Administration Of rTM Research Articles

Effects of combination therapy of antithrombin and thrombomodulin for sepsis-associated disseminated intravascular coagulation: a systematic review and meta-analysis

BackgroundDisseminated intravascular coagulation (DIC) syndrome is a highly lethal condition characterized by the complication of multiple organ damage. Although the effects of combined antithrombin (AT) and recombinant thrombomodulin (rTM) on DIC syndrome have previously been examined, the results are inconsistent and inconclusive. Therefore, we conducted a systematic review on the combined administration of AT and rTM for the treatment of septic DIC to investigate the superiority of the combination therapy over either AT or rTM monotherapy using a random-effects analysis model.MethodWe searched electronic databases, including Medline, Cochrane Central Register of Controlled Trials, Scopus, and Igaku-Chuo Zasshi (ICHU-SHI) Japanese Central Review of Medicine Web from inception to January 2022. Studies assessing the efficacy of combined AT and rTM were included. The primary outcome was all-cause mortality, and the secondary outcome was occurrence of serious bleeding complications compared to monotherapy. We presented the pooled odds ratio (OR) or hazard ratio (HR) with 95% confidence intervals (CI) depending on reporting results in each primary study.ResultsWe analyzed seven enrolled clinical trials, all of which were observational studies. Combination therapy had a non-significant favorable association with lower 28-day mortality compared to monotherapy (HR 0.67 [0.43–1.05], OR 0.73 [0.45–1.18]). The I2 values were 60% and 72%, respectively, suggesting high heterogeneity.As a secondary outcome, bleeding complications were similar between the two groups (pooled OR 1.11 [0.55–2.23], I2 value 55%).ConclusionsAlthough the findings in this analysis could not confirm a statistically significant effect of AT and rTM combination therapy for septic DIC, it showed a promising effect in terms of improving mortality. The incidence of bleeding was low and clinically feasible. Further research is warranted to draw more conclusive results.Trial registrationThis study was registered in the University Hospital Medical Information Network (UMIN) Clinical Trials Registry (UMIN ID: 000049820).

Efficacy of Recombinant Thrombomodulin for Sepsis-Associated Disseminated Intravascular Coagulation Caused by Urinary Tract Infections

Severe urinary tract infections occasionally cause sepsis and disseminated intravascular coagulation (DIC). We examined the efficacy of recombinant thrombomodulin (rTM) for treating DIC caused by urosepsis. We enrolled 40 patients who were diagnosed with DIC caused by urosepsis at our hospital between April 2018 and May 2022. Twenty-six patients were treated with rTM (rTM group), while 14 patients did not receive rTM (non-rTM group). The DIC score before treatment in the rTM group was significantly higher than that in the non-rTM group (P＜0.01). There was no significant difference in disease-specific survival between the two groups. There was a significant improvement in DIC scores on days 1-3 after administering rTM. However, the duration of DIC in the rTM group was significantly longer than that in the non-rTM group (P＝0.038). The administration of rTM may have benefits in patients with DIC caused by urosepsis.

Use of Recombinant Human Soluble Thrombomodulin in a Patient with Disseminated Intravascular Coagulation Associated with Abdominal Aortic Aneurysm: A Case Report.

We herein present a case involving an 86-year-old man with abdominal aortic aneurysm complicated by symptomatic disseminated intravascular coagulation (DIC). The patient received preoperative treatment for DIC using recombinant human soluble thrombomodulin (rTM) followed by open surgical repair of the aneurysm. The patient's coagulopathy cleared quickly after the start of rTM, and the intraoperative and postoperative course went smoothly. The patient was followed without anticoagulant medication, and there was no recurrence of DIC during 14 months of follow-up. The preoperative administration of rTM can be a useful choice to assist safe treatment of aortic aneurysm complicated by aneurysm-related DIC.

Recombinant human thrombomodulin for pneumonia-induced severe ARDS complicated by DIC in children: a preliminary study.

PurposeRecombinant human soluble thrombomodulin (rTM) has been used to treat disseminated intravascular coagulation (DIC). Recent studies have shown the efficacy of rTM through its anti-inflammatory effects for treatment of adults with acute respiratory distress syndrome (ARDS). However, the safety and efficacy of rTM in children with severe ARDS complicated by DIC have not been reported. In this preliminary study, we reported the feasibility of using rTM for the treatment of pneumonia-induced severe ARDS complicated by DIC in children.MethodsSix children (age: median 10 months old) with pneumonia-induced severe ARDS complicated by DIC were enrolled in this preliminary study. rTM (380 U/kg) was administered for a maximum of 6 days, in addition to conventional therapies after diagnosis of severe ARDS complicated by DIC. After administration of rTM, we measured changes in the plasma TM concentration and evaluated the clinical course, status of DIC and ARDS, and other laboratory findings, including levels of cytokines, chemokines, and biomarkers.ResultsIn all six children, the plasma concentration of TM increased and DIC scores decreased after administration of rTM. Four of the six children recovered from the severe ARDS complicated by DIC after treatment, and were discharged from the hospital with no complications. In survived children, levels of soluble receptors for advanced glycation end products, interleukin-6, interleukin-8 and monocyte chemotactic protein-1 decreased after administration of rTM compared to those before rTM.ConclusionsThe rTM administration is feasible as an adjunctive therapeutic strategy for children over 2 months with pneumonia-induced severe ARDS complicated by DIC.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00540-021-02971-3.

