1 (PAI-1) overexpression dampens CD25+ lymphocyte recruitment after lipopolysaccharide endotoxemia in mouse lung. J Thromb Haemost 2007; 5:2467-75. [PMID: 17848179 DOI: 10.1111/j.1538-7836.2007.02757.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Plasma plasminogen activator inhibitor-1 (PAI-1) level rises during sepsis and confers a worse prognosis. PAI-1 participation to sepsis has been poorly documented and was mainly associated with fibrin deposits. Beside fibrin deposits, increased tissue PAI-1 expression may contribute to the poor outcome of endotoxemia through other mechanisms. OBJECTIVE AND METHODS During lipopolysaccharide (LPS) challenge, the role of PAI-1 in the early phase of inflammation was examined in the lungs of transgenic mice that either overexpress or lack the PAI-1 gene (PAI-1Tg or PAI-1(-/-)). RESULTS Analysis of leukocytes revealed that neutrophil and macrophage infiltrations did not differ for PAI-1Tg and wild-type (WT) mice. Remarkably, CD25+ lymphocyte infiltration was totally blunted in PAI-1Tg lungs and inversely correlated with fibrin depositions. In parallel, mRNA levels of the regulatory T cell (Treg) markers FoxP3, CTLA-4, and GITR were significantly lower in PAI-1Tg than in WT lungs after LPS challenge. These data are supported by opposite results in PAI-1(-/-) lungs. The systemic compartments (spleen and peripheral blood) showed no decrease in CD25+, CD4+ CD25+ lymphocytes, and Treg markers in PAI-1Tg mice after LPS injection compared with WT mice. In addition, plasma and lung concentrations of interleukin-6 (IL-6) and macrophage inflammatory protein-1alpha (MIP-1alpha) were significantly higher in PAI-1Tg mice than WT mice. CONCLUSION Our results suggest that chronic tissue PAI-1 overexpression influences the early phase of the inflammatory response during endotoxemia through the control of T lymphocyte traffic.
Collapse
MESH Headings
- Animals
- Antigens, CD/genetics
- Antigens, CD/metabolism
- Antigens, Differentiation/genetics
- Antigens, Differentiation/metabolism
- CTLA-4 Antigen
- Chemokine CCL3/metabolism
- Chemotaxis, Leukocyte
- Disease Models, Animal
- Endotoxemia/chemically induced
- Endotoxemia/complications
- Endotoxemia/immunology
- Endotoxemia/metabolism
- Endotoxemia/pathology
- Fibrin/metabolism
- Forkhead Transcription Factors/genetics
- Forkhead Transcription Factors/metabolism
- Glucocorticoid-Induced TNFR-Related Protein
- Immunity, Innate
- Inflammation/etiology
- Inflammation/immunology
- Inflammation/metabolism
- Inflammation/pathology
- Interferon-gamma/metabolism
- Interleukin-2 Receptor alpha Subunit/analysis
- Interleukin-6/metabolism
- Lipopolysaccharides
- Lung/immunology
- Lung/metabolism
- Lung/pathology
- Macrophages/immunology
- Mice
- Mice, Knockout
- Mice, Transgenic
- Neutrophils/immunology
- Pulmonary Fibrosis/etiology
- Pulmonary Fibrosis/immunology
- Pulmonary Fibrosis/metabolism
- RNA, Messenger/metabolism
- Receptors, Nerve Growth Factor/genetics
- Receptors, Nerve Growth Factor/metabolism
- Receptors, Tumor Necrosis Factor/genetics
- Receptors, Tumor Necrosis Factor/metabolism
- Serpin E2
- Serpins/deficiency
- Serpins/genetics
- Serpins/metabolism
- T-Lymphocytes/immunology
- T-Lymphocytes/metabolism
- T-Lymphocytes/pathology
- T-Lymphocytes, Regulatory/immunology
- T-Lymphocytes, Regulatory/metabolism
- Time Factors
- Up-Regulation
Collapse
Affiliation(s)
- M Poggi
- Faculté de Médecine, Aix-Marseille Université, Marseille, France
| | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Abstract
A careful balance between the inflammatory and anti-inflammatory response is vital in order to survive the daily invasion of pathogens. Sepsis has always been regarded as the result of an exacerbated detrimental inflammatory response towards invading bacteria. However, recent insights have forced us to rethink this sepsis paradigm. This review discusses the latest trends and developments in the sepsis field and helps to set the stage for the current debate on whether the sepsis response is good or bad.
