1
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Zhang L, Qin J, Li P. Bioinformatics analysis of potential common pathogenic mechanisms for COVID-19 and venous thromboembolism. Cytokine 2024; 181:156682. [PMID: 38909539 DOI: 10.1016/j.cyto.2024.156682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 05/20/2024] [Accepted: 06/18/2024] [Indexed: 06/25/2024]
Abstract
BACKGROUND A growing body of research has shown that patients with coronavirus disease 2019 (COVID-19) have significantly higher rates of venous thromboembolism (VTE) than healthy. However, the mechanism remains incompletely elucidated. This study aimed to further investigate the molecular mechanisms underlying the development of this complication. METHODS The gene expression profiles of COVID-19 and VTE were downloaded from the Gene Expression Omnibus (GEO) database. After identifying the common differentially expressed genes (DEGs) for COVID-19 and VTE, functional annotation, a protein-protein interactions (PPI) network, module construction, and hub gene identification were performed. Finally, we constructed a transcription factor (TF)-gene regulatory network and a TF-miRNA regulatory network for hub genes. RESULTS A total of 42 common DEGs were selected for subsequent analyses. Functional analyses showed that biological function and signaling pathways collectively participated in the development and progression of VTE and COVID-19. Finally, 8 significant hub genes were identified using the cytoHubba plugin, including RSL24D1, RPS17, RPS27, HINT1, COX7C, RPL35, RPL34, and NDUFA4, which had preferable values as diagnostic markers for COVID-19 and VTE. CONCLUSIONS Our study revealed the common pathogenesis of COVID-19 and VTE. These common pathways and pivotal genes may provide new ideas for further mechanistic studies.
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Affiliation(s)
- Ling Zhang
- Department of Emergency Medicine, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Jing Qin
- Department of Emergency Medicine, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Peiwu Li
- Department of Emergency Medicine, Lanzhou University Second Hospital, Lanzhou, Gansu, China.
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2
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Pottecher J, Raffi F, Jandrot-Perrus M, Binay S, Comenducci A, Desort-Henin V, François D, Gharakhanian S, Labart M, Meilhoc A, Toledano E, Pletan Y, Avenard G, Sato VH. Targeting GPVI with glenzocimab in COVID-19 patients: Results from a randomized clinical trial. PLoS One 2024; 19:e0302897. [PMID: 38885234 PMCID: PMC11182546 DOI: 10.1371/journal.pone.0302897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 04/11/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Glenzocimab is a novel antithrombotic agent which targets platelet glycoprotein VI (GPVI) and does not induce haemorrhage. SARS-CoV-2 triggers a prothrombotic state and lung injury whose mechanisms include coagulopathy, endothelial dysfunction, and inflammation with dysregulated platelets. METHODS AND PATIENTS GARDEN was a randomised double-blind, exploratory phase II study of glenzocimab in SARS-CoV-2 respiratory failure (NCT04659109). PCR+ adults in Brazil and France (7 centres) were randomized to standard-of-care (SOC) plus glenzocimab (1000 mg/dayx3 days) or placebo, followed for 40 days. Primary efficacy endpoint was clinical progression at Day 4. All analyses concerned the intention-to-treat population. RESULTS Between December 2020 and August 2021, 61 patients received at least one dose (30 glenzocimab vs 32 placebo) and 58 completed the study (29 vs 29). Clinical progression of COVID-19 ARDS was not statistically different between glenzocimab and placebo arms (43.3% and 29.0%, respectively; p = 0.245). Decrease in the NEWS-2 category at D4 was statistically significant (p = 0.0290) in the glenzocimab arm vs placebo. No Serious Adverse Event (SAE) was deemed related to study drug; bleeding related events were reported in 6 patients (7 events) and 4 patients (4 events) in glenzocimab and placebo arms, respectively. CONCLUSIONS Therapeutic GPVI inhibition assessment during COVID-19 was conducted in response to a Public Health emergency. Glenzocimab in coagulopathic patients under therapeutic heparin was neither associated with increased bleeding, nor SAE. Clinical impact of glenzocimab on COVID-19 ARDS was not demonstrated. A potential role for GPVI inhibition in other types of ARDS deserves further experimentation. Glenzocimab is currently studied in stroke (ACTISAVE: NCT05070260) and cardiovascular indications.
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Affiliation(s)
- Julien Pottecher
- Strasbourg University Hospital, UR3072, FHU OMICARE, FMTS, Strasbourg, France
| | - Francois Raffi
- Nantes Université, CHU Nantes, INSERM, Department of Infectious Diseases, CIC 1413, Nantes, France
| | | | | | | | | | | | - Shahin Gharakhanian
- Acticor-Biotech, Paris, France
- Shahin Gharakhanian MD Consulting LLC, Cambridge Innovation Center, Cambridge, MA, United States of America
| | | | | | | | | | | | - Victor H. Sato
- International Research Center, Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil
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3
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Radtke T, Künzi L, Kopp J, Rasi M, Braun J, Zens KD, Winter B, Anagnostopoulos A, Puhan MA, Fehr JS. Effects of Pycnogenol® in people with post-COVID-19 condition (PYCNOVID): study protocol for a single-center, placebo controlled, quadruple-blind, randomized trial. Trials 2024; 25:385. [PMID: 38879571 PMCID: PMC11179231 DOI: 10.1186/s13063-024-08187-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 05/17/2024] [Indexed: 06/19/2024] Open
Abstract
BACKGROUND A significant proportion of the global population has been infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) at some point since the onset of the pandemic. Although most individuals who develop coronavirus disease 2019 (COVID-19) recover without complications, about 6% have persistent symptoms, referred to as post-COVID-19 condition (PCC). Intervention studies investigating treatments that potentially alleviate PCC-related symptoms and thus aim to mitigate the global public health burden and healthcare costs linked to PCC are desperately needed. The PYCNOVID trial investigates the effects of Pycnogenol®, a French maritime pine bark extract with anti-inflammatory and antioxidative properties, versus placebo on patient-reported health status in people with PCC. METHODS This is a single-center, placebo-controlled, quadruple blind, randomized trial. We aim to randomly assign 150 individuals with PCC (1:1 ratio) to receive either 200 mg Pycnogenol® or placebo daily for 12 weeks. Randomization is stratified for duration of PCC symptoms (≤ 6 months versus > 6 months) and presence of symptomatic chronic disease(s). The primary endpoint is perceived health status at 12 weeks (EuroQol-Visual Analogue Scale) adjusted for baseline values and stratification factors. Secondary endpoints include change in self-reported PCC symptoms, health-related quality of life, symptoms of depression and anxiety, cognitive function, functional exercise capacity, physical activity measured with accelerometry, and blood biomarkers for endothelial health, inflammation, coagulation, platelet function, and oxidative stress. Investigators, study participants, outcome assessors, and data analysts are blinded regarding the intervention assignment. Individuals with PCC were involved in the design of this study. DISCUSSION This is the first trial to investigate the effects of Pycnogenol® versus placebo on patient-reported health status in people with PCC. Should the trial proof clinical effectiveness, Pycnogenol® may serve as a therapeutic approach to mitigate symptoms associated with PCC. TRIAL REGISTRATION The study is registered at ClinicalTrials.gov. :NCT05890534, June 6, 2023.
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Affiliation(s)
- Thomas Radtke
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich (UZH), Zurich, Switzerland.
| | - Lisa Künzi
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich (UZH), Zurich, Switzerland
| | - Julia Kopp
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich (UZH), Zurich, Switzerland
| | - Manuela Rasi
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich (UZH), Zurich, Switzerland
| | - Julia Braun
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich (UZH), Zurich, Switzerland
| | - Kyra D Zens
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich (UZH), Zurich, Switzerland
| | - Babette Winter
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich (UZH), Zurich, Switzerland
| | - Alexia Anagnostopoulos
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich (UZH), Zurich, Switzerland
| | - Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich (UZH), Zurich, Switzerland
| | - Jan S Fehr
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich (UZH), Zurich, Switzerland
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4
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Paul O, Akolia IK, Qin Tao J, Jain N, Louneva N, Montone KT, Fisher AB, Rajapakse CS, Bermudez C, Chatterjee S. Reactive oxygen species in endothelial signaling in COVID-19: Protective role of the novel peptide PIP-2. PLoS One 2024; 19:e0289854. [PMID: 38771750 PMCID: PMC11108150 DOI: 10.1371/journal.pone.0289854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 04/02/2024] [Indexed: 05/23/2024] Open
Abstract
INTRODUCTION Recent research suggests that endothelial activation plays a role in coronavirus disease 2019 (COVID-19) pathogenesis by promoting a pro-inflammatory state. However, the mechanism by which the endothelium is activated in COVID-19 remains unclear. OBJECTIVE To investigate the mechanism by which COVID-19 activates the pulmonary endothelium and drives pro-inflammatory phenotypes. HYPOTHESIS The "inflammatory load or burden" (cytokine storm) of the systemic circulation activates endothelial NADPH oxidase 2 (NOX2) which leads to the production of reactive oxygen species (ROS) by the pulmonary endothelium. Endothelial ROS subsequently activates pro-inflammatory pathways. METHODS The inflammatory burden of COVID-19 on the endothelial network, was recreated in vitro, by exposing human pulmonary microvascular endothelial cells (HPMVEC) to media supplemented with serum from COVID-19 affected individuals (sera were acquired from patients with COVID-19 infection that eventually died. Sera was isolated from blood collected at admission to the Intensive Care Unit of the Hospital of the University of Pennsylvania). Endothelial activation, inflammation and cell death were assessed in HPMVEC treated with serum either from patients with COVID-19 or from healthy individuals. Activation was monitored by measuring NOX2 activation (Rac1 translocation) and ROS production; inflammation (or appearance of a pro-inflammatory phenotype) was monitored by measuring the induction of moieties such as intercellular adhesion molecule (ICAM-1), P-selectin and the NLRP3 inflammasome; cell death was measured via SYTOX™ Green assays. RESULTS Endothelial activation (i.e., NOX2 activation and subsequent ROS production) and cell death were significantly higher in the COVID-19 model than in healthy samples. When HPMVEC were pre-treated with the novel peptide PIP-2, which blocks NOX2 activation (via inhibition of Ca2+-independent phospholipase A2, aiPLA2), significant abrogation of ROS was observed. Endothelial inflammation and cell death were also significantly blunted. CONCLUSIONS The endothelium is activated during COVID-19 via cytokine storm-driven NOX2-ROS activation, which causes a pro-inflammatory phenotype. The concept of endothelial NOX2-ROS production as a unifying pathophysiological axis in COVID-19 raises the possibility of using PIP-2 to maintain vascular health.
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Affiliation(s)
- Oindrila Paul
- Institute for Environmental Medicine and Department of Physiology, Philadelphia, Pennsylvania, United States of America
| | - Isha K. Akolia
- Institute for Environmental Medicine and Department of Physiology, Philadelphia, Pennsylvania, United States of America
| | - Jian Qin Tao
- Institute for Environmental Medicine and Department of Physiology, Philadelphia, Pennsylvania, United States of America
| | - Nikita Jain
- Institute for Environmental Medicine and Department of Physiology, Philadelphia, Pennsylvania, United States of America
| | - Natalia Louneva
- Peroxitech Inc., Philadelphia, Pennsylvania, United States of America
| | - Kathleen T. Montone
- Department of Pathology, Philadelphia, Pennsylvania, United States of America
| | - Aron B. Fisher
- Peroxitech Inc., Philadelphia, Pennsylvania, United States of America
| | - Chamith S. Rajapakse
- Department of Radiology, Philadelphia, Pennsylvania, United States of America
- Department of Orthopedic Surgery, Philadelphia, Pennsylvania, United States of America
| | - Christian Bermudez
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Shampa Chatterjee
- Institute for Environmental Medicine and Department of Physiology, Philadelphia, Pennsylvania, United States of America
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5
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Osmanoglu Ö, Gupta SK, Almasi A, Yagci S, Srivastava M, Araujo GHM, Nagy Z, Balkenhol J, Dandekar T. Signaling network analysis reveals fostamatinib as a potential drug to control platelet hyperactivation during SARS-CoV-2 infection. Front Immunol 2023; 14:1285345. [PMID: 38187394 PMCID: PMC10768010 DOI: 10.3389/fimmu.2023.1285345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 12/06/2023] [Indexed: 01/09/2024] Open
Abstract
Introduction Pro-thrombotic events are one of the prevalent causes of intensive care unit (ICU) admissions among COVID-19 patients, although the signaling events in the stimulated platelets are still unclear. Methods We conducted a comparative analysis of platelet transcriptome data from healthy donors, ICU, and non-ICU COVID-19 patients to elucidate these mechanisms. To surpass previous analyses, we constructed models of involved networks and control cascades by integrating a global human signaling network with transcriptome data. We investigated the control of platelet hyperactivation and the specific proteins involved. Results Our study revealed that control of the platelet network in ICU patients is significantly higher than in non-ICU patients. Non-ICU patients require control over fewer proteins for managing platelet hyperactivity compared to ICU patients. Identification of indispensable proteins highlighted key subnetworks, that are targetable for system control in COVID-19-related platelet hyperactivity. We scrutinized FDA-approved drugs targeting indispensable proteins and identified fostamatinib as a potent candidate for preventing thrombosis in COVID-19 patients. Discussion Our findings shed light on how SARS-CoV-2 efficiently affects host platelets by targeting indispensable and critical proteins involved in the control of platelet activity. We evaluated several drugs for specific control of platelet hyperactivity in ICU patients suffering from platelet hyperactivation. The focus of our approach is repurposing existing drugs for optimal control over the signaling network responsible for platelet hyperactivity in COVID-19 patients. Our study offers specific pharmacological recommendations, with drug prioritization tailored to the distinct network states observed in each patient condition. Interactive networks and detailed results can be accessed at https://fostamatinib.bioinfo-wuerz.eu/.
