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The potential role of ischaemia-reperfusion injury in chronic, relapsing diseases such as rheumatoid arthritis, Long COVID, and ME/CFS: evidence, mechanisms, and therapeutic implications. Biochem J 2022; 479:1653-1708. [PMID: 36043493 PMCID: PMC9484810 DOI: 10.1042/bcj20220154] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 02/07/2023]
Abstract
Ischaemia–reperfusion (I–R) injury, initiated via bursts of reactive oxygen species produced during the reoxygenation phase following hypoxia, is well known in a variety of acute circumstances. We argue here that I–R injury also underpins elements of the pathology of a variety of chronic, inflammatory diseases, including rheumatoid arthritis, ME/CFS and, our chief focus and most proximally, Long COVID. Ischaemia may be initiated via fibrin amyloid microclot blockage of capillaries, for instance as exercise is started; reperfusion is a necessary corollary when it finishes. We rehearse the mechanistic evidence for these occurrences here, in terms of their manifestation as oxidative stress, hyperinflammation, mast cell activation, the production of marker metabolites and related activities. Such microclot-based phenomena can explain both the breathlessness/fatigue and the post-exertional malaise that may be observed in these conditions, as well as many other observables. The recognition of these processes implies, mechanistically, that therapeutic benefit is potentially to be had from antioxidants, from anti-inflammatories, from iron chelators, and via suitable, safe fibrinolytics, and/or anti-clotting agents. We review the considerable existing evidence that is consistent with this, and with the biochemical mechanisms involved.
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Cryer MJ, Farhan S, Kaufmann CC, Jäger B, Garg A, Krishnan P, Mehran R, Huber K. Prothrombotic Milieu, Thrombotic Events and Prophylactic Anticoagulation in Hospitalized COVID-19 Positive Patients: A Review. Clin Appl Thromb Hemost 2022; 28:10760296221074353. [PMID: 35068227 PMCID: PMC8793375 DOI: 10.1177/10760296221074353] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The Coronavirus Disease 2019 (COVID-19) pandemic has resulted in significant morbidity and mortality worldwide. Although initial reports concentrated on severe respiratory illness, emerging literature has indicated a substantially elevated risk of thromboembolic events in patients with COVID-19 disease. Pro-inflammatory cytokine release has been linked to endothelial dysfunction and activation of coagulation pathways, as evident by elevated D-dimer levels and deranged coagulation parameters. Both macrovascular and microvascular thromboses have been described in observational cohort and post-mortem studies. Concurrently, preliminary data have suggested the role of therapeutic anticoagulation in preventing major thromboembolic complications in moderately but not critically ill patients. However, pending results from randomized controlled trials, clear guidance is lacking regarding the intensity and duration of anticoagulation in such patients. Herein, we review the existing evidence on incidence and pathophysiology of COVID-19 related thromboembolic complications and guide anticoagulation therapy based on current literature and societal consensus statements.
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Affiliation(s)
- Michael Joseph Cryer
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Tucson Medical Center/Tucson Hospitals Medical Education Program, Tucson, Arizona, USA
| | - Serdar Farhan
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Bernhard Jäger
- Wilhelminenhospital, Vienna, Austria
- Sigmund Freud University, Medical School, Vienna, Austria
| | - Aakash Garg
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Prakash Krishnan
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kurt Huber
- Wilhelminenhospital, Vienna, Austria
- Sigmund Freud University, Medical School, Vienna, Austria
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Agarwal RN, Aggarwal H, Verma A, Tripathi MK. A Case Report of a Patient on Therapeutic Warfarin Who Died of COVID-19 Infection with a Sudden Rise in D-Dimer. Biomedicines 2021; 9:biomedicines9101382. [PMID: 34680499 PMCID: PMC8533641 DOI: 10.3390/biomedicines9101382] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 09/16/2021] [Accepted: 09/23/2021] [Indexed: 12/18/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has disrupted social and economic life globally. The global pandemic COVID-19 caused by this novel SARS-CoV-2 shows variable clinical manifestations, complicated further by cytokine storm, co-infections, and coagulopathy, leading to severe cases and death. Thrombotic complications arise due to complex and unique interplay between coronaviruses and host cells, inflammatory response, and the coagulation system. Heparin and derivatives are World Health Organization (WHO) recommended anticoagulants for moderate and severe Corona Virus Disease 19 (COVID-19), that can also inhibit viral adhesion to the cell membrane by interfering with heparan sulfate-dependent binding to angiotensin-converting enzyme 2 (ACE2) receptor. Heparin also possesses anti-inflammatory, immunomodulatory, antiviral, and anti-complement activity, which offers a benefit in limiting viral and microbial infectivity and anticoagulation from the immune-thrombosis system. Here we present a case study of the pathophysiology of unexpected COVID-19 coagulopathy of an obese African American patient. While being on therapeutic warfarin since admission, he had a dismal outcome due to cardio-pulmonary arrest after the sudden rise in D-dimer value from 1.1 to >20. This indicates that for such patients on chronic warfarin anticoagulation with “moderate COVID 19 syndromes”, warfarin anticoagulation may not be suitable compared to heparin and its derivatives. Further research should be done to understand the beneficial role of heparin and its derivatives compared to warfarin for COVID-19 inflicted patients.
