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Disseminated intravascular coagulation (DIC). Jørn Dalsgaard Nielsen Thrombosis Centre Gentofte Hospital Denmark. Characteristics of DIC. DIC. Arterial thrombosis. Venous thrombosis. DIC Increased fibrin formation. Trombotic microangiopathy Increased platelet aggregation. Introduction.

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Disseminated intravascular coagulation (DIC)


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disseminated intravascular coagulation dic

Disseminated intravascular coagulation(DIC)

Jørn Dalsgaard Nielsen

Thrombosis Centre

Gentofte Hospital

Denmark

characteristics of dic
Characteristics of DIC

DIC

Arterial thrombosis

Venous thrombosis

introduction

DICIncreased fibrin formation

TromboticmicroangiopathyIncreased platelet aggregation

Introduction
  • Thrombotic microangiopathy (TMA) and disseminated intravascular coagulation (DIC) are disorders causing obstruction of the microvascular circulation
slide4

TromboticmicroangiopathyIncreased platelet aggregation

TTP

HELLP

HUS

Thrombotic microangiopathy

TTP: Thrombotic Thrombocytopenic Purpura

HELLP: Haemolysis, Elevated Liver enzymes, Low Platelets

HUS: Haemolytic Uremic Syndrome

slide5

TromboticmicroangiopathyIncreased platelet aggregation

TTP

HELLP

HUS

Thrombotic microangiopathy

Type Symp. Etiology

TTP: CNS vW cleaving factor deficiency, cong/aquired

HELLP: Liver Pregnant women

HUS: Kidney +/- diarrhoea associated (E coli 0157)

slide6

TromboticmicroangiopathyIncreased platelet aggregation

TTP

HELLP

HUS

Thrombotic microangiopathy

  • Treatment: TTP HELLP HUS
  • Eliminate the causal factor +
  • Plasmapheresis (or FFP or cryosupernatant transfusion) +
  • Corticosteroids (+) + (+)
  • IV gamma globulin (+) (+)
  • Rituximab + (+)
  • Avoid platelet transfusions + + +
dic is a complication

DIC

DIC is a complication

Banal

Serious

illness

Critical

illness

causes of dic
Causes of DIC

Other causes

Sepsis

the vicious cycle of inflammation and coagulation1
The Vicious Cycle of Inflammation and Coagulation

Infection

Inflammation

Organ Failure

Coagulation

Ischemia

Death

Endothelial Dysfunction

Inflammation

Coagulation

Inflammation

Inflammation

Coagulation

Esmon. Immunologist. 1998;6:84.

progression of sepsis

Bacteria

Cytokines

Tissue factor

Accelerates coagulation

Progression of SEPSIS

Platelets

Monocytes

Endothelial

cells

Endothelial

cells

Non-adhesive surface

Adhesive surface

Leuko-

cytes

Activation of coagulation  Thrombin  Fibrin

the classic coagulation system

Surface contact

Tissue factor

XII XIIa

XI XIa

IX IXa

II IIa

I Ia (fibrin)

