한국형 출혈열 환자의 혈청 및 뇨의 fibrin-fibrinogen 분해산물의 변동에 관한 연구

Abstract

[한글]

Serum and Urinary Fibrin/Fibrinogen Degradation Products in Patients with Korean

Hemorrhagic Fever; with Particular Reference to Disseminated Intravascular

Coagulation and Acute Renal Failure

Byung Ro Kim, M.D.

Department Of Medical Science The Graduate School, Yonsei University

(Directed by Prof. Dong Sik Kim, M. D. and Prof. In Joon Choi, M.D.)

Korean Hemorrhagic Fever (hemorrhagic nephroso-nephritis, or hemorrhagic fever

with renal syndrome) is a disease characterized by acute onset of a severe

hemorrhagic tendency and acute renal failure, The etiology of this disease is yet

unknown, but is suspected to be a viral infection.

Intensive investigation of the pathogenesis of acute renal failure has been done,

hut still the exact mechanism involved remains unclear. Four pathophysiologic

mechanisms. however, have been recognized as primary factors in the pathogenesis of

acute renal failure; 1) tubular obstruction by casts and debris: 2) passive back

diffusion of glomerular filtrate; 3) renal interstitial edema: and 4) alterations

in renal hemodynamics resulting in the loss of an effective filtration pressure

(Clarkson, et al., 1970: Bullock and Shapiro, 1974).

Acute renal failure may be produced in animals by inducing intravascular

coagulation and Robson (1965) and Hardaway (1966) suggested that such a mechanism

might contribute to renal failure in man. There has been little direct evidence to

support this postulate. However, there is experimental evidences for the

participation of a coagulation process in renal diseases; following the induction

of intravascular coagulation (Robbins and Collins, 1961 ; Thomas and Good,1952) :

the detection of fibrin in the glomeruli: and its prevention by prior anticoagulant

therapy(Vassalli and McClusky, 1964; Halpern, et al., 1965).

Intravascular coagulation with the deposition of fibrin in the glomeruli of the

kidney may bea factor in certain forms of renal diseases (Vassalli and McClusky,

1965: Wadle and Taylor, 1965: Humair, et at., 1969). There are reports that

coagulation mechanisms may play a pathogenetic role in human renal diseases; about

detection of fibrin by light microscopy (Gitlin, et al, 1957), and by

immunofluorescent methods (Paronetto and Koffler, 1965: Koffler and Paronetto,

1965: McClusky, et al., 1966) ; reports of disseminated intravascular

coagulation(Monnens and Schretlin, 1967): and the benefit of anticoagulant therapy

in certain renal diseases (Piel and Phibts, 1966: Kincaid-Smith. et al., 1968:

yardman, et al., 1970)i about the evidence for fibrin deposition in the kidneys

during acute tubular necrosis (Koffler and Paronetto, 1966). Much of the naturally

formed fibrin in vivo is removed by fibrinolysis in which an insoluble gel is

converted to soluble peptide fragments known as fibrin/fibrinogen degradation

products (FDP).

The concentration of serum FDP has been found to reflect the activity and

severity of proliferative renal lesions (Stiehm and Trygstad, 1969) . However,

other non-primary renal conditions, such as deep vein thrombosis and disseminated

intravascular coagulation, may be associated with a rise in serum FDP (Merskey, et

al., 1967: Ruckley, et at., 1910). Clarkson,et at. (1971) reported urinary FDP

concentration was a reliable and sensitive index of activity, progression and

natural history of active proliferative glomerulonephritis, and was of potential

vague in the differential diagnosis of glomerulonephritis. They thought it

predominantly reflected lysis of intraglomerular fibrin deposits.

The etiology of disseminated intravascular coagulation (DIC) can be classified

into three categories: 1) endothelial cell injury which activates the Hageman

factor and the intrinsic clotting system: 2) tissue injury which activates the

extrinsic clotting system ; 3) red cell or platelet injury with the release of

coagulant phospholipids. These initiating mechanisms results in a final common

product, thrombin, which cleaves to fibrinogen, activates factor Ⅶ, aggregates

platelets, releases platelet constituents, and triggers secondary fibrinolysis.

