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Adequate application of recombinant thrombomodulin for sepsis-associated disseminated intravascular coagulation

Critical Care201519:233

https://doi.org/10.1186/s13054-015-0944-3

Published: 22 May 2015

Keywords

AntithrombinDisseminate Intravascular CoagulationDisseminate Intravascular CoagulationAdministrative DatabaseBaseline Risk

Recombinant thrombomodulin (rTM) is widely used for septic disseminated intravascular coagulation (DIC) in Japan. Tagami and colleagues performed an analysis using a nationwide administrative database in Japan and reported that rTM did not reduce the mortality in pneumonia-associated DIC (37.6 % in the rTM group vs 37.0 % in the control group, odds ratio: 1.01 (95 % confidence interval: 0.93 to 1.10)) [1]. They also reported a similar result in patients with bowel perforation-induced DIC [2]. These reports indicate that rTM will not be effective in real clinical practice. In contrast, in a recent issue of Critical Care, Yoshimura and colleagues reported that administration of rTM was significantly associated with reduced mortality in high-risk patients [3]. The same group also reported in their systematic review that the probability of a beneficial effect with rTM increases with increasing baseline risk [4].

Based on these findings, I suppose that rTM is not properly used currently. The decision based on Japanese Association of Acute Medicine DIC diagnostic criteria may not be adequate. As a matter of fact, Tagami and colleagues performed a very similar analysis for antithrombin concentrate and reported its efficacy (odds ratio: 0.85 (95 % confidence interval: 0.75 to 0.97)) [5]. We must remember that the Japanese Association of Acute Medicine criteria were designed specifically with the purpose of helping physicians decide on the timing of anticoagulant treatment, and antithrombin was the primary anticoagulant at that time. I therefore propose establishing different criteria, such as ‘fulfill the Japanese Association of Acute Medicine DIC criteria and Acute Physiology and Chronic Health Evaluation II score >24’, for the application of rTM.

Abbreviations

DIC: 

disseminated intravascular coagulation

rTM: 

recombinant thrombomodulin

Declarations

Authors’ Affiliations

(1)
Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan

References

  1. Tagami T, Matsui H, Horiguchi H, Fushimi K, Yasunaga H. Recombinant human soluble thrombomodulin and mortality in severe pneumonia patients with sepsis-associated disseminated intravascular coagulation: an observational nationwide study. J Thromb Haemost. 2015;13:31–40.View ArticlePubMedGoogle Scholar
  2. Tagami T, Matsui H, Fushimi K, Yasunaga H. Use of recombinant human soluble thrombomodulin in patients with sepsis-induced disseminated intravascular coagulation after intestinal perforation. Font Med. 2015;2:1–7.Google Scholar
  3. Yoshimura J, Yamakawa K, Ogura H, Umemura Y, Takahashi H, Morikawa M, et al. Benefit profile of recombinant human soluble thrombomodulin in sepsis-induced disseminated intravascular coagulation: a multicenter propensity score analysis. Crit Care. 2015;19:810.View ArticleGoogle Scholar
  4. Yamakawa K, Aihara M, Ogura H, Yuhara H, Hamasaki T, Shimazu T. Recombinant human soluble thrombomodulin in severe sepsis: a systematic review and meta-analysis. J Thromb Haemost. 2015;13:508–19.View ArticlePubMedGoogle Scholar
  5. Tagami T, Matsui H, Horiguchi H, Fushimi K, Yasunaga H. Antithrombin and mortality in severe pneumonia patients with sepsis-associated disseminated intravascular coagulation: an observational nationwide study. J Thromb Haemost. 2014;12:1470–9.View ArticlePubMedGoogle Scholar

Copyright

© Iba; licensee BioMed Central. 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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