See

discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/236138074

The anticoagulant therapy for sepsisassociated disseminated intravascular

coagulation
Article in Thrombosis Research April 2013
Impact Factor: 2.45 DOI: 10.1016/j.thromres.2013.03.012 Source: PubMed

CITATIONS

READS

27

233

3 authors, including:
Toshiaki Iba

Isao Nagaoka

Juntendo University

Juntendo University

159 PUBLICATIONS 2,233 CITATIONS

303 PUBLICATIONS 6,510 CITATIONS

SEE PROFILE

All in-text references underlined in blue are linked to publications on ResearchGate,

letting you access and read them immediately.

SEE PROFILE

Available from: Toshiaki Iba

Retrieved on: 22 May 2016

This article appeared in a journal published by Elsevier. The attached

copy is furnished to the author for internal non-commercial research
and education use, including for instruction at the authors institution
and sharing with colleagues.
Other uses, including reproduction and distribution, or selling or
licensing copies, or posting to personal, institutional or third party
websites are prohibited.
In most cases authors are permitted to post their version of the
article (e.g. in Word or Tex form) to their personal website or
institutional repository. Authors requiring further information
regarding Elseviers archiving and manuscript policies are
encouraged to visit:
http://www.elsevier.com/authorsrights

Author's personal copy

Thrombosis Research 131 (2013) 383389

Contents lists available at SciVerse ScienceDirect

Thrombosis Research
journal homepage: www.elsevier.com/locate/thromres

Review Article

The anticoagulant therapy for sepsis-associated disseminated

intravascular coagulation
Toshiaki Iba a,, Isao Nagaoka b, Marcel Boulat a
a
b

Emergency and Disaster Medicine, Juntendo University, Japan

Host Defense and Biochemical Research, Juntendo University, Japan

a r t i c l e

i n f o

a b s t r a c t

Article history:
Received 21 January 2013
Received in revised form 10 March 2013
Accepted 12 March 2013
Available online 6 April 2013

Sepsis is a leading cause of death in critically ill patients and it requires multidisciplinary treatment. The effects
of anticoagulant therapy for sepsis-associated disseminated intravascular coagulation have been long
discussed and intensively studied. The recent topics in this area are 1) withdrawal of recombinant activated
protein C(rAPC) from the market, 2) potential efcacy of the supplement-dose of antithrombin, 3) success
of the recombinant thrombomodulin in a Phase 2B trial.
rAPC had been the only anticoagulant recommended in the global guideline for the treatment of severe sepsis
(Surviving Sepsis Campaign guidelines (SSCG) 2008). However, the recommendation was withdrawn from
the latest version of SSCG after rAPC could not demonstrate sufcient efcacy in the most recent randomized
controlled trial. Antithrombin concentrate is another anticoagulant which can be effective for sepsis-associated
disseminated intravascular coagulation (DIC). However, high-dose antithrombin is recommended not to be
used in SSCG 2012 since it did not show any survival benet and increased the bleeding risks in severe sepsis.
Nonetheless, a recent clinical study reported the potential efcacy of supplement-dose antithrombin in septic
DIC. Recombinant thrombomodulin has been newly developed and its efcacy for DIC was reported. A recent
multinational randomized controlled trial has also demonstrated the potential efcacy of this therapeutic
agent for septic DIC and a Phase 3 study is currently underway.
2013 Elsevier Ltd. All rights reserved.

Keywords:
Disseminated intravascular coagulation (DIC)
Antithrombin
Thrombomodulin
Activated Protein C
Tissue factor pathway inhibitor
Japanese Association for Acute Medicine
(JAAM)

Contents
Introduction . . . . . . . . . . . . . .
Diagnostic Criteria for DIC . . . . . . .
Concept of the Anticoagulant Therapy . .
Natural Anticoagulants . . . . . . . . .
Activated Protein C . . . . . . . .
Antithrombin . . . . . . . . . . .
Tissue Factor Pathway Inhibitor . . .
Thrombomodulin . . . . . . . . .
Heparin and Heparinoids . . . . . . . .
The Dark Side of Anticoagulant Therapy .
Guidelines . . . . . . . . . . . . . . .
Unsolved Problems and Future Direction .
Conclusion . . . . . . . . . . . . . . .
Conict of Interest Statement . . . . . .
Acknowledgement . . . . . . . . . . .
References . . . . . . . . . . . . . . .

