Recombinant Thrombomodulin Research Articles

Assessment of bleeding in patients with disseminated intravascular coagulation after receiving surgery and recombinant human soluble thrombomodulin: A cohort study using a database.

We aimed to investigate the incidence of bleeding-related adverse events (AEs) among patients with disseminated intravascular coagulation (DIC) receiving recombinant thrombomodulin (rTM) and those receiving other DIC treatments, the incidence by type of surgery, and the incidence when either blood transfusion or a hemostatic procedure was administered to treat DIC. In this cohort study, data were obtained from a large medical database (22 centers in Japan). The primary endpoint was the incidence rate of bleeding-related AEs by type of surgery. The secondary endpoint was the incidence rate of bleeding-related AEs based on whether blood transfusion or a hemostatic procedure was administered after the day of DIC treatment. In total, 4234 propensity score-matched patients were included in the main analysis (2117 patients each in the rTM and non-rTM groups). In the rTM and non-rTM groups, respectively, the incidence of bleeding-related AEs was 18.8% and 24.8% (p <0.001; risk ratio [RR] 0.757, 95% confidence interval [CI] 0.674–0.849), among patients requiring any type of surgery; 15.0% and 19.5% (p = 0.0001; RR 0.769, 95% CI 0.673–0.879) in patients requiring blood transfusion or a hemostatic procedure after the day of DIC treatment; 10.2% and 11.6% (p = 0.4470; RR 0.879, 95% CI 0.630–1.226) in patients undergoing hepatic, biliary, or pancreatic surgery; 24.3% and 25.4% (p = 0.6439; RR 0.955, 95% CI 0.786–1.160) in patients undergoing gastrointestinal surgeries; and 18.5% and 30.1% (p = 0.0001; RR 0.614, 95% CI 0.481–0.782) in patients undergoing cardiac or cardiovascular surgery. Our findings suggest that rTM treatment for Japanese postsurgical patients who develop DIC was associated with significantly fewer bleeding-related AEs compared with those receiving other DIC treatments.

Disseminated Intravascular Coagulation: An Update on Pathogenesis, Diagnosis, and Therapeutic Strategies.

Disseminated intravascular coagulation (DIC) is an acquired clinicobiological syndrome characterized by widespread activation of coagulation leading to fibrin deposition in the vasculature, organ dysfunction, consumption of clotting factors and platelets, and life-threatening hemorrhage. Disseminated intravascular coagulation is provoked by several underlying disorders (sepsis, cancer, trauma, and pregnancy complicated with eclampsia or other calamities). Treatment of the underlying disease and elimination of the trigger mechanism are the cornerstone therapeutic approaches. Therapeutic strategies specific for DIC aim to control activation of blood coagulation and bleeding risk. The clinical trials using DIC as entry criterion are limited. Large randomized, phase III clinical trials have investigated the efficacy of antithrombin (AT), activated protein C (APC), tissue factor pathway inhibitor (TFPI), and thrombomodulin (TM) in patients with sepsis, but the diagnosis of DIC was not part of the inclusion criteria. Treatment with APC reduced 28-day mortality of patients with severe sepsis, including patients retrospectively assigned to a subgroup with sepsis-associated DIC. Treatment with APC did not have any positive effects in other patient groups. The APC treatment increased the bleeding risk in patients with sepsis, which led to the withdrawal of this drug from the market. Treatment with AT failed to reduce 28-day mortality in patients with severe sepsis, but a retrospective subgroup analysis suggested possible efficacy in patients with DIC. Clinical studies with recombinant TFPI or TM have been carried out showing promising results. The efficacy and safety of other anticoagulants (ie, unfractionated heparin, low-molecular-weight heparin) or transfusion of platelet concentrates or clotting factor concentrates have not been objectively assessed.

599P - Efficacy and safety of a recombinant soluble human thrombomodulin (ART-123) in preventing oxaliplatin induced peripheral neuropathy (OIPN): Results of a placebo-controlled, randomized, double-blind phase II study

599P - Efficacy and safety of a recombinant soluble human thrombomodulin (ART-123) in preventing oxaliplatin induced peripheral neuropathy (OIPN): Results of a placebo-controlled, randomized, double-blind phase II study

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.