Reducing the risk of developing walled-off necrosis in patients with acute necrotic collection using recombinant human soluble thrombomodulin.

The purpose of the present study was to investigate the possibility of reducing clinical impacts of acute necrotic collection (ANC) on patients with acute pancreatitis (AP) using recombinant human soluble thrombomodulin (rTM). In this retrospective multicenter study, 233 consecutive AP patients with ANC and acute peripancreatic fluid collection (APFC) from 2012 to 2016 were enrolled. To assess clinical impacts of ANC, severity on admission (JPN score, JPN CT grade, and Modified CT severity index), development of walled-off necrosis (WON), imaging costs for follow-up, and mortality were recorded. Finally, we investigated whether rTM could reduce the clinical impacts, adjusting the severity using propensity analysis with Inverse probability of treatment weighting. Patients with ANC developed WON with higher ratio than APFC (58/98 [59.2%] vs 20/135 [14.8%], OR=8.3, P<.01]. Severity on admission and imaging costs for follow-up in ANC patients were significantly higher than those in APFC (P<.01). However, regarding mortality, there was no significant difference between patients with ANC and APFC (P=.41). Adjusting severity, it was revealed that rTM administration significantly reduced the risk of ANC developed WON (OR=0.23, P=.01). While ANC had a higher clinical impact than that of APFC, we found that early administration of rTM may reduce the impact.

Prophylactic Effects of Recombinant Thrombomodulin Against Sclerodermatous Chronic Graft-Versus-Host Disease in a Rodent Model

Graft-versus-host disease (GVHD) is the one of the most serious complications of the allogenic stem cell transplantation (SCT). Especially, chronic GVHD has complex pathologies including the aspects of autoimmune diseases and microangiopathies. Recombinant thrombomoduin (rTM), which shows anticoagulant activity independent of antithrombin through binding to thrombin to activate protein C, has been used for disseminated intravascular coagulation (DIC). Recent studies have also demonstrated that rTM suppresses inflammatory response through various pathways including activated protein C (APC), degradation of HMGB1, inhibiting inflammatory cytokine and increasing regulatory T-cells (Treg), leading to attenuate tissue damages in animal models such as acute respiratory distress syndrome and liver injury by heatstroke. In acute GVHD mice model, rTM is reported to have therapeutic effect with contribution of Treg and blockade of HMGB1. In addition, rTM protects endothelial cells from calcineurin inhibitor-induced cytotoxicity in vitro using human umbilical vein endothelial cells. Thus, rTM is expected to show beneficial effects for post transplant complications. Actually, rTM has been sometimes used for severe veno-occlusive disease, DIC and thrombotic microangiopathy after SCT in clinical settings, but it is not clear whether rTM could have impact on acute or chronic GVHD themselves. In this study, we investigated the role of rTM especially focusing on preventing chronic GVHD in a rodent model.Bone marrow and splenocyte from donor mice (B10.D2) were transplanted into irradiated host mice (Balb/c) to induce sclerodermatous chronic GVHD (Scl-cGVHD). First, to demonstrate whether rTM could ameliorate the Scl-cGVHD, irradiated host mice were given splenocytes with rTM. Compared with the control group, rTM significantly improved chronic skin GVHD. However, rTM did not improve survival rate when increased dose of splenocytes was given to induce lethal intestinal GVHD together with Scl-cGVHD. In addition using another mice strain combination mimicking acute GVHD, rTM did not show any impact on ameliorating GVHD. Collectively, these results suggested that rTM had a beneficial effect on skin sclerodermatous lesions, not systemically. Next, to test whether rTM has therapeutic effects against skin lesions, rTM was started from 3 weeks after transplantation when Scl-cGVHD had already appeared. rTM did not improved Scl-cGVHD anymore. Next, to clarify whether the prophylactic mechanism of rTM to Scl-cGVHD is due to anticoagulant activity alone and/or complicated immure regulations by APC and rTM, Scl-GVHD mice was given dalteparin, APC and rTM, respectively. As shown in figure below, only rTM attenuated Scl-cGVHD with retaining normal skin structure and less inflammatory cell invasion compared to other groups, suggesting that rTM related immune regulation was a significant contributor to skin prophylactic effect, not anticoagulant activity. Though skin lesions were dramatically different among groups, in splenocytes there were no significant difference of cell subpopulation, T-cell activation and inflammatory cytokines (TNFα, IFNγ, IL17A). There was also no significant difference in regulatory B-cell, which was known to have a suppressive role in Scl-cGVHD model, and Treg. Moreover to confirm that rTM dose not influence these properties in vivo and in vitro, we analyzed splenocytes after repetitive administration of rTM to non-treated mice and short-term culture of splenocytes mixed with rTM. As expected, there was no significant difference by adding rTM in cell subpopulation including Treg, Breg and cytokine production in vivo and in vitro. From these findings, prophylactic mechanism of rTM in Scl-cGVHD was not due to anticoagulant activity nor APC related anti-inflammatory effects, but more likely to rTM related immune regulation. HMGB1 is one of the targets that rTM acts on as an immune modulator, but a previous report demonstrated that HMGB1 blockade attenuated GVHD systemically including skin, intestine and liver. In contrast to our findings that rTM worked mainly at skin lesions, unknown mechanisms of immune regulation by rTM might exist. In conclusion, rTM would be a promising drug for preventing sclerodermatous skin GVHD in addition to improving various complications associated with coagulation abnormalities. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Effects of Thrombomodulin in Reducing Lethality and Suppressing Neutrophil Extracellular Trap Formation in the Lungs and Liver in a Lipopolysaccharide-Induced Murine Septic Shock Model.

