Pathologic cells as procoagulant substance of disseminated intravascular coagulation syndrome in acute promyelocytic leukemia.

Pathologic cells of acute promyelocytic leukemia were studied as a potential trigger substance for disseminated intravascular coagulation syndrome (DIC).The pathologic cells had both procoagulant and fibrinolytic activity. When this substance was separated by Sephadex G-200 column chromatography, procoagulant activity and fibrinolytic activity were observed in the same peak. Procoagulant activity was proven by prothrombin conversion activity, and fibrinolytic activity was proven by plasminogen free and plasminogen rich fibrin plate method. This procoagulant activity was inhibited by Trasylol and heparin, and fibrinolytic activity was inhibited by Trasylol and soybean trypsin inhibitor (STI). From the point of the effect of these inhibitors on the proteolytic action of the pathologic cells, Trasylol administration should be the best treatment for DIC of acute promyelocytic leukemia because Trasylol inhibited both hypercoagulation and hyperfibrinolysis.When the lysate of the pathologic cells of acute promyelocytic leukemia was infused into a rabbit, typical DIC was observed in laboratory studies, and many fibrin thrombi were observed in kidneys and lungs.     

Elevated levels of thrombin-heparin cofactor II complex in plasma from patients with disseminated intravascular coagulation.

An ELISA assay for quantitation of the thrombin-heparin cofactor II complex (T-HC II) in plasma was developed. Plasma was incubated with immobilized, specific antibodies to human thrombin. The second, biotinylated antibody was directed against human HC II. The assay was insensitive to thrombin-antithrombin complex (TAT) and to uncomplexed HC II. In plasma samples from 31 normal individuals (aged 21-68, mean 43.3 years), the T-HC II ranged 0.3-6.1 ng/ml; median 1.5, mean 2.0, and SD 1.6 ng/ml. In plasma samples from 13 patients with disseminated intravascular coagulation (DIC), T-HC II ranged 0.4-30.0 (median 13.5) ng/ml. In plasma samples from 6 patients in which the clinical suspicion of DIC was not verified, T-HC II complex ranged 1.4-14.3 (median 3.6) ng/ml. In plasma samples with elevated T-HC II levels, TAT was usually elevated, and on the average more than was T-HC II. These results indicate that HC II contributes significantly to the inactivation of in vivo generated thrombin.     

Heparin cofactor II determination--levels in normals and patients with hereditary antithrombin III deficiency and disseminated intravascular coagulation

A technique is described to completely remove antithrombin III (AT) from small amounts of human plasma by immunoaffinity chromatography on antibodies against human AT linked to Sepharose 4B. The level of heparin cofactor II (HCII) was not affected by the immunoadsorption. HCII activity was then determined by measuring the rate of human thrombin inhibition by 3 ways: a) activation with heparin in AT-free plasma, b) activation with dermatan sulfate in normal plasma and c) activation with dermatan sulfate in AT-free plasma. The normal range of HCII varied between 0.7-1.5 U/ml, as compared to a normal plasma pool containing by definition 1 U/ml. Highly significant correlations between assays as obtained from 40 normal plasmas proved the suitability of the 3 assays, although the progressive thrombin inhibition by AT, when not removed, contributed about one fifth to the thrombin inhibition by HCII in the presence of dermatan sulfate. There were also highly significant correlations between HCII activity and antigen, as determined by rocket immunoelectrophoresis using specific antibodies against HCII. Levels of HCII and AT were examined in 7 patients with hereditary AT deficiency and 7 patients with disseminated intravascular coagulation (DIC). In hereditary AT deficiency, whereas the AT activity was reduced by half, levels of HCII activity and antigen were in the normal range. In DIC, a parallel decrease of HCII and AT suggests that HCII may participate in the inhibition of thrombin released during DIC and thus provides an inhibitor reserve, once the AT level becomes subnormally low.     

