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Chowdary P, Agarwal B, Peralta MR, Bhagani S, Lee S, Goldring J, Lipman M, Waqif E, Phillips M, Philippou H, Foley JH, Mutch NJ, Ariëns RAS, Stringer KA, Ricciardi F, Watissée M, Hughes D, Nathwani A, Riddell A, Patch D, Buckley J, De Neef M, Dimber R, Diaz-Garcia C, Patel H, Nandani A, Dissanayake U, Chadwick N, Alkhatip AAAMM, Watkinson P, Raith E, Singh S, Wolff T, Jha R, Brill SE, Bakhai A, Evans A, Gilani F, Gomez K. Nebulized Recombinant Tissue Plasminogen Activator (rt-PA) for Acute COVID-19-Induced Respiratory Failure: An Exploratory Proof-of-Concept Trial. J Clin Med 2023; 12:5848. [PMID: 37762789 PMCID: PMC10531875 DOI: 10.3390/jcm12185848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/31/2023] [Accepted: 09/04/2023] [Indexed: 09/29/2023] Open
Abstract
Acute lung injury in COVID-19 results in diffuse alveolar damage with disruption of the alveolar-capillary barrier, coagulation activation, alveolar fibrin deposition and pulmonary capillary thrombi. Nebulized recombinant tissue plasminogen activator (rt-PA) has the potential to facilitate localized thrombolysis in the alveolar compartment and improve oxygenation. In this proof-of-concept safety study, adults with COVID-19-induced respiratory failure and a <300 mmHg PaO2/FiO2 (P/F) ratio requiring invasive mechanical ventilation (IMV) or non-invasive respiratory support (NIRS) received nebulized rt-PA in two cohorts (C1 and C2), alongside standard of care, between 23 April-30 July 2020 and 21 January-19 February 2021, respectively. Matched historical controls (MHC; n = 18) were used in C1 to explore efficacy. Safety co-primary endpoints were treatment-related bleeds and <1.0-1.5 g/L fibrinogen reduction. A variable dosing strategy with clinical efficacy endpoint and minimal safety concerns was determined in C1 for use in C2; patients were stratified by ventilation type to receive 40-60 mg rt-PA daily for ≤14 days. Nine patients in C1 (IMV, 6/9; NIRS, 3/9) and 26 in C2 (IMV, 12/26; NIRS, 14/26) received nebulized rt-PA for a mean (SD) of 6.7 (4.6) and 9.1(4.6) days, respectively. Four bleeds (one severe, three mild) in three patients were considered treatment related. There were no significant fibrinogen reductions. Greater improvements in mean P/F ratio from baseline to study end were observed in C1 compared with MHC (C1; 154 to 299 vs. MHC; 154 to 212). In C2, there was no difference in the baseline P/F ratio of NIRS and IMV patients. However, a larger improvement in the P/F ratio occurred in NIRS patients (NIRS; 126 to 240 vs. IMV; 120 to 188) and fewer treatment days were required (NIRS; 7.86 vs. IMV; 10.5). Nebulized rt-PA appears to be well-tolerated, with a trend towards improved oxygenation, particularly in the NIRS group. Randomized clinical trials are required to demonstrate the clinical effect significance and magnitude.
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Affiliation(s)
- Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Cancer Institute, University College London, London WC1E 6DD, UK
| | - Banwari Agarwal
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Maria Rita Peralta
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Cancer Institute, University College London, London WC1E 6DD, UK
| | - Sanjay Bhagani
- Department of Infectious Diseases, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Simon Lee
- Department of Infectious Diseases, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - James Goldring
- Respiratory Medicine, Royal Free London NHS Foundation Trust, London NW1 2BU, UK
| | - Marc Lipman
- Respiratory Medicine, Royal Free London NHS Foundation Trust, London NW1 2BU, UK
- UCL Respiratory, University College London, London WC1E 6JF, UK;
| | - Emal Waqif
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Mark Phillips
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Cancer Institute, University College London, London WC1E 6DD, UK
| | - Helen Philippou
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 9JT, UK
| | | | - Nicola J. Mutch
- Aberdeen Cardiovascular & Diabetes Centre, School of Medicine, Medical Sciences & Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Robert A. S. Ariëns
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 9JT, UK
| | - Kathleen A. Stringer
- Department of Clinical Pharmacy, College of Pharmacy University of Michigan, Ann Arbor, MI 48109, USA
- Division of Pulmonary and Critical Care Medicine, School of Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Federico Ricciardi
- Department of Statistical Science, University College London, London WC1E 6BT, UK
| | | | - Derralynn Hughes
- Cancer Institute, University College London, London WC1E 6DD, UK
| | - Amit Nathwani
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Cancer Institute, University College London, London WC1E 6DD, UK
| | - Anne Riddell
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Haemophilia & Thrombosis Laboratory (Health Services Laboratories), Royal Free Hospital, London WC1H 9AX, UK
| | - David Patch
- Department of Hepatology, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Jim Buckley
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Mark De Neef
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Rahul Dimber
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Cecilia Diaz-Garcia
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Honey Patel
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Aarti Nandani
- Clinical Trials Pharmacy, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Upuli Dissanayake
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Nick Chadwick
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Ahmed A. A. M. M. Alkhatip
- Department of Anaesthesia, Birmingham Children’s Hospital, Birmingham B4 6NH, UK
- Department of Anaesthesia, Faculty of Medicine, Beni-Suef University Hospital, Beni-Suef University, Beni-Suef 2721562, Egypt
| | - Peter Watkinson
- NIHR Biomedical Research Centre Oxford, Oxford University Hospitals NHS Trust, University of Oxford, Oxford OX3 9DU, UK
| | - Eamon Raith
- Bloomsbury Institute for Intensive Care Medicine, Department of Experimental and Translational Medicine, University College London, London WC1E 6JF, UK
- Discipline of Acute Care Medicine, School of Medicine, The University of Adelaide, Adelaide, SA 5005, Australia
| | - Suveer Singh
- Department of Respiratory and Critical Care Medicine, Chelsea & Westminster Hospital, London SW10 9NH, UK
- Department of Adult Intensive Care, Royal Brompton Hospital, London SW3 6NP, UK
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK
| | - Tony Wolff
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Rajeev Jha
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Simon E. Brill
- UCL Respiratory, University College London, London WC1E 6JF, UK;
| | - Ameet Bakhai
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Department of Cardiology, Royal Free London NHS Foundation Trust, London NW3 2PS, UK
| | - Alison Evans
- University College London (UCL)/University College London Hospitals NHS Trust (UCLH) Joint Research Office, London WC1E 6BT, UK; (A.E.)
