Blood derivative therapy

There are three main components manufactured from whole blood: red blood cells (RBCs), plasma, and platelets. Plasma contains a multitude of different proteins, peptides, and biologic substances. Approximately 53 million liters of plasma was collected in the United States in 2019. Following collection, plasma is frozen and manufactured into plasma-derived medicinal products (PDMPs). During the manufacture process, several thousand plasma units are pooled for Cohn fractionation, which is based upon cold ethanol precipitation of proteins. The PDMPs are further prepared using ion exchange or affinity chromatography and additional steps to inactivate and remove infectious diseases such as viruses. Almost 20 different therapeutic plasma proteins are purified from plasma via these multi-step manufacturing processes. Interestingly, the demand for pharmaceutical plasma products, particularly intravenous immunoglobulin (IVIG) products, has been increasing. The manufacture and therapeutic role of blood derivatives particularly immunoglobulin therapy, Rh immunoglobulin (RhIG), COVID-19 convalescent plasma (CCP) and hyperimmune globulins, albumin, clotting factors, fibrin sealants, and platelet rich plasma will be described.Copyright © 2022 AME Publishing Company. All Rights Reserved.

Galectin-3 as a possible marker for increased thrombogenicity in COVID-19

Background: Galectin-3 is a beta-galactoside-binding lectin that has been described to be overexpressed in inflammation, atherosclerosis, and in myocardial fibrosis. In COVID-19, galectin-3 has been proposed as an important regulator of the inflammatory response and fibrosis processes. The role of galectin-3 as a platelet activator and thrombosis enhancer has been also recently described. However, the role of galectin-3 in the thrombotic risk in COVID-19 hasn't been studied extensively. Method(s): Patients with moderate to severe COVID-19 were included in the study. Hospitalized patients with acute respiratory diseases without COVID-19 were examined as controls. We compared the levels of galectin- 3, soluble ST2, tissue factor and tissue factor activity (TFa) as well as several other markers of increased thrombogenicity in both groups. The correlations between galectin-3 and coagulation as well as inflammation markers were assessed. The SOFA score was used as a marker for the clinical outcome. Result(s): 93 patients were included into the study of which 56 were SARS-CoV-2 positive (COV+) and 37 were SARS-CoV-2 negative controls (COV-). Galectin-3 levels were higher in the COV+ group (median 7.10 ng/ml [IQR 4.61-9.81] vs. 5.47 ng/ml [3.63-6.66] p=0.016) as well as the TFa (median 334.48 pM [115.19-632.58] vs. 134.02 pM [86.92- 206.66]) and the ST2 levels (median 5.49 ng/ml [2.40-9.28] vs. 2.19 ng/ml [0.66-3.91] p<0.001). We also observed a positive correlation between galectin-3 and IL-6 (r=0.559, p<0.001), ST2 (r=0.332, p=0.005), SOFA score (r=0.441, p=0.003), von Willebrand factor (r=0.401, p<0.001), plasminogen (r=0.361, p=0.001), antithrombin (r=0.453, p<0.001), and Ddimer (r=0.377, p=0.001). Conclusion(s): In patients with acute respiratory diseases, especially with COVID-19, galectin-3 is a marker for increased hypercoagulability and worse clinical outcome. Galactin-3 might be a useful therapeutic target for patients with COVID-19.

Evaluation of the protein C pathway in critically ill patients with severe COVID-19 as compared to bacterial sepsis