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

Corresponding author at: 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan. Tel.: +81 3 3813 3111x5818; fax: +81 3 3813 5431.
E-mail address: toshiiba@cf6.so-net.ne.jp (T. Iba).
0049-3848/$ see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.thromres.2013.03.012

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

384
384
384
385
385
385
385
386
386
386
387
387
387
387
387
387

Author's personal copy

384

T. Iba et al. / Thrombosis Research 131 (2013) 383389

Introduction
Dysregulation of the hemostatic system leads to disseminated intravascular coagulation (DIC), which results in microvascular thrombosis,
hypoperfusion, and subsequent multiple organ failure and death in
severe sepsis [1]. Therefore, it was hypothesized that the inhibition of
the over-activated coagulation cascade by natural anticoagulants could
help the resolution of DIC and reduce the mortality of sepsis. Following
this hypothesis, the efcacy of recombinant activated protein C (rAPC)
[2], plasma-derived antithrombin concentrates [3] and recombinant tissue factor pathway inhibitor (rTFPI) [4] was examined in large-scale
Phase 3 studies in the 1990s. Although high-dose antithrombin and
rTFPI failed to demonstrate a survival benet, rAPC succeeded to show
the positive effect of improving survival in PROWESS (Protein C Worldwide Evaluation in Severe Sepsis) trial [2]. Consequently, rAPC was
strongly recommended for use in the worldwide therapeutic guideline
for severe sepsis [5].
10-years later, PROWESS-SHOCK [6], the most recent randomized
controlled trial (RCT), failed to conrm the benet reported by the
original PROWESS and rAPC was withdrawn from the market and
Surviving Sepsis Campaign guidelines (SSCG) 2012 [7]. Although
PROWESS-SHOCK did not specically target septic DIC, the resulting
withdrawal of rAPC has meant that we now have no natural anticoagulant available for the treatment of septic DIC. Based on the results from
the sepsis trials, it is not appropriate to conclude anticoagulant therapy
is not effective for septic DIC. In this article, we discuss these issues
mainly based on the results from recent clinical trials.
Diagnostic Criteria for DIC
The original diagnostic criteria for disseminated intravascular
coagulation (DIC) consisted of laboratory tests and was established
by the Japanese Ministry of Health and Welfare (JMHW) in the early
80s [8]. This was followed by the overt-DIC diagnostic criteria proposed by the International Society on Thrombosis and Haemostasis
(ISTH) [9]. These two criteria were designed to detect a specic coagulation disorder to avoid overtreatment, so the delayed initiation of treatment was advocated in the early 2000s. Then, to help initiate treatment
at the appropriate time, the Japanese Association for Acute Medicine
(JAAM) introduced a new criteria after the completion of retrospective
and prospective studies [10]. Since the mortality of septic DIC remained
as high as 31.3% [11], the primary objective of launching the new diagnostic criteria was to improve the mortality by anticoagulant therapy.
Since the platelet count, prothrombin time and brin degradation
products are the common items in all the diagnostic criteria, the modications in scores and/or the ranges only can change the sensitivity and
specicity balance of the criteria. For example, the JAAM criteria is more
sensitive than ISTH overt-DIC and JMHW criteria (Table 1).
Concept of the Anticoagulant Therapy
The tight cross-talk between the coagulation and inammatory
reactions during sepsis has attracted much attention and anticoagulant therapies have been expected to be benecial not only for septic
DIC but also for severe sepsis [1214]. Activation of coagulation is a universal event during sepsis and is initiated by pathogen-associated molecular patterns (PAMPs) such as lipopolysaccharide (LPS) and exotoxins
[15,16]. The degree of activation ranges from subclinical to fulminant
DIC which is the life-threatening status by itself. The coagulation cascade
was previously thought to be mediated by the expression of tissue factor
(TF) on innate immune cells (monocytes-macrophages) [17], and more
recently, TF-expressing microparticles from platelets, monocytes and
macrophages [18]. In addition to PAMPs, recent studies elucidated
that substances that induce inammation named alarmins from host
cells such as histones, nucleosomes and high mobility group box 1
(HMGB1) are also strong initiators of coagulation [19,20]. Eventually,

Table 1
Comparison of JAAM DIC diagnostic criteria and ISTH overt-DIC diagnostic criteria.
JAAM DIC
SIRS score
3
0-2
Platelet counts (109/L)
b80 or more than 50% decrease within 24 h
80 b120 or more than 30% decrease within 24 h
120
PT time (patient/normal value)
1.20
b1.2

ISTH overt-DIC
1
0
3
1
0
1
0

Fibrin/brinogen degradation products (mg/L)

25
10 b25
10b

3
1
0

Diagnosis

Platelet counts (109/L)

