Biomarkers Of Fibrinolysis Research Articles

A Novel Fibrinolysis Resistance Capacity Assay Can Detect Fibrinolytic Phenotypes in Trauma Patients.

To evaluate residual fibrinolysis resistance activity (FRA) in plasma, a detergent-modified plasma clot lysis assay time (dPCLT) was established in which α2-antiplasmin (A2AP) and plasminogen activator inhibitor type 1 (PAI-1) are inactivated without impacting protease activity. We applied this novel assay to severely injured trauma patients' plasma. Tissue-type plasminogen activator (tPA)-induced plasma clot lysis assays were conducted after detergents- (dPCLT) or vehicle- (sPCLT) treatment, and time to 50% clot lysis was measured ("transition midpoint", T m). Residual FRA was then calculated as ([sPCLT T m] - [dPCLT T m]/[sPCLT T m]) x100% = Δ Tm PCLT (%). Assay results were compared to rapid thromboelastography (TEG) LY30, tPA TEG LY30, and plasma fibrinolysis biomarkers in polytrauma patients' plasma (N=43). Δ Tm PCLT(%) in normal plasma (N=5) was 63.0 ± 8.3 whereas in A2AP-depleted plasma was -19.1 ± 1.3%, Plasmin-antiplasmin (PAP) complex increased after complete lysis of sPCLT, whereas that in dPCLT was negligible in normal plasma. In trauma plasma, significant correlations between Δ Tm PCLT and active PAI-1 (r = 0.85, p<0.0001), PAP complex (r = -0.85, p<0.0001), free A2AP (r = 0.66, p<0.0001), total A2AP levels (r = 0.52, p=0.001) and tPA TEG LY30 (r = -0.85, p<0.0001) were found. dPCLT in hyperfibrinolysis patients diagnosed by tPA TEG was significantly shorter than those with low fibrinolysis [10.2 ± 6.4 minutes versus 20.2 ± 2.1 minutes, p=0.0006]. Hyperfibrinolysis after trauma is significantly related to exhaustion of FRA, and our novel assay appears to quickly assess this state and may be a useful clinical diagnostic after additional validation. · We established a new clot lysis assay to measure residual fibrinolysis resistance activity after inactivating PAI-1 and A2AP by detergents without impacting protease function.. · This novel clot lysis assay unmasked the mechanism of hyperfibrinolysis after trauma as exhaustion of fibrinolysis resistance activity, and appeared useful in quickly identifying these patients..

Thromboelastography in dogs with idiopathic epilepsy treated with phenobarbital monotherapy.

Thromboelastography (TEG) is an effective technique to assess the efficiency of coagulation. Phenobarbital (PB) can induce hematological and coagulation disorders in both animals and humans, but its effects on hemostasis have been little investigated and are poorly understood in dogs. The aim of this article was to assess coagulation using TEG in a population of dogs with idiopathic epilepsy treated with PB. Prospective observational study. TEG was performed in blood samples from dogs with idiopathic epilepsy that were divided in three groups: Two groups of treated dogs that were on phenobarbital treatment for less or more than 6 months, and a control group of healthy dogs. Duration of treatment, dose, phenobarbital serum concentration and selected hematological and biochemical parameters were evaluated and correlated with the TEG results. No statistically significant differences were found between groups. None of the animals appeared to be in a hypo- or hypercoagulable state, however 9/19 (47,4%) dogs were classified as hyper-fibrinolytic. A statistically significant negative relationship between MA and G values and increased fibrinolytic activity (LY30) were found. No statistically significant relationship was found between PB dose or PB blood levels and TEG parameters in either group. No bleeding complications were observed. The rise in fibrinolysis might be due to hepatic damage from PB, as indicated by elevated liver enzymes in many dogs with abnormal fibrinolytic patterns. Although TEG showed hyperfibrinolysis in some dogs, the presence of primary or secondary hyperfibrinolysis could not be confirmed due to the lack of D-dimer measurements and liver biopsy. TEG's sensitivity compared to other fibrinolysis biomarkers like PAP might also affect results. TThe cause of hyperfibrinolysis in epileptic dogs treated with phenobarbital remains unclear, with potential links to hepatic effects or handling, and further research is needed to assess its clinical significance.

