Fibrin Network Formation and Lysis in Septic Shock Patients

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

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Altered fibrin clot structure/function in patients with antiphospholipid syndrome: association with thrombotic manifestation

Thrombosis and Haemostasis ◽

10.1160/th13-11-0980 ◽

2014 ◽

Vol 112 (08) ◽

pp. 287-296 ◽

Cited By ~ 21

Author(s):

Magdalena Celińska-Löwenhoff ◽

Teresa Iwaniec ◽

Agnieszka Padjas ◽

Jacek Musiał ◽

Anetta Undas

Keyword(s):

Structure Function ◽

Antiphospholipid Syndrome ◽

Thrombotic Event ◽

Fibrin Clot ◽

Clot Lysis ◽

Lag Phase ◽

Lysis Time ◽

Clot Structure ◽

Clot Lysis Time ◽

D Dimer

SummaryWe tested the hypothesis that plasma fibrin clot structure/function is unfavourably altered in patients with antiphospholipid syndrome (APS). Ex vivo plasma clot permeability, turbidity and susceptibility to lysis were determined in 126 consecutive patients with APS enrolled five months or more since thrombotic event vs 105 controls. Patients with both primary and secondary APS were characterised by 11% lower clot permeability (p<0.001), 4.8% shorter lag phase (p<0.001), 10% longer clot lysis time (p<0.001), and 4.7% higher maximum level of D-dimer released from clots (p=0.02) as compared to the controls. Scanning electron microscopy images confirmed denser fibrin networks composed of thinner fibres in APS. Clots from patients with “triple-antibody positivity” were formed after shorter lag phase (p=0.019) and were lysed at a slower rate (p=0.004) than in the remainder. Clots from APS patients who experienced stroke and/or myocardial infarction were 8% less permeable (p=0.01) and susceptible to lysis (10.4% longer clot lysis time [p=0.006] and 4.5% slower release of D-dimer from clots [p=0.01]) compared with those following venous thromboembolism alone. Multivariate analysis adjusted for potential confounders showed that in APS patients, lupus anticoagulant and “triple-positivity” were the independent predictors of clot permeability, while “triple-positivity” predicted lysis time. We conclude that APS is associated with prothrombotic plasma fibrin clot phenotype, with more pronounced abnormalities in arterial thrombosis. Molecular background for this novel prothrombotic mechanism in APS remains to be established.

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Impaired fibrinolytic capacity and increased fibrin formation associate with myocardial infarction

Thrombosis and Haemostasis ◽

10.1160/th11-11-0760 ◽

2012 ◽

Vol 107 (06) ◽

pp. 1092-1099 ◽

Cited By ~ 18

Author(s):

Karin Leander ◽

Margareta Blombäck ◽

Håkan Wallén ◽

Shu He

Keyword(s):

Myocardial Infarction ◽

Clot Lysis ◽

Coagulation Activation ◽

Global Method ◽

Fibrin Formation ◽

Lysis Time ◽

Activation Profile ◽

Fibrinolytic Capacity ◽

First Myocardial Infarction ◽

Clot Lysis Time

SummaryWe assessed whether abnormality of haemostasis measured by a newly developed global method is associated with risk of a first myocardial infarction (MI). The global markers Coagulation activation profile (Cp), Fibrinolysis activation profile (Fp) and sum of fibrin optical density over time (Fibrin OD- sum) were determined in plasma from 800 MI cases and 1,123 controls included in the Stockholm Heart Epidemiology Program. Clot lysis time (CLT) was also determined based on raw data of fibrin OD from the global assay. Odds ratios (OR) of MI with 95% confidence intervals (CI) were calculated using logistic regression. A Fp value <10th percentile value in controls was significantly associated with increased MI risk; OR after multivariate adjustments for conventional cardiovascular risk factors 1.66 (95% CI 1.22–2.27). For an abnormally long CLT (>90th percentile value in controls) the adjusted OR of MI was 2.62 (95% CI 1.87–3.66) and for a high Fibrin OD-sum value (>90th percentile in controls) it was 1.86 (95% CI 1.37–2.53). A high Cp value was not significantly associated with MI. In conclusion, we found that abnormal haemostasis in platelet-poor plasma, reflected either as an attenuated fibrinolytic capacity or the resulting increase of fibrin formation, was associated with increased MI risk.

