sTM Levels Research Articles

The role of soluble thrombomodulin in the risk stratification and prognosis evaluation of septic patients in the emergency department

Soluble thrombomodulin (sTM) is a sensitive marker of endothelial damage. In this study we investigated the role of sTM in the evaluation of the severity and prognosis of septic patients in the emergency department (ED). A prospective, observational cohort study was performed in the ED of an urban, university hospital. Patients who had suspected infection with two or more criteria of systemic inflammatory response syndrome were consecutively enrolled. sTM, D-Dimer and procalcitonin levels were measured on enrollment, and the Mortality in Emergency Department Sepsis (MEDS) score was calculated. A 30-day follow-up was performed for all patients. A total of 372 patients with sepsis, 210 patients with severe sepsis and 98 patients with septic shock were enrolled in this study. According to the disease severity, patients were divided into sepsis subgroup and severe sepsis subgroup (including septic shock). In addition, patients were divided into survivors subgroup and non-survivors subgroup according to the 30-day mortality. Plasma sTM levels in patients with severe sepsis were higher than those with sepsis (P<0.001). Compared with survivors, non-survivors has higher plasma sTM levels (P<0.001). Multivariate logistic regression analysis showed that sTM was an independent predictor of severe sepsis (odds ratio 1.11) and 30-day mortality (odds ratio 1.059). Receiver operating characteristic curve analysis showed that sTM was a useful parameter in prediction of severe sepsis (0.859) and 30-day mortality (0.78). Compared with the MEDS score alone, combination of sTM and the MEDS score can improve the accuracy in prediction of severe sepsis and 30-day mortality. sTM is a valuable biomarker in the risk stratification and prognosis evaluation of ED sepsis. Furthermore, sTM can enhance the ability of the MEDS score in prediction of severe sepsis and 30-day mortality.

Soluble Thrombomodulin and Endothelial Cell Protein C Receptor Levels in Patients with Cerebral Venous and Sinus Thrombosis

Introduction: Cerebral venous and sinus thrombosis (CVST) is a potentially serious disorder. In search for underlying coagulopathy in CVST patients, we measured plasma levels of soluble thrombomodulin (sTM) and soluble endothelial protein C receptor (sEPCR) in patients with CVST as candidate biomarkers of thrombosis. Materials and Methods: The concentrations of sTM and sEPCR in 19 CVST patients without protein C and protein S deficiency were measured by ELISA and compared with 53 healthy controls. We also examined the association between those plasma markers and the risk of CVST. Results: Significant difference was identified in plasma sTM level between CVST patients and controls (0.95 ± 0.09 vs. 1.26 ± 0.12 ng/ml, respectively; p = 0.038). The plasma level of sEPCR was not different between groups, and no significant quantitative association was identified between the risk of CVST and the levels of sEPCR. The adjusted odds ratio for CVST associated with low (<10th percentile) levels of sTM was 2.3 (95% CI: 1.29-20.08; p = 0.012) after adjustment for confounding factors. Conclusion: Decreased plasma sTM concentration may be associated with an increased risk of CVST.

Microvascular Damage in Type 1 Diabetic Patients Is Reversed in the First Year After Simultaneous Pancreas–Kidney Transplantation

Simultaneous pancreas-kidney transplantation (SPK) is an advanced treatment option for type 1 diabetes mellitus (DM) patients with microvascular disease including nephropathy. Sidestreamdarkfield (SDF) imaging has emerged as a noninvasive tool to visualize the human microcirculation. This study assessed the effect of SPK in diabetic nephropathy (DN) patients on microvascular alterations using SDF and correlated this with markers for endothelial dysfunction. Microvascular morphology was visualized using SDF of the oral mucosa in DN (n = 26) and SPK patients (n = 38), healthy controls (n = 20), DM1 patients (n = 15, DM ≥ 40 mL/min) and DN patients with a kidney transplant (KTx, n = 15). Furthermore, 21 DN patients were studied longitudinally up to 12 months after SPK. Circulating levels of angiopoietin-1 (Ang-1), angiopoietin-2 (Ang-2) and soluble thrombomodulin (sTM) were measured using ELISA. Capillary tortuosity in the DN (1.83 ± 0.42) and DM ≥ 40 mL/min (1.55 ± 0.1) group was increased and showed reversal after SPK (1.31 ± 0.3, p < 0.001), but not after KTx (1.64 ± 0.1). sTM levels were increased in DN patients and reduced in SPK and KTx recipients (p < 0.05), while the Ang-2/Ang-1 ratio was normalized after SPK and not after KTx alone (from 0.16 ± 0.04 to 0.08 ± 0.02, p < 0.05). Interestingly, in the longitudinal study, reversal of capillary tortuosity and decrease in Ang-2/Ang-1 ratio and sTM was observed within 12 months after SPK. SPK is effective in reversing the systemic microvascular structural abnormalities in DN patients in the first year after transplantation.