Introduction Endothelial dysfunction has been shown to play a role in severe COVID-19, the pathophysiology of which may be attributed to a myriad of factors including unmitigated immune and inflammatory response, viral-induced injury to the endothelium, end-stage organ failure, and coagulopathy. In addition, severe COVID-19 is most often seen in patients with multiple comorbidities, which themselves are often associated with endothelial dysfunction (such as myocardial and renal failure, as well as thrombotic disorders). However, the literature is still emerging on this topic and there appears to be no consensus on the extent to which endothelial dysfunction plays a role in severe COVID-19. Method The aim of this study was to assess the functionality of the endothelial protein C pathway in hospitalized patients > 18 years of age with severe COVID-19 as compared to those hospitalized with bacterial sepsis. COVID-19 (n = 31) and sepsis (n = 47) patients who were admitted to the ICU were assessed for rates of thrombin and activated protein C (APC) generation. Indirect markers of thrombin formation, including thrombin-antithrombin (TAT) complex, prothrombin fragment 1 + 2 (F1 + 2), as well as D-dimer, and protein C (PC) were measured additionally. Statistical analysis was performed via the Mann-Whitney test and a p value of < 0.05 was considered statistically significant. Results Plasma levels of free thrombin in COVID-19 and sepsis patients did not differ significantly, with (median, IQR) 0.59 (0.46-1.21) vs 0.57 (0.46-1.10) pmol/L, respectively. TAT was also increased at similar extent in both cohorts (192;111-325 pmol/L in COVID-19 patients, 148;73-213 pmol/L in sepsis patients), whereas F1 + 2 was higher in COVID-19 than in sepsis patients, with 850 (440-1940) vs 380 (130-620) pmol/L (p = 1.3 x 10-5). Interestingly, rates of APC formation did not significantly differ between the two groups, with 7.47 (1.99- 19.14) vs 9.87 (2.08-16.87) pmol/L ( Fig. 1). D-dimer and protein C were significantly higher in the COVID-19 patients than in those with sepsis (14.3 vs 8.1 mg/L, p = 0.01, and 92.9 % vs 58.5 %, p = 3x10-8, respectively). Conclusion We hypothesized that APC formation rates in response to thrombin formation would be significantly lower in patients with severe COVID-19 as compared to those with bacterial sepsis due to the well-known association between severe COVID-19 disease burden and endothelial dysfunction due to the downregulation of thrombomodulin expression. However, our results indicate that this may not be universally true in this patient population, as our observations suggest a largely intact functionality of the protein C pathway. Further studies are warranted to investigate the pathophysiology of severe COVID-19. (Figure Presented).

The predictive value of coagulation parameters for the course of disease in COVID-19 patients

Introduction COVID-19 is a systemic disease associated with a high incidence of thrombotic complications. In this study we aimed to identify coagulation parameters as predictors of mortality in hospitalized patients with severe COVID- 19 infection. Method We conducted a non-interventional, national, monocentric observational study of patients treated for COVID infection at the ICU at Frankfurt University Hospital. A total of 410 patients were enrolled in the study between April 1, 2020 and December 31, 2021. Patients had to be 18 years or older and the diagnosis was confirmed by COVID real-time PCR. Coagulation parameters were analysed once on admission to the clinic and 5 to 8 days later. Variables studied included thromboplastin time, aPTT, fibrinogen, D-dimers, antithrombin, hs-troponin, all coagulation factors and vWF antigen, protein C and protein S. Data was also collected on age, sex, comorbidities, medication, and invasive ventilation, ECMO therapy and dialysis. In order to compare patients regarding their general disease status, the SAPS-II and the Horovitz index were determined at the beginning and end of the observation period. Univariate and multivariate logistic regression models were then used to screen coagulation parameters for association with mortality in critically ill COVID patients. Results The arithmetic mean age of patients was 60.9 ( +/- 14.7) years, with 76.1 % being male. Of 410 patients, 259 (63.2 %) received invasive ventilation, 95 (23.2 %) received ECMO therapy and 105 (25.6 %) received renal replacement therapy. The median inpatient length of stay was 16 (IQR: 10-29) days and ICU length of stay was 12 (IQR: 6-25) days. 176 patients (43 %) died because of their COVID disease, 234 (57 %) were discharged home or to other facilities for further treatment. In univariate logistic regression, increased age (OR = 1,029, 95 %-CI [1,013- 1,1,044]), higher SAPS-II (OR = 1,031, 95 %-CI [1,018-1,045]), fibrinogen (OR = 1,002, 95 %-CI [1,001-1,003]), FVIII (OR = 1,004, 95 %-CI [1,001-1,007]) and vWF antigen (OR = 1,005, 95 %-CI [1,003-1,007]) as well as lower antithrombin (OR = 0,981, 95 %-CI [0,971-0,991]), FII (OR = 0,983, 95 %-CI [0,972-0,993]), FXIII (OR = 0,992, 95 %-CI [0,986-0,999]), Horovitz index at admission (OR = 0,994, 95 %-CI [0,990-0,997]) and decreased protein C activity (OR = 0,989, 95 %-CI [0,982-0,996]) were associated with increased mortality. In the final multivariate regression analysis with backward elimination, low antithrombin activity (OR = 0.987, 95 %-CI [0.974-1.000]), high vWF antigen levels (OR = 1.004, 95 %-CI [1.002-1.007]) and a low Horovitz index (OR = 0.993, 95 %-CI [0.989-0.997]) were identified as independent predictive factors for increased mortality. Conclusion In the study of 410 COVID patients requiring intensive care, the Horovitz index, antithrombin activity and vWF antigen on hospital admission were identified as independent predictors of mortality.

Antithrombin Activity Is Associated with Persistent Thromboinflammation and Mortality in Patients with Severe COVID-19 Illness.

