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Paterno G, Palmieri R, Tesei C, Nunzi A, Ranucci G, Mallegni F, Moretti F, Meddi E, Tiravanti I, Marinoni M, Page C, Fagiolo S, Buzzatti E, Secchi R, Gurnari C, Maurillo L, Buccisano F, Venditti A, Del Principe MI. The ISTH DIC-score predicts early mortality in patients with non-promyelocitic acute myeloid leukemia. Thromb Res 2024; 236:30-36. [PMID: 38387301 DOI: 10.1016/j.thromres.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 02/13/2024] [Accepted: 02/15/2024] [Indexed: 02/24/2024]
Abstract
Coagulation disorders frequently complicate the clinical course of acute myeloid leukemia (AML) patients. This study examined the frequency and prognostic significance, with regards of early mortality, of the presence of overt disseminated intravascular coagulation (DIC) at AML diagnosis and its correlation with clinical and biological characteristics. A retrospective analysis of 351 newly diagnosed non-promyelocytic AML patients was conducted, utilizing the 2018 ISTH DIC-Score criteria to evaluate the presence of overt DIC at AML onset. The study cohort had a median age of 65 years with a predominance of male gender (59 %). Overt DIC was present in 21 % of cases and was associated with advanced age, comorbidities, poor performance status, hyperleukocytosis, LDH levels, NPM1 mutations, expression of CD33 and CD4, and lack of expression of CD34. With a median follow-up of 72 months (3-147 months), the 6-year overall survival (OS) was 17.4 %, with patients having overt DIC showing significantly poorer outcomes (7.2 % compared to 20.3 % of those without DIC, p < 0.001). Patients with overt DIC showed markedly high early mortality rates at 30 (42.5 % vs 8 %), 60 (49.3 % vs 16.9 %), and 120 days (64.4 % vs 25.6 %) from disease onset. In multivariate analysis overt DIC retained its independent prognostic value for early mortality. In conclusion, the prevalence and clinical relevance of DIC in non-promyelocytic AML is not negligible, underlining its potential as an unfavorable prognostic marker. In newly diagnosed patients with AML, early recognition and measure to counteract coagulation disturbances might help mitigate the elevated mortality risk associated with DIC.
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Affiliation(s)
| | - Raffaele Palmieri
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Cristiano Tesei
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Andrea Nunzi
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Giorgia Ranucci
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Flavia Mallegni
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Federico Moretti
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Elisa Meddi
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Ilaria Tiravanti
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Massimiliano Marinoni
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Camilla Page
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Solaria Fagiolo
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Elisa Buzzatti
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Roberto Secchi
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Carmelo Gurnari
- Hematology, Fondazione Policlinico Tor Vergata, Rome, Italy; Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy; Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Luca Maurillo
- Hematology, Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Francesco Buccisano
- Hematology, Fondazione Policlinico Tor Vergata, Rome, Italy; Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Adriano Venditti
- Hematology, Fondazione Policlinico Tor Vergata, Rome, Italy; Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy.
| | - Maria Ilaria Del Principe
- Hematology, Fondazione Policlinico Tor Vergata, Rome, Italy; Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
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2
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Zhao S, Ge Y, Li Z, Yang T. Influence of cytokines on early death and coagulopathy in newly diagnosed patients with acute promyelocytic leukemia. Front Immunol 2023; 14:1100151. [PMID: 37063881 PMCID: PMC10103902 DOI: 10.3389/fimmu.2023.1100151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 03/06/2023] [Indexed: 04/03/2023] Open
Abstract
IntroductionAcute promyelocytic leukemia (APL) is a subtype of acute myeloid leukemia (AML) with a better prognosis. But early death (ED) rate remains high. APL patients are simultaneously accompanied by coagulopathy and hyperinflammation at the onset. It is not known what effects cytokines have on ED and coagulopathy in these patients. Therefore, the purposes of this study are to explore the clinical differences between APL and other types of AML, the link between cytokines and coagulopathy in newly diagnosed APL, and their roles in the ED for APL.MethodsThis study retrospectively collected the information of 496 adult patients with AML (age ≥14 years at admission) newly diagnosed in the First People's Hospital of Yunnan Province between January 2017 to February 2022, including 115 APL patients. The difference of clinical manifestations between two groups [APL and AML (non-APL)] was statistically analyzed. Then, the factors affecting ED in APL patients were screened, and the possible pathways of their influence on ED were further analyzed.ResultsThe results indicate APL at the onset have a younger age and higher incidence of ED and DIC than other types of AML. Intracranial hemorrhage (ICH), age, and PLT count are found to be independent factors for ED in newly APL, among which ICH is the main cause of ED, accounting for 61.54% (8/13). The levels of cytokines in newly APL are generally higher than that in AML (non-APL), and those in the group of ED for APL were widely more than the control group. IL-17A and TNF-β are directly related to the ED in newly APL, especially IL-17A, which also affects ICH in these patients. Moreover, the increase of IL-17A and TNF-β cause the prolongation of PT in APL patients, which reflected the exogenous coagulation pathway. However, they have no effect on APTT prolongation and FIB reduction. Thus, it is speculated that IL-17A leads to early cerebral hemorrhage death in newly APL by inducing tissue factor (TF) overexpression to initiate exogenous coagulation and further leading to excessive depletion of clotting factors and prolongation of PT.ConclusionsIn conclusion, compared with other types of AML, APL patients have a younger age of onset and high inflammatory state, and are more likely to develop into DIC and die early. Age, and PLT count at diagnosis are independent factors for ED of APL, especially ICH. IL-17A is confirmed to be an independent risk factor for ED and ICH of newly APL. Hence, IL-17A may serve as a predictor of ED in newly diagnosed APL patients, and controlling its expression probably reduce ED in these patients.
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Affiliation(s)
- Shixiang Zhao
- Faculty of Life Science and Technology, Kunming University of Science and Technology, Kunming, China
- Department of Hematology, The First People’s Hospital of Yunnan Province, Kunming, China
- Yunnan Blood Disease Clinical Medical Center, The First People’s Hospital of Yunnan Province, Kunming, China
- Yunnan Blood Disease Hospital, The First People’s Hospital of Yunnan Province, Kunming, China
| | - Yuanyuan Ge
- Department of Cardiology, 920th Hospital of Joint Logistics Support Force, Kunming, China
| | - Zengzheng Li
- Department of Hematology, The First People’s Hospital of Yunnan Province, Kunming, China
- Yunnan Blood Disease Clinical Medical Center, The First People’s Hospital of Yunnan Province, Kunming, China
- Yunnan Blood Disease Hospital, The First People’s Hospital of Yunnan Province, Kunming, China
| | - Tonghua Yang
- Faculty of Life Science and Technology, Kunming University of Science and Technology, Kunming, China
- Department of Hematology, The First People’s Hospital of Yunnan Province, Kunming, China
- Yunnan Blood Disease Clinical Medical Center, The First People’s Hospital of Yunnan Province, Kunming, China
- Yunnan Blood Disease Hospital, The First People’s Hospital of Yunnan Province, Kunming, China
- *Correspondence: Tonghua Yang,
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3
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Prevalence and risk factors of disseminated intravascular coagulation in childhood acute lymphoblastic leukemia. Pediatr Res 2023:10.1038/s41390-023-02475-8. [PMID: 36670158 DOI: 10.1038/s41390-023-02475-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND Few studies have examined disseminated intravascular coagulation (DIC) in childhood acute lymphoblastic leukemia (ALL). Our aims were to evaluate the prevalence, risk factors and outcomes of DIC at ALL presentation and during induction chemotherapy. METHODS The medical records of ALL patients aged <15 years were retrospectively reviewed. Logistic regression analysis was used to identify risk factors. The Kaplan-Meier method was used to depict survival. RESULTS Of the 312 patients, 48 (15.4%) and 76 (24.4%) had DIC at presentation and during induction chemotherapy, respectively. Risk factors for DIC at presentation (OR and 95% CI) were antibiotics prior to admission 2.34 (1.17-4.89), white blood cell count ≥100 × 109/L 2.39 (1.04-5.72), platelets <100 × 109/L 5.44 (1.84-23.4) and high National Cancer Institute (NCI) risk 2.68 (1.08-6.62). Risk factors for DIC during induction chemotherapy were antibiotics prior to admission 1.86 (1.07-3.27), high peripheral blasts 1.01 (1.00-1.02) and transaminitis 2.02 (1.18-3.48). Five-year overall survival of patients who had DIC was significantly lower than those who did not (45.0% vs. 74.1%, p <0.001). CONCLUSION Antibiotics prior to admission, hyperleukocytosis, thrombocytopenia and high NCI risk were risk factors of DIC at presentation. Antibiotics prior to admission, high peripheral blasts and transaminitis were risk factors of DIC during induction chemotherapy. IMPACT There are only two studies, both published before 2000, evaluating risk factors of DIC in pediatric ALL patients without reporting outcomes. DIC was associated with lower remission and survival rates in pediatric ALL patients. We identified the risk factors of DIC at presentation as antibiotics prior to admission, hyperleukocytosis, thrombocytopenia and high NCI risk. The risk factors of DIC during induction chemotherapy were antibiotics prior to admission, high peripheral blasts and aspartate transaminitis. Pediatric ALL patients who have the aforementioned risk factors should be closely monitored for DIC secondary to infection, and early treatment with appropriate antimicrobial agents is recommended.
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Muacevic A, Adler JR, Alsabban HH, Al-Marzouki A, Bahashawan S, Daous Y. Rare Presentation of FLT3-ITD-Positive Acute Myeloid Leukemia With Monocytic Differentiation: A Case Report. Cureus 2022; 14:e32988. [PMID: 36582421 PMCID: PMC9793438 DOI: 10.7759/cureus.32988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2022] [Indexed: 12/28/2022] Open
Abstract
Acute myeloid leukemia (AML) is a hematological malignancy that affects adults and has various presenting symptoms, the most common being shortness of breath, bleeding, and infection. Thrombosis is also believed to be a rare presenting symptom of AML; however, information about the association between AML and thrombosis is scarce. Here, we report the case of a 27-year-old female who presented with extensive coagulation disturbances leading to various thromboembolic complications (including multiple strokes and renal and splenic infarcts) and was eventually diagnosed with AML. Owing to the patient's functional status at diagnosis, chemotherapy induction was withheld, and close observation along with supportive treatment was initiated. The findings, in this case, provide useful information on the presentation of such unusual cases, so we aim to enrich and contribute to medical evolution.