Role of Hemostatic Biomarkers for the Identification of Patients with LONG-COVID19 Syndrome: Results from the 'Accordi' Study

Introduction: Hemostatic alterations of patients with acute Covid-19 are well described, while post-Covid-19 clinical and laboratory consequences are less clear. Survivors of Covid-19 exhibit a complex array of symptoms, whose underlying pathology is still to be elucidated. The term 'long-Covid' is used to describe this condition developing after acute Covid-19. Materials and Methods: After the first wave of the pandemic, we started an ad hoc multidisciplinary follow-up project for Covid-19 patients discharged from our Institution (ACCORDI STUDY). The program was run from July to November 2020. Patients were reassessed one time for clinical, instrumental, and laboratory parameters. Blood samples were collected from each participant for the measurement of hemostatic biomarkers. Here we present the first interim analysis of the biomarkers study. The laboratory study included complete blood cell count, liver and renal functional tests, LDH, C-reactive protein, fibrinogen, D-dimer (DD), von Willebrand factor antigen (vWF:Ag), thrombomodulin (TM), tissue plasminogen activator (tPA) and plasminogen activator inhibitor PAI-1, prothrombin fragment 1+2 (F1+2). Results: A cohort of 1471 (554F/917M) patients was recruited in the ACCORDI program with a median age of 60 (19-93). The median time from Covid-19 onset was 107 days (range 65-142). At the onset of disease, patients had the following symptoms: cardiopulmonary (94%), flu-like (91%), respiratory (82%), and neurological (57%). At the follow-up visit, cardiopulmonary symptoms persisted in 88%, flu-like in 64%, respiratory in 42%, and neurological in 13%. No differences in symptoms' distribution were present in relation to age and gender at either disease onset or follow-up visit. Based on the time of symptom persistence, 771 (53%) patients were classified as long-Covid, while the remaining 700 (47%) were symptoms-free. The median age of long-Covid patients was 59 (range 38-80) years, 55% male, with cardiopulmonary as the prevalent symptoms. In a subgroup of 468 patients [322M/146F, age range 65 (38-83) years], 231 long-Covid and 237 symptoms-free, an interim analysis of hemostatic biomarker test results was performed. The analysis (Table 1) showed that, compared to symptoms-free subjects, long-Covid patients had significantly (p<0.05) higher levels of vWF:Ag and PAI-1. In addition, among subjects evaluated within 12 weeks from disease onset, the symptomatic subjects (n=48) had significantly higher levels of PAI-1 and TM (p<0.05) than the symptoms-free ones (n=78), whereas, among subjects evaluated after 12 weeks of disease onset (n=184), i.e. the post-Covid syndrome patients, had significantly (p<0.05) higher levels of vWF:Ag as compared to symptoms-free subjects (n=159). No significant differences were observed in the levels of tPA, DD, fibrinogen, F1+2 of symptomatic vs asymptomatic individuals. In a model of logistic regression analysis corrected for age and gender, having at least one among TM and PAI-1 biomarkers above the 75th percentile within 12 weeks from the disease onset, was significantly associated with a diagnosis of long-Covid (OR 2.425; 95% CI:1.037-5.671; p=0.041). Conclusions: In conclusion, in this study cohort, patients with long-Covid syndrome are characterized by the persistence of cardiopulmonary symptoms. Preliminary results on hemostatic biomarkers analysis show that endothelial (TM and vWF:Ag) and fibrinolytic (PAI) biomarkers are associated with long-Covid symptoms and may be useful for the identification of affected subjects. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Coagulopathy and Brain Injury Pathogenesis in Post-Covid-19 Syndrome.

The post-COVID neurological syndrome has been coined, which describes the functional and structural sequelae of coronavirus infection disease-19 (COVID-19) in the brain. Mild/severe manifestations of the post-COVID neurological syndrome have been identified in approximately 33.00% of COVID-19 survivors. The presence of neurological complications after COVID allowed neuropathologists to investigate in-depth the role of viral infection in neurons. The pathophysiology of the post-COVID neurological syndrome involved the development of a systematic response, including coagulopathy characterized by the formation of microthrombi. Coagulopathy, an old term for a new disease, describes the discrepancy between pro-coagulant and anticoagulant systems due to overexpression of pro-coagulant substances and or their receptors in addition to suppression of the anticoagulant molecules and or their receptors. Vascular endothelial cells and hepatocytes play a central role in the regulation of hemostasis that is disrupted during the acute phase response (APR) of coronavirus-19 (COVID-19). Currently, coagulopathy and inflammation are termed together since both form a complementary system, indicated by the elevation of inflammatory biomarkers (APR) and fibrinolysis biomarkers (D-dimer/fibrin). The later events of the post-COVID neurological syndrome are primarily induced by coagulopathy and direct viral tropism. Therefore, the paper introduces the hypothesis of coagulopathy induced post-COVID neurological syndrome.

The Diagnostic Value of Various Inflammatory Biomarkers for Diagnosing Periprosthetic Joint Infection is Gender-Specific.