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Affiliation(s)
- Özge Osmanoglu
- Functional Genomics & Systems Biology Group, Department of Bioinformatics, Biocenter, University of Wuerzburg, Wuerzburg, Germany
| | - Shishir K. Gupta
- Evolutionary Genomics Group, Center for Computational and Theoretical Biology, University of Würzburg, Würzburg, Germany
- Institute of Botany, Heinrich Heine University, Düsseldorf, Germany
| | - Anna Almasi
- Functional Genomics & Systems Biology Group, Department of Bioinformatics, Biocenter, University of Wuerzburg, Wuerzburg, Germany
| | - Seray Yagci
- Functional Genomics & Systems Biology Group, Department of Bioinformatics, Biocenter, University of Wuerzburg, Wuerzburg, Germany
| | - Mugdha Srivastava
- Core Unit Systems Medicine, University of Wuerzburg, Wuerzburg, Germany
- Algorithmic Bioinformatics, Department of Computer Science, Heinrich Heine University, Düsseldorf, Germany
| | - Gabriel H. M. Araujo
- University Hospital Würzburg, Institute of Experimental Biomedicine, Würzburg, Germany
| | - Zoltan Nagy
- University Hospital Würzburg, Institute of Experimental Biomedicine, Würzburg, Germany
| | - Johannes Balkenhol
- Functional Genomics & Systems Biology Group, Department of Bioinformatics, Biocenter, University of Wuerzburg, Wuerzburg, Germany
- Chair of Molecular Microscopy, Rudolf Virchow Center for Integrative and Translation Bioimaging, University of Würzburg, Würzburg, Germany
| | - Thomas Dandekar
- Functional Genomics & Systems Biology Group, Department of Bioinformatics, Biocenter, University of Wuerzburg, Wuerzburg, Germany
- European Molecular Biology Laboratory (EMBL) Heidelberg, BioComputing Unit, Heidelberg, Germany
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6
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Harte JV, Coleman-Vaughan C, Crowley MP, Mykytiv V. It's in the blood: a review of the hematological system in SARS-CoV-2-associated COVID-19. Crit Rev Clin Lab Sci 2023; 60:595-624. [PMID: 37439130 DOI: 10.1080/10408363.2023.2232010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/27/2023] [Indexed: 07/14/2023]
Abstract
The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to an unprecedented global healthcare crisis. While SARS-CoV-2-associated COVID-19 affects primarily the respiratory system, patients with COVID-19 frequently develop extrapulmonary manifestations. Notably, changes in the hematological system, including lymphocytopenia, neutrophilia and significant abnormalities of hemostatic markers, were observed early in the pandemic. Hematological manifestations have since been recognized as important parameters in the pathophysiology of SARS-CoV-2 and in the management of patients with COVID-19. In this narrative review, we summarize the state-of-the-art regarding the hematological and hemostatic abnormalities observed in patients with SARS-CoV-2-associated COVID-19, as well as the current understanding of the hematological system in the pathophysiology of acute and chronic SARS-CoV-2-associated COVID-19.
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Affiliation(s)
- James V Harte
- Department of Haematology, Cork University Hospital, Wilton, Cork, Ireland
- School of Biochemistry & Cell Biology, University College Cork, Cork, Ireland
| | | | - Maeve P Crowley
- Department of Haematology, Cork University Hospital, Wilton, Cork, Ireland
- Irish Network for Venous Thromboembolism Research (INViTE), Ireland
| | - Vitaliy Mykytiv
- Department of Haematology, Cork University Hospital, Wilton, Cork, Ireland
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7
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Abdelouahed M, Yateem D, Fredericks S. Fc γRIIa - dependent platelet activation identified in COVID-19 vaccine-induced immune thrombotic thrombocytopenia-, heparin-induced thrombocytopenia, streptokinase- and anisoylated plasminogen-streptokinase activator complex-induced platelet activation. Front Cardiovasc Med 2023; 10:1282637. [PMID: 38034388 PMCID: PMC10684751 DOI: 10.3389/fcvm.2023.1282637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19), which was caused by the coronavirus - severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was globally responsible for remarkable morbidity and mortality. Several highly effective vaccines for COVID-19 were developed and disseminated worldwide within an unprecedented timescale. Rare but dangerous clotting and thrombocytopenia events, and subsequent coagulation abnormalities, have been reported after massive vaccination against SARS-CoV-2. Soon after their global rollout, reports of a morbid clinical syndrome following vaccination with adenovirus-DNA-based vaccines appeared. In the spring of 2021, reports of a novel, rare and morbid clinical syndrome, with clinically devastating and fatal complication after vaccination with adenovirus-based coronavirus vaccines (Janssen/Johnson & Johnson and Astra-Zeneca vaccines) led to a brief suspension of their use by several countries. Those complications were associated with unusual cerebral and splanchnic venous thrombosis, and circulating autoantibodies directed against anti-platelet factor 4 (PF4), a protein secreted from platelets, leading to the designation: Vaccine-Induced Immune Thrombotic Thrombocytopenia (VITT). The reported VITT incidence remains very low and does not affect the overall benefit of immunization, however, if left untreated, VITT can be debilitating or even fatal. VITT resembled specific adverse drugs' reactions that also involved the production of autoantibodies and subsequent abnormal platelet activation through platelet FcγRIIa. These unusual but well-documented drug reactions were heparin-induced thrombocytopenia (HIT), streptokinase- (SK), and anisoylated plasminogen-streptokinase activator complex- (APSAC) associated with platelet-activating antibodies. There was considerable overlapping of clinical features between VITT, COVID-19 and these adverse drugs' reactions. We review the phenomenon of VITT against the backdrop of shared and common mechanisms that underlie HIT-, SK-, and APSAC-platelet FcγRIIa-dependent platelet activation. An understanding of VITT's pathogenesis may be achieved by comparing and contrasting VITT-, HIT-, SK- and APSAC-induced platelet activation mechanisms, their respective physiopathology and similarities. Discussing these conditions in parallel provides insight into complex immunological disorders and diseases associated with abnormal hemostasis and thrombosis in particular.
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Affiliation(s)
- Mustapha Abdelouahed
- Department of Medical Sciences and Education, Boston University School of Medicine, Boston, MA, United States
| | - Dana Yateem
- School of Medicine, The Royal College of Surgeons in Ireland, Medical University of Bahrain, Al Sayh, Muharraq Governorate, Bahrain
| | - Salim Fredericks
- School of Medicine, The Royal College of Surgeons in Ireland, Medical University of Bahrain, Al Sayh, Muharraq Governorate, Bahrain
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8
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Kaur K, Kennedy K, Liles D. Crizanlizumab in sickle cell disease. Pain Manag 2023. [PMID: 37850353 DOI: 10.2217/pmt-2023-0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023] Open
Abstract
Vaso-occlusion in sickle cell disease (SCD) leads to a myriad of manifestations driving morbidity and mortality in patients with SCD. Increased leucocyte adhesion and P-selectin expression on platelets and endothelial cells is an inciting event that leads to obstruction of microcirculation by adhesion with rigid sickled red blood cells. Crizanlizumab is a first-in-class monoclonal antibody that inhibits P-selectin and has been shown to decrease the frequency of vaso-occlusive pain crises in patients with SCD in clinical trials. The role of crizanlizumab in other manifestations of SCD still needs further investigation.
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Affiliation(s)
- Kiranveer Kaur
- Division of Hematology/Oncology, East Carolina University, Greenville, NC 27834, USA
| | - Katie Kennedy
- Division of Hematology/Oncology, East Carolina University, Greenville, NC 27834, USA
| | - Darla Liles
- Division of Hematology/Oncology, East Carolina University, Greenville, NC 27834, USA
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9
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Garcia C, Compagnon B, Ribes A, Voisin S, Vardon-Bounes F, Payrastre B. SARS-CoV-2 Omicron variant infection affects blood platelets, a comparative analysis with Delta variant. Front Immunol 2023; 14:1231576. [PMID: 37828997 PMCID: PMC10565689 DOI: 10.3389/fimmu.2023.1231576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/08/2023] [Indexed: 10/14/2023] Open
Abstract
Introduction In November 2021, the SARS-CoV-2 Omicron variant of concern has emerged and is currently dominating the COVID-19 pandemic over the world. Omicron displays a number of mutations, particularly in the spike protein, leading to specific characteristics including a higher potential for transmission. Although Omicron has caused a significant number of deaths worldwide, it generally induces less severe clinical signs compared to earlier variants. As its impact on blood platelets remains unknown, we investigated platelet behavior in severe patients infected with Omicron in comparison to Delta. Methods Clinical and biological characteristics of severe COVID-19 patients infected with the Omicron (n=9) or Delta (n=11) variants were analyzed. Using complementary methods such as flow cytometry, confocal imaging and electron microscopy, we examined platelet activation, responsiveness and phenotype, presence of virus in platelets and induction of selective autophagy. We also explored the direct effect of spike proteins from the Omicron or Delta variants on healthy platelet signaling. Results Severe Omicron variant infection resulted in platelet activation and partial desensitization, presence of the virus in platelets and selective autophagy response. The intraplatelet processing of Omicron viral cargo was different from Delta as evidenced by the distribution of spike protein-positive structures near the plasma membrane and the colocalization of spike and Rab7. Moreover, spike proteins from the Omicron or Delta variants alone activated signaling pathways in healthy platelets including phosphorylation of AKT, p38MAPK, LIMK and SPL76 with different kinetics. Discussion Although SARS-CoV-2 Omicron has different biological characteristics compared to prior variants, it leads to platelet activation and desensitization as previously observed with the Delta variant. Omicron is also found in platelets from severe patients where it induces selective autophagy, but the mechanisms of intraplatelet processing of Omicron cargo, as part of the innate response, differs from Delta, suggesting that mutations on spike protein modify virus to platelet interactions.
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Affiliation(s)
- Cédric Garcia
- Inserm UMR1297 and Université Toulouse 3, Institut des Maladies Métaboliques et Cardiovasculaires (I2MC), Toulouse, France
- Centre Hospitalier Universitaire de Toulouse, Laboratoire d’Hématologie, Toulouse, France
| | - Baptiste Compagnon
- Inserm UMR1297 and Université Toulouse 3, Institut des Maladies Métaboliques et Cardiovasculaires (I2MC), Toulouse, France
- Centre Hospitalier Universitaire de Toulouse, Pôle Anesthésie-Réanimation, Toulouse, France
| | - Agnès Ribes
- Inserm UMR1297 and Université Toulouse 3, Institut des Maladies Métaboliques et Cardiovasculaires (I2MC), Toulouse, France
- Centre Hospitalier Universitaire de Toulouse, Laboratoire d’Hématologie, Toulouse, France
| | - Sophie Voisin
- Inserm UMR1297 and Université Toulouse 3, Institut des Maladies Métaboliques et Cardiovasculaires (I2MC), Toulouse, France
- Centre Hospitalier Universitaire de Toulouse, Laboratoire d’Hématologie, Toulouse, France
| | - Fanny Vardon-Bounes
- Inserm UMR1297 and Université Toulouse 3, Institut des Maladies Métaboliques et Cardiovasculaires (I2MC), Toulouse, France
- Centre Hospitalier Universitaire de Toulouse, Pôle Anesthésie-Réanimation, Toulouse, France
| | - Bernard Payrastre
- Inserm UMR1297 and Université Toulouse 3, Institut des Maladies Métaboliques et Cardiovasculaires (I2MC), Toulouse, France
- Centre Hospitalier Universitaire de Toulouse, Laboratoire d’Hématologie, Toulouse, France
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10
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Solomon SD, Lowenstein CJ, Bhatt AS, Peikert A, Vardeny O, Kosiborod MN, Berger JS, Reynolds HR, Mavromichalis S, Barytol A, Althouse AD, Luther JF, Leifer ES, Kindzelski AL, Cushman M, Gong MN, Kornblith LZ, Khatri P, Kim KS, Baumann Kreuziger L, Wahid L, Kirwan BA, Geraci MW, Neal MD, Hochman JS. Effect of the P-Selectin Inhibitor Crizanlizumab on Survival Free of Organ Support in Patients Hospitalized for COVID-19: A Randomized Controlled Trial. Circulation 2023; 148:381-390. [PMID: 37356038 PMCID: PMC10373640 DOI: 10.1161/circulationaha.123.065190] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 05/12/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND COVID-19 has been associated with endothelial injury, resultant microvascular inflammation and thrombosis. Activated endothelial cells release and express P-selectin and von Willebrand factor, both of which are elevated in severe COVID-19 and may be implicated in the disease pathophysiology. We hypothesized that crizanlizumab, a humanized monoclonal antibody to P-selectin, would reduce morbidity and death in patients hospitalized for COVID-19. METHODS An international, adaptive, randomized controlled platform trial, funded by the National Heart, Lung, and Blood Institute, randomly assigned 422 patients hospitalized with COVID-19 with moderate or severe illness to receive either a single infusion of the P-selectin inhibitor crizanlizumab (at a dose of 5 mg/kg) plus standard of care or standard of care alone in an open-label 1:1 ratio. The primary outcome was organ support-free days, evaluated on an ordinal scale consisting of the number of days alive free of organ support through the first 21 days after trial entry. RESULTS The study was stopped for futility by the data safety monitoring committee. Among 421 randomized patients with known 21-day outcomes, 163 patients (77%) randomized to the crizanlizumab plus standard-of-care arm did not require any respiratory or cardiovascular organ support compared with 169 (80%) in the standard-of-care-alone arm. The adjusted odds ratio for the effect of crizanlizumab on organ support-free days was 0.70 (95% CI, 0.43-1.16), where an odds ratio >1 indicates treatment benefit, yielding a posterior probability of futility (odds ratio <1.2) of 98% and a posterior probability of inferiority (odds ratio <1.0) of 91%. Overall, there were 37 deaths (17.5%) in the crizanlizumab arm and 27 deaths (12.8%) in the standard-of-care arm (hazard ratio, 1.33 [95% CrI, 0.85-2.21]; [probability of hazard ratio>1] = 0.879). CONCLUSIONS Crizanlizumab, a P-selectin inhibitor, did not result in improvement in organ support-free days in patients hospitalized with COVID-19. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04505774.
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Affiliation(s)
- Scott D. Solomon
- Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.D.S., A.S.B., A.P., A.B.)
| | | | - Ankeet S. Bhatt
- Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.D.S., A.S.B., A.P., A.B.)
- Kaiser Permanente San Francisco Medical Center, CA (A.S.B.)
| | - Alexander Peikert
- Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.D.S., A.S.B., A.P., A.B.)
| | - Orly Vardeny
- University of Minnesota and the Minneapolis VA Medical Center (O.V.)
| | - Mikhail N. Kosiborod
- Saint Luke’s Mid America Heart Institute, University of Missouri–Kansas City (M.N.K.)
| | - Jeffrey S. Berger
- Cardiovascular Clinical Research Center, NYU Grossman School of Medicine, New York (J.S.B., H.R.R., S.M., J.S.H.)
| | - Harmony R. Reynolds
- Cardiovascular Clinical Research Center, NYU Grossman School of Medicine, New York (J.S.B., H.R.R., S.M., J.S.H.)
| | - Stephanie Mavromichalis
- Cardiovascular Clinical Research Center, NYU Grossman School of Medicine, New York (J.S.B., H.R.R., S.M., J.S.H.)
| | - Anya Barytol
- Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.D.S., A.S.B., A.P., A.B.)
| | | | - James F. Luther
- University of Pittsburgh, PA (A.D.A., J.F.L., M.W.G., M.D.N.)
| | - Eric S. Leifer
- National Heart, Lung, and Blood Institute, Bethesda, MD (E.S.L., A.L.K.)
| | | | - Mary Cushman
- Larner College of Medicine, University of Vermont, Burlington (M.C.)
| | | | | | - Pooja Khatri
- University of Cincinnati Medical Center, OH (P.K.)
| | | | | | | | | | - Mark W. Geraci
- University of Pittsburgh, PA (A.D.A., J.F.L., M.W.G., M.D.N.)
| | - Matthew D. Neal
- University of Pittsburgh, PA (A.D.A., J.F.L., M.W.G., M.D.N.)
| | - Judith S. Hochman
- Cardiovascular Clinical Research Center, NYU Grossman School of Medicine, New York (J.S.B., H.R.R., S.M., J.S.H.)