| | - Farhat Gilani
- University College London (UCL)/University College London Hospitals NHS Trust (UCLH) Joint Research Office, London WC1E 6BT, UK; (A.E.)
| | - Keith Gomez
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Cancer Institute, University College London, London WC1E 6DD, UK
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Al-Kuraishy HM, Al-Gareeb AI, Al-Harcan NAH, Alexiou A, Batiha GES. Tranexamic Acid and Plasminogen/Plasmin Glaring Paradox in COVID-19. Endocr Metab Immune Disord Drug Targets 2023; 23:35-45. [PMID: 35927893 DOI: 10.2174/1871530322666220801102402] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/27/2022] [Accepted: 03/30/2022] [Indexed: 11/22/2022]
Abstract
Coronavirus disease 2019 (COVID-19) is caused by a severe acute respiratory syndrome, coronavirus type 2 (SARS-CoV-2), leading to acute tissue injury and an overstated immune response. In COVID-19, there are noteworthy changes in the fibrinolytic system with the development of coagulopathy. Therefore, modulation of the fibrinolytic system may affect the course of COVID-19. Tranexamic acid (TXA) is an anti-fibrinolytic drug that reduces the conversion of plasminogen to plasmin, which is necessary for SARS-CoV-2 infectivity. In addition, TXA has anti-inflammatory, anti-platelet, and anti-thrombotic effects, which may attenuate the COVID-19 severity. Thus, in this narrative review, we try to find the beneficial and harmful effects of TXA in COVID-19.
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Affiliation(s)
- Hayder M Al-Kuraishy
- Department of Clinical Pharmacology and Medicine, College of Medicine, AL-Mustansiriyiah University, Baghdad, Iraq
| | - Ali I Al-Gareeb
- Department of Clinical Pharmacology and Medicine, College of Medicine, AL-Mustansiriyiah University, Baghdad, Iraq
| | - Nasser A Hadi Al-Harcan
- Department of Clinical Pharmacology and Medicine, College of Medicine, Al-Rasheed University College, Baghdad, Iraq
| | - Athanasios Alexiou
- Department of Science and Engineering, Novel Global Community Educational Foundation, Hebersham, Australia.,AFNP Med Austria, Wien, Austria
| | - Gaber El-Saber Batiha
- Department of Pharmacology and Therapeutics, Faculty of Veterinary Medicine, Damanhour University, Damanhour 22511, AlBeheira, Egypt
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Chowdary P. COVID-19 coagulopathy - what should we treat? Exp Physiol 2022; 107:749-758. [PMID: 35733235 PMCID: PMC9328279 DOI: 10.1113/ep089404] [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: 01/04/2022] [Accepted: 05/31/2022] [Indexed: 12/15/2022]
Abstract
NEW FINDINGS What is the topic of this review? Overview of the coagulation abnormalities, including elevated D-dimers widely reported with COVID-19, often labelled as COVID coagulopathy. What advances does it highlight? The review highlights the changes in bronchoalveolar haemostasis due to apoptosis of alveolar cells, which contributes to acute lung injury and acute respiratory distress syndrome; the pathophysiological mechanisms, including endothelial dysfunction and damage responsible for thrombosis of pulmonary microcirculation and potential contribution to the hypoxaemia of COVID-19 acute lung injury; and changes in coagulation proteins responsible for the hypercoagulability and increased risk of thrombosis in other venous and arterial beds. The rationale for anticoagulation and fibrinolytic therapies is detailed, and potential confounders that might have led to less than expected improvement in the various randomised controlled trials are considered. ABSTRACT Coronavirus disease 19 (COVID-19) causes acute lung injury with diffuse alveolar damage, alveolar-capillary barrier disruption, thrombin generation and alveolar fibrin deposition. Clinically, hypoxaemia is associated with preserved lung compliance early in the disease, suggesting the lack of excessive fluid accumulation typical of other lung injuries. Notably, autopsy studies demonstrate infection of the endothelium with extensive capillary thrombosis distinct from the embolic thrombi in pulmonary arteries. The inflammatory thrombosis in pulmonary vasculature secondary to endothelial infection and dysfunction appears to contribute to hypoxaemia. This is associated with elevated D-dimers and acquired hypercoagulability with an increased risk of deep vein thrombosis. Hypercoagulability is secondary to elevated plasma tissue factor levels, von Willebrand factor, fibrinogen, reduced ADAMTS-13 with platelet activation and inhibition of fibrinolysis. Multi-platform randomised controlled studies of systemic therapeutic anticoagulation with unfractionated and low molecular mass heparins demonstrated a survival benefit over standard care with full-dose anticoagulation in patients with non-severe disease who require supplemental oxygen, but not in severe disease requiring ventilatory support. Late intervention and the heterogeneous nature of enrolled patients can potentially explain the apparent lack of benefit in severe disease. Improvement in oxygenation has been demonstrated with intravenous fibrinolytics in small studies. Inhaled anticoagulants, thrombolytic agents and non-specific proteolytic drugs in clinical trials for decreasing alveolar fibrin deposition might benefit early disease. Essentially, COVID-19 is a multi-system disorder with pulmonary vascular inflammatory thrombosis that requires an interdisciplinary approach to combination therapies addressing both inflammation and intravascular thrombosis or alveolar fibrin deposits to improve outcomes.