Collapse
Affiliation(s)
- Willem Joost Wiersinga
- Academic Medical Center, Meibergdreef 9, Room G2-132, 1105 AZ Amsterdam, the Netherlands
| | | |
Collapse
|
34
|
Wiersinga WJ, Levi M, van der Poll T. Coagulation in Sepsis. UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2007. [DOI: 10.1007/3-540-30328-6_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
|
35
|
Schetz MR, Van den Berghe G. Do we have reliable biochemical markers to predict the outcome of critical illness? Int J Artif Organs 2006; 28:1197-210. [PMID: 16404695 DOI: 10.1177/039139880502801202] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Current outcome prediction in critically ill patients relies on the art of clinical judgement and/or the science of prognostication using illness severity scores. The biochemical processes underlying critical illness have increasingly been unravelled. Several biochemical markers reflecting the process of inflammation, immune dysfunction, impaired tissue oxygenation and endocrine alterations have been evaluated for their predictive power in small subpopulations of critically ill patients. However, none of these parameters has been validated in large populations of unselected ICU patients as has been done for the illness severity and organ failure scores. A simple biochemical predictor of ICU mortality will probably remain elusive because the processes underlying critical illness are very complex and heterogeneous. Future prognostic models will need to be far more sophisticated.
Collapse
Affiliation(s)
- M R Schetz
- Department of Intensive Care Medicine, Catholic University of Leuven, Leuven, Belgium
| | | |
Collapse
|
36
|
Hryszko T, Inaba K, Ihara H, Suzuki Y, Mogami H, Urano T. Nafamostat Attenuated the Impairment of Fibrinolysis in Animal Sepsis Model by Suppressing the Increase of Plasminogen Activator Inhibitor Type 1. ACTA ACUST UNITED AC 2006; 60:859-64. [PMID: 16612309 DOI: 10.1097/01.ta.0000215566.74588.27] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In endotoxemia, plasminogen activator inhibitor-1 (PAI-1) increases and develops clinical symptoms by suppressing fibrinolysis. We analyzed therapeutic advantage of nafamostat, a broad-range protease inhibitor, on fibrinolysis in an animal sepsis model. METHODS Male Wister rats infused with lipopolysaccharide (LPS) (50 mg/kg) alone or together with nafamostat (0.1 mg/kg/hr) for 4 hours were analyzed. RESULTS Plasma PAI-1 (4.2: 4.0-5.0 ng/mL, median and interquartile range) increased after LPS infusion (3700: 3400-4000), which was attenuated by nafamostat (2300: 2100-2600, p < 0.05). Fibrin(ogen) degradation products after LPS injection (173: 152-182 microg/mL) were further elevated by nafamostat (205: 205-228, p < 0.05), Nafamostat attenuated polymorphonuclear neutrophils infiltration in the liver, and tended to suppress plasma tumor necrosis factor-alpha levels. Nafamostat did not affect thrombin generation, platelet count, markers of liver and kidney function, and overall mortality. CONCLUSIONS Nafamostat appeared to improve impaired fibrinolysis by suppressing the increase of PAI-1 in plasma, though it did not largely improve clinical parameters.
Collapse
Affiliation(s)
- Tomasz Hryszko
- Department of Physiology, Hamamatsu University School of Medicine, Handa-yama, Japan
| | | | | | | | | | | |
Collapse
|
37
|
Abstract
Disseminated intravascular coagulation is a frequent complication of sepsis. Coagulation activation, inhibition of fibrinolysis, and consumption of coagulation inhibitors lead to a procoagulant state resulting in inadequate fibrin removal and fibrin deposition in the microvasculature. As a consequence, microvascular thrombosis contributes to promotion of organ dysfunction. Recently, three randomized, double-blind, placebo-controlled trials investigated the efficacy of antithrombin, activated protein C (APC), and tissue factor pathway inhibitor, respectively, in sepsis patients. A significant reduction in mortality was demonstrated in the APC trial. In this article, we first discuss the physiology of coagulation and fibrinolysis activation. Then, the pathophysiology of coagulation activation, consumption of coagulation inhibitors, and the inhibition of fibrinolysis leading to a procoagulant state are described in more detail. Moreover, therapeutic concepts as well as the three randomized, double-blind, placebo-controlled studies are discussed.