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5
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Hematology Emergencies in Adults With Critical Illness. Chest 2022; 162:120-131. [DOI: 10.1016/j.chest.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/20/2022] [Accepted: 02/07/2022] [Indexed: 11/18/2022] Open
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6
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Versluis J, Pandey M, Flamand Y, Haydu JE, Belizaire R, Faber M, Vedula RS, Charles A, Copson KM, Shimony S, Rozental A, Bendapudi PK, Wolach O, Griffiths EA, Thompson JE, Stone RM, DeAngelo DJ, Neuberg D, Luskin MR, Wang ES, Lindsley RC. Prediction of life-threatening and disabling bleeding in patients with AML receiving intensive induction chemotherapy. Blood Adv 2022; 6:2835-2846. [PMID: 35081257 PMCID: PMC9092400 DOI: 10.1182/bloodadvances.2021006166] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/11/2022] [Indexed: 11/20/2022] Open
Abstract
Bleeding in patients with acute myeloid leukemia (AML) receiving intensive induction chemotherapy is multifactorial and contributes to early death. We sought to define the incidence and risk factors of grade 4 bleeding to support strategies for risk mitigation. Bleeding events were retrospectively assessed between day-14 and day +60 of induction treatment according to the World Health Organization (WHO) bleeding assessment scale, which includes grade 4 bleeding as fatal, life-threatening, retinal with visual impairment, or involving the central nervous system. Predictors were considered pretreatment or prior to grade 4 bleeding. Using multivariable competing-risk regression analysis with grade 4 bleeding as the primary outcome, we identified risk factors in the development cohort (n = 341), which were tested in an independent cohort (n = 143). Grade 4 bleeding occurred in 5.9% and 9.8% of patients in the development and validation cohort, respectively. Risk factors that were independently associated with grade 4 bleeding included baseline platelet count ≤40 × 109/L compared with >40 × 109/L, and baseline international normalized ratio of prothrombin time (PT-INR) >1.5 or 1.3 > 1.5 compared with ≤1.3. These variables were allocated points, which allowed for stratification of patients with low- and high-risk for grade 4 bleeding. Cumulative incidence of grade 4 bleeding at day+60 was significantly higher among patients with high- vs low-risk (development: 31 ± 7% vs 2 ± 1%; P < .001; validation: 25 ± 9% vs 7 ± 2%; P = .008). In both cohorts, high bleeding risk was associated with disseminated intravascular coagulation (DIC) and proliferative disease. We developed and validated a simple risk model for grade 4 bleeding, which enables the development of rational risk mitigation strategies to improve early mortality of intensive induction treatment.
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Affiliation(s)
- Jurjen Versluis
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Manu Pandey
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Yael Flamand
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - J. Erika Haydu
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Roger Belizaire
- Division of Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Mark Faber
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Rahul S. Vedula
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Anne Charles
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Kevin M. Copson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Shai Shimony
- Institute of Hematology, Davidoff Cancer Centre, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel
- Sackler Medical School, Tel Aviv University, Tel Aviv, Israel; and
| | - Alon Rozental
- Institute of Hematology, Davidoff Cancer Centre, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel
- Sackler Medical School, Tel Aviv University, Tel Aviv, Israel; and
| | - Pavan K. Bendapudi
- Division of Hematology and Blood Transfusion Service, Massachusetts General Hospital, Boston, MA
| | - Ofir Wolach
- Institute of Hematology, Davidoff Cancer Centre, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel
- Sackler Medical School, Tel Aviv University, Tel Aviv, Israel; and
| | | | - James E. Thompson
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Richard M. Stone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Daniel J. DeAngelo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Donna Neuberg
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Marlise R. Luskin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Eunice S. Wang
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - R. Coleman Lindsley
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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7
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Martella F, Cerrano M, Di Cuonzo D, Secreto C, Olivi M, Apolito V, D'Ardia S, Frairia C, Giai V, Lanzarone G, Urbino I, Freilone R, Giaccone L, Busca A, Dellacasa CM, Audisio E, Ferrero D, Beggiato E. Frequency and risk factors for thrombosis in acute myeloid leukemia and high-risk myelodysplastic syndromes treated with intensive chemotherapy: a two centers observational study. Ann Hematol 2022; 101:855-867. [PMID: 35128571 DOI: 10.1007/s00277-022-04770-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 01/21/2022] [Indexed: 12/17/2022]
Abstract
The frequency of thrombosis in AML has been evaluated only in a few studies and no validated predictive model is currently available. Recently, DIC score was shown to identify patients at higher thrombotic risk. We aimed to evaluate the frequency of thromboembolism in AML patients treated with intensive chemotherapy and to assess the ability of genetic and clinical factors to predict the thrombotic risk. We performed a retrospective observational study including 222 newly diagnosed adult AML (210) and high-risk MDS (12), treated with intensive chemotherapy between January 2013 and February 2020. With a median follow-up of 44 months, we observed 50 thrombotic events (90% were venous, VTE). The prevalence of thrombosis was 22.1% and the 6-months cumulative incidence of thrombosis was 10%. The median time to thrombosis was 84 days and 52% of the events occurred within 100 days from AML diagnosis. Khorana and DIC score failed to stratify patients according to their thrombotic risk. Only history of a thrombotic event (p = 0.043), particularly VTE (p = 0.0053), platelet count above 100 × 109/L at diagnosis (p = 0.036) and active smoking (p = 0.025) significantly and independently increased the risk of thrombosis, the latter particularly of arterial events. AML genetic profile did not affect thrombosis occurrence. Results were confirmed considering only thromboses occurring within day 100 from diagnosis. DIC score at diagnosis, but not thrombosis, was independently associated with reduced survival (p = 0.004). Previous VTE, platelet count above 100 × 109/L and active smoking were the only factors associate with increased thrombotic risk in AML patients treated intensively, but further studies are needed to validate these results.
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Affiliation(s)
- Federica Martella
- Department of Molecular Biotechnology and Health Sciences, Division of Hematology, University of Torino, Turin, Italy
| | - Marco Cerrano
- Department of Oncology, Division of Hematology, AOU Città della Salute e della Scienza di Torino, Presidio Molinette, 10126, Turin, Italy.
| | - Daniela Di Cuonzo
- Unit of Clinical Epidemiology, CPO, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Carolina Secreto
- Department of Molecular Biotechnology and Health Sciences, Division of Hematology, University of Torino, Turin, Italy
| | - Matteo Olivi
- Department of Molecular Biotechnology and Health Sciences, Division of Hematology, University of Torino, Turin, Italy
| | - Vincenzo Apolito
- Department of Molecular Biotechnology and Health Sciences, Division of Hematology, University of Torino, Turin, Italy
| | - Stefano D'Ardia
- Department of Oncology, Division of Hematology, AOU Città della Salute e della Scienza di Torino, Presidio Molinette, 10126, Turin, Italy
| | - Chiara Frairia
- Department of Oncology, Division of Hematology, AOU Città della Salute e della Scienza di Torino, Presidio Molinette, 10126, Turin, Italy
| | - Valentina Giai
- Department of Oncology, Division of Hematology, AOU Città della Salute e della Scienza di Torino, Presidio Molinette, 10126, Turin, Italy
| | - Giuseppe Lanzarone
- Department of Molecular Biotechnology and Health Sciences, Division of Hematology, University of Torino, Turin, Italy
| | - Irene Urbino
- Department of Molecular Biotechnology and Health Sciences, Division of Hematology, University of Torino, Turin, Italy
| | - Roberto Freilone
- Department of Oncology, Division of Hematology, AOU Città della Salute e della Scienza di Torino, Presidio Molinette, 10126, Turin, Italy
| | - Luisa Giaccone
- Department of Oncology, SSD Trapianto Allogenico, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Alessandro Busca
- Department of Oncology, SSD Trapianto Allogenico, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Chiara Maria Dellacasa
- Department of Oncology, SSD Trapianto Allogenico, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Ernesta Audisio
- Department of Oncology, Division of Hematology, AOU Città della Salute e della Scienza di Torino, Presidio Molinette, 10126, Turin, Italy
| | - Dario Ferrero
- Department of Molecular Biotechnology and Health Sciences, Division of Hematology, University of Torino, Turin, Italy
| | - Eloise Beggiato
- Department of Molecular Biotechnology and Health Sciences, Division of Hematology, University of Torino, Turin, Italy
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8
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Yoshinobu S, Honda G, Kawano N, Uchiyama T, Kawasugi K, Madoiwa S, Takezako N, Takayuki I, Wada H. Clinical Features of Disseminated Intravascular Coagulation According to the French-American-British Classification in Patients With Acute Leukemia and Thrombomodulin Alfa Treatment-A Cohort Study Using a Postmarketing Surveillance Database. Clin Appl Thromb Hemost 2021; 27:10760296211054094. [PMID: 34870471 PMCID: PMC8652184 DOI: 10.1177/10760296211054094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The aims of this study were to analyze the clinical features of a large number of cases with disseminated intravascular coagulation (DIC) associated with acute leukemia and to assess the safety and efficacy of thrombomodulin alfa (TM-α) using the French-American-British (FAB) classification of hematological malignancies. We retrospectively examined 644 patients with acute leukemia in postmarketing surveillance for TM-α. M3, M2, M4, M1, and M5 subtypes of acute myeloid leukemia (AML) and L2 and L1 subtypes of acute lymphoblastic leukemia (ALL) have been found more frequently among patients with DIC. Bleeding symptoms at baseline were more frequent in M3 and M7 subtypes. Fibrinogen concentrations were lower, and plasmin-plasmin inhibitor complex values were higher in M3 and Philadelphia-positive (Ph+) ALL. Overall DIC resolution rate was 60.2%, higher in L1 and Ph+ ALL, lower in M1, and generally higher in ALL than in AML. Overall survival rate was generally high, at 79.8%, with higher rates in L3, Ph+ ALL, and M3. Regardless of FAB subgroup, TM-α showed improved bleeding symptoms and DIC scores in clinical practice for DIC patients with acute leukemia.
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Affiliation(s)
- Seki Yoshinobu
- Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Niigata, Japan
| | | | - Noriaki Kawano
- 13610Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Toshimasa Uchiyama
- 73515National Hospital Organization Takasaki General Medical Center, Gunma, Japan
| | | | | | - Naoki Takezako
- National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | | | - Hideo Wada
- Mie Prefectural General Medical Center, Mie, Japan
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9
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MacDougall K, Chukkalore D, Rehan M, Kashi M, Bershadskiy A. Acute promyelocytic leukemia presenting as recurrent venous and arterial thrombotic events: a case report and review of the literature. J Community Hosp Intern Med Perspect 2021; 11:832-838. [PMID: 34804401 PMCID: PMC8604466 DOI: 10.1080/20009666.2021.1973657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Acute promyelocytic leukemia (APL) is a distinct subtype of acute myeloid leukemia characterized by a translocation of chromosomes 15 and 17, creating an alternation in the retinoic acid receptor-alpha (RAR-alpha) gene. This leads to excessive medullary production of promyelocytic blasts, which are frequently associated with the hemorrhagic complications seen in APL. In contrast, APL-associated thrombosis occurs much less frequently and is an underappreciated life-threatening manifestation of the disease. Most thrombotic events occur during induction chemotherapy with all-transretinoic acid and are rarely seen as the initial presentation on APL. Here we report an exceedingly rare case of a patient with recurrent venous and arterial thrombotic events, including deep vein thrombosis, bilateral segmental pulmonary embolism, an ischemic stroke, splenic infarcts, and renal infarcts, later found to have APL. We aim to discuss the most recent understanding of the pathogenesis of APL-associated thrombosis and to summarize the literature of this rare presentation of APL.
