1
|
Jones R, Robinson AT, Beach LB, Lindsey ML, Kirabo A, Hinton A, Erlandson KM, Jenkins ND. Exercise to Prevent Accelerated Vascular Aging in People Living With HIV. Circ Res 2024; 134:1607-1635. [PMID: 38781293 PMCID: PMC11126195 DOI: 10.1161/circresaha.124.323975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Given advances in antiretroviral therapy, the mortality rate for HIV infection has dropped considerably over recent decades. However, people living with HIV (PLWH) experience longer life spans coupled with persistent immune activation despite viral suppression and potential toxicity from long-term antiretroviral therapy use. Consequently, PLWH face a cardiovascular disease (CVD) risk more than twice that of the general population, making it the leading cause of death among this group. Here, we briefly review the epidemiology of CVD in PLWH highlighting disparities at the intersections of sex and gender, age, race/ethnicity, and the contributions of social determinants of health and psychosocial stress to increased CVD risk among individuals with marginalized identities. We then overview the pathophysiology of HIV and discuss the primary factors implicated as contributors to CVD risk among PLWH on antiretroviral therapy. Subsequently, we highlight the functional evidence of premature vascular dysfunction as an early pathophysiological determinant of CVD risk among PLWH, discuss several mechanisms underlying premature vascular dysfunction in PLWH, and synthesize current research on the pathophysiological mechanisms underlying accelerated vascular aging in PLWH, focusing on immune activation, chronic inflammation, and oxidative stress. We consider understudied aspects such as HIV-related changes to the gut microbiome and psychosocial stress, which may serve as mechanisms through which exercise can abrogate accelerated vascular aging. Emphasizing the significance of exercise, we review various modalities and their impacts on vascular health, proposing a holistic approach to managing CVD risks in PLWH. The discussion extends to critical future study areas related to vascular aging, CVD, and the efficacy of exercise interventions, with a call for more inclusive research that considers the diversity of the PLWH population.
Collapse
Affiliation(s)
- Raymond Jones
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | | | - Lauren B. Beach
- Department of Medical Social Sciences, Northwestern, Chicago, IL
- Department of Preventive Medicine, Northwestern, Chicago, IL
| | - Merry L. Lindsey
- School of Graduate Studies, Meharry Medical College, Nashville, TN
- Research Service, Nashville VA Medical Center, Nashville, TN
| | - Annet Kirabo
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt Center for Immunobiology, Nashville, TN
- Vanderbilt Institute for Infection, Immunology and Inflammation, Nashville, TN
- Vanderbilt Institute for Global Health, Nashville, TN
| | - Antentor Hinton
- Department of Molecular Physiology and Biophysics, Vanderbilt University, Nashville, TN
| | | | - Nathaniel D.M. Jenkins
- Department of Health and Human Physiology, University of Iowa, Iowa City, IA
- Abboud Cardiovascular Research Center, University of Iowa, Iowa City, IA
- Fraternal Order of Eagles Diabetes Research Center, University of Iowa, Iowa City, IA
| |
Collapse
|
2
|
Swilem ES, Elkenany NM, Algazzar AS, Youssef N, Swilem SS, Gendia EA, Swillem AS, Elmalah AA, Sabah Z, Rasool T. The Impact of Periodontal Inflammation on the Severity of Coronary Atherosclerosis. Cureus 2024; 16:e57653. [PMID: 38707087 PMCID: PMC11070142 DOI: 10.7759/cureus.57653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2024] [Indexed: 05/07/2024] Open
Abstract
Introduction Through plausible biological mechanisms, periodontitis causes systemic inflammatory burden and response, thus resulting in damage far beyond the oral cavity. Studies have demonstrated periodontitis to be a significant risk factor for coronary heart disease (CHD) and stroke. The larger the quantum of periodontal inflamed tissue, the greater the chances of periodontitis eliciting bacteremia and systemic inflammatory responses. Studies have reported that periodontitis and other common oral infections play an important role in the development of atherosclerosis. Therefore, the quantity of inflamed periodontal tissue assumes significance in determining the severity of atherosclerosis. Hence, this study investigates the impact of periodontal inflamed surface area (PISA) on the severity of coronary atherosclerosis. Materials and methods In this cross-sectional study, a total of 160 patients who presented at the department of periodontics of The British University in Egypt (BUE) from 1 January 2023 to 30 September 2023 were enrolled. Patients were only enrolled if they had undergone coronary angiography within the last six months, were less than 60 years of age, shared their previous medical history and coronary angiographic report, and gave informed written consent. Data on classic coronary risk factors and periodontal inflammatory status and angiographic findings were recorded and subjected to appropriate statistical analysis. Results The results revealed that the periodontal inflamed surface area (p = 0.002) apart from age (p < 0.047) and low-density lipoprotein cholesterol (LDL-C) (p < 0.001) is a significant independent predictor of the severity of coronary atherosclerosis. Conclusions The periodontal inflamed surface area is an independent predictor of the severity of coronary atherosclerosis.
Collapse
Affiliation(s)
- Esraa S Swilem
- Faculty of Dental Medicine, The British University in Egypt, Cairo, EGY
| | - Nasima M Elkenany
- Department of Cardiology, Faculty of Medicine for Girls, Al-Azhar University, Cairo, EGY
| | - Alaa S Algazzar
- Department of Cardiology, Ahmed Maher Teaching Hospital, Cairo, EGY
| | - Nesma Youssef
- Faculty of Dental Medicine, Al-Azhar University, Cairo, EGY
| | - Sara S Swilem
- Faculty of Dental Medicine, The British University in Egypt, Cairo, EGY
| | - Eslam A Gendia
- Faculty of Dental Medicine, The British University in Egypt, Cairo, EGY
| | - Ahmad S Swillem
- Faculty of Dental Medicine, The British University in Egypt, Cairo, EGY
| | - Abeer A Elmalah
- Faculty of Medicine for Girls, Al-Azhar University, Cairo, EGY
| | - Zia Sabah
- Department of Medicine, King Khalid University, Abha, SAU
| | - Tariq Rasool
- Department of Medical Education and Simulation, University Institute of Computing, Chandigarh University, Chandigarh, IND
| |
Collapse
|
3
|
Wada T, Gando S. Phenotypes of Disseminated Intravascular Coagulation. Thromb Haemost 2024; 124:181-191. [PMID: 37657485 PMCID: PMC10890912 DOI: 10.1055/a-2165-1142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 08/30/2023] [Indexed: 09/03/2023]
Abstract
Two phenotypes of disseminated intravascular coagulation (DIC) are systematically reviewed. DIC is classified into thrombotic and fibrinolytic phenotypes characterized by thrombosis and hemorrhage, respectively. Major pathology of DIC with thrombotic phenotype is the activation of coagulation, insufficient anticoagulation with endothelial injury, and plasminogen activator inhibitor-1-mediated inhibition of fibrinolysis, leading to microvascular fibrin thrombosis and organ dysfunction. DIC with fibrinolytic phenotype is defined as massive thrombin generation commonly observed in any type of DIC, combined with systemic pathologic hyperfibrinogenolysis caused by underlying disorder that results in severe bleeding due to excessive plasmin formation. Three major pathomechanisms of systemic hyperfibrinogenolysis have been considered: (1) acceleration of tissue-type plasminogen activator (t-PA) release from hypoxic endothelial cells and t-PA-rich storage pools, (2) enhancement of the conversion of plasminogen to plasmin due to specific proteins and receptors that are expressed on cancer cells and endothelial cells, and (3) alternative pathways of fibrinolysis. DIC with fibrinolytic phenotype can be diagnosed by DIC diagnosis followed by the recognition of systemic pathologic hyperfibrin(ogen)olysis. Low fibrinogen levels, high fibrinogen and fibrin degradation products (FDPs), and the FDP/D-dimer ratio are important for the diagnosis of systemic pathologic hyperfibrin(ogen)olysis. Currently, evidence-based treatment strategies for DIC with fibrinolytic phenotypes are lacking. Tranexamic acid appears to be one of the few methods to be effective in the treatment of systemic pathologic hyperfibrin(ogen)olysis. International cooperation for the elucidation of pathomechanisms, establishment of diagnostic criteria, and treatment strategies for DIC with fibrinolytic phenotype are urgent issues in the field of thrombosis and hemostasis.
Collapse
Affiliation(s)
- Takeshi Wada
- Department of Anesthesiology and Critical Care Medicine, Division of Acute and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Satoshi Gando
- Department of Anesthesiology and Critical Care Medicine, Division of Acute and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| |
Collapse
|
4
|
Reda S, Schwarz N, Müller J, McRae HL, Oldenburg J, Pötzsch B, Rühl H. Fibrinolysis biomarker, thrombin, and activated protein C level alterations after coagulation activation depend on type of thrombophilia and clinical phenotype. Res Pract Thromb Haemost 2024; 8:102351. [PMID: 38487678 PMCID: PMC10937968 DOI: 10.1016/j.rpth.2024.102351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 01/14/2024] [Accepted: 02/07/2024] [Indexed: 03/17/2024] Open
Abstract
Background Recently, we have shown alterations in the anticoagulant response to recombinant activated factor VII (rFVIIa)-induced coagulation activation in patients with thrombophilia. Objectives This study aimed to extend this in vivo model to fibrinolysis biomarkers. Methods This interventional in vivo study included 56 patients with thrombophilia and previous venous thromboembolism (VTE+), 38 without VTE (VTE-), and 35 healthy controls. Plasma levels of D-dimer, plasmin-α2-antiplasmin (PAP) complex, and plasminogen activator inhibitor-1 (PAI-1) were monitored for over 8 hours after rFVIIa infusion (15 μg/kg) along with thrombin markers and activated protein C (APC). Results Throughout cohorts, median PAP increased by 40% to 52% (P < 3.9 × 10-10) and PAI-1 decreased by 59% to 79% (P < 3.5 × 10-8). In contrast to thrombin-antithrombin (TAT) complex, which also increased temporarily (44% to 115%, P < 3.6 × 10-6), changes in PAP and PAI-1 did not reverse during the observation period. The area under the measurement-time curves (AUCs) of PAP and TAT, which are measures of plasmin and thrombin formation, respectively, were each greater in the VTE+ cohort than in healthy controls (median PAP-AUC = 0.48 vs 0.27 ng·h/L [P = .003], TAT-AUC = 0.12 vs 0.03 nmol·h/L [P = 2.5 × 10-4]) and were correlated with one another (r = 0.554). As evidenced by the respective AUCs, asymptomatic factor (F)V Leiden carriers showed less PAP formation (0.22 vs 0.41 ng·h/L, P = 9 × 10-4), more pronounced PAI-1 decline (0.10 vs 0.18 ng·h/L, P = .01), and increased APC formation (28.7 vs 15.4 pmol·h/L, P = .02) than those within the VTE+ group (n = 19 each). Conclusion rFVIIa-induced thrombin formation is associated with fibrinolysis parameter changes outlasting the concomitant anticoagulant response. Both correlate with thrombosis history in FV Leiden and might help explain its variable clinical expressivity.