ObjectivePrevious studies have suggested that the diagnostic biomarkers of periprosthetic joint infection (PJI) are largely influenced by gender. In the present study, we aimed to evaluate the diagnostic value of traditional inflammatory biomarkers, fibrinolytic biomarkers (fibrinogen and D-dimer), and C-reactive protein (CRP)/albumin for PJI in different genders.MethodsA single-center retrospective analysis was performed on revision total hip or knee arthroplasty between June 2013 to June 2021, and the study included 80 patients in the PJI group and 136 patients in the non-PJI group. PJI was diagnosed based on the International Consensus Meeting (ICM) in 2018. The levels of CRP, fibrinogen, erythrocyte sedimentation rate (ESR), D-dimer, and albumin count were determined. Receiver operating characteristic (ROC) curves and Youden’s index were used to evaluate the diagnostic ability of various biomarkers.ResultsThe levels of CRP, fibrinogen, D-dimer, ESR, and CRP/albumin were significantly higher in the PJI group (P < 0.001). In PJI of females, the predictive value of CRP was the highest among the five biomarkers, with the area under the curve (AUC) of 0.98. The optimal predictive cut-off for CRP was 8.86 mg/L, with a sensitivity and specificity of 90.2% and 95.7%, respectively. When combined with the other four biomarkers, the AUC of CRP was 0.98, 0.99, 0.98, and 0.99, respectively. In PJI of males, the predictive value of ESR was the highest among the five biomarkers, with an AUC of 0.92. The optimal predictive cut-off for ESR was 14.50 mm/h, with a sensitivity and specificity of 84.6% and 86.6%, respectively. When combined with the other four biomarkers, the AUC of ESR was 0.95, 0.94, 0.93, and 0.97, respectively.ConclusionCRP and ESR were excellent biomarkers for diagnosing PJI in female and male patients, respectively, and their combined use with CPR/albumin could provide higher diagnostic value in different genders.

Fibrin clot properties in coronary artery disease: new determinants and prognostic markers.

Despite improved diagnosis and treatment options, coronary artery disease (CAD) is still the leading cause of mortality and morbidity worldwide. Established risk factors such as smoking, hypercholesterolemia, and hypertension only partly explain the pathophysiology of CAD. Besides the well-known role of platelets in atherosclerosis and arterial thrombus formation, reduced endogenous fibrinolytic activity may play a key role in CAD formation and progression. Thus, biomarkers of fibrinolysis may be future CAD risk markers. In this review, we provide an overview of regulators of fibrinolysis and the main factors of importance to fibrin clot formation including coagulation factor XIII, thrombin, and fibrinogen. We summarize markers of altered fibrinolysis and current laboratory methods applied in clinical practice and research. We present today’s evidence on fibrin clot properties in patients with stable CAD or acute coronary syndrome compared with healthy individuals and the significance of altered fibrinolysis as a risk for coronary thrombotic disease. In conclusion, we found evidence that altered fibrin clot properties and impaired fibrinolysis appear to contribute significantly to the thromboembolic risk in CAD patients. Therefore, more research is crucial in order to clarify whether modulation of the fibrinolytic system may pave the way for improved treatment of CAD.

Fibrin Network Formation and Lysis in Septic Shock Patients.

Background: Septic shock patients are prone to altered fibrinolysis, which contributes to microthrombus formation, organ failure and mortality. However, characterisation of the individual patient’s fibrinolytic capacity remains a challenge due to a lack of global fibrinolysis biomarkers. We aimed to assess fibrinolysis in septic shock patients using a plasma-based fibrin clot formation and lysis (clot–lysis) assay and investigate the association between clot–lysis parameters and other haemostatic markers, organ dysfunction and mortality. Methods: This was a prospective cohort study including adult septic shock patients (n = 34). Clot–lysis was assessed using our plasma-based in-house assay. Platelet count, activated partial thromboplastin time (aPTT), international normalised ratio (INR), fibrinogen, fibrin D-dimer, antithrombin, thrombin generation, circulating fibrinolysis markers and organ dysfunction markers were analysed. Disseminated intravascular coagulation score, Sequential Organ Failure Assessment (SOFA) score and 30-day mortality were registered. Results: Three distinct clot–lysis profiles emerged in the patients: (1) severely decreased fibrin formation (flat clot–lysis curve), (2) normal fibrin formation and lysis and (3) pronounced lysis resistance. Patients with abnormal curves had lower platelet counts (p = 0.05), more prolonged aPTT (p = 0.04), higher lactate (p < 0.01) and a tendency towards higher SOFA scores (p = 0.09) than patients with normal clot–lysis curves. Fibrinogen and fibrin D-dimer were not associated with clot–lysis profile (p ≥ 0.37). Conclusion: Septic shock patients showed distinct and abnormal clot–lysis profiles that were associated with markers of coagulation and organ dysfunction. Our results provide important new insights into sepsis-related fibrinolysis disturbances and support the importance of assessing fibrinolytic capacity in septic shock.