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Affiliation(s)
- Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK.,Cancer Institute, University College London, London, UK
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Inhaled Placental Mesenchymal Stromal Cell Secretome from Two- and Three-Dimensional Cell Cultures Promotes Survival and Regeneration in Acute Lung Injury Model in Mice. Int J Mol Sci 2022; 23:ijms23073417. [PMID: 35408778 PMCID: PMC8998959 DOI: 10.3390/ijms23073417] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 02/06/2023] Open
Abstract
Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) is a common clinical problem, leading to significant morbidity and mortality, and no effective pharmacotherapy exists. The problem of ARDS causing mortality became more apparent during the COVID-19 pandemic. Biotherapeutic products containing multipotent mesenchymal stromal cell (MMSC) secretome may provide a new therapeutic paradigm for human healthcare due to their immunomodulating and regenerative abilities. The content and regenerative capacity of the secretome depends on cell origin and type of cultivation (two- or three-dimensional (2D/3D)). In this study, we investigated the proteomic profile of the secretome from 2D- and 3D-cultured placental MMSC and lung fibroblasts (LFBs) and the effect of inhalation of freeze-dried secretome on survival, lung inflammation, lung tissue regeneration, fibrin deposition in a lethal ALI model in mice. We found that three inhaled administrations of freeze-dried secretome from 2D- and 3D-cultured placental MMSC and LFB protected mice from death, restored the histological structure of damaged lungs, and decreased fibrin deposition. At the same time, 3D MMSC secretome exhibited a more pronounced trend in lung recovery than 2D MMSC and LFB-derived secretome in some measures. Taking together, these studies show that inhalation of cell secretome may also be considered as a potential therapy for the management of ARDS in patients suffering from severe pneumonia, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), however, their effectiveness requires further investigation.
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Sehgal T, Gupta N, Kohli S, Khurana A, Dass J, Diwan S, A J M, Khan M, Aggarwal M, Subramanian A. A Prospective Study of Specialized Coagulation Parameters in Admitted COVID-19 Patients and Their Correlation With Acute Respiratory Distress Syndrome and Outcome. Cureus 2021; 13:e17463. [PMID: 34589359 PMCID: PMC8464223 DOI: 10.7759/cureus.17463] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2021] [Indexed: 12/24/2022] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) is a frequent complication of COVID-19 and is associated with a component of thrombo-inflammation and cytokine storm. COVID-19 also affects the hemostatic system causing multiple coagulation abnormalities that is a cause of concern and needs to be addressed. Objective We aimed to assess coagulation parameters of COVID-19 patients and identify whether they could be used as potential prognostic biomarkers to predict ARDS and immediate outcomes. Methods This was a prospective study done on 68 patients at four serial time points. Patients between 18-85 years admitted to the hospital as in-patients and ICU with a confirmed diagnosis of COVID-19 by RT-PCR were included. Exclusion criteria included pregnancy, patients below and above the mentioned age, previously known coagulopathy, systemic anticoagulants or anti-platelet therapy or vitamin K antagonists and moribund patients. Patients were divided into three categories based on SOFA score at admission, presence (group 1) or absence (group 2) of ARDS and outcome (dead or alive). Routine and specialized coagulation tests were performed on patients' platelet-poor plasma at the time of study inclusion (day 0), days 3, 7 and at discharge on STAR Max®3 (Diagnostica Stago France) automated coagulation analyzer and included prothrombin time (PT), international normalized ratio (INR) (STA® -NeoPTimal), activated partial thromboplastin time (APTT) (STA® -Cephascreen), fibrinogen (STA® Liquid Fib), D-dimer (STA® LiatestD- Dimer), Protein C (STA Stachrom® Protein C), Protein S (STA® Latest Free Protein S) and Antithrombin (STA® Chrom ATIII). ELISA did testing for tissue plasminogen activator (Asserachrom® tPA) as per the manufacturer's protocol. Results Sixty-eight patients, including 43 (63%) males and 25 (37%) females, with a median age of 48 years (IQR 20-85), were recruited in this study. The incidence of ARDS was 34%, with a mortality of 13%. History of contact with a COVID-19 case was present in 71% (48/68) of the patients. Fever was the most common presenting symptom in 84% (57/68) of the patients. The most common comorbidities were hypertension and diabetes mellitus (DM) in 22% (15/68) and 21% (14/68) of the patients. DM (p=0.07) and chronic obstructive pulmonary disease (COPD) (p=0.03) were significantly associated with ARDS. DM (p=0.02), hypertension (p=0.01), and COPD (p=0.02) were also significantly associated with mortality. APTT was markedly prolonged among non-survivors at day 0 (D0) and D7 (p=0.03, p=0.02). D-Dimer was elevated in 38/68 (56%) patients at D0. D-Dimer levels were significantly higher in non-survivors (p<0.001), in ARDS patients (p=0.001) and patients with higher SOFA scores (p=0.001). ROC curve showed that D-dimer cut-off > 2.13 (AUC of 0.86) and >0.85 (AUC of 0.74) predicts mortality and ARDS, respectively. Among the natural anticoagulants, protein C was significantly associated with a high SOFA score at D0 and D3 (p=0.04). Conclusion Diabetes mellitus, hypertension and COPD were associated with poor outcomes. D-dimer levels must be monitored in COVID patients due to their association with ARDS and mortality. We observed that the levels of natural anticoagulants fell during the illness, making them prone to coagulopathies; however, none were seen in this study. Elevated tPA levels were also found in our patients; fibrinolytic therapy may benefit COVID-19 patients suffering from ARDS.