Collapse
Affiliation(s)
- Sacha Zeerleder
- Central Hematology Laboratory, University Hospital, Berne, Switzerland
| | | | | |
Collapse
|
38
|
Zeerleder S, Schroeder V, Hack CE, Kohler HP, Wuillemin WA. TAFI and PAI-1 levels in human sepsis. Thromb Res 2005; 118:205-12. [PMID: 16009400 DOI: 10.1016/j.thromres.2005.06.007] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2005] [Revised: 05/24/2005] [Accepted: 06/16/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Plasminogen activator inhibitor type-1 (PAI-1) is considered to be the main inhibitor of fibrinolysis in sepsis. However, the contribution of TAFI to the inhibition of fibrinolysis in sepsis is currently unknown. METHODS TAFI antigen and PAI-1 levels were measured in severe sepsis (n = 32) and septic shock (n = 8) patients. In addition, TAFI antigen levels had been determined in 151 controls. RESULTS Septic patients had significantly (p < 0.0001) decreased TAFI levels (median: 78.9% [range: 32.4-172.6]) as compared to controls (108.1% [35.9-255.4]). TAFI levels were equal in septic shock and severe sepsis (68.9% [32.4-172.6] vs. 82.5% [32.7-144.9], p = 0.987) as well as in survivors and non-survivors (87.1% [32.7-172.6] vs. 65.8% [32.4-129.5], p = 0.166). PAI-1 levels were significantly (705.5 ng/ml [131-5788]) higher in septic shock as in severe sepsis patients (316.5 ng/ml [53-1311], p = 0.016) and were equal in survivors and non-survivors (342 ng/ml [53-1311] vs. 413 ng/ml [55-5788], p = 0.231). TAT/PAP ratio (R((TAT/PAP))) reflecting the dysbalance between coagulation and fibrinolysis was calculated. R((TAT/PAP)) significantly increased with fatality and was significantly dependent on PAI-1, but not on TAFI. PAI-1 levels (570.5 ng/ml [135-5788]) and R((TAT/PAP)) (1.6 [0.3-6.1]) were significantly (p = 0.008 and p = 0.047) higher in patients with overt DIC as compared to patients without overt DIC (310 ng/ml [53-1128] and 0.6 [0.1-4.3]), whereas no difference was found for TAFI levels (68.9% [32.7-133.2] vs. 86.4% [32.4-172.6], p = 0.325). CONCLUSIONS Although inhibition in sepsis is mediated by both, PAI-1 might be involved early in the sepsis process, whereas TAFI might be responsible for ongoing fibrinolysis inhibition in later stages of sepsis.
Collapse
Affiliation(s)
- Sacha Zeerleder
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern, Switzerland.
| | | | | | | | | |
Collapse
|
39
|
Dhainaut JF, Shorr AF, Macias WL, Kollef MJ, Levi M, Reinhart K, Nelson DR. Dynamic evolution of coagulopathy in the first day of severe sepsis: relationship with mortality and organ failure. Crit Care Med 2005; 33:341-8. [PMID: 15699837 DOI: 10.1097/01.ccm.0000153520.31562.48] [Citation(s) in RCA: 181] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine whether changes in coagulation biomarkers during the first day of severe sepsis correlate with progression from single to multiple organ failure and subsequent death. DESIGN Analysis of secondary endpoints in a prospective, randomized, placebo-controlled, multinational clinical trial (PROWESS). SETTING The study involved 164 medical centers. PATIENTS A total of 840 patients who met criteria for severe sepsis and were randomized to receive placebo plus supportive care. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Coagulation biomarkers, prothrombin time, antithrombin activity, and D-dimer and protein C levels were measured, and Sequential Organ Failure Assessment was performed daily. Multiple logistic regression analysis identified baseline antithrombin activity <54% and changes in prothrombin time, D-dimer, and antithrombin activity during the first calendar day after the onset of the first sepsis-induced organ dysfunction (i.e., the first day of severe sepsis, day 1) as predictive of 28-day mortality (p < or = .01). A composite coagulopathy score was determined using points for predetermined levels of change from baseline to day 1. The composite coagulopathy score correlated with progression from single to multiple organ failure (p = .0007), time to resolution of organ failure (p = .0004), and 28-day mortality (p < .0001). Combining the composite coagulopathy score with the Acute Physiology and Chronic Health Evaluation (APACHE) II score improved ability to identify patients who would progress to multiple organ failure (area under receiver operating characteristic curve 0.61 APACHE II vs. 0.65 APACHE II + composite coagulopathy score) and who would die (area under receiver operating characteristic curve 0.69 APACHE II vs. 0.74 APACHE II + composite coagulopathy score). CONCLUSIONS Continuation or worsening of coagulopathy during the first day of severe sepsis was associated with increased development of new organ failure and 28-day mortality. These results further suggest that coagulation abnormalities contribute to organ failure and death.