A Potential Role for Plasma Uric Acid in the Endothelial Pathology of Plasmodium falciparum malaria

BackgroundInflammatory cytokinemia and systemic activation of the microvascular endothelium are central to the pathogenesis of Plasmodium falciparum malaria. Recently, ‘parasite-derived’ uric acid (UA) was shown to activate human immune cells in vitro, and plasma UA levels were associated with inflammatory cytokine levels and disease severity in Malian children with malaria. Since UA is associated with endothelial inflammation in non-malaria diseases, we hypothesized that elevated UA levels contribute to the endothelial pathology of P. falciparum malaria.Methodology/Principal FindingsWe measured levels of UA and soluble forms of intercellular adhesion molecule-1 (sICAM-1), vascular cell adhesion molecule-1 (sVCAM-1), E-selectin (sE-Selectin), thrombomodulin (sTM), tissue factor (sTF) and vascular endothelial growth factor (VEGF) in the plasma of Malian children aged 0.5–17 years with uncomplicated malaria (UM, n = 487) and non-cerebral severe malaria (NCSM, n = 68). In 69 of these children, we measured these same factors once when they experienced a malaria episode and twice when they were healthy (i.e., before and after the malaria transmission season). We found that levels of UA, sICAM-1, sVCAM-1, sE-Selectin and sTM increase during a malaria episode and return to basal levels at the end of the transmission season (p<0.0001). Plasma levels of UA and these four endothelial biomarkers correlate with parasite density and disease severity. In children with UM, UA levels correlate with parasite density (r = 0.092, p = 0.043), sICAM-1 (r = 0.255, p<0.0001) and sTM (r = 0.175, p = 0.0001) levels. After adjusting for parasite density, UA levels predict sTM levels.Conclusions/SignificanceElevated UA levels may contribute to malaria pathogenesis by damaging endothelium and promoting a procoagulant state. The correlation between UA levels and parasite densities suggests that parasitized erythrocytes are one possible source of excess UA. UA-induced shedding of endothelial TM may represent a novel mechanism of malaria pathogenesis, in which activated thrombin induces fibrin deposition and platelet aggregation in microvessels. This protocol is registered at clinicaltrials.gov (NCT00669084).

Effect of Cardiopulmonary Bypass on Thrombin Generation and Protein C Pathway

The purpose of this study was to evaluate the mechanisms of cardiopulmonary bypass (CPB)-induced dysregulation between thrombin and its regulatory anticoagulant activated protein C (APC). A prospective observational cohort study. A tertiary care university hospital and associated research laboratory. Twenty patients undergoing elective coronary artery bypass surgery with (n = 10) or without CPB (n = 10). Blood samples were collected at 7 time points: preinduction; after heparin; 1 hour after the institution of CPB (or the completion of distal anastomoses in off-CPB group); after protamine; and at 0, 4, and 18 hours in the Intensive care unit (ICU). Samples were analyzed for prothrombin fragments (F1+2), thrombin-antithrombin complexes, protein C (PC), APC, soluble thrombomodulin (sTM), and soluble endothelial protein C receptor (sEPCR). F1+2 levels increased significantly 1 hour after the initiation of CPB in comparison with baseline (2.7 ± 0.5 v 0.5 ± 0.2 nmol/L, p < 0.001) (mean ± standard deviation) and remained elevated until 4 hours after ICU admission (p < 0.001). In contrast, APC levels did not show any significant changes over time in either group. sEPCR, sTM, and PC levels did not change during CPB although sEPCR decreased significantly after the termination of CPB compared with baseline in the CPB group. Exposure to CPB is associated with a distinct thrombin surge that continues postoperatively for 4 hours. The impaired ability to generate APC reflects a complex process that is not associated with increased levels of sEPCR and thrombomodulin during CPB. Further studies are required to evaluate the regulation of the host APC response in cardiac surgery.

