Disseminated intravascular coagulation is strongly associated with severe acute kidney injury in patients with septic shock

Association analysis of sepsis progression to sepsis-induced coagulopathy: a study based on the MIMIC-IV database

BACKGROUND

Sepsis-induced coagulopathy (SIC) is a severe complication of sepsis, characterized by poor prognosis and high mortality. However, the predictive factors for the development of SIC in sepsis patients remain to be determined. The aim of this study was to develop an easy-to-use and efficient nomogram for predicting the risk of sepsis patients developing SIC in the intensive care unit (ICU), based on common indicators and complications observed at admission.

METHODS

A total of 12, 455 sepsis patients from the MIMIC database were screened and randomly divided into training and validation cohorts. In the training cohort, LASSO regression was used for variable selection and regularization. The selected variables were then incorporated into a multivariable logistic regression model to construct the nomogram for predicting the risk of sepsis patients developing sepsis-induced coagulopathy (SIC). The model's predictive performance was evaluated using the area under the receiver operating characteristic curve (AUC), and its calibration was assessed through a calibration curve. Additionally, decision curve analysis (DCA) was performed to evaluate the clinical applicability of the model. External validation was conducted using data from the ICU database of Xingtai People's Hospital.

RESULTS

Among the 12, 455 sepsis patients, 5, 145 (41. 3%) developed SIC. The occurrence of SIC was significantly associated with the SOFA score, red blood cell count, red cell distribution width (RDW), white blood cell count, platelet count, INR, and lactate levels. Additionally, hypertension was identified as a potential protective factor. A nomogram was developed to predict the risk of SIC, which showed an AUC of 0. 81 (95% CI: 0. 79-0. 83) in the training set, 0. 83 (95% CI: 0. 82-0. 84) in the validation set, and 0. 79 (95% CI: 0. 74-0. 84) in the external validation. The calibration curve of the nomogram showed good consistency between the observed and predicted probabilities of SIC.

CONCLUSIONS

The novel nomogram demonstrates excellent predictive performance for the incidence of SIC in ICU patients with sepsis and holds promise for assisting clinicians in early identification and intervention of SIC.

CLINICAL TRIAL

Not applicable.

Incidence and risk factors of postpartum urinary retention following cesarean section: a retrospective nationwide inpatient sample database study

AIM

To investigate the risk factors associated with postpartum urinary retention after cesarean section (CS) and to determine the associated morbidity rate.

METHODS

This study was a population-based retrospective case-control study analyzed using National Inpatient Sample (NIS) data from 2010 to 2019. The study classified women according to whether they developed postpartum urinary retention after delivery. Predictors of postpartum urinary retention occurring after CS were identified by multivariate logistic regression analysis, and the corresponding incidence rates were examined after adjusting for basic maternal demographic and clinical characteristics.

RESULTS

A total of 2,397,168 CSs were extracted from the NIS database. The overall incidence of urinary retention after CS was 0.20%. Patients who experienced urinary retention after CS demonstrated longer length of stay (LOS), higher total costs, and more postoperative complications. The following variables have been identified as potential risk factors for urinary retention: age between 25 and 34 years (OR = 1.27; 95% CI = 1.17-1.38; P < 0.001), 35 years and older (OR = 1.35; 95% CI = 1.22-1.48; P < 0.001), Asian and Pacific Islander (OR = 1.85; 95% CI = 1.68-2.05; P < 0.001), one comorbidity (OR = 1.51; 95% CI = 1.28-1.79; P < 0.001), two comorbidities (OR = 1.51; 95% CI = 1.09-2.08; P = 0.013), three and more comorbidities (OR = 1.79; 95% CI = 1.06-3.04; P = 0.031), large hospitals (OR = 1.16; 95% CI = 1.07-1.26; P < 0.001), teaching hospitals (OR = 1.93; 95% CI = 1.79-2.07; P < 0.001), eastern hospitals (OR = 1.24; 95% CI = 1.14-1.35; P < 0.001), coagulation disorders (OR = 1.32; 95% CI = 1.08-1.61), fluid and electrolyte disorders (OR = 2.46; 95% CI = 1.94-3.11), other neurological disorders (OR = 1.51; 95% CI = 1.20-1.89), paralysis (OR = 3.24; 95% CI = 1.95-5.38), and weight loss (OR = 2.34;95% CI = 1.26-4.35). In addition, urinary retention was associated with postoperative complications related to bladder or ureteral injury (OR = 6.12; 95% CI = 2.46-15.23), blood transfusion (OR = 1.51; 95% CI = 1.31-1.76), acute renal failure (OR = 4.74; 95% CI = 3.46-6.48), respiratory failure (OR = 2.21; 95% CI = 1.23-3.98), endometritis (OR = 1.32; 95% CI = 1.02-1.71), hemorrhage/hematoma ( OR = 2.52; 95% CI = 1.38-4.62), uterine rupture (OR = 1.75; 95% CI = 1.21-2.54), hysterectomy (OR = 2.30; 95% CI = 1.66-3.18), peritonitis (OR = 2.86; 95% CI = 1.03-7.92), severe puerperal infections (OR = 3.31; 95% CI = 2.60- 4.22), chorioamnionitis (OR = 1.78; 95% CI = 1.59-2.00). Notably, the presence of cephalopelvic disproportion (OR = 1.37; 95% CI = 1.11-1.67), breech or other fetal position abnormalities (OR = 1.10; 95% CI = 1.00-1.20), placenta previa (OR = 1.39; 95% CI = 1.06-1.84), multiple gestation (OR = 1.39; 95% CI = 1.23-1.58), anatomy of the bladder (OR = 3.93; 95% CI = 1.42-10.90), bladder catheter placement (OR = 22.57; 95% CI = 20.24-25.17) and intravenous infusion (OR = 1.22; 95% CI = 1.09-1.36) was associated with a significantly increased risk of urinary retention, while low cervical CS (OR = 0.62; 95% CI = 0.50-0.76), previous CS (OR = 0.87; 95% CI = 0.82-0.93) and prolapsed cord (OR = 0.52; 95% CI = 0.31-0.86) conferred some protective effect against it.

