Markers Of Coagulation Activation Research Articles

Angiopoietin2 is associated with coagulation activation and tissue factor expression in extracellular vesicles in COVID-19.

Coagulation activation in immunothrombosis involves various pathways distinct from classical hemostasis, offering potential therapeutic targets to control inflammation-induced hypercoagulability while potentially sparing hemostasis. The Angiopoietin/Tie2 pathway, previously linked to embryonic angiogenesis and sepsis-related endothelial barrier regulation, was recently associated with coagulation activation in sepsis and COVID-19. This study explores the connection between key mediators of the Angiopoietin/Tie2 pathway and coagulation activation. The study included COVID-19 patients with hypoxia and healthy controls. Blood samples were processed to obtain platelet-free plasma, and frozen until analysis. Extracellular vesicles (EVs) in plasma were characterized and quantified using flow cytometry, and their tissue factor (TF) procoagulant activity was measured using a kinetic chromogenic method. Several markers of hemostasis were assessed. Levels of ANGPT1, ANGPT2, and soluble Tie2 correlated with markers of coagulation and platelet activation. EVs from platelets and endothelial cells were increased in COVID-19 patients, and a significant increase in TF+ EVs derived from endothelial cells was observed. In addition, ANGPT2 levels were associated with TF expression and activity in EVs. In conclusion, we provide further evidence for the involvement of the Angiopoietin/Tie2 pathway in the coagulopathy of COVID-19 mediated in part by release of EVs as a potential source of TF activity.

Are Gamers Prone to eThrombosis during Long Gaming Sessions?

During the last two decades, several cases of venous thrombosis (VTE) after a prolonged period at a computer have been described, denominated as "eThrombosis". Video gaming on a computer has become very popular and can be a social activity where several players gather to play against each other or in a virtual environment for several days ("LAN (i.e., Local Area Network) parties") where the participants are sedentary and consuming calorie-rich food items. The aim of this study was to investigate potential coagulation activation during a 42 h LAN party. Nine male gamers volunteered for the LAN party. Citrated blood was sampled before and every 6 h, and plasma was analyzed for thrombin generation, thrombin-antithrombin complexes (TAT), prothrombin fragment 1 + 2 (F1 + 2), and D-dimer. Thrombin generation increased slightly but not significantly during the LAN party, whereas the coagulation activation markers were unchanged. These results do not indicate that the coagulation system is activated significantly during 42 h of gaming with minimal physical activity. Although increased activity cannot be excluded, it does not directly indicate a risk of VTE in general.

Abstract TP268: Markers of Coagulation and Hemostatic Activation in Ischemic Stroke Patients With Reduced Ejection Fraction on Antiplatelet Therapy

Introduction: Heart failure with reduced ejection fraction (HFrEF) is a risk factor for ischemic stroke. However, antithrombotic choice in a patient with HFrEF remains challenging. We set out to evaluate serum markers of coagulation and hemostatic activation (MOCHA) among ischemic stroke patients with HFrEF. Methods: We performed a retrospective analysis of ischemic stroke patients with HFrEF (<40%) from July 28, 2017-June 13, 2023 seen at the Emory Stroke Clinic who underwent a MOCHA profile (serum D-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex, and fibrin monomer) ≥2 weeks after the index stroke; abnormal MOCHA profile was defined as ≥2 elevated markers. We excluded patients who were on anticoagulation therapy at the initial visit. Results: Overall, 40 patients (mean age 60 +/- 13.1, 53% female, 85% nonwhite) met criteria; median EF was 25% (IQR 15%-30%). Frequency of abnormal MOCHA profile was 43% in EF ≥25% and 58% in EF <25% (p = 0.52). No MOCHA components were associated with reduced EF in multivariate linear regression analysis (R2 = 0.03, p = 0.28). Over mean follow-up of 2.3 years, recurrent stroke occurred in 5.3 / 100 patient-years and major adverse cardiac events (MACE) occurred at 7.4 / 100 patient-years. Compared to patients with EF <25%, patients with EF ≥25% had higher recurrent stroke rates (6.46 vs 3.07 per 100 patient-years) and MACE (9.69 and 3.07 per 100 patient-years) Patients on antiplatelet regimens and anticoagulant regimens experienced MACE events at a rate of 4.25 and 10.62 per 100 patient-years, respectively. Patients with abnormal MOCHA profiles (n=20) had no recurrent strokes, but experienced other MACE events at a rate of 3.86 per 100 patient years, while patients with normal MOCHA profiles (n=20) experienced 11.73 MACE events per 100 patient-years, all of which were recurrent strokes. Conclusion: In HFrEF patients with an ischemic stroke, the MOCHA profile was not associated with ejection fraction. No difference in recurrent stroke and MACE events was seen among patients with normal vs abnormal MOCHA profile.