Coagulation and Fibrinolysis Biomarkers as Potential Indicators for the Diagnosis and Classification of Ovarian Hyperstimulation Syndrome

Background: Accurate diagnosis and classification of ovarian hyperstimulation syndrome (OHSS) is important for its management. We employed a new high-sensitivity chemiluminescence immunoassay to detect the thrombin-antithrombin complex (TAT), plasmin alpha2-plasmin inhibitor complex (PIC), soluble thrombomodulin (sTM), and tissue plasminogen activator-inhibitor complex (TPAI-C), and evaluated their diagnostic and classification performance for OHSS.Methods: A total of 106 women were enrolled, including 51 patients with OHSS (25 mild or moderate OHSS, 26 severe OHSS), and 55 without OHSS (control group). TAT, PIC, sTM, and TPAI-C levels were measured using the Sysmex HISCL5000 automated analyzer.Results: Compared to the control group, TAT, PIC, and TPAI-C levels were significantly higher (P < 0.001, P < 0.001, P < 0.001, respectively), whereas the sTM level was significantly lower (P < 0.001) in the patients with OHSS. The receiver operating characteristic was used to evaluate the diagnostic efficiency. For the diagnosis of OHSS, the area under the curves (AUCs) for TAT, PIC, sTM, and TPAI-C were 0.991, 0.973, 0.809, and 0.722, respectively. In particular, the sensitivity, specificity, positive predictive value, and negative predictive value for TAT and PIC were all above 90%. For the differential diagnosis of mild–moderate and severe OHSS, the AUCs for TAT, PIC, and TPAI-C were 0.736, 0.735, and 0.818, respectively. The cutoff values of TAT, PIC, and TPAI-C for the differential diagnosis of mild–moderate and severe OHSS were 11.5 ng/mL, 2.4 μg/mL, and 5.8 ng/mL, respectively. Based on these cutoff values, eight cases of mild–moderate OHSS exceeded the cutoff values, two of which developed to severe OHSS in the following days. However, of the remaining 17 cases of mild–moderate OHSS patients with negative biomarkers, none subsequently developed severe OHSS.Conclusions: TAT, PIC, sTM, and TPAI-C can be used as sensitive biomarkers in the diagnosis of OHSS. Meanwhile, TAT, PIC, and TPAI-C also displayed remarkable potential in the classification of OHSS. In addition, the levels of TAT, PIC, and TPAI-C above the cutoff values in patients with mild–moderate OHSS might predict a high risk of developing severe OHSS.

Association of the Circulating Supar Levels with Inflammation, Fibrinolysis, and Outcome in Severe Burn Patients.

ABSTRACTBackground:Hyperfibrinolysis and pro/anti-inflammatory imbalance usually occur in the early stage of severe burns. Soluble urokinase-type plasminogen activator receptor (suPAR) is involved in fibrinolysis and inflammation. To date, the levels of circulating suPAR in non-survivors with severe burns remain unknown. This study aimed to investigate the early association between circulating suPAR levels and biomarkers of fibrinolysis, pro/anti-inflammatory, and prognosis.Methods:Sixty-four consecutive Chinese patients with severe burns and 26 healthy volunteers were enrolled in a prospective observational cohort. Clinical characteristics and laboratory data were collected prospectively. Blood samples were collected at 48 h post-burn, and suPAR and biomarkers of pro/anti-inflammatory and fibrinolysis were detected by enzyme-linked immunosorbent assays. Important indicators between non-survivors and survivors were compared. Linear regression analysis was performed to screen variables associated with suPAR. Logistic regression analysis and receiver operating characteristic curve (ROC) analysis were performed to evaluate the prognostic value of suPAR.Result:Compared with the control group, the circulating suPAR levels in the survivors (P < 0.001) and non-survivors (P = 0.017) were higher. Compared with survivors, non-survivors had lower circulating suPAR levels at 48 h post-burn, and they showed a higher degree of fibrinolysis (higher D-dimer) and a lower TNF-α/IL-10 ratio. According to linear regression analysis, the variables independently associated with a lower suPAR level were lower platelet factor 4 (PF-4), urokinase-type plasminogen activator (uPA), and TNF-α/IL-10 levels and a higher D-dimer level. Logistic regression and ROC analyses indicated that a suPAR level ≤ 4.70 μg/L was independently associated with 30-day mortality.Conclusion:Low circulating suPAR levels at 48 h post-burn in severe burn patients may reflect decreased TNF-α/IL-10 ratio and increased hyperfibrinolysis. suPAR can predict 30-day mortality in patients with severe burn.