Endothelial Vulnerability and Endothelial Damage Are Associated with Risk of Graft-versus-Host Disease and Response to Steroid Treatment

There is accumulating evidence indicating that endothelial factors are involved in the pathogenesis of GVHD. We have recently shown that steroid-refractory, but not sensitive, GVHD is characterized by higher pretransplantation serum levels of angiopoetin-2 (ANG2), a hormone mediating endothelial vulnerability. To evaluate whether endothelial vulnerability is a risk factor for GVHD per se or becomes important only when noticeable GVHD is established, we measured ANG2 along with additional serum markers of endothelial stress, including soluble thrombomodulin (sTM), IL-8 (CXCL8), and hepatocyte growth factor (HGF), in patients with no, low-grade, or severe GVHD. Patients with refractory GVHD exhibited elevated serum levels of ANG2, sTM, HGF, and IL-8 posttransplantation compared with patients with sensitive GVHD and patients without GVHD. Pretransplantation ANG2 was the only growth factor correlated with the risk of refractoriness and mortality, and then only within the subset of patients who developed grade III-IV GVHD. In contrast, ANG2 was not predictive of GVHD or nonrelapse mortality (NRM) in patients with no GVHD or low-grade GVHD. These findings provide evidence that endothelial function plays an important role in the pathogenesis of steroid refractoriness in ongoing GVHD; however, endothelial vulnerability does not predict incidence of GVHD.

Soluble thrombomodulin levels in plasma of multiple sclerosis patients and their implication

Thrombomodulin (TM) on the cell-surface of cerebrovascular endothelial cells (CECs) is released into blood upon CEC damage. TM promotes activation of protein C (APC), an anticoagulant, anti-inflammatory, neuroprotective molecule that protects CECs and impedes inflammatory cell migration across the blood–brain barrier (BBB). Multiple sclerosis (MS) is associated with CEC damage and BBB dysfunction. We evaluated soluble TM (sTM) levels as a biomarker of BBB integrity and whether glatiramer acetate (GA) influenced sTM levels in MS patients. sTM levels quantified by 2-site ELISA from sera of healthy controls and systemic lupus erythematosus (SLE) patients (CEC-damage positive control) were compared with levels from patients with relapsing–remitting (RRMS) or secondary-progressive MS (SPMS), stratified as: RRMS/GA/no relapse, RRMS/GA/in relapse, RRMS no GA/no relapse, RRMS/no GA/in relapse; and SPMS/no GA. Additionally, soluble endothelial protein C receptor (sEPCR) levels were assessed in the non-stratified MS group, SLE patients, and controls. sTM levels were highest in RRMS patients taking GA with or without relapse, followed in decreasing order by SLE, RRMS/no GA/in relapse, SPMS, RRMS/no GA/no relapse, healthy controls. sEPCR levels were highest in MS patients, then SLE, then controls. sTM may be a useful biomarker of BBB integrity in RRMS patients. Further evaluation of sEPCR is needed. The finding that the highest sTM levels were in RRMS patients taking GA is interesting and warrants further investigation.

Role of thrombomodulin gene in Indian population with coronary artery disease

Context: Thrombomodulin (TM), a natural anticoagulant have been implicated in the pathogenesis of coronary artery disease (CAD) thus emphasizing its potential role as a biomarker.Objectives: To investigate the role of the TM genetic variants and soluble TM (sTM) plasma levels in Indian population with CAD.Materials and methods: This case–control study involved genotyping of the entire TM gene and sTM levels estimation in 266 subjects.Results: None of the four TM genetic variants identified significantly increased CAD risk in the study population. However, further subgroup analysis revealed that in subjects ≤49 years, C1418T variant (Ala455Val substitution) was significantly associated with CAD.Conclusion: The increased CAD risk in subjects ≤49 years due to TM Ala455Val substitution is a promising finding. Further validation on large Indian cohorts is required in order to screen asymptomatic young subjects for CAD risk and to establish the clinical utility of Ala455Val substitution.