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11
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Zaira B, Yulianti T, Levita J. Correlation between Hepatocyte Growth Factor (HGF) with D-Dimer and Interleukin-6 as Prognostic Markers of Coagulation and Inflammation in Long COVID-19 Survivors. Curr Issues Mol Biol 2023; 45:5725-5740. [PMID: 37504277 PMCID: PMC10377933 DOI: 10.3390/cimb45070361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/03/2023] [Accepted: 07/07/2023] [Indexed: 07/29/2023] Open
Abstract
In general, an individual who experiences the symptoms of Severe Acute Respiratory Syndrome Coronavirus 2 or SARS-CoV-2 infection is declared as recovered after 2 weeks. However, approximately 10-20% of these survivors have been reported to encounter long-term health problems, defined as 'long COVID-19', e.g., blood coagulation which leads to stroke with an estimated incidence of 3%, and pulmonary embolism with 5% incidence. At the time of infection, the immune response produces pro-inflammatory cytokines that stimulate stromal cells to produce pro-hepatocyte growth factor (pro-HGF) and eventually is activated into hepatocyte growth factor (HGF), which helps the coagulation process in endothelial and epithelial cells. HGF is a marker that appears as an inflammatory response that leads to coagulation. Currently, there is no information on the effect of SARS-CoV-2 infection on serum HGF concentrations as a marker of the prognosis of coagulation in long COVID-19 survivors. This review discusses the pathophysiology between COVID-19 and HGF, IL-6, and D-dimer.
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Affiliation(s)
- Bena Zaira
- Student at Master Program in Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Sumedang 45363, Indonesia
- Prodia Education and Research Institute, Jakarta 10430, Indonesia
| | - Trilis Yulianti
- Prodia Education and Research Institute, Jakarta 10430, Indonesia
| | - Jutti Levita
- Department of Pharmacology and Clinical Pharmacy, Padjadjaran University, Sumedang 45363, Indonesia
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12
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Arockiam S, Staniforth B, Kepreotis S, Maznyczka A, Bulluck H. A Contemporary Review of Antiplatelet Therapies in Current Clinical Practice. Int J Mol Sci 2023; 24:11132. [PMID: 37446310 DOI: 10.3390/ijms241311132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/03/2023] [Accepted: 07/04/2023] [Indexed: 07/15/2023] Open
Abstract
Antiplatelet therapy plays a crucial role in a number of cardiovascular disorders. We currently have a range of antiplatelet agents in our armamentarium. In this review, we aim to summarise the common antiplatelet agents currently available, and their use in clinic practice. We not only highlight recent trials exploring antiplatelet therapy in atherosclerotic cardiovascular disease, but also in trials related to transcatheter aortic valve implantation and coronavirus disease 2019. Inevitably, the antithrombotic benefits of these drugs are accompanied by an increase in bleeding complications. Therefore, an individualised approach to weighing each patient's thrombotic risk versus bleeding risk is imperative, in order to improve clinical outcomes.
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Affiliation(s)
- Sacchin Arockiam
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS2 3AX, UK
| | - Brittany Staniforth
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS2 3AX, UK
| | - Sacha Kepreotis
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS2 3AX, UK
| | - Annette Maznyczka
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS2 3AX, UK
| | - Heerajnarain Bulluck
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS2 3AX, UK
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 9JT, UK
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13
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Subramaniam S, Reinhardt C, Kulkarni PP, Spiezia L. Editorial: COVID-19 and thrombo-inflammatory responses. Front Cardiovasc Med 2023; 10:1231909. [PMID: 37396577 PMCID: PMC10311441 DOI: 10.3389/fcvm.2023.1231909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/06/2023] [Indexed: 07/04/2023] Open
Affiliation(s)
- Saravanan Subramaniam
- Pulmonary Center, Department of Medicine, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, United States
| | - Christoph Reinhardt
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site RhineMain, Mainz, Germany
| | - Paresh P. Kulkarni
- Department of Biochemistry, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Luca Spiezia
- Thrombosis and Hemorrhagic Diseases Unit Medicine, Padova University Hospital, Padova, Italy
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14
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Abstract
COVID-19 is characterized by dysregulated thrombosis and coagulation that can increase mortality in patients. Platelets are fast responders to pathogen presence, alerting the surrounding immune cells and contributing to thrombosis and intravascular coagulation. The SARS-CoV-2 genome has been found in platelets from patients with COVID-19, and its coverage varies according to the method of detection, suggesting direct interaction of the virus with these cells. Antibodies against Spike and Nucleocapsid have confirmed this platelet-viral interaction. This review discusses the immune, prothrombotic, and procoagulant characteristics of platelets observed in patients with COVID-19. We outline the direct and indirect interaction of platelets with SARS-CoV-2, the contribution of the virus to programmed cell death pathway activation in platelets and the consequent extracellular vesicle release. We discuss platelet activation and immunothrombosis in patients with COVID-19, the effect of Spike on platelets, and possible activation of platelets by classical platelet activation triggers as well as contribution of platelets to complement activation. As COVID-19-mediated thrombosis and coagulation are still not well understood in vivo, we discuss available murine models and mouse adaptable strains.
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Affiliation(s)
- Anthony Sciaudone
- Department of Medicine, Divisions of Cardiovascular Medicine (A.S., H.C., M.K.), University of Massachusetts Chan Medical School, Worcester, MA
| | - Heather Corkrey
- Department of Medicine, Divisions of Cardiovascular Medicine (A.S., H.C., M.K.), University of Massachusetts Chan Medical School, Worcester, MA
| | - Fiachra Humphries
- Innate Immunity (F.H.). University of Massachusetts Chan Medical School, Worcester, MA
| | - Milka Koupenova
- Department of Medicine, Divisions of Cardiovascular Medicine (A.S., H.C., M.K.), University of Massachusetts Chan Medical School, Worcester, MA
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15
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Vassiliou AG, Vrettou CS, Keskinidou C, Dimopoulou I, Kotanidou A, Orfanos SE. Endotheliopathy in Acute COVID-19 and Long COVID. Int J Mol Sci 2023; 24:ijms24098237. [PMID: 37175942 PMCID: PMC10179170 DOI: 10.3390/ijms24098237] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 04/28/2023] [Accepted: 04/30/2023] [Indexed: 05/15/2023] Open
Abstract
The pulmonary endothelium is a highly regulated organ that performs a wide range of functions under physiological and pathological conditions. Since endothelial dysfunction has been demonstrated to play a direct role in sepsis and acute respiratory distress syndrome, its role in COVID-19 has also been extensively investigated. Indeed, apart from the COVID-19-associated coagulopathy biomarkers, new biomarkers were recognised early during the pandemic, including markers of endothelial cell activation or injury. We systematically searched the literature up to 10 March 2023 for studies examining the association between acute and long COVID-19 severity and outcomes and endothelial biomarkers.
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Affiliation(s)
- Alice G Vassiliou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece
| | - Charikleia S Vrettou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece
| | - Chrysi Keskinidou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece
| | - Ioanna Dimopoulou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece
| | - Anastasia Kotanidou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece
| | - Stylianos E Orfanos
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece
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16
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The Long Term Residual Effects of COVID-Associated Coagulopathy. Int J Mol Sci 2023; 24:ijms24065514. [PMID: 36982589 PMCID: PMC10049638 DOI: 10.3390/ijms24065514] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 03/15/2023] Open
Abstract
During the acute phase of COVID-19, many patients experience a complex coagulopathy characterized by a procoagulant pattern. The present study investigates the persistence of hemostatic changes in post-COVID patients at a long-term follow up, and the link with the persistence of physical and neuropsychological symptoms. We completed a prospective cohort study on 102 post-COVID patients. Standard coagulation and viscoelastic tests were performed, along with an assessment of persistent symptoms and recording of acute phase details. A procoagulant state was adjudicated in the presence of fibrinogen > 400 mg/dL, or D-dimer > 500 ng/mL, or platelet count > 450,000 cells/µL, or a maxim clot lysis at viscoelastic test < 2%. A procoagulant state was identified in 75% of the patients at 3 months follow up, 50% at 6 months, and 30% at 12–18 months. Factors associated with the persistence of a procoagulant state were age, severity of the acute phase, and persistence of symptoms. Patients with major physical symptoms carry a procoagulant state relative risk of 2.8 (95% confidence interval 1.17–6.7, p = 0.019). The association between persistent symptoms and a procoagulant state raises the hypothesis that an ongoing process of thrombi formation and/or persistent microthrombosis may be responsible for the main physical symptoms in long-COVID patients.
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17
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Li J, Liang Y. Associations Between Mean Platelet Volume and Risk of Deep Vein Thrombosis: A Mendelian Randomization Study and a Retrospective Study. Int J Gen Med 2023; 16:515-524. [PMID: 36789132 PMCID: PMC9922513 DOI: 10.2147/ijgm.s401059] [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: 12/11/2022] [Accepted: 01/18/2023] [Indexed: 02/11/2023] Open
Abstract
Objective In this study, it was intended to explore the causal association between mean platelet volume (MPV) and risk of deep vein thrombosis (DVT) using a two-sample Mendelian randomization (MR) analysis and a retrospective study. Methods This study applied two-sample MR analysis to estimate the causal association between MPV and risk of DVT. Twenty-one single nucleotide polymorphisms (SNPs) were selected as genetic variants from two independent consortiums cohorts (p-value <5×10-8, linkage disequilibrium r2<0.1). Inverse variance weighted (IVW), MR-egger method and weighted median were performed. A retrospective study was also conducted to verify the associations identified from the MR study. Results The MR analysis demonstrated that genetically predicted higher MPV was associated with significantly lower risk of DVT (OR 0.982, 95% CI = 0.967-0.998, P = 0.023), with the consistent result in weighted median and MR-Egger. There was no directional horizontal pleiotropy in the method of MR-Egger regression (intercept=2.9e-04, P = 0.194). There was no single SNP was found to strongly drive the combined causal effect in the leave-one-out sensitivity analysis. Additionally, the similar result was observed in the retrospective study. Conclusion This study suggested that MPV was negatively associated with the risk of DVT. More basic researches are needed in the future to explore its specific mechanism.
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Affiliation(s)
- Jianhong Li
- Department of Radiology, Foshan Hospital of Traditional Chinese Medicine, Foshan, People’s Republic of China
| | - Yingna Liang
- Department of Gynaecology and Obstetrics, Guangzhou Baiyun First People’s Hospital (Baiyun District Maternal and Child Health Hospital), Guangzhou, Guangdong Province, People’s Republic of China,Correspondence: Yingna Liang, Department of Gynaecology and Obstetrics, Guangzhou Baiyun First People’s Hospital (Baiyun District Maternal and Child Health Hospital), Guangzhou, Guangdong Province, People’s Republic of China, Email
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18
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Carnevale R, Cammisotto V, Bartimoccia S, Nocella C, Castellani V, Bufano M, Loffredo L, Sciarretta S, Frati G, Coluccia A, Silvestri R, Ceccarelli G, Oliva A, Venditti M, Pugliese F, Maria Mastroianni C, Turriziani O, Leopizzi M, D'Amati G, Pignatelli P, Violi F. Toll-Like Receptor 4-Dependent Platelet-Related Thrombosis in SARS-CoV-2 Infection. Circ Res 2023; 132:290-305. [PMID: 36636919 DOI: 10.1161/circresaha.122.321541] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND SARS-CoV-2 is associated with an increased risk of venous and arterial thrombosis, but the underlying mechanism is still unclear. METHODS We performed a cross-sectional analysis of platelet function in 25 SARS-CoV-2 and 10 healthy subjects by measuring Nox2 (NADPH oxidase 2)-derived oxidative stress and thromboxane B2, and investigated if administration of monoclonal antibodies against the S protein (Spike protein) of SARS-CoV-2 affects platelet activation. Furthermore, we investigated in vitro if the S protein of SARS-CoV-2 or plasma from SARS-CoV-2 enhanced platelet activation. RESULTS Ex vivo studies showed enhanced platelet Nox2-derived oxidative stress and thromboxane B2 biosynthesis and under laminar flow platelet-dependent thrombus growth in SARS-CoV-2 compared with controls; both effects were lowered by Nox2 and TLR4 (Toll-like receptor 4) inhibitors. Two hours after administration of monoclonal antibodies, a significant inhibition of platelet activation was observed in patients with SARS-CoV-2 compared with untreated ones. In vitro study showed that S protein per se did not elicit platelet activation but amplified the platelet response to subthreshold concentrations of agonists and functionally interacted with platelet TLR4. A docking simulation analysis suggested that TLR4 binds to S protein via three receptor-binding domains; furthermore, immunoprecipitation and immunofluorescence showed S protein-TLR4 colocalization in platelets from SARS-CoV-2. Plasma from patients with SARS-CoV-2 enhanced platelet activation and Nox2-related oxidative stress, an effect blunted by TNF (tumor necrosis factor) α inhibitor; this effect was recapitulated by an in vitro study documenting that TNFα alone promoted platelet activation and amplified the platelet response to S protein via p47phox (phagocyte oxidase) upregulation. CONCLUSIONS The study identifies 2 TLR4-dependent and independent pathways promoting platelet-dependent thrombus growth and suggests inhibition of TLR4. or p47phox as a tool to counteract thrombosis in SARS-CoV-2.