Association of biomarkers of fibrinolysis and inflammation with mortality in acute coronary syndrome

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Universidad de Buenos Aires. Introduction in acute coronary syndromes (ACS), plaque rupture elicits a prothrombotic response that is counter balanced by a fibrinolytic response. D-dimer (DD) serves as a marker of both processes, reflecting thrombin activity and through cross-linked fibrin degradation. Inflammatory mediators are also involved, evidenced with the rise of C-reactive protein (CPR) levels, enhancing the prothrombotic and proatherogenic endothelial vascular response. Current evidence with these biomarkers has shown conflicting results with no conclusive impact on cardiovascular outcomes, risk stratification nor potential treatments. Purpose our aim was to determine an association between DD and CRP with in-hospital and 1-year mortality in patients with ACS. Methods observational study of patients admitted to a coronary care unit with ACS and elevated troponin. Clinical characteristics, in-hospital and 1-year outcomes and serum levels at admission of DD and CRP were assessed. Results we included 127 patients with ACS. Mean age was 68.4 ± 12.8 years and 61% were male, 57.7% had hypertension, 17.1% had dyslipidemia, 25.2% had diabetes and 17.9% had previous myocardial infarction. Most patients received DAPT and 67.5% underwent PCI or CABG during the index hospitalization. In-hospital mortality was 5.7% and 1-year all-cause and cardiovascular mortality were 14.6% and 9.7% respectively. The median of admission DD for patients who died during hospital stay was higher than those who survived (4.59 [IQR 1.94-6.05 ug/ml FEU] vs 0.56 [IQR 0.31-1.12 ug/ml FEU], p = 0.001). At 1-year follow-up, the median of admission DD for patients who died was significantly higher than those who survived: 1.55 (IQR 0.91-5.08 ug/ml FEU) vs. 0.53 (IQR 0.29-0.90 ug/ml FEU), p &amp;lt; 0.001 (figure A). We analyzed positive DD vs. negative DD at admission, with 0.5 ug/ml FEU cut-off value, almost a quarter of the positive patients were dead at 1-year follow up (22.4% vs. 2.4% negative DD, p= 0.011). We found a positive significative correlation between DD and CRP levels (R = 0.56, p &amp;lt; 0.001) (figure B). Conclusion high levels of DD at admission were strongly associated with in-hospital and 1-year mortality. Significant correlations with CRP could explain the inflammatory nature that lead to poorer outcomes. DD could be useful in risk-stratification in ACS; however, a specific threshold should be defined for this type of patients. Abstract Figure A. Figure B.

Brain Injury in Critical Illness and a Note on the Virus

Brain Injury in Critical Illness and a Note on the Virus

Dynamic changes of coagulation and fibrinolytic biomarkers in peri operaive arthroplasty patients.

To evaluate coagulation and fibrinolytic parameters after total joint arthroplasty (TJA) and provide evidence for optimization of timing of perioperative anticoagulation medicine. The prospective study was conducted at the Jishuitan Hospital of Peking University from January to April in 2016, and comprised patients who were scheduled consecutively to undergo primary total knee arthroplasty (TKA) or total hip arthroplasty (THA). Blood samples were obtained at day 1 preoperatively and day1, day 3 postoperatively. Antigenic levels of protein C (PC), endothelial protein C receptor (EPCR), tissue factor pathway inhibitor (TFPI), antithrombin III (AT-III), plasminogen activator inhibitor 1 (PAI-1) and tissue plasminogen activator (tPA) were measured with commercially available enzyme-linked immunosorbent assay kits. Postoperative levels of coagulation parameters TFPI and AT-III were increased compared to preoperative values (118.7±34.6 vs 70.0±20.5 μg/ml for AT-III, and 26.37±7.91vs 16.68±8.92 μg/l for TFPI), while postoperative levels of coagulation parameters PC and EPCR were decreased (0.88±0.30 vs 2.03±0.66 μg/ml for PC, and 100.8±31.0 vs 199.4±57.4 μg/ml for EPCR). Postoperative levels of fibrinolytic parameter tPA was increased compared to preoperative values (2.87±0.83 vs 2.03±1.03 μg/l), while its specific inhibitor PAI-1 was decreased (0.88±0.30 vs 2.03±0.66 μg/l). These results demonstrated the perturbation of the coagulation and fibrinolytic system of patients undergoing TJA. Hypercoagulation and hyperfibrinolysis were observed in postoperative patients, which suggested anticoagulant therapy is effective and necessary.

Reductions in plasmin inhibitor and fibrinogen predict the improved fibrin clot lysis 6 months after obesity surgery.