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Affiliation(s)
- Kira MacDougall
- Department of Internal Medicine, Zucker School of Medicine at Hofstra/Northwell at Staten Island University Hospital, New York, NY, USA
| | - Divya Chukkalore
- Department of Internal Medicine, Zucker School of Medicine at Hofstra/Northwell at Staten Island University Hospital, New York, NY, USA
| | - Maryam Rehan
- Division of Hematology & Medical Oncology, Zucker School of Medicine at Hofstra/Northwell at Staten Island University Hospital, New York, NY, USA
| | - Meena Kashi
- Department of Pathology, Zucker School of Medicine at Hofstra/Northwell at Staten Island University Hospital, New York, NY, USA
| | - Alexander Bershadskiy
- Division of Hematology & Medical Oncology, Zucker School of Medicine at Hofstra/Northwell at Staten Island University Hospital, New York, NY, USA
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10
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Kumar K, Patel S, Chiang KY, Solh Z, Saleh M, Ernewein L, Decourcy M, Laudenbach L, Tole S. Hiding in plain sight: Diagnosing congenital dysfibrinogenemia in a child presenting with acute myeloid leukemia. Pediatr Blood Cancer 2021; 68:e29050. [PMID: 33822462 DOI: 10.1002/pbc.29050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 11/06/2022]
Affiliation(s)
- Kriti Kumar
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Serina Patel
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.,Division of Hematology/Oncology, Department of Pediatrics, London Health Sciences Centre, London, Ontario, Canada
| | - K Y Chiang
- Division of Hematology/Oncology, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ziad Solh
- Department of Pathology and Laboratory Medicine (PaLM), Western University, London, Ontario, Canada.,Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Maha Saleh
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.,Medical Genetics Program of Southwestern Ontario, London Health Sciences Centre, London, Ontario, Canada
| | - Lauren Ernewein
- Children's Hospital, London HealthSciences Centre, London, Ontario, Canada
| | - MaryJo Decourcy
- Children's Hospital, London HealthSciences Centre, London, Ontario, Canada
| | - Lori Laudenbach
- Children's Hospital, London HealthSciences Centre, London, Ontario, Canada
| | - Soumitra Tole
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.,Division of Hematology/Oncology, Department of Pediatrics, London Health Sciences Centre, London, Ontario, Canada
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11
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Pathophysiology of Coagulopathy in Hematological Malignancies and in COVID-19. Hemasphere 2021; 5:e571. [PMID: 34095755 PMCID: PMC8171377 DOI: 10.1097/hs9.0000000000000571] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 04/07/2021] [Indexed: 01/08/2023] Open
Abstract
Many severe illnesses with a systemic impact may cause activation of coagulation. While systemic activation of coagulation leads to a coagulopathy that follows many common activation pathways and failure of endogenous regulatory anticoagulant systems, underlying conditions may utilize distinctive pathogenetic routes and may vary in clinical manifestations of the coagulopathy. The coagulation derangement associated with hematological malignancies and the coagulopathy of coronavirus disease 2019 (COVID-19) clearly demonstrate such differences. Malignancies are associated with venous thromboembolism due to the biological effect of malignant cells, frequent medical interventions, or the presence of indwelling vascular catheters. The underlying pathogenesis of cancer-associated coagulopathy relies on tissue factor-mediated activation of coagulation, cytokine-controlled defective anticoagulant pathways, fibrinolytic changes, and dysfunctional endothelium. There is an additional risk caused by anti-cancer agents including chemotherapy and immunotherapy. The underlying pathogenetic factor that contributes to the thrombotic risk associated with chemotherapy is endothelial cell injury (or loss of protection of endothelial integrity, for example, by vascular endothelial growth factor inhibition). In addition, individual anti-cancer agents may have specific prothrombotic effects. One of the remarkable features of severe COVID-19 infections is a coagulopathy that mimics but is not identical to the disseminated intravascular coagulation and thrombotic microangiopathy and has been identified as a strong marker for an adverse outcome. Severe COVID-19 infections cause inflammation-induced changes in coagulation in combination with severe endothelial cell injury. This coagulopathy likely contributes to pulmonary microvascular thrombosis, bronchoalveolar fibrin deposition (which is a hallmark of acute respiratory distress syndrome) and venous thromboembolic complications.
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12
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Ten Cate H, Leader A. Management of Disseminated Intravascular Coagulation in Acute Leukemias. Hamostaseologie 2021; 41:120-126. [PMID: 33860520 DOI: 10.1055/a-1393-8302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Disseminated intravascular coagulation (DIC) is characterized by the intravascular activation of coagulation with loss of localization arising from different causes, and is diagnosed using scoring systems which rely upon the presence of an underlying disorder compatible with DIC alongside hemostatic derangements such as low platelet count, prolonged prothrombin time, and elevated fibrinogen degradation products. DIC is common in patients with acute leukemia, with prevalence ranging from 17 to 100% in acute promyelocytic leukemia (APL) and 8.5 to 25% in acute lymphoblastic leukemia (ALL) and non-APL acute myeloid leukemia (AML). The pathophysiology is complex and varies between the leukemia subtypes, and is not fully reflected by the laboratory markers currently used to classify DIC. Similarly, the clinical consequence of DIC in acute leukemia also varies across the types of leukemia. DIC is primarily associated with bleeding in APL, while thrombosis is the dominant phenotype in ALL and non-APL AML. The cornerstone of managing DIC is the treatment of the underlying disease, as exemplified by the important role of early administration of all-trans retinoic acid in APL. Other aspects of management focus on supportive care aimed at minimizing the risk of bleeding, via transfusion of blood products. The use of blood products is more liberal in APL, due to the hemorrhagic phenotype and unacceptably high rates of early hemorrhagic death. This review will focus on the pathophysiology, risk factors, clinical implications, and the management of DIC in patients across the spectrum of acute leukemias.
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Affiliation(s)
- Hugo Ten Cate
- Department of Internal Medicine and Thrombosis Expert Center, Maastricht University Medical Center, Maastricht, The Netherlands.,CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Avi Leader
- CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Hematology Institute, Rabin Medical Center, Petah Tikva, Israel
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13
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Khadka S, Solanki D, Singh J, Kichloo A, Patel NR, Sharma P, Chugh S, Solanki S. Trends and outcomes of venous thromboembolism in adult hospitalizations with acute myeloid leukemia: analysis of nationwide inpatient sample from 2010 to 2014. Postgrad Med 2020; 133:160-165. [PMID: 33305685 DOI: 10.1080/00325481.2020.1863717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background: Venous thromboembolism (VTE) occurs frequently in acute myeloid leukemia (AML) patients. There are no population-based studies from the United States (U.S.) analyzing this association. The study aims to analyze the trends, predictors of mortality, and outcomes of VTE in AML patients.Methods: We analyzed the publicly available Nationwide Inpatient Sample (NIS) for years 2010-2014. Hospitalizations due to AML were identified by previously validated International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes as the primary diagnosis. VTE was identified by ICD-9-CM codes as secondary diagnosis. Hospitalizations with age less than 18 years of age were excluded. The trends and outcomes were determined using Chi-squared (χ2) test and multivariate regression models.Results: From 2010 to 2014, there were 313,282 hospitalizations with a primary diagnosis of AML and 1,633 hospitalizations (0.1%) had VTE as a concurrent diagnosis. There was a significant increase in the proportion of AML hospitalizations with VTE from 0.47% in 2010 to 0.56% in 2014 (P = 0.014). Multivariable regression analysis showed that the odds of in-hospital mortality were not higher in AML hospitalizations with VTE (odds ratio [OR] 1.11; 95% confidence interval [CI] 0.81-1.52; P = 0.5) than those without VTE. Age group above 84 years carried the highest risk of mortality (OR 3.20; 95% CI 2.77-3.70; P < 0.0001) in AML-VTE patients. Black (OR 1.23; 95% CI 1.13-1.35; P < 0.0001) and uninsured patients (OR 1.50; 95% CI 1.31-1.73; P < 0.0001) were at significantly higher odds of in-hospital mortality amongst the AML-VTE hospitalizations.Conclusion: The proportion of AML hospitalizations with VTE continues to rise in the U.S. After adjusting for confounders, increasing age, Black race, and lack of insurance were found to have higher risk of in-hospital mortality in the AML-VTE cohort. The odds of in-hospital mortality in AML hospitalizations with VTE are not higher than those without VTE.
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Affiliation(s)
- Sushmita Khadka
- Department of Medicine, Guthrie Robert Packer Hospital, Sayre, PA, USA
| | | | - Jagmeet Singh
- Department of Medicine, Guthrie Robert Packer Hospital, Sayre, PA, USA
| | - Asim Kichloo
- Department of Medicine, Central Michigan University, Saginaw, MI, USA
| | - Neil R Patel
- Division of Cardiology, The Wright Center for Graduate Medical Education, Scranton, PA, USA
| | - Purnima Sharma
- Internal Medicine Associates, University of Arizona, Phoenix, AZ, USA
| | - Savneek Chugh
- Division of Nephrology, Westchester Medical Center, Valhalla, NY, USA
| | - Shantanu Solanki
- Department of Medicine, Geisinger Commonwealth School of Medicine, Scranton, PA, USA
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14
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Wang TF, Makar RS, Antic D, Levy JH, Douketis JD, Connors JM, Carrier M, Zwicker JI. Management of hemostatic complications in acute leukemia: Guidance from the SSC of the ISTH. J Thromb Haemost 2020; 18:3174-3183. [PMID: 33433069 PMCID: PMC7909744 DOI: 10.1111/jth.15074] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/17/2020] [Accepted: 08/20/2020] [Indexed: 11/29/2022]
Abstract
Patients with acute leukemia frequently develop thrombocytopenia and hemostatic complications caused by coagulopathy. Coagulopathy complicates the management of these patients and can lead to significant morbidity and mortality. This guidance document aims to review and provide guidance on the management of hemostatic complications in adult patients with acute leukemia, addressing four main issues, including platelet transfusion, disseminated intravascular coagulation, L-asparaginase-related hypofibrinogenemia, and the use of antifibrinolytic agents.
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Affiliation(s)
- Tzu-Fei Wang
- Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Robert S. Makar
- Blood Transfusion Service, Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Darko Antic
- Clinic for Hematology, Clinical Center Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Jerrold H. Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
| | | | - Jean M. Connors
- Division of Hematology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Marc Carrier
- Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Jeffrey I. Zwicker
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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15
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Abstract
The recognition and management of oncologic emergencies are becoming increasingly relevant in the intensive care unit, particularly in the era of novel biologic therapies. Early recognition and multidisciplinary collaboration are essential to improving patient outcomes. This article discusses aspects of diagnosis and management for important malignancy-associated emergencies.
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Affiliation(s)
- Jenna Spring
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Sinai Health System and University Health Network, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D108, Toronto, Ontario M4N 3M5, USA. https://twitter.com/jennaspring
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Sinai Health System and University Health Network, Toronto, Ontario, Canada; Mount Sinai Hospital, 600 University Avenue, Suite 18-206, Toronto, Ontario M5G 1X5, Canada.
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16
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Kongstad C, Mikkelsen TS, Hvas AM. Disseminated intravascular coagulation in children with cancer: A systematic review. Pediatr Hematol Oncol 2020; 37:390-411. [PMID: 32202958 DOI: 10.1080/08880018.2020.1733717] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Disseminated intravascular coagulation (DIC) may complicate malignant disease. Numerous studies have investigated this association in adults, however only sparse knowledge exists on DIC in pediatric cancer patients. The objective of this article was to systematically review the literature regarding DIC in pediatric malignancies. PubMed and Embase were searched for relevant articles on January 31, 2020. In total, 6,070 articles were identified out of which 24 articles met inclusion and exclusion criteria. These were included in the qualitative synthesis. The National Institutes of Health's Quality Assessment Tools was used to assess bias in the included articles. The studies were of only moderate quality mainly based on medical charts and demonstrated high heterogeneity, especially as regards to diagnostic criteria. DIC was reported most frequently in patients with acute leukemia, particularly the subtype acute promyelocytic leukemia (APL). Standard coagulation parameters were used as diagnostic laboratory tests supporting the diagnosis of DIC. Hemorrhage was the predominant clinical manifestation, whereas thromboembolic events and organ failure were reported less frequently. Unfractionated heparin, platelet concentrate and fresh frozen plasma were the most frequently used supportive treatment agents. Hemorrhage accounted for the majority of deaths in children with acute leukemia and solid tumors. In conclusion, only a limited number of studies, being heterogenous and of moderate quality, have investigated DIC in pediatric malignancy. Notably, this entity seems to be complicated mainly by hemorrhage. High quality studies are needed to evaluate diagnosis, clinical manifestations and optimal treatment of DIC in childhood cancers.