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Newborns Are Hyperfibrinolytic at Physiologic tPA Concentrations and the Increased Fibrinolysis Is Related to Decreased Apparent TAFIa.

Blood ◽

10.1182/blood.v110.11.1756.1756 ◽

2007 ◽

Vol 110 (11) ◽

pp. 1756-1756

Author(s):

Lesley G. Mitchell ◽

Laszlo Bajzar ◽

Amal Rahal

Keyword(s):

Specific Inhibitor ◽

Lag Time ◽

Fibrin Clot ◽

Molecular Devices ◽

Clot Lysis ◽

Activity Inhibition ◽

Carboxypeptidase Inhibitor ◽

Adult Plasma ◽

Fibrinolytic Capacity ◽

Normal Adults

Abstract INTRODUCTION: Differences in both quantitative and qualitative components of the fibrinolytic system in newborns are well described. The overall impact of these variations in components on actual fibrinolytic capacity in response to various concentrations of tPA has not been assessed. There were two objectives for the current study, To determine the relative clot lysis capacity of the newborn compared to the adult at various rt-PA levels. To determine the effect of endogenous thrombin activated fibrinolytic inhibitor (TAFIa) on clot lysis in newborns compared to adults. METHODS: Plasma from 20 normal adults and 20 normal cords were pooled. Plasma, 2.5 pM tissue factor, 5mM CaCl2 and 8 concentrations of rt-PA ranging from physiologic levels (0.02nM) to therapeutic levels (3.0 nM) was added to microtitre plates. Plates were sealed and clot turbidity was monitored at 405nm using a SpectraMax Platereader (Molecular Devices, USA) at 37°C over 72 hours. The following parameters of clot lysis were calculated: lag time to clot lysis initiation (lag time), slope/maximum absorbance-minimum absorbance correcting for differences in fibrin clot formed (slope), time at which clot turbidity equals one-half of the full-scale value (t 1/2) and iv) end of clot lysis (end time). In some experiments, potato tuber carboxypeptidase inhibitor (PTCI) a specific inhibitor of TAFIa, was added to plasma. RESULTS: Comparison of newborn to adult: for clarity only 2 concentrations of r-tPA are shown (Table I). At therapeutic concentrations of rt-PA (3.0 nM) newborns were comparable to adults on all parameters of clot lysis. In contrast, at physiologic concentrations of rt-PA (0.023nM) when compared to adults, newborns demonstrated decreased lag time more rapid completion of clot lysis more rapid t1/2 clot lysis increased slope of clot lysis. Effect of endogenous TAFI activity: Inhibition of TAFIa had no effect on the slope of lysis in either adult or newborn (data not shown). However, there was a large effect on decreasing lag time to lysis initiation in adults but little effect in newborns (Figure I). The lag time was comparable in adults with PTCI and to newborns. These data show that TAFIa activity has little effect on inhibiting fibrinolysis in newborns. CONCLUSIONS: The concentration of rt-PA has a profound effect on the relative clot lysis in newborns compared to adults. At physiologic rt-PA concentrations the newborn initiates and completes clot lysis earlier and lyses clots at a faster rate than adults. Therefore, the newborn appears hyperfibrinolytic as compared to the adult at endogenous rt-PA concentrations. The hyperfibrinolytic response in the newborn can be explained, in part, by low apparent TAFIa concentrations. In contrast, at therapeutic rt-PA concentrations newborn clot lysis is comparable to the adult. Table I Comparision of clot lysis in newborn and adult plasma Lag time t 1/2 Slope Completion ** p<0.0001 when compared to adult 0.023nM tPA Adult 24,881±3628 74,267±6394 1.6±0.5 127,441±13,958 Newborn 11,971±2148** 27,469±3413** 3.6±0.7** 39,505±3,408** 3.0 nM tPA Adult 496±92 709±39 203±17 839±106 Newborn 577±47 734±44 228±26 900±42 Figure Figure