THE ”CLASSIC” COAGULATION SYSTEM

APTT

Prothrombin time

VIIa VII

Ca++

Phospholipid, Ca++, VIII

X Xa X

Phospholipid, Ca++, V

slide14

IL-1

TNF-C5a

EXPRESSION OF TISSUE FACTOR

CONSTITUTIVEe.g.:epithelial cellsglial cells

INDUCEDe.g.:monocytic cellsendothelial cells

PROHIBITEDe.g.:lymphocyteserythrocytes

slide15

TF

Local clot formation

TF

TF

Cytokines

TF

TF

Endothelial damage

SUBENDOTHELIAL TISSUE

ENDOTHELIAL CELLS

NORMAL HAEMOSTASIS

Haemostatic mechanisms

Intravascular

clot formation

Activated

monocyte

Monocyte

Activation of monocytes

SYSTEMIC INFLAMMATION

causes of dic mechanisms
Causes of DIC (mechanisms)
  • Extensive release of tissue factor
  • Increased formation of tissue factor
  • Abnormal activators of coagulation
  • Contact activation  hypotension
causes of dic clinical conditions i
Causes of DIC (Clinical conditions, I)
  • Infections
      • Sepsis
        • Gram negative (endotoxin)
        • Gram positive (polysaccharides, peptides)
      • Viremias
        • Varicella
        • Hepatitis
        • Cytomegalovirus
        • HIV
causes of dic clinical conditions ii
Causes of DIC (Clinical conditions, II)
  • Trauma
      • Crush injuries
      • Other trauma with tissue necrosis
      • Severe burns
      • Extensive surgery
  • Obstetric complications
      • Amniotic fluid embolism
      • Placental abruption
      • (Pre)eclampsia
      • Dead fetus syndrome
causes of dic clinical conditions iii
Causes of DIC (Clinical conditions, III)
  • Hemolysis
      • Hemolytic transfusion reactions
      • Massive transfusions
      • Malaria
      • Other severe hemolysis
  • Malignant disorders
      • Metastatic malignancy
      • Tumors producing cancer procoagulant
      • Tumor with tissue necrosis
causes of dic clinical conditions iv
Causes of DIC (Clinical conditions, IV)
  • Vascular abnormalities
      • Giant hemangioma
      • Heriditary teleangiectasis
      • Prosthetic devices
        • Aortic balloon assist devices
        • Denver shunts
  • Other conditions
      • Pancreatitis
      • Acute liver necrosis
      • Transplant rejection
      • Heat stroke
progression of dic

Systemic fibrin formation

Systemic inflammation

Multiple organ dysfunction

Systemic bleeding

Progression of DIC

Onset of DIC

Time

progression of dic1

Systemic inflammation

Multiple organ dysfunction

High fibrinolytic activity

Low fibrinolytic activity

Systemic bleeding

Progression of DIC

Systemic fibrin formation

Abrupt onset of DIC

Onset of DIC

Time

examples of hyperfibrinolytic dic
Examples of hyperfibrinolytic DIC
  • DIC in women with post-partum bleeding
  • DIC in patients with promyelocytic leukaemia
  • Early after severe trauma
  • Contact with Lonomia caterpillars
fibrinolytic activity in patients with dic

Thrombin- and stasis-induced release of tissue plasminogen activator

FXII  FXIIa PrekallikreinKallikrein

Plasminogen

activator

inhibitor-1 

2-Plasmin

inhibitor

During DIC

PC  APC inhibits PAI-1

Fibrinolytic activity in patients with DIC

Abrupt onset of DIC

Plasminogen

Plasmin

Fibrin

Fibrin degradation products

hyper and non hyperfibrinolytic dic
Hyper- and non-hyperfibrinolytic DIC
  • Hyperfibrinolytic DIC
    • Main problem: Severe bleeding
  • Non-hyperfibrinolytic DIC
    • Main problem: Microvascular occlusion
  • DIC in septic patients is a
  • non-hyperfibrinolytic type of DIC
tf and lps induced dic
TF and LPS induced DIC

DIC was induced in rats by infusion of TF or LPS

TF LPS p

Platelets *109/l 204 177 ns

Fibrinogen mg/dl <50 <50 ns

TAT ng/ml 162 170 ns

D-dimer g/ml 12,4 1,2 0,001

PAI U/ml 22 245 0,001

Glomerular fibrin 12% 73% 0,001

Asakura et al. Crit Care Med 2002; 30: 161-4

symptoms of dic
Symptoms of DIC
  • Dysfunction of multiple organs
    • The pulmonary microembolism syndrome
      • Acute: vascular and bronchial constriction
      • Late: ARDS
    • Acute renal failure
      • Oliguria, increasing serum creatinine, haematuria
    • Cerebral dysfunction
      • Confusion, blurred consciousness, coma
    • Cutane haemorrhagic necroses
    • Failure of liver, endocrine glands etc.
slide30

Circulating mediators

Circulating mediators

Local haemostatic response to an injury

Local immunological response to an injury

Modification

(Amplification)

DIC

SIRS

Ischaemia

Destruction

MODS

slide31

SIRS+DIC = hyperproteolysis

Coagulation

Fibrinolysis

Complement

Kinines

Cytokines

slide32

Platelet count

Activated partial thromboplastin time (APTT)

Prothrombin time (PT)

Fibrin D-dimer fragment

Antithrombin

Fibrinogen

BLOOD TESTS WHEN DIC IS SUSPECTED

Simple screening

Extended screening

Supplementary tests

Further evidence for activation of coagulation

and fibrinolysis

slide33

D fragmentsE fragments

Activation of coagulation

Fibrinogen

Prothrombin

Fragment 1+2

THROMBIN

Fibrino-peptideA + B

Antithrombin

Fibrin

Plasmin

FXIII FXIIIa

Thrombin-Antithrombincomplex(TAT)