INTRODUCTION: Severe COVID-19 illness can lead to thrombotic complications, organ failure, and death. Antithrombin (AT) regulates thromboinflammation and is a key component of chemical thromboprophylaxis. Our goal was to examine the link between AT activity and responsiveness to thromboprophylaxis, markers of hypercoagulability, and inflammation among severe COVID-19 patients. METHODS: This was a single-center, prospective observational study enrolling SARS-CoV-2-positive patients admitted to the intensive care unit on prophylactic enoxaparin. Blood was collected daily for 7 days to assess AT activity and anti-factor Xa levels. Patient demographics, outcomes, and hospital laboratory results were collected. Continuous variables were compared using Mann-Whitney tests, and categorical variables were compared using χ2 tests. Multivariable logistic regression was used to determine the association between AT activity and mortality. RESULTS: In 36 patients, 3 thromboembolic events occurred, and 18 (50%) patients died. Patients who died had higher fibrinogen, D-dimer, and C-reactive protein (CRP) levels and lower AT activity. Reduced AT activity was independently associated with mortality and correlated with both markers of hypercoagulability (D-dimer) and inflammation (CRP). CONCLUSION: Low AT activity is associated with mortality and persistent hypercoagulable and proinflammatory states in severe COVID-19 patients. The anti-thromboinflammatory properties of AT make it an appealing therapeutic target for future studies.

Increased risk of dialysis circuit clotting in hemodialysis patients with COVID-19 is associated with elevated FVIII, fibrinogen and D-dimers.

INTRODUCTION: Severe COVID-19 infections increase the risk of thrombotic events and Intensive Care Units reported increased extracorporeal circuit clotting (ECC) in COVID-19 patients with acute kidney injury. We wished to determine whether hemodialysis (HD) patients with COVID-19 also have increased risk of circuit clotting. METHODS: We reviewed coagulation studies and HD records, 4 weeks before and after COVID-19 polymerase chain reaction detection in HD patients between April 2020 and June 2021. FINDINGS: Sixty-eight (33.5%) of 203 HD patients with COVID-19, 65% male, mean age 64.9 ± 15.3 years, experienced some circuit clotting, and no clotting recorded prior to positive test results. In those who experienced ECC, prothrombin, activated partial thromboplastin or thrombin times were not different, whereas median factor VIII (273 [168-419] vs. 166 [139-225] IU/dl, p < 0.001), D-dimers (2654 [1381-6019] vs. 1351 [786-2334] ng/ml, p < 0.05), and fibrinogen (5.6 ± 1.4 vs. 4.9 ± 1.4 g/L, p < 0.05) were greater. Antithrombin (94 [83-112] vs. 89 [84-103] IU/dl), protein C (102 [80-130] vs. 86 [76-106] IU/dl), protein S (65 [61-75] vs. 65 [52-79] IU/dl) and platelet counts (193 [138-243] vs. 174 [138-229] × 109 /L) did not differ. On multivariable logistic analysis, circuit clotting was associated with log factor VIII (odds ratio [OR] 14.8 (95% confidence limits [95% CL] 1.12-19.6), p = 0.041), fibrinogen (OR 1.57 [95% CL 1.14-21.7], p = 0.006) and log D dimer (OR 4.8 [95% CL 1.16-12.5], p = 0.028). DISCUSSION: Extracorporeal circuit clotting was increased within 4 weeks of testing positive for COVID-19. Clotting was associated with increased factor VIII, fibrinogen and D-dimer, suggesting that the risk of circuit clotting was related to the inflammatory response to COVID-19.

Native and activated antithrombin inhibits TMPRSS2 activity and SARS-CoV-2 infection.

Host cell proteases such as TMPRSS2 are critical determinants of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) tropism and pathogenesis. Here, we show that antithrombin (AT), an endogenous serine protease inhibitor regulating coagulation, is a broad-spectrum inhibitor of coronavirus infection. Molecular docking and enzyme activity assays demonstrate that AT binds and inhibits TMPRSS2, a serine protease that primes the Spike proteins of coronaviruses for subsequent fusion. Consequently, AT blocks entry driven by the Spikes of SARS-CoV, MERS-CoV, hCoV-229E, SARS-CoV-2 and its variants of concern including Omicron, and suppresses lung cell infection with genuine SARS-CoV-2. Thus, AT is an endogenous inhibitor of SARS-CoV-2 that may be involved in COVID-19 pathogenesis. We further demonstrate that activation of AT by anticoagulants, such as heparin or fondaparinux, increases the anti-TMPRSS2 and anti-SARS-CoV-2 activity of AT, suggesting that repurposing of native and activated AT for COVID-19 treatment should be explored.