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Affiliation(s)
- Reita N. Agarwal
- Department of Internal Medicine, Memphis VA Hospital, Memphis, TN 38104, USA
- Correspondence: (R.N.A.); (M.K.T.); Tel.: +901-523-8990 (ext. 6660) (R.N.A.); +956-296-1735 (M.K.T.)
| | - Hersheth Aggarwal
- Health Science Center, College of Medicine, The University of Tennessee, Memphis, TN 38104, USA;
| | - Ashmit Verma
- Department of Biomedical Engineering, Samrat Ashok Technological Institute, Vidisha 464001, India;
| | - Manish K. Tripathi
- South Texas Center of Excellence in Cancer Research, School of Medicine, University of Texas Rio Grande Valley, McAllen, TX 78504, USA
- Department of Immunology and Microbiology, School of Medicine, University of Texas Rio Grande Valley, McAllen, TX 78504, USA
- Correspondence: (R.N.A.); (M.K.T.); Tel.: +901-523-8990 (ext. 6660) (R.N.A.); +956-296-1735 (M.K.T.)
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4
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Alfarouk KO, AlHoufie STS, Ahmed SBM, Shabana M, Ahmed A, Alqahtani SS, Alqahtani AS, Alqahtani AM, Ramadan AM, Ahmed ME, Ali HS, Bashir A, Devesa J, Cardone RA, Ibrahim ME, Schwartz L, Reshkin SJ. Pathogenesis and Management of COVID-19. J Xenobiot 2021; 11:77-93. [PMID: 34063739 PMCID: PMC8163157 DOI: 10.3390/jox11020006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/11/2021] [Accepted: 05/12/2021] [Indexed: 12/13/2022] Open
Abstract
COVID-19, occurring due to SARS-COV-2 infection, is the most recent pandemic disease that has led to three million deaths at the time of writing. A great deal of effort has been directed towards altering the virus trajectory and/or managing the interactions of the virus with its subsequent targets in the human body; these interactions can lead to a chain reaction-like state manifested by a cytokine storm and progress to multiple organ failure. During cytokine storms the ratio of pro-inflammatory to anti-inflammatory mediators is generally increased, which contributes to the instigation of hyper-inflammation and confers advantages to the virus. Because cytokine expression patterns fluctuate from one person to another and even within the same person from one time to another, we suggest a road map of COVID-19 management using an individual approach instead of focusing on the blockbuster process (one treatment for most people, if not all). Here, we highlight the biology of the virus, study the interaction between the virus and humans, and present potential pharmacological and non-pharmacological modulators that might contribute to the global war against SARS-COV-2. We suggest an algorithmic roadmap to manage COVID-19.
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Affiliation(s)
- Khalid O. Alfarouk
- Hala Alfarouk Cancer Center, Department of Evolutionary Pharmacology and Tumor Metabolism, Khartoum 11123, Sudan;
- Research Center, Zamzam University College, Khartoum 11123, Sudan;
| | - Sari T. S. AlHoufie
- Medical Laboratories Technology Department, College of Applied Medical Sciences, Taibah University, Medina 42353, Saudi Arabia;
| | - Samrein B. M. Ahmed
- College of Medicine, University of Sharjah, Sharjah 27272, United Arab Emirates;
| | - Mona Shabana
- Pharmacology Department, Faculty of Medicine, Fayoum University, Fayoum 63514, Egypt;
| | - Ahmed Ahmed
- Department of Oesphogastric and General Surgery, University Hospitals of Leicester, Leicester LE5 4PW, UK;
| | - Saad S. Alqahtani
- Pharmacy Practice Research Unit, Clinical Pharmacy Department, College of Pharmacy, Jazan University, Jazan 45142, Saudi Arabia;
| | - Ali S. Alqahtani
- Department of Medical Laboratories Sciences, College of Applied Medical Sciences, Najran University, Najran 66446, Saudi Arabia;
| | - Ali M. Alqahtani
- Department of Pharmacology, College of Pharmacy, King Khalid University, Abha 61421, Saudi Arabia;
| | - AbdelRahman M. Ramadan
- Department of Preventive Dental Sciences, Ibn Sina National College, Jeddah 22421, Saudi Arabia;
| | - Mohamed E. Ahmed
- Research Center, Zamzam University College, Khartoum 11123, Sudan;
- Department of Surgery, Faculty of Medicine Al-Neelain University, Khartoum 11111, Sudan
| | - Heyam S. Ali
- Faculty of Pharmacy, University of Khartoum, P. O. Box 321, Khartoum 11111, Sudan;
| | - Adil Bashir
- Hala Alfarouk Cancer Center, Department of Evolutionary Pharmacology and Tumor Metabolism, Khartoum 11123, Sudan;
- Institute of Endemic Diseases, University of Khartoum, Khartoum 11111, Sudan;
| | - Jesus Devesa
- Scientific Direction, Foltra Medical Centre, 15886 Teo, Spain;
| | - Rosa A. Cardone
- Department of Biosciences, Biotechnologies, and Biopharmaceutics, University of Bari, 70126 Bari, Italy; (R.A.C.); (S.J.R.)
| | - Muntaser E. Ibrahim
- Institute of Endemic Diseases, University of Khartoum, Khartoum 11111, Sudan;
| | | | - Stephan J. Reshkin
- Department of Biosciences, Biotechnologies, and Biopharmaceutics, University of Bari, 70126 Bari, Italy; (R.A.C.); (S.J.R.)
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