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Abstract 16780: Disease Severity Assessed by Thromboelastography in a Minority Population With COVID-19

Circulation ◽

10.1161/circ.142.suppl_3.16780 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Kevin Bliden ◽

Amit Rout ◽

Rahul Chaudhary ◽

Jaime Barnes ◽

Udaya Tantry ◽

...

Keyword(s):

Disease Severity ◽

Point Of Care ◽

Fibrin Clot ◽

Clot Lysis ◽

Minority Population ◽

Clot Strength ◽

Co Morbidity ◽

Wide Range ◽

Patients At Risk ◽

D Dimer

Background: Thromboelastography (TEG®) is used across a wide range of clinical settings to identify patients at risk for thrombosis and coagulopathic bleeding and may be a useful diagnostic tool to guide antithrombotic treatment in patients with COVID-19. Hypothesis: TEG® identifies symptom progression in COVID -19 patients, particularly in the high-risk minority population known to have worse clinical outcomes. Methods: Whole blood from African American and Hispanic hospitalized COVID positive (n=22) and negative outpatients (n=24) was analyzed using point-of-care TEG®6s (Haemonetics, Corp). TEG® parameters including clot initiation (R), fibrin clot strength (FCS), platelet-fibrin clot strength (PFCS) and clot lysis (LY30) were compared across disease severity groups (table). Routine labs including D-Dimer, C-reactive protein (CRP), ferritin, and procalcitonin were also collected. Results: Ninety- five percent of COVID positive patients had at least one co-morbidity with the incidence of hypertension (73%), diabetes (55%), and obesity (45%) being the most frequent. R time was more rapid, and FCS and PFCS was significantly higher in COVID positive as compared to negative groups (p<0.03). A stepwise increase in FCS and PFCS was observed with worsening respiratory function (table). Similarly, D-Dimer, CRP, ferritin, and procalcitonin levels were highest in patients receiving ventilator support. No differences were observed in clot lysis between the groups despite elevated D-Dimer levels. Conclusion: We have demonstrated that TEG®6s can identify a prothrombotic phenotype characterized by rapid clot initiation and increased fibrin and platelet-fibrin clot strength in a minority population with COVID-19. Future studies are warranted implementing the TEG6s® in clinical trials to personalize antithrombotic therapy in COVID-19 and improve outcomes.

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A preliminary report of clinical experience in managing patients with sepsis and septic shock in emergency medicine ward

Hong Kong Journal of Emergency Medicine ◽

10.1177/1024907918779318 ◽

2018 ◽

Vol 26 (1) ◽

pp. 15-25

Author(s):

Chun Kit Li ◽

Oi Fung Wong ◽

Shing Ko ◽

Hing Man Ma ◽

Chau Hung Albert Lit

Keyword(s):