2
b50
1
50 b100
0
100
Prolonged PT time (sec)
2
6
1
3 b6
0
b3
Elevated brin-related
marker
3
Strong increase
Moderate increase 2
0
No increase
Fibrinogen level (g/ml)
b100
1
100
0
Diagnosis
5

SIRS: systemic inammatory response syndrome, PT: prothrombin.

inammation and malcirculation of the tissue result in cell apoptosis

and necrosis, and alarmins released from these dead cells propagate coagulation [21,22], and this vicious cycle further accelerates both inammation and coagulation systems. This procoagulant reaction is partially
reversed by temporal activation of brinolysis due to increased expression of tissue plasminogen activator (t-PA). Then the reaction is rapidly
inhibited by an increased synthesis of plasminogen activator inhibitor 1
(PAI-1) [23]. Thrombin-activatable brinolysis inhibitor (TAFI) is also
involved in sepsis-associated hypobrinolysis. In patients with severe
sepsis, the levels of TAFI were reported to increase in patients complicated
DIC [24], and the enhancement of TAFI activation further accelerates the
thrombogenic pathway. If infection is controlled, this hemostatic imbalance diminishes within a few days, however, if the insult is strong enough
and uncontrolled, the hemostatic sequence loses control continuously
and induces widespread thrombosis and hemorrhages, recognized as
DIC. To counteract the hemostatic reaction, natural coagulation inhibitors,
such as activated protein C, antithrombin, tissue factor pathway inhibitor
and thrombomodulin play major roles. There is compelling evidence that
in addition to their role as anticoagulants, they also have important functions in modulating inammation. For example, Taylor et al. demonstrated that activated protein C (APC) ameliorated the inammatory reactions
in the primate model of E. coli infusion [25]. Other experiments in rodents
showed similar results and demonstrated the benecial effects on inammation [26]. An in vitro study demonstrated the anti-inammatory effects
of APC of blocking NF-B nuclear translocation, which is a prerequisite for
increases in pro-inammatory cytokines and adhesion molecules [27].
Furthermore, in mice with genetic deciencies of protein C, endotoxemia
was associated with a more marked increase in pro-inammatory cytokines compared with wild-type mice [28]. These in vitro and in vivo ndings are also reported for the other anticoagulants [29].
Following the preclinical studies, a number of clinical trials using
rAPC [2], antithrombin [3] or rTFPI [4] were performed, but none of
them have been recognized as a standard therapy after the Eli Lilly
and Company (Indianapolis, IN, USA) announced the withdrawal of
rAPC from the worldwide market. The failure of the anticoagulant
RCTs to show efcacy is thought to be due to the inclusion of patients
without DIC, uncertainty of when to initiate therapy, and the tendency
to underestimate the importance of bleeding. We have to focus on these
points when we design the next trials.
After all, here remains the unanswered query is anticoagulant
therapy effective for sepsis or septic DIC? We will try to address this
important question in this review.

Author's personal copy

T. Iba et al. / Thrombosis Research 131 (2013) 383389

Natural Anticoagulants
The current strategy for handling sepsis-associated DIC primarily
focuses on the treatment of infection and use of supplemental clotting
factors or platelets depending on the necessity [30]. In many countries, anticoagulant therapy has not been considered as an essential
treatment. However, increasing evidence has proposed the new idea
that anticoagulant therapy may have the favorable effects for DIC.
In the following part, we discuss natural anticoagulants which were
tested in severe sepsis or septic DIC.