Collapse
Affiliation(s)
- Sara Reda
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Nadine Schwarz
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Jens Müller
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Hannah L. McRae
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Bernd Pötzsch
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Heiko Rühl
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| |
Collapse
|
5
|
Fibrinolytic Impairment and Mortality in Pediatric Septic Shock: A Single-Center Prospective Observational Study. Pediatr Crit Care Med 2021; 22:969-977. [PMID: 33965991 DOI: 10.1097/pcc.0000000000002759] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Fibrinolytic shutdown is associated with poor prognosis in adult sepsis, but data in the pediatric population are sparse. This study aimed to identify the association between impaired fibrinolysis and mortality in pediatric septic shock. DESIGN A prospective, observational study conducted between August 2019 and August 2020. SETTING PICU at a pediatric tertiary hospital in Hanoi, Vietnam. PATIENTS Fifty-six pediatric patients who met septic shock criteria were enrolled. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Conventional coagulation tests and rotational thromboelastometry were performed at diagnosis. The fibrinolytic activity on extrinsic pathway thromboelastometry was negatively correlated with the Vasoactive-Inotropic Score at 24 hours post-PICU admission, peak lactate level during the first 24 hours, Pediatric Logistic Organ Dysfunction-2 score, and Pediatric Risk of Mortality-III score (all p < 0.05). Compared with patients with nonovert disseminated intravascular coagulation, dysfunction of less than two organs, and who survived, patients with overt disseminated intravascular coagulation, dysfunction of greater than two organs, and who died showed significantly lower fibrinolytic activity, represented by significantly higher lysis indexes (%) and lower maximum lysis (%) (all p < 0.05). The threshold values for prediction of mortality were lysis index 60 minutes greater than 97.5 (area under the curve = 0.86; sensitivity = 73%; specificity = 90%), maximum lysis less than 6.5 (area under the curve = 0.83; sensitivity = 73%; specificity = 87%), and lysis index 45 minutes greater than 99.5 (area under the curve = 0.83; sensitivity = 73%; specificity = 85%). Hypofibrinolysis was associated with prolonged PICU length of stay in survivors and with early mortality in nonsurvivors. CONCLUSIONS Fibrinolytic shutdown in pediatric septic shock is associated with an increase in disease severity and mortality. This highlights the need for further investigations regarding whether fibrinolytic therapy improved the outcome of pediatric septic shock.
Collapse
|
6
|
Larsen JB, Hvas AM. Fibrinolytic Alterations in Sepsis: Biomarkers and Future Treatment Targets. Semin Thromb Hemost 2021; 47:589-600. [PMID: 33878784 DOI: 10.1055/s-0041-1725096] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Sepsis is a life-threatening condition which develops as a dysregulated immune response in the face of infection and which is associated with profound hemostatic disturbances and in the most extreme cases disseminated intravascular coagulation (DIC). In addition, the fibrinolytic system is subject to alterations during infection and sepsis, and impaired fibrinolysis is currently considered a key player in sepsis-related microthrombus formation and DIC. However, we still lack reliable biomarkers to assess fibrinolysis in the clinical setting. Furthermore, drugs targeting the fibrinolytic system have potential value in sepsis patients with severe fibrinolytic disturbances, but these are still being tested in the preclinical stage. The present review provides an overview of key fibrinolytic changes in sepsis, reviews the current literature on potential laboratory markers of altered fibrinolysis in adult sepsis patients, and discusses future perspectives for diagnosis and treatment of fibrinolytic disturbances in sepsis patients.
Collapse
Affiliation(s)
- Julie Brogaard Larsen
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| |
Collapse
|
7
|
Disrupted eNOS activity and expression account for vasodilator dysfunction in different stage of sepsis. Life Sci 2020; 264:118606. [PMID: 33091444 DOI: 10.1016/j.lfs.2020.118606] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/30/2020] [Accepted: 10/12/2020] [Indexed: 12/19/2022]
Abstract
AIMS Sepsis is a severe endothelial dysfunction syndrome. The role of endothelial nitric oxide synthase (eNOS) in endothelial dysfunction induced by sepsis is controversial. To explore the role of eNOS in vascular dysfunction. MAIN METHODS The effect of sepsis on vasodilation and eNOS levels was examined in septic mouse arteries and in cell models. KEY FINDINGS In early sepsis mouse arteries, endothelium-dependent relaxation decreased and phosphorylation of the inhibitory Thr495 site in endothelial nitric oxide synthase increased. Mechanically, the phosphorylation of endothelial nitric oxide synthase at Thr497 in bovine aortic endothelial cells occurred in a protein kinase C-α dependent manner. In late sepsis, both nitric oxide-dependent relaxation responses and endothelial nitric oxide synthase levels were decreased in septic mice arteries. Endothelial nitric oxide synthase levels expression levels decreased in tumor necrosis factor-α-treated human umbilical vein endothelial cells and this could be prevented by the ubiquitin proteasome inhibitor (MG-132). MG-132 could reverse the decrease in endothelial nitric oxide synthase expression and improve nitric oxide-dependent vasodilator dysfunction in septic mice arteries. SIGNIFICANCE These data indicate that vasodilator dysfunction is induced by the increased phosphorylation of endothelial nitric oxide synthase in early sepsis and its degradation in late sepsis.
Collapse
|
8
|
Moore HB, Gando S, Iba T, Kim PY, Yeh CH, Brohi K, Hunt BJ, Levy JH, Draxler DF, Stanworth S, Görlinger K, Neal MD, Schreiber MA, Barrett CD, Medcalf RL, Moore EE, Mutch NJ, Thachil J, Urano T, Thomas S, Scărlătescu E, Walsh M. Defining trauma-induced coagulopathy with respect to future implications for patient management: Communication from the SSC of the ISTH. J Thromb Haemost 2020; 18:740-747. [PMID: 32112533 DOI: 10.1111/jth.14690] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/12/2019] [Accepted: 11/25/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Hunter B Moore
- Department of Surgery, University of Colorado, Denver, CO, USA
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Paul Y Kim
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Calvin H Yeh
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON,, Canada
| | - Karim Brohi
- Queen Mary University of London, London, UK
- Centre for Trauma Sciences, London, UK
| | | | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Dominik F Draxler
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria,, Australia
| | - Simon Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre,, University of Oxford,, Oxford,, UK
| | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, Essen, Germany
- TEM Innovations GmbH, Munich, Germany
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Martin A Schreiber
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Christopher D Barrett
- Koch Institute for Integrative Cancer Research, Center for Precision Cancer Medicine, Massachusetts Institute of Technology, Cambridge, MA, USA
- Division of Acute Care Surgery and Critical Care, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Robert L Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria,, Australia
| | - Ernest E Moore
- Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - Nicola J Mutch
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| | - Tetsumei Urano
- Department of Medical Physiology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Scott Thomas
- Beacon Medical Group Trauma and Surgical Research Services, South Bend, IN, USA
| | - Ecaterina Scărlătescu
- Department of Anaesthesia and Intensive Care, Fundeni Clinical Institute, Bucharest, Romania
| | - Mark Walsh
- Beacon Medical Group Trauma and Surgical Research Services, South Bend, IN, USA
- Departments of Emergency and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, USA
- Indiana University School of Medicine, South Bend Campus, South Bend, IN, USA
| |
Collapse
|
9
|
Scarlatescu E, Juffermans NP, Thachil J. The current status of viscoelastic testing in septic coagulopathy. Thromb Res 2019; 183:146-152. [PMID: 31678709 DOI: 10.1016/j.thromres.2019.09.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 08/11/2019] [Accepted: 09/16/2019] [Indexed: 12/26/2022]
Abstract
Sepsis can be associated with different degrees of coagulopathy, ranging from a mild activation of the coagulation system to disseminated intravascular coagulation (DIC). The evaluation of haemostasis in the context of sepsis is important since it has been shown that anticoagulant therapies were beneficial mainly in patients with sepsis-induced DIC, but not in the general population of septic patients. Sepsis-induced haemostatic disturbances are not adequately reflected by standard coagulation tests (SCTs) which only consider the plasmatic components of the haemostatic system and not the cellular components. In addition, SCTs only assess the initiation phase of coagulation and reflect the activity of pro-coagulant factors, but lack sensitivity for the anticoagulant drive and the fibrinolytic activity. Viscoelastic tests (VET) are whole-blood tests which can assess clot formation and dissociation, and the contribution of both plasmatic and cellular components with a shorter turnaround time compared to SCTs. The use of VET in septic patients has proved useful for the assessment of the fibrinolytic activity, detecting hypercoagulable status and for the diagnosis of DIC and mortality risk prediction. While having relevant advantages over SCTs, the VET also present some blind spots or limitations leaving space for future improvement by the development of new reagents or new viscoelastic parameters.
Collapse
Affiliation(s)
- Ecaterina Scarlatescu
- Department of Anaesthesia and Intensive Care, Fundeni Clinical Institute, Bucharest, Romania.
| | - Nicole P Juffermans
- Department of Intensive Care, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, United Kingdom
| |
Collapse
|
10
|
Wu H, Wang X, Gao S, Dai L, Tong H, Gao H, Lei Z, Han Y, Wang Z, Han L, Qi D. Yiqi-Huoxue Granule (YQHX) Downregulates Prothrombotic Factors by Modulating KLF2 and NF- κB in HUVECs following LPS Stimulation. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2019; 2019:9425183. [PMID: 30881601 PMCID: PMC6381561 DOI: 10.1155/2019/9425183] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 10/27/2018] [Accepted: 11/27/2018] [Indexed: 12/31/2022]
Abstract
The Yiqi-Huoxue granule (YQHX) is a traditional Chinese medication widely used in the therapy of the traditional Chinese medicine diagnosis "Qi deficiency" or "blood stasis" in China. Both these symptoms are related to inflammation, but the mechanisms of YQHX against inflammation are largely unknown. Thus, our present study investigated the effects of YQHX on regulating inflammatory responses induced by lipopolysaccharides (LPS) in HUVECs. Our data found that YQHX remarkably inhibits the production of prothrombotic factors, plasminogen activator inhibitor-1 (PAI-1) and tissue factor (TF), while it upregulates the protein expression of Kruppel-like factor 2 (KLF2). The increase in PAI-1 and TF was significantly attenuated through a transgenic knockdown in KLF2 with a Lenti-shKLF2 vector. YQHX also decreases the phosphorylation of nuclear factor-κB (NF-κB) p65 and IκB following LPS stimulation, and it effectively suppresses PAI-1 and TF via a NF-κB-dependent mechanism. Taken together, our results suggest that YQHX provides a notable antithrombotic activity via regulating the KLF2 expression and NF-κB signaling pathway in HUVECs. The KLF2 and NF-κB may be potential therapeutic targets for interventions of inflammation associated with atherosclerosis.