Risk Factors ◽

Septic Shock ◽

Hospital Mortality ◽

Sequential Organ Failure Assessment ◽

Organ Failure ◽

Organ Dysfunction ◽

Medical Ward ◽

Factors Associated ◽

Emergency Medical ◽

Failure Assessment

Background: Sepsis and septic shock are common causes of hospital admission, morbidity, and mortality, posing a significant burden on the health-care systems. Objective: The objective of this study was to report the clinical experience of management and outcomes of sepsis patients in the emergency medical ward of a community hospital. The risk factors associated with adverse outcomes of sepsis patients were also analyzed. Methods: This was a retrospective cohort study of patients with sepsis or septic shock managed in the emergency medical ward of North Lantau Hospital from 1 March 2015 to 31 March 2017. Their characteristics, clinical outcomes, risk factors associated with in-hospital mortality, 28-day mortality, and prolonged hospital stay (>14 days) were analyzed. Results: A total of 68 eligible patients met the inclusion criteria during the study period. The mean age of the patients was 73 (standard deviation, 16.7; range, 34–100) years. The mean Sequential Organ Failure Assessment score of all the cases was 4.5 (standard deviation, 2.4); range, 2–11). The most common source of infection was pneumonia (50%). During the stay in the emergency medical ward, 35 cases (49%) required vasopressor support for management of septic shock, and 12 cases required non-invasive ventilation (NIV) support. Five patients were eventually transferred to tertiary hospital (Princess Margaret Hospital) for further management. There were five in-hospital mortality cases and two 28-day mortality cases. From the univariate analysis, factors associated with in-hospital mortality included Sequential Organ Failure Assessment score >6 (p < 0.000), increasing number of organ dysfunction (p < 0.000), presence of chronic liver disease (p = 0.025), respiratory dysfunction during admission (p = 0.028); factors associated with 28-day mortality were advanced age (p < 0.000), increasing number of organ dysfunction (p = 0.033), presence of congestive heart failure (p = 0.004), and the presence of cancer (p = 0.034); factors associated with prolonged hospital stay were advanced age, presence of chronic obstructive airway disease (p = 0.003), advanced age (p = 0.041), and the use of NIV support (p = 0.001). In multivariate analysis, weak associations between in-hospital mortality and Sequential Organ Failure Assessment score >6 (p = 0.226) and increased number of organ dysfunction (p = 0.108) were demonstrated; there was a trend of prolonged length of stay with increased age (p = 0.139). Conclusion: Our experience and knowledge in managing sepsis patients in the emergency medical ward with implementation of critical care bed services increased significantly. These preliminary results demonstrated that, with appropriate patient selection, sepsis patients can be safely managed in the emergency medical ward. Further study with larger sample size is needed to identify risk factors of adverse outcomes in this group of patients managed in the emergency medical ward.

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Rates and Mechanisms of Clot Lysis During Various Streptokinase (SK)-Plasminogen (PLGN) Treatments

10.1055/s-0039-1684723 ◽

1979 ◽

Author(s):

P.J. Gaffney ◽

A.N. Whitaker

Keyword(s):

Molecular Weight ◽

Gel Electrophoresis ◽

Fibrin Clot ◽

Clot Lysis ◽

Two Dimensional ◽

D Dimer

Iodine labelled washed plasma clots were immersed alternately in SK solutions (7.5-4000 iu/ml) and lys-PLGN solutions (2.0 PLGN units/ml) and lysis rates were assessed by release of the 125I label. The composition of the lysates obtained during the SK → PLGN and PLGN → SK regimens was studied by detergent gel electrophoresis and by two-dimensional Immunoelectrophoresis. Lysis rates were also monitored in serum and plasma environments compared to buffered systems. Clots lysed completed in buffered PLGN during the SK → PLGN regimen while the PLGN → SK regimen yielded only partial lysis;the composition of the respective lysates suggested a more vigorous digestive procedure (free D dimer and fragment E present) during the SK → PLGN regimen. During the buffered PLGN → SK regimen the concentration of SK marginally affected lysis rates while a concentration of 125-250 iu/ml was found optimal during the SK → PLGN regimen. These data were confirmed when lysis was achieved in serum and plasma using an SK → PLGN regimen and suggested that the inhibitive effect of fibrin clot lysis was in the order:serum inhibitors, SK antibodies and fibrinogen. Lysis of clots in serum or plasma with either regimen always yielded only D dimer-E and its higher molecular weight complexes.