Cross-linkedfibrin

D dimerE fragments

soluble fibrin monomer as predictor for dic in neonatal sepsis
Soluble fibrin monomer as predictor for DIC in neonatal sepsis
  • Healthy neonates: 24,5 ± 6,09 mg/l
  • Sepsis, no DIC: 33,7 ± 11,9 mg/l
  • Sepsis + DIC*: 73,2 ± 31,6 mg/l

*ISTH DIC score 5

Critical level: 48,5 mg/l

Sensitivity: 100%

Specificity: 93%

Overall accuracy: 97,5%

Selim et al. Haematologica 2005;90:419-20

slide35

FIBRIN

THROMBUS

SCHISTOCYTES

Longitudinally cut blood vessel

definition of disseminated intravascular coagulation
Definition of disseminated intravascular coagulation

DIC is an acquired syndrome characterized by the intravascular activation of coagulation with loss of localization arising from different causes. It can originate from and cause damage to the microvasculature, which if sufficiently severe, can produce organ dysfunction

ISTH´s Scientific Subcommittee on DIC, July 2001

scoring system for overt dic
Scoring system for overt DIC
  • Underlying disorder known to be associated with overt DIC

YES

NO

continue

stop

  • Platelet count
    • (>100=0, <100=1, <50=2) ..............................
  • Soluble fibrin/D-dimer
    • (normal=0, =2, =3) .............................
  • Prolongation of PT
    • (<3s=0, 3-6s=1, >6s=2) ................................
  • Fibrinogen
    • (>1g/l=0, <1g/l=1) ..........................................
  • Calculate sum ........................................

ISTH´s Scientific Subcommittee on DIC, July 2001

scoring system for overt dic1
Scoring system for overt DIC

- Example -

  • Underlying disorder known to be associated with overt DIC

YES

NO

Polytrauma

continue

stop

  • Platelet count
    • (>100=0, <100=1, <50=2) ..............................
  • Soluble fibrin/D-dimer
    • (normal=0, =2, =3) .............................
  • Prolongation of PT
    • (<3s=0, 3-6s=1, >6s=2) ................................
  • Fibrinogen
    • (>1g/l=0, <1g/l=1) ..........................................
  • Calculate sum ........................................

85 1

8 3

+3 1

2,2 0

5

ISTH´s Scientific Subcommittee on DIC, July 2001

scoring system for overt dic2
Scoring system for overt DIC
  • If the calculated score is
    • 5: compatible with overt DIC repeat scoring daily
    • <5: suggestive (not affirmative) for non-overt DIC repeat next 1-2 days.

ISTH´s Scientific Subcommittee on DIC, July 2001

scoring system for non overt dic
Scoring system for non-overt DIC
  • Presence of underlying disorder
    • (no=0, yes=2) ..........................................................
  • Platelet count + changes
    • (100=0, <100=1) + (=-1, stable=0, =1) .......
  • Sol.fibrin/D-dimer + changes
    • (normal=0, =1) + (=-1, stable=0, =1) ........
  • Prolongation of PT + changes
    • (3s=0, >3s=1) + (=-1, stable=0, =1) ...........
  • Antithrombin
    • (normal=-1, low=1) .................................................
  • Protein C
    • (normal=-1, low=1) .................................................
  • TAT complexes
    • (normal=-1, high=1) .................................................
  • Calculate sum ................................................

ISTH´s Scientific Subcommittee on DIC, July 2001

validation of the isth scoring system for overt dic
Validation of the ISTH scoring system for overt DIC

Distribution of DIC scores in 217 patients in intensive care unit

Bakhtiari et al. Crit Care Med 2004; 32:2416 –2421

validation of the isth scoring system for overt dic1
Validation of the ISTH scoring system for overt DIC

Bakhtiari et al. Crit Care Med 2004; 32:2416 –2421

validation of the isth scoring system for non overt dic
Validation of the ISTH scoring system for non-overt DIC

Survivors

Deaths

Non-overt DIC scores in 490 patients in intensive care unit

Toh & Downey. Blood Coagul Fibrinolysis 2005;16:69–74

validation of the isth scoring system for non overt dic1
Validation of the ISTH scoring system for non-overt DIC

Toh & Downey. Blood Coagul Fibrinolysis 2005;16:69–74

validation of the isth scoring system for non overt dic2
Validation of the ISTH scoring system for non-overt DIC
  • The mortality rate for non-overt DIC was
    • 29% (105 of 360) for scores below 5
    • 78% (70 of 90) for scores of 5 or above
  • The mortality rate for overt DIC was also 78% (38 of 49).
  • The non-overt DIC scoring template is workable and has prognostic relevance.
  • A score of 5 and greater is recommended as diagnostic of non-overt DIC.