Collapse
Affiliation(s)
- Hong Wu
- Laboratory of Cell Imaging, Henan University of Chinese Medicine, Zhengzhou 450002, China
- Institute of Cardiovascular Disease, Henan University of Chinese Medicine, Zhengzhou 450002, China
| | - Xinzhou Wang
- Laboratory of Cell Imaging, Henan University of Chinese Medicine, Zhengzhou 450002, China
| | - Shuibo Gao
- Laboratory of Cell Imaging, Henan University of Chinese Medicine, Zhengzhou 450002, China
| | - Liping Dai
- School of Pharmacy, Henan University of Chinese Medicine, Zhengzhou 450046, China
| | - Haibin Tong
- College of Life and Environmental Science, Wenzhou University, Wenzhou 325035, China
| | - Haixia Gao
- Laboratory of Cell Imaging, Henan University of Chinese Medicine, Zhengzhou 450002, China
| | - Zhen Lei
- Laboratory of Cell Imaging, Henan University of Chinese Medicine, Zhengzhou 450002, China
| | - Yongjun Han
- Laboratory of Cell Imaging, Henan University of Chinese Medicine, Zhengzhou 450002, China
| | - Zhentao Wang
- Institute of Cardiovascular Disease, Henan University of Chinese Medicine, Zhengzhou 450002, China
| | - Lihua Han
- Institute of Cardiovascular Disease, Henan University of Chinese Medicine, Zhengzhou 450002, China
| | - Dake Qi
- Memorial University of Newfoundland, Division of Biomedical Sciences, Faculty of Medicine, Newfoundland, Canada A1B 3V6
| |
Collapse
|
11
|
Gando S, Mayumi T, Ukai T. The roles of activated protein C in experimental trauma models. Chin J Traumatol 2018; 21:311-315. [PMID: 30594428 PMCID: PMC6354177 DOI: 10.1016/j.cjtee.2018.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/01/2018] [Accepted: 06/19/2018] [Indexed: 02/04/2023] Open
Abstract
Trauma-induced coagulopathy is classified into primary and secondary coagulopathy, with the former elicited by trauma and traumatic shock itself and the latter being acquired coagulopathy induced by anemia, hypothermia, acidosis, and dilution. Primary coagulopathy consists of disseminated intravascular coagulation and acute coagulopathy of trauma shock (ACOTS). The pathophysiology of ACOTS is the suppression of thrombin generation and neutralization of plasminogen activator inhibitor-1 mediated by activated protein C that leads to hypocoagulation and hyperfibrinolysis in the circulation. This review tried to clarify the validity of activated protein C hypothesis that constitutes the main pathophysiology of the ACOTS in experimental trauma models.
Collapse
Affiliation(s)
- Satoshi Gando
- Acute and Critical Care Center, Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Japan,Corresponding author.
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Tomohiko Ukai
- Department of Social Medicine, Graduate School of Medicine, Osaka University, Japan
| |
Collapse
|
12
|
|
13
|
Abstract
Despite progress in antibiotic treatment, mechanical ventilation, fluid resuscitation and blood glucose maintenance, sepsis remains a cause of high mortality in the intensive care unit to date, there are no proven treatment strategies for the routine management of septic patients. The extensive interaction between inflammation and coagulation contributes to the basic pathophysiology of sepsis. Thus, the agents that attenuate the activation of both inflammation and coagulation may improve the outcome in sepsis. Apart from the well-known anticoagulant effects of heparin, it also possesses various immunomodulatory properties and protects glycocalyx from shedding. Hence, heparin seems to be such an agent. Immunothrombosis plays an important role in early host defence against bacterial dissemination, thus the proper timing for anticoagulant therapy should be determined. We review the available experimental and clinical data supporting the use of heparin in sepsis. At this time the use of heparin in the treatment of sepsis is conflicting. Future trials of heparin therapy for sepsis should concentrate on the very severely ill patients, in whom benefit is most likely to be demonstrated.
Collapse
Affiliation(s)
- Xu Li
- Department of Intensive Care Unit, the First Affiliated Hospital, China Medical University, Shenyang, Liaoning Province, China
| | - Xiaochun Ma
- Department of Intensive Care Unit, the First Affiliated Hospital, China Medical University, Shenyang, Liaoning Province, China
| |
Collapse
|
14
|
Park SI, Kim J, Yu KS, Jang IJ, Lee S. Changes in Cardiac Function After a Single Intravenous Administration of CKD-712 in Healthy Male Volunteers. Clin Drug Investig 2017; 37:393-403. [PMID: 28160190 DOI: 10.1007/s40261-017-0494-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES CKD-712, a candidate treatment for septic shock, acts by increasing cardiac output. This study investigated changes in the pharmacodynamics, pharmacokinetics, and tolerability of CKD-712 after a single intravenous administration. METHODS A dose-block-randomized, double-blind, placebo-controlled, single-dose escalation study was conducted in 44 healthy subjects receiving 20, 40, 80, 160, 240, or 320 μg/kg CKD-712 or placebo. Pharmacodynamics were evaluated using computerized impedance cardiography, vital signs, platelet aggregation, and bleeding time. Serial blood and urine samples for pharmacokinetic analysis were collected up to 12 and 24 h, respectively, after the initiation of intravenous drug infusion. Tolerability assessments were performed throughout the study. RESULTS The area under the effect-time curve of the cardiac index (AUECCI) and systolic blood pressure (AUECSBP) changed significantly with the 160 and 320 µg/kg doses of CKD-712 compared with placebo. Furthermore, the AUECCI and AUECSBP tended to increase as the systemic exposure of CKD-712 increased from 20 to 240 µg/kg. The frequency of drug-related adverse events (AEs), including cardiovascular symptoms, was higher with the 320 µg/kg dose. CONCLUSION The pharmacological effects and on-target AEs of CKD-712 increased relative to the dose increments. The results of this study suggest that potentially therapeutic doses of CKD-712 could range from 160 to 240 μg/kg.
Collapse
Affiliation(s)
- Sang-In Park
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
| | - JaeWoo Kim
- Clinical Trials Center, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Kyung-Sang Yu
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
| | - In-Jin Jang
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
| | - SeungHwan Lee
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea.
| |
Collapse
|
15
|
Affiliation(s)
- JJ Emeis
- Gaubius Laboratory TNO-PG, Leiden, The Netherlands
| |
Collapse
|
16
|
Bahador M, Cross AS. Review: From therapy to experimental model: a hundred years of endotoxin administration to human subjects. ACTA ACUST UNITED AC 2016; 13:251-79. [DOI: 10.1177/0968051907085986] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This article is a review of studies in which endotoxin has been administered to human subjects for experimental purposes. Data are presented in tabular form so the reader can better appreciate the objectives of individual studies. Although the original intention was to focus on the adverse events associated with these studies, unexpected serious adverse events rarely have been reported.
Collapse
Affiliation(s)
- Marjan Bahador
- Center for Vaccine Development and Division of Infectious Diseases, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA,
| | - Alan S. Cross
- Center for Vaccine Development and Division of Infectious Diseases, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
17
|
Kennedy AR, Maity A, Sanzari JK. A Review of Radiation-Induced Coagulopathy and New Findings to Support Potential Prevention Strategies and Treatments. Radiat Res 2016; 186:121-40. [PMID: 27459701 DOI: 10.1667/rr14406.1] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Results from our recent studies have led to the novel hypothesis that radiation-induced coagulopathy (RIC) and associated hemorrhage occurring as part of the acute radiation syndrome (ARS) is a major cause of death resulting from radiation exposure in large mammals, including humans. This article contains information related to RIC, as well as potential strategies for the prevention and treatment of RIC. In addition, new findings are reported here on the occurrence of RIC biomarkers in humans exposed to radiation. To determine whether irradiated humans have RIC biomarkers, blood samples were obtained from radiotherapy patients who received treatment for different types of malignancies. Blood samples from allogeneic hematopoietic cell transplantation (allo-HCT) patients obtained before, during and after irradiation indicated that exposure led to prolonged clot formation times, increased levels of thrombin-antithrombin III (TAT) complex and increased circulating nucleosome/histone (cNH) levels, which suggest potential coagulopathies in the allo-HCT patients. Since these allo-HCT patients received chemotherapy prior to radiotherapy, it is possible that the chemical agents could have influenced the observed results. Frozen plasma samples from radiotherapy patients with prostate, lung and breast cancer were also obtained for analyses of cNH levels. The results indicated that some of these patients had very high cNH blood levels. Analysis of cNH levels in plasma samples from irradiated ferrets also indicated increased cNH levels compared to preirradiation baseline levels. The results from irradiated animals and some radiotherapy patients suggest the possibility that anti-histone antibodies, which block the toxic effects of elevated cNH levels in the blood, might be useful as therapeutic agents for adverse biological radiation-induced effects. The detection of increased levels of cNH in some radiotherapy patient blood samples demonstrates its potential as a biomarker for diagnosing and/or predicting the propensity for developing coagulopathies/hemorrhage, offering possible treatment options with personalized medicine therapies for cancer patients.
Collapse
Affiliation(s)
- Ann R Kennedy
- Department of Radiation Oncology Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amit Maity
- Department of Radiation Oncology Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jenine K Sanzari
- Department of Radiation Oncology Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
18
|
Abstract
Sepsis is a serious clinical problem involving complex mechanisms which requires better understanding and insight. Animal models of sepsis have played a major role in providing insight into the complex pathophysiology of sepsis. There have been various animal models of sepsis with different paradigms. Endotoxin, bacterial infusion, cecal ligation and puncture, and colon ascendens stent peritonitis models are the commonly practiced methods at present. Each of these models has their own advantages and also confounding factors. We have discussed the underlying mechanisms regulating each of these models along with possible reasons why each model failed to translate into the clinic. In animal models, the timing of development of the hemodynamic phases and the varied cytokine patterns could not accurately resemble the progression of clinical sepsis. More often, the exuberant and transient pro-inflammatory cytokine response is only focused in most models. Immunosuppression and apoptosis in the later phase of sepsis have been found to cause more damage than the initial acute phase of sepsis. Likewise, better understanding of the existing models of sepsis could help us create a more relevant model which could provide solution to the currently failed clinical trials in sepsis.