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Fibrinolysis during liver transplantation: analysis by the Thrombodynamics method

Journal of Clinical Pathology ◽

10.1136/jclinpath-2018-205560 ◽

2019 ◽

Vol 72 (9) ◽

pp. 636-638

Author(s):

Stéphanie Roullet ◽

Sylvie Labrouche ◽

Geneviève Freyburger

Keyword(s):

Liver Transplantation ◽

Observational Study ◽

Dynamic Analysis ◽

Fibrin Clot ◽

Clot Lysis ◽

Lysis Time ◽

Three Samples ◽

Euglobulin Clot Lysis Time ◽

Fibrinolytic Capacity ◽

Clot Lysis Time

An issue in orthotopic liver transplantation (OLT) is the diagnosis of hyperfibrinolysis. The Thrombodynamics-4D assay (TD4D) is a videomicroscopy system allowing the dynamic analysis of fibrin clot. Fibrinolysis is highlighted by a change in clot intensity. The aim of this observational study was to evaluate the TD4D as a tool to diagnose fibrinolysis during OLT. Thirty consecutive patients were included. We studied a subset of 41 samples from 13 patients who demonstrated hyperfibrinolysis during OLT by global fibrinolytic capacity studied by the Lysis Timer (GFC/LT) and/or euglobulin clot lysis time (ECLT) and/or EXTEM maximum lysis (EXTEM ML) on ROTEM. Three samples exhibited fibrinolysis. They exhibited significantly shorter ECLT, higher lysis on EXTEM graphs, shorter GFC/LT clot lysis time and higher t-PA activity values. After adding urokinase, 13 samples exhibited fibrinolysis. In conclusion, TD4D allows the dynamic analysis of fibrin clot formation and lysis. It only recognises the most severe forms of hyperfibrinolysis during OLT.

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Fibrin clot structure - pro-fibrinolytic effect of oral contraceptives in apparently healthy women

Thrombosis and Haemostasis ◽

10.1160/th16-10-0748 ◽

2017 ◽

Vol 117 (04) ◽

pp. 700-705 ◽

Cited By ~ 12

Author(s):

Cornelis Kluft ◽

Andrea Krug ◽

Ulrich Winkler ◽

Jørgen Jespersen ◽

Jørgen Gram ◽

...

Keyword(s):

Plasma Concentration ◽

Oral Contraceptives ◽

Thrombin Generation ◽

Fibre Diameter ◽

Coagulation Factors ◽

Fibrin Clot ◽

Coagulation System ◽

Clot Lysis ◽

Fibrin Structure ◽

D Dimer

SummaryFibrin metabolism is influenced by many factors. The velocity of fibrin formation, genetic polymorphisms, fibrinolytic features and the structure of the fibrin clot are determinants of fibrin turnover. Oral contraceptives (OCs) have significant impact on the haemostatic system, by increasing the concentration of coagulation factors, plasminogen and tissue plasminogen activator activity, and decreasing the concentration of haemostatic inhibitors. The present study addresses the influence of OCs on fibrin structure and fibrin metabolism. The study included 70 women treated with seven different OC-formulations. Blood was collected at baseline and after six months of OCs. The plasma concentration of fibrinogen, thrombin-antithrombin complex (TAT), plasminogen, plasmin-antiplasmin complex (PAP), D-Dimer and thrombin generation measures were determined. Fibrin structure measures and fibrin clot lysis not affected by the plasma concentration of plasminogen activators and inhibitors were determined. OCs increased the concentration of fibrinogen, TAT, plasminogen, PAP and D-dimer significantly and affected measures of thrombin generation (p<0.001). The maximal optical density of fibrin (p<0.001), the fibrin fibre density (p=0.03), fibrin fibre diameter (p=0.003), fibrin mass-length ratio (p<0.001) and lysis per hour (p<0.001) increased significantly upon OC-treatment. Lysis per hour was not correlated to the concentration of plasminogen. We conclude that the effect of OCs on the coagulation system is balanced by alterations in fibrin structure, facilitating clot lysis and contributing to the fibrinolytic susceptibility already present in women treated with OC. These alterations may counterbalance the OC-induced increased thrombin generation and reduced coagulation inhibitory potential, contributing to maintenance of the haemostatic balance in women receiving OCs.