術前に確定診断困難であった感染性肝嚢胞穿孔による汎発性腹膜炎の1例(A case of generalized peritonitis caused by infected liver cyst perforation which was difficult to definitive diagnose before surgery)

感染性肝嚢胞はしばしば症例報告され経皮的ドレナージの対象となるが，感染性肝嚢胞穿孔は極めて稀な疾患である。今回我々は，術前に診断困難であった感染性肝嚢胞穿孔により汎発性腹膜炎を来した1例を経験したため報告する。症例は86歳の男性。既往に肝S2に嚢胞の指摘あり。胆嚢炎，胆管炎で1か月の入院歴があり，内視鏡的乳頭切開術および抗菌薬治療で改善し退院となっていたが，退院当日夜間より39℃の発熱があり，改善に乏しいため再入院となった。CTで胆嚢腫大，壁肥厚があることと胆管炎を否定できないことから，内視鏡的胆嚢・胆管ドレナージを施行し抗菌薬投与を開始した。既知の肝嚢胞は壁の造影効果に乏しく感染は否定的であった。解熱傾向にあったが，入院4日目に40℃の発熱と腹膜刺激徴候を認め緊急手術を行った。手術所見として，既知の肝嚢胞に穿孔を来し膿汁流出を認め，嚢胞開窓ドレナージ術および胆嚢摘出術を施行した。術中よりショック状態であり集中治療管理を要するも，術後経過は良好であり術後37日目に自宅退院した。胆道系感染からの逆行性感染により既知の肝嚢胞に感染を来し穿孔したものと考えられたが，術前診断は困難であった。しばしば診断確定困難な急性腹症が散見され低侵襲治療が試みられるが，腹部所見を手がかりにして手術のタイミングを逃してはならない。 Infected liver cysts are often reported in cases and are treated by percutaneous drainage. However, infected liver cyst perforation occurs very rarely. Herein, we report a case of peritonitis caused by perforation of an infected liver cyst that was difficult to diagnose before surgery. The patient was an 86–year–old man with a cyst in liver S2. He had a history of hospitalization for 1 month with cholecystitis and cholangitis. Although he was discharged from hospital, he had a fever of 39℃ on the night of discharge. Therefore, he was re–hospitalized. Endoscopic gall bladder/bile duct drainage was performed and antibiotic drug administration was initiated. While there was a tendency towards fever, he ultimately developed a fever of 40℃ and signs of peritoneal irritation on the fourth day of hospitalization, which required an emergency operation. Perforation and pus were observed in the known liver cyst, and cyst open fenestration drainage and cholecystectomy were performed. The postoperative course was good and the patient was discharged from hospital on the 37th postoperative day. Often acute abdominal disease, which is hard to diagnose, is only found incidentally. However, we should not miss the clues from abdominal findings that lead to surgery. 肝嚢胞はcomputed tomography（以下CT），腹部超音波検査で発見されるありふれた病変であり，ときに感染を併発し治療を要するが感染性肝嚢胞穿孔は極めて稀な疾患である。我々は，肝嚢胞感染から穿孔および汎発性腹膜炎を呈し緊急手術を要した稀な1例を経験したため報告する。 なお，本研究はHelsinki人権宣言に基づいており，所属施設の倫理委員会の承認を得ている。また個人情報保護に基づき匿名化をしている。 患 者：86歳の男性 主 訴：全身倦怠感，食欲不振 現病歴：7日前からの発熱，全身倦怠感が改善せず，食事摂取困難となり当院受診。 既往歴：発作性心房細動，慢性腎不全，肝嚢胞（S2），急性胆管炎 来院時現症：意識清明。血圧71/52mmHg，脈拍80bpm，呼吸数16/分，SpO2 98%（room air），体温38.9℃であった。身体診察では腹部を含め有意な異常所見を認めなかった。 血液検査では，WBC 15,400/μL，CRP 20.86mg/dLと炎症値の上昇，BUN 53.0mg/dL，Cre 2.19mg/dLと腎機能の増悪，T–Bil 2.9mg/dLと上昇を認めるもその他の肝胆道系酵素の上昇は認めなかった。尿培養は陰性，血液培養は1/4本でEscherichia coliが陽性であった。胸腹部CT，magnetic resonance cholangiopancreatography（以下MRCP）で胆嚢腫大およびび漫性の総胆管拡張を認めたため，endoscopic retrograde cholangiopancreatography（以下ERCP）を施行したが造影欠損は認めず，傍乳頭憩室による生理的変化と判断した（Fig. 1a, b）。乳頭炎の可能性は否定できず悪性腫瘍の関与も懸念されたことから，endoscopic sphincterotomy（EST）および生検を施行したが悪性所見は認めなかった。絶食，meropenem（以下MEPM）による抗菌薬治療で速やかに解熱，炎症値の低下が得られ，経過中出血性十二指腸潰瘍合併などがあり入院が長期化したものの第37病日に独歩退院となった。しかし，退院当日夜間より39℃の発熱を認め改善に乏しく退院後4日目に当院再受診した。 (a) MRCP recognized diffuse biliary dilatation. (b) ERCP recognized diffuse biliary dilatation but did not recognize image of contrast defect. (c) Pneumobillia considered to be a change after EST is admitted. (d) Accepted gallbladder swelling and surrounding fluid accumulation. (e) No contrast effect of liver cyst wall was recognized. (f) Endoscopic gallbladder biliary duct drainage was performed. 