Prednisolone inhibits endotoxin-induced disseminated intravascular coagulation and improves mortality in rats: importance of inflammatory cytokine suppression

HMG-CoA reductase inhibitors and the attenuation of risk for disseminated intravascular coagulation in patients with sepsis

BACKGROUND

Disseminated Intravascular Coagulation (DIC) is a syndrome of dysregulated coagulation. Patients with sepsis are at increased risk for DIC. HMG-CoA Reductase Inhibitors (Statins) are primarily used as lipid-lowering agents; however, studies have suggested statins may possess anti-inflammatory, antithrombotic, anticoagulant, and endothelial stabilizing properties. These mechanisms may oppose those that underlie the pathogenesis of septic DIC.

METHODS

To evaluate whether statins may be protective against the development of DIC, we conducted a multi-center, retrospective case-control study where 86,638 critically ill patients admitted to the ICU with sepsis, severe sepsis or septic shock were identified during a 3-year period. Patients who developed DIC during their hospitalization were identified and stratified by whether they received a statin or not during their hospitalization. Odds ratios for development of DIC was calculated by composite of any statin, as well as low, moderate, and high intensity statins.

RESULTS

2236 patients would develop DIC compared to 84,402 who did not. The use of any statin was associated with a reduced likelihood for developing DIC (odds ratio [OR], 0.69; 95% CI, 0.61-0.78). This was observed with use of both moderate (OR, 0.64; 95% CI, 0.53-0.77) and high (OR, 0.72; 95% CI, 0.61-0.84) but not low intensity statins (OR, 0.84; 95% CI, 0.53-1.32).

CONCLUSIONS

The use of moderate and high intensity statins was associated with a significantly reduced odds of developing DIC in critically ill patients with sepsis. This present study may be the first to suggest that statin medications may independently reduce the frequency of DIC in critically ill patients with severe sepsis or septic shock. More research is needed to investigate the potential for this class of medication to be protective against DIC.

The efficacy and safety of glucocorticoid for perioperative patients with hepatectomy: a systematic review and meta-analysis

OBJECTIVE

Glucocorticoids have been used in patients undergoing perioperative hepatectomy, however their safety and efficacy remain controversial. This meta-analysis was conducted to investigate this issue and further provide reference for clinical practice.

METHODS

PubMed/MEDLINE, Embase, and Cochrane Library were searched for randomized controlled trials (RCTs) from database inception to December 2022. Literature screening and data extraction were performed independently by two reviewers. The methodological quality of the RCTs was assessed using the Jadad scale. RevMan 5.4 was used for the meta-analysis.

RESULTS

A total of 11 RCTs involving 905 patients were included. Compared with the control group, we found perioperative glucocorticoid administration significantly lowered overall complication rate [RR = 0.67; 95% CI (0.55, 0.83); P = 0.0003], infectious complication rate [RR = 0.41; 95% CI (0.21, 0.82); P = 0.01] and postoperative liver failure [RR = 0.63; 95% CI (0.41, 0.97); P = 0.03]. In addition, glucocorticoids appear to improve liver function (TBil) [MD = -0.36, 95% CI (-0.59, -0.14), P = 0.001] and reduce the release of certain inflammatory cytokines (IL-6) [MD = -48.52, 95% CI (-56.88, -40.16), P < 0.00001].

CONCLUSION

Based on the available evidence, glucocorticoids appear to be safe and effective in patients undergoing hepatectomy, but further research is needed.

Disseminated intravascular coagulation in Stevens-Johnson syndrome and toxic epidermal necrolysis

BACKGROUND

Patients with Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) have high mortality rates. Disseminated intravascular coagulation has been reported in SJS/TEN patients. The influence of this lethal complication in patients with SJS/TEN is not well known.

OBJECTIVE

This study aimed to investigate the risk and outcomes of disseminated intravascular coagulation in patients with SJS/TEN.

METHODS

We analyzed the disseminated intravascular coagulation profiles of patients receiving a diagnosis of SJS/TEN between 2010 and 2019.