Antithrombin Iii (At3) in Covid-19: A Pilot Study Defining At3 Levels and Safety of Exogenous At3

INTRODUCTION: COVID pathogenesis involves a dysregulated inflammatory state and coagulopathy. Affected patients are at risk for thrombosis and bleeding as well as cytokine storming. Antithrombin 3 (AT3) has antiinflammatory and anti-coagulant properties but its role in COVID is unknown. The incidence of AT3 deficiency (< 80% activity) in COVID is unknown. We hypothesize that AT3 supplementation is safe in patients with COVID and AT3 deficiency. METHOD(S): Prospective randomized control trial of COVID, IRB approved at 2 centers from July 2021 to March 2022. Those with plasma AT3< 100% were randomized to either standard of care (SOC) or SOC+AT3 q48hr weight-based for a goal of 120% for up to 5 doses. An additional group with AT3>100% received SOC. Data are compared using ANOVA and Fisher's exact test. Enrollment was concluded early due to reduced COVID cases and reduced length of stay. RESULT(S): In 531 subjects assessed for eligibility, 324 did not meet inclusion criteria, 151 did not consent, 4 withdrew consent, and 52 subjects completed the study. Enrollment AT3 (M+/-SD) was 96+/-12%. AT3 levels were < 100% in 40 (77%) and < 80% in 11(21%). SOC+AT3, SOC only, and AT3>100% had a Disseminated Intravascular Coagulation (DIC) score change (M+/-SD) of 0.4+/-1.5, -0.13+/-1.85 and 0+/-1.2, respectively, (p=0.63). Hospital length of stay was 13.9+/-14.9, 9.1+/-8.4, and 13+/-0.5 days respectively, (p=0.39). Mortality occurred in 2 (10%), 3 (15%), and 3 (25%), respectively, (p=0.56). There was 1 bleeding event in a subject with AT3>100% and no bleeding events were observed with exogenous AT3. There were no observed drug-related adverse events. Of the 18 subjects assigned to receive AT3, 15 received a median of 2 doses (IQR 2) for a total of 38 doses with a median dose of 1825.5 IU (IQR 794). CONCLUSION(S): COVID is associated with a relative AT3 deficiency and was observed in 21% of this cohort with reports of .02% to .2% in the general population. Exogenous AT3 supplementation was safe with no bleeding complications or drug-related adverse events. There was no significant change in outcomes, likely due to under-dosing and sample size. Further studies should evaluate higher doses of exogenous AT3 and focus on higher risk groups.

Pre-analytical screening and removal of Argatroban interference for haemostasis assays

Background: Argatroban is a direct thrombin inhibitor licenced in the UK and USA for treatment of Heparin Induced Thrombocytopenia and has been utilised as alternative anticoagulation for critically ill COVID-19 patients. Interferences in specialised haemostasis assays may be clinically important when bridging anticoagulant regimens or investigating thrombotic and bleeding complications common in critically ill patients. Aim(s): * Assess effect of Argatroban on specialised haemostasis assays * Assess effectiveness of DOAC-Remove (DR) in removing Argatroban interference Methods: Argatroban calibration plasma, spanning concentrations of 0 mug/ml-2.08 mug/ml, was tested for Antithrombin (IIa activator), Factors IX, and XI, and dilute Russel's viper venom time (dRVVT) to assess Argatroban interference. Samples were treated with DOAC-Remove and re-run for these assays. A p value of <0.05 was used to assess significance using paired t-tests Results: * Antithrombin results were significantly and linearly increased by increasing Argatroban concentrations (R -0.99). * Factor IX and XI concentrations were significantly decreased by increasing Argatroban concentrations from 83.4 IU/dl at 0 mug/ml to 3.79 IU/ dL at 2.07 mug/ml Argatroban * dRVVT screen results were significantly increased by increasing Argatroban concentrations (DRVVT ratio 1.07 (no Argatroban) to 3.79 at 2.07 ng/ml Argatroban) * Pre-treatment of samples with DOAC-Remove completely removes Argatroban interference to baseline. Conclusion(s): Argatroban has significant effects on specialist haemostasis assays. Antithrombin overestimation was observed when IIa activator is used, a Xa activator should be considered in such patients. dRVVT screen ratios were significantly increased, which could lead to false positive Lupus anticoagulant results. Factors IX and XI results were significantly decreased. Similar results have been published for direct oral anticoagulants with the need for pre-analytical screening, where anticoagulant status is unknown, becoming more important. For Argatroban, dilute thrombin time can be used as a pre-analytical screening tool. (Table Presented).