来院時血圧83/54mmHg，脈拍130bpmで心房細動，呼吸数18/分，SpO2 98%（room air），体温37.5℃であった。身体診察では心窩部に軽度圧痛を認めるのみであった。 血液検査では，WBC 13,900/μL，CRP 16.43mg/dLと炎症値の上昇，BUN 39.0mg/dL，Cre 1.21g/dLと腎機能の増悪，肝胆道系酵素はT–Bil 1.4mg/dL，ALP 411IU/Lと上昇を認める以外は正常であった。 CTではEST後の変化と思われるpneumobilliaおよび胆嚢腫大を認めた（Fig. 1c, d）が，肝嚢胞壁の造影効果は認めなかった（Fig. 1e）。胆道系感染と判断したが腹部所見に乏しく，手術などより低侵襲であるERCPによる胆嚢・胆管内瘻化ドレナージを行った（Fig. 1f）。胆汁培養ではEscherichia coli，Enterococcus faeciumが検出された。絶食，MEPM投与で熱型，炎症値ともに改善傾向にあったが，第4病日に再度39.8℃まで発熱し，心窩部痛の増悪と腹壁全体の緊張を伴う腹膜刺激徴候を呈した。頻呼吸および発熱からやや不穏，SIRSを呈しqSOFA スコアは2点，SOFAスコアは1点であった。血液検査ではWBC 11,300/μL，CRP 10.83mg/dLと炎症値の増悪は認めなかったが，日本止血血栓止血学会DIC診断基準2017年版感染症型で5点とDICを呈していた（Table 1）。CT上多量の腹水の出現および既知の肝嚢胞に壁の造影効果を認めた（Fig. 2a, b）。感染性肝嚢胞が疑われたが，汎発性腹膜炎を呈していたため緊急手術を行ったところ，腹腔内に大量の混濁した腹水を認めた。胆嚢は肉眼的な炎症所見には乏しかったが，胆汁培養から細菌検出があり摘出，また肝S2の嚢胞にpin hole上の穿孔所見と膿汁流出を認め（Fig. 2c），嚢胞開窓術，洗浄ドレナージ術を施行した。手術時間は3時間42分，出血量は140mL，腹水および膿汁培養からは細菌検出は認めなかったものの膿汁中白血球は強陽性であった。術中より平均動脈圧65mmHgの維持にノルアドレナリン0.06γ，ドーパミン5γ投与を要するショック状態であったが，lactateは2mmol/Lを超えることなく推移し敗血症よりも循環血液量減少性ショックの要素が強かった。術後人工呼吸器管理，昇圧薬投与，アンチトロンビンIII製剤，トロンボモジュリン製剤の使用，ヒドロコルチゾン200mg/日使用など集中治療を要した（Fig. 3）が第37病日に独歩退院となった。 (a) Contrast effect of liver cyst wall was recognized. (b) A large amount of ascites appeared. (c) Liver cyst was infected and perforated. (d) Contrast agent reflux from the duodenum to the common bile duct. Clinical course of the patient. NAD: noradrenalin, AT III: antithrombin III, rTM: recombinant thrombomodulin, MEPM: meropenem, VCM: vancomycin, LVFX: levofloxacin, MBP: mean blood pressure 退院後経過は良好も，上部消化管造影で十二指腸から総胆管への逆流所見を認め（Fig. 2d）乳頭機能不全もしくはESTにより逆流を招いた可能性が示唆された。 肝嚢胞は日常診療においてよく遭遇する病変であるが治療を必要とする頻度は高くない 1。嚢胞の巨大化による圧迫症状や，嚢胞の細菌感染や出血を合併すれば治療対象となるが，感染性肝嚢胞の本邦報告例は100例に満たず 2, 3比較的稀な病態である。感染性肝嚢胞の臨床像として，肝膿瘍が左葉に生じることが稀であるのに対し，比較的均等に右葉，左葉に認めることおよび感染例の多くが5cm以上の嚢胞であることが報告されている 4。治療として経皮的ドレナージ術が試みられる報告が多く 5手術加療を要する例は少ないものの，経皮的ドレナージ術困難，ドレナージ後の再燃，感染コントロール不良を理由に手術施行となった報告が散見される 6, 7, 8。また細菌性肝膿瘍が穿孔し手術を要した報告も認める 9が，本症例のように感染性肝嚢胞が穿孔し手術となった例は検索し得る限り報告がなく，極めて稀な例であるといえる。細菌性肝膿瘍での穿孔頻度は7.1～15.1% 10，肝膿瘍全体での腹腔内への穿孔頻度は1.8% 11と報告されており，感染性肝嚢胞穿孔となるとそれ以下の頻度であると考えられる。 肝嚢胞への感染経路として胆道系が多いと言われており 12，本症例も再入院時胆汁培養から細菌が検出され，先行する胆道系感染から逆行性に嚢胞内感染を来したものと考えられた。嚢胞内感染では超音波検査で嚢胞内容物のエコー輝度増加など画像変化が生じることは知られているが，その変化は１か月程度遅れてから認める例もあり早期診断は困難である 13。CT上の嚢胞壁造影効果についても，感染性肝嚢胞の60%程度にしか認めないという報告があり画像上の確定診断は困難である 14。本症例でも再入院時CTでは，肝嚢胞壁の造影効果は乏しくこの時点で嚢胞内感染を起こしていたかは不明であった。また，手術前CTでも後方視的に読影すれば嚢胞壁の造影効果を認めるように観察されるものの確定できるほどの所見とはいえず，少なくとも穿孔を予測することは困難であった。穿孔後の画像変化に関しては稀な例であり，有用な報告がなく，多量の膿汁流出を伴えば嚢胞サイズの縮小を認めることが考えられるが，本症例ではpin hole上の穿孔で流出膿汁も少なく嚢胞サイズの変化は明らかでなかった。感染性肝嚢胞と診断し得たとしても穿孔を来しており，経皮的ドレナージ術では治癒し得ず手術加療の選択は妥当であったと考える。 本症例では膿汁培養から白血球が強陽性であったものの細菌検出は認めなかった。感染性肝嚢胞では，嚢胞内容の培養検査に先駆けて抗菌薬が投与される例がほとんどであり，40%の例で起炎菌が陰性になることが報告されている 2。本症例においても膿汁培養提出3日前より抗菌薬投与がなされており細菌検出を認めなかったのであろう。胆道系からの逆行性感染と考えられる例であり，起炎菌は入院時胆汁培養から検出されたEscherichia coli，Enterococcus faeciumと推察される。 内視鏡的治療や経皮的ドレナージの発達に伴い肝胆道系感染に対する手術機会は著しく減少している。CTなど画像診断の発達に伴い診断確定困難な急性腹症も減少し，診断未確定で手術加療を選択することはしばしばためらわれる。しかし，本症例のように術前確定診断困難ながら手術加療を要する例は確実に存在し，手術のタイミングを逃さないためにも丁寧な腹部診察と腹部所見に基づく手術選択の決断力が腹部救急に携わる医師には求められる。 本症例は感染性肝嚢胞穿孔という稀な疾患であり術前診断は困難であった。しばしば確定診断困難な急性腹症が散見され低侵襲治療から加療が試みられるが，腹部所見を手がかりにして手術のタイミングを逃してはならない。 本論文の要旨は，第45回日本救急医学会総会・学術集会（大阪）で発表した。 本研究に対して企業・組織または団体からの資金提供はなく，著者全員に発表内容に関係する企業・組織に関して利益相反はない。