Pharmacokinetics and coagulation biomarkers in children and adults with hemophilia A receiving emicizumab prophylaxis every 1, 2, or 4 weeks

BackgroundEmicizumab is a bispecific antibody that bridges activated factor (F)IX and FX, mimicking the function of missing activated FVIII and thus improving hemostasis in people with hemophilia A. The efficacy and safety of emicizumab were demonstrated in 4 phase III clinical trials (HAVEN 1-4). ObjectivesHere, we describe pharmacokinetics (PKs), pharmacodynamics (PDs), and exploratory safety biomarkers in HAVEN 1 to 4. MethodsParticipants received emicizumab at a loading dose of 3 mg/kg weekly for 4 weeks, followed by maintenance doses of 1.5 mg/kg weekly, 3 mg/kg every 2 weeks, or 6 mg/kg every 4 weeks. PKs, PDs, and safety biomarkers were assessed in samples collected at regular intervals during the trials. ResultsEmicizumab plasma trough concentrations increased during the loading dose period, reaching a mean of 52.9 μg/mL (SD, 13.6 μg/mL) at week 5, and were sustained at 42.1 to 52.3 μg/mL thereafter with maintenance dosing. Activated partial thromboplastin time shortened following the first emicizumab dose. Mean FVIII-like activity and thrombin generation peak height increased to 25.2 IU/dL (SD, 6.9 IU/dL) and 115.2 nM (SD, 42.5 nM) at week 5, with levels sustained at 17 to 23 IU/dL and >116 nM thereafter, respectively. Emicizumab did not notably affect FIX or FX plasma antigen levels, prothrombin time, or concentrations of exploratory safety markers of coagulation activation (D-dimer, prothrombin fragment 1 + 2, and fibrinogen). ConclusionIn HAVEN 1 to 4, emicizumab demonstrated sustained PKs and PDs and improved coagulation parameters without affecting safety biomarkers.

Damage-associated cellular markers in the clinical and pathogenic profile of vaccine-induced immune thrombotic thrombocytopenia

BackgroundAdenoviral vector-based COVID-19 vaccine-induced immune thrombotic thrombocytopenia (VITT) is rare but carries significant risks of mortality and long-term morbidity. The underlying pathophysiology of severe disease is still not fully understood. The objectives were to explore the pathophysiological profile and examine for clinically informative biomarkers in patients with severe VITT. MethodsTwenty-two hospitalized patients with VITT, 9 pre- and 21 post-ChAdOx1 vaccine controls, were recruited across England, United Kingdom. Admission blood samples were analyzed for cytokine profiles, cell death markers (lactate dehydrogenase and circulating histones), neutrophil extracellular traps, and coagulation parameters. Tissue specimens from deceased patients were analyzed. ResultsThere were strong immune responses characterized by significant elevations in proinflammatory cytokines and T helper 1 and 2 cell activation in patients with VITT. Markers of systemic endothelial activation and coagulation activation in both circulation and organ sections were also significantly elevated. About 70% (n = 15/22) of patients met the International Society for Thrombosis and Haemostasis criteria for disseminated intravascular coagulation despite negligible changes in the prothrombin time. The increased neutrophil extracellular trap formation, in conjunction with marked lymphopenia, elevated lactate dehydrogenase, and circulating histone levels, indicates systemic immune cell injury or death. Both lymphopenia and circulating histone levels independently predicted 28-day mortality in patients with VITT. ConclusionThe coupling of systemic cell damage and death with strong immune-inflammatory and coagulant responses are pathophysiologically dominant and clinically relevant in severe VITT.

Idiopathic Multicentric Castleman Disease Results in Endothelium Activation and Coagulation Dysregulation Via Tissue Factor and PAI-1

Idiopathic Multicentric Castleman disease (iMCD) is an inflammatory disease which may be associated with thrombosis. Diagnosis of this condition may be delayed with increase in morbidity and mortality. We investigated the cause of hypercoagulability in one patient with iMCD, who presented with shortness of breath, anasarca, abdominal distension and severe pulmonary hypertension with clinicopathologic findings consistent with iMCD with some features of TAFRO (thrombocytopenia, anasarca, fever, reticulin myelofibrosis, organomegaly) variant. Lab results detected high levels of inflammatory markers IL-6, CRP and ferritin. During the patient's hospital course, our patient developed evidence of consumptive coagulopathy, based on prolonged PT, aPTT, thrombocytopenia, high D-dimers and reduced fibrinogen levels, with associated microvascular thrombosis, limb gangrene, and biopsy-proven vascular fibrin formation. We examined several markers of coagulation activation in this patient to characterize the pattern of hypercoagulability in mCD. Cytokine and chemokine arrays and ELISA for selected coagulation factors were employed. We found an elevation in FVIIa/AT suggestive of in vivo upregulation of Tissue Factor (TF) as well as an increase in microparticles expressing functional TF (inhibited by Ixolaris). Our patient also demonstrated a marked increase in C5a and C3b. With respect to anticoagulants associated with the endothelium, both thrombomodulin and sEPCR were augmented in our patient, indicating endothelial cell injury and decreased protein C activation (APC). High levels of PAI-1, the main fibrinolysis inhibitor was evident. In addition, an increase in the chemoattractants for monocytes MCP-1, MCP-4 was noted. Similarly, we noted an increase in angiopoietin-2 and other markers associated with endothelial cell activation including adhesion molecules E-selectin, sICAM-1, sICAM-3 and sVCAM-1. Molecules affecting angiogenesis such as endoglin, IL-8, VEGF-A were also increased. Most markers were at normal levels when the patient was in remission. Our findings suggest that multiple pathways influence hypercoagulability in iMCD, including direct activation of coagulation through TF and complement, increase in thromboinflammation via monocytes, and endotheliopathy. Mechanistically, it is likely that the cytokine storm in iMCD, characterized by endothelial activation, components of immunothrombosis and complement activation result in TF-mediated coagulation dysregulation, shifting hemostasis towards a prothrombotic and antifibrinolytic state. Components of immunothrombosis, including inhibitors of TF, emerge as a therapeutic target in iMCD.