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Affiliation(s)
- Roberto Carnevale
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy (R.C., S.S., G.F., M.L.).,IRCCS Neuromed, Località Camerelle, Pozzilli (IS), Italy (R.C., S.S., G.F.)
| | - Vittoria Cammisotto
- Department of Clinical Internal, Anaesthesiological and Cardiovascular Sciences (V. Cammisotto, S.B., C.N., L.L., P.P.), Sapienza University of Rome, Italy
| | - Simona Bartimoccia
- Department of Clinical Internal, Anaesthesiological and Cardiovascular Sciences (V. Cammisotto, S.B., C.N., L.L., P.P.), Sapienza University of Rome, Italy
| | - Cristina Nocella
- Department of Clinical Internal, Anaesthesiological and Cardiovascular Sciences (V. Cammisotto, S.B., C.N., L.L., P.P.), Sapienza University of Rome, Italy
| | - Valentina Castellani
- Department of General Surgery and Surgical Speciality (V. Castellani, F.P.), Sapienza University of Rome, Italy
| | - Marianna Bufano
- Laboratory affiliated with the Institute Pasteur Italy - Cenci Bolognetti Foundation, Department of Drug Chemistry and Technologies (M.B., A.C., R.S.), Sapienza University of Rome, Italy
| | - Lorenzo Loffredo
- Department of Clinical Internal, Anaesthesiological and Cardiovascular Sciences (V. Cammisotto, S.B., C.N., L.L., P.P.), Sapienza University of Rome, Italy
| | - Sebastiano Sciarretta
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy (R.C., S.S., G.F., M.L.).,IRCCS Neuromed, Località Camerelle, Pozzilli (IS), Italy (R.C., S.S., G.F.)
| | - Giacomo Frati
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy (R.C., S.S., G.F., M.L.).,IRCCS Neuromed, Località Camerelle, Pozzilli (IS), Italy (R.C., S.S., G.F.)
| | - Antonio Coluccia
- Laboratory affiliated with the Institute Pasteur Italy - Cenci Bolognetti Foundation, Department of Drug Chemistry and Technologies (M.B., A.C., R.S.), Sapienza University of Rome, Italy
| | - Romano Silvestri
- Laboratory affiliated with the Institute Pasteur Italy - Cenci Bolognetti Foundation, Department of Drug Chemistry and Technologies (M.B., A.C., R.S.), Sapienza University of Rome, Italy
| | - Giancarlo Ceccarelli
- Department of Public Health and Infectious Diseases (G.C., A.O., M.V., C.M.M.), Sapienza University of Rome, Italy
| | - Alessandra Oliva
- Department of Public Health and Infectious Diseases (G.C., A.O., M.V., C.M.M.), Sapienza University of Rome, Italy
| | - Mario Venditti
- Department of Public Health and Infectious Diseases (G.C., A.O., M.V., C.M.M.), Sapienza University of Rome, Italy
| | - Francesco Pugliese
- Department of General Surgery and Surgical Speciality (V. Castellani, F.P.), Sapienza University of Rome, Italy
| | - Claudio Maria Mastroianni
- Department of Public Health and Infectious Diseases (G.C., A.O., M.V., C.M.M.), Sapienza University of Rome, Italy
| | - Ombretta Turriziani
- Laboratory of Virology, Department of Molecular Medicine (O.T.), Sapienza University of Rome, Italy
| | - Martina Leopizzi
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy (R.C., S.S., G.F., M.L.)
| | - Giulia D'Amati
- Department of Radiological, Oncological and Pathological Sciences (G.D.), Sapienza University of Rome, Italy
| | - Pasquale Pignatelli
- Department of Clinical Internal, Anaesthesiological and Cardiovascular Sciences (V. Cammisotto, S.B., C.N., L.L., P.P.), Sapienza University of Rome, Italy.,Mediterranea Cardiocentro- Napoli, Italy (P.P., F.V.)
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Jing H, Wu X, Xiang M, Liu L, Novakovic VA, Shi J. Pathophysiological mechanisms of thrombosis in acute and long COVID-19. Front Immunol 2022; 13:992384. [PMID: 36466841 PMCID: PMC9709252 DOI: 10.3389/fimmu.2022.992384] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 10/27/2022] [Indexed: 08/02/2023] Open
Abstract
COVID-19 patients have a high incidence of thrombosis, and thromboembolic complications are associated with severe COVID-19 and high mortality. COVID-19 disease is associated with a hyper-inflammatory response (cytokine storm) mediated by the immune system. However, the role of the inflammatory response in thrombosis remains incompletely understood. In this review, we investigate the crosstalk between inflammation and thrombosis in the context of COVID-19, focusing on the contributions of inflammation to the pathogenesis of thrombosis, and propose combined use of anti-inflammatory and anticoagulant therapeutics. Under inflammatory conditions, the interactions between neutrophils and platelets, platelet activation, monocyte tissue factor expression, microparticle release, and phosphatidylserine (PS) externalization as well as complement activation are collectively involved in immune-thrombosis. Inflammation results in the activation and apoptosis of blood cells, leading to microparticle release and PS externalization on blood cells and microparticles, which significantly enhances the catalytic efficiency of the tenase and prothrombinase complexes, and promotes thrombin-mediated fibrin generation and local blood clot formation. Given the risk of thrombosis in the COVID-19, the importance of antithrombotic therapies has been generally recognized, but certain deficiencies and treatment gaps in remain. Antiplatelet drugs are not in combination with anticoagulant treatments, thus fail to dampen platelet procoagulant activity. Current treatments also do not propose an optimal time for anticoagulation. The efficacy of anticoagulant treatments depends on the time of therapy initiation. The best time for antithrombotic therapy is as early as possible after diagnosis, ideally in the early stage of the disease. We also elaborate on the possible mechanisms of long COVID thromboembolic complications, including persistent inflammation, endothelial injury and dysfunction, and coagulation abnormalities. The above-mentioned contents provide therapeutic strategies for COVID-19 patients and further improve patient outcomes.
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Affiliation(s)
- Haijiao Jing
- Department of Hematology, The First Hospital, Harbin Medical University, Harbin, China
| | - Xiaoming Wu
- Department of Hematology, The First Hospital, Harbin Medical University, Harbin, China
| | - Mengqi Xiang
- Department of Hematology, The First Hospital, Harbin Medical University, Harbin, China
| | - Langjiao Liu
- Department of Hematology, The First Hospital, Harbin Medical University, Harbin, China
| | - Valerie A. Novakovic
- Department of Research, VA Boston Healthcare System, Harvard Medical School, Boston, MA, United States
| | - Jialan Shi
- Department of Hematology, The First Hospital, Harbin Medical University, Harbin, China
- Department of Research, VA Boston Healthcare System, Harvard Medical School, Boston, MA, United States
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
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20
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Conway EM, Mackman N, Warren RQ, Wolberg AS, Mosnier LO, Campbell RA, Gralinski LE, Rondina MT, van de Veerdonk FL, Hoffmeister KM, Griffin JH, Nugent D, Moon K, Morrissey JH. Understanding COVID-19-associated coagulopathy. Nat Rev Immunol 2022; 22:639-649. [PMID: 35931818 PMCID: PMC9362465 DOI: 10.1038/s41577-022-00762-9] [Citation(s) in RCA: 126] [Impact Index Per Article: 63.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2022] [Indexed: 02/06/2023]
Abstract
COVID-19-associated coagulopathy (CAC) is a life-threatening complication of SARS-CoV-2 infection. However, the underlying cellular and molecular mechanisms driving this condition are unclear. Evidence supports the concept that CAC involves complex interactions between the innate immune response, the coagulation and fibrinolytic pathways, and the vascular endothelium, resulting in a procoagulant condition. Understanding of the pathogenesis of this condition at the genomic, molecular and cellular levels is needed in order to mitigate thrombosis formation in at-risk patients. In this Perspective, we categorize our current understanding of CAC into three main pathological mechanisms: first, vascular endothelial cell dysfunction; second, a hyper-inflammatory immune response; and last, hypercoagulability. Furthermore, we pose key questions and identify research gaps that need to be addressed to better understand CAC, facilitate improved diagnostics and aid in therapeutic development. Finally, we consider the suitability of different animal models to study CAC.
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Affiliation(s)
- Edward M Conway
- Centre for Blood Research, Life Sciences Institute, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nigel Mackman
- Department of Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ronald Q Warren
- Molecular Cellular and Systems Blood Science Branch, Division of Blood Diseases and Resources, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Laurent O Mosnier
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA, USA
| | - Robert A Campbell
- Department of Internal Medicine, Division of General Medicine, University of Utah, Salt Lake City, UT, USA
| | - Lisa E Gralinski
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Matthew T Rondina
- Department of Internal Medicine, Division of General Medicine, University of Utah, Salt Lake City, UT, USA
| | - Frank L van de Veerdonk
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Karin M Hoffmeister
- Versiti Translational Glycomics Center, Blood Research Institute and Medical College of Wisconsin, Milwaukee, WI, USA
| | - John H Griffin
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA, USA
| | - Diane Nugent
- Department of Paediatrics, School of Medicine, University of California at Irvine, Irvine, CA, USA
| | - Kyung Moon
- Molecular Cellular and Systems Blood Science Branch, Division of Blood Diseases and Resources, National Heart, Lung, and Blood Institute, Bethesda, MD, USA.
- Bacteriology and Mycology Branch, Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA.
| | - James H Morrissey
- Department of Biological Chemistry, University of Michigan Medical School, Ann Arbor, MI, USA.
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.
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21
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Xiang M, Wu X, Jing H, Liu L, Wang C, Wang Y, Novakovic VA, Shi J. The impact of platelets on pulmonary microcirculation throughout COVID-19 and its persistent activating factors. Front Immunol 2022; 13:955654. [PMID: 36248790 PMCID: PMC9559186 DOI: 10.3389/fimmu.2022.955654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 08/15/2022] [Indexed: 12/05/2022] Open
Abstract
Patients with COVID-19 often have hypoxemia, impaired lung function, and abnormal imaging manifestations in acute and convalescent stages. Alveolar inflammation, pulmonary vasculitis, and thromboembolism synergistically damage the blood-air barrier, resulting in increased pulmonary permeability and gas exchange disorders. The incidence of low platelet counts correlates with disease severity. Platelets are also involved in the impairment of pulmonary microcirculation leading to abnormal lung function at different phases of COVID-19. Activated platelets lose the ability to protect the integrity of blood vessel walls, increasing the permeability of pulmonary microvasculature. High levels of platelet activation markers are observed in both mild and severe cases, short and long term. Therefore, the risk of thrombotic events may always be present. Vascular endothelial injury, immune cells, inflammatory mediators, and hypoxia participate in the high reactivity and aggregation of platelets in various ways. Microvesicles, phosphatidylserine (PS), platelets, and coagulation factors are closely related. The release of various cell-derived microvesicles can be detected in COVID-19 patients. In addition to providing a phospholipid surface for the synthesis of intrinsic factor Xase complex and prothrombinase complex, exposed PS also promotes the decryption of tissue factor (TF) which then promotes coagulant activity by complexing with factor VIIa to activate factor X. The treatment of COVID-19 hypercoagulability and thrombosis still focuses on early intervention. Antiplatelet therapy plays a role in relieving the disease, inhibiting the formation of the hypercoagulable state, reducing thrombotic events and mortality, and improving sequelae. PS can be another potential target for the inhibition of hypercoagulable states.
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Affiliation(s)
- Mengqi Xiang
- Department of Hematology, the First Hospital, Harbin Medical University, Harbin, China
| | - Xiaoming Wu
- Department of Hematology, the First Hospital, Harbin Medical University, Harbin, China
| | - Haijiao Jing
- Department of Hematology, the First Hospital, Harbin Medical University, Harbin, China
| | - Langjiao Liu
- Department of Hematology, the First Hospital, Harbin Medical University, Harbin, China
| | - Chunxu Wang
- Department of Hematology, the First Hospital, Harbin Medical University, Harbin, China
| | - Yufeng Wang
- Department of Hematology, the First Hospital, Harbin Medical University, Harbin, China
| | - Valerie A. Novakovic
- Department of Research, Veterans Affairs (VA) Boston Healthcare System, Harvard Medical School, Boston, MA, United States
| | - Jialan Shi
- Department of Hematology, the First Hospital, Harbin Medical University, Harbin, China
- Department of Research, Veterans Affairs (VA) Boston Healthcare System, Harvard Medical School, Boston, MA, United States
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
- *Correspondence: Jialan Shi, ;
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22
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Zong X, Wang X, Liu Y, Li Z, Wang W, Wei D, Chen Z. Antiplatelet therapy for patients with COVID-19: Systematic review and meta-analysis of observational studies and randomized controlled trials. Front Med (Lausanne) 2022; 9:965790. [PMID: 36160149 PMCID: PMC9490267 DOI: 10.3389/fmed.2022.965790] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 08/19/2022] [Indexed: 11/13/2022] Open
Abstract
Background Hyperinflammation and coagulopathy are hallmarks of COVID-19 and synergistically contribute to illness progression. Antiplatelet agents have been proposed as candidate drugs for COVID-19 treatment on the basis of their antithrombotic and anti-inflammatory properties. A systematic review and meta-analysis that included early observational studies and recent randomized controlled trials (RCTs) was performed to summarize and compare evidence on this issue. Methods PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched to identify studies published up to Nov 7, 2021, and the results of registered clinical trials were followed up to Mar 30, 2022. We included RCTs and observational studies assessing the effect of antiplatelet therapy in adult patients with COVID-19. Data on baseline patient characteristics, interventions, controls, and outcomes were extracted by two independent reviewers. The primary outcome was mortality. Data were pooled using a random-effects model. Results Twenty-seven studies were included, of which 23 observational studies were pooled in a meta-analysis, and the remaining four RCTs (ACTIV-4B, RECOVERY, ACTIV-4a, and REMAP-CAP) were narratively synthesized. Based on 23 observational studies of 87,824 COVID-19 patients, antiplatelet treatment favors a lower risk of mortality [odds ratio (OR) 0.72, 95% confidence interval (CI) 0.61–0.85; I2 = 87.0%, P < 0.01]. The narrative synthesis of RCTs showed conflicting evidence, which did not support adding antiplatelet therapy to the standard care, regardless of the baseline illness severity and concomitant anticoagulation intensity. Conclusion While the rationale for using antiplatelet treatment in COVID-19 patients is compelling and was supported by the combined result of early observational studies, evidence from RCTs did not confirm this approach. Several factors that could explain this inconsistency were highlighted alongside perspectives on future research directions.