Neutrophil extracellular trap (NET) formation, an innate immune system response, is associated with thrombogenesis and vascular endothelial injury. Circulatory disorders due to microvascular thrombogenesis are one of the principal causes of organ damage. NET formation in organs contributes to the exacerbation of sepsis, which is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. We have previously reported that recombinant human soluble thrombomodulin (rTM) reduces lipopolysaccharide (LPS)-induced NET formation in vitro. Here, we aimed to show that thrombomodulin (TM)-mediated suppression of NET formation protects against organ damage in sepsis. Mice were injected intraperitoneally (i.p.) with 10 mg/kg LPS. rTM (6 mg/kg/day) or saline was administered i.p. 1 h after LPS injection. In the LPS-induced murine septic shock model, extracellular histones, which are components of NETs, were observed in the liver and lungs. In addition, the serum cytokine (interleukin-1β (IL-1β), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), macrophage chemotactic protein-1 (MCP-1), and interleukin-10 (IL-10)) levels were increased. The administration of rTM in this model prevented NET formation in the organs and suppressed the increase in the levels of all cytokines except IL-1β. Furthermore, the survival rate improved. We provide a novel role of TM in treating inflammation and NETs in organs during sepsis.

Efficacy of Recombinant Human-Soluble Thrombomodulin for Severe Acute Pancreatitis in a Rat Experimental Model.

Early death in severe acute pancreatitis (SAP) is caused by pancreatic necrosis and multiple-organ failure due to microcirculation disorder. The aim of this study was to prove that recombinant human-soluble thrombomodulin (rTM) has therapeutic effects on SAP by preventing pancreatic necrosis and organ failure. Male Wister rats were used. Cerulein was administered intraperitoneally 4 times every 1 hour, and lipopolysaccharide was administered intraperitoneally 3 hours after. One hour after administration of lipopolysaccharide, rTM was injected intravenously. Rats were observed for 24 hours after starting the experiment, and the survival rate was evaluated. All surviving rats were killed, and the blood sample, liver, and pancreas were excised. Serum amylase, aspartate aminotransferase, alanine aminotransferase, and high mobility group box 1 were measured, and the liver and pancreas were examined histologically. For the evaluation of microcirculation, von Willebrand factor staining was performed. Serum amylase, aspartate aminotransferase, and alanine aminotransferase were significantly decreased. The survival rate was significantly improved to 100%. Moreover, serum high mobility group box 1 was decreased. Liver injury and pancreatic necrosis became less severe, and microcirculation was preserved histologically. Early administration of rTM prevents organ failure by maintenance of microcirculation and improves prognoses of SAP.

Recombinant thrombomodulin prevents acute lung injury induced by renal ischemia-reperfusion injury

Acute kidney injury (AKI) complicated by acute lung injury has a detrimental effect on mortality among critically ill patients. Recently, a renal ischemia-reperfusion (IR) model suggested the involvement of histones and neutrophil extracellular traps (NETs) in the development of distant lung injury after renal IR. Given that recombinant thrombomodulin (rTM) has anti-inflammatory roles by binding to circulating histones, we aimed to clarify its effect on distant lung injury induced by AKI in a murine bilateral renal IR model. Both pretreatment and delayed treatment with rTM significantly decreased pulmonary myeloperoxidase activity, but they did not affect renal dysfunction at 24 h after renal IR. Additionally, rTM mitigated the renal IR-augmented expression of proinflammatory cytokines (tumor necrosis factor-α, interleukin-6, and keratinocyte-derived chemokine), and vascular leakage, as well as the degree of lung damage. Intense histone accumulation and active NET formation occurred in both the kidneys and the lungs; however, rTM significantly decreased the histone and NET accumulation only in the lungs. Administration of rTM may have protective impact on the lungs after renal IR by blocking histone and NET accumulation in the lungs, although no protection was observed in the kidneys. Treatment with rTM may be an adjuvant strategy to attenuate distant lung injury complicating AKI.