The Effect of Voxelotor on Erythrocyte Deformability, Neutrophil Phenotype and Endothelial Activation

Introduction Sickle cell disease (SCD) is characterized by chronic intravascular hemolysis, caused by polymerization of abnormal sickle hemoglobin. The ongoing intravascular hemolysis leads to release of cell-free heme and iron, resulting in widespread oxidative damage, inflammation, neutrophil activation, endothelial activation and hypercoagulability, all contributing to vaso-occlusive events and end organ damage. Voxelotor, a small molecule reversibly binding to hemoglobin S (HbS) increases its oxygen affinity, thereby decreasing HbS polymerization and sickling, resulting in decreased hemolysis. The decrease in erythrocyte sickling might lead to improved erythrocyte deformability and decreased adhesion, while reductions in cell-free heme and labile plasma iron levels might result in decreased neutrophil activation, adhesion and aging and decreased endothelial activation. The aim of this study is to assess the effects of voxelotor on erythrocyte deformability, neutrophil activation, adhesion and aging and endothelial activation. Methods SCD patients (HbSS and HbSβ 0-thalassemia), with hemoglobin (Hb) ≤ 10.5 g/dL were treated with voxelotor 1500 mg in a single arm interventional study. Blood was collected at baseline and after 3 months of treatment. Erythrocyte deformability was assessed by ektacytometry (Lorrca, RR mechatronics), measuring elongation index (EI) and point of sickling (PoS). EI max and EI min indicate the highest and lowest erythrocyte deformability upon oxygenation and deoxygenation respectively. PoS is the oxygen tension at which 5% reduction of the EI max is observed. Antigen expression of neutrophil markers for activation, adhesion and aging were assessed with flow cytometry. Reactive oxygen species (ROS) production of neutrophils was measured by Amplex Red Assay (Molecular probes), measuring hydrogen peroxide (H 2O 2) production under unstimulated and stimulated (zymosan, streptozotocin (STZ), factor-n-formyl-MET-LEU-Phe (fMLP), Phorbol myristate acetate (PMA)) and platelet-activating factor-fMLP (PAF-fMLP)). Endothelial activation was assessed by measuring von Willebrand Factor antigen (vWF-Ag) using enzyme-linked immunosorbent assay (ELISA) (Glostrup). Prothrombin fragment 1+2 (F 1+2), thrombin-antithrombin complexes (TAT) and D-dimer were measured using ELISA. Data are presented as median with interquartile range (IQR), unless stated otherwise. A P value of <0.05 was considered significant. Results 15 SCD patients (11 HbSS, 4 HbSβ 0-thalassemia), 5 female, median age 35 years (IQR 27-46)) completed 3-month follow-up. Hb levels increased significantly after 3 months of treatment (from 7.4 (6.9 - 8.1) g/dL to 9.7 (7.9 - 11.0) g/dL, p=0.002), corresponding to significant decreases in LDH and bilirubin levels and reticulocyte counts as markers of hemolysis (p<0.05). PoS decreased significantly after 3 months (from 20.1 (17.5 - 26.1) mmHg to 16.1 (10.3 - 18.1) mmHg, p=0.006). Both EI max and EI min increased after 3 months of treatment (from 0.33 (0.24 - 0.42) to 0.38 (0.28 - 0.48), p=0.029 and from 0.13 (0.07 - 0.26) to 0.21 (0.16 - 0.41), p=0.007 respectively). Markers of neutrophil activation, adhesion and aging were generally lower after 3 months of treatment, though the differences were not statistically significant (Figure 1 A-C). Neutrophil ROS production in both unstimulated and stimulated condition remained unchanged (Figure 1D). After 3 months of treatment vWF-Ag significantly decreased (from 252 (187 - 284) % to 183 (153-205) %, p = 0.033). No changes were observed in markers of coagulation activation (F 1+2 and TAT, and D-dimer). Conclusion Voxelotor significantly improved erythrocyte deformability as suggested by decreased PoS and increased EI max and EI min, potentially leading to improved rheological properties. While markers of neutrophil activation seem to decrease, the differences are not statistically significant, possibly due to the relatively small sample size. A reduction in vWF-Ag was observed possibly reflecting diminished endothelial activation, due to a decrease in intravascular hemolysis.