Anti‑inflammatory and anticoagulant properties of the protein C system in inflammatory bowel disease

In patients with inflammatory bowel disease (IBD), disbalance between procoagulant, anticoagulant, and fibrinolytic factors has been shown. The hemostatic system is an indispensable component of the inflammatory process. Deficiencies in the protein C (PC) pathway components not only promote thrombosis, but also exacerbate inflammation. The aim of the study was to assess the components of the PC system and their correlations with disease activity in patients with IBD. The levels of PC, free protein S (PS), and soluble thrombomodulin (sTM) were measured in 55 consecutive patients with ulcerative colitis (UC), 50 patients with Crohn's disease (CD), and 41 healthy volunteers. Correlations between PC system components and disease activity, hemostatic variables, and inflammatory markers were assessed. sTM levels in patiens with UC were higher compared with controls (24.5 vs. 17.5 ng/ml; P = 0.0042). In patients with IBD, PC activity was higher and PS activity was lower compared with controls (P <0.001). Tumor necrosis factor α (TNF-α) levels were higher in patients with IBD, and interleukin 6 (IL-6) levels were higher only in patients with CD. In patients with UC, a positive correlation was observed between sTM and both PC and PS levels (r = 0.28 and r = 0.34, respectively, P <0.05). Only PC levels correlated with UC activity (r = 0.3, P <0.05). No correlations of TNF-α, IL-6, and C-reactive protein with PC, PS, and sTM levels were observed. The PC pathway is defective in patients with CD and UC. Hypercoagulability in IBD might be associated not only with the inflammatory process but also with disturbances in the anticoagulant system, since defective PC pathway was observed both in active and nonactive disease.

Biomarkers of endothelial dysfunction in patients with primary focal segmental glomerulosclerosis

Endothelial dysfunction occurs in nephrotic syndrome (NS) and may constitute a link between NS and vascular complications. Focal segmental glomerulosclerosis (FSGS) is a common cause of NS. This study aimed to assess endothelial markers at different stages of FSGS and define whether they were associated with thromboembolic complications and disease activity. Forty-four patients with nephrotic-range proteinuria and biopsy-proven primary FSGS were included in this study. Nine of them had concurrent thromboembolisms. Thirty-two sex- and age- matched healthy volunteers served as controls. Endothelial markers including circulating endothelial cells (CECs), soluble thrombomodulin (sTM), von Willebrand factor (vWf), soluble vascular cell adhesion molecule-1 (sVCAM-1) and sE-selectin were assessed at the commencement of the study in all participants and were repeated at 2, 6 and 12 months of follow-up in patients without thromboembolisms. Patients with FSGS during active stage showed significantly higher levels of CECs, sTM, vWf, sVCAM-1 and sE-selectin when compared with controls. Moreover, patients with thromboembolisms had higher CECs and vWf than those without thromboembolisms. In patients without thromboembolisms, endothelial markers except sE-selectin had inverse correlations with serum albumin and were positively related to cholesterol. Multiple analyses showed that cholesterol and serum albumin were independent predictors of CECs and sTM, and vWf and sVCAM-1, respectively. At follow-up, these markers systematically decreased as the disease went into remission, but the increase in vWf and sVCAM-1 persisted even in patients obtaining complete remission for nearly a year. In patients with no response, levels of endothelial markers exhibited no obvious change. Patients with FSGS had elevated markers of endothelial dysfunction, which were largely related to the activity of the disease. Meanwhile, levels of CECs and vWf were higher in patients concurrent with thromboembolisms.

Biochemical predictors of cardiac rhythm at 1year follow-up in patients with non-valvular atrial fibrillation.

C-reactive protein (CRP) is increased in patients with atrial fibrillation (AF) and it might predict the lack of sinus rhythm maintenance in the long term follow-up. Scarce data have been reported relating endothelial dysfunction and/or haemostatic or platelet markers to sinus rhythm maintenance in AF patients. We aimed to determine whether some biochemical markers including soluble thrombomodulin (sTM), soluble P-selectin, thrombin-antithrombin (TAT) complex and CRP levels could predict sinus rhythm maintenance at 1year follow-up in non-valvular AF patients. 130 patients (70 males, mean age 67±13years) with newly diagnosed AF naïve of antithrombotic or antiplatelet therapy were studied. Baseline CRP, P-selectin, sTM and TAT levels were compared to those of 20 matched-healthy subjects in sinus rhythm. AF patients had significantly higher plasma CRP (10.5±2.2 vs 3.25±0.3mg/l, p=0.001), P-selectin (219±141 vs 126ng/ml, p=0.01), and TAT (54±237 vs 2.7±3.3ng/l, p=0.001) levels compared with controls. Soluble TM levels, although higher than controls, did not reach statistical significance. Multivariate regression analyses showed that elevated CRP (OR=4.8, p=0.02) and sTM (OR=1.05, p=0.04) were the only two predictors of lack of sinus rhythm at 1year follow-up. An altered inflammatory, haemostatic, endothelial and platelet environment exists in newly diagnosed AF patients. CRP and sTM levels might be used as biochemical markers to predict the status of cardiac rhythm at 1year follow-up in some AF patients.