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Affiliation(s)
- Xiaolong Zong
- Department of Clinical Laboratory, The Second Hospital of Tianjin Medical University, Tianjin, China
- Institute of Infectious Diseases, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Xiao Wang
- Department of Emergency Medicine, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Yaru Liu
- Department of Emergency Medicine, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Zhenyu Li
- Institute of Infectious Diseases, The Second Hospital of Tianjin Medical University, Tianjin, China
- Department of Emergency Medicine, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Weiding Wang
- Department of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Dianjun Wei
- Department of Clinical Laboratory, Yanda Hospital, Langfang, China
- *Correspondence: Dianjun Wei
| | - Zhuqing Chen
- Medical Security Center, The No. 983 Hospital of the Joint Service Support Force, Tianjin, China
- Zhuqing Chen
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23
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Yang M. Redox stress in COVID-19: Implications for hematologic disorders. Best Pract Res Clin Haematol 2022; 35:101373. [PMID: 36494143 PMCID: PMC9374492 DOI: 10.1016/j.beha.2022.101373] [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: 05/20/2022] [Revised: 08/01/2022] [Accepted: 08/07/2022] [Indexed: 01/08/2023]
Abstract
COVID-19 is the respiratory illness caused by the beta coronavirus SARS-CoV-2. COVID-19 is complicated by an increased risk for adverse thrombotic events that promote organ failure and death. While the mechanism of action for SARS-CoV-2 is still being understood, how SARS-CoV-2 infection impacts the redox environment in hematologic conditions is unclear. In this review, the redox mechanisms contributing to SARS-CoV-2 infection, coagulopathy and inflammation are briefly discussed. Specifically, sources of oxidant generation by hematopoietic and non-hematopoietic cells are identified with special emphasis on leukocytes, platelets, red cells, and endothelial cells. Furthermore, reactive cysteines in SARS-CoV-2 are also discussed with respect to oxidative cysteine modification and current therapeutic implications. Lastly, sickle cell disease will be discussed as a hematologic disorder with a pre-existing prothrombotic redox condition that complicates treatment strategies for COVID-19. An understanding of the redox mechanism may identify potential targets for COVID-19-mediated thrombosis in hematologic disorders.
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Affiliation(s)
- Moua Yang
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center and Harvard Medical School, Center for Life Science Building, 3 Blackfan Circle, Rm 924, Boston, MA 02115, United States
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24
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Soltani-Zangbar MS, Parhizkar F, Abdollahi M, Shomali N, Aghebati-Maleki L, Shahmohammadi Farid S, Roshangar L, Mahmoodpoor A, Yousefi M. Immune system-related soluble mediators and COVID-19: basic mechanisms and clinical perspectives. Cell Commun Signal 2022; 20:131. [PMID: 36038915 PMCID: PMC9421625 DOI: 10.1186/s12964-022-00948-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/02/2022] [Indexed: 12/04/2022] Open
Abstract
During SARS-CoV-2 infection, an effective immune response provides the first line of defense; however, excessive inflammatory innate immunity and impaired adaptive immunity may harm tissues. Soluble immune mediators are involved in the dynamic interaction of ligands with membrane-bound receptors to maintain and restore health after pathological events. In some cases, the dysregulation of their expression can lead to disease pathology. In this literature review, we described current knowledge of the basic features of soluble immune mediators and their dysregulation during SARS-CoV-2 infections and highlighted their contribution to disease severity and mortality. Video Abstract
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Affiliation(s)
- Mohammad Sadegh Soltani-Zangbar
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Immunology, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Forough Parhizkar
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Immunology, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mojtaba Abdollahi
- School of Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | - Navid Shomali
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Sima Shahmohammadi Farid
- Department of Immunology, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Leila Roshangar
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ata Mahmoodpoor
- Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehdi Yousefi
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran. .,Department of Immunology, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran.
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25
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Abstract
On 4 September, 2020, the US National Institutes of Health launched a new clinical trial, “A Multicenter, Adaptive, Randomized Controlled Platform Trial of the Safety and Efficacy of Antithrombotic and Additional Strategies in Hospitalized Adults with COVID-19.” This open-label, placebo-controlled, multicenter, adaptive platform study was designed to evaluate therapeutic options for patients hospitalized with mild, moderate, or severe COVID-19. A variety of drugs and drug classes were selected, including heparin, the monoclonal antibody crizanlizumab, sodium-glucose cotransporter-2 inhibitors, and purinergic signaling receptor Y12 inhibitors. These medications have been widely used in the treatment of other conditions, from sick cell disease to type 2 diabetes mellitus and some forms of cardiovascular disease, but their inclusion in a study of COVID-19 was somewhat unexpected. This article examines the rationale behind the use of these disparate agents in the treatment and prevention of adverse outcomes in patients with COVID-19 and explores how these strategies may be utilized in the future to address the severe acute respiratory syndrome coronavirus 2 pandemic.
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Affiliation(s)
- Matthew W McCarthy
- Department of Medicine, Weill Cornell Medicine, 525 East 68th Street, Box 130, New York, NY, 10065, USA.
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26
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Plasma biomarkers associated with survival and thrombosis in hospitalized COVID-19 patients. Int J Hematol 2022; 116:937-946. [PMID: 35994163 PMCID: PMC9395834 DOI: 10.1007/s12185-022-03437-2] [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: 02/03/2022] [Revised: 07/25/2022] [Accepted: 08/01/2022] [Indexed: 10/26/2022]
Abstract
Severe coronavirus disease-19 (COVID-19) has been associated with fibrin-mediated hypercoagulability and thromboembolic complications. To evaluate potential biomarkers of coagulopathy and disease severity in COVID-19, we measured plasma levels of eight biomarkers potentially associated with coagulation, fibrinolysis, and platelet function in 43 controls and 63 COVID-19 patients, including 47 patients admitted to the intensive care unit (ICU) and 16 non-ICU patients. COVID-19 patients showed significantly elevated levels of fibrinogen, tissue plasminogen activator (t-PA), and its inhibitor plasminogen activation inhibitor 1 (PAI-1), as well as ST2 (the receptor for interleukin-33) and von Willebrand factor (vWF) compared to the control group. We found that higher levels of t-PA, ST2, and vWF at the time of admission were associated with lower survival rates, and that thrombotic events were more frequent in patients with initial higher levels of vWF. These results support a predictive role of specific biomarkers such as t-PA and vWF in the pathophysiology of COVID-19. The data provide support for the case that hypercoagulability in COVID-19 is fibrin-mediated, but also highlights the important role that vWF may play in the genesis of thromboses in the pathophysiology of COVID-19. Interventions designed to enhance fibrinolysis might prove to be useful adjuncts in the treatment of coagulopathy in a subset of COVID-19 patients.
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27
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Falcinelli E, Petito E, Gresele P. The role of platelets, neutrophils and endothelium in COVID-19 infection. Expert Rev Hematol 2022; 15:727-745. [PMID: 35930267 DOI: 10.1080/17474086.2022.2110061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION COVID-19 is associated to an increased risk of thrombosis, as a result of a complex process that involves the activation of vascular and circulating cells, the release of soluble inflammatory and thrombotic mediators and blood clotting activation. AREAS COVERED This article reviews the pathophysiological role of platelets, neutrophils and the endothelium, and of their interactions, in the thrombotic complications of COVID-19 patients, and the current and future therapeutic approaches targeting these cell types. EXPERT OPINION Virus-induced platelet, neutrophil and endothelial cell changes are crucial triggers of the thrombotic complications and of the adverse evolution of COVID-19. Both the direct interaction with the virus and the associated cytokine storm concur to trigger cell activation in a classical thromboinflammatory vicious circle. Although heparin has proven to be an effective prophylactic and therapeutic weapon for the prevention and treatment of COVID-19-associated thrombosis, it acts downstream of the cascade of events triggered by SARS-CoV-2. The identification of specific molecular targets interrupting the thromboinflammatory cascade upstream, and more specifically acting either on the interaction of SARS-CoV-2 with blood and vascular cells or on the specific signalling mechanisms associated with their COVID-19-associated activation, might theoretically offer greater protection with potentially lesser side effects.
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Affiliation(s)
- E Falcinelli
- Section of Internal and Cardiovascular Medicine, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - E Petito
- Section of Internal and Cardiovascular Medicine, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - P Gresele
- Section of Internal and Cardiovascular Medicine, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
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28
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Gawelek KL, Padera R, Connors J, Pinkus GS, Podznyakova O, Battinelli EM. Cardiac megakaryocytes in SARS-CoV-2 positive autopsies. Histopathology 2022; 81:600-624. [PMID: 35925828 PMCID: PMC9538948 DOI: 10.1111/his.14734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/08/2022] [Accepted: 06/10/2022] [Indexed: 01/08/2023]
Abstract
Thromboembolic phenomena are an important complication of infection by severe acute respiratory coronavirus 2 (SARS‐CoV‐2). Increasing focus on the management of the thrombotic complications of Coronavirus Disease 2019 (COVID‐19) has led to further investigation into the role of platelets, and their precursor cell, the megakaryocyte, during the disease course. Previously published postmortem evaluations of patients who succumbed to COVID‐19 have reported the presence of megakaryocytes in the cardiac microvasculature. Our series evaluated a cohort of autopsies performed on SARS‐CoV‐2‐positive patients in 2020 (n = 36) and prepandemic autopsies performed in early 2020 (n = 12) and selected to represent comorbidities common in cases of severe COVID‐19, in addition to infectious and noninfectious pulmonary disease and thromboembolic phenomena. Cases were assessed for the presence of cardiac megakaryocytes and correlated with the presence of pulmonary emboli and laboratory platelet parameters and inflammatory markers. Cardiac megakaryocytes were detected in 64% (23/36) of COVID‐19 autopsies, and 40% (5/12) prepandemic autopsies, with averages of 1.77 and 0.84 megakaryocytes per cm2, respectively. Within the COVID‐19 cohort, autopsies with detected megakaryocytes had significantly higher platelet counts compared with cases throughout; other platelet parameters were not statistically significant between groups. Although studies have supported a role of platelets and megakaryocytes in the response to viral infections, including SARS‐CoV‐2, our findings suggest cardiac megakaryocytes may be representative of a nonspecific inflammatory response and are frequent in, but not exclusive to, COVID‐19 autopsies.
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Affiliation(s)
- Kara L Gawelek
- Department of Pathology, Brigham and Women's Hospital Harvard Medical School, Boston, Massachusetts, USA
| | - Robert Padera
- Department of Pathology, Brigham and Women's Hospital Harvard Medical School, Boston, Massachusetts, USA
| | - Jean Connors
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, Massachusetts, USA
| | - Geraldine S Pinkus
- Department of Pathology, Brigham and Women's Hospital Harvard Medical School, Boston, Massachusetts, USA
| | - Olga Podznyakova
- Department of Pathology, Brigham and Women's Hospital Harvard Medical School, Boston, Massachusetts, USA
| | - Elisabeth M Battinelli
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, Massachusetts, USA
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29
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Platelet activation and partial desensitization are associated with viral xenophagy in patients with severe COVID-19. Blood Adv 2022; 6:3884-3898. [PMID: 35789374 PMCID: PMC9068266 DOI: 10.1182/bloodadvances.2022007143] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/19/2022] [Indexed: 12/17/2022] Open
Abstract
During severe COVID-19, platelets get activated and become partly desensitized through mechanisms involving glycoprotein shedding. Platelets from patients with severe COVID-19 internalize SARS-CoV-2 and develop viral xenophagy.
Mild thrombocytopenia, changes in platelet gene expression, enhanced platelet functionality, and presence of platelet-rich thrombi in the lung have been associated with thromboinflammatory complications of patients with COVID-19. However, whether severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) gets internalized by platelets and directly alters their behavior and function in infected patients remains elusive. Here, we investigated platelet parameters and the presence of viral material in platelets from a prospective cohort of 29 patients with severe COVID-19 admitted to an intensive care unit. A combination of specific assays, tandem mass spectrometry, and flow cytometry indicated high levels of protein and lipid platelet activation markers in the plasma from patients with severe COVID-19 associated with an increase of proinflammatory cytokines and leukocyte-platelets interactions. Platelets were partly desensitized, as shown by a significant reduction of αIIbβ3 activation and granule secretion in response to stimulation and a decrease of surface GPVI, whereas plasma from patients with severe COVID-19 potentiated washed healthy platelet aggregation response. Transmission electron microscopy indicated the presence of SARS-CoV-2 particles in a significant fraction of platelets as confirmed by immunogold labeling and immunofluorescence imaging of Spike and nucleocapsid proteins. Compared with platelets from healthy donors or patients with bacterial sepsis, platelets from patients with severe COVID-19 exhibited enlarged intracellular vesicles and autophagolysosomes. They had large LC3-positive structures and increased levels of LC3II with a co-localization of LC3 and Spike, suggesting that platelets can digest SARS-CoV-2 material by xenophagy in critically ill patients. Altogether, these data show that during severe COVID-19, platelets get activated, become partly desensitized, and develop a selective autophagy response.
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30
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Li D, Li Y, Yang S, Yu Z, Xing Y, Wu M. Mechanism and Potential Target of Blood-Activating Chinese Botanical Drugs Combined With Anti-Platelet Drugs: Prevention and Treatment of Atherosclerotic Cardiovascular Diseases. Front Pharmacol 2022; 13:811422. [PMID: 35721128 PMCID: PMC9204194 DOI: 10.3389/fphar.2022.811422] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 04/25/2022] [Indexed: 11/14/2022] Open
Abstract
Atherosclerotic cardiovascular diseases (ASCVDs) are the most important diseases that endanger people’s health, leading to high morbidity and mortality worldwide. In addition, various thrombotic events secondary to cardiovascular and cerebrovascular diseases need must be considered seriously. Therefore, the development of novel anti-platelet drugs with high efficiency, and fewer adverse effects has become a research focus for preventing of cardiovascular diseases (CVDs). Blood-activation and stasis-removal from circulation have been widely considered as principles for treating syndromes related to CVDs. Blood-activating Chinese (BAC botanical drugs, as members of traditional Chinese medicine (TCM), have shown to improve hemodynamics and hemorheology, and inhibit thrombosis and atherosclerosis. Modern medical research has identified that a combination of BAC botanical drugs and anti-platelet drugs, such as aspirin or clopidogrel, not only enhances the anti-platelet effects, but also reduces the risk of bleeding and protects the vascular endothelium. The anti-platelet mechanism of Blood-activating Chinese (BAC) botanical drugs and their compounds is not clear; therefore, their potential targets need to be explored. With the continuous development of bioinformatics and “omics” technology, some unconventional applications of BAC botanical drugs have been discovered. In this review, we will focus on the related targets and signaling pathways of anti-atherosclerotic treatments involving a combination of BAC botanical drugs and anti-platelet drugs reported in recent years.