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Affiliation(s)
- Tushar Sehgal
- Laboratory Medicine, All India Institute of Medical Sciences, New Delhi, IND
| | - Nitesh Gupta
- Internal Medicine • Pulmonology, Vardhman Mahavir Medical College, Safdarjung Hospital, New Delhi, IND
| | - Santvana Kohli
- Anesthesiology, Vardhaman Mahavir Medical College, Safdarjang Hospital, New Delhi, IND
| | - Aditi Khurana
- Emergency Department, Vardhaman Mahavir Medical College, Safdarjang Hospital, New Delhi, IND
| | - Jasmita Dass
- Hematology, All India Institute of Medical Sciences, New Delhi, IND
| | - Sahil Diwan
- Anaesthesiology, Vardhaman Mahavir Medical College, Safdarjang Hospital, New Delhi, IND
| | - Mahendran A J
- Internal Medicine • Pulmonology, Safdarjung Hospital, New Delhi, IND
| | - Maroof Khan
- Biostatistics, All India Institute of Medical Sciences, New Delhi, IND
| | - Mukul Aggarwal
- Pediatrics • Hematology, All India Institute of Medical Sciences, New Delhi, IND
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Peiris S, Mesa H, Aysola A, Manivel J, Toledo J, Borges-Sa M, Aldighieri S, Reveiz L. Pathological findings in organs and tissues of patients with COVID-19: A systematic review. PLoS One 2021; 16:e0250708. [PMID: 33909679 PMCID: PMC8081217 DOI: 10.1371/journal.pone.0250708] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 04/13/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Coronavirus disease (COVID-19) is the pandemic caused by SARS-CoV-2 that has caused more than 2.2 million deaths worldwide. We summarize the reported pathologic findings on biopsy and autopsy in patients with severe/fatal COVID-19 and documented the presence and/or effect of SARS-CoV-2 in all organs. METHODS AND FINDINGS A systematic search of the PubMed, Embase, MedRxiv, Lilacs and Epistemonikos databases from January to August 2020 for all case reports and case series that reported histopathologic findings of COVID-19 infection at autopsy or tissue biopsy was performed. 603 COVID-19 cases from 75 of 451 screened studies met inclusion criteria. The most common pathologic findings were lungs: diffuse alveolar damage (DAD) (92%) and superimposed acute bronchopneumonia (27%); liver: hepatitis (21%), heart: myocarditis (11.4%). Vasculitis was common only in skin biopsies (25%). Microthrombi were described in the placenta (57.9%), lung (38%), kidney (20%), Central Nervous System (CNS) (18%), and gastrointestinal (GI) tract (2%). Injury of endothelial cells was common in the lung (18%) and heart (4%). Hemodynamic changes such as necrosis due to hypoxia/hypoperfusion, edema and congestion were common in kidney (53%), liver (48%), CNS (31%) and GI tract (18%). SARS-CoV-2 viral particles were demonstrated within organ-specific cells in the trachea, lung, liver, large intestine, kidney, CNS either by electron microscopy, immunofluorescence, or immunohistochemistry. Additional tissues were positive by Polymerase Chain Reaction (PCR) tests only. The included studies were from numerous countries, some were not peer reviewed, and some studies were performed by subspecialists, resulting in variable and inconsistent reporting or over statement of the reported findings. CONCLUSIONS The main pathologic findings of severe/fatal COVID-19 infection are DAD, changes related to coagulopathy and/or hemodynamic compromise. In addition, according to the observed organ damage myocarditis may be associated with sequelae.
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Affiliation(s)
- Sasha Peiris
- Pan American Health Organization, Health Emergencies Department, Washington, Columbia, United States of America
- Pan American Health Organization, Incident Management Systems for COVID-19, Washington, Columbia, United States of America
| | - Hector Mesa
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Agnes Aysola
- Department of Pathology and Laboratory Medicine, University of Florida College of Medicine, Jacksonville, Florida, United States of America
| | - Juan Manivel
- Department of Pathology and Laboratory Medicine, University of Minnesota and VA Healthcare System, Minneapolis, Minnesota, United States of America
| | - Joao Toledo
- Pan American Health Organization, Health Emergencies Department, Washington, Columbia, United States of America
- Pan American Health Organization, Incident Management Systems for COVID-19, Washington, Columbia, United States of America
| | - Marcio Borges-Sa
- Multidisciplinary Sepsis Unit, Intensive Care Unit, Institute of Health Research of de Balearic Islands (IDISBA), Son Llatzer University Hospital, Palma de Mallorca, Spain
| | - Sylvain Aldighieri
- Pan American Health Organization, Health Emergencies Department, Washington, Columbia, United States of America
- Pan American Health Organization, Incident Management Systems for COVID-19, Washington, Columbia, United States of America
| | - Ludovic Reveiz
- Pan American Health Organization, Incident Management Systems for COVID-19, Washington, Columbia, United States of America
- Pan American Health Organization, Evidence and Intelligence for Action in Health Department, Washington, Columbia, United States of America
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Kellici TF, Pilka ES, Bodkin MJ. Therapeutic Potential of Targeting Plasminogen Activator Inhibitor-1 in COVID-19. Trends Pharmacol Sci 2021; 42:431-433. [PMID: 33867130 PMCID: PMC7997307 DOI: 10.1016/j.tips.2021.03.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/19/2021] [Accepted: 03/22/2021] [Indexed: 02/07/2023]
Abstract
Latest research shows that SERPINE1 overexpression has an important role in Coronavirus 2019 (COVID-19)-associated coagulopathy leading to acute respiratory distress syndrome (ARDS). However, ways to target this protein remain elusive. In this forum, we discuss recent evidence linking SERPINE1 with COVID-19-related ARDS and summarize the available data on inhibitors of this target.
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Plasma tissue plasminogen activator and plasminogen activator inhibitor-1 in hospitalized COVID-19 patients. Sci Rep 2021; 11:1580. [PMID: 33452298 PMCID: PMC7810990 DOI: 10.1038/s41598-020-80010-z] [Citation(s) in RCA: 147] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/14/2020] [Indexed: 02/07/2023] Open
Abstract
Patients with coronavirus disease-19 (COVID-19) are at high risk for thrombotic arterial and venous occlusions. However, bleeding complications have also been observed in some patients. Understanding the balance between coagulation and fibrinolysis will help inform optimal approaches to thrombosis prophylaxis and potential utility of fibrinolytic-targeted therapies. 118 hospitalized COVID-19 patients and 30 healthy controls were included in the study. We measured plasma antigen levels of tissue-type plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) and performed spontaneous clot-lysis assays. We found markedly elevated tPA and PAI-1 levels in patients hospitalized with COVID-19. Both factors demonstrated strong correlations with neutrophil counts and markers of neutrophil activation. High levels of tPA and PAI-1 were associated with worse respiratory status. High levels of tPA, in particular, were strongly correlated with mortality and a significant enhancement in spontaneous ex vivo clot-lysis. While both tPA and PAI-1 are elevated among COVID-19 patients, extremely high levels of tPA enhance spontaneous fibrinolysis and are significantly associated with mortality in some patients. These data indicate that fibrinolytic homeostasis in COVID-19 is complex with a subset of patients expressing a balance of factors that may favor fibrinolysis. Further study of tPA as a biomarker is warranted.