Increased Plasma Soluble Thrombomodulin Levels in Cardioembolic Stroke

Soluble thrombomodulin (sTM) has been proposed as a potential marker of ischemic stroke. Results from previous studies remain controversial among different populations. We performed an analysis of plasma levels of sTM in Thai patients with acute ischemic stroke and determined whether sTM levels correlate with stroke subtypes, severity, and risk factors. Ninety-three patients and 76 controls were enrolled. Blood samples were obtained within 24 hours after stroke onset. Plasma sTM levels, measured using quantitative enzyme-linked immunosorbent assay, were significantly higher in patients than controls (P < .005), with the mean ± standard deviation (SD) levels of 3.08 ± 1.05 and 2.57 ± 1.15 ng/mL, respectively. Plasma levels of sTM in patients with cardioembolic subtype were significantly higher than in patients with other stroke subtypes, with the mean ± SD levels of 3.79 ± 1.26, 2.38 ± 0.68 (P < .009), and 2.38 ± 0.44 (P < .05) ng/mL for cardioembolism, large artery atherosclerosis, and small artery occlusion, respectively. Plasma sTM levels were not associated with stroke severity and risk factors of stroke; however, there was a slight relationship between high sTM levels and the presence of atrial fibrillation in the patient group. In conclusion, plasma sTM levels were increased in Thai patients with cardioembolic stroke and may be a potential marker during the acute phase.

Endothelial Stress in Steroid-Refractory Gvhd: A Burden Statins Cannot Lift

Abstract 1012Graft-versus-host disease (GvHD) is the major complication of allogeneic stem cell transplantation (alloSCT) and its therapy-resistant form causes significant morbidity and mortality. The pathomechanism of steroid resistance is currently not completely understood; however, we have recently suggested that endothelial dysfunction seems to play an important role (Luft et al., Blood 2011). The aim of this study was to validate in a large cohort of patients that steroid refractory acute GvHD is associated with endothelial stress. Secondly we assessed if this endothelial stress can be overcome by statins, which are known to have endothelial protective effects.We have therefore performed a retrospective study of 393 patients who underwent alloSCT in our institution between 2002–2010. Endothelial stress serum markers were correlated with the course of GvHD, non relapse mortality (NRM) and statins intake. Overall, 169 of 393 patients (43%) developed GVHD. Of these, 101 patients (60%) had steroid-sensitive GvHD grade 1–2, 26 patients (15%) steroid-sensitive GvHD grade 3–4 and 42 patients (25%) had steroid-refractory GvHD which was always grade 3–4 at its maximum severity. 224 patients had no signs of GvHD. In order to elucidate the pathomechanisms that contribute to steroid resistance, serum markers of endothelial stress and vascular growth (Angiopoietin-2 (ANG2), IL-8, soluble thrombomodulin (sTM), and vascular endothelial growth factor (VEGF)) were measured by ELISA and multiplex assays before and on days +50 and +100 after alloSCT. RESULTS:Landmark analyses at days +50 and +100 after alloSCT showed that NRM was dramatically high in the steroid refractory group but was equivalently low in the no GvHD-, sensitive grade 1–2 - and grade 3–4 - groups (p<0.001, Figure 1). ANG2, a mediator of endothelial cell vulnerability, measured before transplant was predictive for a steroid refractory course of GvHD (p=0.05) and higher NRM (p=0.06) under the prerequisite that patients developed grade 3–4 GvHD. Moreover, patients who developed an acute steroid refractory GvHD displayed significantly higher levels of the endothelial stress markers IL-8 (day +50: p<0.001; day +100: p<0.001) and sTM (day +50: p<0.009; day +100: p=0.003) compared to steroid-sensitive GvHD patients and patients with no GvHD. High levels of sTM, IL8 and ANG2 were significantly associated with increased NRM rates (day +50: IL8 p=0.02, sTM p=0.0008, ANG2 p=0.0001; day +100: IL8 p=0.0007, sTM p<0.0001, ANG2 p=0.05); even after multivariate adjustment for donor, conditioning intensity, disease status at alloSCT and sex mismatch. In contrast, no influence of VEGF levels on steroid-refractory GvHD. [Display omitted] When IL8, sTM, ANG2 and VEGF kinetics were compared in patients with and without concomitant statin therapy (n=81), no differences were observed in the whole patient cohort nor in the subset with steroid-refractory GVHD. Consequently, patients with or without statins had similar NRM, relapse rates and overall survival in univariate as well as multivariate analysis. CONCLUSION:This supports the hypothesis that steroid-refractory GVHD is associated with progressive microangiopathy. Statins, although reported to have protective effects on endothelial cells, were inefficient to alleviate endothelial stress in this context and, accordingly, did not change the outcome of acute GVHD patients. Disclosures:Luft:Celgene: Research Funding.