Collapse
|
19
|
Abstract
Disseminated intravascular coagulation (DIC) is an acquired syndrome characterized by widespread intravascular activation of coagulation that can be caused by infectious insults (such as sepsis) and non-infectious insults (such as trauma). The main pathophysiological mechanisms of DIC are inflammatory cytokine-initiated activation of tissue factor-dependent coagulation, insufficient control of anticoagulant pathways and plasminogen activator inhibitor 1-mediated suppression of fibrinolysis. Together, these changes give rise to endothelial dysfunction and microvascular thrombosis, which can cause organ dysfunction and seriously affect patient prognosis. Recent observations have pointed to an important role for extracellular DNA and DNA-binding proteins, such as histones, in the pathogenesis of DIC. The International Society on Thrombosis and Haemostasis (ISTH) established a DIC diagnostic scoring system consisting of global haemostatic test parameters. This scoring system has now been well validated in diverse clinical settings. The theoretical cornerstone of DIC management is the specific and vigorous treatment of the underlying conditions, and DIC should be simultaneously managed to improve patient outcomes. The ISTH guidance for the treatment of DIC recommends treatment strategies that are based on current evidence. In this Primer, we provide an updated overview of the pathophysiology, diagnosis and management of DIC and discuss the future directions of basic and clinical research in this field.
Collapse
|
20
|
Kanno Y, Ishisaki A, Kawashita E, Kuretake H, Ikeda K, Matsuo O. uPA Attenuated LPS-induced Inflammatory Osteoclastogenesis through the Plasmin/PAR-1/Ca(2+)/CaMKK/AMPK Axis. Int J Biol Sci 2016; 12:63-71. [PMID: 26722218 PMCID: PMC4679399 DOI: 10.7150/ijbs.12690] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 08/25/2015] [Indexed: 02/03/2023] Open
Abstract
Chronic inflammatory diseases, such as rheumatoid arthritis and periodontitis-caused bone destruction, results from an increase of bone-resorbing osteoclasts (OCs) induced by inflammation. However, the detailed mechanisms underlying this disorder remain unclear. We herein investigated that the effect of urokinase-type plasminogen activator (uPA) on inflammatory osteoclastogenesis induced by lipopolysaccharide (LPS), which is a potent stimulator of bone resorption in inflammatory diseases. We found that the uPA deficiency promoted inflammatory osteoclastogenesis and bone loss induced by LPS. We also showed that LPS induced the expression of uPA, and the uPA treatment attenuated the LPS-induced inflammatory osteoclastogenesis of RAW264.7 mouse monocyte/macrophage lineage cells. Additionally, we showed that the uPA-attenuated inflammatory osteoclastgenesis is associated with the activation of plasmin/protease-activated receptor (PAR)-1 axis by uPA. Moreover, we examined the mechanism underlying the effect of uPA on inflammatory osteoclastogenesis, and found that uPA/plasmin/PAR-1 activated the adenosine monophosphate-activated protein kinase (AMPK) pathway through Ca2+/calmodulin dependent protein kinase kinase (CaMKK) activation, and attenuated inflammatory osteoclastogenesis by inactivation of NF-κB in RAW264.7 cells. These data suggest that uPA attenuated inflammatory osteoclastogenesis through the plasmin/PAR-1/Ca2+/CaMKK/AMPK axis. Our findings may provide a novel therapeutic approach to bone loss caused by inflammatory diseases.
Collapse
Affiliation(s)
- Yosuke Kanno
- 1. Department of Clinical Pathological Biochemistry, Faculty of Pharmaceutical Science, Doshisha Women's College of Liberal Arts, 97-1 Kodo Kyo-tanabe, Kyoto 610-0395, Japan
| | - Akira Ishisaki
- 2. Division of Cellular Biosignal Sciences, Department of Biochemistry, Iwate Medical University, 2-1-1 Nishitokuta, Yahaba-cho, Shiwa-gun, Iwate 028-3694, Japan
| | - Eri Kawashita
- 1. Department of Clinical Pathological Biochemistry, Faculty of Pharmaceutical Science, Doshisha Women's College of Liberal Arts, 97-1 Kodo Kyo-tanabe, Kyoto 610-0395, Japan
| | - Hiromi Kuretake
- 1. Department of Clinical Pathological Biochemistry, Faculty of Pharmaceutical Science, Doshisha Women's College of Liberal Arts, 97-1 Kodo Kyo-tanabe, Kyoto 610-0395, Japan
| | - Kanako Ikeda
- 1. Department of Clinical Pathological Biochemistry, Faculty of Pharmaceutical Science, Doshisha Women's College of Liberal Arts, 97-1 Kodo Kyo-tanabe, Kyoto 610-0395, Japan
| | - Osamu Matsuo
- 3. Kinki University Faculty of Medicine 377-2 Ohnohigashi, Osaka-sayama 589-8511, Japan
| |
Collapse
|
21
|
Panigada M, Zacchetti L, L’Acqua C, Cressoni M, Anzoletti MB, Bader R, Protti A, Consonni D, D’Angelo A, Gattinoni L. Assessment of Fibrinolysis in Sepsis Patients with Urokinase Modified Thromboelastography. PLoS One 2015; 10:e0136463. [PMID: 26308340 PMCID: PMC4550424 DOI: 10.1371/journal.pone.0136463] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 08/03/2015] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Impairment of fibrinolysis during sepsis is associated with worse outcome. Early identification of this condition could be of interest. The aim of this study was to evaluate whether a modified point-of-care viscoelastic hemostatic assay can detect sepsis-induced impairment of fibrinolysis and to correlate impaired fibrinolysis with morbidity and mortality. METHODS This single center observational prospective pilot study was performed in an adult Intensive Care Unit (ICU) of a tertiary academic hospital. Forty consecutive patients admitted to the ICU with severe sepsis or septic shock were included. Forty healthy individuals served as controls. We modified conventional kaolin activated thromboelastography (TEG) adding urokinase to improve assessment of fibrinolysis in real time (UK-TEG). TEG, UK-TEG, plasminogen activator inhibitor (PAI)-1, thrombin-activatable fibrinolysis inhibitor (TAFI), d-dimer, DIC scores and morbidity (rated with the SOFA score) were measured upon ICU admission. Logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (95% CIs) of mortality at ICU discharge. RESULTS UK-TEG revealed a greater impairment of fibrinolysis in sepsis patients compared to healthy individuals confirmed by PAI-1. TAFI was not different between sepsis patients and healthy individuals. 18/40 sepsis patients had fibrinolysis impaired according to UK-TEG and showed higher SOFA score (8 (6-13) vs 5 (4-7), p = 0.03), higher mortality (39% vs 5%, p = 0.01) and greater markers of cellular damage (lactate levels, LDH and bilirubin). Mortality at ICU discharge was predicted by the degree of fibrinolysis impairment measured by UK-TEG Ly30 (%) parameter (OR 0.95, 95% CI 0.93-0.98, p = 0.003). CONCLUSIONS Sepsis-induced impairment of fibrinolysis detected at UK-TEG was associated with increased markers of cellular damage, morbidity and mortality.
Collapse
Affiliation(s)
- Mauro Panigada
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
- * E-mail:
| | - Lucia Zacchetti
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Camilla L’Acqua
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Cressoni
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Boscolo Anzoletti
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Rossella Bader
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandro Protti
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Dario Consonni
- Epidemiology Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Armando D’Angelo
- Coagulation Service and Thrombosis Research Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Luciano Gattinoni
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
22
|
Foster JP, Richards R, Showell MG, Jones LJ. Intravenous in-line filters for preventing morbidity and mortality in neonates. Cochrane Database Syst Rev 2015; 2015:CD005248. [PMID: 26244380 PMCID: PMC9240919 DOI: 10.1002/14651858.cd005248.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: 11/06/2022]
Abstract
BACKGROUND Venous access is an essential part of caring for the sick neonate. However, problems such as contamination of fluids with bacteria, endotoxins and particulates have been associated with intravenous infusion therapy. Intravenous in-line filters claim to be an effective strategy for the removal of bacteria, endotoxins and particulates associated with intravenous therapy in adults and are increasingly being recommended for use in neonates. OBJECTIVES To determine the effect of intravenous in-line filters on morbidity and mortality in neonates. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group. We searched the electronic databases MEDLINE (from 1966 to May, 2015), EMBASE (from 1980 to May, 2015), CINAHL (from 1982 to May 2015) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 5). We did not impose any language restrictions. Further searching included cross references, abstracts, conferences, symposia proceedings, expert informants and journal handsearching. SELECTION CRITERIA We included randomised controlled trials (RCTs) or quasi-RCTs that compared the use of intravenous in-line filters with placebo or nothing in neonates. DATA COLLECTION AND ANALYSIS We followed the procedures of the Cochrane Neonatal Review Group throughout. We checked titles and abstracts identified from the search. We obtained the full text of all studies of possible relevance. We independently assessed the trials for their methodological quality and subsequent inclusion in the review. We contacted authors for further information as needed. Statistical analysis followed the procedures of the Cochrane Neonatal Review Group. MAIN RESULTS There were four eligible studies that recruited a total of 704 neonates. This review of low to very low quality evidence found that the use of in-line filters compared with unfiltered fluids for intravenous infusion had no statistically significant difference in effectiveness on overall mortality (typical RR 0.87, 95% CI 0.52 to 1.47; typical RD -0.01, 95% CI -0.06 to 0.04; two studies, 530 infants), proven and suspect septicaemia (typical RR 0.86, 95% CI 0.59 to 1.27; typical RD -0.02, 95% CI -0.09 to 0.04; two studies, 530 infants), or other secondary outcomes (including local phlebitis and thrombus, necrotising enterocolitis, duration of cannula patency, length of stay in hospital, number of catheters inserted and financial costs). AUTHORS' CONCLUSIONS There is insufficient evidence to recommend the use of intravenous in-line filters to prevent morbidity and mortality in neonates.