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Affiliation(s)
- Christine Kongstad
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Torben Stamm Mikkelsen
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
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17
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Guo Z, Chen X, Tan Y, Xu Z, Xu L. Coagulopathy in cytogenetically and molecularly distinct acute leukemias at diagnosis: Comprehensive study. Blood Cells Mol Dis 2020; 81:102393. [DOI: 10.1016/j.bcmd.2019.102393] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/20/2019] [Accepted: 11/28/2019] [Indexed: 11/24/2022]
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18
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Abstract
Cancer can be associated with several distinct coagulation defects which can lead to bleeding complications. The primary hyperfibrinolytic syndrome associated with acute promyelocytic leukemia has been well recognized and is one of the most severe bleeding disorders. Acquired hemophilia, while rare and not only seen in the oncology setting, can be triggered by a malignancy and must be promptly recognized in order to prevent catastrophic hemorrhage. Other, less serious coagulopathic states have been linked to cancer, including acquired von Willebrand disease. Finally, several anti-neoplastic drugs can alter hemostasis and increase the risk of bleeding. A good understanding of this field can help mitigate the risk of complications in the cancer patient.
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Affiliation(s)
- Simon Mantha
- Department of Medicine, Hematology Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
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19
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[Clinical evaluation of Chinese disseminated intravascular coagulation scoring system (version 2017) in patients with acute promyelocytic leukemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 39:480-484. [PMID: 30032565 PMCID: PMC7342919 DOI: 10.3760/cma.j.issn.0253-2727.2018.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
目的 探索2017年版中国DIC诊断积分系统(CDSS)在急性早幼粒细胞白血病(APL)DIC诊断中的适用性。 方法 回顾性分析2004年1月至2018年2月就诊于中国医学科学院血液病医院并行诱导治疗的220例APL患者病历资料,采用CDSS、国际血栓与止血协会(ISTH)DIC积分系统和日本卫生福利部(JMHW)DIC积分系统分别进行评价及比较分析。 结果 220例APL患者中,男114例,女106例,中位年龄38.5(12~70)岁,其中低/中危组173例,高危组47例。11例患者诱导治疗期死亡。CDSS、ISTH、JMHW三种标准诊断DIC阳性率分别为62.27%、54.09%、69.09%。CDSS和ISTH诊断DIC的一致率为78.10%,CDSS和JMHW诊断DIC的一致率为88.32%。ROC曲线比较三者互为参照的敏感度及特异度,敏感度JMHW>CDSS>ISTH,特异度ISTH>CDSS>JMHW。CDSS DIC(+)和DIC(−)组患者PT、APTT、纤维蛋白原(FIB)、D-二聚体及纤维蛋白原/纤维蛋白降解产物(FDP)之间差异均有统计学意义(P值均<0.05);但采用ISTH诊断积分系统时DIC(−)组的D-二聚体水平高于DIC(+)组[26.3(0.6~488.7)mg/L对21.9(1.2~477.1)mg/L,χ2=1.871,P=0.002];采用JMHW诊断积分系统时DIC(+)与DIC(−)组的APTT差异无统计学意义[27.05(18.0~181.0)s对26.15(18.2~35.5)s,χ2=1.162,P=0.134]。CDSS DIC(+)和DIC(−)组患者的年龄及性别差异无统计学意义(P>0.05);单因素Logistic回归显示患者起病时WBC、骨髓中异常早幼粒细胞比例对DIC的发生存在影响(P<0.05),而多因素分析显示在CDSS中起病时WBC>3×109/L是DIC发生的独立危险因素(OR=3.525,95%CI 1.875~6.629,P<0.001)。 结论 2017年版CDSS诊断DIC的敏感度高于ISTH DIC积分系统,特异度优于JMHW DIC积分系统。CDSS较ISTH、JMHW对于DIC相关指标具有较好区分度,适用于中国APL患者的DIC诊断。
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20
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Ghaffari H, Varner JD, Petzold LR. Analysis of the role of thrombomodulin in all-trans retinoic acid treatment of coagulation disorders in cancer patients. Theor Biol Med Model 2019; 16:3. [PMID: 30764845 PMCID: PMC6376718 DOI: 10.1186/s12976-019-0099-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 01/24/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Clinical studies have shown that all-trans retinoic acid (RA), which is often used in treatment of cancer patients, improves hemostatic parameters and bleeding complications such as disseminated intravascular coagulation (DIC). However, the mechanisms underlying this improvement have yet to be elucidated. In vitro studies have reported that RA upregulates thrombomodulin (TM) expression on the endothelial cell surface. The objective of this study was to investigate how and to what extent the TM concentration changes after RA treatment in cancer patients, and how this variation influences the blood coagulation cascade. RESULTS In this study, we introduced an ordinary differential equation (ODE) model of gene expression for the RA-induced upregulation of TM concentration. Coupling the gene expression model with a two-compartment pharmacokinetic model of RA, we obtained the time-dependent changes in TM and thrombomodulin-mRNA (TMR) concentrations following oral administration of RA. Our results indicated that the TM concentration reached its peak level almost 14 h after taking a single oral dose (110 [Formula: see text]) of RA. Continuous treatment with RA resulted in oscillatory expression of TM on the endothelial cell surface. We then coupled the gene expression model with a mechanistic model of the coagulation cascade, and showed that the elevated levels of TM over the course of RA therapy with a single daily oral dose (110 [Formula: see text]) of RA, reduced the peak thrombin levels and endogenous thrombin potential (ETP) up to 50 and 49%, respectively. We showed that progressive reductions in plasma levels of RA, observed in continuous RA therapy with a once-daily oral dose (110 [Formula: see text]) of RA, did not affect TM-mediated reduction of thrombin generation significantly. This finding prompts the hypothesis that continuous RA treatment has more consistent therapeutic effects on coagulation disorders than on cancer. CONCLUSIONS Our results indicate that the oscillatory upregulation of TM expression on the endothelial cells over the course of RA therapy could potentially contribute to the treatment of coagulation abnormalities in cancer patients. Further studies on the impacts of RA therapy on the procoagulant activity of cancer cells are needed to better elucidate the mechanisms by which RA therapy improves hemostatic abnormalities in cancer.
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Affiliation(s)
- Hamed Ghaffari
- Department of Mechanical Engineering, University of California Santa Barbara, Santa Barbara, CA, 93106, USA.
| | - Jeffrey D Varner
- School of Chemical and Biomolecular Engineering, Cornell University, Ithaca, NY, 14853, USA
| | - Linda R Petzold
- Department of Mechanical Engineering, University of California Santa Barbara, Santa Barbara, CA, 93106, USA.,Department of Computer Science, University of California Santa Barbara, Santa Barbara, CA, 93106, USA
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21
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Cancer-Associated Thrombosis: An Overview of Mechanisms, Risk Factors, and Treatment. Cancers (Basel) 2018; 10:cancers10100380. [PMID: 30314362 PMCID: PMC6209883 DOI: 10.3390/cancers10100380] [Citation(s) in RCA: 322] [Impact Index Per Article: 53.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/04/2018] [Accepted: 10/07/2018] [Indexed: 12/15/2022] Open
Abstract
Cancer-associated thrombosis is a major cause of mortality in cancer patients, the most common type being venous thromboembolism (VTE). Several risk factors for developing VTE also coexist with cancer patients, such as chemotherapy and immobilisation, contributing to the increased risk cancer patients have of developing VTE compared with non-cancer patients. Cancer cells are capable of activating the coagulation cascade and other prothrombotic properties of host cells, and many anticancer treatments themselves are being described as additional mechanisms for promoting VTE. This review will give an overview of the main thrombotic complications in cancer patients and outline the risk factors for cancer patients developing cancer-associated thrombosis, focusing on VTE as it is the most common complication observed in cancer patients. The multiple mechanisms involved in cancer-associated thrombosis, including the role of anticancer drugs, and a brief outline of the current treatment for cancer-associated thrombosis will also be discussed.
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22
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Safavi M, Safaei A, Lotfi M. A rare variant of t(17;19) in a case of Philadelphia positive adult acute lymphoblastic leukemia presenting with disseminated intravascular coagulation. Blood Res 2018; 53:92-94. [PMID: 29662872 PMCID: PMC5899007 DOI: 10.5045/br.2018.53.1.92] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 08/26/2017] [Accepted: 10/11/2017] [Indexed: 12/22/2022] Open
Affiliation(s)
- Moeinadin Safavi
- Department of Molecular Pathology and Cytogenetic, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Molecular Pathology and Cytogenetic, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.,Department of Pathology, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Akbar Safaei
- Department of Molecular Pathology and Cytogenetic, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahnaz Lotfi
- Department of Hemato-Oncology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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23
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Levi M. Clinical characteristics of disseminated intravascular coagulation in patients with solid and hematological cancers. Thromb Res 2018; 164 Suppl 1:S77-S81. [DOI: 10.1016/j.thromres.2018.01.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 01/05/2018] [Accepted: 01/08/2018] [Indexed: 01/15/2023]
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24
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How I treat disseminated intravascular coagulation. Blood 2018; 131:845-854. [DOI: 10.1182/blood-2017-10-804096] [Citation(s) in RCA: 134] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 12/17/2017] [Indexed: 12/31/2022] Open
Abstract
Abstract
Disseminated intravascular coagulation (DIC) is a condition characterized by systemic activation of coagulation, potentially leading to thrombotic obstruction of small and midsize vessels, thereby contributing to organ dysfunction. At the same time, ongoing consumption of platelets and coagulation proteins results in thrombocytopenia and low concentrations of clotting factors, which may cause profuse hemorrhagic complications. DIC is always secondary to an underlying condition, such as severe infections, solid or hematologic malignancies, trauma, or obstetric calamities. A reliable diagnosis of DIC can be made through simple scoring algorithms based on readily available routine hemostatic parameters. The cornerstone of supportive treatment of this coagulopathy is management of the underlying condition. Additionally, administration of heparin may be useful, and restoration of physiological anticoagulants has been suggested, but has not been proven successful in improving clinically relevant outcomes so far. In patients with major bleeding or at risk for hemorrhagic complications, administration of platelet concentrates, plasma, or coagulation factor concentrates should be considered.
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25
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Potter TM, Rodriguez JC, Neun BW, Ilinskaya AN, Cedrone E, Dobrovolskaia MA. In Vitro Assessment of Nanoparticle Effects on Blood Coagulation. Methods Mol Biol 2018; 1682:103-124. [PMID: 29039097 DOI: 10.1007/978-1-4939-7352-1_10] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Blood clotting is a complex process which involves both cellular and biochemical components. The key cellular players in the blood clotting process are thrombocytes or platelets. Other cells, including leukocytes and endothelial cells, contribute to clotting by expressing the so-called pro-coagulant activity (PCA) complex on their surface. The biochemical component of blood clotting is represented by the plasma coagulation cascade, which includes plasma proteins also known as coagulation factors. The coordinated interaction between platelets, leukocytes, endothelial cells, and plasma coagulation factors is necessary for maintaining hemostasis and for preventing excessive bleeding. Undesirable activation of all or some of these components may lead to pathological blood coagulation and life-threatening conditions such as consumptive coagulopathy or disseminated intravascular coagulation (DIC). In contrast, unintended inhibition of the coagulation pathways may lead to hemorrhage. Thrombogenicity is the property of a test material to induce blood coagulation by affecting one or more elements of the clotting process. Anticoagulant activity refers to the property of a test material to inhibit coagulation. The tendency to cause platelet aggregation, perturb plasma coagulation, and induce leukocyte PCA can serve as an in vitro measure of a nanomaterial's likelihood to be pro- or anticoagulant in vivo. This chapter describes three procedures for in vitro analyses of platelet aggregation, plasma coagulation time, and activation of leukocyte PCA. Platelet aggregation and plasma coagulation procedures have been described earlier. The revision here includes updated details about nanoparticle sample preparation, selection of nanoparticle concentration for the in vitro study, and updated details about assay controls. The chapter is expanded to describe a method for the leukocyte PCA analysis and case studies demonstrating the performance of these in vitro assays.