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Affiliation(s)
- Dan Li
- Guang'an Men Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yujuan Li
- Guang'an Men Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Shengjie Yang
- Guang'an Men Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Zongliang Yu
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yanwei Xing
- Guang'an Men Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Min Wu
- Guang'an Men Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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31
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Denorme F, Ajanel A, Campbell RA. Shining a light on platelet activation in COVID-19. J Thromb Haemost 2022; 20:1286-1289. [PMID: 35175688 PMCID: PMC9115194 DOI: 10.1111/jth.15678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 01/17/2023]
Affiliation(s)
- Frederik Denorme
- University of Utah Molecular Medicine Program, Salt Lake City, Utah, USA
| | - Abigail Ajanel
- University of Utah Molecular Medicine Program, Salt Lake City, Utah, USA
- Department Pathology, Division of Microbiology and Pathology, University of Utah, Salt Lake City, Utah, USA
| | - Robert A Campbell
- University of Utah Molecular Medicine Program, Salt Lake City, Utah, USA
- Department Pathology, Division of Microbiology and Pathology, University of Utah, Salt Lake City, Utah, USA
- Department of Internal Medicine, Division of General Medicine, University of Utah, Salt Lake City, Utah, USA
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32
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Osburn WO, Smith K, Yanek L, Amat-Alcaron N, Thiemann DR, Cox AL, Leucker TM, Lowenstein CJ. Markers of endothelial cell activation are associated with the severity of pulmonary disease in COVID-19. PLoS One 2022; 17:e0268296. [PMID: 35588115 PMCID: PMC9119480 DOI: 10.1371/journal.pone.0268296] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 04/26/2022] [Indexed: 12/13/2022] Open
Abstract
Severe coronavirus disease-19 (COVID-19) is characterized by vascular inflammation and thrombosis. We and others have proposed that the inflammatory response to coronavirus infection activates endothelial cells, leading to endothelial release of pro-thrombotic proteins. These mediators can trigger obstruction of the pulmonary microvasculature, leading to worsening oxygenation, acute respiratory distress syndrome, and death. In the current study, we tested the hypothesis that higher levels of biomarkers released from endothelial cells are associated with worse oxygenation in patients with COVID-19. We studied 83 participants aged 18–84 years with COVID-19 admitted to a single center. The severity of pulmonary disease was classified by oxygen requirement, including no oxygen requirement, low-flow oxygen, high-flow nasal cannula oxygen, mechanical ventilation, and death. We measured plasma levels of two proteins released by activated endothelial cells, von Willebrand Factor (VWF) antigen and soluble P-Selectin (sP-Sel), and a biomarker of systemic thrombosis, D-dimer. Additionally, we explored the association of endothelial biomarker levels with the levels of pro-inflammatory cytokine and chemokines, and vascular inflammation biomarkers. We found that levels of VWF, sP-sel, and D-dimer were increased in individuals with more severe COVID-19 pulmonary disease. Biomarkers of endothelial cell activation were also correlated with proinflammatory cytokines and chemokines. Taken together, our data demonstrate increased levels of VWF and sP-selectin are linked to the severity of lung disease in COVID-19 and correlated with biomarkers of inflammation and vascular inflammation. Our data support the concept that COVID-19 is a vascular disease which involves endothelial injury in the context of an inflammatory state.
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Affiliation(s)
- William O. Osburn
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Kimberly Smith
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Lisa Yanek
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Nuria Amat-Alcaron
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - David R. Thiemann
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Andrea L. Cox
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Thorsten M. Leucker
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Charles J. Lowenstein
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
- * E-mail:
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Alahyari S, Moradi M, Rajaeinejad M, Jalaeikhoo H. Post-COVID-19 hematologic complications: a systematic review. Expert Rev Hematol 2022; 15:539-546. [PMID: 35584541 DOI: 10.1080/17474086.2022.2080051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION COVID-19 crisis continues around the world. Some patients developed complications after the disease, which have been reported in limited studies. The aim of this study is to comprehensively assess the post-COVID hematologic complications in patients. AREAS COVERED We searched PubMed, Scopus and Google Scholar between January 2020 and August 2021 using related keywords. Evaluation of the articles was performed by two independent researchers. The extracted data included number of patients, age, type of hematological complication, duration of follow-up, response to treatment and prognosis. EXPERT OPINION Sixty five articles reported post-COVID hematologic complications. The most frequent hematologic complication in COVID-19 patients is thromboembolic events, which often occur in two forms: deep vein thrombosis (DVT) and pulmonary emboli (PE). In a group of patients after the diagnosis of COVID-19, a significant decrease in platelets was observed, which was attributed to the ITP induced by COVID-19. Hemolytic anemia and aplastic anemia have also been reported rarely in patients. Finally, post-COVID hematologic complications appear to go beyond thromboembolic events. Although these complications have been reported rarely, searching for methods to identify susceptible patients and prevent these complications could be the subject of future research.
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Affiliation(s)
- Sam Alahyari
- Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Milad Moradi
- Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Rajaeinejad
- AJA Cancer Epidemiology Research and Treatment Center (AJA- CERTC), AJA University of Medical Sciences, Tehran, Iran
| | - Hasan Jalaeikhoo
- AJA Cancer Epidemiology Research and Treatment Center (AJA- CERTC), AJA University of Medical Sciences, Tehran, Iran
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Hottz ED, Bozza PT. Platelet‐leukocyte interactions in COVID‐19: Contributions to hypercoagulability, inflammation, and disease severity. Res Pract Thromb Haemost 2022; 6:e12709. [PMID: 35509326 PMCID: PMC9058941 DOI: 10.1002/rth2.12709] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/29/2022] [Accepted: 03/31/2022] [Indexed: 12/20/2022] Open
Abstract
A State of the Art lecture titled "Platelet-leukocyte interactions in COVID-19: Contributions to hypercoagulability, inflammation and disease severity" was presented at the International Society for Thrombosis and Hemostasis (ISTH) congress in 2021. Severe coronavirus disease 2019 (COVID-19) has been associated with a high incidence of coagulopathy and thromboembolic events that contributes to disease severity and poor outcomes. Therefore, understanding the mechanisms of COVID-19-associated hypercoagulability and thromboinflammation has gained great interest. Here, we review the mechanisms involved in platelet activation and platelet interactions with leukocytes during COVID-19. We highlight recent evidence that platelet activation, platelet-monocyte, and platelet-neutrophil interactions in COVID-19 support pathological thromboinflammation, including in driving tissue factor expression and NETosis, which have been associated with thromboembolic complication and poor outcomes in critically ill patients. The contributions of platelet-leukocyte interactions to COVID-19 immunoregulation, inflammation, and hypercoagulability, as well as their potential implications in disease severity and therapeutic strategies, will be discussed. Finally, we summarize relevant new data on this topic presented during the 2021 ISTH Congress.
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Affiliation(s)
- Eugenio D. Hottz
- Laboratory of Immunothrombosis Department of Biochemistry Federal University of Juiz de Fora (UFJF) Juiz de Fora MG Brazil
| | - Patrícia T. Bozza
- Laboratory of Immunopharmacology Oswaldo Cruz Institute Oswaldo Cruz Foundation RJ Brazil
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Welty FK, Rajai N, Amangurbanova M. Comprehensive Review of Cardiovascular Complications of Coronavirus Disease 2019 and Beneficial Treatments. Cardiol Rev 2022; 30:145-157. [PMID: 35384908 PMCID: PMC8983616 DOI: 10.1097/crd.0000000000000422] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 and was first reported in December 2019 in Wuhan, China. Since then, it caused a global pandemic with 212,324,054 confirmed cases and 4,440,840 deaths worldwide as of August 22, 2021. The disease spectrum of COVID-19 ranges from asymptomatic subclinical infection to clinical manifestations predominantly affecting the respiratory system. However, it is now evident that COVID-19 is a multiorgan disease with a broad spectrum of manifestations leading to multiple organ injuries including the cardiovascular system. We review studies that have shown that the relationship between cardiovascular diseases and COVID-19 is indeed bidirectional, implicating that preexisting cardiovascular comorbidities increase the morbidity and mortality of COVID-19, and newly emerging cardiac injuries occur in the settings of acute COVID-19 in patients with no preexisting cardiovascular disease. We present the most up-to-date literature summary to explore the incidence of new-onset cardiac complications of coronavirus and their role in predicting the severity of COVID-19. We review the association of elevated troponin with the severity of COVID-19 disease, which includes mild compared to severe disease, in nonintensive care unit compared to intensive care unit patients and in those discharged from the hospital compared to those who die. The role of serum troponin levels in predicting prognosis are compared in survivors and non-survivors. The association between COVID-19 disease and myocarditis, heart failure and coagulopathy are reviewed. Finally, an update on beneficial treatments is discussed.
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Affiliation(s)
- Francine K. Welty
- From the Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Nazanin Rajai
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Maral Amangurbanova
- From the Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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36
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Xiang M, Jing H, Wang C, Novakovic VA, Shi J. Persistent Lung Injury and Prothrombotic State in Long COVID. Front Immunol 2022; 13:862522. [PMID: 35464473 PMCID: PMC9021447 DOI: 10.3389/fimmu.2022.862522] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/17/2022] [Indexed: 12/19/2022] Open
Abstract
Lung injury may persist during the recovery period of COVID-19 as shown through imaging, six-minute walk, and lung function tests. The pathophysiological mechanisms leading to long COVID have not been adequately explained. Our aim is to investigate the basis of pulmonary susceptibility during sequelae and the possibility that prothrombotic states may influence long-term pulmonary symptoms of COVID-19. The patient’s lungs remain vulnerable during the recovery stage due to persistent shedding of the virus, the inflammatory environment, the prothrombotic state, and injury and subsequent repair of the blood-air barrier. The transformation of inflammation to proliferation and fibrosis, hypoxia-involved vascular remodeling, vascular endothelial cell damage, phosphatidylserine-involved hypercoagulability, and continuous changes in serological markers all contribute to post-discharge lung injury. Considering the important role of microthrombus and arteriovenous thrombus in the process of pulmonary functional lesions to organic lesions, we further study the possibility that prothrombotic states, including pulmonary vascular endothelial cell activation and hypercoagulability, may affect long-term pulmonary symptoms in long COVID. Early use of combined anticoagulant and antiplatelet therapy is a promising approach to reduce the incidence of pulmonary sequelae. Essentially, early treatment can block the occurrence of thrombotic events. Because impeded pulmonary circulation causes large pressure imbalances over the alveolar membrane leading to the infiltration of plasma into the alveolar cavity, inhibition of thrombotic events can prevent pulmonary hypertension, formation of lung hyaline membranes, and lung consolidation.
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Affiliation(s)
- Mengqi Xiang
- Department of Hematology, First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Haijiao Jing
- Department of Hematology, First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Chengyue Wang
- Department of Hematology, First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Valerie A Novakovic
- Department of Research, Veterans Affairs Boston Healthcare System, Harvard Medical School, Boston, MA, United States
| | - Jialan Shi
- Department of Hematology, First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China.,Department of Research, Veterans Affairs Boston Healthcare System, Harvard Medical School, Boston, MA, United States.,Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
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Platelet activation by SARS-CoV-2 implicates the release of active tissue factor by infected cells. Blood Adv 2022; 6:3593-3605. [PMID: 35443030 PMCID: PMC9023084 DOI: 10.1182/bloodadvances.2022007444] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/06/2022] [Indexed: 11/20/2022] Open
Abstract
Platelets are hyperactivated in coronavirus disease 2019 (COVID-19). However, the mechanisms promoting platelet activation by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are not well understood. This may be due to inherent challenges in discriminating the contribution of viral vs host components produced by infected cells. This is particularly true for enveloped viruses and extracellular vesicles (EVs), as they are concomitantly released during infection and share biophysical properties. To study this, we evaluated whether SARS-CoV-2 itself or components derived from SARS-CoV-2-infected human lung epithelial cells could activate isolated platelets from healthy donors. Activation was measured by the surface expression of P-selectin and the activated conformation of integrin αIIbβ3, degranulation, aggregation under flow conditions, and the release of EVs. We find that neither SARS-CoV-2 nor purified spike activates platelets. In contrast, tissue factor (TF) produced by infected cells was highly potent at activating platelets. This required trace amounts of plasma containing the coagulation factors FX, FII, and FVII. Robust platelet activation involved thrombin and the activation of protease-activated receptor (PAR)-1 and -4 expressed by platelets. Virions and EVs were identified by electron microscopy. Through size-exclusion chromatography, TF activity was found to be associated with a virus or EVs, which were indistinguishable. Increased TF messenger RNA (mRNA) expression and activity were also found in lungs in a murine model of COVID-19 and plasma of severe COVID-19 patients, respectively. In summary, TF activity from SARS-CoV-2–infected cells activates thrombin, which signals to PARs on platelets. Blockade of molecules in this pathway may interfere with platelet activation and the coagulation characteristic of COVID-19.
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Schrottmaier WC, Schmuckenschlager A, Pirabe A, Assinger A. Platelets in Viral Infections - Brave Soldiers or Trojan Horses. Front Immunol 2022; 13:856713. [PMID: 35419008 PMCID: PMC9001014 DOI: 10.3389/fimmu.2022.856713] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/03/2022] [Indexed: 11/13/2022] Open
Abstract
Viral infections are often associated with platelet activation and haemostatic complications. In line, low platelet counts represent a hallmark for poor prognosis in many infectious diseases. The underlying cause of platelet dysfunction in viral infections is multifaceted and complex. While some viruses directly interact with platelets and/or megakaryocytes to modulate their function, also immune and inflammatory responses directly and indirectly favour platelet activation. Platelet activation results in increased platelet consumption and degradation, which contributes to thrombocytopenia in these patients. The role of platelets is often bi-phasic. Initial platelet hyper-activation is followed by a state of platelet exhaustion and/or hypo-responsiveness, which together with low platelet counts promotes bleeding events. Thereby infectious diseases not only increase the thrombotic but also the bleeding risk or both, which represents a most dreaded clinical complication. Treatment options in these patients are limited and new therapeutic strategies are urgently needed to prevent adverse outcome. This review summarizes the current literature on platelet-virus interactions and their impact on viral pathologies and discusses potential intervention strategies. As pandemics and concomitant haemostatic dysregulations will remain a recurrent threat, understanding the role of platelets in viral infections represents a timely and pivotal challenge.