Plasmin produces FDP, which participates in the hemorrhagic diathesis. Therefore,

detection of these fragments is a sensitive method of diagnosing DIC (Cowman, et

al., 1972).

DIC may lead to three clinical consequences. First, the consumption of platelets

and clotting factors plus antihemostatic properties of FDP created a potential

bleeding tendency. Second, deposits of fibrin may block capillary flow in an organ

with resulting serious ischemic tissue damage. The kidney is particularly

vulnerable to such ischemic damage; the lesions may be produced that vary in

severity from reversible tubular necrosis to a complete, irreversible, bilateral

renal cortical necrosis. Third, the red cells are damaged as they move through the

loose strands of fibrin (Rapaport, 1972).

Recently, Mckay and Margaretten (1967) summarized the histopathologic evidence

for the frequent occurrence of DIC in various exanthematous viral diseases and

certain hemorrhagic fevers caused by arboviruses. However, there is only one

reported cases of Korean hemorrhagic fevers suggesting that DIC had played an

important role in the morbidity and mortality of this disease (Dennis and Conrad,

1965).

Current reliable methods to indicate intravascular coagulation include : 1)

fibrin deposition studies by the histopathologic or immunofluorescent method : 2)

accelerated fibrin catabolism ; 3) decreased plasma levels of factors such as

fibrinogen, prothrombin, factor Ⅴ, factor Ⅷ, and platelets; and 4) rise of FDP in

the serum. The latter, increased level of FDP in the serum, has been a constant

feature in documented cases of intravascular coagulation studied by Merskey and

co-workers and others (Rodriguez-Erdman, 1965; Merskey. et al., 1966: Merskey, et

al.,1967: Hillman and Phillips, 1967). Therefore, FDP assay is a more sensitive and

reliable test for the detection of intravascular coagulation than are other

coagulation studies (Stiehm and Trygstad, 1969).

There is a report of five theoretical categories for the treatment of DIC

(Colman, et al., 1972), and recently Kincaid-Smith, et al. (1969) reported the

considerably improvement in six cases of consecutive irreversible oliguric acute

renal failure, histologically due to glomerulo-nephritis or obstructive lesions in

the arterioles and the glomeruli, following a continuous high-dose in infusion of

heparin, given in addition to steroids and immunosuppressive drugs.

The mortality rate 7f Korean hemorrhagic fever is still high. Therefore, to study

the exact pathogenesis of acute renal failure in this discase is very essential and

important. The pathogenesis and the mechanisms of this disease is still unclear.

Therefore, to study the alterations of the level of FDP, net only in the urine,

but also in the serum seems to be very important to measure the disease intensity.

and to correlate to prognosis and also to detect the evidence of DIC and the

relationship to acute renal failure. Furthermore, the possibility of benefit in

selection of patients for anticoagulant therapy alone or in combination with the

steroid and immunosuppressive drugs.

The present study, therefore, is designed to detect the presence of FDP, and to

compare the alterations of FDP both in the serum and in the urine, with particular

references to DIC and acute renal failure, and furthermore, to establish prognostic

and therapeutic criterias for the improvement of the treatment of Korean

hemorrhagic fever.

Materials anti Methods

A. Materials;

From September, 1973 to January, 1974, the serum and the urine of the selected

patients with Korean hemorrhagic fever who had a typical clinical course were used.

The patients were divided as follows:

Febrile phase………………………………………………………38 cases

Hypotensive phase…………………………………………………26 cases

Oliguric phase…………………………………………………… 46 cases

Diuretic phase…………………………………………………… 35 cases

Convalescent phase……………………………………………… 32 cases

3. Methods;

For general information, routine peripheral blood examinations, including

hemoglobin, hematocrit, and white blood cell counts, and routine urinalysis,

including specific gravity and proteinuria, were performed. Additionally. blood

urea nitrogen and creatinine were measured.

Platelets ware counted by phase contrast microscopy (Brecher and Cronkite, 1950).