CONCLUSION

In this study, we identified an overall prevalence of 0.20% for urinary retention after CS and several risk factors, including advanced maternal age, Asian and Pacific Islander background, comorbidities, and delivery in large or teaching hospitals, particularly in the Eastern region. Protective factors included hospitals in the southern region, urban hospitals, obesity, and hypertension. Urinary retention was associated with increased postoperative complications, longer LOS, and higher healthcare costs. Several confounders also significantly influenced the incidence of urinary retention. To mitigate these risks, healthcare professionals should prioritize antenatal screening, manage comorbidities, and closely monitor high-risk patients during the postpartum period to reduce adverse outcomes.

Predictive factors for disseminated intravascular coagulation following colorectal perforation

PURPOSE

To determine the relationship between postoperative disseminated intravascular coagulation (DIC) and patient prognosis after surgery for colorectal perforation and to identify preoperative predictive factors for DIC.

METHODS

We included 112 patients who underwent emergency surgery for colorectal perforation between April 2014 and September 2023. We performed a Kaplan-Meier analysis to assess 30-day postoperative survival with and without postoperative DIC, log-rank test to compare survival curves, and logistic regression analysis to identify preoperative predictive factors for postoperative DIC.

RESULTS

The postoperative DIC and 30-day mortality rates were 37.5 ​% and 8 ​%, respectively. The 30-day postoperative mortality rates significantly differed between patients with postoperative DIC and those without (16.7 ​% vs. 2.9 ​%). The preoperative Sequential Organ Failure Assessment (SOFA) score was an independent predictive factor for postoperative DIC.

CONCLUSION

Evaluating preoperative SOFA scores may help assess postoperative DIC risk and enable early initiation of anticoagulant therapy in patients undergoing surgery for colorectal perforation.

Influence of CAR T-cell therapy associated complications

Since the introduction of chimeric antigen receptor (CAR) T-cell therapy, it has elicited an immense response in both targeted and residual cancers. Its clinical efficacy is often accompanied by a group of side effects that may become serious because of factors such as tumor burden, the extent of lymphodepletion, and the type of co-stimulus. It is also crucial to know the common toxicities associated with CAR T-cell therapy, including cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), cardiotoxicity, metabolic disorders, pulmonary toxicity, macrophage activation syndrome (MAS), prolonged cytopenia, coagulation disorders, and potential off-target effects on various organs. If not well managed, these can be fatal. However, knowledge about molecular pathways, calcineurin inhibitors, IL-6 receptor antagonists, steroids, suppression of nitric oxide synthase, various therapeutic approaches, and other recent advances have been developed to mitigate the fatal results of various short-term and chronic adverse events related to CAR T-cell therapy. This study provides a comprehensive perspective on contemporary management strategies and presumed causative processes of CAR T-cell-related adverse effects, albeit with several limitations. When CAR T-cell complications, costs, and challenges of toxicity management are properly considered, the CAR T-cell therapy of the future will include a number of toxicity-escaping options.