Abstract 14010: Synergistic Influence of Rivaroxaban on Platelets, Inflammation and Coagulation Biomarkers in Patients With CAD and/or PAD on Aspirin Therapy

Background: Cardiovascular benefits of 2.5 mg twice daily rivaroxaban plus aspirin therapy (RIV+ASA) has been demonstrated in patients with arterial diseases. Hypothesis: RIV+ASA is associated with reduced platelet activation and plasma inflammation and coagulation activation markers in patients with CAD and/or PAD who were on ASA. Methods: In this open-label biomarker study, patients on 81 mg/day ASA were randomized to continue ASA or RIV+ASA for 12 weeks. We assessed ADP-, α-thrombin-, and tissue factor-induced platelet aggregation (PA) using conventional aggregometry, platelet-fibrin clot strength (PFCS) by INTEM (intrinsic pathway activator) and EXTEM (extrinsic pathway activator) using thromboelastometry, shear-induced PA by platelet function analyzer-100, D-dimer and fibrinogen using coagulation analyzer, hs-CRP and interleukin-6 using ELISA method at baseline, and four weeks and 12 weeks post-randomization. Results: Data was available in 9 patients with RIV + ASA and ten patients with ASA-only therapy. Most patients were male, Caucasians, obese and older. There were no differences in baseline demographics, medications, and laboratory values between groups, except patients in RIV + ASA group had higher white blood cell counts (p=0.028) and lower baseline 2uM ADP-induced PA (p=0.03). There were no differences in other laboratory measurements between baseline and post-randomization time points within the group or at 4- and 12-week time points between groups, except D-dimer values were significantly lower at 12 weeks (p=0.038) in the RIV + ASA vs. ASA-only group. No significant adverse events were observed. Conclusions: Twelve weeks of rivaroxaban plus aspirin vs. aspirin was associated with similar levels of platelet aggregation, platelet fibrin clot strength, fibrinogen and inflammation markers, and lower d-dimer levels.

Abstract 17813: Markers of Cellular Damage, Inflammatory Response, Coagulation and Platelet Activity, and Apoptosis During Catheter Ablation for Atrial Fibrillation Using Radiofrequency and Pulsed-Field Energy

Introduction: Pulsed-field ablation (PFA) presents a new technology for the ablation of AF using non-thermal ablation energy. Ablation energies producing thermal injury are associated with an inflammatory response, platelet activation, and coagulation cascade activation. The study aimed to compare markers of cell damage and platelet and coagulation activation in patients undergoing PVI using PF and radiofrequency (RF) energy. Hypothesis: PFA will be associated will more pronounced myocardial damage, but less pronounced activation of platelets and inflammation. Methods: Patients with AF indicated for PVI were enrolled and randomly assigned to undergo PVI using RF (CARTO Smart Touch, Biosense Webster, USA) or PF (Farapulse, Boston-Scientific, USA) energy. Markers of myocardial damage (high-sensitivity troponin I), apoptosis (Fas ligand, caspase-3), inflammation (interleukin-6), coagulation (D-dimers, Fibrin monomers, von Willebrand antigen and factor activity), platelet activation (P-selectin, activated Gp IIb/IIIa antigen and CD42b), and neuron axon damage (NGF-β) were measured before the procedure (T1), after transseptal puncture, (T2), after completing the ablation in the left atrium (T3), and one day after the procedure (T4). Results: Sixty-five patients were enrolled in the PFA (n=33) and RFA (n=32) groups. Both groups were similar in baseline characteristics (age 60.5±12.7 vs. 64.0±10.7 and 20 (60.6%) non-paroxysmal vs. 20 (62.5%) paroxysmal AF). Procedural and left atrial dwelling times were substantially shorter in the PFA group (55:09±11:57 vs. 151:19±41:25 min, p< 0.001; 36:00±8:05 vs. 115:58±36:49 min, p<0.001). Troponin release (1 d after the procedure) was substantially higher in the PFA group (10,102, IQR 8,272-14,207 vs. 1,006, IQR 603-1,433) and was ten times higher in PFA patients. However, during the procedure, markers of platelet activation, coagulation activation, and inflammation were similar between groups. Conclusions: PF ablation was associated with substantially more myocardial damage compared to radiofrequency ablation. However, coagulation activation, platelet activation, and inflammatory responses were similar.

Myocardial Damage, Inflammation, Coagulation, and Platelet Activity During Catheter Ablation Using Radiofrequency and Pulsed-Field Energy

BackgroundPulsed-field ablation (PFA) represents a new, nonthermal ablation energy for the ablation of atrial fibrillation (AF). Ablation energies producing thermal injury are associated with an inflammatory response, platelet activation, and coagulation activation. ObjectivesThis study aimed to compare the systemic response in patients undergoing pulmonary vein isolation (PVI) using pulsed-field and radiofrequency (RF) energy. MethodsPatients with AF indicated for PVI were enrolled and randomly assigned to undergo PVI using RF (CARTO Smart Touch, Biosense Webster) or pulsed-field (Farapulse, Boston-Scientific) energy. Markers of myocardial damage (troponin I), inflammation (interleukin-6), coagulation (D-dimers, fibrin monomers, von Willebrand antigen and factor activity), and platelet activation (P-selectin, activated GpIIb/IIIa antigen) were measured before the procedure (T1), after trans-septal puncture (T2), after completing the ablation in the left atrium (T3), and 1 day after the procedure (T4). ResultsA total of 65 patients were enrolled in the pulsed-field ablation (n = 33) and RF ablation (n = 32) groups. Both groups were similar in baseline characteristics (age 60.5 ± 12.7 years vs 64.0 ± 10.7 years; paroxysmal AF: 60.6% vs 62.5% patients). Procedural and left atrial dwelling times were substantially shorter in the PFA group (55:09 ± 11:57 min vs 151:19 ± 41:25 min; P < 0.001; 36:00 ± 8:05 min vs 115:58 ± 36:49 min; P < 0.001). Peak troponin release was substantially higher in the PFA group (10,102 ng/L [IQR: 8,272-14,207 ng/L] vs 1,006 ng/L [IQR: 603-1,433ng/L]). Both procedures were associated with similar extents (>50%) of platelet and coagulation activation. The proinflammatory response 24 h after the procedure was slightly but nonsignificantly higher in the RF group. ConclusionsDespite 10 times more myocardial damage, pulsed-field ablation was associated with a similar degree of platelet/coagulation activation, and slightly lower inflammatory response. (The Effect of Pulsed-Field and Radiofrequency Ablation on Platelet, Coagulation and Inflammation; NCT05603637)

TIME-DEPENDENT CHANGES IN PROINFLAMMATORY MEDIATORS ARE ASSOCIATED WITH TRAUMA-RELATED VENOUS THROMBOEMBOLISM.