Collapse
Affiliation(s)
- Jann P Foster
- University of Western SydneySchool of Nursing & MidwiferySydneyAustralia
- University of SydneyCentral Clinical School, Discipline of Obstetrics, Gynaecology and NeonatologyCamperdownAustralia
- Ingham InstituteLiverpoolNSWAustralia
| | - Robyn Richards
- Liverpool HospitalNewborn CareLocked Bag 7103South Western Sydney Area Health ServiceLiverpoolNSWAustralia1871
| | - Marian G Showell
- University of AucklandObstetrics and GynaecologyPark Road GraftonAucklandNew Zealand
| | - Lisa J Jones
- University of SydneyCentral Clinical School, Discipline of Obstetrics, Gynaecology and NeonatologyCamperdownAustralia
| | | |
Collapse
|
23
|
White AFB, Demchenko AV. Modulating LPS signal transduction at the LPS receptor complex with synthetic Lipid A analogues. Adv Carbohydr Chem Biochem 2015; 71:339-89. [PMID: 25480508 DOI: 10.1016/b978-0-12-800128-8.00005-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Sepsis, defined as a clinical syndrome brought about by an amplified and dysregulated inflammatory response to infections, is one of the leading causes of death worldwide. Despite persistent attempts to develop treatment strategies to manage sepsis in the clinical setting, the basic elements of treatment have not changed since the 1960s. As such, the development of effective therapies for reducing inflammatory reactions and end-organ dysfunction in critically ill patients with sepsis remains a global priority. Advances in understanding of the immune response to sepsis provide the opportunity to develop more effective pharmaceuticals. This article details current information on the modulation of the lipopolysaccharide (LPS) receptor complex with synthetic Lipid A mimetics. As the initial and most critical event in sepsis pathophysiology, the LPS receptor provides an attractive target for antisepsis agents. One of the well-studied approaches to sepsis therapy involves the use of derivatives of Lipid A, the membrane-anchor portion of an LPS, which is largely responsible for its endotoxic activity. This article describes the structural and conformational requirements influencing the ability of Lipid A analogues to compete with LPS for binding to the LPS receptor complex and to inhibit the induction of the signal transduction pathway by impairing LPS-initiated receptor dimerization.
Collapse
Affiliation(s)
- Aileen F B White
- Dextra Laboratories Ltd., Science and Technology Centre, Earley Gate, Reading, United Kingdom.
| | - Alexei V Demchenko
- Department of Chemistry and Biochemistry, University of Missouri-St. Louis, One University Boulevard, St. Louis, Missouri, USA.
| |
Collapse
|
24
|
Chudý P, Chudá D, Ivanková J, Sinák I, Talapková R, Staško J, Kubisz P. Therapeutic angiogenesis improves fibrinolytic imbalance in patients with critical limb ischemia. Blood Coagul Fibrinolysis 2014; 25:156-60. [PMID: 24300022 DOI: 10.1097/mbc.0000000000000014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The mechanisms of fibrinolysis have been suggested to be linked to the pathogenesis of peripheral artery disease. The impact of therapeutic angiogenesis on the parameters of fibrinolysis was studied in critical limb ischemia (CLI). CLI patients (N = 29) and blood donors as controls (N = 29) were enrolled. Bone marrow (600 ± 50 ml) was centrifuged (3200g, 20 min, 22°C), bone marrow-derived mononuclear cells (100-120 ml) were separated by Optipress I and implanted into the ischemic limb using intramuscular injections. ELISA was employed for the assessment of plasma tissue plasminogen activator (t-PA) and plasminogen activator inhibitor-1 (PAI-1) levels. Patients were followed-up prior to the procedure and after 1, 3 and 6 months. All stage-IV patients (N = 22) had ischemic lesions. The lesions resolved in 10 patients. Five patients underwent major amputation; they all were stage-IV. Ischemic lesions persisted in seven patients beyond 6 months. The t-PA levels were higher in patients compared with the healthy controls both at baseline (P < 0.01) and after 6 months (P < 0.05). No significant changes were observed in the t-PA levels during the follow-up. PAI-1 was higher in patients than in the healthy individuals at baseline (P < 0.001) and at month 1 (P < 0.05). However, no difference in PAI-1 levels between the patients and the healthy individuals was found after 3 and 6 months. The PAI-1 levels were significantly downregulated during the follow-up compared with the baseline (P < 0.0001). Therapeutic angiogenesis for the CLI downregulates PAI-1 levels, thus having a systemic effect on fibrinolysis.
Collapse
Affiliation(s)
- Peter Chudý
- aDepartment of Hematology and Blood Transfusion, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin University Hospital bNational Transfusion Service of the Slovak Republic cDepartment of Transplant and Vascular Surgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin University Hospital, Martin, Slovakia
| | | | | | | | | | | | | |
Collapse
|
25
|
Lorente L, Martín MM, Borreguero-León JM, Solé-Violán J, Ferreres J, Labarta L, Díaz C, Jiménez A, Páramo JA. Sustained high plasma plasminogen activator inhibitor-1 levels are associated with severity and mortality in septic patients. Thromb Res 2014; 134:182-6. [PMID: 24814968 DOI: 10.1016/j.thromres.2014.04.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 03/26/2014] [Accepted: 04/17/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Higher plasma plasminogen activator inhibitor-1 (PAI-1) levels have been reported in septic patients. However, some questions remain unanswered, such as whether there is an association between plasma PAI-1 levels and sepsis severity and mortality, and inflammation state during the first week. METHODS Multicenter, observational and prospective study carried out in six Spanish Intensive Care Units of 260 patients with severe sepsis. Circulating levels of PAI-1 and tumour necrosis factor (TNF)-α were measured at day 1, 4 and 8. End-point was 30-day mortality. RESULTS Nonsurviving septic patients (n=89) presented higher PAI-1 levels than surviving (n=171) at day 1 (58.4 (33.3-83.8) vs 36.5 (21.1-62.5) ng/mL; p<0.001), 4 (34.0 (14.7-53.3) vs 16.2 (10.2-27.4) ng/mL; p<0.001) and 8 (30.6 (16.2-47.8) vs 18.9 (10.4-29.5) ng/mL; p=0.004). We found a positive correlation of PAI-1 levels with SOFA, lactic acid, aPTT, INR and TNF-α, and negative with platelet count at day 1, 4 and 8. Logistic regression analyses showed that PAI-1 levels at day 1 (p<0.001), 4 (p<0.001) and 8 (p=0.001) were associated with 30-day mortality. On ROC curve analysis to predict 30- day survival, the area under the curve of PAI-1 levels at day 1, 4 and 8 were 0.65 (95% CI=0.58-0.72; p<0.001), 0.69 (95% CI=0.60-0.78; p<0.001) and 0.65 (95% CI=0.54-0.75; p=0.005) respectively. CONCLUSIONS The most interesting findings of our study, to our knowledge the largest series reporting PAI-1 levels during follow-up in septic patients, were that plasma PAI-1 levels during the first week were associated with inflammation, severity and mortality.
Collapse
Affiliation(s)
- Leonardo Lorente
- Intensive Care Unit, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain.
| | - María M Martín
- Intensive Care Unit. Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Juan M Borreguero-León
- Laboratory Deparment, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain
| | - Jordi Solé-Violán
- Intensive Care Unit, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - José Ferreres
- Intensive Care Unit, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Lorenzo Labarta
- Intensive Care Unit, Hospital San Jorge de Huesca, Huesca, Spain
| | - César Díaz
- Intensive Care Unit, Hospital Insular, Las Palmas de Gran Canaria, Spain
| | - Alejandro Jiménez
- Research Unit, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain
| | - José A Páramo
- Atherosclerosis Research Laboratory, CIMA, University of Navarra, Pamplona, Spain
| |
Collapse
|
26
|
Weisshaar S, Gouya G, Nguyen D, Kapiotis S, Wolzt M. The LPS-induced increase in circulating microparticles is not affected by vitamin C in humans. Eur J Clin Invest 2013; 43:708-15. [PMID: 23594362 DOI: 10.1111/eci.12096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Accepted: 03/19/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Microparticles (MP) are considered to promote coagulation. This study aimed to characterize the time course of MP levels and the effect of high-dose vitamin C on MP formation during inflammation in an in vivo Escherichia coli endotoxin (LPS) model. METHODS Microparticle formation was studied in 14 male subjects in a cross-over trial who received either intravenous vitamin C at 320 mg/kg body weight (BW) or 480 mg/kg BW or saline solution in a random order on alternate trial days 3 h after intravenous exposure to LPS (2 ng/kg BW). Venous blood samples were taken before, 3 and 6 h after LPS. D-dimer, leucocyte count, C-reactive protein, plasma vitamin C and body temperature were assessed as inflammatory parameters. MP were detected using flow cytometric analysis and expressed in 10³ MP/mL plasma. RESULTS Microparticles levels were decreased from baseline 848 units [range 431-1705] by 21% to 671 units [253-1586] at 3 h and increased by 32% to 1119 units [288-4443] at 6 h after LPS. This pattern was not influenced by administration of vitamin C, with a change from 730 units [399-1396] at baseline by an increase to 832 units [215-2168] at 3 h to 1055 units [350-4858] at 6 h. MP subpopulations followed similar dynamics. Alterations in inflammatory parameters were independent from vitamin C administration during endotoxemia. CONCLUSION Microparticles are increased in acute systemic inflammation with inconsistent changes in MP subgroups in healthy subjects. Systemic vitamin C administration does not mitigate MP formation and D-dimer levels during acute systemic inflammation, suggesting that MP-induced coagulation activity is not affected by vitamin C.
Collapse
Affiliation(s)
- Stefan Weisshaar
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | | | | | | | | |
Collapse
|
27
|
Gando S, Wada H, Thachil J. Differentiating disseminated intravascular coagulation (DIC) with the fibrinolytic phenotype from coagulopathy of trauma and acute coagulopathy of trauma-shock (COT/ACOTS). J Thromb Haemost 2013; 11:826-35. [PMID: 23522358 DOI: 10.1111/jth.12190] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Accepted: 02/25/2013] [Indexed: 11/28/2022]
Abstract
Two concepts have been proposed for the hemostatic changes occurring early after trauma. Disseminated intravascular coagulation (DIC) with the fibrinolytic phenotype is characterized by activation of the coagulation pathways, insufficient anticoagulant mechanisms and increased fibrinolysis. Coagulopathy of trauma and acute coagulopathy of trauma-shock (COT/ACOTS) occurs as a result of increased activation of the thrombomodulin and protein C pathways, leading to the suppression of coagulation and activation of fibrinolysis. Despite the differences between these two conditions, independent consideration of COT/ACOTS from DIC with the fibrinolytic phenotype is probably incorrect. Robust diagnostic criteria based on its pathophysiology are required to establish COT/ACOTS as a new independent disease concept. In addition, the independency of its characteristics, laboratory data, time courses and prognosis from DIC should be confirmed. Confusion between two concepts may be based on studies of trauma lacking the following: (i) a clear distinction of the properties of blood between the inside and outside of vessels, (ii) a clear distinction between physiologic and pathologic hemostatic changes, (iii) attention to the time courses of the changes in hemostatic parameters, (iv) unification of the study population, and (v) recognition that massive bleeding is not synonymous with coagulation disorders. More information is needed to elucidate the pathogenesis of these two entities, DIC with the fibrinolytic phenotype and COT/ACOTS after trauma. However, available data suggest that COT/ACOTS is not a new concept but a disease entity similar to or the same as DIC with the fibrinolytic phenotype.