Activated Protein C
Activated protein C plays a major role in controlling microvascular
coagulation and inammation. Protein C is the zymogen of the vitamin
K-dependent serine protease activated protein C. Protein C is activated
when thrombin complexes with thrombomodulin, an endothelial surface transmembrane glycoprotein. Activated protein C inactivates factors
Va and VIIIa which effectively limits further thrombin generation. This
protein also enhances endogenous brinolytic activity and modulates
the inammatory response [31,32]. A rapid depletion of protein C occurs
in sepsis, which contributes to sepsis-induced coagulopathy and correlates with a poor prognosis [33,34]. Besides exerting anticoagulant and
probrinolytic activity, activated protein C also has important inammation modulating effects: down-regulation of inammatory cytokines and
TF in activated leukocytes, antioxidant properties, anti-apoptotic activity,
and prevention of loss of endothelial barrier function [35].
Based on these observations, recombinant activated protein C (rAPC,
Xigris) was produced and the efcacy of this agent was tested in a large
scale RCT which reported a positive result in 2001 [2] (Table 1). However, as described before, the production and distribution of rAPC was
discontinued in October 2011. This decision was directly attributable
to PROWESS-SHOCK [6]. In this study, 1696 adults with septic shock
were randomly allocated to either rAPC treatment or placebo. The
28-day mortality did not differ signicantly between the treatment
group (26.4%) and the placebo group (24.2%), with the relative risk of
death being 1.09. However, subgroup analysis revealed an association
between the efcacy of rAPC and the protein C activity. The relative
risk of death was lower (0.93) in the cases with markedly reduced protein C activity at the time of entry into the study.
Since rAPC was rst approved, numerous clinical studies have
been conducted on this drug and its effectiveness has been discussed
for more than a decade. Therefore, more than a few investigators may
feel dissatised with the withdrawal of rAPC on the basis of the results of
a single RCT. In the study by Casserly B et al. [36] who analyzed the
usefulness of rAPC therapy using the SSCG database containing 15022
registered cases, 1009 (8%) of all the registered patients received rAPC
treatment. The results of their analysis revealed that the in-hospital
death rate was signicantly lower in the rAPC treatment group than in
the group not treated with rAPC (Odds ratio (OR): 0.76, 95%, Condence
interval (CI): 0.66-0.86, P b 0.001). The demonstrated efcacy of rAPC
was statistically signicant in cases complicated by multiple organ
failure, but not in those complicated by single organ failure. The
meta-analysis reported by Kalil et al. [37] covered the data from all
clinical studies conducted on rAPC. For analysis of the efcacy, 9
controlled studies (41401 cases) and 16 single-group studies (5822
cases) were included. Analysis of the safety covered 20 studies
(8245 cases). The meta-analysis revealed an 18% reduction of the
in-hospital death rate following rAPC treatment (relative risk 0.822,
95% CI: 0.78-0.86, P b 0.0001). While the effect of rAPC in improving
the survival rate was more marked in severe cases, it was also observed
in mild cases (0.844, 95% CI: 0.80-0.89; P b 0.0001). On the other hand,
the incidence of severe bleeding rose to 5.6% following rAPC treatment.
The authors concluded that rAPC elevates the risk of bleeding, but nonetheless improved the outcome of severe sepsis, and that such effects of

385

rAPC could still be observed when the PROWESS-SHOCK data were

added to the analysis.
At the end, it is unlikely that the decision to withdraw rAPC will be
overturned any time soon, since this decision was made voluntarily
by the manufacturer. However, we cannot help but feel uncomfortable
about the nal decision pertaining to this drug being made on the basis
of a single study.
Antithrombin
Antithrombin is one major natural anticoagulant that has been
extensively studied [3840]. It inhibits thrombin in a 1:1 fashion
and leads to thrombin-antithrombin complex (TAT) formation and
subsequent elimination. Its activity is maximized after binding with
glycosaminoglycans (GAGs) serving as cofactors on the endothelial
surface [41].
Regarding plasma derived antithrombin, a large-scale RCT named
KyberSept failed to demonstrate the efcacy in severe sepsis [3]
(Table 1). Since then, no RCT has been performed, however, the results of a Phase 4 study in patients with septic DIC have been reported
recently [42]; this study was a non-randomized multicenter study
aimed at evaluating the efcacy and hemorrhagic adverse events.
729 patients with septic DIC are included in this study, and a decrease
of the antithrombin activity to 70% or less were treated for 3 consecutive days with antithrombin (1500 or 3000 IU/day), and the outcome
and incidence of hemorrhagic events were evaluated. The overall incidence of hemorrhagic events was 6.5%, and the incidence of severe
bleeding was as low as 1.71% (Table 2). The attending physician selected
one of the two dose levels (1500 and 3000 IU/day) for each case. The
percentage of patients with antithrombin activity under 50% at the
start of treatment was below 50% in the 1500 IU/day group, but higher
(approximately 70%) in the 3000 IU/day group. Thus, patients with
markedly reduced antithrombin activity were signicantly more frequently treated at the dose level of 3000 IU/day (P b 0.01). According
to the logistic regression analysis: higher pre-treatment antithrombin
activity (OR: 1.032, P b 0.001), dose level of 3000 IU/day (OR: 1.912,
P = 0.026) and lower age were identied as factors contributing to
improvement in the survival rate. Taken together, antithrombin supplement therapy at the dose of 3000 IU/day is a valid option for the
treatment of septic DIC. However, since the difference did not reach
statistically signicant, the study has been continued with larger subjects.
In addition to above, a multicenter RCT has also been conducted by the
DIC Committee of JAAM to conrm the efcacy of supplement-dose of
antithrombin in septic DIC.
Actually, maintenance dose of 3000 IU/day for the treatment of severe sepsis has ever been tested in Europe. Lamy et al. [43] performed
RCT on 42 cases with severe sepsis and reported a 39% decrease in mortality in the treated group. Although the difference was not statistically
signicant, the treated group had a shorter ICU stay and a lower incidence of developing organ failure.
Tissue Factor Pathway Inhibitor
Infection upregulates TF expression, which mediates local or
systemic inammation as well as thrombogenicity and may lead to
substantial tissue damage and multiple organ failure. Tissue factor
pathway inhibitor inhibits the activity of TF-Factor VII complex and
Factor X-prothrombinase complex, thus suppressing the primary
steps of thrombin generation [19].
Regarding recombinant TFPI (rTFPI, Tifacogin), a large-scale RCT in
severe sepsis had been carried out and the results indicated the absence of any improvement in 28-day mortality (OPTIMIST trial [4]).
However, subgroup analysis revealed a tendency towards improvement
in the survival rate following rTFPI treatment among patients with severe
community-acquired pneumonia. Thus, the other placebo-controlled RCT
named CAPTIVATE [44] was carried out. CAPTIVATE involved 2138