Background: Tissue trauma and hemorrhage result in pronounced activation of the innate immune system. Given known crosstalk between inflammation and coagulation, soluble inflammatory mediators could be associated with venous thromboembolisms (VTEs) after major trauma. Objectives : This study aimed to identify plasma inflammatory mediators that are independent predictors of VTE risk in trauma patients. Methods: We performed a secondary analysis of the Pragmatic Randomized Optimal Platelets and Plasma Ratios (PROPPR) study. Plasma levels of 27 cytokines/chemokines were measured by Bio-Plex at admission and 2, 4, 6, 12, 24, 48, and 72 h later. Patients who died from exsanguination or within 24 h were excluded. Mann-Whitney tests were performed to assess no-VTE and VTE groups at each time point. Multivariable logistic regression was used to determine the adjusted effects of inflammatory mediators on VTE risk. Results: Eighty-six of the 575 patients (15%) included developed VTE. Interleukin (IL)-1ra, IL-6, IL-8, IL-10, eotaxin, granulocyte colony-stimulating factor, interferon-γ-inducible protein, monocyte chemoattractant protein 1 (MCP-1), and chemokine ligand 5 (regulated on activation, normal T cell expressed and secreted) were all significantly increased among VTE patients. Multivariable analyses demonstrated that IL-6, IL-8, interferon-γ-inducible protein, and MCP-1 were independently associated with VTE. Cox proportional hazards modeling identified IL-6, IL-8, and MCP-1 as independent predictors of accelerated VTE development. We identified significant correlations between inflammation and markers of coagulation and endothelial activation. Conclusion: Sustained systemic inflammation is a key driver of VTE risk after major trauma. Therapeutics targeting innate immune activation should be considered for development of future multimodal strategies to augment current VTE prophylaxis.

Prognostic value of D-dimers in patients with COVID-19: narrative synthesis

Introduction. Contemporary researchers have suggested and demonstrated the hypothesis that the elevated level of D-dimers, which is a valuable marker of coagulation and fibrinolysis activation, can predict the severity of COVID-19, pulmonary complications, and thromboembolic events before they occur.&#x0D; Material and methods. The bibliographic resources were analyzed and selected from databases such as PubMed, Hinari, SpringerLink, and Google Search using keywords such as “COVID-19,” “SARS-CoV-2,” “coronavirus,” “D-dimers,” “biomarkers,” and “severity prediction,” which were used in various combinations to maximize search efficiency. Therefore, the manuscript contains 51 representative articles for the purpose of this synthesis article.&#x0D; Results. The D-dimer levels are significantly higher in patients with severe forms of COVID-19 compared to those with non-severe forms, in patients with acute respiratory distress syndrome compared to those without acute respiratory distress syndrome, and in deceased patients compared to those who have survived. D-dimers positively correlate with the degree of severity and the increased risk of progression to severe disease, inversely proportional to the survival rate. They can predict prognosis, determine therapeutic strategies, prevent complications, positively influence the disease’s course, and monitor the prognosis.&#x0D; Conclusions. D-dimers should be used as a pre-radiographic screening tool as early as possible after admission and as an indicator for risk stratification of venous thromboembolism in hospitalized patients with COVID-19. Based on the increase in D-dimer levels, adjusting therapeutic doses of anticoagulants is more beneficial for patients compared to administering prophylactic doses.