Prophylactic Effect of Recombinant Human Soluble Thrombomodulin for Hepatic Sinusoidal Obstruction Syndrome Model Mice.

The present study aimed to examine the effects of prophylactic administration of recombinant human soluble thrombomodulin (rTM) for the prevention of sinusoidal obstruction syndrome (SOS). Crl:CD1 mice were allocated to the rTM, placebo, and control groups. The rTM group received an intraperitoneal administration of rTM, with intraperitoneal administration of monocrotaline (MCT) 1 h later. The placebo group received PBS instead of rTM, and the control group received PBS instead of rTM and MCT. Mice were sacrificed 48 h after MCT administration, and blood and liver tissues were evaluated. Immunostaining was performed using anti-CD42b and anti-SE-1 antibodies, and AZAN staining. Levels of plasminogen activator inhibitor (PAI-1) and endothelial nitric oxide synthase (eNOS) in whole liver tissues were estimated using RT-PCR. Hematoxylin-eosin staining showed that SOS-related findings were markedly attenuated in the rTM group compared to the placebo group. CD42b immunostaining showed the presence of extravasated platelet activation (EPA) in the Disse space in the placebo group, but this was less noticeable in the rTM group. PAI-1 levels were significantly lower in the rTM group than in the placebo group in RT-PCR. However, eNOS levels were significantly higher in the rTM group than in the placebo group. Administration of rTM may prevent SOS by protecting sinusoidal endothelial cells.

297. Attenuation of angiotensin II-induced preeclamptic symptoms by recombinant thrombomodulin in mice – A novel therapeutic approach for preeclampsia

Introduction Placental dysfunction and disturbance of systemic endothelial function in the mother is involved in the pathetiology of preeclampsia (PE). According to the recent reports, recombinant thrombomodulin (rTM), an anticoagulant clinically used as a treatment for disseminated intravascular coagulation, plays a protective role to diminish endothelial damage under variety of pathological situations. Objective To examine the efficacy of rTM administration in PE developed by angiotensin II (AngII) infusion in pregnant mice. Methods Pregnant mice were continuously infused with AngII for 7 days from pc 10 to 17 using the osmotic mini pump. rTM was administered intraperitoneally for 4 days from pc 13 to 16. In the control group, saline was administered instead of rTM during the same period. Blood pressure (BP) was monitored daily. Blood and urine samples were collected before and after rTM or saline injection. On pc 17, the mice were sacrificed to check the fetal growth and the placental status. Results Continuous infusion of Ang II induced the symptoms mimicking human PE. Significant elevation of BP was confirmed from day 3 after starting Ang II infusion. Occurrence of proteinuria on pc 17 was limited to AngII infused pregnant mice. AngII infusion caused growth restriction to the fetuses. Administration of rTM significantly attenuated all three symptoms of PE. Discussion rTM attenuated Ang II-induced PE symptoms in the mouse model. Our findings suggest that rTM could be a novel approach for the tretment of PE.

Tuberculous pneumonia-induced severe ARDS complicated with DIC in a female child: a case of successful treatment

BackgroundTuberculous (TB) pneumonia can induce acute respiratory distress syndrome (ARDS). Although TB pneumonia is one of the causes of disease and death among children worldwide, the literature on TB pneumonia-induced ARDS is limited. We report herein on the successful treatment of a two-year-old female child with TB pneumonia-induced severe ARDS complicated with disseminated intravascular coagulation (DIC).Case presentationA two-year-old Vietnamese female child with sustained fever and cough for 20 days was transferred to our hospital. She had severe dyspnea and a chest X-ray showed bilateral infiltration without findings of heart failure. After tracheal intubation, her oxygenation index (OI) and PaO2/FiO2 (PF) ratio were 29 and 60 mmHg, respectively. Mycobacterium tuberculosis was detected by real-time polymerase chain reaction (rPCR) assay of tracheal lavage fluid. She was diagnosed as having severe ARDS that developed from TB pneumonia. Anti-tuberculous therapy and cardiopulmonary support were started. However, her respiratory condition deteriorated despite treatment with high-frequency oscillating ventilation (HFO), vasopressor support, and 1 g/kg of immunoglobulin. On the third day after admission, her International Society on Thrombosis and Hemostasis DIC score had increased to 5. Recombinant human soluble thrombomodulin (rTM) was administered to treat the DIC. After the administration of rTM was completed, OI gradually decreased, after which the mechanical ventilation mode was changed from HFO to synchronized intermittent mandatory ventilation. The DIC score also gradually decreased. Plasma levels of soluble receptor for advanced glycan end products (sRAGE) and high mobility group box 1 (HMGB-1), which are reported to be associated with ARDS severity, also decreased. In addition, inflammatory biomarkers, including interferon-gamma (IFN-γ) and interleukin-6 (IL-6), decreased after the administration of rTM. Although severe ARDS (P/F ratio ≦ 100 mmHg) continued for 19 days, the patient’s OI and P/F ratio improved gradually, and she was extubated on the 27th day after admission. The severe ARDS with DIC was successfully treated, and she was discharged from hospital on day 33 post-admission.ConclusionsWe successfully treated a female child suffering from TB pneumonia-induced severe ARDS complicated with DIC using multimodal interventions. (338/350).