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Affiliation(s)
- Timothy M Potter
- Cancer Research Technology Program¸ Nanotechnology Characterization Laboratory, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, P.O. Box B, Frederick, MD, 21702, USA
| | - Jamie C Rodriguez
- Cancer Research Technology Program¸ Nanotechnology Characterization Laboratory, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, P.O. Box B, Frederick, MD, 21702, USA
| | - Barry W Neun
- Cancer Research Technology Program¸ Nanotechnology Characterization Laboratory, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, P.O. Box B, Frederick, MD, 21702, USA
| | - Anna N Ilinskaya
- Cancer Research Technology Program¸ Nanotechnology Characterization Laboratory, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, P.O. Box B, Frederick, MD, 21702, USA
| | - Edward Cedrone
- Cancer Research Technology Program¸ Nanotechnology Characterization Laboratory, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, P.O. Box B, Frederick, MD, 21702, USA
| | - Marina A Dobrovolskaia
- Cancer Research Technology Program¸ Nanotechnology Characterization Laboratory, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, P.O. Box B, Frederick, MD, 21702, USA.
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Lad D, Jain A, Varma S. Complications and management of coagulation disorders in leukemia patients. BLOOD AND LYMPHATIC CANCER-TARGETS AND THERAPY 2017; 7:61-72. [PMID: 31360085 PMCID: PMC6467343 DOI: 10.2147/blctt.s125121] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Patients with leukemia are predisposed to various coagulation abnormalities. Thrombosis and bleeding continue to be a major cause of morbidity and mortality in leukemias. The pathophysiology of these disorders is unique, and not only the disease but also the treatment and other factors play a role. There has been an increase in the understanding of these disorders in leukemias. However, it is still difficult to predict when and which patients will have these complications. The evidence for the management of coagulation abnormalities in leukemias is still evolving and not as established as in solid malignancies. The management of these disorders is complex, and making clinical decisions is often challenging. In the era of specialization, where there are different hematologists looking after benign- and malignant-hematology patients, opinions of thrombosis experts are often sought by leukemia specialists. This review aims to bridge the gap in the knowledge of these disorders between these specialists.
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Affiliation(s)
- Deepesh Lad
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India,
| | - Arihant Jain
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India,
| | - Subhash Varma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India,
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Shahmarvand N, Oak JS, Cascio MJ, Alcasid M, Goodman E, Medeiros BC, Arber DA, Zehnder JL, Ohgami RS. A study of disseminated intravascular coagulation in acute leukemia reveals markedly elevated D-dimer levels are a sensitive indicator of acute promyelocytic leukemia. Int J Lab Hematol 2017; 39:375-383. [DOI: 10.1111/ijlh.12636] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 01/07/2017] [Indexed: 11/29/2022]
Affiliation(s)
| | - J. S. Oak
- Stanford University; Stanford CA USA
| | - M. J. Cascio
- Oregon Health and Science University; Portland OR USA
| | | | - E. Goodman
- Virginia Office of the Chief Medical Examiner; Roanoke VA USA
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Wei Q, Niu T, Wang M, Yang J, Liu P, Yi Y. A Revised Fibrinogen Cutoff Value in the Chinese Disseminated Intravascular Coagulation Scoring System May Provide a Better Prognostic Value for Hematological Malignancies. Acta Haematol 2017; 137:132-140. [PMID: 28355601 DOI: 10.1159/000456645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 01/17/2017] [Indexed: 02/05/2023]
Abstract
To retrospectively validate the prognostic value of the latest Chinese disseminated intravascular coagulation (DIC) scoring system (CDSS) in hematological malignancies, 260 patients with confirmed hematological malignancies and suspected DIC in West China Hospital between 2011 and 2015 were included in this study. We evaluated via univariate and multivariate analyses the diagnostic biomarkers, and the cutoff levels used in the CDSS, except those for fibrinogen, were found to be valid. In subgroup analyses, the value of fibrinogen was found to be mainly unfit for the acute promyelocytic leukemia group. Forty-six patients (17.7%) had elevated fibrinogen levels (>4 g/L) and tended to have a poor prognosis, and thus we redetermined the cutoff value of fibrinogen (<1 g/L or >4 g/L was defined as abnormal). As a result, all of the markers used in the CDSS had prognostic value (including for the promyelocytic leukemia group); meanwhile, this modification also resulted in a larger area under the receiver operating characteristic curve compared to the CDSS and the International Society on Thrombosis and Haemostasis score. We believe that, with regard to prognosis prediction, this cutoff value modification for fibrinogen is preferable for DIC patients with a tendency toward severe hypofibrinogenemia. However, a multicenter, prospective study is needed to validate this possibility.
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Affiliation(s)
- Qing Wei
- Department of Hematology and Research Laboratory of Hematology, West China Hospital, Sichuan University, Chengdu, China
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Yokoyama H, Takahashi N, Katsuoka Y, Inomata M, Ito T, Meguro K, Kameoka Y, Tsumanuma R, Murai K, Noji H, Ishizawa K, Ito S, Onishi Y, Harigae H. Evaluation of the safety and efficacy of recombinant soluble thrombomodulin for patients with disseminated intravascular coagulation associated with acute leukemia: multicenter prospective study by the Tohoku Hematology Forum. Int J Hematol 2017; 105:606-613. [PMID: 28176226 DOI: 10.1007/s12185-017-2190-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 01/31/2017] [Accepted: 01/31/2017] [Indexed: 11/28/2022]
Abstract
It has been suggested that use of recombinant soluble thrombomodulin (rTM) is superior to conventional drugs in treatment of disseminated intravascular coagulation (DIC) complicating acute leukemia. However, its safety and efficacy have not been fully examined in prospective studies. Here, we performed a multicenter prospective study to examine outcomes of rTM treatment for DIC in patients with acute leukemia. Of 33 patients registered in this study, 13 had acute myeloid leukemia (AML), three had acute lymphoblastic leukemia (ALL), and 17 had acute promyelocytic leukemia (APL). The cumulative rates of DIC resolution at day 7 and day 35 were 56 and 81% in AML/ALL and 53 and 77% in APL, respectively. The median time from the initiation of rTM to DIC resolution was 4 days in AML/ALL and 6 days in APL patients. Adverse events related to hemorrhage occurred in two AML/ALL patients (13%) and three APL patients (18%). Of these, one AML/ALL patient died with intracranial hemorrhage, and two APL patients died with intracranial hemorrhage and pulmonary hemorrhage. These results suggest that rTM may improve the survival of acute leukemia patients with DIC by inhibiting early death related to hemorrhagic events, as reported previously.
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Affiliation(s)
- Hisayuki Yokoyama
- Department of Hematology, Sendai Medical Center, National Hospital Organization, 2-8-8, Miyagino, Miyagino-ku, Sendai, 983-8520, Japan.
| | - Naoto Takahashi
- Department of Hematology, Nephrology, and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Yuna Katsuoka
- Department of Hematology, Sendai Medical Center, National Hospital Organization, 2-8-8, Miyagino, Miyagino-ku, Sendai, 983-8520, Japan
| | - Mitsue Inomata
- Department of Hematology, Sendai Medical Center, National Hospital Organization, 2-8-8, Miyagino, Miyagino-ku, Sendai, 983-8520, Japan
| | - Toshihiro Ito
- Department of Hematology, Sendai Medical Center, National Hospital Organization, 2-8-8, Miyagino, Miyagino-ku, Sendai, 983-8520, Japan
| | - Kuniaki Meguro
- Department of Hematology, Sendai Medical Center, National Hospital Organization, 2-8-8, Miyagino, Miyagino-ku, Sendai, 983-8520, Japan
| | - Yoshihiro Kameoka
- Department of Hematology, Nephrology, and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Riko Tsumanuma
- Department of Hematology, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Kazunori Murai
- Department of Hematology, Iwate Prefectural Central Hospital, Morioka, Japan
| | - Hideyoshi Noji
- Department of Hematology, Fukushima Medical University, Fukushima, Japan
| | - Kenichi Ishizawa
- Department of Hematology and Cell Therapy, Yamagata University Graduate School of Medicine, Yamagata, Japan
| | - Shigeki Ito
- Department of Hematology/Oncology, Iwate Medical University School of Medicine, Morioka, Japan
| | - Yasushi Onishi
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hideo Harigae
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
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Chen G, He JQ. Rifampicin-induced disseminated intravascular coagulation in pulmonary tuberculosis treatment: A case report and literature review. Medicine (Baltimore) 2017; 96:e6135. [PMID: 28207542 PMCID: PMC5319531 DOI: 10.1097/md.0000000000006135] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
RATIONALE Disseminated intravascular coagulation (DIC) induced by daily rifampicin therapy is rare, especially the patient is absent of malignancy, severe infection, and prior exposure to rifampicin. PATIENT CONCERNS We report a case of DIC induced by daily rifampicin treatment for pulmonary tuberculosis. A 22-year-old, previously healthy man received an anti-tuberculosis therapy consisting of isoniazid, rifampicin, ethambutol, and pyrazinamide on the daily dose recommended by the World Health Organization tuberculosis guidelines after a diagnosis of pulmonary tuberculosis. Two weeks later, he was transferred to the West China Hospital with nasal hemorrhage for 1 week, hematochezia, hematuria, and petechiae for 5 days. DIAGNOSES Laboratory data and symptoms on admission indicated DIC. INTERVENTIONS The anti-tuberculosis drugs were discontinued after admission and he was initiated with targeted treatment for DIC, omeprazole and polyene hosphatidylcholine infusion, as well as nutrition supportive treatment. Five days after admission, ethambutol, moxifloxacin, and amikacin were added to the patient without further active hemorrhage. Eight days after admission, the platelet count had risen gradually. Isoniazid was administered on 24 days after admission, while his liver function tests and platelet counts returned to normal. No recurrence of DIC occurred. The diagnosis of rifampicin-induced DIC was confirmed. OUTCOMES The patient recovered and left hospital with isoniazid, ethambutol, levofloxacin, and streptomycin after 4 weeks of hospitalization. There was no recurrence of DIC or hemorrhage during the 8 months of follow-up. The literature review revealed that there were 10 other cases of rifampicin-induced DIC. Only 4 cases received rifampicin on a daily basis for pulmonary tuberculosis treatment and the others were on intermittent dosing schedule for pulmonary tuberculosis or leprosy treatment. LESSONS As a rare adverse effect, DIC induced by rifampicin occurs irregularly and unpredictably, which is reported to be more associated with the intermittent usage of rifampicin, but can occur with rifampicin daily administration. Identification of early symptoms, drug discontinuation, supportive management, and regular monitoring are the key points to correct this adverse effect, which may contribute to severe even fetal results in patients and deserves more attention.