#3372 HOST RESPONSE CHANGES ASSOCIATED WITH PERSISTENT ACUTE KIDNEY INJURY IN CRITICALLY ILL PATIENTS WITH COVID-19

Abstract Background and Aims In sepsis, the dysregulated host response has been, at least in part, linked to development of acute kidney injury (AKI) and its duration. Data on the host response to COVID-19 and development of persistent-AKI (duration &amp;gt; 48 h) in critically ill patients are scarce. We hypothesized that COVID-19 infected patients who develop persistent-AKI have different host response aberrations. To address this hypothesis, we sequentially measured host immune response biomarkers in critically ill patients admitted to the intensive care unit (ICU). Method We included patients admitted to the ICU from two tertiary hospitals and one primary care hospital between March and July 2020 (first wave). All patients had PCR-confirmed COVID-19. Excluded were readmitted patients, transfers from another ICU, and patients with chronic kidney disease (CKD stage 3 or higher). The presence of AKI was assessed by using hourly urine output and daily serum creatinine levels, and classified into 3 stages according to Kidney Disease: Improving Global Outcomes (KDIGO) criteria. In a subset of patients admitted to the two tertiary hospitals (n=113), 41 plasma protein biomarkers were sequentially measured using a Luminex platform or ELISA, and categorized into five pathophysiological domains: systemic inflammation, endothelial cell activation and dysfunction, coagulation activation, kidney dysfunction, and lung dysfunction. Mixed effects models were used to analyse longitudinal data. Results Of 185 ICU admissions enrolled, 8 were excluded because of existing CKD. Of the remaining 177 patients, 106 patients (59.9%) had AKI within the first 48 h of admission; of these, 76 patients (71.7%) had persistent AKI and 30 patients (28.3%) transient AKI. Patients with persistent AKI more often were obese and had a history of hypertension. A higher disease severity – as determined by the sequential organ failure assessment (SOFA) score - was observed in the persistent AKI group, which was driven by the renal component as the non-renal SOFA score was similar between no-AKI, transient-, and persistent AKI. Sequential protein biomarker analyses revealed that five biomarkers were significantly elevated in persistent-AKI compared to transient-AKI in the first four days, mainly related to inflammation (triggering receptor expressed on myeloid cells-1 [TREM-1], p=.003; tumour necrosis factor receptor 1 [TNF-RI], p &amp;lt; 0.001); lung dysfunction (clara cell secretory protein [CC16], p &amp;lt; 0.001), and kidney dysfunction (Cystatin C [p &amp;lt; 0.001]; neutrophil gelatinase-associated lipocalin [NGAL], p &amp;lt; 0.001). Plasma protein biomarkers reflective of endothelial cell- and coagulation activation were not different in patients with persistent-AKI as compared to patients with transient-AKI. No differences in plasma biomarkers were observed between transient AKI and no-AKI. Conclusion Transient AKI and no-AKI revealed little to no differences, while the persistent AKI group demonstrated stronger host response anomalies across the pathophysiological domains of inflammation and lung dysfunction. In contrast to what has been observed in non-COVID-19-related sepsis, endothelial injury and coagulation activation markers were not associated with AKI trajectories. These findings suggest that COVID-19 can induce a robust immune response that contributes to persistence of AKI, largely mediated through inflammatory responses.

Altered platelet reactivity, coagulation, endothelial and inflammatory markers early after smoking cessation verified with cotinine plasma concentration

Background/Introduction: Cigarette smoking is a potent modifiable risk factor for coronary artery disease (CAD). However, little is known about alterations to prothrombotic state and platelet reactivity early after smoking cessation following percutaneous coronary interventions (PCI). Purpose: We investigated alterations to platelet reactivity, coagulation and markers of platelet, endothelial, inflammatory and coagulation activation in clopidogrel-treated patients with CAD after PCI before and after smoking cessation. Methods: Smoking patients aged 18 years or older at least 30 days after PCI were recruited and encouraged to quit the habit. At baseline and at 30 days, we measured platelet reactivity with VerifyNow system, thrombomodulin, P-selectin, platelet factor 4 (CXCL4/PF4), citrullinated histone H3 (H3cit) and cotinine level. Results: Among 117 patients, 84 patients (72%) at a median age of 60.5 years (40 [interquartile range 30–47] pack-years) completed a 30-day follow-up. At day 30, 30 (35.7%) patients stopped smoking with cotinine level < 50 ng/ml. Baseline characteristics were similar in both groups. In smoking quitters a change in platelet reactivity was larger (Δ platelet reactivity units (PRU) 19 [2, 43] vs. -6 [-32, 37], p = 0.018), along with a change in P-selectin concentration (-11.82 [-23.62, 1.34] vs. 7.19 [-14.24, 17.19] ng/ml, p = 0.005). Positive correlations was noticed between cotinine and both P-selectin ( r = 0.23, p = 0.045) and CXCL4 (r = 0.27, p = 0.02). Conclusion: After smoking cessation in CAD patients following PCI an increase in platelet reactivity and a decrease in P-selectin levels were observed. The risk of thrombotic complications post PCI might be paradoxically enhanced among patients who stopped smoking.

Prevalence of Polymorphisms of Genes Responsible for Coagulation System and Folate Metabolism and Their Predictive Value for Thrombosis Development in MINOCA Patients: Immediate and Long-Term Prognoses