Measurements of prothrombin time and partial thromboplastin time were performed by

a fibrometer using the Hyland kit.

Serum and urinary fibrin/fihrinogen degradation products (FDP) were measured in

all patients periodically during each phase. FDP were mensured both for serum and

urine by the staphylococcal clumping test of Hawiger (1970) Twelve or 24-hours

urine samples were used.

Results and Summary

In order to detect and evaluate the relationship between Korean hemorrhagic fever

and disseminated intravascular coagulation (DIC), and to study the pathogenesis of

acute renal failure in patients with Korean hemorrhagic fever, alterations of the

serum and urinary fibrin/fibrinogen degradation product (FDP) concentrations were

studied in 39 cases of febrile phase; 26 cases in the hypotensive phase; 46 cases

during the oliguric phase; 35 cases in the diuretic phase; and 32 cases in the

convalescent phase.

1. The platelet count was markedly decreased in the febrile and hypotensive

phases, increased in the oliguric phase, and returned to normal in the convalescent

phase.

2. In the severe cases, the prothrombin time and partial thromboplastin time were

more prolonged than in moderate and mild cases, The values for blood urea nitrogen

began to increase during febrile and the hypotensive phases, and were markedly

increased in the oliguric phase. It was gradually decreased in the diuretic phase

and return to normal in the convalescent phase.

3. The serum FDP concentration was gradually increased in the early phase;

increased markedly in the oliguric phase, and became normal in the convalescent

phase. The serum FDP concentration was lower than the urinary FDP concentration.

4. Marked proteinuria which was observed from the febrile phase through the

oliguric phase later gradually disappeared. The urinary PDP concentration in severe

cased increased in the early phases, at the highest level in the oliguric phase,

and returned to normal after the diuretic phase.

This data indicates that DIC is detected in Korean hemorrhagic fever, where it

may play a major role. Also the urinary FDP concentration more closely reflects the

severity of renal lesions in this disease than dues the serum FDP concentration and

the blood urea nitrogen level. It can be assumed that the concentration of urinary

FDP can be used as a therapeutic criteria, and is correlated to intensity and

prognosis of the disease. Also the concentration may be correlated with the

possibility of improvement following anticoagulant treatment.

It appears that acute renal failure in this disease has a close relationship to

DIC. Its etiology and pathogenesis can be assumed that disruption of the normal

renal cortical perfusion ploys major role in this Korean hemorrhagic fever.

[영문]

Korean Hemorrhagic Fever (hemorrhagic nephroso-nephritis, or hemorrhagic fever with renal syndrome) is a disease characterized by acute onset of a severe hemorrhagic tendency and acute renal failure, The etiology of this disease is yet unknown, but is suspected to be a viral infection.

Intensive investigation of the pathogenesis of acute renal failure has been done, hut still the exact mechanism involved remains unclear. Four pathophysiologic mechanisms. however, have been recognized as primary factors in the pathogenesis of acute renal failure; 1) tubular obstruction by casts and debris: 2) passive back diffusion of glomerular filtrate; 3) renal interstitial edema: and 4) alterations in renal hemodynamics resulting in the loss of an effective filtration pressure (Clarkson, et al., 1970: Bullock and Shapiro, 1974).

Acute renal failure may be produced in animals by inducing intravascular coagulation and Robson (1965) and Hardaway (1966) suggested that such a mechanism might contribute to renal failure in man. There has been little direct evidence to support this postulate. However, there is experimental evidences for the

participation of a coagulation process in renal diseases; following the induction of intravascular coagulation (Robbins and Collins, 1961 ; Thomas and Good,1952) : the detection of fibrin in the glomeruli: and its prevention by prior anticoagulant therapy(Vassalli and McClusky, 1964; Halpern, et al., 1965).