Toh & Downey. Blood Coagul Fibrinolysis 2005;16:69–74

scoring system for overt dic3
Scoring system for overt DIC
  • Underlying disorder known to be associated with overt DIC

YES

NO

continue

stop

  • Platelet count
    • (>100=0, <100=1, <50=2) ..............................
  • Soluble fibrin/D-dimer
    • (normal=0, =2, =3) .............................
  • Prolongation of PT
    • (<3s=0, 3-6s=1, >6s=2) ................................
  • Fibrinogen
    • (>1g/l=0, <1g/l=1) ..........................................
  • Calculate sum ........................................

ISTH´s Scientific Subcommittee on DIC, July 2001

d dimer low cutoff
D-dimer- low cutoff -
  • A low cutoff of 1 mg/l was used by:
  • Dempfle et al. Thromb Haemost 2004; 91: 812–8
  • Toh et al. Blood Coagul Fibrinolysis 2005; 16: 69-74
  • Angstwurm et al. Crit Care Med 2006; 34: 314–20
interassay variation of d dimer
Interassay variation of D-dimer

D-dimer was determined in 39 plasma samples with 23 D-dimer assays

Dempfle et al. Thromb Haemost 2001; 85: 671–8

d dimer tests giving comparable results

Stago Liatest D-Di

Roche Tinaquant

Roche Cardiac D-dimer

D-dimer tests giving comparable results

Suggested cutoffs:

Low: 1 mg/l

High: 4 mg/l

BioMérieux Vidas D-dimer

BioMérieux MDA D-dimer

the atryn study
The ATryn Study

Clinical Study Protocol

Exploratory efficacy and safety, pharmacokinetics and dosefinding study of recombinant human antithrombin in patients with disseminated intravascular coagulation associated with severe sepsis

slide56

T

hrombin-signaling

Endothelial cell

PC

A

EPCR

TM

A

From normal haemostasis to sepsis

PC

EPCR

A

TM

A

NFB

PAR-1

A

TM

PC

A

EPCR

A

TM

PC

A

EPCR

slide57

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

hrombin-signaling in sepsis

Endothelial cell

PC

A

EPCR

T

TM

EPCR

A

T

Cytokines

Adhesion

molecules

NFB

NFB

PAR-1

T

PAR-1

A

T

EPCR

A

TM

PC

A

EPCR

slide58

T

T

T

T

T

T

T

T

T

T

T

T

T

hrombin-signaling in sepsis

Endothelial cell

Treatment with heparin

PC

A

EPCR

TM

T

A

EPCR

A

A

Cytokines

Adhesion

molecules

T

NFB

NFB

PAR-1

T

PAR-1

T

A

A

T

EPCR

Heparin

A

TM

Elastase

PC

A

EPCR

Pulletz et al. Crit Care Med 2000; 28: 2881-6. Jordan et al. Am J Med 1989; 87 Suppl 3B: 1989

slide59

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

hrombin-signaling in sepsis

Endothelial cell

Treatment with heparin and antithrombin

PC

A

EPCR

TM

T

A

EPCR

A

T

A

A

Cytokines

Adhesion

molecules

T

T

A

NFB

NFB

PAR-1

T

PAR-1

T

A

A

A

A

T

EPCR

T

A

Heparin

A

TM

Elastase

PC

A

EPCR

slide60

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

T

hrombin-signaling in sepsis

Endothelial cell

Treatment with activated protein C +/- heparin

PC

A

EPCR

TM

T

APC

A

EPCR

A

T

A

A

T

T

A

NFB

PAR-1

T

PAR-1

T

A

A

A

A

T

APC

EPCR

T

A

Heparin

A

TM

Elastase

PC

A

EPCR

role of heparin in sepsis

CLP+heparin

Role of heparin in sepsis

Heparin treatment after cecum ligation and puncture increases mortality in rats (13%  75%, p < 0.015).