Collapse
Affiliation(s)
- S Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
| | | | | |
Collapse
|
28
|
Cornet AD, Hofstra JJ, Vlaar AP, Tuinman PR, Levi M, Girbes AR, Schultz MJ, Groeneveld AB, Beishuizen A. Activated protein C attenuates pulmonary coagulopathy in patients with acute respiratory distress syndrome. J Thromb Haemost 2013; 11:894-901. [PMID: 23433188 PMCID: PMC9906436 DOI: 10.1111/jth.12179] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Accepted: 02/15/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Acute respiratory distress syndrome (ARDS) frequently complicates critical illness. We hypothesized that an infusion of recombinant human activated protein C (rh-APC), a natural anticoagulant, would attenuate pulmonary coagulopathy and injury. METHODS In this sub study of a multicenter open-label randomized controlled trial of patients with ARDS, we compared an intravenous (i.v.) infusion of rh-APC (24 mcg kg(-1) h(-1) for 96 h) with placebo. Patients with sepsis or septic shock were excluded. RESULTS In 27 patients serial non-directed bronchoalveolar lavage fluid (NBLF) samples were obtained: 16 patients were treated with rh-APC and 11 patients with placebo. The rh-APC infusion was associated with higher APC levels in plasma during the infusion period of 4 days (P = 0.001), as well as higher APC levels in NBLF up to day 5 after the start of the infusion (P = 0.028). An infusion of rh-APC was associated with lower levels of thrombin-antithrombin complexes (P = 0.009) and soluble tissue factor (P = 0.011) in NBLF, compared with treatment with placebo. An infusion of rh-APC affected fibrinolysis, as plasminogen activator activity levels in NBLF were higher in the patients treated with rh-APC (P = 0.01), presumably as a result of lower NBLF levels of plasminogen activator inhibitor 1, (P = 0.01). The rh-APC infusion decreased the lung injury score (P = 0.005) and simplified the acute physiology score (P = 0.013) on day 5, when compared with baseline. The rh-APC infusion was not associated with bleeding complications. CONCLUSION An infusion of rh-APC in patients with ARDS attenuates pulmonary coagulopathy and injury.
Collapse
Affiliation(s)
- A D Cornet
- Department of Intensive Care Medicine, VU University Medical Center Amsterdam, Amsterdam, The Netherlands.
| | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Crocetin administration ameliorates endotoxin-induced disseminated intravascular coagulation in rabbits. Blood Coagul Fibrinolysis 2013; 24:305-10. [DOI: 10.1097/mbc.0b013e32835bdc8f] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
30
|
Morris ME, Maijub JG, Walker SK, Gardner GP, Jones RG. Meningococcal sepsis and purpura fulminans: the surgical perspective. Postgrad Med J 2013; 89:340-5. [PMID: 23389283 DOI: 10.1136/postgradmedj-2012-130989] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Meningococcal sepsis and purpura fulminans is a rare but highly lethal disease process that requires a multidisciplinary team of experts to optimise morbidity and mortality outcomes due to the breadth of complications of the disease. The surgical perspective involves the critical care management which utilises all currently available measured outcomes of critical care management as well as experimental therapies. Limb loss is common, and is reflective of the high incidence of compartment syndrome compounded by the significant soft tissue loss secondary to purpura and limb ischaemia, presumptively due to digital microemboli. A multidisciplinary approach involving current standards in critical care and early surgical evaluation are important in improving patient outcomes and limb salvage.
Collapse
Affiliation(s)
- Marvin E Morris
- Department of Surgery, University of Louisville School of Medicine, Louisville, KY 40202, USA.
| | | | | | | | | |
Collapse
|
31
|
SuPAR and PAI-1 in critically ill, mechanically ventilated patients. Intensive Care Med 2012; 39:489-96. [PMID: 23100007 DOI: 10.1007/s00134-012-2730-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Accepted: 10/04/2012] [Indexed: 01/19/2023]
Abstract
PURPOSE SuPAR (soluble urokinase plasminogen activator receptor) and PAI-1 (plasminogen activator inhibitor 1) are active in the coagulation-fibrinolysis pathway. Both have been suggested as biomarkers for disease severity. We evaluated them in prediction of mortality, acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), sepsis and renal replacement therapy (RRT) in operative and non-operative ventilated patients. METHODS We conducted a prospective, multicenter, observational study. Blood samples and data of intensive care were collected. Mechanically ventilated patients with baseline suPAR and PAI-1 measurements were included in the analysis, and healthy volunteers were analysed for comparison. Receiver operating characteristics (ROC), logistic regression, likelihood ratios and Kaplan-Meier analysis were performed. RESULTS Baseline suPAR was 11.6 ng/ml (quartiles Q1-Q3, 9.6-14.0), compared to healthy volunteers with suPAR of 0.6 ng/ml (0.5-11.0). PAI-1 concentrations were 2.67 ng/ml (1.53-4.69) and 0.3 ng/ml (0.3-0.4), respectively. ROC analysis for suPAR 90-day mortality areas under receiver operating characteristic curves (AUC) 0.61 (95 % confidence interval (CI): 0.55-0.67), sepsis 0.68 (0.61-0.76), ALI/ARDS 0.64 (0.56-0.73) and RRT 0.65 (0.56-0.73). Patients with the highest quartile of suPAR concentrations had an odds ratio of 2.52 (1.37-4.64, p = 0.003) for 90-day mortality and 3.16 (1.19-8.41, p = 0.02) for ALI/ARDS. In non-operative patients, the AUC's for suPAR were 90-day mortality 0.61 (0.54-0.68), RRT 0.73 (0.64-0.83), sepsis 0.70 (0.60-0.80), ALI/ARDS 0.61 (0.51-0.71). Predictive value of PAI-1 was negligible. CONCLUSIONS In non-operative patients, low concentrations of suPAR were predictive for survival and high concentrations for RRT and mortality. SuPAR may be used for screening for patients with potentially good survival. The association with RRT may supply an early warning sign for acute renal failure.
Collapse
|
32
|
Calvano SE, Coyle SM. Experimental human endotoxemia: a model of the systemic inflammatory response syndrome? Surg Infect (Larchmt) 2012; 13:293-9. [PMID: 23072275 DOI: 10.1089/sur.2012.155] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The normal human intravenous endotoxin model has been used for more than 50 years. It was once considered a possible model of sepsis, but, because no infection is present, it is better described as a model of systemic inflammation. We demonstrate herein that at least three of four systemic inflammatory response syndrome (SIRS) criteria are achieved with the model. METHODS Otherwise healthy human volunteers were given Escherichia coli endotoxin 2 ng/kg intravenously. Vital signs were monitored, and blood samples were collected over time for assessment of white blood cells (WBCs), cytokines, counter-regulatory hormones, and monocyte receptors. RESULTS The means of three variables (core temperature, heart rate, WBC) met the SIRS criteria. Compared with baseline, cytokines were elevated acutely, with tumor necrosis factor-alpha (TNFα) exhibiting temporal primacy over the other cytokines. Counter-regulatory hormones (cortisol, epinephrine) also were elevated acutely. Finally, the monocyte cell-surface receptors cluster of differentiation molecule (CD) 11b and TNF receptor-II were elevated and decreased, respectively. CONCLUSIONS The experimental human endotoxin model satisfies SIRS criteria and probably is best described as a model of Toll-like receptor 4 agonist-induced systemic inflammation.
Collapse
Affiliation(s)
- Steve E Calvano
- Department of Surgery, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA.
| | | |
Collapse
|
33
|
Raeven P, Feichtinger GA, Weixelbaumer KM, Atzenhofer S, Redl H, Van Griensven M, Bahrami S, Osuchowski MF. Compartment-specific expression of plasminogen activator inhibitor-1 correlates with severity/outcome of murine polymicrobial sepsis. Thromb Res 2012; 129:e238-45. [DOI: 10.1016/j.thromres.2012.02.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 01/24/2012] [Accepted: 02/05/2012] [Indexed: 01/28/2023]
|
34
|
Wong HR. Clinical review: sepsis and septic shock--the potential of gene arrays. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:204. [PMID: 22316118 PMCID: PMC3396217 DOI: 10.1186/cc10537] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Over the past decade several investigators have applied microarray technology and related bioinformatic approaches to clinical sepsis and septic shock, thus allowing for an assessment of how, or if, this branch of genomic medicine has meaningfully impacted the field of sepsis research. The ability to simultaneously and efficiently measure the steady-state mRNA abundance of thousands of transcripts from a given tissue source (that is, 'transcriptomics') has provided an unprecedented opportunity to gain a broader, genome-level 'picture' of complex and heterogeneous clinical syndromes such as sepsis. A trancriptomic approach to sepsis and septic shock is technically challenging on multiple levels, but nonetheless modest, tangible advances are being realized. These include a genome-level understanding of the complexity of sepsis and septic shock, identification of novel candidate pathways and targets for potential intervention, discovery of novel, candidate diagnostic and stratification biomarkers, and the ability to stratify patients into clinically relevant, expression-based subclasses. The challenges moving forward include robust validation studies, standardization of technical approaches, standardization and further development of analytical algorithms, and large-scale collaborations.
Collapse
Affiliation(s)
- Hector R Wong
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45229-3039, USA.
| |
Collapse
|
35
|
Hook KM, Abrams CS. The loss of homeostasis in hemostasis: new approaches in treating and understanding acute disseminated intravascular coagulation in critically ill patients. Clin Transl Sci 2012; 5:85-92. [PMID: 22376264 PMCID: PMC5439915 DOI: 10.1111/j.1752-8062.2011.00351.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Disseminated intravascular coagulation (DIC) profoundly increases the morbidity and mortality of patients who have sepsis. Both laboratory and clinical research advanced the understanding of the biology and pathophysiology of DIC. This, in turn, gave rise to improved therapies and patient outcomes. Beginning with a stimulus causing disruption of vascular integrity, cytokines and chemokines cause activation of systemic coagulation and inflammation. Seemingly paradoxically, the interplay between coagulation and inflammation also inhibits endogenous anticoagulants, fibrinolytics, and antiinflammatory pathways. The earliest documented and best-studied microbial cause of DIC is the lipopolysaccharide endotoxin of Gram-negative bacteria. Extensive microvascular thrombi emerge in the systemic vasculature due to dysregulation of coagulation. The result of this unrestrained, widespread small vessel thromboses multiorgan system failure. Consumption of platelets and coagulation factors during this process can lead to an elevated risk of hemorrhage. The management of these patients with simultaneous hemorrhage and thrombosis is complex and challenging. Definitive treatment of DIC, and attenuation of end-organ damage, requires control of the inciting cause. Currently, activated protein C is the only approved therapy in the United States for sepsis complicated by DIC. Further research is needed in this area to improve clinical outcomes for patients with sepsis.