High Plasma Levels of Activated Factor VII-Antithrombin Complex Point to Increased Tissue Factor Expression in Patients with SARS-CoV-2 Pneumonia: A Potential Link with COVID-19 Prothrombotic Diathesis.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causal agent of coronavirus disease 2019 (COVID-19), in which coagulation abnormalities and endothelial dysfunction play a key pathogenic role. Tissue factor (TF) expression is triggered by endothelial dysfunction. Activated factor VII-antithrombin (FVIIa-AT) complex reflects indirectly FVIIa-TF interaction and has been proposed as a potential biomarker of prothrombotic diathesis. FVIIa-AT plasma concentration was measured in 40 patients (30 males and 10 females; 64.8 ± 12.3 years) admitted with SARS-CoV-2 pneumonia during the first pandemic wave in Italy. Two sex- and age-matched cohorts without COVID-19, with or without signs of systemic inflammation, were used to compare FVIIa-AT data. The FVIIa-AT plasma levels in COVID-19 patients were higher than those in non-COVID-19 subjects, either with or without inflammation, while no difference was observed among non-COVID-19 subjects. The association between COVID-19 and FVIIa-AT levels remained significant after adjustment for sex, age, C-reactive protein, renal function, fibrinogen, prothrombin time and activated partial thromboplastin time. Our results indicate that SARS-CoV-2 infection, at least during the first pandemic wave, was characterized by high FVIIa-AT levels, which may suggest an enhanced FVIIa-TF interaction in COVID-19, potentially consistent with SARS-CoV-2-induced endotheliopathy.

Fatal Cerebral Venous Thrombosis in a Pregnant Woman with Inherited Antithrombin Deficiency after BNT162b2 mRNA COVID-19 Vaccination.

Antithrombin deficiency is a high-risk factor for venous thromboembolism during pregnancy, whereas cerebral venous thrombosis is rare. Cerebral venous thrombosis related to coronavirus disease 2019 (COVID-19) vaccines has been reported; however, there are a few reports of cerebral venous thrombosis after a messenger RNA (mRNA) vaccination. A 25-year-old female in her sixth week of pregnancy presented with headache 24 days after BNT162b2 mRNA COVID-19 vaccination. The following day, she presented with altered sensorium and was diagnosed with severe cerebral venous thrombosis. She demonstrated heparin resistance and was found to have an inherited antithrombin deficiency. A heterozygous missense variant in SERPINC1 (c.379T>C, p.Cys127Arg, 'AT Morioka') was detected by DNA analysis. Despite intensive care with unfractionated heparin, antithrombin concentrate, and repeated endovascular treatments, she died on the sixth day of hospitalization. Cerebral venous thrombosis in pregnant women with an antithrombin deficiency can follow a rapid and fatal course. Treatment with unfractionated heparin and antithrombin concentrate may be ineffective in severe cerebral venous thrombosis cases with antithrombin deficiency. Early recognition of antithrombin deficiency and an immediate switch to other anticoagulants may be required. Although the association between cerebral venous thrombosis and the vaccine is uncertain, COVID-19 vaccinations may require careful evaluation for patients with prothrombic factors.

Antithrombin as Therapeutic Intervention against Sepsis-Induced Coagulopathy and Disseminated Intravascular Coagulation: Lessons Learned from COVID-19-Associated Coagulopathy.

Recent research has contributed significantly to our understanding of the pathogenesis of acute disseminated intravascular coagulation. COVID-19 can be considered as a new underlying condition of disseminated intravascular coagulation. In this narrative review, current evidence is presented regarding biomarker differences between sepsis-induced and COVID-19-associated coagulopathies, supporting the importance of acquired antithrombin deficiency in the early differential diagnosis of septic coagulopathy and its potential impact on treatment with endogenous anticoagulants. Establishing new scoring systems for septic coagulopathy in combination with endogenous anticoagulant biomarker activities may allow for the identification of those in the heterogeneous population of sepsis patients who are more likely to benefit from targeted specific treatment interventions.

LUSPATERCEPT REDUCES THE BURDEN OF RED BLOOD CELL TRANSFUSION IN PATIENTS WITH BETA -THALASSEMIA AND COMORBIDITIES: THE EXPERIENCE OF A SINGLE THALASSEMIA AND SICKLE CELL UNIT IN A UNIVERSITY HOSPITAL