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Zuo Y, Warnock M, Harbaugh A, Yalavarthi S, Gockman K, Zuo M, Madison JA, Knight JS, Kanthi Y, Lawrence DA. Plasma tissue plasminogen activator and plasminogen activator inhibitor-1 in hospitalized COVID-19 patients. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020. [PMID: 32909005 DOI: 10.1101/2020.08.29.20184358] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Patients with coronavirus disease-19 ( COVID-19 ) are at high risk for thrombotic arterial and venous occlusions. However, bleeding complications have also been observed in some patients. Understanding the balance between coagulation and fibrinolysis will help inform optimal approaches to thrombosis prophylaxis and potential utility of fibrinolytic-targeted therapies. 118 hospitalized COVID-19 patients and 30 healthy controls were included in the study. We measured plasma antigen levels of tissue-type plasminogen activator (tPA ) and plasminogen activator inhibitor-1 ( PAI-1 ) and performed spontaneous clot-lysis assays. We found markedly elevated tPA and PAI-1 levels in patients hospitalized with COVID-19. Both factors demonstrated strong correlations with neutrophil counts and markers of neutrophil activation. High levels of tPA and PAI-1 were associated with worse respiratory status. High levels of tPA, in particular, were strongly correlated with mortality and a significant enhancement in spontaneous ex vivo clot-lysis. While both tPA and PAI-1 are elevated among COVID-19 patients, extremely high levels of tPA enhance spontaneous fibrinolysis and are significantly associated with mortality in some patients. These data indicate that fibrinolytic homeostasis in COVID-19 is complex with a subset of patients expressing a balance of factors that may favor fibrinolysis. Further study of tPA as a biomarker is warranted.
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José RJ, Williams A, Manuel A, Brown JS, Chambers RC. Targeting coagulation activation in severe COVID-19 pneumonia: lessons from bacterial pneumonia and sepsis. Eur Respir Rev 2020; 29:29/157/200240. [PMID: 33004529 PMCID: PMC7537941 DOI: 10.1183/16000617.0240-2020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 08/20/2020] [Indexed: 12/15/2022] Open
Abstract
Novel coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), has rapidly spread throughout the world, resulting in a pandemic with high mortality. There are no effective treatments for the management of severe COVID-19 and current therapeutic trials are focused on antiviral therapy and attenuation of hyper-inflammation with anti-cytokine therapy. Severe COVID-19 pneumonia shares some pathological similarities with severe bacterial pneumonia and sepsis. In particular, it disrupts the haemostatic balance, which results in a procoagulant state locally in the lungs and systemically. This culminates in the formation of microthrombi, disseminated intravascular coagulation and multi-organ failure. The deleterious effects of exaggerated inflammatory responses and activation of coagulation have been investigated in bacterial pneumonia and sepsis and there is recognition that although these pathways are important for the host immune response to pathogens, they can lead to bystander tissue injury and are negatively associated with survival. In the past two decades, evidence from preclinical studies has led to the emergence of potential anticoagulant therapeutic strategies for the treatment of patients with pneumonia, sepsis and acute respiratory distress syndrome, and some of these anticoagulant approaches have been trialled in humans. Here, we review the evidence from preclinical studies and clinical trials of anticoagulant treatment strategies in bacterial pneumonia and sepsis, and discuss the importance of these findings in the context of COVID-19.
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Affiliation(s)
- Ricardo J José
- Centre for Inflammation and Tissue Repair, University College London, London, UK .,Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Andrew Williams
- Centre for Inflammation and Tissue Repair, University College London, London, UK
| | - Ari Manuel
- University Hospital Aintree, Liverpool, UK
| | - Jeremy S Brown
- Centre for Inflammation and Tissue Repair, University College London, London, UK.,Dept of Thoracic Medicine, University College London Hospital, London, UK
| | - Rachel C Chambers
- Centre for Inflammation and Tissue Repair, University College London, London, UK
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11
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Medcalf RL, Keragala CB, Myles PS. Fibrinolysis and COVID-19: A plasmin paradox. J Thromb Haemost 2020; 18:2118-2122. [PMID: 32543119 PMCID: PMC7323332 DOI: 10.1111/jth.14960] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/19/2020] [Accepted: 06/01/2020] [Indexed: 12/24/2022]
Abstract
The COVID-19 pandemic has provided many challenges in the field of thrombosis and hemostasis. Among these is a novel form of coagulopathy that includes exceptionally high levels of D-dimer. D-dimer is a marker of poor prognosis, but does this also imply a causal relationship? These spectacularly raised D-dimer levels may actually signify the failing attempt of the fibrinolytic system to remove fibrin and necrotic tissue from the lung parenchyma, being consumed or overwhelmed in the process. Indeed, recent studies suggest that increasing fibrinolytic activity might offer hope for patients with critical disease and severe respiratory failure. However, the fibrinolytic system can also be harnessed by coronavirus to promote infectivity and where antifibrinolytic measures would also seem appropriate. Hence, there is a clinical paradox where plasmin formation can be either deleterious or beneficial in COVID-19, but not at the same time. Hence, it all comes down to timing.