The efficacy and safety of recombinant thrombomodulin on severe urinary tract infection induced disseminated intravascular coagulation; a retrospective comparative study

The efficacy and safety of recombinant thrombomodulin on severe urinary tract infection induced disseminated intravascular coagulation; a retrospective comparative study

Prophylactic recombinant thrombomodulin treatment prevents hepatic sinusoidal obstruction syndrome in high-risk pediatric patients that undergo hematopoietic stem cell transplants.

Hepatic SOS is a potentially life-threatening complication of conditioning for allogeneic HSCT. rTM is a new drug for treating DIC. We report our experience of the use of rTM as a prophylaxis against SOS in high-risk pediatric patients that underwent HSCT. We evaluated the cases of 19 pediatric hematology and oncology patients who underwent HSCT at our institution between 2007 and 2016. The patients who received HSCT after 2012 (n=8) were treated with rTM as a prophylaxis against SOS together with UDCA and LMWH, whereas the others (n=11) were only treated with UDCA and LMWH. Although SOS occurred by post-HSCT day 35 in 3 (27%) patients in the control group, SOS was not seen in the rTM group. Two of the former three patients suffered severe SOS, and one died of the condition. The mean peak level of PAI-1 (a marker of endothelial damage) was significantly lower in the rTM group. rTM appears to be a safe prophylaxis for SOS. The present findings suggest that prophylactic rTM after HSCT might help to prevent SOS.

Recombinant Thrombomodulin Alpha Protects Kidney Graft from Damage after Long Cold Ischemia Time in a Rat Kidney Transplant Model