Author's personal copy

386

T. Iba et al. / Thrombosis Research 131 (2013) 383389

Table 2
Comparison of efcacy in anticoagulant studies.
Name/ref. No.

Agent/Patients

Study design/No. of cases

groups

28-day mortality

Statistical analysis

PROWESS/2)

rAPC(Xigris)/severe sepsis

RCT/1690

PROWESS
-SHOCK/10)
KyberSept/3)

rAPC(Xigris)/severe sepsis with shock

RCT/1680

antithrombin high-dose/severe sepsis

RCT/2316

antithrombin supplement-dose/septic DIC

non-randomized Phase-4/729

Saito et al./35)

rTM/septic DIC (subgroup)

RCT/102

Online data/36)

rTM/severe sepsis

Phase-2B/741

24.7%
30.8%
26.4%
24.2%
38.9%
38.7%
25.3%
34.8%
28.0%
34.6%
17.8%
21.6%

P = 0.005
RRR: 19.4% (95%CI: 6.6-30.5)
P = 0.31
RR: 1.09 (95%CI: 0.92-1.28)
P = 0.94

Iba et al./34)

treatment
placebo control
treatment
placebo control
treatment
placebo control
3000 IU/day
1500 IU/day
rTM
low-dose heparin
rTM
placebo

P = 0.06
ARR: -6.6%
(95%CI: -24.6-11.3)
P = 0.273

rAPC: recombinant activated protein C, rTM: recombinant thrombomodulin, DIC: disseminated intravascular coagulation, RCT: randomized controlled trial, RRR: relative risk reduction, CI: condence interval, ARR: absolute risk reduction.

patients but was discontinued before the efcacy could be veried since
no benecial trend was recognized (rTFPI group: 18% vs. placebo group:
17.9%, P = 0.56).
Thrombomodulin
Thrombomodulin exerts an anticoagulant effect mainly via the
activation of protein C [45]. Other expected mechanisms of actions
for thrombomodulin are neutralization of inammatory mediators
and suppression of leukocyte-endothelial interaction [46]. However,
since the expression of thrombomodulin is largely downregulated
[47], the external administration is expected.
The recombinant thrombomodulin (rTM, ART-123) was rst introduced in Japan after the success of a Phase 3 study involving 232 patients with DIC complicated hematological malignancies (n = 131) or
infection (n = 101) [48]. The results revealed a DIC recovery rate of
66.1% in the rTM group and 49.9% in the unfractionated heparin group
(95% CI: 3.3-29.1%), and the 28-day mortality was 28.0% in the rTM
group and 34.6% in the unfractionated heparin group (Table 1). The
rTM group also had a lower incidence of hemorrhagic adverse events.
The bleeding risk was further examined in the post-marketing survey
and revealed that it was as low as 5.4% (Table 2). Following these
studies, a Phase 2B study involving 741 sepsis patients had been carried
out in multiple nations, and the results were uploaded on the website
[49]. According to the results, the 28-day mortality was 17.8% in rTM
group and 21.6% in the placebo group (P = 0.273 (0.137 one-sided),
which met the predened statistical test for evidence suggestive of
efcacy (0.15 one-sided alpha level). Interestingly, subgroup analyses
suggested that the greatest survival benet was seen in patients with
respiratory or cardiac dysfunction and coagulopathy characterized by
PT-INR > 1.4 with lower platelet count. Mortality was lower in the
treatment group; however, it did not reach statistical signicance
(26.3% in rTM group vs. 38.2% in placebo group). The difference in the
resolution rate of overt DIC reached the suggestive level of statistical evidence (P = 0.175 (28.9% in rTM group vs. 18.9% in placebo group)). In
the analysis of adverse events, no increase in the incidence of severe
bleeding was seen following treatment with rTM. On the basis of
these results, a Phase 3 study is currently being conducted in the US
among patients suffering from severe sepsis with coagulopathy [50].
Heparin and Heparinoids
Unfractionated heparin (UFH), Low-molecular-weight heparin
(LMWH), and danaparoid sodium are currently available for the treatment of septic DIC. These anticoagulants do not have anticoagulant
activity by themselves and are expected to modulate the hemostatic
abnormalities through maximizing the effect of antithrombin. Although
there is no reliable RCT, a retrospective analysis showed that the mortality rate tended to be lower in the low-dose heparin group than in