Thrombopenia and disseminated intravascular coagulation during treatment with heparin: 2 cases with neurological complications

We report two cases of heparin-induced thrombocytopenia (H.T.) associated with a disseminated intravascular coagulopathy (DIC). Heparin was prescribed after a cerebral infarct in the first case and after an orthopedic surgical procedure in the second case. The DIC induced neurological complications and the death of both patients. Heparin-induced thrombocytopenia is common but is exceptionally associated with neurological symptoms. Heparin-induced DIC is quite uncommon, since only 20 cases have been reported but neurological complications (focal deficits or disturbances of consciousness) are noted in about one third of the cases and the outcome is fatal in 60 percent of the cases. The treatment of heparin-induced DIC and thrombocytopenia is disappointing. Monitoring of the platelets count is warranted during heparin treatment to prevent this severe complication.     

Thrombomodulin alfa treatment in patients with acute promyelocytic leukemia and disseminated intravascular coagulation: A retrospective analysis of an open-label,multicenter, post-marketing surveillance study cohort

Introduction

Patients with acute promyelocytic leukemia (APL) can develop disseminated intravascular coagulation (DIC) that results in life-threatening hemorrhagic complications. Studies regarding the safety and efficacy of thrombomodulin alfa (TM-α; recombinant human soluble thrombomodulin) in patients with APL and DIC are limited.

Materials and methods

A retrospective evaluation was performed on a cohort of 172 patients with APL from an open-label, multicenter, post-marketing surveillance study of TM-α.

Results

Of the 172 patients, 31 were relapse/refractory APL patients, and 141 were newly diagnosed APL patients. Within the first 30 days, 24 patients (14.0%) died, and six of those deaths (3.5%) were due to hemorrhage. In total, 12 patients (7.0%) had severe hemorrhagic complications. Both the early death rate due to hemorrhage as well as the severe hemorrhage rate did not exceed those in some recent population-based studies of patients with APL. Forty-nine patients received TM-α prior to the initiation of antileukemic treatment, and one patient experienced hemorrhagic early death (ED), suggesting that early TM-α treatment appeared to result in a reduction in the hemorrhagic ED rate. Moreover, TM-α improved coagulopathy regardless of concomitant all-trans retinoic acid treatment.

Conclusions

This study confirmed the safety and efficacy of TM-α in daily clinical practice for patients with APL and DIC. TM-α appeared to reduce hemorrhagic early deaths due to DIC in patients with APL who were receiving antileukemic treatment.     

Consumption of heparin cofactor II (dermatan sulfate cofactor) and antithrombin during coagulation

In vitro coagulation produces a consumption of heparin co factor II (HC II) of 8-10% both in plasma from normal individuals and patients whereas antithrombin (AT) consumption ranges 40-50%. In blood from heparin treated patients consumption is similar or greater. In blood from warfarin treated patients, consumption is decreased. Addition of heparin prior to clotting has little effect on HC II consumption, but high heparin concentration reduces AT consumption. Addition of dermatan sulfate has no effect on AT consumption, but increases HC II consumption dramatically. In consumption coagulopathy, the HC II levels are as low as AT, possibly reflecting intravascular consumption accelerated by vascular glycosaminoglycans.     

Immunologic measurement of antithrombin III-heparin cofactor and alpha2 macroglobulin in disseminated intravascular coagulation and hepatic failure coagulopathy.

Antithrombin III (AT III) and α₂Macroglobulin (α-2M) were measured immunologically in the plasma of five patients with Disseminated Intravascular Coagulation (DIC) and eight with severe hepatic failure. In DIC secondary to sepsis both AT III and α-2M levels fell to very low levels. When DIC was associated with hepatic failure or with aspirin overdosage, α-2M levels remained near normal while AT III levels were low. In hepatic failure without associated DIC, α-2M levels remained elevated while AT III was found to be extremely low. The significance of these findings is discussed.     

Changes in plasma thrombomodulin antigen in rabbit developing endotoxin-induced disseminated intravascular coagulation and the effect of heparin.