Heparin treatment after cecum ligation and puncture

CLP+PBS

Echtenacher et al.

Infect Immun 2001; 69: 3550-5

the role of heparin in sepsis
The role of heparin in sepsis

A DIC model:

22 sheeps had intravenous infusion of E. coli endotoxin

Schiffer et al. Crit Care Med 2002; 30:2689 –2699

the role of heparin in sepsis1
The role of heparin in sepsis

A meta-analysis of animal studies

Cornet et al. Thromb Haemost 2007; 98: 579–586

the role of heparin in sepsis2

LPS studies

E. Coli antiserum

LPS studies

Dunn et al. 1983

The role of heparin in sepsis

N=2x5

Two studies showing negative effect of heparin were not included in the meta-analysis:

Corrigan et al. J Infect Dis 1975;131: 139–143. Echtenacher et al. Infect Immun 2001; 69: 3550-5

Cornet et al. Thromb Haemost 2007; 98: 579–586

role of heparin in sepsis1
Role of heparin in sepsis
  • Heparin seems to have:
    • a beneficial effect in animal models where DIC is induced by endotoxin – probably due to the anti-inflammatory effect of binding and neutralisation of TNF
    • a harmful effect when given to septic animals containing living bacteria.
sepsis induced capillary leak syndrome
Sepsis-induced capillary leak syndrome

Severe sepsis induces

systemic capillary leak

decreased plasma activity of at and pc in septic patients with dic
Decreased plasma activity of AT and PC in septic patients with DIC

Asakura et al. Eur J Haematol 2001; 67: 170-5

  • Among 139 septic patients the 68 patients with DIC had significantly higher levels of TAT and lower levels of AT and PC than the 71 patients without DIC (p<0.001 for all variables) but no significant correlation was observed between plasma levels of TAT and AT or between plasma levels of TAT and PC.
  • When the patients were classified into three groups according to the albumin level, no significant differences in AT activity or PC activity were observed between the patients with and without DIC.
decreased plasma activity of at and pc in septic patients with dic1
Decreased plasma activity of AT and PC in septic patients with DIC

Asakura et al. Eur J Haematol 2001; 67: 170-5

The results suggest that the reduced activity of AT and PC is not due to consumption coagulopathy but rather to capillary leak, degradation by elastase, and/or reduced synthesis.

dual chamber system to analyze endothelial cell layer permeability

Dual-chamber system to analyze endothelial cell layer permeability

Evans blue-labelled bovine serum albumin

Upper 500 µl chamber for addition of test material

Endothelial cell layer

Polycarbonate membrane of 3µm pore size

Lower 1500 µl chamber for collection of media to be analyzed for Evans blue labelled bovine serum albumin (OD at 650 nm)

Feistritzer & Riewald. Blood 2005; 105: 3178-84

slide71
Endothelial barrier protection by activated protein C through PAR1-dependentsphingosine 1–phosphate receptor-1 crossactivation

PAR1-dependent signaling by the interdependent procoagulant and anticoagulant proteases thrombin and APC can have opposite effects on endothelial barrier integrity. Barrier protection by APC or low concentrations of thrombin is mediated by sphingosine kinase-1 activity and crossactivation of S1P1 signaling.

Feistritzer et al. Blood. 2005;105:3178-84

apc reduces the mortality of lps induced endotoxemia in mice
APC reduces the mortality of LPS-induced endotoxemia in mice

APC

Saline

Kerschen et al. J Exp Med. 2007;204:2439-48

apc reduces the mortality of lps induced endotoxemia in mice1
APC reduces the mortality of LPS-induced endotoxemia in mice

- No effect in EPCR / mice -

EPCR / mice

APC

Saline

Kerschen et al. J Exp Med. 2007;204:2439-48

apc reduces the mortality of lps induced endotoxemia in mice2
APC reduces the mortality of LPS-induced endotoxemia in mice

- Reduced effect in PAR1 -/- mice -

PAR1 -/- mice

APC

Saline

Kerschen et al. J Exp Med. 2007;204:2439-48

apc reduces the mortality of lps induced endotoxemia in mice3
APC reduces the mortality of LPS-induced endotoxemia in mice

- and so does 5A-APC -

5A-APC: A recombinant APC variant with normal signaling but <10% anticoagulant activity

5A-APC 2, 10g

Saline

Kerschen et al. J Exp Med. 2007;204:2439-48

sepsis and dic
Sepsis and DIC
  • Septic patients may develope DIC as a result of activation of Toll-like receptors (TLRs) on monocytes, neutrophils and endothelial cells by microbial products like lipopolysaccharides, peptidoglycan, and lipoteichoic acid.