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Affiliation(s)
- Waltraud C Schrottmaier
- Institute of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Anna Schmuckenschlager
- Institute of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Anita Pirabe
- Institute of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Alice Assinger
- Institute of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
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39
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Shukla AK, Misra S. An overview of post COVID sequelae. J Basic Clin Physiol Pharmacol 2022; 33:715-726. [PMID: 35428040 DOI: 10.1515/jbcpp-2022-0057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 03/18/2022] [Indexed: 11/15/2022]
Abstract
After healing from COVID-19, patients often experience a slew of symptoms known as post COVID-19 sequelae. Despite the fact that the SARS-CoV-2 pandemic is still ongoing, post-Covid-19 syndrome is already a difficult problem to address: long-term multiorgan sequelae, while frequently described, have yet to be systematized. As a result, post-Covid-19 syndrome can have a major influence on surviving patients' working capacity as well as their personal lives. The clinical spectrum and long-term course of this clinical entity must be better understood. Post-Covid syndrome affects a wide spectrum of individuals (16-87%), with pneumological and cognitive symptoms being the most common. Pulmonary fibrosis was the most common organic consequence seen in post-Covid patients. In conclusion, post-Covid-19 syndrome can have a major impact on the health of survivors. Working-age patients should seek rehabilitation and follow-up in interdisciplinary rehabilitation programmes. Given the pandemic's global extent, it's obvious that COVID-19-related healthcare demands will continue to climb for the foreseeable future. For COVID-19 survivors' long-term mental and physical health, present outpatient infrastructure will be utilised, scalable healthcare models will be built, and cross-disciplinary collaboration will be required.
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Affiliation(s)
- Ajay Kumar Shukla
- Department of Pharmacology, AIIMS Bhopal, Bhopal, Madhya Pradesh, India
| | - Saurav Misra
- Department of Pharmacology, Kalpana Chawla Government Medical College, Karnal, India
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Shafqat A, Shafqat S, Salameh SA, Kashir J, Alkattan K, Yaqinuddin A. Mechanistic Insights Into the Immune Pathophysiology of COVID-19; An In-Depth Review. Front Immunol 2022; 13:835104. [PMID: 35401519 PMCID: PMC8989408 DOI: 10.3389/fimmu.2022.835104] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/02/2022] [Indexed: 12/15/2022] Open
Abstract
Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), which causes coronavirus-19 (COVID-19), has caused significant morbidity and mortality globally. In addition to the respiratory manifestations seen in severe cases, multi-organ pathologies also occur, making management a much-debated issue. In addition, the emergence of new variants can potentially render vaccines with a relatively limited utility. Many investigators have attempted to elucidate the precise pathophysiological mechanisms causing COVID-19 respiratory and systemic disease. Spillover of lung-derived cytokines causing a cytokine storm is considered the cause of systemic disease. However, recent studies have provided contradictory evidence, whereby the extent of cytokine storm is insufficient to cause severe illness. These issues are highly relevant, as management approaches considering COVID-19 a classic form of acute respiratory distress syndrome with a cytokine storm could translate to unfounded clinical decisions, detrimental to patient trajectory. Additionally, the precise immune cell signatures that characterize disease of varying severity remain contentious. We provide an up-to-date review on the immune dysregulation caused by COVID-19 and highlight pertinent discussions in the scientific community. The response from the scientific community has been unprecedented regarding the development of highly effective vaccines and cutting-edge research on novel therapies. We hope that this review furthers the conversations held by scientists and informs the aims of future research projects, which will potentially further our understanding of COVID-19 and its immune pathogenesis.
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Affiliation(s)
- Areez Shafqat
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | | | | | - Junaid Kashir
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Center of Comparative Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Khaled Alkattan
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
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Ning Q, Wu D, Wang X, Xi D, Chen T, Chen G, Wang H, Lu H, Wang M, Zhu L, Hu J, Liu T, Ma K, Han M, Luo X. The mechanism underlying extrapulmonary complications of the coronavirus disease 2019 and its therapeutic implication. Signal Transduct Target Ther 2022; 7:57. [PMID: 35197452 PMCID: PMC8863906 DOI: 10.1038/s41392-022-00907-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/10/2022] [Accepted: 01/17/2022] [Indexed: 02/06/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) is a highly transmissible disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that poses a major threat to global public health. Although COVID-19 primarily affects the respiratory system, causing severe pneumonia and acute respiratory distress syndrome in severe cases, it can also result in multiple extrapulmonary complications. The pathogenesis of extrapulmonary damage in patients with COVID-19 is probably multifactorial, involving both the direct effects of SARS-CoV-2 and the indirect mechanisms associated with the host inflammatory response. Recognition of features and pathogenesis of extrapulmonary complications has clinical implications for identifying disease progression and designing therapeutic strategies. This review provides an overview of the extrapulmonary complications of COVID-19 from immunological and pathophysiologic perspectives and focuses on the pathogenesis and potential therapeutic targets for the management of COVID-19.
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Affiliation(s)
- Qin Ning
- National Medical Center for Major Public Health Events, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Di Wu
- National Medical Center for Major Public Health Events, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaojing Wang
- National Medical Center for Major Public Health Events, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dong Xi
- National Medical Center for Major Public Health Events, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tao Chen
- National Medical Center for Major Public Health Events, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guang Chen
- National Medical Center for Major Public Health Events, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hongwu Wang
- National Medical Center for Major Public Health Events, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huiling Lu
- National Medical Center for Major Public Health Events, Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ming Wang
- National Medical Center for Major Public Health Events, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lin Zhu
- National Medical Center for Major Public Health Events, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Junjian Hu
- National Medical Center for Major Public Health Events, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tingting Liu
- National Medical Center for Major Public Health Events, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ke Ma
- National Medical Center for Major Public Health Events, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Meifang Han
- National Medical Center for Major Public Health Events, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Xiaoping Luo
- National Medical Center for Major Public Health Events, Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Ostermeier B, Soriano-Sarabia N, Maggirwar SB. Platelet-Released Factors: Their Role in Viral Disease and Applications for Extracellular Vesicle (EV) Therapy. Int J Mol Sci 2022; 23:2321. [PMID: 35216433 PMCID: PMC8876984 DOI: 10.3390/ijms23042321] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/13/2022] [Accepted: 02/17/2022] [Indexed: 02/04/2023] Open
Abstract
Platelets, which are small anuclear cell fragments, play important roles in thrombosis and hemostasis, but also actively release factors that can both suppress and induce viral infections. Platelet-released factors include sCD40L, microvesicles (MVs), and alpha granules that have the capacity to exert either pro-inflammatory or anti-inflammatory effects depending on the virus. These factors are prime targets for use in extracellular vesicle (EV)-based therapy due to their ability to reduce viral infections and exert anti-inflammatory effects. While there are some studies regarding platelet microvesicle-based (PMV-based) therapy, there is still much to learn about PMVs before such therapy can be used. This review provides the background necessary to understand the roles of platelet-released factors, how these factors might be useful in PMV-based therapy, and a critical discussion of current knowledge of platelets and their role in viral diseases.
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Affiliation(s)
| | | | - Sanjay B. Maggirwar
- Department of Microbiology Immunology and Tropical Medicine, The George Washington University, 2300 I Street NW, Washington, DC 20037, USA; (B.O.); (N.S.-S.)
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Ji W, Chen L, Yang W, Li K, Zhao J, Yan C, You C, Jiang M, Zhou M, Shen X. Transcriptional landscape of circulating platelets from patients with COVID-19 reveals key subnetworks and regulators underlying SARS-CoV-2 infection: implications for immunothrombosis. Cell Biosci 2022; 12:15. [PMID: 35139909 PMCID: PMC8827164 DOI: 10.1186/s13578-022-00750-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 01/24/2022] [Indexed: 12/28/2022] Open
Abstract
Background Thrombosis and coagulopathy are pervasive pathological features of coronavirus disease 2019 (COVID-19), and thrombotic complications are a sign of severe COVID-19 disease and are associated with multiple organ failure and increased mortality. Platelets are essential cells that regulate hemostasis, thrombus formation and inflammation; however, the mechanism underlying the interaction between platelets and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remains unclear. Results The present study performed RNA sequencing on the RNA isolated from platelets obtained from 10 COVID-19 patients and eight healthy donors, and discovered that SARS-CoV-2 not only significantly altered the coding and non-coding transcriptional landscape, but also altered the function of the platelets, promoted thrombus formation and affected energy metabolism of platelets. Integrative network biology analysis identified four key subnetworks and 16 risk regulators underlying SARS-CoV-2 infection, involved in coronavirus disease-COVID-19, platelet activation and immune response pathways. Furthermore, four risk genes (upstream binding transcription factor, RNA polymerase II, I and III subunit L, Y-box binding protein 1 and yippee like 2) were found to be associated with COVID-19 severity. Finally, a significant alteration in the von Willebrand factor/glycoprotein Ib-IX-V axis was revealed to be strongly associated with platelet aggregation and immunothrombosis. Conclusions The transcriptional landscape and the identification of critical subnetworks and risk genes of platelets provided novel insights into the molecular mechanisms of immunothrombosis in COVID-19 progression, which may pave the way for the development of novel therapeutic strategies for preventing COVID-19-associated thrombosis and improving the clinical outcome of COVID-19 patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13578-022-00750-5.
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Affiliation(s)
- Weiping Ji
- New Coronavirus Infectious Disease Prevention and Control Leadership Office, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325003, People's Republic of China
| | - Lu Chen
- School of Biomedical Engineering, School of Ophthalmology & Optometry and Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, 325027, People's Republic of China
| | - Wei Yang
- School of Laboratory Medicine and Life Science, Wenzhou Medical University, 325035, Wenzhou, Zhejiang, People's Republic of China
| | - Ke Li
- School of Biomedical Engineering, School of Ophthalmology & Optometry and Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, 325027, People's Republic of China
| | - Jingting Zhao
- School of Biomedical Engineering, School of Ophthalmology & Optometry and Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, 325027, People's Republic of China
| | - Congcong Yan
- School of Biomedical Engineering, School of Ophthalmology & Optometry and Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, 325027, People's Republic of China
| | - Cancan You
- New Coronavirus Infectious Disease Prevention and Control Leadership Office, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325003, People's Republic of China
| | - Minghua Jiang
- New Coronavirus Infectious Disease Prevention and Control Leadership Office, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325003, People's Republic of China
| | - Meng Zhou
- School of Biomedical Engineering, School of Ophthalmology & Optometry and Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, 325027, People's Republic of China.
| | - Xian Shen
- New Coronavirus Infectious Disease Prevention and Control Leadership Office, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325003, People's Republic of China.
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Durmus Kocak N, Oruc O, Boga S, Acar C, Kavas M, Aydogan Eroglu S, Gundogus B, Sogukpinar O, Bekir S, Oztin Guven AA, Akbay MO, Arinc S, Duman D, Takir HB, Yaman F, Ozbaki F, Sonkaya E, Bulbul EU, Anil Tokyay D, Dagyildizi L, Akturk UA, Oztas S, Ernam D, Gungor G, Adiguzel N, Yildiz T, Mocin OY, Gunen H, Yildiz R, Sevim T, Torun T. Use of Radiology, D-Dimer, and Mean Platelet Volume Combination as a Prognostic Marker in Hospitalized Coronavirus Disease-19 Patients. Front Med (Lausanne) 2022; 8:788551. [PMID: 35186972 PMCID: PMC8850409 DOI: 10.3389/fmed.2021.788551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 12/31/2021] [Indexed: 01/08/2023] Open
Abstract
IntroductionThe search for biomarkers that could help in predicting disease prognosis in the Coronavirus Disease-2019 (COVID-19) outbreak is still high on the agenda.ObjectiveTo find out the efficacy of D-dimer and mean platelet volume (MPV) combination as a prognostic marker in hospitalized COVID-19 patients with bilateral infiltration.Materials and MethodsStudy design: Retrospective observational cohort. Patients who were presented to our hospital between March 16, 2020 and June 07, 2020 were reviewed retrospectively. The primary outcome of the study was specified as the need for intensive care, while the secondary outcomes were duration of treatment and hospitalization. Receiver operator curve (ROC) analyzes were carried out to assess the efficacy of D-dimer and MPV parameters as prognostic markers.ResultsBetween the mentioned dates, 575 of 1,564 patients were found to be compatible with COVID-19, and the number of patients who were included in the study was 306. The number of patients who developed the need for intensive care was 40 (13.1%). For serum D-dimer levels in assessing the need for intensive care, the area under the curve (AUC) was found to be 0.707 (95% CI: 0.620–0.794). The AUC for MPV was 0.694 (95% CI: 0.585–0.803), when D-dimer was ≥1.0 mg/L. When patients with a D-dimer level of ≥1.0 mg/L were divided into two groups considering the MPV cut-off value as 8.1, the rate of intensive care transport was found to be significantly higher in patients with an MPV of ≥8.1 fL compared to those with an MPV of <8.1 fL (32.6 vs. 16.0%, p = 0.043). For the prognostic efficacy of the combination of D-dimer ≥ 1.0 mg/L and MPV ≥ 8.1 fL in determining the need for intensive care, following values were determined: sensitivity: 57.7%, specificity: 70.8%, positive predictive value (PPV): 32.0%, negative predictive value (NPV): 84.0%, and accuracy: 63.0%. When D-dimer was ≥1.0, the median duration of treatment in MPV <8.1 and ≥8.1 groups was 5.0 [interquartile range (IQR): 5.0–10.0] days for both groups (p = 0.64). The median length of hospital stay (LOS) was 7.0 (IQR: 5.0–10.5) days in the MPV <8.1 group, while it was 8.5 (IQR: 5.0–16.3) days in the MPV ≥ 8.1 group (p = 0.17).ConclusionIn COVID-19 patients with a serum D-dimer level of at least 1.0 mg/L and radiological bilateral infiltration at hospitalization, if the MPV value is ≥8.1, we could predict the need for intensive care with moderate efficacy and a relatively high negative predictive value. However, no correlation could be found between this combined marker and the duration of treatment and the LOS.