RESULTS

We analyzed 150 patients with SJS/TEN (75 with SJS, 22 with overlapping SJS/TEN, and 53 with TEN) and their complete disseminated intravascular coagulation profiles. Disseminated intravascular coagulation was diagnosed in 32 patients (21.3%), primarily those with TEN. It was significantly associated with systemic complications, including gastrointestinal bleeding, respiratory failure, renal failure, liver failure, infection, and bacteremia. Additionally, SJS/TEN patients with disseminated intravascular coagulation had elevated procalcitonin levels. Among patients with SJS/TEN, disseminated intravascular coagulation was associated with a greater than 10-fold increase in mortality (78.1% vs 7%).

LIMITATIONS

The study limitations include small sample size and a single hospital system.

CONCLUSION

Disseminated intravascular coagulation is a potential complication of SJS/TEN and associated with higher mortality. Early recognition and appropriate management of this critical complication are important for patients with SJS/TEN.

Animal models of DIC and their relevance to human DIC: a systematic review

Disseminated intravascular coagulation (DIC) is a severe clinical condition with activation of coagulation and fibrinolysis. Its diagnosis is based on the International Society of Thrombosis and Haemostasis (ISTH) scoring system of DIC. Animal models of DIC, used to investigate pathophysiology and evaluate treatments, have not been developed in a standardized way, which impedes comparison between models and translation to the human setting. In the current review of animal models of DIC an overview of species, inducers, and dosing regimens is provided. Diagnostic approaches are compared in the light of the ISTH score and treatments tested in animal models of DIC are summarized. Systematic analysis revealed that the rat is by far the preferred species amongst animal models of DIC and lipopolysaccharides (LPS) the preferred inducer of DIC. An overview of the reporting of ISTH DIC score parameters elucidated that only about 25% of the studies measure all of the four parameters necessary for the implementation the ISTH scoring system. Furthermore, most therapeutic interventions tested in animal models of DIC are administered prophylactically, which may be irrelevant to the clinical setting and could explain why compounds effective in preclinical animal models often fail in clinical trials. It is concluded that Implementation of a scoring system in animal models of DIC may increase the ability to compare DIC amongst animal models and improve the translational aspect of treatment effect.

Pharmacokinetics and anti-inflammatory pharmacodynamics of prednisolone in cynomolgus monkey

The purpose was to investigate whether the pharmacokinetics and pharmacodynamics of prednisolone in the non-human primate was an appropriate surrogate for man. After single intravenous doses of 0.03, 0.3, and 3 mg kg(-1), prednisolone demonstrated a dose-dependent clearance and volume of distribution. When corrected for concentration-dependent protein binding, the free clearance was linear at the tested dose levels. The protein binding-corrected volume of distribution was similar across doses. The serum half-life was estimated as being between 2 and 4 h. Prednisolone exhibits near complete inhibition of the cytokines TNF-alpha, IL-1beta, IL-6 and IL-8 with very similar IC50 estimates from 0.09 to 0.16 microg ml(-1) (from 0.24 to 0.44 microM). The monkey demonstrated a similar pharmacokinetics-pharmacodynamics profile of prednisolone when compared with man (from the literature).

A combination of a thrombin inhibitor and dexamethasone prevents the development of experimental disseminated intravascular coagulation in rats

INTRODUCTION

Disseminated intravascular coagulation (DIC) is a serious and potentially lethal complication of severe sepsis. DIC is characterised primarily by widespread platelet aggregation and fibrin deposition, followed by consumption of platelets, coagulation factors, and inhibitors. The aim of the study was to evaluate the efficacy of the active-site thrombin inhibitor melagatran, the active form of the oral direct thrombin inhibitor ximelagatran, in reducing fibrinogen and platelet consumption in blood and fibrin deposition in organs, in an experimental endotoxinaemia rat model.

MATERIALS AND METHODS

In this model, DIC was induced by an intravenous injection of endotoxin (1 mg/kg). Melagatran was compared with unfractionated heparin and the synthetic glucocorticoid analogue dexamethasone. Animals were divided into 16 treatment groups in which high and low doses of each agent were tested alone and in combination with melagatran.

RESULTS

Fibrinogen consumption was reduced by melagatran, dexamethasone, and heparin, and was completely prevented by melagatran in combination with dexamethasone. Platelet consumption was partially reduced by melagatran, unfractionated heparin, and dexamethasone, but complete protection was observed only with melagatran in combination with dexamethasone. Melagatran in combination with dexamethasone or heparin protected the liver and spleen from fibrin deposition.