Disseminated intravascular coagulopathy and subsequent kidney injury requiring dialysis after a second-trimester dilation and evacuation procedure

A primigravida in her 20s with a body mass index of 18 underwent dilation and evacuation at 22 and 4 weeks gestational age to manage an intrauterine fetal demise (IUFD) that had occurred 14 days ago. Hypoxaemia and vaginal bleeding developed 90 min postprocedure. Investigations demonstrated changes compatible with acute respiratory distress syndrome secondary to disseminated intravascular coagulopathy which was managed with intubation, mechanical ventilation and transfusion of blood products. Although the coagulopathy and respiratory failure resolved, severe acute kidney injury ensued resulting in acute tubular necrosis, severe labial oedema and the need for prolonged support with haemodialysis until kidney recovery 7 weeks later.

Understanding, assessing and treating immune, endothelial and haemostasis dysfunctions in bacterial sepsis

The interplay between the immune system, coagulation, and endothelium is critical in regulating the host response to infection. However, in sepsis and other critical illnesses, a dysregulated immune response can lead to excessive alterations in these mechanisms, resulting in coagulopathy, endothelial dysfunction, and multi-organ dysfunction. This review aims to provide a comprehensive analysis of the pathophysiological mechanisms that govern the complex interplay between immune dysfunction, endothelial dysfunction, and coagulation in sepsis. It emphasises clinical significance, evaluation methods, and potential therapeutic interventions. Understanding these mechanisms is essential for developing effective treatments that can modulate the immune response, mitigate thrombosis, restore endothelial function, and ultimately improve patient survival.

Eriocitrin prevents Sepsis-induced acute kidney injury through anti-inflammation and anti-oxidation via modulating Nrf2/DRP1/OPA1 signaling pathway

BACKGROUND

Severe inflammation and oxidative stress are characteristics of sepsis-associated kidney injury with high morbidity and mortality. Eriocitrin (ERI) has shown promise in suppressing sepsis-associated kidney injury and LPS-induced periodontal disease, however, its efficacy in alleviating SAKI remains unexplored. This study aimed to investigate the therapeutic potential of ERI on SAKI through in vivo and in vitro experiments, elucidating its underlying mechanism.

METHODS

The therapeutic effects of ERI against SAKI were evaluated by survival rate, changes of serum creatinine (Scr) and blood urea nitrogen (BUN) and statistic of renal histological score in a Cecal ligation and puncture (CLP)-induced septic mice. Impactions about anti-coagulation, anti-inflammation, anti-oxidative stress and improvement of mitochondrial damage and mitochondrial morphology were further assayed. In vitro, HUVECs upon stimulation of LPS with or without different dosage of ERI, followed by evaluating changes in inflammation, mitochondrial dynamic equilibrium and signaling pathways.

RESULTS

ERI demonstrated ameliorative effects on SAKI by attenuating inflammation, oxidative stress and coagulation evidenced by the improved survival rate, alleviated kidney histological injury, declined BUN and Scr in serum and diminished levels of inflammation cytokines, and coagulation factors. Mechanistically, ERI suppressed DRP1-regulated mitochondrial fission and promoted OPA1-modulated mitochondrial fusion by activating Nrf2 in septic mice and LPS-stimulated HUVECs, which maintained mitochondrial dynamic equilibrium, improved mitochondrial morphology, assured integrity of mitochondrial function, decreased oxidative stress, impeded overwhelming inflammation, and thus, played a pivotal role in ERI's protection against SAKI.

CONCLUSION

Our data confirmed the therapeutic potential of ERI in mitigating SAKI，suggesting its viability as a pharmacological agent in clinic settings.

The role of thromboinflammation in acute kidney injury among patients with septic coagulopathy

Inflammation and coagulation are critical self-defense mechanisms for mitigating infection that can nonetheless induce tissue injury and organ dysfunction. In severe cases, like sepsis, a dysregulated thromboinflammatory response may result in multiorgan dysfunction. Sepsis-associated acute kidney injury (AKI) is a significant contributor to patient morbidity and mortality. The connection between AKI and thromboinflammation is largely due to unique aspects of the renal vasculature. Specifically, the interaction between blood cells with the endothelial, glomerular, and peritubular capillary systems during thromboinflammation reduces oxygen supply to tubular epithelial cells. Previous studies have focused on tubular epithelial cell damage due to hypoxia, oxidative stress, and nephrotoxins. Although these factors are pivotal in acute tubular injury or necrosis, recent studies have demonstrated that AKI in sepsis encompasses a mixture of tubular and glomerular damage subtypes. In cases of sepsis-induced coagulopathy, thromboinflammation within the glomerulus and peritubular capillaries is an important pathogenic mechanism for AKI. Unfortunately, and despite the use of renal replacement therapy, the development of AKI in sepsis continues to be associated with high morbidity, mortality, and clinical challenges requiring alternative approaches. This review introduces the important role of thromboinflammation in AKI pathogenesis and details innovative vascular-targeting therapeutic strategies.