Background: An erythroid maturation agent, Luspatercept is approved to treat adults with β -thalassemia. Its availability in Greece coincided with severe blood shortages due to the COVID outbreak, making its administration even more necessary. Aims: Luspatarept's usage in patients with comorbidities. Methods: Between May and December 2021, luspatercept was administered for a period of 12 to 24 weeks to twelve individuals with confirmed β -thalassemia (β 0/β +: 4/12, β +/β +:3/12, β 0/β ++:1/12, β 0/β 0 :1/12,β +/β ++:1/12) and significant comorbidities such as chronic heart failure (3/12), osteoporosis (3/12), atrial fibrillation (2/12), extramedullary hematopoiesis (2/12) and cirrhosis (1/12). The average age was 48.3 years;7male /5 female. Prior to initiating luspatercept, the patient's medical history was reviewed for risk factors for thrombophilia (9/12 had low protein S and C and 2/12 had also low ATIII) as well as anticoagulant (4/12 on acenocoumarol) and antiplatelet (3/12 on aspirin ) medication related to splenectomy (10/12) or past thrombotic episodes (4/12).Transfusion requirements, transfusion intervals, mean hemoglobin and LDH values were documented for 12 weeks prior to and during luspatercept initiation. To maintain stable blood volumes in each transfusion, prestorage leukoreduced RBCs with an average volume per unit of 320 ml was used. Results: Table 1 summarizes the study's main results.Statistical significance is p <0.05. Throughout treatment, all but one patient (11/12) received a dose of 1 mg/kg. One patient did not respond to a dose increase of 1.25 g / kg and discontinued on week 12. Additionally, two other luspatercept responders discontinued treatment after the 12th and 24th week, respectively, due to significant fatigue. After 12 and 24 weeks, all patients who continued in luspatercept had a significant decrease in transfusion blood needs, approximately -29.4% and -36.1 % compared to baseline. They also showed significant increase in transfusion intervals for an average of 20.7 days. In addition, it became apparent that, although the volume of blood supplied was reduced and the interval between transfusions increased, the patients' hemoglobin levels remained adequately high in luspatercept treated patients. LDH as hemolysis biomarker, did not reveal any significant changes. During the follow-up period, no patient reported progression of existing comorbidities or the development of new ones. As far as their cardiovascular disease is concerned, the patients clinical status was stable NYHA II despite the reduction of transfusions. Six months after taking luspatercept, one patient showed an improvement in extramedullary hematopoiesis as evaluated by magnetic resonance imaging. Additionally, despite the presence of predisposing factors and the significant increase of platelets, no new thrombosis developed. Summary/Conclusion: In patients with significant comorbidities, luspatercept significantly decreased transfusion burden and prolonged transfusion intervals , without any observed worsening of their comorbidities or development of new ones. (Table Presented).

Symptomatic Renal Infarct Secondary to COVID-19 Infection and Concomitantly Positive Antiphospholipid Antibody

COVID-19 infection predisposes patients to a hypercoagulable state. The clinical significance of concomitantly positive antiphospholipid antibodies as a risk factor for thrombus formation is unknown. We report a case of renal infarct secondary to COVID-19 infection with mildly elevated antiphospholipid antibodies. A 71-year- old woman with a history of hypertension, supraventricular tachycardia, resected carcinoid tumor in remission, COVID-19 infection (20 days prior), presented to the hospital with acute onset severe left lower quadrant pain radiating to the left flank for one day. She reported a fever of 101 F. Vital signs were normal in the emergency room. Physical exam showed left costovertebral angle tenderness, otherwise benign abdomen with no guarding or rigidity. Laboratory findings showed normal liver function tests, mildly elevated creatinine at 1.1 mg/dl (baseline 0.8 mg/dl), and leukocytosis (14.2 K/ul). Urinalysis showed no evidence of proteinuria or microscopic hematuria. CT scan of the abdomen demonstrated a large area of patchy hypoattenuation involving the upper pole and interpolar region of the left kidney with adjacent perinephric inflammation representing a sequela of an infarct. Hypercoagulable workup including HIV, hepatitis, ANA, ANCA, complements, B2 glycoprotein, homocysteine, factor V Leiden, anti-thrombin III, protein C, protein S were done. All tests resulted negative except for mildly elevated anticardiolipin antibody, IgM 12.90 MPL (normal 0.00-12.49 MPL). Holter monitor was negative for atrial fibrillation. An echocardiogram did not show any thrombus. Considering her negative tests, renal infarct was believed to be secondary to a hypercoagulable state from COVID-19 infection. Antiphospholipid antibodies repeated 3 months after this admission were mildly elevated. Renal infarction was treated with a heparin infusion and was subsequently transitioned to apixaban. Acute kidney injury resolved with intravenous fluid resuscitation. At a 3-month follow-up, her renal function remained stable with a resolution of symptoms. Renal artery infarct is a possible thrombotic complication of COVID -19. Role of lupus anticoagulant antibodies in increasing this risk warrants further studies.