Thromboembolic events are associated with prolonged clot lysis time in patients with permanent atrial fibrillation

Atrial fibrillation (AF) is associated with a prothrombotic state. We evaluated associations of previous thromboembolic events with fibrinolytic parameters in patients with AF. We studied 62 consecutive patients with permanent AF (27 men, 35 women, aged 46-89 years [median, 78 years]). Patients receiving warfarin or acenocoumarol on a long-term basis were eligible. We determined plasma fibrin clot lysis time (CLT), plasminogen activator inhibitor-1 (PAI-1) antigen, thrombin-activatable fibrinolysis inhibitor (TAFI) activity and antigen, plasminogen, α2-antiplasmin (α2AP), and soluble thrombomodulin (sTM). There were 19 subjects (30.6%) with a history of thrombotic events (stroke in 11, myocardial infarction in 8, and pulmonary embolism in 3 patients). They had longer CLT (P = 0.0035 for patients with previous stroke and P = 0.001 for patients with any previous thrombotic event), together with higher PAI-1 (P = 0.025 and P = 0.016, respectively), TAFI activity (P = 0.002 and P = 0.011, respectively), sTM (P = 0.0023 and P = 0.012, respectively), and α2AP (P = 0.007 and P = 0.0006, respectively) than the remaining subjects. AF patients with previous stroke had also higher TAFI antigen than the remainder (P = 0.04). CLT (P = 0.024), PAI-1 (P = 0.022), TAFI activity (P = 0.048), and sTM (P = 0.032, all P for trend) increased with higher CHA2DS2-VASc scores. CLT was not associated with time from thrombotic event to enrollment. Patients taking oral anticoagulants (n = 46) had only slightly higher sTM levels (3.6 [2.9-6.3] vs. 2.9 [2.2-4.1] ng/ml, P = 0.049) than the remaining subjects. Stroke or other thromboembolic event in AF patients is associated with impaired lysability of fibrin clots combined with elevated PAI-1, TAFI, sTM, and α2AP.

Impact of leukocytapheresis on the coagulation and lung injury in the endotoxemia dogs

To explore the role of leucocyte in the coagulation and fibrinolysis system in endotoxin-induced lung injury, the impact of peripheral leukocytapheresis (LCAP) on the coagulation and fibrinolysis system, and the lung injury in the endotoxemia dogs were observed. Endotoxemia was introduced in dogs with lipopolysaccharidea (LPS, 2 mg/kg). A total of 30 dogs were randomly assigned into LPS group (dogs were treated with LPS alone), sham group (dogs underwent LPS treatment and then sham LCAP 12-14 h later) and LCAP group (dogs underwent LPS treatment and LCAP 12-14 h later) (n=10 per group). The levels of peripheral activator protein C (APC), soluble thrombomodulin (sTM) and plasminogen activator inhibitor-1 (PAI-1) were measured 0 h before LPS treatment and 2, 6, 12, 14, 16, 24 and 36 h after LPS treatment. Result showed that the serum level of APC at 14 and 16 h after LPS treatment in LCAP group was significantly higher than that in LPS group at corresponding time points (P<0.05). The serum levels of sTM and PAI-1 at 14 and 16 h after LPS treatment in LCAP group was significantly lower than those in LPS group at corresponding time points (P<0.05). The incidence of lung injury in LCAP group was lower than that in LPS group (P<0.05). At the early stage of endotoxemia, LCAP can improve the balance of coagulation and fibrinolysis which may partly contribute to the improvement of oxygenation index and attenuation of lung injury. Key words: Endotoxemia, leukocytapheresis, coagulation/fibrinolysis.