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Affiliation(s)
- Nagihan Durmus Kocak
- University of Health Sciences Sancaktepe Martyr Prof. Dr. Ilhan Varank Training and Research Hospital, Istanbul, Turkey
- *Correspondence: Nagihan Durmus Kocak
| | - Ozlem Oruc
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Sibel Boga
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Cem Acar
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Murat Kavas
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Selma Aydogan Eroglu
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Baran Gundogus
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ozlem Sogukpinar
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Sumeyye Bekir
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Aysem Askim Oztin Guven
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Makbule Ozlem Akbay
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Sibel Arinc
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Dildar Duman
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Huriye Berk Takir
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | | | - Fatma Ozbaki
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Esin Sonkaya
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Esra Usta Bulbul
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Dilem Anil Tokyay
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Lale Dagyildizi
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ulku Aka Akturk
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Selahattin Oztas
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Dilek Ernam
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Gokay Gungor
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Nalan Adiguzel
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Tekin Yildiz
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ozlem Yazicioglu Mocin
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Hakan Gunen
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Reyhan Yildiz
- Department of Chest Diseases Immunology and Allergy Diseases Science, Faculty of Medicine, Ankara, Turkey
| | - Tulin Sevim
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Tulay Torun
- University of Health Sciences Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
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Schrottmaier WC, Pirabe A, Pereyra D, Heber S, Hackl H, Schmuckenschlager A, Brunnthaler L, Santol J, Kammerer K, Oosterlee J, Pawelka E, Treiber SM, Khan AO, Pugh M, Traugott MT, Schörgenhofer C, Seitz T, Karolyi M, Jilma B, Rayes J, Zoufaly A, Assinger A. Platelets and Antiplatelet Medication in COVID-19-Related Thrombotic Complications. Front Cardiovasc Med 2022; 8:802566. [PMID: 35141292 PMCID: PMC8818754 DOI: 10.3389/fcvm.2021.802566] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 12/24/2021] [Indexed: 12/22/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) induces a hypercoagulatory state that frequently leads to thromboembolic complications. Whereas anticoagulation is associated with reduced mortality, the role of antiplatelet therapy in COVID-19 is less clear. We retrospectively analyzed the effect of anticoagulation and antiplatelet therapy in 578 hospitalized patients with COVID-19 and prospectively monitored 110 patients for circulating microthrombi and plasma markers of coagulation in the first week of admission. Moreover, we determined platelet shape change and also thrombi in postmortem lung biopsies in a subset of patients with COVID-19. We observed no association of antiplatelet therapy with COVID-19 survival. Adverse outcome in COVID-19 was associated with increased activation of the coagulation cascade, whereas circulating microthrombi did not increase in aggravated disease. This was in line with analysis of postmortem lung biopsies of patients with COVID-19, which revealed generally fibrin(ogen)-rich and platelet-low thrombi. Platelet spreading was normal in severe COVID-19 cases; however, plasma from patients with COVID-19 mediated an outcome-dependent inhibitory effect on naïve platelets. Antiplatelet medication disproportionally exacerbated this platelet impairment in plasma of patients with fatal outcome. Taken together, this study shows that unfavorable outcome in COVID-19 is associated with a profound dysregulation of the coagulation system, whereas the contribution of platelets to thrombotic complications is less clear. Adverse outcome may be associated with impaired platelet function or platelet exhaustion. In line, antiplatelet therapy was not associated with beneficial outcome.
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Affiliation(s)
- Waltraud C. Schrottmaier
- Department of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Anita Pirabe
- Department of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - David Pereyra
- Department of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, General Hospital Vienna, Vienna, Austria
| | - Stefan Heber
- Institute of Physiology, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Hubert Hackl
- Institute of Bioinformatics, Biocenter, Medical University of Innsbruck, Innsbruck, Austria
| | - Anna Schmuckenschlager
- Department of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Laura Brunnthaler
- Department of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Jonas Santol
- Department of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, General Hospital Vienna, Vienna, Austria
| | - Kerstin Kammerer
- Department of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Justin Oosterlee
- Department of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Erich Pawelka
- Department of Medicine IV, Clinic Favoriten, Vienna, Austria
| | - Sonja M. Treiber
- Department of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Abdullah O. Khan
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Matthew Pugh
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | | | - Christian Schörgenhofer
- Department of Clinical Pharmacology, Medical University of Vienna, General Hospital Vienna, Vienna, Austria
| | - Tamara Seitz
- Department of Medicine IV, Clinic Favoriten, Vienna, Austria
| | - Mario Karolyi
- Department of Medicine IV, Clinic Favoriten, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, General Hospital Vienna, Vienna, Austria
| | - Julie Rayes
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | | | - Alice Assinger
- Department of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
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Berger JS, Kornblith LZ, Gong MN, Reynolds HR, Cushman M, Cheng Y, McVerry BJ, Kim KS, Lopes RD, Atassi B, Berry S, Bochicchio G, de Oliveira Antunes M, Farkouh ME, Greenstein Y, Hade EM, Hudock K, Hyzy R, Khatri P, Kindzelski A, Kirwan BA, Baumann Kreuziger L, Lawler PR, Leifer E, Lopez-Sendon Moreno J, Lopez-Sendon J, Luther JF, Nigro Maia L, Quigley J, Sherwin R, Wahid L, Wilson J, Hochman JS, Neal MD. Effect of P2Y12 Inhibitors on Survival Free of Organ Support Among Non-Critically Ill Hospitalized Patients With COVID-19: A Randomized Clinical Trial. JAMA 2022; 327:227-236. [PMID: 35040887 PMCID: PMC8767444 DOI: 10.1001/jama.2021.23605] [Citation(s) in RCA: 79] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 12/13/2021] [Indexed: 12/17/2022]
Abstract
Importance Platelets represent a potential therapeutic target for improved clinical outcomes in patients with COVID-19. Objective To evaluate the benefits and risks of adding a P2Y12 inhibitor to anticoagulant therapy among non-critically ill patients hospitalized for COVID-19. Design, Setting, and Participants An open-label, bayesian, adaptive randomized clinical trial including 562 non-critically ill patients hospitalized for COVID-19 was conducted between February 2021 and June 2021 at 60 hospitals in Brazil, Italy, Spain, and the US. The date of final 90-day follow-up was September 15, 2021. Interventions Patients were randomized to a therapeutic dose of heparin plus a P2Y12 inhibitor (n = 293) or a therapeutic dose of heparin only (usual care) (n = 269) in a 1:1 ratio for 14 days or until hospital discharge, whichever was sooner. Ticagrelor was the preferred P2Y12 inhibitor. Main Outcomes and Measures The composite primary outcome was organ support-free days evaluated on an ordinal scale that combined in-hospital death (assigned a value of -1) and, for those who survived to hospital discharge, the number of days free of respiratory or cardiovascular organ support up to day 21 of the index hospitalization (range, -1 to 21 days; higher scores indicate less organ support and better outcomes). The primary safety outcome was major bleeding by 28 days as defined by the International Society on Thrombosis and Hemostasis. Results Enrollment of non-critically ill patients was discontinued when the prespecified criterion for futility was met. All 562 patients who were randomized (mean age, 52.7 [SD, 13.5] years; 41.5% women) completed the trial and 87% received a therapeutic dose of heparin by the end of study day 1. In the P2Y12 inhibitor group, ticagrelor was used in 63% of patients and clopidogrel in 37%. The median number of organ support-free days was 21 days (IQR, 20-21 days) among patients in the P2Y12 inhibitor group and was 21 days (IQR, 21-21 days) in the usual care group (adjusted odds ratio, 0.83 [95% credible interval, 0.55-1.25]; posterior probability of futility [defined as an odds ratio <1.2], 96%). Major bleeding occurred in 6 patients (2.0%) in the P2Y12 inhibitor group and in 2 patients (0.7%) in the usual care group (adjusted odds ratio, 3.31 [95% CI, 0.64-17.2]; P = .15). Conclusions and Relevance Among non-critically ill patients hospitalized for COVID-19, the use of a P2Y12 inhibitor in addition to a therapeutic dose of heparin, compared with a therapeutic dose of heparin only, did not result in an increased odds of improvement in organ support-free days within 21 days during hospitalization. Trial Registration ClinicalTrials.gov Identifier: NCT04505774.
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Affiliation(s)
| | | | | | | | - Mary Cushman
- College of Medicine, University of Vermont, Burlington
| | - Yu Cheng
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | | | - Bassel Atassi
- OSF Little Company of Mary Medical Center, Evergreen Park, Illinois
| | | | | | | | | | | | | | - Kristin Hudock
- University of Cincinnati Medical Center, Cincinnati, Ohio
| | | | - Pooja Khatri
- University of Cincinnati Medical Center, Cincinnati, Ohio
| | | | | | | | | | - Eric Leifer
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | | | | | | | - Lilia Nigro Maia
- Fundação Faculdade Regional De Medicina De São José Do Rio Preto, São José do Rio Preto, Brazil
| | | | | | - Lana Wahid
- Duke University Hospital, Durham, North Carolina
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Janus Kinase Signaling Pathway and Its Role in COVID-19 Inflammatory, Vascular, and Thrombotic Manifestations. Cells 2022; 11:cells11020306. [PMID: 35053424 PMCID: PMC8773838 DOI: 10.3390/cells11020306] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/05/2022] [Accepted: 01/07/2022] [Indexed: 12/12/2022] Open
Abstract
Acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection continues to be a worldwide public health crisis. Among the several severe manifestations of this disease, thrombotic processes drive the catastrophic organ failure and mortality in these patients. In addition to a well-established cytokine storm associated with the disease, perturbations in platelets, endothelial cells, and the coagulation system are key in triggering systemic coagulopathy, involving both the macro- and microvasculatures of different organs. Of the several mechanisms that might contribute to dysregulation of these cells following SARS-CoV-2 infection, the current review focuses on the role of activated Janus kinase (JAK) signaling in augmenting thrombotic processes and organ dysfunction. The review concludes with presenting the current understanding and emerging controversies concerning the potential therapeutic applications of JAK inhibitors for ameliorating the inflammation-thrombosis phenotype in COVID-19 patients.
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48
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Current and novel biomarkers of thrombotic risk in COVID-19: a Consensus Statement from the International COVID-19 Thrombosis Biomarkers Colloquium. Nat Rev Cardiol 2022; 19:475-495. [PMID: 35027697 PMCID: PMC8757397 DOI: 10.1038/s41569-021-00665-7] [Citation(s) in RCA: 153] [Impact Index Per Article: 76.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2021] [Indexed: 02/06/2023]
Abstract
Coronavirus disease 2019 (COVID-19) predisposes patients to thrombotic and thromboembolic events, owing to excessive inflammation, endothelial cell activation and injury, platelet activation and hypercoagulability. Patients with COVID-19 have a prothrombotic or thrombophilic state, with elevations in the levels of several biomarkers of thrombosis, which are associated with disease severity and prognosis. Although some biomarkers of COVID-19-associated coagulopathy, including high levels of fibrinogen and D-dimer, were recognized early during the pandemic, many new biomarkers of thrombotic risk in COVID-19 have emerged. In this Consensus Statement, we delineate the thrombotic signature of COVID-19 and present the latest biomarkers and platforms to assess the risk of thrombosis in these patients, including markers of platelet activation, platelet aggregation, endothelial cell activation or injury, coagulation and fibrinolysis as well as biomarkers of the newly recognized post-vaccine thrombosis with thrombocytopenia syndrome. We then make consensus recommendations for the clinical use of these biomarkers to inform prognosis, assess disease acuity, and predict thrombotic risk and in-hospital mortality. A thorough understanding of these biomarkers might aid risk stratification and prognostication, guide interventions and provide a platform for future research.
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49
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Elahi S. Hematopoietic responses to SARS-CoV-2 infection. Cell Mol Life Sci 2022; 79:187. [PMID: 35284964 PMCID: PMC8918078 DOI: 10.1007/s00018-022-04220-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 02/03/2022] [Accepted: 02/22/2022] [Indexed: 01/09/2023]
Abstract
Under physiological conditions, hematopoietic stem and progenitor cells (HSPCs) in the bone marrow niches are responsible for the highly regulated and interconnected hematopoiesis process. At the same time, they must recognize potential threats and respond promptly to protect the host. A wide spectrum of microbial agents/products and the consequences of infection-induced mediators (e.g. cytokines, chemokines, and growth factors) can have prominent impact on HSPCs. While COVID-19 starts as a respiratory tract infection, it is considered a systemic disease which profoundly alters the hematopoietic system. Lymphopenia, neutrophilia, thrombocytopenia, and stress erythropoiesis are the hallmark of SARS-CoV-2 infection. Moreover, thrombocytopenia and blood hypercoagulability are common among COVID-19 patients with severe disease. Notably, the invasion of erythroid precursors and progenitors by SARS-CoV-2 is a cardinal feature of COVID-19 disease which may in part explain the mechanism underlying hypoxia. These pieces of evidence support the notion of skewed steady-state hematopoiesis to stress hematopoiesis following SARS-CoV-2 infection. The functional consequences of these alterations depend on the magnitude of the effect, which launches a unique hematopoietic response that is associated with increased myeloid at the expense of decreased lymphoid cells. This article reviews some of the key pathways including the infectious and inflammatory processes that control hematopoiesis, followed by a comprehensive review that summarizes the latest evidence and discusses how SARS-CoV-2 infection impacts hematopoiesis.
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Affiliation(s)
- Shokrollah Elahi
- Faculty of Medicine and Dentistry, School of Dentistry, Division of Foundational Sciences, Department of Oncology, and Li Ka Shing Institute of Virology, University of Alberta, 7020 Katz Group Centre, 11361-87th Ave NW, Edmonton, AB T6G 2E1 Canada
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50
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Daniels S, Wei H, van Tongeren M, Denning DW. Are platelet volume indices of clinical use in COVID-19? A systematic review. Front Cardiovasc Med 2022; 9:1031092. [PMID: 36329999 PMCID: PMC9623063 DOI: 10.3389/fcvm.2022.1031092] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/03/2022] [Indexed: 12/15/2022] Open
Abstract
Background The incidence of thrombotic complications is high in COVID-19 patients with severe disease. As key regulators of thrombus formation, platelets likely play a crucial role as mediators of severe acute respiratory syndrome coronavirus 2 associated pathogenesis. Studies have reported that parameters reflecting platelet size, known as platelet volume indices (PVI), are raised in patients with thrombosis and can predict poor outcomes. This systematic review evaluates the potential for PVI to be used as a predictor of COVID-19 morbidity and mortality. Methods English and Chinese databases were searched electronically to identify studies reporting data on mean platelet volume, platelet distribution width or platelet-large cell ratio in COVID-19 patients. Included articles underwent a quality rating and descriptive narrative analysis. Results Thirty-two studies were included in the systematic review. The results show a general trend for PVI to be raised in severe COVID-19 patients and non-survivors, with 14 studies reporting significant differences of baseline PVI between severe and mild disease. Nonetheless, longitudinal studies showed varying PVI trends over the course of the disease and evidence for PVI to be associated with disease progression was limited. The quality rating of 12 studies was poor, 16 were rated fair and four were good. Most studies were retrospective in design, used small study populations and did not consider confounding factors that influence platelet volume. Studies also contained technical flaws in PVI measurement, limiting the reliability of the results. Conclusion The evidence on the clinical usefulness of PVI is greatly limited by the lack of prospective evaluation, together with technical problems in measuring PVI. Carefully designed prospective studies are warranted. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=304305, identifier CRD42022304305.
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Affiliation(s)
- Sarah Daniels
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, University of Manchester, Manchester, United Kingdom.,Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Hua Wei
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, University of Manchester, Manchester, United Kingdom.,Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Martie van Tongeren
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, University of Manchester, Manchester, United Kingdom.,Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - David W Denning
- Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom.,Division of Evolution, Infection and Genomics, School of Biological Sciences, University of Manchester, Manchester, United Kingdom
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