Prothrombotic and metabolic variables are decreased after obesity surgery, and fibrin clot lysis is increased. It is unknown how fibrinolytic variables are affected, and whether fibrinolytic and metabolic changes predict the enhanced clot lysis. Study aims were to determine fibrinolytic biomarkers before and 6 months after Roux-en-Y gastric bypass (RYGB) and to identify predictors of the RYGB-induced increase in clot lysis. Women (n = 42) and men (n = 18) with obesity underwent RYGB, and factor XIII (FXIII), thrombin activatable fibrinolysis inhibitor (TAFI), plasminogen and plasmin inhibitor (PI) were measured before and 6 months after surgery. Regression analyses identified determinants of the RYGB-induced increase in clot lysis among changes in fibrinogen and in fibrinolytic and metabolic variables. Results showed that after RYGB, FXIII, TAFI, plasminogen and PI were reduced (P < .0005). Reductions in PI (β = -0.59) and fibrinogen (β = -0.35), together with age (β = -0.22) and male sex (β = 0.22), predicted the enhanced clot lysis with the model explaining 56% (P < .0005). Predictors of the reduction in PI were reductions in cholesterol (β = 0.37) and glucose (β = 0.29), together with male sex (β = -0.28), whereas reductions in fibrinogen were predicted by lowering of interleukin-6 (IL-6) (β = 0.32). In conclusion, fibrinolytic variables were reduced 6 months after RYGB. Targeting PI and fibrinogen, by reducing metabolic variables such as glucose, cholesterol and IL-6, has a profibrinolytic effect in obesity.

Comparative Study of Fibrinolytic Response amongst Malarious Pregnant and Non Malarious Subjects in Rivers State, Nigeria

Aim: The study was designed to comparatively assess the degree of fibrinolytic response amongst malaria-positive pregnant women, and non-malaria positive subjects in Rivers State, Nigeria.&#x0D; Methods: The study area covered University of Port Harcourt Teaching Hospital, Port Harcourt [UPTH] and Rivers State University Teaching Hospital, [RSUTH] both in Port Harcourt metropolis Rivers State. It was a cross-sectional study carried out on a total of two hundred and forty female attendees at the obstetrics and gynecology clinics of the two hospitals. The subjects were grouped into three comprising of eighty subjects in each group; malarious pregnant women, non- malarious pregnant women and apparently healthy non-pregnant women. Venous blood sample measuring 5 milliliter volume was drawn from each subject, The sample was dispensed into two separate EDTA anticoagulant bottles, 3 milliliter and 2 milliliter meant for measuring the levels of markers of fibrinolysis which were Plasminogen, Plasminogen activator inhibitor-1, Plasminogen activator inhibitor-2, Tissue Plasminogen activator, alpha-2-antiplasmin, D-dimers and fibrinogen, and preparation of blood films for malaria microscopy respectively.&#x0D; Results: Fibrinogen result; 760.44±16.18 ng/ml of malaria-positive pregnant women was elevated compared to the malaria-negative women; 697.70±18.84 ng/ml and the non-pregnant control values of 704.73±15.25 ng/ml. These values were significantly different [P&lt;.011] between the study groups. Results of tissue plasminogen activator [tPA]; 46.39±2.69 ng/ml, D-dimer; 77.64±6.94 ng/ml, plasminogen activator inhibitor-1 [PAI-1]; 89.73±2.14 ng/ml, plasminogen activator inhibitor-2 [PAI-2]; 568.00±12.51 ng/ml, plasminogen; 23.82±0.75 ng/ml and 2-antiplasmin; 1314.06±34.64 ng/ml of the malaria-positive pregnant women were significantly different [P=0.0001] from non-positive pregnant women; tPA; 28.87±1.38 ng/ml, D-dimer; 53.90±1.18 ng/ml., PAI-1; 80.00± 1.81 ng/ml, PAI-2; 456.31±5.94 ng/ml, Plasminogen; 16.63±0.67 ng/ml and 2-antiplasmin; 1130.61±29.74 ng/ml . Both results were significantly different [P=0.0001] from the non-pregnant control group; tPA; 31.34±1.64 ng/ml, D-dimer; 30.24±1.04 ng/ml, PAI-1; 65,47±2,33 ng/ml, PAI-2; 427.86±6.95 ng/ml, plasminogen; 16.49±0.04 ng/ml and 2-antiplasmin; 1016.98±24.51 ng/ml.&#x0D; Conclusion: The study witnessed significantly high concentrations of fibrinolytic markers in malaria-positive pregnant women. This could be due to compromised endothelial cell function resulting to overproduction of biomarkers of fibrinolysis. The implication is thrombus formation and excessive bleeding in pregnancy which could lead to miscarriages, fetal death or maternal mortality.