Soluble thrombomodulin (TM) antigen level was 1.64 +/- 0.64 microgram/ml (n = 18, mean +/- S.D.) in plasma of normal male rabbits as measured by enzyme immunoassay, and the antigen consisted of subspecies of 94, 83 and 51 kd. When disseminated intravascular coagulation (DIC) was induced by intravenous infusion of endotoxin into rabbits, the TM antigen level in plasma was elevated to about 1.5 times of the control value, and an increase in the 83 kd subspecies as well as the appearance of new subspecies of 76 and 48 kd was observed concomitantly with disappearance of the 94 kd subspecies in plasma. Elevation of the antigen level and disappearance of the 94 kd subspecies caused by infusion of endotoxin were reduced by simultaneous infusion of heparin. Addition of leukocytes stimulated with endotoxin plus FMLP to cultured endothelial cells induced release of TM antigen to the medium accompanying cell injury as measured by 51Cr release, which was prevented by treatment with heparin. It was suggested that the increase in plasma TM antigen level in parallel with the generation of DIC reflected endothelial injury of rabbits, and that the elevation of TM antigen and the endothelial cell injury were prevented by heparin treatment.     

Fibrinolysis and fibrinogenolysis in disseminated intravascular coagulation

In order to assess precisely the fibrinolytic state in disseminated intravascular coagulation (DIC), plasma levels of fibrinogenolysis products (FgDP), fibrinolysis products (FbDP) and fibrinogenolysis plus fibrinolysis products (TDP) were measured with newly developed enzyme-linked immunosorbent assays based on monoclonal antibodies in 72 patients with DIC at presentation. Not only FbDP and TDP but also FgDP were markedly elevated in patients with DIC. When analyzed according to the underlying disease categories, the relative proportion of FgDP to TDP was high in patients with acute promyelocytic leukemia and vascular diseases, and it was the lowest in patients with sepsis. Correlation analysis revealed that plasma levels of FgDP correlated negatively with alpha 2-antiplasmin and positively with plasmin-alpha 2-antiplasmin complex (PAP) and a ratio of PAP to thrombin-antithrombin III complex (TAT). These findings indicate that besides fibrinolysis, fibrinogenolysis is markedly accelerated in the majority of the patients with DIC.     

Juvenile cerebral infarction associated with heparin cofactor II abnormality. A case report]

A 15-year-old woman with a history of transient dysarthria two years before, suddenly developed weakness of right upper extremity, right facial palsy, and dysarthria. She was admitted to our hospital on the third day. She had no hypertension, heart murmur and oedema. On neurological examination, she had mild right hemiparesis including face muscles and mild dysarthria. The right knee jerk was brisk with no Babinski's sign. Ataxia and sensory disturbance were not present. T2-weighted MRI showed a hyperintensity at the posterior limb of the left internal capsule. Cerebral angiography was unremarkable. Ultracardiography and 24-hour electrocardiography were normal. Laboratory data revealed no inflammatory findings, liver dysfunction, hyperglycemia and hyperlipidemia. Antinuclear and anticardiolipin antibodies were negative. Prothrombin time was normal, but activated partial thromboplastin time was slightly prolonged (35.4 sec, normal 25.2-34.4). Protein C, protein S and antithrombin III were normal. Heparin cofactor II (HC II) activity was decreased (44%) with normal HC II antigen (79%) and so she was diagnosed as heparin cofactor II deficiency type II (heparin cofactor II abnormality). Her father manifesting thromboangitis obliterans also had low HC II activity with normal HC II antigen. However, on her genetic analysis, we didn't detect any mutations in the coding region of HC II gene. Until now she has no recurrence of cerebrovascular attacks. On the basis of these results, we suspect that HC II deficiency was a possible risk factor of cerebral infarction in this case because she was so young and had no general risk factors except for HC II. No stroke associated with HC II deficiency type II has been reported up to date. This case is worth considering etiologies of juvenile cerebral infarction.     