Collapse
Affiliation(s)
- Jean-Francois Dhainaut
- Department of Intensive Care, Cochin Hospital, AP-HP, Cochin Institute, Cochin Port-Royal Medical School, Paris V University, Paris, France.
| | | | | | | | | | | | | |
Collapse
|
40
|
van der Poll T, Levi M, Nick JA, Abraham E. Activated protein C inhibits local coagulation after intrapulmonary delivery of endotoxin in humans. Am J Respir Crit Care Med 2005; 171:1125-8. [PMID: 15750041 PMCID: PMC2718442 DOI: 10.1164/rccm.200411-1483oc] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Acute lung injury and pneumonia are associated with pulmonary activation of coagulation and suppression of fibrinolysis, resulting in fibrin deposition in the lung. Activated protein C (APC) has systemic anticoagulant effects in patients with sepsis. OBJECTIVE To determine the effect of systemic administration of recombinant human APC on endotoxin-induced hemostatic alterations in the bronchoalveolar space in humans. METHODS Healthy humans received intravenous APC (24 microg/kg/hour; n = 8) or vehicle (n = 7); all subjects were administered saline in one lung subsegment and endotoxin (4 ng/kg) into the contralateral lung. Bronchoalveolar lavage was performed 16 hours after saline and endotoxin administration. MEASUREMENTS AND MAIN RESULTS Endotoxin induced local activation of coagulation, as reflected by elevated levels of thrombin-antithrombin complexes (1.9 +/- 0.1 ng/ml) and soluble tissue factor (15.0 +/- 0.6 pg/ml) in bronchoalveolar lavage fluid, which was inhibited by APC (1.4 +/- 0.1 ng/ml and 12.3 +/- 0.4 pg/ml, respectively; both p < 0.01). Concurrently, endotoxin suppressed fibrinolysis, as indicated by reduced bronchoalveolar levels of plasminogen activator activity accompanied by elevated levels of plasminogen activator inhibitor type I activity. APC diminished the rise in plasminogen activator inhibitor type I activity (from 3.9 +/- 0.1 to 3.0 +/- 0.2 ng/ml, p = 0.002), while not significantly influencing plasminogen activator activity levels. Endotoxin reduced bronchoalveolar protein C concentrations, which was prevented by APC. Protein C did not influence the endotoxin-induced rise in local soluble thrombomodulin levels. CONCLUSION APC exerts an anticoagulant effect in the human lung challenged with endotoxin.
Collapse
Affiliation(s)
- Tom van der Poll
- Department of Medicine, Academic Medical Center, Room G2-130, Meibergdreef 9, 1105AZ Amsterdam, Netherlands.
| | | | | | | |
Collapse
|
41
|
Moir E, Greaves M, Adey GD, Bennett B. Polymorphonuclear leukocytes from patients with severe sepsis have lost the ability to degrade fibrin via u-PA. J Leukoc Biol 2004; 76:571-6. [PMID: 15277568 DOI: 10.1189/jlb.0502257] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Fibrin persistence in the vasculature is an important complication of sepsis that can often lead to mortality. We have previously established that polymorphonuclear leukocytes (PMN) from healthy individuals have the capacity to degrade fibrin via urokinase-type plasminogen activator (u-PA). We have also demonstrated an increase in u-PA antigen in the plasma of patients suffering from septic shock. In this study, we investigate the hypothesis that PMN from patients with sepsis have lost their fibrinolytic ability and that this might contribute to the persistence of fibrin deposits. We show here that PMN from these patients do not express any u-PA activity, despite retaining some u-PA antigen. Additionally, thrombi prepared from the whole blood of the patients exhibit reduced endogenous lysis compared with those from healthy individuals. These data indicate that loss of fibrinolytic activity from PMN may be a contributing factor in fibrin persistence in the microvasculature in sepsis.