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Affiliation(s)
- Robert L Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Charithani B Keragala
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia
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12
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Abdelaal Ahmed Mahmoud A, Mahmoud HE, Mahran MA, Khaled M. Streptokinase Versus Unfractionated Heparin Nebulization in Patients With Severe Acute Respiratory Distress Syndrome (ARDS): A Randomized Controlled Trial With Observational Controls. J Cardiothorac Vasc Anesth 2020; 34:436-443. [DOI: 10.1053/j.jvca.2019.05.035] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 05/19/2019] [Accepted: 05/23/2019] [Indexed: 02/08/2023]
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13
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Joslyn LR, Pienaar E, DiFazio RM, Suliman S, Kagina BM, Flynn JL, Scriba TJ, Linderman JJ, Kirschner DE. Integrating Non-human Primate, Human, and Mathematical Studies to Determine the Influence of BCG Timing on H56 Vaccine Outcomes. Front Microbiol 2018; 9:1898. [PMID: 30177934 PMCID: PMC6110197 DOI: 10.3389/fimmu.2018.01898] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 07/31/2018] [Indexed: 12/21/2022] Open
Abstract
Background Acute lung injury (ALI) is characterized by suppressed fibrinolytic activity in bronchoalveolar lavage fluid (BALF) attributed to elevated plasminogen activator inhibitor-1 (PAI-1). Restoring pulmonary fibrinolysis by delivering tissue-type plasminogen activator (tPA), urokinase plasminogen activator (uPA), and plasmin could be a promising approach. Objectives To systematically analyze the overall benefit of fibrinolytic therapy for ALI reported in preclinical studies. Methods We searched PubMed, Embase, Web of Science, and CNKI Chinese databases, and analyzed data retrieved from 22 studies for the beneficial effects of fibrinolytics on animal models of ALI. Results Both large and small animals were used with five routes for delivering tPA, uPA, and plasmin. Fibrinolytics significantly increased the fibrinolytic activity both in the plasma and BALF. Fibrin degradation products in BALF had a net increase of 408.41 ng/ml vs controls (P < 0.00001). In addition, plasma thrombin–antithrombin complexes increased 1.59 ng/ml over controls (P = 0.0001). In sharp contrast, PAI-1 level in BALF decreased 21.44 ng/ml compared with controls (P < 0.00001). Arterial oxygen tension was improved by a net increase of 15.16 mmHg, while carbon dioxide pressure was significantly reduced (11.66 mmHg, P = 0.0001 vs controls). Additionally, fibrinolytics improved lung function and alleviated inflammation response: the lung wet/dry ratio was decreased 1.49 (P < 0.0001 vs controls), lung injury score was reduced 1.83 (P < 0.00001 vs controls), and BALF neutrophils were lesser (3 × 104/ml, P < 0.00001 vs controls). The mortality decreased significantly within defined study periods (6 h to 30 days for mortality), as the risk ratio of death was 0.2-fold of controls (P = 0.0008). Conclusion We conclude that fibrinolytic therapy may be effective pharmaceutic strategy for ALI in animal models.
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Affiliation(s)
- Louis R Joslyn
- Department of Chemical Engineering, University of Michigan, Ann Arbor, MI, United States.,Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Elsje Pienaar
- Department of Chemical Engineering, University of Michigan, Ann Arbor, MI, United States.,Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Robert M DiFazio
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Sara Suliman
- South African Tuberculosis Vaccine Initiative and Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Benjamin M Kagina
- South African Tuberculosis Vaccine Initiative and Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - JoAnne L Flynn
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Thomas J Scriba
- South African Tuberculosis Vaccine Initiative and Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Jennifer J Linderman
- Department of Chemical Engineering, University of Michigan, Ann Arbor, MI, United States
| | - Denise E Kirschner
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, United States
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14
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de Beer F, Lagrand W, Glas GJ, Beurskens CJP, van Mierlo G, Wouters D, Zeerleder S, Roelofs JJTH, Juffermans NP, Horn J, Schultz MJ. Nebulized C1-Esterase Inhibitor does not Reduce Pulmonary Complement Activation in Rats with Severe Streptococcus Pneumoniae Pneumonia. Cell Biochem Biophys 2016; 74:545-552. [PMID: 27683129 PMCID: PMC5101262 DOI: 10.1007/s12013-016-0766-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 09/20/2016] [Indexed: 01/19/2023]
Abstract
Complement activation plays an important role in the pathogenesis of pneumonia. We hypothesized that inhibition of the complement system in the lungs by repeated treatment with nebulized plasma-derived human C1-esterase inhibitor reduces pulmonary complement activation and subsequently attenuates lung injury and lung inflammation. This was investigated in a rat model of severe Streptococcus pneumoniae pneumonia. Rats were intra–tracheally challenged with S. pneumoniae to induce pneumonia. Nebulized C1-esterase inhibitor or saline (control animals) was repeatedly administered to rats, 30 min before induction of pneumonia and every 6 h thereafter. Rats were sacrificed 20 or 40 h after inoculation with bacteria. Brochoalveolar lavage fluid and lung tissue were obtained for measuring levels of complement activation (C4b/c), lung injury and inflammation. Induction of pneumonia was associated with pulmonary complement activation (C4b/c at 20 h 1.24 % [0.56–2.59] and at 40 h 2.08 % [0.98–5.12], compared to 0.50 % [0.07–0.59] and 0.03 % [0.03–0.03] in the healthy control animals). The functional fraction of C1-INH was detectable in BALF, but no effect was found on pulmonary complement activation (C4b/c at 20 h 0.73 % [0.16–1.93] and at 40 h 2.38 % [0.54–4.19]). Twenty hours after inoculation, nebulized C1-esterase inhibitor treatment reduced total histology score, but this effect was no longer seen at 40 h. Nebulized C1-esterase inhibitor did not affect other markers of lung injury or lung inflammation. In this negative experimental animal study, severe S. pneumoniae pneumonia in rats is associated with pulmonary complement activation. Repeated treatment with nebulized C1-esterase inhibitor, although successfully delivered to the lungs, does not affect pulmonary complement activation, lung inflammation or lung injury.