Zhang & Ghosh. J Clin Invest 2001; 107: 13-19

Henneke & Golenbock. Crit Care Med 2002; 30 Suppl: 207-13

tlr mediated activation of nf b
TLR-mediated activation of NFB

Zhang & Ghosh.

J Clin Invest 2001; 107: 13-19

role of nf b in sepsis
Role of NFB in sepsis

NFB in nuclear extracts from peripheral blood mononuclear cells is comparable to the APACHE-II score as a predictor of outcome in septic patients.

Böhrer et al. J Clin Invest 1997; 100: 972-85

apc inhibits activation of nf b
APC inhibits activation of NFB
  • Esmon CT. J Autoimmun 2000; 15 113-6:
  • Activated protein C reduces nuclear translocation of NFB resulting in reduction of cytokine synthetic rates.
antiinflammatory effects of apc
Antiinflammatory effects of APC
  • APC blocks cytokine elaboration by mononuclear cells

Grey et al, J Immunol 1994;153:3664 –68

  • Endothelial Protein C Receptor

Fukudome & Esmon, J Biol Chem 1994;269:26486-91

  • Mononuclear Phagocyte Protein C Receptor

Hancock et al, Transplantation 1995;60:1525-32

anti inflammatory effects of at
Anti-inflammatory effects of AT
  • Binding to endothelium stimulates prostanoid release
    • Yamauchi et al. BBRC 1989
    • Horie et al. Thromb Res 1990
  • Increased prostacyclin levels in animal models
    • Uchiba et al. Thromb Res 1995
    • Uchiba et al. Am J Physiol 1996
  • Inhibition of endotoxin-induced cytokine synthesis, platelet aggregation, leukocyte differentiation and vascular permeability by prostacyclin
    • Uchiba et al. Thromb Res 1996
  • Reduction of ischemia-reperfusion injury
    • Ostrovsky et al. Circulation 1997
    • Harada et al. Blood 1999
anti inflammatory effects of at1
Anti-inflammatory effects of AT
  • Inhibition of IL-6 and tissue factor release from endothelial cells and monocytes
    • Souter et al. Crit Care med 2001
  • Inhibition of endothelial cell proliferation
    • Larson et al. J Biol Chem 2001
  • ICAM-1-dependent inhibition of adhesion of neutrophils to endothelial cells
    • Kaneider et al. Ann Hematol 2003
  • Inhibition of NFB activation in endothelial cells and monocytes
    • Mansell et al. FEBS Lett 2001
    • Oelschlager et al Blood 2002
  • Effect on endothelial-leukocyte interactions in endotoxemia exerted predominantly via the endothelium
    • Mizutani et al. Blood 2003
at inhibits lps induced activation of nf b
AT inhibits LPS-induced activation of NFB

Mansell et al. FEBS Letters 2001; 508: 313-7:

  • LPS-induced, TLR4-mediated activation of NFB in human mononuclear cells was inhibited dose-dependently by AT.
  • Modified AT without serpin activity had no effect.
  • The effect was not increased by addition of heparin.
slide84

 IL-6

 TF

AT inhibits LPS-induced TF and IL-6 production by mononuclear cells, endothelial cells, and whole blood
  • TF and IL-6 were determined after stimulation of whole blood, HUVEC, and MNC with LPS for 4-6 hours.
  • Production of TF and IL-6 was reduced in the presence of varying concentrations of AT.

Souter et al.