Adhesion molecules and high‐sensitivity C‐reactive protein levels in patients with sickle cell beta‐thalassaemia

The primary symptoms of sickle cell disease (SCD) arise from vaso-occlusive crises. The pathogenesis of these crises is complex phenomenon where endothelial activation and damage has a major role. Chronic inflammation also plays an important role in the pathophysiology of SCD. We aimed to investigate endothelial activation in Caucasian Greek patients with SCD by means of measuring adhesion molecules and markers of inflammation. Twenty-eight patients with SCD aged 5-63 years were included in the study. Most of the patients (23/28) were double heterozygotes for sickle cell/beta-thalassaemia, while five patients (5/28) were sickle cell homozygotes. Patients were treated with one/or more of hydroxyurea, therapeutic phlebotomies, blood transfusion or splenectomy. Twenty apparently healthy individuals matched for age and sex formed the control group. Measurements of soluble intercellular adhesion molecule-1, (sICAM-1), soluble vascular cell adhesion molecule-1 (sVCAM-1), P-selectin, E-selectin, soluble thrombomodulin (sTM) and high-sensitivity C-reactive protein (hs-CRP) levels were performed using immunoassays in both patients and healthy individuals. We found that all endothelial adhesion molecules and hs-CRP were significantly increased (P < 0·001) in patients with SCD compared with controls, while sTM levels did not differ significantly (P > 0·05) and this increase was not influenced by the treatment. Our findings demonstrate the high degree of endothelial activation and damage seen in sickle cell patients even in steady-state condition, as well as the important chronic inflammation underlying the pathophysiology of this widespread disease.

Effect of Coupled Plasma Filtration Adsorption on Endothelial Cell Function in Patients with Multiple Organ Dysfunction Syndrome

The purpose of our study was to investigate the effect of coupled plasma filtration adsorption (CPFA) on endothelial cell (EC) function in patients with multiple organ dysfunction syndrome (MODS). Besides routine therapy, the 24 MODS patients underwent both CPFA and high volume hemofiltration (HVHF), scheduled randomly at intervals of 12 hours. Patient serum from 0, 5, and 10 hours of therapy was collected to measure soluble E-selectin (sE-selectin) and soluble thrombomodulin (sTM) by the ELISA method. Human umbilical vein endothelial cells (HUVEC) were incubated for 24 hours with the patient serum and the supernatant liquid was gathered to detect sTM and sE-selectin. The proliferation function of the ECs was detected by methyl thiazolyl tetrazolium (MTT) method. 1. The serum levels of sE-selectin and sTM were significantly higher in MODS patients than in controls; serum sE-selectin and sTM decreased remarkably after a single circulation in CPFA (p<0. 05) but not in HVHF (p>0. 05); the level of sE-selectin and sTM in systemic circulation had no change during CPFA or HVHF (p>0.05); 2. sTM in supernatant liquid incubated with serum from 5 hours of CPFA and 10 hours of HVHF decreased remarkably (p<0.05), while sE-selectin decreased significantly (p<0. 05) from 10 hours of CPFA , but there was no change from 5 hours and 10 hours of HVHF (p>0. 05); 3. when incubated with serum taken from the device pre- or post-CPFA, the optical density (OD) value of the latter was higher. The OD value increased gradually when incubated with serum from 0, 5, and 10 hours of CPFA (p<0.05), but changed little from HVHF. CPFA can eliminate sE-selectin and sTM and improve the secretion function of ECs. CPFA was somewhat better and earlier than HVHF, while to a certain degree it can weaken the inhibitory effect of serum on the proliferation function of ECs.