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Affiliation(s)
- Guo Chen
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University
- Department of Geriatrics, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan, China
| | - Jian-Qing He
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University
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Dixit A, Chatterjee T, Mishra P, Kannan M, Choudhry DR, Mahapatra M, Choudhry VP, Saxena R. Disseminated Intravascular Coagulation in Acute Leukemia at Presentation and During Induction Therapy. Clin Appl Thromb Hemost 2016; 13:292-8. [PMID: 17636191 DOI: 10.1177/1076029607302435] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Between January 2001 and December 2003, 67 patients with acute leukemia were evaluated prospectively for hemostatic abnormality at presentation, of which 43 (64.2%) had acute lymphoblastic leukemia and 24 (35.8%) had acute myelogenous leukemia. At presentation, 27 patients (40.3%) had bleeding manifestations. Thrombocytopenia was present in 57 patients (85%), and 33(49.3%) had some abnormality of global coagulation markers. Disseminated intravascular coagulation was defined by International Society of Thrombosis and Hemostasis criteria. Disseminated intravascular coagulation was more often associated with bleeding manifestations in acute myelogenous leukemia cases than in acute lymphoblastic leukemia cases. Two patients presented disseminated intravascular coagulation on day 7 of chemotherapy, without any bleeding manifestations. Four of 15 evaluated cases who had a bleeding or infection complication after day 7 of induction therapy also had disseminated intravascular coagulation. It is recommended that all patients with leukemia be investigated for disseminated intravascular coagulation at presentation.
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Affiliation(s)
- Ashish Dixit
- Department of Haematology, All India Institute of Medical Sciences, New Delhi, India
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Disseminated intravascular coagulation at diagnosis is a strong predictor for thrombosis in acute myeloid leukemia. Blood 2016; 128:1854-1861. [PMID: 27354723 DOI: 10.1182/blood-2016-02-701094] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 06/19/2016] [Indexed: 12/21/2022] Open
Abstract
Venous thromboembolism is a common complication in patients with cancer, but only limited data are available in acute myeloid leukemia (AML). In a prospective study in a cohort of 272 adult patients (aged 18-65) and an independent validation cohort of 132 elderly adults (aged >60) with newly diagnosed AML, we assessed markers of disseminated intravascular coagulation (DIC) (fibrinogen, D-dimer, α-2-antiplasmin, antitrombin, prothrombin time, and platelet count) and the DIC score according the International Society of Thrombosis and Haemostasis and their associations with the occurrence of venous and arterial thrombosis during follow-up. The prevalence of thrombosis was 8.7% (4.7% venous, 4.0% arterial) in the younger adults over a median follow-up of 478 days and 10.4% (4.4% venous, 5.9% arterial) in elderly patients. Most thrombotic events (66%) occurred before the start of the second course of chemotherapy. The calculated DIC score significantly predicted venous and arterial thrombosis with a hazard ratio (HR) for a high DIC score (≥5) of 4.79 (1.71-13.45). These results were confirmed in the validation cohort of elderly patients with AML (HR 11.08 [3.23-38.06]). Among all DIC parameters, D-dimer levels are most predictive for thrombosis with an HR of 12.3 (3.39-42.64) in the first cohort and an HR of 7.82 (1.95-31.38) in validation cohort for a D-dimer >4 mg/L vs ≤4 mg/L. It is concluded that venous and arterial thrombosis may develop in ∼10% of AML patients treated with intensive chemotherapy, which to a large extent can be predicted by the presence of DIC at time of AML diagnosis.
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Mamez AC, Raffoux E, Chevret S, Lemiale V, Boissel N, Canet E, Schlemmer B, Dombret H, Azoulay E, Lengliné E. Pre-treatment with oral hydroxyurea prior to intensive chemotherapy improves early survival of patients with high hyperleukocytosis in acute myeloid leukemia. Leuk Lymphoma 2016; 57:2281-8. [PMID: 26849624 DOI: 10.3109/10428194.2016.1142083] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Acute myeloid leukemia with high white blood cell count (WBC) is a medical emergency. A reduction of tumor burden with hydroxyurea may prevent life-threatening complications induced by straight chemotherapy. To evaluate this strategy, we reviewed medical charts of adult patients admitted to our institution from 1997 to 2011 with non-promyelocytic AML and WBC over 50 G/L. One hundred and sixty patients were included with a median WBC of 120 G/L (range 50-450), 107 patients received hydroxyurea prior to chemotherapy, and 53 received emergency induction chemotherapy (CT). Hospital mortality was lower for patients treated with hydroxyurea (34% versus 19%, p = 0.047) even after adjusting for age (p < 0.01) and initial WBC count (p = 0.02). No evidence of any difference between treatment groups in terms of WBC decline kinetics and disease free survival (p = 0.87) was found. Oral hydroxyurea prior to chemotherapy seems a safe and efficient strategy to reduce early death of hyperleukocytic AML patients.
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Affiliation(s)
- Anne-Claire Mamez
- a Medical Intensive Care Unit , Hôpital Saint-Louis, APHP, Université Paris Diderot , Paris , France
| | - Emmanuel Raffoux
- b Department of Hematology , Hôpital Saint-Louis, APHP, Université Paris Diderot , Paris , France ;,c EA-3518, Institut Universitaire D'hématologie Université Paris Diderot , Paris , France
| | - Sylvie Chevret
- d Biostatistic Unit , Hôpital Saint-Louis, APHP, Université Paris Diderot , Paris , France ;,e ECSTRA Team, CRESS (UMR 1153), Inserm , Université Paris Diderot , Paris , France
| | - Virginie Lemiale
- a Medical Intensive Care Unit , Hôpital Saint-Louis, APHP, Université Paris Diderot , Paris , France
| | - Nicolas Boissel
- b Department of Hematology , Hôpital Saint-Louis, APHP, Université Paris Diderot , Paris , France ;,c EA-3518, Institut Universitaire D'hématologie Université Paris Diderot , Paris , France
| | - Emmanuel Canet
- a Medical Intensive Care Unit , Hôpital Saint-Louis, APHP, Université Paris Diderot , Paris , France ;,e ECSTRA Team, CRESS (UMR 1153), Inserm , Université Paris Diderot , Paris , France
| | - Benoît Schlemmer
- a Medical Intensive Care Unit , Hôpital Saint-Louis, APHP, Université Paris Diderot , Paris , France
| | - Hervé Dombret
- b Department of Hematology , Hôpital Saint-Louis, APHP, Université Paris Diderot , Paris , France ;,c EA-3518, Institut Universitaire D'hématologie Université Paris Diderot , Paris , France
| | - Elie Azoulay
- a Medical Intensive Care Unit , Hôpital Saint-Louis, APHP, Université Paris Diderot , Paris , France ;,e ECSTRA Team, CRESS (UMR 1153), Inserm , Université Paris Diderot , Paris , France
| | - Etienne Lengliné
- a Medical Intensive Care Unit , Hôpital Saint-Louis, APHP, Université Paris Diderot , Paris , France ;,b Department of Hematology , Hôpital Saint-Louis, APHP, Université Paris Diderot , Paris , France ;,c EA-3518, Institut Universitaire D'hématologie Université Paris Diderot , Paris , France
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Yoon BG, Baek HJ, Oh BS, Han DK, Choi YD, Kook H. Alveolar rhabdomyosarcoma with massive disseminated intravascular coagulopathy treated with systemic chemotherapy. KOREAN JOURNAL OF PEDIATRICS 2016; 58:505-8. [PMID: 26770227 PMCID: PMC4705332 DOI: 10.3345/kjp.2015.58.12.505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 05/13/2014] [Accepted: 05/16/2014] [Indexed: 11/27/2022]
Abstract
It is uncommon for pediatric patients with rhabdomyosarcoma to present with clinical and/or laboratory features of disseminated intravascular coagulation (DIC). We report a case of metastatic alveolar rhabdomyosarcoma with severe bleeding because of DIC in a 13-year-old boy. He experienced persistent oozing at the site of a previous operation, gross hematuria, and massive epistaxis. Two weeks after initiating combination chemotherapy consisting of vincristine, doxorubicin, and cyclophosphamide, the patients' laboratory indications of DIC began to resolve. During this period, the patient received massive blood transfusion of a total of 311 units (26 units of red blood cells, 26 units of fresh frozen plasma, 74 units of platelet concentrates, 17 units of single donor platelets, and 168 units of cryoprecipitate), antithrombin-III and a synthetic protease inhibitor. Despite chemotherapy and radiation therapy, he died 1 year later because of disease progression. In children with metastatic rhabdomyosarcoma and massive DIC, prompt chemotherapy and aggressive supportive care is important to decrease malignancy-triggered procoagulant activities.
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Affiliation(s)
- Byung Gyu Yoon
- Department of Pediatrics, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Hee Jo Baek
- Department of Pediatrics, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Burm Seok Oh
- Department of Pediatrics, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Dong Kyun Han
- Department of Pediatrics, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Yoo Duk Choi
- Department of Pathology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Hoon Kook
- Department of Pediatrics, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
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Abstract
Heat stroke is a life-threatening condition clinically diagnosed as a severe elevation in body temperature with central nervous system dysfunction that often includes combativeness, delirium, seizures, and coma. Classic heat stroke primarily occurs in immunocompromised individuals during annual heat waves. Exertional heat stroke is observed in young fit individuals performing strenuous physical activity in hot or temperature environments. Long-term consequences of heat stroke are thought to be due to a systemic inflammatory response syndrome. This article provides a comprehensive review of recent advances in the identification of risk factors that predispose to heat stroke, the role of endotoxin and cytokines in mediation of multi-organ damage, the incidence of hypothermia and fever during heat stroke recovery, clinical biomarkers of organ damage severity, and protective cooling strategies. Risk factors include environmental factors, medications, drug use, compromised health status, and genetic conditions. The role of endotoxin and cytokines is discussed in the framework of research conducted over 30 years ago that requires reassessment to more clearly identify the role of these factors in the systemic inflammatory response syndrome. We challenge the notion that hypothalamic damage is responsible for thermoregulatory disturbances during heat stroke recovery and highlight recent advances in our understanding of the regulated nature of these responses. The need for more sensitive clinical biomarkers of organ damage is examined. Conventional and emerging cooling methods are discussed with reference to protection against peripheral organ damage and selective brain cooling.