Objectives Thrombomodulin (TM) extensively expresses on the endothelial cells in the steady state and is known to prevent hypercoagulation via combining with thrombin and inactivating its procoagulant activity. TM also has anti-inflammatory effects. In inflammatory situation including ischemia reperfusion injury TM is known to decrease its expression on the endothelial cells. The purpose of this study is to investigate whether perfusate solution saturated with recombinant TM alpha (rTM) can protect the kidney grafts from the damage after long cold ischemia time. Methods We employed a rat syngeneic kidney transplant model using Lewis strain. Donor kidney grafts were preserved in a cold UW perfusate solution saturated with rTM (Group A, n=7), or not (Group B, n=8) for 24 hours. Then kidney transplantation (Lewis to Lewis) was performed. Blood and urine samples were sequentially collected (post operative day 1, 2, and 7) to measure creatinine clearance. Neutrophil gelatinase-associated lipocalin (NGAL), an acute kidney injury marker, was also measured by ELISA. Kidney graft samples in an acute phase (2 hours after operation) were collected to investigate the grade of tubular damage. TUNEL assay by immunofluorescence was performed. Immunohistochemistry (IHC) for TM was also performed. Results IHC revealed that the expression of TM on kidney grafts after 24-hour cold ischemia was extensively reduced compared with those after 0-hour ischemia. Creatinine clearance (ml/min/kg) in Group A was significantly ameliorated compared with that in Group B: mean (SD), 95% CI of Group A vs Group B; 0.68 (0.33), 0.41-0.96 vs 0.23 (0.13), 0.11-0.35 on POD 1; 1.22 (0.40), 0.86-1.59 vs 0.59 (0.30), 0.31-0.86 on POD 2; and 2.63 (1.41), 1.45-3.81 vs 1.17 (0.69), 0.47-1.87 on POD 7; p=0.02, two-way repeated measured ANOVA. Furthermore, serum levels of NGAL (mg/ml) in Group A were significantly lower than those in Group B: mean (SD), 95% CI of Group A vs Group B; 6.5 (1.7), 0.70-4.71 vs 9.1 (1.1), 7.8-10.4 on POD 1; and 4.3 (2.7), 1.5-7.1 vs 8.9 (1.8), 6.6-11.1 on POD 2; p=0.021, two-way repeated measured ANOVA. Fewer damaged tubular cells and apoptosis positive cells at a very acute phase were observed in Group A (Figure 1), compared with in Group B (Figure 2). Conclusion Perfusion with rTM significantly attenuates kidney graft damage after long cold ischemia time by abrogating apoptosis in tubular cells

781 - Clinical Impact of Recombinant Soluble Thrombomodulin for Disseminated Intravascular Coagulation Associated with Severe Acute Cholangitis

781 - Clinical Impact of Recombinant Soluble Thrombomodulin for Disseminated Intravascular Coagulation Associated with Severe Acute Cholangitis

Effect of double-filtration plasmapheresis for antibody-mediated rejection on hemostasis parameters and thrombin generation

IntroductionDonor-specific alloantibodies (DSAs) cause kidney-allograft loss in chronic antibody-mediated rejection (CAMR). Treatment relies on blocking antibody-producing cells and removing DSAs by apheresis: e.g., double-filtration plasmapheresis (DFPP). Materials and methodsTo determine the impact of DFPP (6 or 8 sessions/patient) on clotting factors and natural anticoagulants, and on thrombin generation, we performed a prospective and observational study in five CAMR kidney-transplant patients who received DFPP plus rituximab therapy. Thrombin generation was performed in poor platelet plasma (PPP) with 5 pM tissue factor without and with 2 nM recombinant human thrombomodulin. ResultsAfter the first DFPP session, median levels of high molecular-weight proteins (fibrinogen, FV, FVIII, FXI, FXIII, von Willebrand factors and α2-MG) decreased significantly to <50% of baseline values, whereas levels of low molecular-weight factors (<100 kDa) were not significantly modified, except for protein S and TFPI. Of note, binding-protein (BP) S, i.e., C4BP, was significantly decreased. Over the course of successive DFPP sessions, both high and lower molecular-weight proteins (<100 kDa) with longer half-lives (>2 days, prothrombin and factor XII) were significantly decreased. DFPP also highly affected thrombin generation in the absence of thrombomodulin but not significantly in the presence of thrombomodulin. After the first DFPP session, mean endogenous thrombin potential (ETP) and peak thrombin (PH) significantly decreased when the thrombin generation assay was performed without thrombomodulin (respectively, 1084 nM·min for ETP and 210 nM for PH after the first DFPP session compared to 1616 nM·min and 264 nM at baseline). In the presence of thrombomodulin, there was only a slight decrease in ETP and PH (respectively 748 nM·min, and 172 nM after the first DFPP session compared to 822 nM·min and 179 nM at baseline). After the last session, median ETP and PH decreased respectively to 646 nM·min and 143 nM without thrombomodulin, and, to 490 nM·min and 117 nM with thrombomodulin. ConclusionsDFPP significantly removed high molecular-weight proteins from the haemostatic system and profoundly decreased levels of protein S and TFPI. Overall thrombin-generation balance was only moderately affected in the presence of thrombomodulin. Nevertheless, high depletion of fibrinogen, FXIII and Von Willebrand Factor may expose patients to an increased risk of bleeding.