Kidney function and multiple hemostatic markers: cross sectional associations in the multi-ethnic study of atherosclerosis

BackgroundDefined as estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m2, chronic kidney disease (CKD) is strongly and independently associated with cardiovascular and overall mortality. We hypothesized that reduced kidney function would be characterized by abnormalities of hemostasis.MethodsWe tested cross-sectional associations between (eGFR) and multiple hemostatic markers among 6751 participants representing a broad spectrum of kidney function in the Multi-Ethnic Study of Atherosclerosis (MESA). Kidney function was measured using cystatin C (eGFRcys) or creatinine, using CKD Epidemiology Collaboration (eGFRcr). Hemostatic markers included soluble thrombomodulin (sTM), soluble tissue factor (sTF), D-Dimer, von Willebrand factor (vWF), factor VIII, plasmin-antiplasmin complex (PAP), tissue factor pathway inhibitor (TFPI), plasminogen activator inhibitor-1 (PAI-1), and fibrinogen. Associations were tested using multivariable linear regression with adjustment for demographics and comorbidities.ResultsIn comparison to persons with eGFRcys >90 ml/min/1.73 m2, subjects with eGFRcys < 60 ml/min/1.73 m2 had adjusted levels of sTM, sTF, D-Dimer, PAP, Factor VIII, TFPI, vWF and fibrinogen that were respectively 86%, 68%, 44%, 22%, 17%, 15%, 12% and 6% higher. Subjects with eGFRcys 60-90 ml/min/1.73 m2 had adjusted levels that were respectively 16%, 14%, 12%, 6%, 6%, 6%, 11% and 4% higher (p < 0.05 for all). Percent differences were not significantly different when groups were categorized by eGFRcr.ConclusionsThroughout a broad spectrum of kidney function, lower eGFR was associated with higher levels of hemostatic markers. Dysregulation of hemostasis may be a mechanism by which reduced kidney function promotes higher cardiovascular risk.

Soluble Thrombomodulin Levels are Related to Inflammation after Coronary Bypass Surgery

Background: Soluble Thrombomodulin (sTM) is released from endothelial cells after injury by activated leukocytes in inflammatory states and it has been associated with worse prognosis in inflammatory conditions. The purpose of this study was to analyze the association between levels of sTM and inflammation and to describe the possible explanations about association between sTM and post-operative complications. Methods and Materials: We measured levels of sTM, IL6 and leukocytes in different moments during the first month in 18 patients after coronary by-pass graft surgery. Chisquare test and Fisher test were used for categorical variables. For continuous variables we used either Student t test or Wilcoxon rank-sum test depending on whether the data were normally distributed. Results: The levels of sTM increased during the first post-surgery week, and then decreased to values similar to those recorded pre-operatively. IL6 peaked at after 24 hours, and significantly correlated with white blood cell count (Spearman 0.69, p=<0.0001). There was a significant association between sTM at T3 and white blood cells count at T1 (p=0.01224). Two patients had three or more post-operative complications, and they presented higher levels of sTM. Conclusions: We found a transient increase in sTM during the first week after CABG associated with an inflammatory response and leukocytosis. These changes could imply endothelial dysfunction after surgery and may represent prognostic factors for outcomes.

Impaired anti-platelet effect of aspirin, inflammation and platelet turnover in cardiac surgery☆☆☆

A reduced platelet inhibitory response to acetyl salicylic acid (ASA) has been associated with an increased risk of graft thrombotic occlusion after coronary artery bypass grafting (CABG). We performed a prospective, observational study of 18 patients on 100 mg/day ASA before and after CABG. We assessed antiplatelet response to ASA and its relationship with platelet turnover, inflammatory markers, and soluble thrombomodulin (sTM) levels. All patients showed optimal response to ASA preoperatively but had higher values during follow-up. Platelet aggregation and platelet count in the perioperative period were significantly associated (P=0.05). Platelet turnover was defined as the average daily turnover (ADTO). The lowest inhibitory value (28% of patients > or =6 Omega) was recorded at the same time of the highest platelet turnover (>10% daily in 77.77% of patients), one week after CABG. ADTO >10% was associated with an increased risk of platelet aggregation > or =6 Omega. Levels of sTM were significantly higher one week after CABG (median 13 vs. 3 ng/ml preoperatively, P=0.0011). There is a transient impairment in ASA antiplatelet effect after CABG related to an increased platelet turnover caused by the inflammatory process. This could be responsible for the high risk of occlusive thrombosis.