Altered coagulation in systemic inflammatory response syndrome: role of protein C in diagnosis and prognosis

Background

Evidence has accumulated to suggest that more complex mechanisms might be involved in the relationship between inflammation and coagulation.

Objective

In this study we aimed to use some coagulation markers, especially activated protein C (APC), in the diagnosis and prognosis of patients with systemic inflammatory response syndrome (SIRs), whether infectious or non-infectious.

Methods

We enrolled 20 patients who had been hospitalized for SIRS as well as 20 age-matched and sex-matched subjects who served as the control group. All patients and control groups were subjected to full clinical evaluation with application of APACHE II scoring, routine laboratory investigations as well as specific investigations, namely; plasma levels of protein C, D-dimer (DD), antithrombin III (ATIII), and thrombin-antithrombin complex (TAT) upon admission, 48 and 96 hours later and on discharge in survivors.

Results

The study showed that APC levels were significantly lower in patients with SIRS compared with control subjects (38.6 ± 23% vs 87.8 ± 6.1% P < 0.0001) respectively. When we compared levels in survivors and nonsurvivors, the former showed a persistent rise of the level to normal values in contrast to the latter, in which the levels were persistently low (34.8 ± 26% vs 40.6 ± 22% on admission and 82 ± 13% vs 41 ± 21%, P < 0.01 after 144 hours), respectively. Patients with septic shock also showed significantly lower levels of APC compared with those without shock (28.8 ± 12% vs 56.8 ± 28% P < 0.007 on admission and 41.7 ± 21.8% vs 82 ± 13% after 144 hours, P < 0.001), respectively. APC levels also were lower in patients with multiorgan failure syndrome (MODS) as compared with those without MODS (40.8 ± 27.8% vs 116 ± 29%, P < 0.01), respectively, with a statistically insignificant lower level in patients with APACHE score >20 as compared with those with APACHE score <20 (35.2 ± 22% vs 45 ± 24%, P = NS). The other coagulopathy markers of sepsis, DD, ATIII, TAT complex, did not show any significant difference between survivors and nonsurvivors (2 ± 3.6 ng/ml vs 4.9 ± 8 ng/ml for DD, 40.75 ± 17.6% vs 40 ± 15.7% for AT III and 24.7 ± 25 μg/ml vs 22 ± 19 μg/ml for TAT, P = NS), respectively.

Conclusion

The protein C level is a useful biological marker in patients with SIRS for both diagnostic and prognostic aspects regarding MODS, septic shock and mortality, and also it is superior to other coagulopathy markers for determining the ultimate clinical outcome. In the view of our study results, we recommend monitoring APC levels in patients with SIRS as early as possible to screen those with sepsis syndrome to target aggressive therapy for them