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Combination of Antibiotic Treatment with the Thrombin Inhibitor Recombinant Hirudin for the Therapy of Experimental Klebsiella pneumoniae Sepsis

Thrombosis and Haemostasis ◽

10.1055/s-0038-1642520 ◽

1994 ◽

Vol 71 (06) ◽

pp. 768-772 ◽

Cited By ~ 14

Author(s):

Gerhard Dickneite ◽

Jörg Czech

Keyword(s):

Septic Shock ◽

Klebsiella Pneumoniae ◽

Organ Failure ◽

Therapeutic Effect ◽

Disseminated Intravascular Coagulation ◽

Post Infection ◽

Thrombin Inhibitor ◽

Bolus Administration ◽

Bacterial Burden ◽

Recombinant Hirudin

SummaryRats which were infected with the gramnegative pathogen Klebsiella pneumoniae develop disseminated intravascular coagulation (DIC), multi-organ failure (MOF) and finally die in a septic shock. We investigated the therapeutic effect of antibiotic (tobramycin) treatment combined with the infusion of the highly specific thrombin inhibitor rec. hirudin. Although administration of 2 mg/kg tobramycin alone leads to a decrease of the bacterial burden, DIC could not be prevented. Infusion of rec. hirudin (0.25 mg/kg x h) for 4 h (start of treatment 1 h post infection), in addition to a bolus administration of tobramycin, led to an amelioration of DIC parameters as fibrinogen, thrombin-antithrombin complex (TAT) and platelets. Serum transaminase levels (GOT, GPT) as a marker of MOF were significantly improved by rec. hirudin, the T50 value increased from 17 h in the tobramycin group to 42 h in the tobramycin + rec. hirudin giuup, muilality rates were 90% or 60%, respectively. Combination of heparin (10011/kg x h) and tobramycin was not effective on survival.

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Association of Increased Fibrin Turnover and Defective Fibrinolytic Capacity with Leg Atherosclerosis

Thrombosis and Haemostasis ◽

10.1055/s-0038-1648855 ◽

1994 ◽

Vol 72 (02) ◽

pp. 292-296 ◽

Cited By ~ 24

Author(s):

M Cortellaro ◽

E Cofrancesco ◽

C Boschetti ◽

L Mussoni ◽

M B Donati ◽

...

Keyword(s):

Arterial Disease ◽

Venous Stasis ◽

Stepwise Discriminant Analysis ◽

Predisposing Factor ◽

Risk Of Death ◽

Peripheral Arterial ◽

Fibrinolytic Potential ◽

Fibrinolytic Capacity ◽

Control Study ◽

D Dimer

SummaryPatients with peripheral arterial disease have a high risk of death from cardiovascular events. As defective fibrinolysis associated with leg atherosclerosis has been suggested as a predisposing factor, we sought a relation among decreased fibrinolysis, the presence of leg atherosclerosis and the incidence of thrombotic events in a case control study nested in the PLAT.Fifty-eight patients with coronary and/or cerebral atherothrombotic disease, free of leg atherosclerosis at Doppler examination, were compared with 50 atherosclerotic patients with leg involvement. High D-dimer (153.0 vs 81.3 ng/ml, p <0.001) and tPA antigen before venous stasis (14.4 vs 11.8 ng/ml, p <0.03), and low tPA antigen (6.7 vs 15.6 ng/ml, p <0.01) and fibrinolytic activity released after venous stasis (fibrinolytic capacity: 113.2 vs 281.4 mm2, p <0.001) were found in patients with leg atherosclerosis. D-dimer and fibrinolytic capacity, in addition to age, were selected by stepwise discriminant analysis as characterizing patients with leg atherosclerosis. Moreover, higher D-dimer and tPA inhibitor characterized patients with leg atherosclerosis who subsequently experienced thrombotic events.These findings constitute evidence of high fibrin turnover and impaired fibrinolytic potential in patients with leg atherosclerosis. Thus impaired fibrinolysis may contribute to the prothrombotic state in these patients.

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