Immune Response Profile of SARS-CoV-2 Associated AARDS Patients During Extracorporeal Membrane Oxygenation

Background: Extracorporeal membrane oxygenation (ECMO) is a life-saving rescue therapy in COVID-19 patients with ARDS. Extracorporeal support has been associated with development of lymphocytopenia that is common finding in COVID-19 outbreak. Cytokines storm complicates early stage of SARS-CoV-2 pneumonia, prompting therapy with steroids and immunomodulatory drugs. There is a paucity of data detailing the host immune response status of COVID-19 patients that require ECMO. We aimed to assess time course of leukocytes, lymphocyte and subpopulation count and of inflammatory and fibrinolysis markers during ECMO and how it might be affected by immunomodulatory therapies such as steroids and tocilizumab, an IL6 receptor blockade. Methods: All consecutive patients with confirmed COVID-19 associated ARDS who required veno-venous ECMO were enrolled. Data collected included patients’ demographic information, comorbidities, severity disease at ICU entry, new diagnoses of bloodstream infection (BSI) and ventilator associated pneumonia (VAP) and aetiologic pathogens. Time course of leukocytes, lymphocyte, subpopulation count, inflammatory and fibrinolysis biomarkers levels (such as c-reactive protein, procalcitonin, ferritin and DDdimer) was analyzed within 24, 72 hours, one week and three weeks from the beginning of ECMO support. Lymphocytes and subpopulation count and inflammatory and fibrinolysis markers concentration were compared in absence of treatment with both steroids and tocilizumab (No Treatment), in presence of treatment with steroids (Steroids), with tocilizumab (Tocilizumab) and with both drugs (Steroids + Tocilizumab). Results: Seventy-nine leukocyte, lymphocyte and thirty-eight subpopulation counts were obtained during 3 weeks of ECMO support from thirteen patients with COVID-19 associated ARDS. Among all lymphoid cells, CD3+ CD4+ and NK cells (CD16+ CD56+) displayed a trend of reduction, while CD3+ CD+ and CD19+ did not change. C-reactive protein, procalcitonin and ferritin significantly decreased over time, reaching the lowest value by 3 weeks. On the contrary, DDimer did not change over time. In presence of steroids and tocilizumab, total lymphocytes and all subpopulations were significantly lower compared to those obtained without treatment. Inflammatory and fibrinolysis markers were significantly reduced by steroids and tocilizumab alone or in combination. In a multivariable linear regression model, therapy with steroids, tocilizumab alone or in combination was significantly associated with reduction of lymphocytes count; instead time spent on ECMO was not associated with changes in lymphocytes count. Eleven over thirteen patients had bacterial superinfections, such as VAP and BSI. Multi-drug resistant Gram-negative bacilli were identified in seven over thirteen patients. Conclusions: In severe COVID-19 critically ill patients requiring ECMO, concomitant immunomodulatory therapies such as steroids and tocilizumab, along with mitigation of inflammation and fibrinolysis, had significant impact on the reduction of B and CD4+ T lymphocytes and natural killer cell count. Funding: None. Conflict of Interest: None. Ethical Approval: The hospital institutional review board approved the study using data collected for routine clinical practice and waived the requirement for informed consent (approval number 0028437).

A prospective observational study of acute traumatic coagulopathy in traumatic bleeding from the battlefield.

Acute trauma coagulopathy (ATC) after military trauma has not been comprehensively studied. ATC is defined as a prolonged prothrombin time ratio (PTr) or reduced clot amplitude (A5) in viscoelastic testing. Compared to civilian trauma, military trauma has more injuries from explosions and gunshot wounds (GSWs), potentially leading to a different pathophysiology for traumatic coagulopathy. This study aimed to characterize military ATC on admission to a military hospital in Afghanistan and to explore any differences due to the mechanism of injury. Severely injured military casualties were enrolled in the study. Blood samples were taken on admission and after routine testing, waste plasma was prepared, frozen, and transported to the United Kingdom for in-depth hemostatic analysis. Seventy-seven percent of casualties had ATC defined by a PTr greater than 1.2 and 19% when defined by rotational thromboelastometry (ROTEM) A5 less than 36 mm. Coagulation factor depletion correlated with degree of shock, particularly factor V (p < 0.01), factor X (p < 0.01), and fibrinogen levels (p < 0.01). Thrombin generation was well preserved. Fibrinolytic biomarkers were raised correlating with the degree of shock (p < 0.01), and 8% of casualties had hyperfibrinolysis on ROTEM analysis. Plasmin-antiplasmin complexes (p < 0.01) and d-dimer levels (p = 0.01) were higher and clot firmness lower (p = 0.02) in those injured by explosion compared to GSW's. ATC was present and correlated with shock, similar to civilian trauma. Thrombin generation remained adequate. Fibrinogen and factor V levels were disproportionately low but still sufficient to allow clot formation. Fibrinolysis is a key feature, probably due to a tissue plasminogen activator surge at the time of injury. Blast injuries are associated with a greater activation of fibrinolysis than GSWs.