Recombinant Thrombomodulin Exerts Anti-autophagic Action in Endothelial Cells and Provides Anti-atherosclerosis Effect in Apolipoprotein E Deficient Mice

Stress-induced alteration in endothelial cells (ECs) integrity precedes the development of atherosclerosis. Previous studies showed that the soluble recombinant thrombomodulin (rTM) not only increases ECs proliferation but also exerts anti-apoptotic activity in ECs. However, the functional significance of soluble rTM on autophagy-related apoptosis in ECs is still undetermined. Implicating a cytoprotective role for rTM in persistent serum starvation (SS)-induced autophagy in cultured ECs, we found that treatment of rTM decreased the expression of SS-induced autophagy-related proteins, ATG5 and LC3, and the formation of autophagosomes through activation of AKT/mTOR pathway. In addition, treatment of rTM decreased SS-induced EC apoptosis, but this effect of rTM could not be recapitulated by co-treatment with a potent autophagy inducer, rapamycin and in ECs with ATG5 knockdown. In human atherosclerosis specimens, expression of autophagy markers, ATG13 and LC3, were more abundant in aortic intimal ECs with severe atherosclerosis than those without atherosclerosis. Moreover, compared to saline treatment group, administration of rTM reduced LC3 and ATG13 expression, intimal EC apoptosis, and atherosclerotic lesion severity in the aorta of apolipoprotein E deficient mice. In conclusion, treatment with rTM suppressed stress-induced autophagy overactivation in ECs, provided ECs protective effects, and decreased atherosclerosis in apolipoprotein E deficient mice.

Evaluation of the effect of recombinant thrombomodulin on a lipopolysaccharide-induced murine sepsis model.

To evaluate the effect of recombinant human thrombomodulin (rTM) on sepsis, the levels of nucleosome as well as high-mobility group box 1 (HMGB1) and cytokines in sera and peritoneal fluids were measured in a mouse model of lipopolysaccharide (LPS)-induced sepsis after administration of rTM. C57BL/6 mice were intraperitoneally injected with LPS (15 mg/kg; Escherichia coli O111:B4) with or without the intravenous administration of rTM (3 mg/kg; 30 min prior to or 2 h after LPS injection). The survival rates were evaluated and levels of tumor necrosis factor (TNF)-α, interleukin (IL)-6, monocyte chemoattractant protein (MCP)-1, HMGB1 and nucleosome in sera and peritoneal fluids were analyzed by ELISA. Administration of rTM prior to or after LPS improved the survival rate of septic mice. In addition, rTM administered prior to or after LPS suppressed the level of pro-inflammatory cytokine TNF-α in sera at 1-3 h after LPS injection, whereas only the administration of rTM after LPS suppressed the levels of HMGB1 and nucleosome (late-phase mediators of sepsis) (9-12 h) in sera after the LPS injection. Furthermore, administration of rTM prior to or after LPS suppressed the level of TNF-α in the peritoneal fluids at 1-3 h after LPS injection, whereas only the administration of rTM after LPS suppressed the levels of IL-6 and MCP-1 in the peritoneal fluids at 6-9 h after LPS injection. These observations indicated that administration of rTM significantly improves the survival rate and suppresses the increased levels of TNF-α, IL-6, MCP-1, HMGB1 and nucleosome in the LPS-induced septic shock model. Thus, rTM may exert a protective action on sepsis and reduce mortality, possibly by reducing not only the levels of cytokines and chemokine but also the levels of late-phase mediators of sepsis.

Adequate application of recombinant thrombomodulin for sepsis-associated disseminated intravascular coagulation.