Microcirculatory Predictors of Thrombosis in Patients After COVID-19

Introduction: The lack of a history of the course of a new coronavirus infection and the lack of data from randomised trials makes it difficult to choose the right treatment tactics and prescribe adequate prophylaxis in patients who have suffered from COVID-19. Comorbid patients with cardiovascular diseases and endothelial dysfunction have a high risk of a severe course of COVID-19 and subsequent thrombotic complications, which manifest clinically as cardiomyopathy;venous thrombo-embolism (deep vein thrombosis and pulmonary embolism);pulmonary thrombosis in situ;stroke;arterial thrombangiitis;rarely, arterial peripheral thrombosis and microvascular thrombosis, in the lungs, liver, kidneys, brain, etc.;and mild disseminated intravascular coagulation syndrome. The role of endothelial dysfunction in the development of severe complications is underestimated. In the pathogenesis of COVID-19, the defeat of the microcirculatory bed plays a crucial role. The SARS-CoV-2 virus causes associated endotheliitis damage to the endothelium due to virus entry and cytokine storm. Endotheliitis leads to the release of tissue factor, which leads to the formation of an excess of thrombin and fibrin;the body tries to cover the virus with these and prevent its spread, which entails negative side effect such as thrombosis Methods: Sixty-six patients who had COVID-19 were examined (42 women and 24 men;mean age 48 years [range 20 – 80 years]). Patients complained of a feeling of paraesthesia, mainly in the lower extremities, a feeling of heaviness, stiffness in the popliteal region, an increased vascular pattern on the entire surface of the skin, a burning sensation in all vessels, and a feeling of weakness. Ultrasound colour duplex scanning showed no signs of thrombosis in the large vessels. Using a high frequency ultrasound Doppler and a 25 MHz sensor, the nailbed of the first finger of the upper limb was examined. The microcirculatory images were analysed by the shape and spectrum of the curves. Twenty patients received prophylaxis with rivaroxaban 10 mg daily (group 1) and 46 patients did not (group 2). The control examination was carried out four weeks after the start of therapy: sulodexide one capsule twice daily. The coagulogram parameters were also studied. Results: A depletion in spectral characteristics was seen in patients after COVID-19 disease, in comparison to microcirculatory images recorded in healthy individuals. Predominantly, the red part of the spectrum was recorded in patients after COVID-19, the lighter part of the spectrum was not recorded. Group 1 patients had higher amplitude parameters than group 2, but they also registered a depletion in spectral characteristics. Soluble fibrin monomer complexes were increased 4 – 5 times, D-dimer 2 – 2.5 times, and antithrombin III 1.5 times. The international normalised ratio, activated partial thromboplastin time, fibrinogen, prothrombin according to Quick, prothrombin time, clotting time, and bleeding time were within the reference intervals both before and after treatment. Upon repeat examination four weeks after the course of sulodexide therapy, the spectral characteristics were normalised, and the coagulogram parameters were also normalised. Conclusion: The red part of the spectrum, according to the Doppler criteria, corresponds to the fastest particles moving in the middle of the stream. The lighter part of the spectrum corresponds to particles moving more slowly. The reduction in spectral characteristics in patients after COVID-19 disease corresponds to parietal stasis and readiness for thrombosis, which was confirmed by the coagulogram data. Examination of the nailbed using high frequency ultrasound Doppler in patients who have COVID-19 allows the identification of stasis of the parietal blood flow, which corresponds to a prethrombotic state. The prescription of sulodexide allows for an improvement in the condition of patients and normalisation of microcirculation indicators

Association of COVID-19 Vaccines ChAdOx1-S and BNT162b2 with Circulating Levels of Coagulation Factors and Antithrombin.

BACKGROUND: Severe coronavirus disease 2019 (COVID-19) is associated with increased risk of thrombosis and thromboembolism. Exposure to COVID-19 vaccines is also associated with immune thrombotic thrombocytopenia, ischemic stroke, intracerebral haemorrhage, and cerebral venous thrombosis, and it is linked with systemic activation of coagulation. METHODS: We assess the circulating levels of coagulation factors (factors XI, XII, XIII, and prothrombin) and antithrombin in individuals who completed two doses of either ChAdOx1-S or BNT162b2 COVID-19 vaccine, within the timeframe of two months, who had no previous history of COVID-19. RESULTS: Elevated levels of factors XI, XII, XIII, prothrombin, and antithrombin were seen compared to unvaccinated controls. Levels of coagulation factors, antithrombin, and prothrombin to antithrombin ratio were higher with BNT162b2 compared to ChAdOx1-S vaccine. CONCLUSIONS: The clinical significance of such coagulation homeostasis disruption remains to be elucidated but it is worthy of global scientific follow-up effort.