Elevated plasminogen activators are associated with hematoma progression in spontaneous intracerebral hemorrhage

Endogenous fibrinolysis might lead to hematoma progression in spontaneous intracerebral hemorrhage (ICH). We studied plasma biomarkers of fibrinolysis and hemostasis in twenty-two patients with ICH and nine healthy controls (HC) in a single-center study. Patients with ICH had significantly higher D-dimer and plasmin-alpha-2-antiplasmin complexes compared to HC. At baseline, patients with hematoma progression had higher urokinase-type plasminogen activator (uPA) and tissue-type plasminogen activator (tPA) and lower plasminogen levels, compared to those with no progression. 24-hour and day-7 matrix metalloproteinase-9 (MMP-9) was significantly increased in patients with hematoma progression.

Elevated levels of d-dimer are associated with inflammation and disease activity rather than risk of venous thromboembolism in patients with granulomatosis with polyangiitis in long term observation

PurposeGranulomatosis with polyangiitis (GPA) is one of antineutrophil cytoplasmic autoantibody (ANCA) - associated vasculitis. The disease is characterized by necrotizing inflammation of small vessels causing tissue ischemia in a variety of organs. The aim of the present study was an evaluation of inflammation, coagulation and fibrinolysis biomarkers, and their possible associations with various clinical and laboratory parameters in GPA patients. MethodsA group of 100 consecutive patients with GPA were prospectively followed in the study. In all patients, echocardiography and laboratory tests were performed. ResultsThe patients were followed-up for a median of 4.0 ± 1.9 years. Circulating d-dimer concentrations were elevated in a majority (56%) of GPA patients, and were significantly higher in GPA patients in the active stage compared to those in remission (median 652 vs. 405 ng/ml, p = 0.0002). In 23 patients (23%) venous thromboembolism (VTE) was diagnosed during observation. However, there were no differences in d-dimer concentrations between patients with and without VTE either in active stage or in remission. Correlation analysis showed that the levels of d-dimer correlated with hs-CRP (r = 0.42, p < 0.0001) and creatinine concentrations (r = 0.58; p < 0.0001), but not with ANCA levels. ConclusionsIn patients with GPA elevated levels of d-dimer are associated with disease activity and inflammation rather than with the risk of venous thromboembolism. The value of d-dimer as a biomarker of venous thromboembolism episodes in patients with small vessel vasculitis is low.

Dynamic changes of coagulation and fibrinolytic biomarkers in perioperaive arthroplasty patients

Dynamic changes of coagulation and fibrinolytic biomarkers in perioperaive arthroplasty patients

Potent reduction of plasma lipoprotein (a) with an antisense oligonucleotide in human subjects does not affect ex vivo fibrinolysis

It is postulated that lipoprotein (a) [Lp(a)] inhibits fibrinolysis, but this hypothesis has not been tested in humans due to the lack of specific Lp(a) lowering agents. Patients with elevated Lp(a) were randomized to antisense oligonucleotide [IONIS-APO(a)Rx] directed to apo(a) (n = 7) or placebo (n = 10). Ex vivo plasma lysis times and antigen concentrations of plasminogen, factor XI, plasminogen activator inhibitor 1, thrombin activatable fibrinolysis inhibitor, and fibrinogen at baseline, day 85/92/99 (peak drug effect), and day 190 (3 months off drug) were measured. The mean ± SD baseline Lp(a) levels were 477.3 ± 55.9 nmol/l in IONIS-APO(a)Rx and 362.1 ± 89.9 nmol/l in placebo. The mean± SD percentage change in Lp(a) for IONIS-APO(a)Rx was -69.3 ± 12.2% versus -5.4 ± 6.9% placebo (P < 0.0010) at day 85/92/99 and -15.6 ± 8.9% versus 3.2 ± 12.2% (P = 0.003) at day 190. Clot lysis times and coagulation/fibrinolysis-related biomarkers showed no significant differences between IONIS-APO(a)Rx and placebo at all time points. Clot lysis times were not affected by exogenously added Lp(a) at concentrations up to 200 nmol/l to plasma with very low (12.5 nmol/l) Lp(a) levels, whereas recombinant apo(a) had a potent antifibrinolytic effect. In conclusion, potent reductions of Lp(a) in patients with highly elevated Lp(a) levels do not affect ex vivo measures of fibrinolysis; the relevance of any putative antifibrinolytic effects of Lp(a) in vivo needs further study.