(1) Background. One of the causes of myocardial infarction (MI) with nonobstructive coronary arteries (MINOCA) is thrombus formation in situ followed by lysis, resulting in a morphologically normal angiogram but with an underlying prothrombotic state that is potentially predisposed to recurrence. Recent studies have shown that a subset of MINOCA patients may have thrombophilic conditions at screening. Objective: To compare the prothrombotic trend in MINOCA patients with that of subjects with MI and obstructive coronary arteries (MIOCA) by testing for known congenital thrombophilias and markers of coagulation activation. (2) Materials and methods. Screening included congenital thrombophilias (factor V Leiden; assessment of protein C, protein S, and antithrombin III) and eight genes. Of these, four genes represented the folate pathway enzymes: MTHFR 677 C&gt;T (rs1801133), MTHFR 1298 A&gt;C (rs1801131), MTR 2756 A&gt;G (rs1805087), and MTRR 66 A&gt;G (rs1801394). The other four genes represented the blood coagulation system: F13 (163 G&gt;T) rs5985, F1 (−455 G&gt;A) rs1800790, GP IIb–IIIa (1565 T&gt;C) rs5918, and PAI-I (−675 5G&gt;4G) rs1799889. Additionally, we examined the levels of homocysteine and lipoprotein (LP) (a). (3) Results. Our study included 269 patients: 114 MINOCA patients and 155 MIOCA patients with lesions of one coronary artery. The frequencies of polymorphisms in the genes of the blood coagulation system and the folate pathway did not differ between the groups. The following genes were associated with in-hospital mortality in the MINOCA group: MTHFR 1298 A&gt;C rs1801131 (OR 8.5; 95% CI 1.67–43.1) and F1 (−455 G&gt;A) rs1800790 (OR 5.8; 95% CI 1.1–27.8). In the MIOCA group, the following genes were associated with in-hospital mortality: MTHFR 1298 A&gt;C rs1801131 (OR 9.1; 95% CI 2.8–28.9), F1 (−455 G&gt;A) rs1800790 (OR 11.4; 95% CI 3.6–35.9), GP IIb–IIIa (1565 T&gt;C) rs5918 (OR 10.5; 95% CI 3.5–30.8), and PAI-I (−675 5G&gt;4G) rs1799889 (OR 12.9; 95% CI 4.2–39.7). We evaluated long-term outcomes (case fatality rate, recurrent MI, and stroke) over a period of 12 months in both groups. The variables associated with these outcomes were laboratory parameters, such as protein C deficiency, hyperhomocysteinemia, and a content of LP (a) &gt; 30 mg/dL. However, we did not reveal the prognostic value of polymorphisms of the studied genes representing the blood coagulation system and the folate pathway. (4) Conclusion. We established no statistically significant differences between the MINOCA and MIOCA groups in the prevalence of congenital thrombophilias and the prevalence of folate pathway enzyme genes and blood coagulation system genes. The MTHFR 1298 A&gt;C (rs1801131) and F1 (−455 G&gt;A) rs1800790 genes were associated with in-hospital mortality in both groups. More significant prognostic factors in both groups during the one-year period were protein C deficiency, hyperhomocysteinemia, and LP (a) &gt; 30 mg/dL.

Absence of Malaria-Associated Coagulopathy in Asymptomatic Plasmodium falciparum Infection: Results From a Cross-sectional Study in the Ashanti Region, Ghana.

Coagulopathy is common in acute symptomatic Plasmodium falciparum malaria, and the degree of coagulation abnormality correlates with parasitemia and disease severity. Chronic asymptomatic malaria has been associated with increased morbidity. However, the role of coagulation activation in asymptomatic, semi-immune individuals remains unclear. This study investigates the potential effect of asymptomatic P falciparum infection on coagulation activation in semi-immune Ghanaian adults. Blood from asymptomatic Ghanaian adults with P falciparum blood stage infection detectable by polymerase chain reaction (PCR) or by both PCR and rapid diagnostic test and from noninfected individuals, was investigated. Markers of coagulation activation including global coagulation tests, D-dimer, antithrombin III, fibrinogen, and von Willebrand factor antigen were tested. Furthermore, blood count, inflammation markers, and liver and kidney function tests were assessed. Acquired coagulopathy was not found in asymptomatic P falciparum infection. Asymptomatic malaria was associated with significantly lower platelet counts. Systemic inflammation markers and liver and kidney function tests were not altered compared to noninfected controls. There is no laboratory evidence for acquired coagulopathy in adults with asymptomatic P falciparum malaria in highly endemic regions. Lack of laboratory evidence for systemic inflammation and liver and kidney dysfunction indicates that asymptomatic malaria may not be associated with significant morbidity.

Association of heme-oxygenase 1, hemopexin, and heme levels with markers of disease severity in COVID-19.

Heme-oxygenase 1 (HO-1) is an enzyme with well-known anti-inflammatory and antioxidant properties, whose levels have been previously associated with disease severity in the context of sterile and infectious diseases. Moreover, the heme/HO-1 pathway has been associated with prothrombotic changes in other diseases. Accordingly, the potential of modulating HO-1 levels for the treatment of COVID-19 was extensively speculated during the COVID-19 pandemic, but very few actual data were generated. The aim of our study was to explore the association of HO-1, heme, and hemopexin (HPX) levels with COVID-19 severity and with markers of inflammation and coagulation activation. The study was conducted in 30 consecutive patients with COVID-19 admitted due to hypoxemia, and 30 healthy volunteers matched by sex, age, and geographic region. HO-1 and HPX levels were measured by enzyme immunoassay (ELISA) and heme levels were measured by a colorimetric method. A comprehensive panel of coagulation and fibrinolysis activation was also used. Patients with COVID-19 presented increased levels of HO-1 when compared to controls (5741 ± 2696 vs 1953 ± 612 pg/mL, respectively, P < 0.0001), as well as a trend toward increased levels of HPX (3.724 ± 0.880 vs 3.254 ± 1.022 mg/mL, respectively; P = 0.06). In addition, HO-1 and HPX levels reduced from admission to day + 4. HO-1 levels were associated with duration of intensive care unit stay and with several markers of coagulation activation. In conclusion, modulation of HO-1 could be associated with the prothrombotic state observed in COVID-19, and HO-1 could also represent a relevant biomarker for COVID-19. New independent studies are warranted to explore and expand these findings.