Recombinant thrombomodulin (rTM) is widely used for septic disseminated intravascular coagulation (DIC) in Japan. Tagami and colleagues performed an analysis using a nationwide administrative database in Japan and reported that rTM did not reduce the mortality in pneumonia-associated DIC (37.6 % in the rTM group vs 37.0 % in the control group, odds ratio: 1.01 (95 % confidence interval: 0.93 to 1.10)) [1]. They also reported a similar result in patients with bowel perforation-induced DIC [2]. These reports indicate that rTM will not be effective in real clinical practice. In contrast, in a recent issue of Critical Care, Yoshimura and colleagues reported that administration of rTM was significantly associated with reduced mortality in high-risk patients [3]. The same group also reported in their systematic review that the probability of a beneficial effect with rTM increases with increasing baseline risk [4]. Based on these findings, I suppose that rTM is not properly used currently. The decision based on Japanese Association of Acute Medicine DIC diagnostic criteria may not be adequate. As a matter of fact, Tagami and colleagues performed a very similar analysis for antithrombin concentrate and reported its efficacy (odds ratio: 0.85 (95 % confidence interval: 0.75 to 0.97)) [5]. We must remember that the Japanese Association of Acute Medicine criteria were designed specifically with the purpose of helping physicians decide on the timing of anticoagulant treatment, and antithrombin was the primary anticoagulant at that time. I therefore propose establishing different criteria, such as ‘fulfill the Japanese Association of Acute Medicine DIC criteria and Acute Physiology and Chronic Health Evaluation II score >24’, for the application of rTM.

Recombinant Thrombomodulin Safely Controls Disseminated Intravascular Coagulopathy in Acute Promyelocytic Leukemia – Results from the Japanese Pediatric Leukemia/Lymphoma Study Group AML-P05 Study

[Background] Acute promyelocytic leukemia (APL) cells induce dysregulation of coagulation and fibrinolysis, and most of the cases are complicated with disseminated intravascular coagulopathy (DIC) at the time of diagnosis. Administration of all-trans retinoic acid (ATRA) rapidly corrects dysregulation and improves DIC. But in some cases, management of DIC with ATRA alone is very difficult because addition of chemotherapeutic agents may reactivate fibrinolytic state. Thus the control of DIC is still an issue for the initial management of APL even in the ATRA era. Recombinant thrombomodulin (rTM) improves DIC by inhibiting excessive coagulation through the activation of protein C cascade (Saito H, et al. J Thromb Haemost 2007), and was approved in Japan for the treatment of DIC induced by severe infection or hematological malignancy in 2008. However, because activated protein C also facilitate fibrinolytic pathway by inhibiting plasminogen activator inhibitor-I, administration of rTM may lead to severe hemorrhage complication in patients with APL. Therefore, we retrospectively analyzed its efficacy and safety in pediatric APL.[Object & Methods] This study included 45 cases; 42 who registered to the Japanese Pediatric Leukemia/Lymphoma Study Group (JPLSG) AML-P05 study (UMIN Clinical Trials Registry, # UMIN000000645) and responded to the questionnaire and 3 cases outside the study. Questionnaire regarding the use of rTM and efficacy and safety issues, such as “Worst DIC score according to the diagnostic criteria of the Japanese Ministry of Health and Welfare (worst DIC score)” and “Days until resolution of DIC score from diagnosis of DIC (DIC duration)” were investigated.[Results] Among 45 cases analyzed, 38 (84%) were diagnosed to complicate with DIC, and 9 (24%) among them used rTM by physician’s decision. In these 9 cases (rTM+ group), mean duration of rTM administration was 13.8 days (7–24 days). WBC count and FDP level at diagnosis of APL were not different between rTM+ group and rTM-NOT used group (rTM- group). In rTM+ group, mean value of “Worst DIC score” was 5.8 and mean “DIC duration” from diagnosis was 16.8 days, both of them were not statistically significant with those in rTM- group (5.4 and 13.0 days, respectively). However, median “DIC duration” from commencement of rTM (11.5 days) seems shorter than “DIC duration” from diagnosis of DIC in rTM- group (13.0 days), although the difference was not statistically significant. Regarding safety issues, there was no death or severe hemorrhage in rTM+ group, while 3 cases (10%) of severe hemorrhage due to uncontrolled DIC were reported in rTM- group, with fatal brain hemorrhage in 1 case (3%) among them. There was no significant difference of induction rate between rTM+ group (1 case, 11%) and rTM- group (3 cases, 10%), although 2 cases of ATRA-refractory APL in rTM+ group who were additionally treated with arsenic trioxide.[Conclusions] In this retrospective analysis investigating efficacy and safety of rTM in the management of pediatric APL-related DIC, there were no significant differences regarding the efficacy of rTM because of the limited cases of rTM+ group. However, it is notable that there was no severe hemorrhage or death in rTM+ group. rTM seems to be safely used for the management of pediatric APL-related DIC. DisclosuresNo relevant conflicts of interest to declare.