Differentiation of the anti‐coagulant effects of Activated Protein C and Recombinant Thrombomodulin as studied in whole blood and retrieved plasma

IntroductionActivated protein C (APC) mediates its anti‐coagulant effects by digesting Factor Va &amp; Factor VIIa, whereas recombinant thrombomodulin (rTM) produces its effects by complexing with thrombin and mediating the formation of APC. Both agents have been developed for clinical indications such as Sepsis associated coagulopathy. The purpose of this study is to compare the anti‐coagulant effects of these two agents in deidentified patients whole blood and retrieved plasma.Materials &amp; MethodRecombinant thrombomodulin (recomodulin) was obtained from Asahi kasei Tokyo, Japan. Plasma derived activated protein C was obtained from Hematologic technologies, Burlington Vermont, USA. Both agents were supplemented in 39 individual citrated whole blood collected from patient from clinical coagulation laboratories at a concentration of 2.5ug/ml. Whole blood was analyzed for PT and aPTT on a ST4 instrument (Stago Paris, France). Whole blood was centrifuge at 2500 g to contained plasma samples, which was analyzed for PT &amp; aPTT. Saline supplemented individual blood samples were used as control. Individual blood and plasma results were compiled as group Mean ± SD and Percent change levels were calculated.ResultsIn the whole blood studies, rTM produced a modest increase in the PT assay (2%), in contrast to APC which produced stronger response (36%). In the aPTT assay both agents produced stronger effects, rTM produced a 36% increase whereas APC produced a much stronger increase amounting to 172%. In retrieved plasma rTM produced slight increase in PT assay (2%) while APC produced strong response (20%). In the aPTT assay rTM produced strong effects with 13% however APC produced much stronger effects about 198%. These results were given in Table.ConclusionThese results indicates that APC is a stronger anti‐coagulant then the rTM in both the whole blood and plasma system as measured by the PT and aPTT. Both agents produced stronger anti‐coagulant effects in the aPTT assay suggesting that the intrinsic coagulation pathway is strongly inhibited by these agents in comparison to the extrinsic pathway.This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Plasma Fibrinogen and D-dimer in Children With Sepsis: A Single-center Experience

In sepsis, enhanced fibrin formation, impaired fibrin degradation, and intravascular fibrin deposition lead to a prothrombotic state. The current study aimed at measuring various coagulation parameters to predict an early marker for disseminated intravascular coagulation(DIC). The current prospective study was conducted from January 2012 to April 2013 on 50 children aged 1-10 years with clinically suspected sepsis referred to the Department of Pediatrics of a tertiary care center in New Delhi, India. Patients were evaluated in accordance with criteria for acute infection (ie, symptoms less than seven days) confirmed in all patients in the laboratory. Patients receiving antibiotics 24-48 hours preceding admission were excluded from the study. Prothrombin time, activated partial thromboplastin time, plasma fibrinogen, and D-dimer were measured at the time of admission in 50 patients and 50 controls. D-dimer was positive in 36 (72%) patients and negative in all controls. The difference was statistically significant (P<0.01). Plasma fibrinogen was significantly (P<0.01) higher in patients compared with the controls. It was decreased in 6% and increased in 8% of the patients, and normal in all controls.PT and APTT were significantly (P<0.01) higher in patients compared with the controls.Though none of the current study patients developed overt disseminated intravascular coagulation, the high positivity for D-dimer suggested that it should be measured in children with sepsis for early identification of DIC. This can aid better management as additional coagulation based therapy such as recombinant anti-thrombin and thrombomodulin may help to improve prognosis.

Recombinant human soluble thrombomodulin as an anticoagulation therapy improves recurrent miscarriage and fetal growth restriction due to placental insufficiency – The leading cause of preeclampsia

IntroductionPlacental insufficiency is one of the major risk factors for growth restriction and preeclampsia. The aim of this study is to investigate whether recombinant human Thrombomodulin(r-TM) improves fetal conditions and physiological outcomes. MethodsWe used CBA/J × BALB/C mice as a control and CBA/J × DBA/2 mice – a well-studied model of recurrent spontaneous miscarriage. Pregnant mice received daily subcutaneous injections of r-TM or saline from day 0–15. The fetal resorption rate, fetal weight, and litter size were calculated at day 15. Additionally, we analyzed the mRNA expression of angiogenic factors and the concentration of soluble Flt-1 (sFlt-1) using the ELISA kit. ResultsThe rate of fetal resorption in CBA/J × DBA/2 mice treated with r-TM was significantly lower compared with mice without r-TM treatment. Additionally, fetal weight and litter size were also significantly higher in the r-TM treated mice. Fibrinogen deposition in the labyrinth area of the CBA/J × DBA/2 mice treated with r-TM was significantly lower compared with deposits in the mice untreated with r-TM. As well, r-TM significantly increased the gene expression level of VEGF and Flt-1 mRNA in the placentas of the CBA/J × DBA/2 mice. r-TM treatment also significantly decreased the production of sFlt-1 protein in the placentas of preeclampsia-like diseased mice. Conclusionr-TM as an anticoagulation therapy has the potential for the medical treatment of recurrent miscarriage and fetal growth restriction due to improved angiogenic factors. Additionally, r-TM treatment has the potential for the recovery of preeclampsia.

Recombinant thrombomodulin ameliorates experimental autoimmune encephalomyelitis by suppressing high mobility group box 1 and inflammatory cytokines.