Collapse
Affiliation(s)
- Karen M Hook
- Division of Hematology/Oncology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.
| | | |
Collapse
|
36
|
|
37
|
Abstract
The treatment of sepsis is an ongoing challenge for clinicians; despite the wide choice of effective antibiotics to treat infection, sepsis remains the leading cause of morbidity and mortality for patients admitted to an intensive care unit. Dysregulation of the immune response is now recognized to be a key factor in multiple organ dysfunction, yet our therapy for inflammation remains ineffective. It has been advocated for more than a decade that cytokine reduction in blood compartment could lead to a reduction in mortality in sepsis. Over the years, multiple extracorporeal techniques have evolved, with the intent of influencing the circulating levels of inflammatory mediators like cytokines and chemokines, the complement system, as well as factors of the coagulation system. These include high-volume hemofiltration, use of high cutoff membranes, and systems based on adsorption, such as coupled plasma filtration adsorption and the polymyxin-B column. In addition, new experimental systems that utilize human phagocytic cells and immobilized antibodies for targeted immunomodulation have emerged. In the context of limited resources and growing expansion in the availability of technologies, a better understanding of these therapies is required before they can be properly integrated into standard clinical practice in the hope of influencing major clinical outcomes. In this article, we will provide a concise overview of selected extracorporeal modalities currently in clinical use and briefly introduce some new promising techniques for sepsis.
Collapse
Affiliation(s)
- Anthi Panagiotou
- Department of Nephrology Dialysis & Transplantation, San Bortolo Hospital, Vicenza, Italy
| | | | | |
Collapse
|
38
|
Abstract
Nucleotides, including ADP, ATP and uridine triphosphate (UTP), are discharged profusely in the circulation during many pathological conditions including sepsis. Sepsis can cause hypotension and systemic activation of the coagulation and fibrinolytic systems in humans, which may cause disseminated intravascular coagulation. We investigated whether nucleotide-induced cardiovascular collapse as provoked by systemic infusion of adenosine, ADP, ATP, UTP and nitric oxide affected the haemostatic system as assessed by whole blood thromboelastography (TEG) analysis. Ten pigs received a randomized infusion of adenosine, ADP, ATP, UTP or nitric oxide until mean arterial pressure was reduced to approximately 40% of baseline simulating sepsis-induced hypotension. The effect of the infusions on the haemostatic system was evaluated by TEG, and endothelial release of tissue plasminogen activator and plasminogen activator inhibitor-1 was measured. In contrast to the other infused substrates, ADP caused a reduction in maximum amplitude (71.4 to 64.2; P < 0.05), and reduced the angle, representing the thrombus formation (75.6 to 66.4; P < 0.05), indicating hypocoagulation. Despite increases in t-PA release (2.1 to 2.7 ng/ml; P < 0.05) and reductions in plasminogen activator inhibitor (33.9 +/- 10.9-17.8 +/- 4.4 ng/ml; P < 0.05) no increased fibrinolysis was found when whole blood was evaluated by TEG. Circulating ADP induces hypocoagulation without signs of increased fibrinolysis as evaluated by TEG. The potential clinical significance of these findings should be investigated further because ADP discharged systemically may possibly contribute to the coagulopathy observed in severe sepsis.
Collapse
|
39
|
Schöchl H, Solomon C, Schulz A, Voelckel W, Hanke A, Van Griensven M, Redl H, Bahrami S. Thromboelastometry (TEM) findings in disseminated intravascular coagulation in a pig model of endotoxinemia. Mol Med 2010; 17:266-72. [PMID: 21170471 DOI: 10.2119/molmed.2010.00159] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Accepted: 12/14/2010] [Indexed: 11/06/2022] Open
Abstract
Standard coagulation tests have a low specificity and sensitivity for diagnosing disseminated intravascular coagulation. The aim of this study was to determine whether whole blood thromboelastometry (TEM) detects lipopolysaccharide (LPS)-induced changes in coagulation. Blood samples from 10 pigs were drawn at baseline, before and at the end of LPS infusion and 2, 3, 4 and 5 h after the start of endotoxinemia. Simultaneous to TEM, standard coagulation tests and extended coagulation analysis including tissue plasminogen activator (t-PA) and plasminogen activator inhibitor 1 (PAI-1) were performed. Endotoxinemia resulted in a significant acceleration of the nonactivated TEM (NATEM) clotting time 2 h after the end of LPS infusion; in contrast, the changes in international normalized ratio and activated partial thromboplastin time suggested delayed initiation of coagulation. NATEM maximum clot firmness (MCF) and fibrin-based thromboelastometry test (FIBTEM)-MCF decreased significantly from baseline until the last time point (from 64.6 ± 7.8 and 35.1 ± 12.8 mm to 52.8 ± 4.6 and 21.4 ± 11.8 mm, respectively; P = 0.01 for both parameters). A sharp, transient increase of t-PA had no effect on maximum lysis in the NATEM test. PAI-1 increased significantly 3 h after the start of LPS infusion, paralleled by a decrease in maximum lysis. In conclusion, TEM was superior to standard coagulation tests in reflecting initial activation of coagulation during endotoxinemia. TEM further suggested consumption of coagulation substrate; at the same time, inhibition of plasminogen activation was accompanied by improved clot stability. Further investigations are necessary to establish the clinical relevance of these findings.
Collapse
Affiliation(s)
- Herbert Schöchl
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria.
| | | | | | | | | | | | | | | |
Collapse
|
40
|
Cesari M, Pahor M, Incalzi RA. Plasminogen activator inhibitor-1 (PAI-1): a key factor linking fibrinolysis and age-related subclinical and clinical conditions. Cardiovasc Ther 2010; 28:e72-91. [PMID: 20626406 PMCID: PMC2958211 DOI: 10.1111/j.1755-5922.2010.00171.x] [Citation(s) in RCA: 292] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION The close relationship existing between aging and thrombosis has growingly been studied in this last decade. The age-related development of a prothrombotic imbalance in the fibrinolysis homeostasis has been hypothesized as the basis of this increased cardiovascular and cerebrovascular risk. Fibrinolysis is the result of the interactions among multiple plasminogen activators and inhibitors constituting the enzymatic cascade, and ultimately leading to the degradation of fibrin. The plasminogen activator system plays a key role in a wide range of physiological and pathological processes. METHODS Narrative review. RESULTS Plasminogen activator inhibitor-1 (PAI-1) is a member of the superfamily of serine-protease inhibitors (or serpins), and the principal inhibitor of both the tissue-type and the urokinase-type plasminogen activator, the two plasminogen activators able to activate plasminogen. Current evidence describing the central role played by PAI-1 in a number of age-related subclinical (i.e., inflammation, atherosclerosis, insulin resistance) and clinical (i.e., obesity, comorbidities, Werner syndrome) conditions is presented. CONCLUSIONS Despite some controversial and unclear issues, PAI-1 represents an extremely promising marker that may become a biological parameter to be progressively considered in the prognostic evaluation, in the disease monitoring, and as treatment target of age-related conditions in the future.
Collapse
Affiliation(s)
- Matteo Cesari
- Area di Geriatria, Università Campus Bio-Medico, Rome, Italy.
| | | | | |
Collapse
|
41
|
Fischer CM, Yano K, Aird WC, Shapiro NI. Abnormal coagulation tests obtained in the emergency department are associated with mortality in patients with suspected infection. J Emerg Med 2010; 42:127-32. [PMID: 20542399 DOI: 10.1016/j.jemermed.2010.05.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2009] [Revised: 12/07/2009] [Accepted: 05/02/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND Early recognition of acute organ dysfunction in emergency department (ED) patients with suspected infection may help select patients at increased risk of mortality. The hematologic system is often overlooked in the evaluation and management of patients with infection because it is poorly circumscribed and serves a multitude of functions. STUDY OBJECTIVES We examine the hypothesis that abnormalities in commonly and easily obtained markers of coagulation function (international normalized ratio [INR], partial thromboplastin time [PTT], and platelet count [PLT]) are associated with mortality in ED patients admitted to the hospital with suspected infection. METHODS DESIGN Secondary analysis of a prospective observational cohort study. SETTING Urban tertiary care university hospital with 50,000 annual ED visits. PATIENTS Included patients: adults (age 18 ≥ years) evaluated in the ED for a suspected infection, had an INR, PTT, and PLT obtained during the ED stay, admitted to the hospital. Excluded patients: on oral anticoagulant therapy, received heparin, or pre-existing severe liver disease. RESULTS There were 1688 patients included. The in-hospital mortality rate was 5.9%. After adjusting for elderly status, comorbid illness burden, and severity of illness, elevated INR was associated with a 2.9 (95% confidence interval [CI] 1.6-5.2) increased odds of death, and a low platelet count (< 150,000/uL) was associated with 2.0 (95% CI 1.2-3.3) increased odds of death. The C-statistic for the model was 0.80. CONCLUSION We found an independent association between abnormalities in the coagulation system and mortality in ED patients with suspected infection. These findings underscore the close interaction between inflammation and coagulation and provide evidence that these simple laboratory tests should be routinely considered during the early evaluation of the infected patient.