Sepsis induces heterogeneous transcription of coagulation- and inflammation-associated genes in renal microvasculature

BACKGROUND

Acute kidney injury (AKI) in sepsis patients increases patient mortality. Endothelial cells are important players in the pathophysiology of sepsis-associated AKI (SA-AKI), yet knowledge regarding their spatiotemporal involvement in coagulation disbalance and leukocyte recruitment is lacking. This study investigated the identity and kinetics of responses of different microvascular compartments in kidney cortex in response to SA-AKI.

METHODS

Laser microdissected arterioles, glomeruli, peritubular capillaries, and postcapillary venules from kidneys of mice subjected to cecal ligation and puncture (CLP) were analyzed using RNA sequencing. Differential expression and pathway enrichment analyses identified genes involved in coagulation and inflammation. A selection of these genes was evaluated by RT-qPCR in microvascular compartments of renal biopsies from patients with SA-AKI. The role of two identified genes in lipopolysaccharide-induced endothelial coagulation and inflammatory activation were determined in vitro in HUVEC using siRNA-based gene silencing.

RESULTS

CLP-sepsis in mice induced altered expression of approximately 400 genes in the renal microvasculature, with microvascular compartments exhibiting unique spatiotemporal responses. In mice, changes in gene expression related to coagulation and inflammation were most extensive in glomeruli at early and intermediate time points, with high induction of Plat, Serpine1, Thbd, Icam1, Stat3, and Ifitm3. In human SA-AKI, PROCR and STAT3 were induced in postcapillary venules, while SERPINE1 expression was diminished. IFITM3 was increased in arterioles and glomeruli. In vitro studies revealed that STAT3 and IFITM3 partly control endothelial coagulation and inflammatory activation.

CONCLUSION

Renal microvascular compartments in mice and humans exhibited heterogeneous changes in coagulation- and inflammation-related gene expression in response to SA-AKI. Additional research should aim at understanding the functional consequences of the here described heterogeneous microvascular responses to establish the usefulness of identified genes as therapeutic targets in SA-AKI.

Organ Dysfunction in Sepsis-associated Intravascular Coagulation

Sepsis is frequently associated with disseminated intravascular coagulation (DIC) and multiple organ damage. It is widely accepted that DIC is not merely a complication but also plays a role in the development of organ dysfunction. Thrombus formation in the microvasculature leads to impaired tissue perfusion and organ damage. Activated neutrophils interacting with platelets, endothelial injury, and an imbalance of coagulation and fibrinolysis are the essence of thromboinflammation induced in sepsis-associated DIC. The above mechanisms are typically seen in sepsis-associated acute kidney injury (AKI), and the development of AKI is known to be strongly associated with the severity of sepsis. It is important to recognize the pathway of this mechanism in the context of sepsis management.

Impact of Hemoglobin Level, White Blood Cell Count, Renal Dysfunction, and Staphylococcus as the Causative Organism on Prediction of In-Hospital Mortality from Infective Endocarditis

Infective endocarditis (IE) is a highly fatal disease in cases of delayed diagnosis and treatment, although its incidence is low. However, there have been few single-center studies in which the risk of in-hospital death from IE was stratified according to laboratory findings on admission and the organism responsible for IE. In this study, a total of 162 patients who were admitted to our hospital during the period from 2009 to 2021, who were suspected of having IE according to the modified Duke classification, and for whom IE was confirmed by transesophageal echocardiography were retrospectively analyzed. Patients were observed for a mean-period of 43.7 days with the primary endpoint being in-hospital death. The in-hospital death group had a lower level of hemoglobin (Hb), higher white blood cell (WBC) count, lower level of estimated glomerular filtration rate (eGFR), and higher frequency of Staphylococcus being the causative agent than those in the non-in-hospital death group. In overall multivariate analysis, Hb, WBC count, eGFR, and Staphylococcus as the causative agent were identified to be significant prognostic determinants. IE patients with Hb < 10.6 g/dL, WBC count > 1.4 × 104/μL, eGFR < 28.1 mL/minute/1.7 m2, and Staphylococcus as the causative agent had significantly and synergistically increased in-hospital death rates compared to those in other IE patients. Low level of Hb, high WBC count, low eGFR, and Staphylococcus as the causative agent of IE were independent predictors of in-hospital mortality, suggesting that these 4 parameters may be combined to additively stratify the risk of in-hospital mortality.