Collapse
Affiliation(s)
- E Moir
- Department of Medicine, Institute of Medical Science, Polwarth Building, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZD, Scotland, UK
| | | | | | | |
Collapse
|
42
|
Zakynthinos SG, Papanikolaou S, Theodoridis T, Zakynthinos EG, Christopoulou-Kokkinou V, Katsaris G, Mavrommatis AC. Sepsis severity is the major determinant of circulating thrombopoietin levels in septic patients. Crit Care Med 2004; 32:1004-10. [PMID: 15071393 DOI: 10.1097/01.ccm.0000121433.61546.a0] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To measure serum thrombopoietin levels and to investigate their relationship with platelet counts and other potential determinants in septic patients. DESIGN Prospective study comparing septic patients and healthy volunteers. SETTING General intensive care units in two tertiary university hospitals. PATIENTS A total of 152 consecutive septic patients (69 with sepsis, 24 with severe sepsis, and 59 with septic shock). Twenty-two healthy volunteers served as control subjects. Sepsis severity was determined by grading septic patients in those having sepsis, severe sepsis, and septic shock. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS After blood sampling, platelet counts, and serum thrombopoietin, interleukin-6 and C-reactive protein levels were measured. Platelets did not decrease in patients with sepsis, but they significantly decreased in patients with severe sepsis and septic shock (p <.01 vs. controls and sepsis). In contrast, thrombopoietin levels (median [range]) increased in patients with sepsis (159 [34-1272] pg/mL) compared with controls (57 [33-333] pg/mL, p <.001), exhibiting further significant increase in patients with severe sepsis and septic shock (461 [73-1550] and 522 [45-2313] pg/mL, respectively, p <.001 vs. sepsis). In multiple regression analysis, thrombopoietin levels were independently related only to sepsis severity (higher in patients with increased sepsis severity, p <.001) and platelet counts (higher in patients with lower platelet counts, p =.004). Sepsis severity accounted for most of the variance explained by the model. Thrombopoietin was significantly related to interleukin-6 (r =.26) and C-reactive protein (r =.37, p <.001 for both). In serial measurements, interleukin-6 peak values constantly preceded those of thrombopoietin, whereas peaks in thrombopoietin levels coincided with clinical episodes of septic shock. CONCLUSIONS Sepsis severity is the major determinant of elevated thrombopoietin levels in septic patients, whereas platelet count is a secondary determinant. Thrombopoietin represents a potential marker of sepsis severity.
Collapse
Affiliation(s)
- Spyros G Zakynthinos
- Associate Professor of Intensive Care Medicine, University of Athens Medical School, Athens, Greece.
| | | | | | | | | | | | | |
Collapse
|
43
|
Abstract
Following on the heels of multiple failed clinical trials of adjunctive therapeutic agents in sepsis, the positive outcome of a recent phase III study using activated protein C (APC) has led to a renewed optimism in targeted biotherapies for this syndrome. A growing body of data (both preclinical and clinical) suggests that the protection against death afforded by APC cannot be solely explained by its antithrombotic activity but rather is likely explained by its associated anti-inflammatory and profibrinolytic effects. Although a recent phase III study failed to demonstrate any protective effect of another important antithrombotic molecule, antithrombin, it is premature to conclude that the benefit observed with APC is unique among inhibitors of the coagulation system. The result of a third phase III study examining the effect of tissue factor pathway inhibitor (TFPI) in sepsis is currently awaited, and the possibility that other antithrombotic agents--and combinations thereof--have a place in the therapeutic armamentarium will undoubtedly be the topic of future studies.
Collapse
Affiliation(s)
- Nigel S Key
- Department of Medicine, University of Minnesota Medical School, 480 Mayo Building, 420 Delaware St SE, Minneapolis, MN 55455, USA.
| | | |
Collapse
|
44
|
Psuja P, Zozulińska M, Turowiecka Z, Cieślikowski W, Vinazzer H, Zawilska K. Plasma markers of hypercoagulability in patients with serious infections and risk of septic shock. Clin Appl Thromb Hemost 2002; 8:225-30. [PMID: 12361199 DOI: 10.1177/107602960200800305] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hyperthrombinogenesis due to bacterial septicemia may aggravate the risk of irreversible septic shock. In 22 patients with septicemia complicating urinary or alimentary infections, daily assessment of hemostasis was performed throughout 1 week. Standard screening of hemostasis revealed significantly increased mean values of prothrombin time, fibrinogen, and fibrinogen degradation product (FDP) concentration. However, platelet counts, activated partial thromboplastin times (APTT), thrombin times, ethanol gelation tests, and antithrombin activity remained within the normal range. By contrast, except for insignificant changes in protein C activity and activated factor VII content, specific markers of plasma hypercoagulability, that is, thrombin-antithrombin (TAT) complexes, prothrombin activating factor F 1+2, activated factor XII (XIIa), and dimer D were all markedly increased. Pathologic levels of TAT and Xlla were found in 82% and 73% of all plasma samples, respectively. The augmentation of TAT correlated with prolongation of thrombin time and increases in F 1+2 levels. The increase in XIIa correlated with thrombocytopenia, prolongation of APTT, exhaustion of antithrombin, and accumulation of F 1+2 and FDP in the plasma. Moreover, a significant increase in XIIa, stronger positivity of the ethanol gelation test, a greater increase in FDP, and a more pronounced decrease in protein C activity were observed in 8 patients with fatal septic shock. This study suggests the usefulness of TAT and XIIa measurements in the early recognition of plasma hypercoagulation in serious infections.
Collapse
Affiliation(s)
- Piotr Psuja
- Department of Haematology, Karol Marcinkowski University of Medical Sciences, Poznań, Poland
| | | | | | | | | | | |
Collapse
|