Intravascular coagulation with the deposition of fibrin in the glomeruli of the kidney may bea factor in certain forms of renal diseases (Vassalli and McClusky, 1965: Wadle and Taylor, 1965: Humair, et at., 1969). There are reports that coagulation mechanisms may play a pathogenetic role in human renal diseases; about detection of fibrin by light microscopy (Gitlin, et al, 1957), and by immunofluorescent methods (Paronetto and Koffler, 1965: Koffler and Paronetto, 1965: McClusky, et al., 1966) ; reports of disseminated intravascular coagulation(Monnens and Schretlin, 1967): and the benefit of anticoagulant therapy

in certain renal diseases (Piel and Phibts, 1966: Kincaid-Smith. et al., 1968: yardman, et al., 1970)i about the evidence for fibrin deposition in the kidneys during acute tubular necrosis (Koffler and Paronetto, 1966). Much of the naturally formed fibrin in vivo is removed by fibrinolysis in which an insoluble gel is converted to soluble peptide fragments known as fibrin/fibrinogen degradation products (FDP).

The concentration of serum FDP has been found to reflect the activity and severity of proliferative renal lesions (Stiehm and Trygstad, 1969) . However, other non-primary renal conditions, such as deep vein thrombosis and disseminated intravascular coagulation, may be associated with a rise in serum FDP (Merskey, et al., 1967: Ruckley, et at., 1910). Clarkson,et at. (1971) reported urinary FDP concentration was a reliable and sensitive index of activity, progression and natural history of active proliferative glomerulonephritis, and was of potential vague in the differential diagnosis of glomerulonephritis. They thought it

predominantly reflected lysis of intraglomerular fibrin deposits.

The etiology of disseminated intravascular coagulation (DIC) can be classified into three categories: 1) endothelial cell injury which activates the Hageman factor and the intrinsic clotting system: 2) tissue injury which activates the extrinsic clotting system ; 3) red cell or platelet injury with the release of coagulant phospholipids. These initiating mechanisms results in a final common product, thrombin, which cleaves to fibrinogen, activates factor Ⅶ, aggregates platelets, releases platelet constituents, and triggers secondary fibrinolysis. Plasmin produces FDP, which participates in the hemorrhagic diathesis. Therefore, detection of these fragments is a sensitive method of diagnosing DIC (Cowman, et al., 1972).

DIC may lead to three clinical consequences. First, the consumption of platelets and clotting factors plus antihemostatic properties of FDP created a potential bleeding tendency. Second, deposits of fibrin may block capillary flow in an organ with resulting serious ischemic tissue damage. The kidney is particularly vulnerable to such ischemic damage; the lesions may be produced that vary in severity from reversible tubular necrosis to a complete, irreversible, bilateral renal cortical necrosis. Third, the red cells are damaged as they move through the loose strands of fibrin (Rapaport, 1972).

Recently, Mckay and Margaretten (1967) summarized the histopathologic evidence for the frequent occurrence of DIC in various exanthematous viral diseases and certain hemorrhagic fevers caused by arboviruses. However, there is only one reported cases of Korean hemorrhagic fevers suggesting that DIC had played an important role in the morbidity and mortality of this disease (Dennis and Conrad, 1965).

Current reliable methods to indicate intravascular coagulation include : 1) fibrin deposition studies by the histopathologic or immunofluorescent method : 2) accelerated fibrin catabolism ; 3) decreased plasma levels of factors such as fibrinogen, prothrombin, factor Ⅴ, factor Ⅷ, and platelets; and 4) rise of FDP in the serum. The latter, increased level of FDP in the serum, has been a constant feature in documented cases of intravascular coagulation studied by Merskey and co-workers and others (Rodriguez-Erdman, 1965; Merskey. et al., 1966: Merskey, et al.,1967: Hillman and Phillips, 1967). Therefore, FDP assay is a more sensitive and reliable test for the detection of intravascular coagulation than are other coagulation studies (Stiehm and Trygstad, 1969).

There is a report of five theoretical categories for the treatment of DIC (Colman, et al., 1972), and recently Kincaid-Smith, et al. (1969) reported the considerably improvement in six cases of consecutive irreversible oliguric acute renal failure, histologically due to glomerulo-nephritis or obstructive lesions in the arterioles and the glomeruli, following a continuous high-dose in infusion of heparin, given in addition to steroids and immunosuppressive drugs.