Abstract WP178: Markers Of Coagulation And Hemostatic Activation Predict Occult Malignancy In Cryptogenic Stroke Patients

Introduction: One potential cause of embolic strokes of undetermined source (ESUS) is occult malignancy. The objective of the study was to evaluate the frequency of and potential predictors of occult malignancy among ESUS patients. Methods: Consecutive ESUS patients seen at a single institution from May 1, 2017 to March 1, 2021 were included in this analysis. Patients with occult malignancy were defined as those who had newly diagnosed malignancy within one year of index stroke. We evaluated demographics, blood biomarkers and imaging to identify predictors of occult malignancy diagnosis after ESUS. Results: Of 365 patients [Median age: 66 (IQR 53-75), female 60%), non-White 52%], 35 (9.6%) had a history of malignancy before the index stroke and 8 (2.5%) were diagnosed with occult malignancy within 12 months of index stroke. Occult malignancies included colorectal cancer (4), blood cancer (3), and bladder cancer. Stage 4 malignancy was found in 1 (13%) patient diagnosed with occult malignancy. Elevation in ≥2 markers of coagulation and hemostatic activation (MOCHA) (d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex, fibrin monomer) was significantly more frequent in occult malignancy versus other patients (88% vs 42%, Fisher exact p=0.023, OR=9.6 95%CI 1.2-79, p=0.035). MOCHA elevation in ≥2 markers for the detection of occult cancer had sensitivity 87.5%, specificity 57.9%, PPV 4.7%, NPV 99.5%. Conclusions: Hematologic markers such as MOCHA may be potentially useful to identify patients more likely to have underlying malignancy after ESUS. MOCHA abnormalities in &lt;2 markers effectively rules out occult malignancy as the cause of ESUS.

Markers of coagulation and inflammation and adverse events in patients with active cancer and atherosclerosis: common features and differences

Introduction. Thrombotic complications (TC) in different vascular systems dictate the fate of high-risk patients. In cardiological practice, patients with advanced atherosclerotic vascular disease (MFA) represent the most vulnerable group. Malignant neoplasm (MN) is one of the most significant risk factors for developing TCs, especially in the context of antineoplastic therapy. The presence of significant differences in the mechanisms of thrombogenesis in malignant neoplasms and atherosclerosis determines the appropriateness of a comparative study of markers of coagulation activation and endothelial damage in order to identify common features and differences specific to each pathology. Aim. To examine markers of coagulation activation and growth factors in active cancer and advanced atherosclerotic vascular disease, to identify their common features and differences specific to each pathology. Materials and methods. A total of 22 patients with MN (Group 1) and 58 patients with MFA (Group 2) were enrolled in the study. The assessed biomarkers included: von Willebrand factor (VWF), D-dimer, growth differentiation factor-15 (GDF-15) and vascular endothelial growth factor A (VEGF-A). Results. Patients with MN had an increased likelihood of disease progression within 6 months at D-dimer level &gt; 1121 ng/mL (OR = 10.5; 95% CI 1.4–81.0, p = 0.014) or VWF &gt; 189% (OR 10.5, 95% CI 1.36–81.0, p = 0.014); the likelihood of death within two years of follow-up at D-dimer level &gt; 1121 ng/mL (OR = 7.0; 95% CI 0.97–50.57, p = 0.04), or VWF &gt; 203% (OR = 10, 5, 95% CI 1.36–81.06, p = 0.014). In patients with MFA, the likelihood of prognosis determining events within one-year of follow-up was determined by increased levels of VWF &gt; 157% (OR = 9.2, 95% CI 1.02–82.8, p = 0.048) and GDF-15 &gt; 1548 pg/ml (OR = 5.7; 95% CI 1.09–29.5, p = 0.04). Conclusions. Endothelial damage and coagulation activation are more pronounced in patients with MN than in patients with MFA. In patients with malignant neoplasms, the outcomes were associated with D-dimer and VWF levels, and in patients with MFA – with VWF and GDF-15 levels.

High fragmentation in platelet concentrates impacts the activation, procoagulant, and aggregatory capacity of platelets

Platelets are transfused to patients to prevent bleeding. Since both preparation and storage can impact the hemostatic functions of platelets, we studied platelet concentrates (PCs) with different initial composition in regard to platelet fragmentation and its impact on storage-induced changes in activation potential. Ten whole blood derived PCs were assessed over 7 storage days. Using flow cytometry, platelet (CD41+) subpopulations were characterized for activation potential using activation markers (PAC-1, P-selectin, and LAMP-1), phosphatidylserine (Annexin V), and mitochondrial integrity (DiIC1(5)). Aggregation response, coagulation, and soluble activation markers (cytokines and sGPVI) were also measured. Of the CD41+ events, the PCs contained a median of 82% normal-sized platelets, 10% small platelets, and 8% fragments. The small platelets exhibited procoagulant hallmarks (increased P-selectin and Annexin V and reduced DiIC1(5)). Normal-sized platelets responded to activation, whereas activation potential was decreased for small and abolished for fragments. Five PCs contained a high proportion of small platelets and fragments (median of 28% of CD41+ events), which was significantly higher than the other five PCs (median of 9%). A high proportion of small platelets and fragments was associated with procoagulant hallmarks and decreased activation potential, but, although diminished, they still retained some activation potential throughout 7 days storage.