The Association between Protein C and Antithrombin III Levels with the Severity of Coronavirus Disease-2019 Symptoms

BACKGROUND: Coronavirus disease-2019 (COVID-19) has various symptoms ranging from mild to critical. Hypercoagulation state is often observed in severe and critical COVID-19. Both coagulation and inflammation are interrelated and amplifying each other, with protein C and antithrombin (AT) III as two important mediators. AIM: The aim of the study was to determine the association between protein C and AT III levels with the severity of COVID-19 symptoms. METHODS: This analytical study was conducted at Haji Adam Malik Hospital from April to July 2021. Subjects were obtained by consecutive sampling method. Inclusion criteria were patients with confirmed COVID-19 using reverse transcription polymerase chain reaction and willing to participate. Subjects were divided into two groups: Mild-moderate and severe-critical symptom groups. Demographic and blood sample was obtained from each subject. Blood samples underwent examination for leukocyte, thrombocyte, PT, aPTT, protein C, and AT III. RESULTS: A total of 50 patients were obtained with female domination (58%) and mean age of 41.44 (standard deviation 20.90) years. Most subjects (86%) were in mild-to-moderate symptom group. There were significant differences in the level of protein C and AT III in both group (p = 0.029 and 0.034, respectively). Using the cutoff value for AT III of 45.6%, subjects who had mediator level below the value tend to develop severe and critical symptoms compared to their counterparts (odds ratio = 6.458). CONCLUSION: AT III is associated with severity of COVID-19 symptoms. Lower AT III level increases the risk for developing severe and critical symptoms.

Two cases of COVID vaccine-induced immune thrombotic thrombocytopenia in Luxembourg

Introduction: In March 2021, a signal for embolic and thrombotic events with Vaxzevria (COVID-19 Vaccine AstraZeneca) was raised in Austria and Germany, and on 7 April 2021, the European Pharmacovigilance Risk Assessment Committee (PRAC) concluded that a causal relationship between Vaxzevria and thrombosis combined to thrombocytopenia (TTS) was at least a reasonable possibility [1]. TTS mechanism is close to heparin-induced thrombocytopenia [2,3]. We report two Luxembourg cases of TTS that occurred one before and one after this confirmed signal. Results: The first case is a 74-year-old woman, with no medical history, who received her first dose of Vaxzevria in March 2021. Fourteen days later, she was hospitalised for sudden loss of consciousness. On admission she had thrombocytopenia (18 G/L), D-Dimers >20 000 ng/mL, antithrombin III 79%, fibrinogen 0.69 g/dL. Brain CT scan showed cerebral and meningeal haemorrhages. She died three days later. Autopsy confirmed multiple intracranial haemorrhages and showed right transverse sinus organised thrombosis. Post-mortem analysis revealed positive heparin-Platelet Factor 4 (PF4) antibodies (HIPA and PIPA). The second case is a 31-year-old man with medical history of splenic infarction in 2017 during mononucleosis. He received his first dose of Vaxzevria in June 2021, and 12 days later was admitted for right lower limb and lumbar pain with severe thrombocytopenia (28 G/L), low fibrinogen and elevated D-Dimers. Angiography showed sub-occlusive cruoric impactions of the left carotid bifurcation, the sub-renal abdominal aorta and the right common femoral artery. PF4 antibody initially negative (Zymutest Hyphen) were positive with IMMUCOR technique. Management included clots removal, intravenous immunoglobulins started for 3 days and anticoagulation with sodium danaparoid. The patient recovered within one month without sequelae. Discussion/Conclusion: The quick communication about TTS signal and the rapid identification of its mechanism both allowed, as reported here for the second patient, adapted management (prohibiting heparin), with full recovery.

Trend of fluctuations of antithrombin in plasma of patients with COVID-19: a meta-analysis and systematic review.

BACKGROUND: Antithrombin is considered as one of the accused markers for the development of thrombosis in patients with COVID-19. Because plasma levels of antithrombin vary in patients with COVID-19, a meta-analysis was performed to determine the trend of antithrombin levels in patients with COVID-19. RESEARCH DESIGN AND METHODS: A literature search was performed on PubMed, Scopus, and the Web of Science to find papers on antithrombin levels in patients with COVID-19. After removing duplicate papers, inclusion and exclusion criteria were applied. The full texts of the articles were read to select relevant articles and then to identify the data needed. All meta-analyses were performed using Stata software v16.0. RESULTS: Testing for differences between subgroups showed a significant difference between ICU and non-ICU patients. Analysis showed a significant decrease in antithrombin level in patients with severe COVID-19. Analysis showed that the mean value of antithrombin level was 89.65% in all patients. The antithrombin level was significantly lower in the non-survivor group (87.52%) than in the survivor group (92.38%). CONCLUSION: Determination of antithrombin may be useful to determine the susceptibility of COVID-19 patients to hypercoagulability and to indicate the severity of COVID-19 infection.