Crit Care Med 2001; 29: 134-9

at prevents lps induced pulmonary vascular injury
AT prevents LPS-induced pulmonary vascular injury

Uchiba & Okajima. Semin Thromb Haemost 1997; 23:583-90:

  • Intravenous administration of AT (250 U/Kg) to rats prevented LPS-induced accumulation of leukocytes and increases in pulmonary vascular permeability.
  • Trp49-modified AT, which lacks affinity for heparin, had no effect.
  • AT had no effect in animals pretreated with indomethacin, suggesting that the protective effect was a result of endothelial release of prostacyclin.
  • Inhibition of thrombin formation by inactive FXa did not prevent pulmonary vascular injury
prevention of vascular leakage during sublethal porcine sepsis by antithrombin dickneite g kroez m
Prevention of vascular leakage during sublethal porcine sepsis by antithrombinDickneite, G & Kroez, M
  • Sepsis was induced in 18 pigs by a 3 hours infusion of LPS 0,25 g/kg/h.
  • 90 minutes after start of LPS infusion the animals were randomised to:
    • AT 120 IU/kg iv bolus + 5 IU/kg/h iv infusion
    • AT 250 IU/kg iv bolus + 10 IU/kg/h iv infusion
    • Placebo (HSA)

Presented at the 13th Annual Congress of ESICM in Rome, 1-4 October 2000

prevention of vascular leakage during sublethal porcine sepsis by antithrombin dickneite g kroez m1
Prevention of vascular leakage during sublethal porcine sepsis by antithrombinDickneite, G & Kroez, M
  • The broadening and dispersal of interlobular connective tissue was decreased significantly and dose-dependently by AT.
  • Also the periportal edematisation and accumulation of leukocytes could be reduced.

Conclusion:

Presented at the 13th Annual Congress of ESICM in Rome, 1-4 October 2000

effect of at on dic in man the first randomised study
Effect of AT on DIC in man- the first randomised study -

Blauhut et al. Thromb Res 1985; 39: 81-9:

  • 51 patients with DIC were randomised to substitution with
    • AT infusion, target: 100%
    • Heparin infusion, 3000 IU as bolus + 300 IU/h
    • AT + reduced dose of heparin (1000 IU + 100 IU/h)
  • Conclusion:
    • AT reduced duration of DIC
    • Concomitant heparin caused:
      • Acccelerated reduction of platelet count
      • Increased consumption of AT
      • Increased need of blood transfusion
randomised trials on the use of at in patients with sepsis or evidence of dic1
Randomised trials on the use of AT in patients with sepsis or evidence of DIC

Mortality odds ratio

AT vs. Hep (N = 133)

AT vs. Placebo (N = 130)

AT+Hep vs. Hep (N = 150)

0,37 (0,15-0,88)

0,43 (0,20-0,92)

0,63 (0,28-1,39)

0,0

1,0

2,0

AT reduces mortality significantly when used alone but not when accompanied by heparin treatment

slide91
Randomised trials on AT replacement in intensive care management of patients with an antithrombin activity below 70%

Mortality

Odds ratio

Harper (1991)

Albert (1992)

Diaz-Cremadez (1994)

Baudo (1998)

Waydhas (1998)

Total

0,85 (0,51-1,73)

0,0

1,0

2,0

3,0

4,0

kybersept study
KyberSept Study
  • A phase 3 trial of antithrombin versus placebo in patients with severe sepsis or septic shock.
  • The trial was powered to detect a 15% reduction of an expected placebo 28-day mortality of 45%.
  • 2339 patients were randomised. In the treatment group the mean increase in plasma antithrombin at 24 hours of inclusion was 130%.
  • Mortality was lower than expected and almost identical in the two groups (Antithrombin: 38,9% and placebo: 38,7%).

Warren et al. JAMA 2001; 286: 1869-78

kybersept study1
KyberSept Study
  • A shortcoming of the study was that use of unfractionated or LMW heparin 10.000 IU was allowed without randomisation.
  • Less than a quarter of the patients in the study had no heparin.
  • Heparin increased the risk of poor outcome and adverse bleeding.

Warren et al. JAMA 2001; 286: 1869-78

kybersept study2

KyberSept: No Hep. N = 698

Placebo 43,6%

Antithrombin 37,8%

Difference: 5,8%

p = 0,08

KyberSept Study

28-day mortality:

Warren et al. JAMA 2001; 286: 1869-78

randomised trials on the use of at in patients with sepsis or evidence of dic2
Randomised trials on the use of AT in patients with sepsis or evidence of DIC

KyberSept results included:

Mortality odds ratio

AT vs. Hep (N = 133)

AT vs. Placebo (N = 828)

AT+Hep vs. Hep (N = 1766)

0,37 (0,15-0,88)

0,72 (0,55-0,96)

1,09 (0,89-1,32)