Administration of recombinant thrombomodulin before progression of disease causing disseminated intravascular coagulation might be better compared with administration after progression of disease

As disseminated intravascular coagulation (DIC) causes multiple organ failure, recombinant thrombomodulin (rTM) is widely used in Japan for treating DIC. However, the optimal timing of rTM administration has not yet been determined. We hypothesized that the administration of rTM before progression of disease causing DIC might be better for the treatment of DIC than that after progression of disease. A total of 101 patients received rTM in the intensive care unit (ICU) between August 2008 and November 2013 were enrolled. Depending on survival at hospital discharge, the patients were divided into survivor (group S) and non-survivor groups (group NS). Patient characteristics before DIC development, acute physiology and chronic health evaluation II (APACHEII) score and sequential organ failure assessment (SOFA) score at the start of rTM administration, rTM administration dose, duration of time between the onset of disease causing DIC and rTM administration, and combination therapy were collected. Group S had 57 patients, and group NS had 44 patients. More than 70% of patients in group S were administrated rTM within 1 day from the onset of disease causing DIC (0 days, 40% vs 20%; 1 day, 33% vs 30%; more than 2 days, 26% vs 50%). At the start of the rTM administration, the APACHEII and SOFA scores were significantly lower in group S (26 ± 6 vs 32 ± 6, p < 0. 001; 9.5 ± 4.2 vs 13.4 ± 3.6, p < 0.001). Multivariate logistic regression analysis of outcomes was performed. The duration of time between the onset of disease causing DIC and rTM administration, the APACHEII score, the SOFA score, and use of continuous renal replacement therapy (CRRT) were selected as candidate variables (p < 0.05). The SOFA scores and use of CRRT were highly correlated with the APACHEII score (Pearson correlation = 0.63 and 0.43, respectively). Therefore, the SOFA score and the use of CRRT were excluded from this model. Late administration of rTM (more than 2 days between the onset of disease and rTM administration) was associated with undesirable outcome (odds ratio = 3.36, 95% confidence interval = 1.03–10.92, p = 0.044). This study suggested that the administration of rTM before the progression of disease causing DIC might be better than that after progression of disease causing DIC. Further randomized clinical trials are required to elucidate whether early administration of rTM is actually effective.

HSCT-Associated Hepatic VOD Is Initiated With Preceding Appearance Of Unusually Large Von Willebrand Factor Multimers In Patient Plasmas

Backgrounds and AimsHepatic veno-occlusive disease (VOD) associated with hematopoietic stem cell transplantation (HSCT) is characterized by a clinical triad of jaundice (total bilirubin, >2 mg/mL), hepatomegaly with right upper quadrant pain, and ascites and/or unexplained body weight gain (>5% of baseline) within 30 days after operation. Although the pathogenesis of hepatic VOD has not been fully elucidated, the common pathological features are thrombi formed in hepatic central vein.We previously reported that a significant decrease of plasma ADAMTS13 activity was noted in patients undergoing HSCT, who subsequently developed VOD (Park et al, BMT 2002). Then, we showed that plasma antigen levels of von Willebrand factor (VWF) has been kept higher in HSCT-patients with VOD than in those without, and in fact prophylactic infusions of fresh frozen plasma (FFP) with a dose of 10 ml/kg body weight 3 times per week were effective to reduce the frequency of VOD occurrence in high risk patients (Matsumoto et al, BMT 2007). However, more recent studies by ours indicate that FFP infusion alone is not enough to totally eliminate the occurrence (unpublished). Recently, it has been shown that the treatment with recombinant soluble thrombomodulin (rTM) is sometimes highly efficient to reverse VOD progression. But its pharmacokinetics and regimen for the treatment has not been established. As a first step to elucidate a possible combination regimen of FFP and rTM to VOD patients, here we have analyzed the transitional changes of unusually large VWF multimers (UL-VWFMs). The UL-VWFMs are released from damaged endothelial cells and induce platelet hyperagglutination under high shear stress generated in microvasculatures, and are often observed in patient plasmas undergoing HSCT. Patients and MethodsDuring 2011-2012, 45 patients were received allogenic HSCT in the second internal medicine department of our university hospital. None of these patients ,however, were received planned prophylactic FFP infusions, and as a result six patients undergoing allogenic cord blood transplantation (CBT) developed VOD. Clinical features of these 6 patients are shown in Table 1. [Display omitted] Under approval of Ethics Committee of Nara Medical University, we consecutively collected patient's citrated plasmas (ca 2.5 ml) and stored at -80°C until use. Using these deep-frozen plasma samples, we here extensively analyzed plasma levels of ADAMTS13 activity (ADAMTS13:AC), VWF antigen (VWF:Ag), and VWF collagen binding activity (VWF: CBA), together with VWF multimer analysis. More importantly, we also measured the corrected platelet count increment (CCI) to evaluate the efficiency of Platelet trsnsfusions. Then, we comprehensively evaluated these data with routine clinical and laboratory findings. Results and Discussion1) Plasma levels of ADAMTS13:AC were moderately but consistently decreased during two months after HSCT, whereas those of VWF:Ag were kept high, usually more than 200% and often 500% of the normal. 2) The UL-VWFMs appeared soon after HSCT, and continued at least until absolute neutrophil count (ANC) increased to >500 (usually 20-30 days after HSCT). 3) Until platelet engraftment (usually 40-60 days after HSCT), platelet transfusions (every 2-3 days interval) are usually performed to prevent the bleeding complications. During that period, the CCI values were consistently low, but those values were significantly increased during the administration of rTM. 4) Excess platelet transfusions before platelet engraftment induced the consumption of larger VWFMs in patient's plasmas, and often almost simultaneously hepatic VOD developed. Thus, platelet transfusions during the appearance of UL-VWFMs in patient's plasmas may induce platelet clumping in microvasculatures, and lead to the development of thrombotic complications including hepatic VOD. 5) The measurement of plasma levels of VWF:CB activity appeared to well predict the presence of UL-VWFMs. A representative case is shown in Figure. [Display omitted] Thus, a combination regimen of FFP and rTM might be advisable when the patients show the early clinical signs of hepatic VOD and the laboratory data such as VWF:CBA suggest the presence of UL-VWFMs in patient's plasmas. Disclosures:Matsumoto:Alexion Pharma: Membership on an entity's Board of Directors or advisory committees. Fujimura:Alexion Pharma: Membership on an entity's Board of Directors or advisory committees; Baxter International Inc: Membership on an entity's Board of Directors or advisory committees.