the placebo group in severe sepsis [51]. However, the use of UFH is
generally not recommended for the patients with a tendency to bleed.
With respect to LMWH, dalteparin signicantly reduced the organ failure and bleeding symptoms in the DIC patients compared with UFH in a
multicenter co-operative double-blind trial performed in Japan [52].
Danaparoid sodium is also approved for the DIC patients by the
Japanese Ministry of Health and Welfare. In a multicenter co-operative
double-blind trial [53], no signicant difference was observed in the efcacy between danaparoid sodium and UFH, however, the adverse effect
of bleeding tends to be rarer with danaparoid sodium.
The Dark Side of Anticoagulant Therapy
The older randomized trials such as PROWESS [2] and KyberSept
[3] revealed a consistent hemorrhagic tendency when anticoagulant
group was compared to a placebo control. For example, in KyberSept
trial, the frequency of bleeding events was more than 1.7 times higher
in the treatment group. This was not surprising since anticoagulants
efciently suppress the thrombin generation. But at the same time,
we learned that this adverse event often cancels out the benecial
effects of anticoagulants. We also learned that bleeding risks are signicantly different depending on the inhibitors, their concentration,
half-life and associated hemostatic disturbances. For example, rTM
demonstrated lower incidence of bleeding compared to rAPC, the
frequency could be much lower in supplement-dose of antithrombin
compared to high-dose (Table 3). Even if the risk is low, since there
still is an increased risk of bleeding, it is important to carefully select
the patients who may benet from treatment.
The other concern about anticoagulant therapy is the effect it has on
the host defense mechanism. As mentioned in the other section, recent
studies have revealed that both activation of coagulation and suppression
of brinolysis contribute to the host defense against microbial dissemination. Indeed, activation of coagulation fosters compartmentalization of
bacteria and reduces bacterial invasion. Therefore, the ability of coagulation to suppress pathogen dissemination indicates that microvessel
thrombosis represents a physiological tool of the host defense mechanism [54]. In contrast, it was generally accepted in the early 2000s that
the inhibition of coagulation should be begun as early as possible with
high-doses of inhibitors of coagulation system to reduce the inammation [38]. The anti-inammatory properties of natural anticoagulants
were considered to be the major benet, and high-doses were justied
in the hope of eliciting these properties. The high doses were supported
by animal studies which showed that only supranormal plasma levels
were able to modulate inammation, leukocyte adhesion, microcirculatory changes, and apoptosis [55,56]. However, the aforementioned results were mostly obtained from short-term observations and may not
apply to sepsis in humans. In future studies, the benets and side effects
of the anticoagulant therapy should be carefully balanced to obtain the
optimum outcome.

Author's personal copy

T. Iba et al. / Thrombosis Research 131 (2013) 383389

387

Table 3
Comparison of bleeding risks in anticoagulant studies.
Name/ref. No.