0,0

1,0

2,0

AT reduces mortality significantly when used alone but not when accompanied by heparin treatment

effects of activated protein c
Effects of activated protein C
  • inhibits leukocyte-endothelial cell interaction
  • inhibits thrombin formation
  • increases fibrinolytic activity

*Bernard GR et al. N Engl J Med 2001; 344: 699-709

slide97

FVa

Protein S

FVIIIa

Activation of protein C

Activated

protein C

Thrombomodulin

Thrombomodulin

PAI-1 

TAFI 

Protein C

Thrombin

EPCR

Endothelial cell

protein c in septic patients
Protein C in septic patients
  • The plasma concentration of PC is reduced in septic patients due to
    • Capillary leak
    • Degradation by elastase
    • Decreased synthesis
    • Increased consumption during DIC
  • Activation of PC is compromised in septic patients because the endothelial expression of thrombomodulin and endothelial protein C receptor is suppressed
the prowess study
The PROWESS Study
  • Protein C Worldwide Evaluation in Sepsis
  • Clinical controlled phase III multicenter double-
  • blind placebo-controlled trial in severe sepsis

Bernard GR et al. N Engl J Med 2001; 344: 699-709

prowess study description
PROWESS Study Description
  • Design
      • Randomized, double-blind, placebo-controlled trial
      • 11 countries at 164 sites
  • Population - Severe Sepsis
      • Presence of a known or suspected infection
      • Evidence of a systemic response to the infection (3 SIRS criteria)
      • At least one sepsis-associated organ dysfunction of no greater than 24 hours duration
  • Treatment Arms
      • 1:1 randomization to Drotrecogin Alfa (activated) 24 µg/kg/hr or placebo for 96 hours

Data from the PROWESS Trial

prowess study design
PROWESS Study Design

Infection with organ failure

Assessment of 28-day

all-cause mortality

Alive or Dead?

Start of study drug infusion

48 Hours Maximum

- Consent

- Start Drug

Routine Patient Care

End of 96 hour infusion of study drug

Data from the PROWESS Trial

results
Results
  • Drotrecogin Alfa (activated) in patients with severe sepsis:
    • Acceptable safety profile
    • Significantly reduces mortality
      • 6.1% absolute, 19.4% relative risk reduction
      • Lower mortality observed across most subgroups
  • Number needed to treat to save one additional life equals 16
treatment of sepsis and dic
Treatment of sepsis and DIC
  • Probably the primary goal of DIC treatment should not be inhibition of coagulation but protection of endothelial cells from being activated to produce inflammatory cytokines and adhesion molecules.
  • Increased leukocyte-endothelial cell interaction may be the key mechanism in the development of organ dysfunction.
  • Neutropenic patients are unlikely to develope septic ARDS*.

*Okajima et al. Am J Hematol 1991; 36: 265-71

treatment of sepsis and dic1
Treatment of sepsis and DIC
  • Activated protein C (APC) has in addition to its anticoagulant effect been shown to inhibit leukocyte-endothelial cell interaction
  • In the PROWESS trial (N = 1690) 28-days mortality was 6.1% lower in the APC group than in the control group (p < 0.01)*
  • AT has EC protective properties when heparin is avoided.
  • In the non-heparin groups of the KyberSept trial (N = 698) 28-days mortality was 5.8% lower in the AT group than in the control group (n.s.)**

*Bernard GR et al. N Engl J Med 2001; 344: 699-709

**Warren et al. JAMA 2001; 286: 1869-78

treatment of sepsis and dic2
Natural anticoagulant

Present on EC surface

EC protective properties:

Inhibits activation of NFB

Reduces effects of LPS

.

Natural anticoagulant

Present on EC surface

EC protective properties:

Inhibits activation of NFB

Reduces effects of LPS

.

.

Treatment of sepsis and DIC

AT

aPC

treatment of sepsis and dic3
Natural anticoagulant

Present on EC surface

EC protective properties:

Inhibits activation of NFB

Reduces effects of LPS

Displaced from EC surface by heparin

Reduction of mortality in patients with sepsis/DIC not proven in phase III trial

Natural anticoagulant

Present on EC surface

EC protective properties:

Inhibits activation of NFB

Reduces effects of LPS

Not displaced from EC surface by heparin

Reduction of mortality in patients with sepsis/DIC proven in phase III trial

Treatment of sepsis and DIC

AT

aPC

the face of sepsis

DIC

Systemic

inflam-

mation

The face of sepsis