The mortality rate 7f Korean hemorrhagic fever is still high. Therefore, to study the exact pathogenesis of acute renal failure in this discase is very essential and important. The pathogenesis and the mechanisms of this disease is still unclear.

Therefore, to study the alterations of the level of FDP, net only in the urine, but also in the serum seems to be very important to measure the disease intensity. and to correlate to prognosis and also to detect the evidence of DIC and the relationship to acute renal failure. Furthermore, the possibility of benefit in selection of patients for anticoagulant therapy alone or in combination with the steroid and immunosuppressive drugs.

The present study, therefore, is designed to detect the presence of FDP, and to compare the alterations of FDP both in the serum and in the urine, with particular references to DIC and acute renal failure, and furthermore, to establish prognostic and therapeutic criterias for the improvement of the treatment of Korean hemorrhagic fever.

Materials anti Methods

A. Materials;

From September, 1973 to January, 1974, the serum and the urine of the selected patients with Korean hemorrhagic fever who had a typical clinical course were used. The patients were divided as follows:

Febrile phase………………………………………………………38 cases

Hypotensive phase…………………………………………………26 cases

Oliguric phase…………………………………………………… 46 cases

Diuretic phase…………………………………………………… 35 cases

Convalescent phase……………………………………………… 32 cases

3. Methods;

For general information, routine peripheral blood examinations, including hemoglobin, hematocrit, and white blood cell counts, and routine urinalysis, including specific gravity and proteinuria, were performed. Additionally. blood urea nitrogen and creatinine were measured.

Platelets ware counted by phase contrast microscopy (Brecher and Cronkite, 1950).

Measurements of prothrombin time and partial thromboplastin time were performed by a fibrometer using the Hyland kit.

Serum and urinary fibrin/fihrinogen degradation products (FDP) were measured in all patients periodically during each phase. FDP were mensured both for serum and urine by the staphylococcal clumping test of Hawiger (1970) Twelve or 24-hours urine samples were used.

Results and Summary

In order to detect and evaluate the relationship between Korean hemorrhagic fever and disseminated intravascular coagulation (DIC), and to study the pathogenesis of acute renal failure in patients with Korean hemorrhagic fever, alterations of the

serum and urinary fibrin/fibrinogen degradation product (FDP) concentrations were studied in 39 cases of febrile phase; 26 cases in the hypotensive phase; 46 cases during the oliguric phase; 35 cases in the diuretic phase; and 32 cases in the

convalescent phase.

1. The platelet count was markedly decreased in the febrile and hypotensive phases, increased in the oliguric phase, and returned to normal in the convalescent phase.

2. In the severe cases, the prothrombin time and partial thromboplastin time were more prolonged than in moderate and mild cases, The values for blood urea nitrogen began to increase during febrile and the hypotensive phases, and were markedly increased in the oliguric phase. It was gradually decreased in the diuretic phase and return to normal in the convalescent phase.

3. The serum FDP concentration was gradually increased in the early phase; increased markedly in the oliguric phase, and became normal in the convalescent phase. The serum FDP concentration was lower than the urinary FDP concentration.

4. Marked proteinuria which was observed from the febrile phase through the oliguric phase later gradually disappeared. The urinary PDP concentration in severe cased increased in the early phases, at the highest level in the oliguric phase, and returned to normal after the diuretic phase.

This data indicates that DIC is detected in Korean hemorrhagic fever, where it may play a major role. Also the urinary FDP concentration more closely reflects the severity of renal lesions in this disease than dues the serum FDP concentration and the blood urea nitrogen level. It can be assumed that the concentration of urinary FDP can be used as a therapeutic criteria, and is correlated to intensity and prognosis of the disease. Also the concentration may be correlated with the

possibility of improvement following anticoagulant treatment.

It appears that acute renal failure in this disease has a close relationship to DIC. Its etiology and pathogenesis can be assumed that disruption of the normal renal cortical perfusion ploys major role in this Korean hemorrhagic fever.