Agent/Patients

Study design
/No. of cases

Bleeding type

Treatment

Control

Statistical analysis

PROWESS/2)

rAPC(Xigris)/severe sepsis

RCT/1690

PROWESS-SHOCK/10)

rAPC(Xigris)/severe sepsis with shock

RCT/1666

KyberSept/3)

antithrombin high-dose/severe sepsis

RCT/2314

Iba et al./34)

antithrombin supplement-dose/septic DIC

non-randomized Phase-4/729

Online data/36)
Post-marketing survey

rTM/severe sepsis
rTM/septic DIC

Phase-2B/741
Phase-4/2516

any
major
any
major
any
major
any
major
major
any

12.5%
3.5%
8.6%
1.2%
22.0%
10.0%
6.52%
1.71%
6.7%
5.4%

12.1%
2.0%
4.8%
1.0%
12.8%
5.7%
6.2%
-

P = 0.84
P = 0.06
P = 0.002
P = 0.81
RR: 1.71 (95%CI: 1.42-2.06)
RR: 1.75 (95%CI: 1.32-2.33)
-

rAPC: recombinant activated protein C, rTM: recombinant thrombomodulin, DIC: disseminated intravascular coagulation, RCT: randomized controlled trial, RR: relative risk, CI: condence interval.

Guidelines
Guidelines for the diagnosis and treatment of DIC were rstly simultaneously published by the UK [57] and Japan [58] in 2009 followed by
Italy a few years later [59]. However, considerable differences exist
between the various guidelines, especially in the areas of diagnosis
and treatment. The British guidelines recommended the use of the International Society on Thrombosis and Haemostasis (ISTH) overt-DIC
criteria [60] for the diagnosis, while the Japanese Society of Thrombosis
Hemostasis (JSTH) guidelines introduced both ISTH overt-DIC criteria
and the Japanese Association for Acute Medicine (JAAM) DIC diagnostic
criteria [61], which is more sensitive than ISTH overt-DIC criteria [62]
Regarding the use of natural anticoagulants, the British guidelines
had promoted the use of rAPC in serious cases, while it is not mentioned in the Japanese guidelines since rAPC has not been approved
in Japan. The Japanese guidelines assign a higher recommendation
level to supplement-dose antithrombin, whereas the British guidelines
recommend not to use antithrombin. As mentioned before, while there
is no large-scale RCT targeting septic DIC with regards to both agents,
small-size RCTs and subgroup analyses indicate the potential benet of
these therapeutics. Although rAPC was withdrawn from the British guidelines, we strongly expect the use of rAPC in septic DIC patients to be
reevaluated in the future. With respect to supplement-dose of antithrombin, the DIC Committee of the JAAM has performed a placebo-controlled
RCT and reported its efcacy in septic DIC patients. We understand why
there are signicant differences between the guidelines, however, as
new evidence is accumulated, we expect that these differences will disappear. We hope that the mutual exchange of information will enable the
scientic community to reach a consensus and create a set of international guidelines in the near future.

Unsolved Problems and Future Direction

The previously discussed trials revealed the various benecial effects
of anticoagulants: improvement of laboratory parameters, shortening of
the duration of DIC, and an improvement in organ function and survival
rates [2,42,48]. Therefore, anticoagulants may have high potential for
the treatment of sepsis-associated DIC. However, even if the efcacy is
acceptable, there still remain many unanswered questions such as
who should receive treatment, at what timing, with which anticoagulant, and at what dose. We have to address each of these questions
and the effectiveness needs to be proved in a large-scale prospective validation trial. It wont be an easy task; however, there is already some
progress. Subgroup analyses of PROWESS, KyberSept and Phase 2B
rTM study indicated that these anticoagulants are more effective in the
patients with a severe coagulation disorder [39,63]. In the case of antithrombin, supplement-dose may be more suitable than high-dose for
the treatment of sepsis-associated DIC [42].

Another concern is the potential need for combination therapy.

Levels of natural anticoagulants including antithrombin, protein C and
cell-surface thrombomodulin are all known to decrease signicantly during sepsis [6466]; and this is the basis of substitution therapy. Since both
the antithrombin-GAGs system and the thrombomodulin-protein C system, down regulate signicantly and act independently, combination
therapy might be required. Although no clinical study has been completed, we examined the effects of combination therapy in LPS challenged
models and reported that the combination therapy attenuates the
organ damage and leads to a greater improvement in survival than single
therapy [67].
We have discussed the new players in sepsis-associated organ
dysfunction-failure, alarmins such as histones and, HMGB1. Alarmins
are released actively by stimulated innate immune cells and passively
by necrotic cells into the extracellular environment where it becomes
a lethal mediator of systemic inammation [68]. These substances
could be the targets of new anticoagulant therapy.
Conclusion
Close attention has recently been paid to the association between
coagulation and inammation, and anticoagulant therapy has been
actively applied to patients with severe sepsis. However, the usefulness
of anticoagulant therapy was not conrmed. Indeed, patients with
sepsis show activation of coagulation and relative suppression of brinolysis in the early stages, resulting in a state of excessive coagulation.
Such a state stimulates coagulation within small vessels, thereby serving as a factor responsible for the disturbed circulation through organs.
Therefore, it would be useful to suppress excessive coagulation to maintain circulation in the treatment of sepsis. We have, however, learned
recently that anticoagulant therapy serves no benet if it is applied in
a blind manner. It now seems essential to review and discuss the indications and timings of this therapy, and also the suitable drugs and their
dose level/frequency of administration.
Conict of Interest Statement
Iba T. is a member of DIC Committee of JAAM and Scientic Subcommittee of JSTH. The authors have no other conict of interest to declare.
Acknowledgement
A part of this review was presented in the 41th Annual Meeting in
Japanese Society of Intensive Care Medicine.
References
[1] Kidokoro A, Iba T, Fukunaga M, Yagi Y. Alterations in coagulation and brinolysis
during sepsis. Shock 1996;5:2238.