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Affiliation(s)
- Friso de Beer
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - Wim Lagrand
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Gerie J Glas
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Charlotte J P Beurskens
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Gerard van Mierlo
- Department of Immunopathology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Diana Wouters
- Department of Immunopathology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Sacha Zeerleder
- Department of Immunopathology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Hematology, Sanquin Research and Landsteiner laboratory, Academic Medical Center, Amsterdam, The Netherlands
| | - Joris J T H Roelofs
- Department of Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Janneke Horn
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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15
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Shaver CM, Grove BS, Putz ND, Clune JK, Lawson WE, Carnahan RH, Mackman N, Ware LB, Bastarache JA. Regulation of alveolar procoagulant activity and permeability in direct acute lung injury by lung epithelial tissue factor. Am J Respir Cell Mol Biol 2016; 53:719-27. [PMID: 25884207 DOI: 10.1165/rcmb.2014-0179oc] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Tissue factor (TF) initiates the extrinsic coagulation cascade in response to tissue injury, leading to local fibrin deposition. Low levels of TF in mice are associated with increased severity of acute lung injury (ALI) after intratracheal LPS administration. However, the cellular sources of the TF required for protection from LPS-induced ALI remain unknown. In the current study, transgenic mice with cell-specific deletions of TF in the lung epithelium or myeloid cells were treated with intratracheal LPS to determine the cellular sources of TF important in direct ALI. Cell-specific deletion of TF in the lung epithelium reduced total lung TF expression to 39% of wild-type (WT) levels at baseline and to 29% of WT levels after intratracheal LPS. In contrast, there was no reduction of TF with myeloid cell TF deletion. Mice lacking myeloid cell TF did not differ from WT mice in coagulation, inflammation, permeability, or hemorrhage. However, mice lacking lung epithelial TF had increased tissue injury, impaired activation of coagulation in the airspace, disrupted alveolar permeability, and increased alveolar hemorrhage after intratracheal LPS. Deletion of epithelial TF did not affect alveolar permeability in an indirect model of ALI caused by systemic LPS infusion. These studies demonstrate that the lung epithelium is the primary source of TF in the lung, contributing 60-70% of total lung TF, and that lung epithelial, but not myeloid, TF may be protective in direct ALI.
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Affiliation(s)
- Ciara M Shaver
- 1 Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Brandon S Grove
- 1 Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Nathan D Putz
- 1 Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jennifer K Clune
- 1 Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - William E Lawson
- 1 Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.,2 Department of Veterans Affairs Medical Center, Nashville, Tennessee
| | - Robert H Carnahan
- 3 Department of Cancer Biology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Nigel Mackman
- 4 Thrombosis and Hemostasis Program, Division of Hematology and Oncology, University of North Carolina McAllister Heart Institute, University of North Carolina, Chapel Hill, North Carolina; and
| | - Lorraine B Ware
- 1 Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.,5 Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Julie A Bastarache
- 1 Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
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16
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Feasibility and Safety of Local Treatment with Recombinant Human Tissue Factor Pathway Inhibitor in a Rat Model of Streptococcus pneumoniae Pneumonia. PLoS One 2015; 10:e0127261. [PMID: 25992779 PMCID: PMC4436292 DOI: 10.1371/journal.pone.0127261] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 04/14/2015] [Indexed: 12/31/2022] Open
Abstract
Pulmonary coagulopathy is intrinsic to pulmonary injury including pneumonia. Anticoagulant strategies could benefit patients with pneumonia, but systemic administration of anticoagulant agents may lead to suboptimal local levels and may cause systemic hemorrhage. We hypothesized nebulization to provide a safer and more effective route for local administration of anticoagulants. Therefore, we aimed to examine feasibility and safety of nebulization of recombinant human tissue factor pathway inhibitor (rh-TFPI) in a well-established rat model of Streptococcus (S.) pneumoniae pneumonia. Thirty minutes before and every 6 hours after intratracheal instillation of S. pneumonia causing pneumonia, rats were subjected to local treatment with rh-TFPI or placebo, and sacrificed after 42 hours. Pneumonia was associated with local as well as systemic activation of coagulation. Nebulization of rh-TFPI resulted in high levels of rh-TFPI in bronchoalveolar lavage fluid, which was accompanied by an attenuation of pulmonary coagulation. Systemic rh-TFPI levels remained undetectable, and systemic TFPI activity and systemic coagulation were not affected. Histopathology revealed no bleeding in the lungs. We conclude that nebulization of rh-TFPI seems feasible and safe; local anticoagulant treatment with rh-TFPI attenuates pulmonary coagulation, while not affecting systemic coagulation in a rat model of S. pneumoniae pneumonia.
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17
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Raeven P, Drechsler S, Weixelbaumer KM, Bastelica D, Peiretti F, Klotz A, Jafarmadar M, Redl H, Bahrami S, Alessi MC, Declerck PJ, Osuchowski MF. Systemic inhibition and liver-specific over-expression of PAI-1 failed to improve survival in all-inclusive populations or homogenous cohorts of CLP mice. J Thromb Haemost 2014; 12:958-69. [PMID: 24655755 DOI: 10.1111/jth.12565] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 03/11/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND The role of plasminogen activator inhibitor type-1 (PAI-1) in abdominal sepsis remains elusive. OBJECTIVES To study the influence of inhibition and over-expression of PAI-1 upon survival in cecal ligation and puncture (CLP) sepsis. METHODS (i) Mice underwent moderate CLP and received 10 mg kg(-1) of either monoclonal anti-PAI-1 (MA-MP6H6) or control (MA-Control) antibody intravenously at 0, 18 or 30 h post-CLP. The 30-h treatment group was additionally stratified into mice predicted to survive (P-SUR) or die (P-DIE) based on IL 6 measured at 24 h post-CLP. (ii) PAI-1 expression was induced with pLIVE.PAI-1 plasmid administered 72 h pre-CLP. Blood was sampled for 5 days and survival was monitored for 28 days. RESULTS MA-MP6H6 effectively neutralized active PAI-1 and fully restored fibrinolysis while PAI-1 over-expression was liver-specific and correlated with PAI-1 increase in the blood. Without stratification, MA-MP6H6 co-/post-treatment conferred no survival benefit. Prospective stratification (IL-6 cut-off: 14 ng mL(-1) ) suggested increased mortality by MA-MP6H6 treatment in P-SUR that reached 30% difference (vs. MA-Control; P < 0.05) after a retrospective cut-off readjustment to 3.3 ng mL(-1) for better P-SUR homogeneity. Subsequent prospective anti-PAI-1 treatment in P-SUR mice with 3.3 ng mL(-1) cut-off demonstrated a negative but statistically insignificant effect: mortality was higher by 17% after MA-MP6H6 vs. MA-Control. Over-expression of PAI 1 did not alter post-CLP survival. Neither PAI-1 inhibition nor over-expression meaningfully modified inflammatory response and/or organ function. CONCLUSIONS Restoration of fibrinolysis in early abdominal sepsis was not beneficial and it may prove detrimental in subjects with the lowest risk of death, while preemptive PAI-1 up-regulation at the current magnitude was not protective.