Neutrophil CD64 expression is associated with severity and prognosis of disseminated intravascular coagulation

INTRODUCTION: Although neutrophil can be activated by microcirculatory disturbances in DIC, its relation with the severity and prognosis of DIC has not been elucidated. We investigated the relationship between neutrophil activation and DIC severity and determined the prognostic value of neutrophil activation markers in patients with DIC. MATERIALS AND METHODS: We measured two neutrophil activation markers, neutrophil CD64 expression and plasma neutrophil elastase, in 94 patients with suspected DIC and 55 healthy controls. Neutrophil CD64 expression and plasma neutrophil elastase were measured using CD64 quantitation kit, and PMN Elastase enzyme immunoassay kit. RESULTS: Neutrophil CD64 expression and plasma neutrophil elastase level were significantly increased in patients with overt and non-overt DIC compared to normal controls (P<0.001, each). Neutrophil CD64 expression showed a significant linear trend of increase with increasing DIC score (P<0.001). In DIC patients, significant differences were observed between those with and without infection both in overt (P=0.003) and non-overt DIC (P=0.004). Neutrophil CD64 expression was significantly increased in 28-day non-survival group compared to survival group in both overt (P<0.001) and non-overt DIC (P=0.032). The 28-day survival rate showed a stronger association with the neutrophil CD64 expression (P<0.001) than with DIC score (P=0.028) or plasma neutrophil elastase level (P=0.246). CONCLUSIONS: Neutrophil CD64 expression is significantly correlated with DIC severity and has a good predictive value for the 28-day mortality in patients suspected of having DIC. Neutrophil CD64 expression might be useful in monitoring the disease course and in predicting mortality in DIC patients.     

Experimental disseminated intravascular coagulation effect of heparin and e-aminocaproic acid on test of hemostatic function

In an effort to evaluate some laboratory procedures and therapeutic modalities commonly employed in patients suspected of suffering from disseminated intravascular coagulation (DIC), such a state was induced in dogs by means of intravascular infusion of Thrombin. The laboratory procedures included the protamine sulfate and ethanol gelation tests, platelet count, prothrombin time, partial thromboplastin time, thrombin time, fibrinogen concentration and euglobulin lysis time. Heparin, e-aminocaproic acid, and a combination of both drugs represented the therapeutic measures used. Of the laboratory tests mentioned, the protamine sulfate test was both sensitive and specific and was therefore considered the most useful procedure in recognizing intravascular fibrin formation. As regards the other tests, a marked drop in the fibrinogen level and in the platelet count were the most consistent findings. The thrombin time tended to be markedly prolonged, whereas the euglobulin lysis time was found to undergo the least change. The effect of treatment was gauged by the extent to which the drugs employed appeared to minimize the change in results of the various tests caused by thrombin infusion. The combination of Heparin with e-aminocaproic acid seemed to be most effective in this respect, particularly with regard to the platelet count and the fibrinogen level. The Reptilase time which replaced the thrombin time in the testing of Heparin-containing blood specimens was very useful in monitoring the effect of Heparin in the prevention or treatment of thrombin-induced changes in the laboratory tests.     

The effect of heparin on multiple organ failure and disseminated intravascular coagulation in a sepsis model

In order to elucidate a possible role of hypercoagulability leading to disseminated intravascular coagulation (DIC) in the pathogenesis of multiple organ failure (MOF), unfractionated heparin and the related agents were administered to septic rabbits which manifest DIC and MOF. Administration of heparin resulted in prevention of thrombocytopenia, leukopenia and elevation of plasma bilirubin and creatinine. The morphological hepatic damage was also ameliorated by heparin. Similar favorable effects were obtained by the administration of low molecular weight heparin. Dextran sulfate prevented the hepatic damage to some extent without improvement on other parameters. No significant effect was observed by the administration of a synthetic thrombin inhibitor (MD805). These results indicate that the favorable effect of heparin is due to its anticoagulant property, especially anti-Xa activity. Thereby, it is concluded that the hypercoagulable state leading to DIC is a prerequisite for the occurrence of MOF in sepsis.