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Affiliation(s)
- Lisa R Leon
- US Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
| | - Abderrezak Bouchama
- King Abdullah International Medical Research Center/King Saud bin Abdulaziz University for Health Sciences, Experimental Medicine Department-King Abdulaziz Medical City-Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
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Martí‐Carvajal AJ, Anand V, Solà I. Treatment for disseminated intravascular coagulation in patients with acute and chronic leukemia. Cochrane Database Syst Rev 2015; 2015:CD008562. [PMID: 26107113 PMCID: PMC7173718 DOI: 10.1002/14651858.cd008562.pub3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Disseminated intravascular coagulation (DIC) is an acquired syndrome characterized by systemic intravascular activation of coagulation, leading to deposition of fibrin in the bloodstream. It may occur in patients with acute and chronic leukemia and is particularly associated with acute promyelocytic leukemia (a subtype of acute myeloid leukemia). OBJECTIVES To assess the clinical benefits and harms of any pharmacological intervention for treating DIC in patients with acute or chronic leukemia. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2015, Issue 05), MEDLINE (1946 to 7 May 2015), LILACS (1982 to 7 May 2015) and African Index Medicus (7 May 2015). There was no language restrictions. We sought additional randomized controlled trials (RCTs) from the World Health Organization International Clinical Trials Registry Platform and the reference lists of primary studies identified. SELECTION CRITERIA RCTs assessing the clinical benefits and harms of interventions for treating DIC in patients with acute and chronic leukemia. DATA COLLECTION AND ANALYSIS Two review authors independently performed trial selection, 'Risk of bias' assessment and data extraction. Primary outcomes were overall mortality, in-hospital mortality from any cause (15-day and 30-day) and adverse events. MAIN RESULTS In this Cochrane Review update we did not include any new RCT compared with the first review version. Accordingly, four RCTs (388 participants) met the inclusion criteria. These trials evaluated the human activated protein C, recombinant human soluble thrombomodulin, tranexamic acid and dermatan sulphate. Included trials reported data on mortality and bleeding. The studies were conducted in Japan, Italy and the Netherlands. We classified the included trials as: 1) including patients with or without leukemia which did not report data for the leukemia subgroup (366 participants); and 2) only including patients with leukemia (22 participants). Overall, the risk of bias of the included trials was high, since the trial authors did not provide a detailed description about trial design and execution.According to the GRADE recommendations, we judged the overall quality of the body of evidence for all prefixed outcomes as 'very low', due to methodological limitations and very small sample size.One trial, including 10 participants with leukemia and comparing dermatan sulphate with heparin, reported no deaths during trial treatment.In terms of bleeding data, we were unable to pool results from two studies that were only conducted with leukemia patients due to the inconsistency in the measurement and reporting of this outcome. One trial, including 12 participants with leukemia, found very low quality evidence that tranexamic acid can reduce the cumulative hemorrhagic score in participants compared with those assigned to placebo (P = 0.0015, very low quality evidence). On the contrary, there is no evidence that dermatan sulphate compared with placebo reduces new events of hemorrhagic diathesis (1/5 (20%) versus 2/5 (40%); RR 0.50; 95% CI 0.06 to 3.91; P = 0.51, very low quality evidence).No thromboembolic complications were reported in either trial that included patients with leukemia only (very low quality evidence). The safety profile was inconclusive.The included trials did not assess overall mortality, resolution of respiratory failure, renal failure or shock. AUTHORS' CONCLUSIONS Due to a lack of new RCTs, our conclusions in this Cochrane Review update are the same as the previous review version. We included four RCTs which reported mortality and bleeding data. It is not possible to determine whether human activated protein C, recombinant human soluble thrombomodulin, tranexamic acid and dermatan sulphate are effective or harmful for patients presenting with DIC related to acute or chronic leukemia. The quality of the evidence was low to very low. Therefore, prescription of these interventions for treating DIC in patients with acute and chronic leukemia can neither be supported nor rejected, unless new evidence from a large high-quality trial alters this conclusion.
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Affiliation(s)
| | - Vidhu Anand
- University of MinnesotaDepartment of Medicine420 Delaware Street SEMayo Mail Code 195MinneapolisMNUSA55455
| | - Ivan Solà
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 171 ‐ Edifici Casa de ConvalescènciaBarcelonaCatalunyaSpain08041
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Hifumi T, Sakai A, Kondo Y, Yamamoto A, Morine N, Ato M, Shibayama K, Umezawa K, Kiriu N, Kato H, Koido Y, Inoue J, Kawakita K, Kuroda Y. Venomous snake bites: clinical diagnosis and treatment. J Intensive Care 2015; 3:16. [PMID: 25866646 PMCID: PMC4393627 DOI: 10.1186/s40560-015-0081-8] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 03/09/2015] [Indexed: 11/21/2022] Open
Abstract
Snake bites are life-threatening injuries that can require intensive care. The diagnosis and treatment of venomous snake bites is sometimes difficult for clinicians because sufficient information has not been provided in clinical practice. Here we review the literature to present the proper management of bites by mamushi, habu, and yamakagashi snakes, which widely inhabit Japan and other Asian countries. No definite diagnostic markers or kits are available for clinical practice; therefore, definitive diagnosis of snake-venom poisoning requires positive identification of the snake and observation of the clinical manifestations of envenomation. Mamushi (Gloydius blomhoffii) bites cause swelling and pain that spreads gradually from the bite site. The platelet count gradually decreases due to the platelet aggregation activity of the venom and can decrease to <100,000/mm(3). If the venom gets directly injected into the blood vessel, the platelet count rapidly decreases to <10,000/mm(3) within 1 h after the bite. Habu (Protobothrops flavoviridis) bites result in swelling within 30 min. Severe cases manifest not only local signs but also general symptoms such as vomiting, cyanosis, loss of consciousness, and hypotension. Yamakagashi (Rhabdophis tigrinus) bites induce life-threatening hemorrhagic symptoms and severe disseminated intravascular coagulation with a fibrinolytic phenotype, resulting in hypofibrinogenemia and increased levels of fibrinogen degradation products. Previously recommended first-aid measures such as tourniquets, incision, and suction are strongly discouraged. Once airway, breathing, and circulation have been established, a rapid, detailed history should be obtained. If a snake bite is suspected, hospital admission should be considered for further follow-up. All venomous snake bites can be effectively treated with antivenom. Side effects of antivenom should be prevented by sufficient preparation. Approved antivenoms for mamushi and habu are available. Yamakagashi antivenom is used as an off-label drug in Japan, requiring clinicians to join a clinical research group for its use in clinical practice.
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Affiliation(s)
- Toru Hifumi
- />Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki, Kita, Kagawa, 761-0793 Japan
| | - Atsushi Sakai
- />The Japan Snake Institute, Yabuzuka 3318, Ota, Gunma, 379-2301 Japan
| | - Yutaka Kondo
- />Department of Emergency Medicine, Graduate School of Medicine, University of the Ryukyus, 207, Uehara, Nishihara, Okinawa, 903-0215 Japan
| | - Akihiko Yamamoto
- />Department of Bacteriology II, National Institute of Infectious Disease, Gakuen 4-7-1, Musashimurayama, Tokyo, 208-0011 Japan
| | - Nobuya Morine
- />Okinawa Prefectural Institute of Health and Environment, 2085 Ozato, Ozato, Nanjo, Okinawa, 901-1202 Japan
| | - Manabu Ato
- />Department of Immunology, National Institute of Infectious Disease, Toyama 1-23-1, Shinjuku, Tokyo, 162-8640 Japan
| | - Keigo Shibayama
- />Department of Bacteriology II, National Institute of Infectious Disease, Gakuen 4-7-1, Musashimurayama, Tokyo, 208-0011 Japan
| | - Kazuo Umezawa
- />Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193 Japan
| | - Nobuaki Kiriu
- />Division of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, 3256 Midoricho, Tachikawa, Tokyo, 190-0014 Japan
| | - Hiroshi Kato
- />Division of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, 3256 Midoricho, Tachikawa, Tokyo, 190-0014 Japan
| | - Yuichi Koido
- />Division of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, 3256 Midoricho, Tachikawa, Tokyo, 190-0014 Japan
| | - Junichi Inoue
- />Division of Critical Care Medicine and Trauma, Yamanashi Prefectural Central Hospital, 1-1-1 Fujimicho, Kofu, Yamanashi, 400-8506 Japan
| | - Kenya Kawakita
- />Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki, Kita, Kagawa, 761-0793 Japan
| | - Yasuhiro Kuroda
- />Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki, Kita, Kagawa, 761-0793 Japan
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Abstract
The association between cancer and thrombosis is known for years. Besides the well-recognized connection between venous thromboembolism and malignancies, there are, however, also other manifestations of cancer-related activation of coagulation and (micro)vascular dysfunction. In fact, coagulation derangements and vascular disturbances in patients with cancer cover a wide spectrum of diseases and various clinical manifestations. In this review we will highlight the mechanisms that play a role in the systemic activation of coagulation in cancer patients, in its most severe form manifested as disseminated intravascular coagulation. Clinically, disseminated intravascular coagulation (DIC) in cancer has in general a less fulminant presentation than the types of DIC complicating sepsis and trauma. A more gradual, but also more chronic, systemic activation of coagulation can proceed subclinically. The relationship between venous thromboembolism and cancer as a consequence of the hypercoagulability will be discussed as well. Furthermore, the role of perturbed endothelium in the pathogenesis of microvascular dysfunction and microangiopathy in particular in the setting of cancer and chemo- or radiotherapy will be reviewed.
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Affiliation(s)
- Marcel Levi
- Department of Medicine and Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
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41
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Hifumi T, Murakawa M, Sakai A, Ginnaga A, Yamamoto A, Ato M, Kato H, Koido Y, Kawakita K, Hagiike M, Kuroda Y. Potentially fatal coagulopathy secondary to yamakagashi ( Rhabdophis tigrinus) bites that completely recovered with antivenom treatment. Acute Med Surg 2014; 2:123-126. [PMID: 29123706 DOI: 10.1002/ams2.69] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 06/11/2014] [Indexed: 11/06/2022] Open
Abstract
Case A healthy 40-year-old man was admitted with severe coagulopathy that developed after Rhabdophis tigrinus bites. On admission, he showed significantly elevated levels of thrombin-antithrombin III complex (60 ng/mL), plasmin-alpha 2-plasmin inhibitor complex (22.3 μg/mL), and fibrinogen degradation products (592 μg/mL). He subsequently developed severe hypofibrinogenemia (50 mg/dL). Outcome Antivenom was given 28 h after the patient was bitten, following which his hemorrhagic symptoms resolved. By day 3 of admission, scabs had formed over the bite wounds. Furthermore, his fibrinogen levels increased to >100 mg/dL, while his thrombin-antithrombin III complex, plasmin-alpha 2-plasmin inhibitor complex, and fibrinogen degradation product levels normalized. He was discharged on day 6 of admission. Conclusion Rhabdophis tigrinus bites induced disseminated intravascular coagulation with a fibrinolytic phenotype, which completely recovered with antivenom treatment.
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Affiliation(s)
- Toru Hifumi
- Emergency Medical Center Kagawa University Hospital Kagawa Japan
| | | | | | - Akihiko Ginnaga
- The Chemo-Sero-Therapeutic Research Institute Kumamoto Japan
| | - Akihiko Yamamoto
- Department of Bacteriology II National Institute of Infectious Disease Tokyo Japan
| | - Manabu Ato
- Department of Immunology National Institute of Infectious Disease Tokyo Japan
| | - Hiroshi Kato
- Division of Critical Care Medicine and Trauma National Hospital Organization Disaster Medical Center Tokyo Japan
| | - Yuichi Koido
- Division of Critical Care Medicine and Trauma National Hospital Organization Disaster Medical Center Tokyo Japan
| | - Kenya Kawakita
- Emergency Medical Center Kagawa University Hospital Kagawa Japan
| | - Masanobu Hagiike
- Emergency Medical Center Kagawa University Hospital Kagawa Japan
| | - Yasuhiro Kuroda
- Emergency Medical Center Kagawa University Hospital Kagawa Japan
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42
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Cowan AJ, Altemeier WA, Johnston C, Gernsheimer T, Becker PS. Management of Acute Myeloid Leukemia in the Intensive Care Setting. J Intensive Care Med 2014; 30:375-84. [DOI: 10.1177/0885066614530959] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 12/16/2013] [Indexed: 01/18/2023]
Abstract
Patients with acute myeloid leukemia (AML) who are newly diagnosed or relapsed and those who are receiving cytotoxic chemotherapy are predisposed to conditions such as sepsis due to bacterial and fungal infections, coagulopathies, hemorrhage, metabolic abnormalities, and respiratory and renal failure. These conditions are common reasons for patients with AML to be managed in the intensive care unit (ICU). For patients with AML in the ICU, providers need to be aware of common problems and how to manage them. Understanding the pathophysiology of complications and the recent advances in risk stratification as well as newer therapy for AML are relevant to the critical care provider.