Recombinant Human Soluble Thrombomodulin Safely and Effectively Rescues Acute Promyelocytic Leukemia Patients From Disseminated Intravascular Coagulation.

Abstract 2226Acute promyelocytic leukemia (APL) is an uncommon subtype of acute myelogenous leukemia (AML) with a high mortality rate, mostly attributable to intracranial hemorrhage caused by disseminated intravascular coagulation (DIC). Almost all patients with APL develop DIC. The introduction of all-trans retinoic acid (ATRA) into the induction chemotherapy regimen has revolutionized the treatment of individuals with APL, with nearly 90% of newly diagnosed APL patients achieving complete remission and over 70% of patients surviving longer than 5 years. However, population-based studies have shown that the early death-rate during induction chemotherapy remains extremely high with nearly 30% incidence and the most common cause of death is associated with hemorrhage. Thus, development of a novel treatment strategy to alleviate abnormal coagulation in APL patients is urgently required.Recombinant human soluble thrombomodulin (rTM) comprises the active, extracellular domain of TM, and inactivates coagulation. A phase III trial comparing efficacy and safety between rTM and low-dose heparin showed that rTM significantly improved DIC associated with hematological malignancies or infections. This clinical trial excluded almost all patients with APL, because concomitant use of ATRA was prohibited. The use of rTM for the treatment of DIC was approved in Japan in be 2008.In this study, we treated individuals for DIC caused by APL (n=9) using rTM in combination with ATRA and chemotherapy, and compared the clinical outcomes with historical control patients (n=8) treated with ATRA and/or chemotherapy. Two control patients developed intracranial vascular incidents. On the other hand, no bleeding related mortality was noted in rTM-treated patients. Percentage change of FDP and change of fibrinogen were significantly higher in the rTM group than the control group (repeated measures ANOVA, p=0.041 and p=0.045, respectively). Interestingly, treatment with rTM significantly reduced the transfusion units of FFP required to maintain plasma levels of fibrinogen above 150 mg/dl (0.63 ± 0.93 U/d vs. 4.3 ± 1.6 U/d, p=0.001). Notably, treatment with rTM rescued patients from DIC earlier than historical controls (log rank test, p=0.019). These results suggest that administration of rTM should be considered for the treatment of individuals with DIC associated with APL. Disclosures:No relevant conflicts of interest to declare.

Intermittent administration of recombinant human soluble thrombomodulin successfully controlled chronic disseminated intravascular coagulation in a patient with dissecting aortic aneurysm on an outpatient basis

Chronic disseminated intravascular coagulation (DIC) is a rare but life-threatening complication of dissecting aortic aneurysm. Although anticoagulant therapy may often proves effective for controlling DIC itself, patients would have to be hospitalized for a long period due to continuous infusion therapy. Subcutaneous injection of a highly concentrated preparation of heparin calcium may offer one alternative treatment for DIC; however, daily subcutaneous use of heparin for the treatment of DIC has impaired quality of life (QOL). The other alternative therapy is intravenous administration of recombinant human soluble thrombomodulin (rTM), which includes the active extracellular domain of thrombomodulin. Reportedly, rTM effectively resolves DIC by only 6 consecutive days of administration; however, how frequently rTM should be administered after the resolution of chronic DIC to have good control of it has been unclear. We report herein a case of chronic DIC complicated with dissecting aortic aneurysm, whose resolution of chronic DIC achieved by 6 consecutive days of rTM has been maintained by once a week administration of rTM on an outpatient basis.