Recombinant thrombomodulin (rTM) has pleiotrophic properties, including anti-coagulation and anti-inflammation; however, its effectiveness as a treatment for multiple sclerosis (MS) has not been evaluated fully. High mobility group box 1 (HMGB1) and proinflammatory cytokines, working as inflammatory mediators, are reportedly involved in the inflammatory pathogenesis of MS. The aim of this study was to determine whether rTM canbe a potential therapeutic agent for experimental autoimmune encephalomyelitis (EAE). EAE mice received rTM treatment (1 mg or 0·1 mg/kg/day) from days 11 to 15 after immunization. The clinical variables, plasma levels of inflammatory cytokines and HMGB1 and pathological findings in EAE were evaluated. rTM administration ameliorated the clinical and pathological severity of EAE. An immunohistochemical study of the spinal cord showed weaker cytoplasmic HMGB1 staining in the rTM-treated EAE mice than in the untreated EAE mice. Plasma levels of inflammatory cytokines and HMGB1 were suppressed by rTM treatment. In conclusion, rTM down-regulated inflammatory mediators in the peripheral circulation and prevented HMGB1 release from nuclei in the central nervous system, suppressing EAE-related inflammation. rTM could have a novel therapeutic potential for patients with MS.

潜在的脾機能低下が疑われたCapnocytophaga感染症の1例(A case of Capnocytophaga infections with suggestive of splenic dysfunction)

要旨Capnocytophaga canimorsusはイヌやネコの口腔内常在菌で，極めて稀であるが咬傷によりヒトに感染する。症例は58歳の女性。発熱と下痢，嘔吐を主訴に近医を受診し白血球数の著明な低下を指摘され，感染源不明の敗血症疑いとしてメロペネムの投与が開始されたが，その後全身に紫斑を生じ，感染性電撃性紫斑病として当院救命救急センターへ搬送された。来院時APACHE IIスコア 14点，SOFAスコア 8点，急性期DICスコア 8点であった。末梢血でHowell–Jolly小体が認められ，血液スメアでグラム陰性桿菌が検出された。第5病日に患者が飼い犬に頻回に咬まれていたことが判明し，検査結果と併せてCapnocytophaga感染症を疑い，抗菌薬をスルバクタム/アンピシリンとクリンダマイシンに変更した。第6病日に原因菌はCapnocytophaga canimorsusと確定した。播種性血管内凝固症候群（DIC）に対してはトロンボモデュリン製剤の投与と血小板の補充を行った。電撃性紫斑を呈した四肢末端は壊死し切断術が必要な状態となったが，その他の部分は発症前と同程度にまで改善した。本症例は比較的若年の明確な免疫不全既往のない患者に発症し，電撃性紫斑病・DICを合併したCapnocytophaga感染症であり，劇症化には潜在的な脾機能低下の関与が示唆された。

Concomitant Versus Individual Administration of Antithrombin and Thrombomodulin for Sepsis-Induced Disseminated Intravascular Coagulation: A Nationwide Japanese Registry Study

Background:Antithrombin and recombinant human thrombomodulin (rhTM) are individually reported to improve survival in sepsis-induced disseminated intravascular coagulation (DIC). However, continuing controversy exists as to which agent is superior and whether concomitant therapy is superior to individual administration.Methods:This post hoc analysis included adult patients with sepsis-induced DIC from a nationwide multicenter registry database in Japan. We categorized patients into 4 groups: patients who received (1) individual administration of antithrombin, (2) individual administration of rhTM, (3) both, and (4) neither. In-hospital mortality was compared between every 2 groups among the 4 groups by Cox proportional hazards model adjusted with propensity scores.Results:In total, 1432 patients with sepsis-induced DIC were included. Although both antithrombin and rhTM were associated better outcome compared with no anticoagulants, mortality benefits were similar between each individual anticoagulant. Similarly, no significant difference in mortality was detected between individual administrations and concomitant therapy.Conclusion:Antithrombin and rhTM might have comparable efficacy in reducing mortality in patients with sepsis; however, concomitant therapy appeared to offer no additional survival benefit.

Plasma clot formation and clot lysis to compare effects of different anticoagulation treatments on hemostasis in patients with atrial fibrillation