CONCLUSION

In this experimental DIC rat model, the direct thrombin inhibitor melagatran given together with dexamethasone protected against the consequences of activated haemostasis.

Coagulation disorders in dogs with hepatic disease

Liver disease has been associated with abnormalities in haemostasis. In this study, coagulation times, platelet counts, platelet activity parameters, activities of individual coagulation factors, D-dimers, antithrombin (AT) and protein C activity were measured in 42 dogs with histologically confirmed liver disease. Outcome was correlated with histological diagnosis. One or more coagulation abnormalities were present in 57% of dogs with hepatic disease. Activated partial thromboplastin time was significantly prolonged in dogs with chronic hepatitis (CH), with or without cirrhosis. Mean platelet numbers, AT and factor IX activity were significantly lower in dogs with CH plus cirrhosis, compared to dogs with other hepatopathies. D-dimers were not significantly increased in any group. Only three dogs, all with different histological diagnoses, satisfied the criteria for disseminated intravascular coagulation (DIC). Haemostatic abnormalities were primarily seen in dogs with cirrhosis and this may be due to reduced synthesis rather than increased consumption of coagulation factors.

Preoperative methylprednisolone administration maintains coagulation homeostasis in patients undergoing liver resection: importance of inflammatory cytokine modulation

Alterations in hemostatic parameters are a common finding after major hepatic resection. There is growing evidence that inflammation has a significant role in inducing coagulation disarrangement that follows major surgery. To determine whether preoperative methylprednisolone administration has a protective effect against the development of coagulation disorders, we evaluated the effect of preoperative steroids administration on changes in hemostatic parameters and plasma levels of inflammatory cytokines in patients undergoing liver surgery. Seventy-three patients undergoing liver resection were randomized to a steroid group or to a control group. Patients in the steroid group received 500 mg of methylprednisolone preoperatively. Serum levels of coagulation parameters (prothrombin time, platelets, fibrinogen, plasma fibrin degradation products [D-dimer], antithrombin III) and inflammatory mediators (IL-6 and TNF-alpha) were measured before and immediately after the operation and on postoperative days 1, 2, and 5. Multivariate analysis was performed to identify factors related to the characteristics of the patients and surgery affecting coagulation parameters between the two groups. Decreases in antithrombin III, platelet count and fibrinogen levels, prolongation of prothrombin time, and increases in the plasma fibrin degradation products were significantly suppressed by the administration of methylprednisolone. Cytokines production was also significantly suppressed by the administration of methylprednisolone, and there was significant correlation between plasma levels of cytokines and coagulation alterations. These findings suggest that preoperative methylprednisolone administration inhibits the development of coagulation disarrangements in patients undergoing liver resection, possibly through suppressing the production of inflammatory cytokines.

Impact of preoperative steroids administration on ischemia-reperfusion injury and systemic responses in liver surgery: a prospective randomized study

Hepatic injury secondary to warm ischemia-reperfusion (I/R) injury and alterations in haemostatic parameters are often unavoidable events after major hepatic resection. The release of inflammatory mediator is believed to play a significant role in the genesis of these events. It has been suggested that preoperative steroid administration may reduce I/R injury and improve several aspects of the surgical stress response. The aim of this prospective randomized study was to investigate the clinical benefits on I/R injury and systemic responses of preoperatively administered corticosteroids. Seventy-six patients undergoing liver resection were randomized either to a steroid group or to a control group. Patients in the steroid group received preoperatively 500 mg of methylprednisolone. Serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, coagulation parameters, and inflammatory mediators, interleukin 6 and tumor necrosis factor alpha were compared between the 2 groups. Length of stay, and type and number of complications were recorded as well. Postoperative serum levels of ALT, AST, total bilirubin, and inflammatory cytokines were significantly lower in the steroid than in the control group at postoperative days 1 and 2. Changes in hemostatic parameters were also significantly attenuated in the steroid group. In conclusion, the incidence of postoperative complications in the steroid group tended to be significantly lower than the control group. It is of clinical interest that preoperative steroids administration before major surgery may reduce I/R injury, maintain coagulant/anticoagulant homeostasis, and reduce postoperative complications by modulating the inflammatory response.