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Affiliation(s)
- P Raeven
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology in the Trauma Research Center of the AUVA, Vienna, Austria; Department of Anesthesiology, University Medical Center, Regensburg, Germany
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18
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Advantages and pitfalls of combining intravenous antithrombin with nebulized heparin and tissue plasminogen activator in acute respiratory distress syndrome. J Trauma Acute Care Surg 2014; 76:126-33. [PMID: 24368367 DOI: 10.1097/ta.0b013e3182ab0785] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pulmonary coagulopathy has become an important therapeutic target in adult respiratory distress syndrome (ARDS). We hypothesized that combining intravenous recombinant human antithrombin (rhAT), nebulized heparin, and nebulized tissue plasminogen activator (TPA) more effectively improves pulmonary gas exchange compared with a single rhAT infusion, while maintaining the anti-inflammatory properties of rhAT in ARDS. Therefore, the present prospective, randomized experiment was conducted using an established ovine model. METHODS Following burn and smoke inhalation injury (40% of total body surface area, third-degree flame burn, and 4 × 12 breaths of cold cotton smoke), 18 chronically instrumented sheep were randomly assigned to receive intravenous saline plus saline nebulization (control), intravenous rhAT (6 IU/kg/h) started 1 hour after injury plus saline nebulization (AT i.v.) or intravenous rhAT combined with nebulized heparin (10,000 IU every 4 hours, started 2 hours after injury), and nebulized TPA (2 mg every 4 hours, started 4 hours after injury) (triple therapy, n = 6 each). All animals were mechanically ventilated and fluid resuscitated according to standard protocols during the 48-hour study period. RESULTS Both treatment approaches attenuated ARDS compared with control animals. Notably, triple therapy was associated with an improved PaO2/FiO2 ratio (p = 0.007), attenuated pulmonary obstruction (p = 0.02) and shunting (p = 0.025), as well as reduced ventilatory pressures (p < 0.05 each) versus AT i.v. at 48 hours. However, the anti-inflammatory effects of sole AT i.v., namely, the inhibition of neutrophil activation (neutrophil count in the lymph and pulmonary polymorphonuclear cells, p < 0.05 vs. control each), pulmonary transvascular fluid flux (lymph flow, p = 0.004 vs. control), and systemic vascular leakage (cumulative net fluid balance, p < 0.001 vs. control), were abolished in the triple therapy group. CONCLUSION Combining intravenous rhAT with nebulized heparin and nebulized TPA more effectively restores pulmonary gas exchange, but the anti-inflammatory effects of sole rhAT are abolished with the triple therapy. Interferences between the different anticoagulants may represent a potential explanation for these findings.
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Cornélio Favarin D, Robison de Oliveira J, Jose Freire de Oliveira C, de Paula Rogerio A. Potential effects of medicinal plants and secondary metabolites on acute lung injury. BIOMED RESEARCH INTERNATIONAL 2013; 2013:576479. [PMID: 24224172 PMCID: PMC3810192 DOI: 10.1155/2013/576479] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 08/16/2013] [Accepted: 08/23/2013] [Indexed: 12/20/2022]
Abstract
Acute lung injury (ALI) is a life-threatening syndrome that causes high morbidity and mortality worldwide. ALI is characterized by increased permeability of the alveolar-capillary membrane, edema, uncontrolled neutrophils migration to the lung, and diffuse alveolar damage, leading to acute hypoxemic respiratory failure. Although corticosteroids remain the mainstay of ALI treatment, they cause significant side effects. Agents of natural origin, such as medicinal plants and their secondary metabolites, mainly those with very few side effects, could be excellent alternatives for ALI treatment. Several studies, including our own, have demonstrated that plant extracts and/or secondary metabolites isolated from them reduce most ALI phenotypes in experimental animal models, including neutrophil recruitment to the lung, the production of pro-inflammatory cytokines and chemokines, edema, and vascular permeability. In this review, we summarized these studies and described the anti-inflammatory activity of various plant extracts, such as Ginkgo biloba and Punica granatum, and such secondary metabolites as epigallocatechin-3-gallate and ellagic acid. In addition, we highlight the medical potential of these extracts and plant-derived compounds for treating of ALI.
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Affiliation(s)
- Daniely Cornélio Favarin
- Departamento de Clínica Médica, Laboratório de ImunoFarmacologia Experimental, Instituto de Ciências da Saúde, Universidade Federal do Triângulo Mineiro, Rua Manoel Carlos 162, 38025-380 Uberaba, MG, Brazil
| | - Jhony Robison de Oliveira
- Departamento de Clínica Médica, Laboratório de ImunoFarmacologia Experimental, Instituto de Ciências da Saúde, Universidade Federal do Triângulo Mineiro, Rua Manoel Carlos 162, 38025-380 Uberaba, MG, Brazil
| | | | - Alexandre de Paula Rogerio
- Departamento de Clínica Médica, Laboratório de ImunoFarmacologia Experimental, Instituto de Ciências da Saúde, Universidade Federal do Triângulo Mineiro, Rua Manoel Carlos 162, 38025-380 Uberaba, MG, Brazil
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