The effect of direct oral anticoagulants (DOACs) on turbidimetric measurements of plasma clot formation and susceptibility to fibrinolysis may facilitate a comparison between different classes of anticoagulants in plasma samples. We obtained 424 citrate plasma samples from 226 atrial fibrillation patients on anticoagulation and 24 samples without anticoagulation serving as controls. As comparators, we measured the international normalized ratio (INR) for phenprocoumon samples (N = 166), anti-Xa for low molecular weight heparin (LMWH) samples (N = 42), and DOAC levels with mass spectrometry (dabigatran N = 40, rivaroxaban N = 110, apixaban N = 42). Plasma clot formation and lysis were recorded continuously on a photometer after addition of an activation mix (tissue factor 2 pmol/l and tissue plasminogen activator 333 ng/ml). We used linear regression and ANCOVA for correlation analysis. Clot formation lag phase was prolonged in the presence of anticoagulants in a concentration-dependent manner for DOACs (dabigatran Spearman r = 0.74; rivaroxaban r = 0.78; apixaban r = 0.72, all p < 0.0001), INR dependent for phenprocoumon (r = 0.59, p < 0.0001), anti-Xa level dependent in LMWH samples (r = 0.90, p < 0.0001). Maximum rate of clot formation and peak clot turbidity were reduced in the presence of anticoagulants, but correlated only moderately with the comparator measures of anticoagulation. The clot lysis time was inversely correlated with DOAC concentrations in the presence of recombinant thrombomodulin. A direct ex vivo comparison between the effects of different classes of anticoagulants is possible with turbidimetric measurement of plasma clot formation and lysis. Anticoagulation inhibited clot formation in a plasma concentration manner for DOACs, INR dependent for phenprocoumon, and anti-Xa dependent for LMWH. Susceptibility to fibrinolysis increased with increasing DOAC concentrations.

Protective effect of a newly developed fucose-deficient recombinant antithrombin against histone-induced endothelial damage.

Antithrombin is expected to modulate both prothrombotic and proinflammatory reactions in sepsis; vascular endothelium is the primary target. In the present study, we sought to evaluate the protective effects of a newly developed fucose-deficient recombinant antithrombin. Endothelial cells were treated in vitro with histone H4 to induce cellular damage. Low to high doses of either plasma-derived antithrombin or recombinant thrombomodulin were used as treatment interventions. Morphological change, apoptotic rate, cell viability, cell injury, and syndecan-4 level in the medium were evaluated. Immunofluorescent staining with anti-syndecan-4 was also performed. Both types of antithrombin reduced cellular damage and apoptotic cell death. Both plasma-derived and recombinant antithrombin improved cell viability and reduced cellular injury when administered at a physiological concentration or higher. Syndecan-4 staining became evident after treatment with histone H4, and both antithrombins suppressed the staining intensity at similar levels. The syndecan-4 level in the medium was significantly decreased by both antithrombins. None of the indicators showed a significant difference between plasma-derived and recombinant antithrombin. In conclusion, both recombinant and plasma-derived antithrombin can protect vascular endothelial cells. Recombinant antithrombin may represent a useful new therapeutic agent for sepsis-associated vascular damage.

Potential effect of recombinant thrombomodulin on ischemia-reperfusion liver injury in rats.

Liver ischemia-reperfusion (I/R) injury is a severe complication of liver surgery. However, the responsible molecular mechanism remains unclear. High-mobility group box 1 (HMGB1) is released from the nuclei of cells and behaves as a damage-associated molecular pattern. The aim of this study is to reveal the roles of HMGB1 and the effects of recombinant thrombomodulin (rTM) in I/R liver injury. Rats underwent partial hepatic ischemia followed by reperfusion, and changes in HMGB1 were assessed. Recombinant thrombomodulin was used as an inhibitor of HMGB1. In rats with I/R injury, the HMGB1 level significantly decreased in the liver tissue and significantly increased in the serum after surgery (P < 0.001 for both). No difference in the HMGB1 level in the hepatocytes was observed between the rTM(-) group and rTM(+) group after surgery. Conversely, the serum HMGB1 level was significantly lower in the rTM(+) group than the rTM(-) group after surgery (P < 0.001). The levels of tumor necrosis factor-α and interleukin-6 in the liver tissue 24h after surgery were significantly lower in the rTM(+) group than the rTM(-) group (P < 0.001). The plasma alanine aminotransferase level at 24h after surgery of the rTM(+) group was significantly decreased after surgery compared with that of the rTM(-) group (P < 0.001). The necrotic area of the liver tissue 24h after surgery was significantly smaller in the rTM(+) group than the rTM(-) group (P < 0.001). Recombinant thrombomodulin can serve as a treatment for I/R liver injury by inhibiting HMGB1.

Successful Recombinant Thrombomodulin Treatment for Thrombotic Microangiopathy After Liver Transplantation: A Case Report

Transplant-associated thrombotic microangiopathy (TA-TMA) is a rare but severe complication after liver transplantation. In contrast to other thrombotic microangiopathies, treatment for TA-TMA has yet to be clarified. A 52-year-old male patient with liver cirrhosis due to hepatitis C underwent split liver transplantation from a deceased donor. His clinical course was without complication until 4 days after transplantation, when he experienced impaired consciousness, hemolytic anemia with fragmented erythrocytes, and marked thrombocytopenia. TA-TMA was diagnosed, and recombinant thrombomodulin was administered for 4 days. The patient's clinical symptoms and laboratory data rapidly improved. He has been followed up for 6 months and has not shown any complications. The pathogenesis of TA-TMA is endothelial damage in the vasculature. Recombinant thrombomodulin, an endothelial cell–protecting agent, is a promising new therapeutic choice for TA-TMA after liver transplantation.