Cold Injury Syndrome and Neurodevelopmental Changes in Survivors

BACKGROUND

The aim of this study was to extend and develop knowledge of the clinical parameters of cold injury syndrome (CIS) in hypothermic infants and newborns, so that morbidity, mortality, and neurodevelopmental disturbances associated with the condition can be reduced.

METHODS

This retrospective, 10-year cohort study investigated 103 hypothermic infant and newborn patients (aged 0-60 days) admitted to the Pediatric Department between January 1, 1976 and December 31, 1985. Medical records of 67 survivors and 36 children who died were analyzed. Of the survivors, 24 consented to undergo assessment of neuropsychological and neurodevelopmental outcomes.

RESULTS

At presentation, all patients manifested cold skin and limbs, while 96 (93.2%) were sleepy, hypotonic and inactive. Cyanosis with bradycardia, bradypnea, and apneic crisis (AC) was observed in 80 (77.7%) patients, and 65 (63.1%) demonstrated diffuse intravascular coagulation (DIC). Pulmonary hemorrhage, AC, respiratory distress syndrome, and DIC represented the primary causes of death. Higher body temperatures on admission reduced the risk of death. Of the 24 patients assessed for neuropsychological and neurodevelopmental outcomes, all but one had normal intellectual capabilities, whereas 16 (66.7%) showed signs of neurodevelopmental disturbances.

CONCLUSIONS

The severity of hypothermia, leukopenia, and thrombocytopenia with DIC correlates with prognosis and death rate. Hypothermia in infants and newborns can cause psychological and neurodevelopmental disturbances in survivors.

Effect of pentoxifylline on endotoxin-induced haemostatic disturbances in rabbits

Pentoxifylline (PTX, a methylxanthine derivative) has been found to interrupt early gene activation for tumour necrosis factor, interleukin-1, interleukin-6 and tissue factor production and to improve survival from experimental sepsis. During endotoxaemia, lipopolysaccharide (LPS, endotoxin) and proinflammatory cytokines trigger the development of disseminated intravascular coagulation (DIC) via the tissue factor-dependent pathway of coagulation. The present study was undertaken to determine whether pentoxifylline could prevent coagulation disturbances in LPS-treated rabbits. Endotoxaemia was induced with E. coli lipopolysaccharide in New Zealand White rabbits. Forty rabbits were used and divided into four equal groups. Group 1 served as a control group; Group 2: lipopolysaccharide was injected intravenously, Group 3: pentoxifylline was injected intraperitoneally, Group 4: lipopolysaccharide and pentoxifylline were injected simultaneously. Blood samples were collected 6 h after the treatments. In rabbits with endotoxin-induced DIC, platelet count, leukocyte count, percentage of differential leukocyte values, fibrinogen level, antithrombin III (AT-III) and protein C (PC) activity were decreased. Moreover, activated partial thromboplastin time (APTT) and prothrombin time (PT) were prolonged when compared to the control group. In conclusion, haemostatic disturbances associated with endotoxin-induced DIC were moderately suppressed by the administration of PTX.

Prednisolone inhibits LPS-induced bone marrow suppressor cell activity in vitro but not in vivo

Glucocorticoids are used clinically to treat a variety of inflammatory diseases including endotoxemia. We hypothesized that injecting mice with the steroid prednisolone (pred) would mitigate the enhanced bone marrow (BM) natural suppressor (NS) cell activity that occurs in mice after receiving an injection of lipopolysaccharide (LPS). In vitro, prednisolone blocked the ability of NS cells to produce the immunosuppressive molecule nitric oxide (NO) and also the ability to suppress T cell proliferation. Prednisolone acted both indirectly, by blocking synthesis of cytokines necessary for NS cell activation, and also directly on NS cells, by blocking production of NO. In vivo, variable results were obtained. Prednisolone at 20 microg/gm did decrease NS activity when injected into normal mice. However, when mice were injected with both LPS and prednisolone (0.2 or 20 microg/gm), a large increase in BM NS activity was observed. The increase was evident in both the ability of the BM cells to suppress T cell proliferation and to produce NO. The data show that, in vivo, the steroid prednisolone in conjunction with the inflammatory compound LPS act to enhance BM NS activity.