Collapse
Affiliation(s)
- Christopher M Fischer
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | | | | |
Collapse
|
42
|
Abstract
OBJECTIVE The aim of this study is to clarify the effect of sepsis on the physiologic inhibition system of coagulation including protein S, protein C, and antithrombin III, and to study their further effect on thromboembolic accidents of septic newborns. DESIGN Clinical study including 30 septic neonates and 30 normal neonates served as control group. DATA SOURCES MEDLINE, pediatric textbooks, Neonatal Intensive Care Unit, Department of Pediatrics, Faculty of Medicine, Cairo University. RESULTS The results of this study showed marked decrease in the level of the physiologic inhibition system of coagulation including antithrombin III, protein C, and protein S in 100% of cases, compared to the control group (p < .001). Disseminated intravascular coagulation developed and death occurred in 33.3% of cases, necrotizing enterocolitis developed in 40% of cases, rectal bleeding developed in 33.3%, hematuria developed in 20% of cases, hematemesis developed in 26.7% of cases, intracranial hemorrhage developed in 23.3% of cases, and convulsions developed in 23.3% of cases. CONCLUSIONS In this study we have tried to evaluate the effect of sepsis on the physiologic inhibition system of coagulation in neonates. We should expect the effect of sepsis and its severity and perform the necessary laboratory investigations for coagulation including antithrombin III, protein C and protein S levels to help prevent thromboembolic accidents in neonates with sepsis, including disseminated intravascular coagulation, necrotizing enterocolitis and intracranial hemorrhage. Based on the findings of our study and the results of the other studies, we are in agreement that protein C is a very useful biomarker in severe sepsis, and it is a possible tool for monitoring treatment with activated protein C. We also encourage further placebo-controlled clinical trials to investigate the role of activated protein C and antithrombin III in severe neonatal sepsis and especially in the states before disseminated intravascular coagulation and the disseminated intravascular coagulation states, on the condition that they are guided by the experience and recommendations gained from the PROWESS, ENHANCE, and RESOLVE clinical trials. Protein C might be more effective if dosed according to protein C levels rather according to weight. Furthermore, we encourage future research on activated protein C mutants, which are anticipated to appear very soon because they can reduce some side effects associated with the use of recombinant human activated protein C, such as intracranial hemorrhage and bleeding tendencies, because they have reduced anticoagulant activity while retaining the cytoprotective effects.
Collapse
|
43
|
Ronco C, Ratanarat R, Bellomo R, Salvatori G, Petras D, Cal MD, Nalasso F, Bonello M, Brendolan A. Multiple organ support therapy for the critically ill patient in intensive care. ACTA ACUST UNITED AC 2009. [DOI: 10.1080/17471060500233109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
44
|
Activation of coagulation and inhibition of fibrinolysis in the human lung on bronchial instillation of lipoteichoic acid and lipopolysaccharide*. Crit Care Med 2009; 37:619-25. [DOI: 10.1097/ccm.0b013e31819584f9] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
45
|
Akkus MN, Polat G, Yurtdas M, Akcay B, Ercetin N, Cicek D, Doven O, Sucu N. Admission Levels of C-Reactive Protein and Plasminogen Activator Inhibitor-1 in Patients With Acute Myocardial Infarction With and Without Cardiogenic Shock or Heart Failure on Admission. Int Heart J 2009; 50:33-45. [DOI: 10.1536/ihj.50.33] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
| | - Gurbuz Polat
- Department of Clinical Biochemistry, Mersin University School of Medicine
| | - Mustafa Yurtdas
- Department of Cardiology, Mersin University School of Medicine
| | - Burak Akcay
- Department of Cardiology, Mersin University School of Medicine
| | - Neslihan Ercetin
- Department of Clinical Biochemistry, Mersin University School of Medicine
| | - Dilek Cicek
- Department of Cardiology, Mersin University School of Medicine
| | - Oben Doven
- Department of Cardiology, Mersin University School of Medicine
| | - Nehir Sucu
- Department of Cardiovascular Surgery, Mersin University School of Medicine
| |
Collapse
|
46
|
Fong IW. New Concepts and Emerging Issues in Sepsis. EMERGING ISSUES AND CONTROVERSIES IN INFECTIOUS DISEASE 2009. [PMCID: PMC7122214 DOI: 10.1007/978-0-387-84841-9_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- I. W. Fong
- Professor of Medicine University of Toronto, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8 Canada
| |
Collapse
|
47
|
Binder A, Endler G, Müller M, Mannhalter C, Zenz W. 4G4G genotype of the plasminogen activator inhibitor-1 promoter polymorphism associates with disseminated intravascular coagulation in children with systemic meningococcemia. J Thromb Haemost 2007; 5:2049-54. [PMID: 17697137 DOI: 10.1111/j.1538-7836.2007.02724.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Meningococcal disease may present as sepsis, meningitis or a combination of both. Impaired fibrinolysis and massive elevation of the plasminogen activator inhibitor-1 (PAI-1) is a characteristic feature of meningococcal sepsis. We and others have reported an association between mortality and the functional 4G/5G promoter polymorphism of the PAI-1 gene in children with meningococcal sepsis. OBJECTIVE Multicenter study to investigate the association of the 4G/5G PAI-1 polymorphism and disseminated intravascular coagulation (DIC) in children with meningococcal disease in a Central European population. PATIENTS/METHODS Blood samples and clinical information of 326 previously healthy children with meningococcal infection were collected from 95 pediatric hospitals in Germany, Switzerland, Italy, and Austria from 2000 to 2002. RESULTS DIC, defined as platelet counts below 100 G L(-1), increased D-dimer levels and prolonged prothrombin time, was significantly associated with the 4G4G genotype [31 of 63 (49%) vs. 55 of 175 (31%), P = 0.014], resulting in a hazard ratio (HR) of 1.5 (95% confidence interval 1.1-2.1) to develop DIC. Carriers of the 4G4G genotype showed significantly lower platelet counts (183 G L(-1) vs. 227 G L(-1), P = 0.009) on admission. Fibrinogen and C-reactive protein levels were not associated with the PAI-1 4G/5G polymorphism, nor were white blood cell counts. CONCLUSIONS Our data show a correlation between the 4G4G genotype of the PAI-1 gene and development of DIC in meningococcal infection.
Collapse
Affiliation(s)
- A Binder
- Department of General Pediatrics, Medical University of Graz, Graz, Austria
| | | | | | | | | |
Collapse
|
48
|
Lim JH, Stirling B, Derry J, Koga T, Jono H, Woo CH, Xu H, Bourne P, Ha UH, Ishinaga H, Xu H, Andalibi A, Feng XH, Zhu H, Huang Y, Zhang W, Weng X, Yan C, Yin Z, Briles DE, Davis RJ, Flavell RA, Li JD. Tumor Suppressor CYLD Regulates Acute Lung Injury in Lethal Streptococcus pneumoniae Infections. Immunity 2007; 27:349-60. [PMID: 17723219 DOI: 10.1016/j.immuni.2007.07.011] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2007] [Revised: 05/30/2007] [Accepted: 07/10/2007] [Indexed: 11/21/2022]
Abstract
Streptococcus pneumoniae (S. pneumoniae) causes high early mortality in pneumococcal pneumonia, which is characterized by acute lung injury (ALI). The molecular mechanisms underlying ALI and the high early mortality remain unknown. Despite recent studies that identify deubiquitinating enzyme cylindromatosis (CYLD) as a key regulator for T cell development, tumor cell proliferation, and NF-kappaB transcription factor signaling, its role in regulating bacteria-induced lethality, however, is unknown. Here, we showed that CYLD deficiency protected mice from S. pneumoniae pneumolysin (PLY)-induced ALI and lethality. CYLD was highly induced by PLY, and it inhibited MKK3-p38 kinase-dependent expression of plasminogen activator inhibitor-1 (PAI-1) in lung, thereby potentiating ALI and mortality. Thus, CYLD is detrimental for host survival, thereby indicating a mechanism underlying the high early mortality of pneumococcal pneumonia.
Collapse
Affiliation(s)
- Jae Hyang Lim
- Department of Microbiology and Immunology, University of Rochester Medical Center, Rochester, NY 14642, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Komissarov AA, Zhou A, Declerck PJ. Modulation of serpin reaction through stabilization of transient intermediate by ligands bound to alpha-helix F. J Biol Chem 2007; 282:26306-15. [PMID: 17613529 DOI: 10.1074/jbc.m702089200] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Mechanism-based inhibition of proteinases by serpins involves enzyme acylation and fast insertion of the reactive center loop (RCL) into the central beta-sheet of the serpin, resulting in mechanical inactivation of the proteinase. We examined the effects of ligands specific to alpha-helix F (alphaHF) of plasminogen activator inhibitor-1 (PAI-1) on the stoichiometry of inhibition (SI) and limiting rate constant (k(lim)) of RCL insertion for reactions with beta-trypsin, tissue-type plasminogen activator (tPA), and urokinase. The somatomedin B domain of vitronectin (SMBD) did not affect SI for any proteinase or k(lim) for tPA but decreased the k(lim) for beta-trypsin. In contrast to SMBD, monoclonal antibodies MA-55F4C12 and MA-33H1F7, the epitopes of which are located at the opposite side of alphaHF, decreased k(lim) and increased SI for every enzyme. These effects were enhanced in the presence of SMBD. RCL insertion for beta-trypsin and tPA is limited by different subsequent steps of PAI-1 mechanism as follows: enzyme acylation and formation of a loop-displaced acyl complex (LDA), respectively. Stabilization of LDA through the disruption of the exosite interactions between PAI-1 and tPA induced an increase in the k(lim) but did not affect the SI. Thus it is unlikely that LDA contributes significantly to the outcome of the serpin reaction. These results demonstrate that the rate of RCL insertion is not necessarily correlated with SI and indicate that an intermediate, different from LDA, which forms during the late steps of PAI-1 mechanism, and could be stabilized by ligands specific to alphaHF, controls bifurcation between the inhibitory and the substrate pathways.
Collapse
Affiliation(s)
- Andrey A Komissarov
- Department of Chemistry, Portland State University, Portland, Oregon 97207-0751, USA.
| | | | | |
Collapse
|
50
|
Hermans PWM, Hazelzet JA. Plasminogen activator inhibitor type 1 gene polymorphism and sepsis. Clin Infect Dis 2007; 41 Suppl 7:S453-8. [PMID: 16237647 DOI: 10.1086/431996] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Plasminogen activator inhibitor type 1 (PAI-1) is a 50-kilodalton glycoprotein of the serine protease inhibitor family. The primary role of PAI-1 in vivo is the inhibition of both tissue- and urokinase-type plasminogen activators. In addition to this function, PAI-1 acts as an acute-phase protein during acute inflammation. PAI-1 is a pivotal player in the pathogenesis of sepsis, a complex clinical syndrome that results from a systemic inflammatory response. In patients with sepsis, the levels of PAI-1 are positively related to poor outcome, increased severity of disease, and increased levels of various cytokines, acute-phase proteins, and coagulation parameters. The 4G/5G insertion/deletion promoter polymorphism, which leads to differences in PAI-1 production, has been demonstrated to affect the risk of developing severe complications and dying from sepsis during meningococcal infection and multiple trauma.
Collapse
Affiliation(s)
- P W M Hermans
- Department of Pediatrics, Erasmus Medical Center Rotterdam-Sophia, Rotterdam, The Netherlands
| | | |
Collapse
|