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Affiliation(s)
- Andrew J. Cowan
- Division of Hematology, University of Washington, Seattle, WA, USA
- Division of Medical Oncology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA, USA
| | - William A. Altemeier
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA, USA
| | - Christine Johnston
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Terry Gernsheimer
- Division of Hematology, University of Washington, Seattle, WA, USA
- Puget Sound Blood Center, Seattle, WA, USA
| | - Pamela S. Becker
- Division of Hematology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA, USA
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43
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Abstract
There is an increased risk not only of bleeding but also of thrombosis in the cancer patient. The double jeopardy creates an additional problem in their management and requires special attention. This review provides information on pathophysiology in the regulation of hemostasis, leading to bleeding and thrombotic complications. The process is complex with multiple factors being involved. In addition to the pathogenesis, a number of clinical syndromes, diagnostic methods and the management of hemostatic abnormalities in the cancer patient are presented. Potential effects of cancer treatment on these risks magnify the hazards encountered by the managing team. Wherever management is discussed, emphasis is placed on the scientific basis for the rationale of the therapeutic approach.
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Affiliation(s)
- Anaadriana Zakarija
- Division of Hematology/Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611-3008, USA.
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44
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Gheldof D, Mullier F, Bailly N, Devalet B, Dogné JM, Chatelain B, Chatelain C. Microparticle bearing tissue factor: a link between promyelocytic cells and hypercoagulable state. Thromb Res 2013; 133:433-9. [PMID: 24290525 DOI: 10.1016/j.thromres.2013.11.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 09/17/2013] [Accepted: 11/11/2013] [Indexed: 12/21/2022]
Abstract
Patients with hematological malignancies have a 28-fold increased risk of venous thromboembolism (VTE). Among patients with acute myelogenous leukemia (AML), the 2-year cumulative incidence of VTE is 5.2%. Several studies suggest that microvesicles (MVs) harboring TF may play a role in VTE and disseminated intravascular coagulation (DIC) in acute promyelocytic leukemia (APL). The aim of this study was to assess the capacity of untreated (APL) cells to shed procoagulant MVs. APL cells (NB4 and HL-60 cell lines) and MVs were separated by filtration (0.1-0.22-0.45-0.65 μm). The procoagulant activity (PCA) was assessed by thrombin generation assay (TGA). Alternatively, MVs were incubated with anti-Tissue Factor (TF) antibodies, with annexin V to assess the contribution of TF and phospholipids (PL) to the PCA, respectively. NB4 cells had a high PCA mainly triggered by MVs of size under 0.45 μm. The PCA of MVs was related to the expression of active TF and PL. HL-60 cells had a weaker PCA since TF is mostly present in its inactive form. Moreover, HL-60 do not produce MVs<0.65 μm associated with PCA. MVs could have a predicting value for VTE and DIC in patients with acute promyelocytic leukemia and could inform physicians about the optimal use of a thromboprophylaxis.
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Affiliation(s)
- Damien Gheldof
- Hematology Laboratory, NARILIS, Namur Thrombosis and Hemostasis Center (NTHC), CHU UCL Mont-Godinne-Dinant, Université Catholique de Louvain, Belgium.
| | - François Mullier
- Hematology Laboratory, NARILIS, Namur Thrombosis and Hemostasis Center (NTHC), CHU UCL Mont-Godinne-Dinant, Université Catholique de Louvain, Belgium; Department of Pharmacy, NARILIS, Namur Thrombosis and Hemostasis Center (NTHC), University of Namur, Belgium
| | - Nicolas Bailly
- Hematology Laboratory, NARILIS, Namur Thrombosis and Hemostasis Center (NTHC), CHU UCL Mont-Godinne-Dinant, Université Catholique de Louvain, Belgium
| | - Bérangère Devalet
- Hematology, CHU UCL Mont-Godinne-Dinant, Université Catholique de Louvain, Belgium
| | - Jean-Michel Dogné
- Department of Pharmacy, NARILIS, Namur Thrombosis and Hemostasis Center (NTHC), University of Namur, Belgium
| | - Bernard Chatelain
- Hematology Laboratory, NARILIS, Namur Thrombosis and Hemostasis Center (NTHC), CHU UCL Mont-Godinne-Dinant, Université Catholique de Louvain, Belgium
| | - Christian Chatelain
- Hematology, CHU UCL Mont-Godinne-Dinant, Université Catholique de Louvain, Belgium
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45
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Singh B, Hanson AC, Alhurani R, Wang S, Herasevich V, Cartin-Ceba R, Kor DJ, Gangat N, Li G. Trends in the Incidence and Outcomes of Disseminated Intravascular Coagulation in Critically Ill Patients (2004-2010). Chest 2013; 143:1235-1242. [DOI: 10.1378/chest.12-2112] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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46
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Basmaci M, Hasturk AE. Chronic subdural hematoma in a child with acute myeloid leukemia after leukocytosis. Indian J Crit Care Med 2013; 16:222-4. [PMID: 23559733 PMCID: PMC3610458 DOI: 10.4103/0972-5229.106508] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Severe complications that develop in the early stages in patients with acute leukemia have a mortal course. Bleeding, leukostasis, and less frequently, infections are responsible for early mortality. Hemorrhage is most common in acute leukemia and usually leads to death. Hemorrhage may occur due to chemotherapy or bone marrow transplantation in patients with acute leukemia. Leukocytosis, thrombocytopenia, sepsis, and coagulopathy increase the risk of bleeding. There may be multiple etiologic factors. Subdural or subarachnoid hemorrhage is less common than an intra-axial hemorrhage. The incidence of spontaneous subdural hematoma is higher in patients with leukemia. Although advances in the treatment of platelet transfusion and disseminated intravascular coagulation have decreased the incidence of hemorrhagic complications in patients receiving chemotherapy for acute leukemia, intracranial hemorrhage-related deaths are a significant problem. We discussed the etiology and management of chronic subdural hematoma detected in a two-year-old male patient with Acute Myeloid Leukemia and hyperleukocytosis.
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Affiliation(s)
- Mehmet Basmaci
- Department of Neurosurgery, Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital, Ankara, Turkey
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47
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Abstract
With current predictions of climate change, the incidence of heat-related illnesses is projected to increase. Heat-related illnesses occur on a continuum from mild symptoms to fatalities. To prevent heat-related illnesses, nurses should have comprehension of persons at risk. Primary treatment of heat-related illness centers on cooling, but not overcooling, the patient. Heatstroke involves coagulopathies and cytokines, and can result in systemic inflammatory response syndrome and multiple organ dysfunction. Critical care nursing intervention requires more than effective cooling to support bodily processes that have been damaged or destroyed by the pathophysiology of heatstroke.
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48
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Chinen Y, Kuroda J, Ohshiro M, Shimura Y, Mizutani S, Nagoshi H, Sasaki N, Nakayama R, Kiyota M, Yamamoto-Sugitani M, Kobayashi T, Matsumoto Y, Horiike S, Taniwaki M. Low ADAMTS-13 activity during hemorrhagic events with disseminated intravascular coagulation. Int J Hematol 2013; 97:511-9. [PMID: 23494361 DOI: 10.1007/s12185-013-1308-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 03/01/2013] [Accepted: 03/03/2013] [Indexed: 01/23/2023]
Abstract
Disseminated intravascular coagulation (DIC) is a life-threatening complication, and its control is essential for therapeutic success. Recombinant human soluble thrombomodulin alfa (rTM) is a novel therapeutic agent for DIC. The efficacy of rTM in the treatment of DIC is reportedly superior to that of conventional anti-DIC treatments, such as unfractionated heparin or low molecular weight heparin, but hemorrhagic events occasionally interfere with the therapeutic benefits of rTM. We assessed the clinical features of 20 consecutive patients who were given rTM for DIC associated with various hematologic disorders. Eight patients achieved remission of both primary disease and DIC, eight died due to progression of the primary disease, and four died of various hemorrhagic complications. Assessment of 16 biomarkers for coagulation showed that the four patients who died of hemorrhagic complications despite remission of their primary disease showed lower ADAMTS-13 (a disintegrin and metalloproteinase with a thrombospondin Type 1 motif, member 13) plasma activity than other patients (P = 0.016). The optimal cut-off level of ADAMTS-13 for predicting risk of hemorrhagic complications was 42 % (P = 0.007). Plasma ADAMTS-13 activity determined at diagnosis of DIC may help predict the risk of hemorrhagic events during and/or following DIC treatment with hematologic disorders.
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Affiliation(s)
- Yoshiaki Chinen
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, Japan
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49
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Levi M, van der Poll T. Disseminated intravascular coagulation: a review for the internist. Intern Emerg Med 2013; 8:23-32. [PMID: 23015284 DOI: 10.1007/s11739-012-0859-9] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 09/15/2012] [Indexed: 02/02/2023]
Abstract
Disseminated intravascular coagulation (DIC) is a syndrome characterized by systemic intravascular activation of coagulation, leading to widespread deposition of fibrin in the circulation. Recent knowledge on important pathogenetic mechanisms that may lead to DIC has resulted in novel preventive and therapeutic approaches to patients with DIC. The diagnosis of DIC can be made by sensitive laboratory tests; however, most of these tests are not readily available in a clinical setting. A reliable diagnosis can also be made on the basis of a small series of laboratory tests that can be combined in a scoring algorithm. The cornerstone of the management of DIC is the specific and vigorous treatment of the underlying disorder. Strategies aimed at the inhibition of coagulation activation may theoretically be justified and have been found beneficial in experimental and clinical studies. These strategies comprise inhibition of tissue factor-mediated activation of coagulation or restoration of physiological anticoagulant pathways.
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Affiliation(s)
- Marcel Levi
- Department of Medicine, University of Amsterdam, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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50
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The biochemistry and regulation of S100A10: a multifunctional plasminogen receptor involved in oncogenesis. J Biomed Biotechnol 2012; 2012:353687. [PMID: 23118506 PMCID: PMC3479961 DOI: 10.1155/2012/353687] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Accepted: 06/01/2012] [Indexed: 12/16/2022] Open
Abstract
The plasminogen receptors mediate the production and localization to the cell surface of the broad spectrum proteinase, plasmin. S100A10 is a key regulator of cellular plasmin production and may account for as much as 50% of cellular plasmin generation. In parallel to plasminogen, the plasminogen-binding site on S100A10 is highly conserved from mammals to fish. S100A10 is constitutively expressed in many cells and is also induced by many diverse factors and physiological stimuli including dexamethasone, epidermal growth factor, transforming growth factor-α, interferon-γ, nerve growth factor, keratinocyte growth factor, retinoic acid, and thrombin. Therefore, S100A10 is utilized by cells to regulate plasmin proteolytic activity in response to a wide diversity of physiological stimuli. The expression of the oncogenes, PML-RARα and KRas, also stimulates the levels of S100A10, suggesting a role for S100A10 in pathophysiological processes such as in the oncogenic-mediated increases in plasmin production. The S100A10-null mouse model system has established the critical role that S100A10 plays as a regulator of fibrinolysis and oncogenesis. S100A10 plays two major roles in oncogenesis, first as a regulator of cancer cell invasion and metastasis and secondly as a regulator of the recruitment of tumor-associated cells, such as macrophages, to the tumor site.
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