Author's personal copy

388

T. Iba et al. / Thrombosis Research 131 (2013) 383389

[2] Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A,
et al. Efcacy and safety of recombinant human activated protein C for severe sepsis.
N Engl J Med 2001;344:699709.
[3] Warren BL, Eid A, Singer P, Pillay SS, Carl P, Novak I, et al. High-dose antithrombin
III in severe sepsis. A randomized controlled trial. JAMA 2001;286:186978.
[4] Abraham E, Reinhart K, Opal S, Demeyer I, Doig C, Rodriguez AL, et al. Efcacy and
safety of tifacogin (recombinant tissue factor pathway inhibitor) in severe sepsis:
a randomized controlled trial. JAMA 2003;290:23847.
[5] Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J. Surviving Sepsis
Campaign guidelines for management of severe sepsis and septic shock. Crit Care
Med 2004;32:85873.
[6] Ranieri VM, Thompson BT, Barie PS, Dhainaut JF, Douglas IS, Finfer S, et al.
Drotrecogin alfa (activated) in adults with septic shock. N Engl J Med 2012;366:
205564.
[7] Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving
Sepsis Campaign: International Guidelines for Management of Severe Sepsis and
Septic Shock: 2012. Crit Care Med 2013;41:580637.
[8] Kobayashi N, Maekawa T, Takada M, Tanaka H, Gonmori H. Criteria for diagnosis of
DIC based on the analysis of clinical and laboratory ndings in 345 DIC patients collected by the Research Committee on DIC in Japan. Bibl Haematol 1983;49:26575.
[9] Taylor Jr FB, Toh CH, Hoot WK, Wada H, Levi M. Toward denition, clinical and
laboratory criteria, and a scoring system for disseminated intravascular coagulation.
Thromb Haemost 2001;86:132730.
[10] Gando S, Iba T, Eguchi Y, Ohtomo Y, Okamoto K, Koseki K, et al. A multicenter, prospective validation of disseminated intravascular coagulation diagnostic criteria for
critically ill patients: Comparing current criteria. Crit Care Med 2006;34:62531.
[11] Gando S, Saitoh D, Ogura H, Mayumi T, Koseki K, Ikeda T, et al. Disseminated intravascular coagulation (DIC) diagnosed based on the Japanese Association for
Acute Medicine criteria is a dependent continuum to overt DIC in patients with
sepsis. Thromb Res 2009;123:7158.
[12] Shimaoka M, Park EJ. Advances in understanding sepsis. Eur J Anesthesiol Suppl
2008;42:14653.
[13] Zeerleder S, Hack CE, Wuillemin WA. Disseminated intravascular coagulation in
sepsis. Chest 2005;128:286475.
[14] Esmon CT. The interactions between inammation and coagulation. Br J Haematol
2005;131:41730.
[15] Anas AA, Wiersinga WJ, de Vos AF, van der Poll T. Recent insights into the pathogenesis of bacterial sepsis. Neth J Med 2010;68:14752.
[16] Kinasewitz GT, Yan SB, Basson B, Comp P, Russell JA, Cariou A, et al. Universal
changes in biomarkers of coagulation and inammation occur in patients with
severe sepsis, regardless of causative micro-organism. Crit Care 2004;8:R8290.
[17] Chu AJ. Tissue Factor, blood coagulation, and beyond: An overview. Int J Inamm
2011:367284.
[18] Pawlinski R, Mackman N. Cellular sources of tissue factor in endotoxemia and sepsis.
Thromb Res 2010;125:S703.
[19] Bianchi ME. DAMPs, PAMPs and alarmins: all we need to know about danger.
J Leukoc Biol 2007;81:15.
[20] Kambas K, Mitroulis I, Apostolidou E, Girod A, Chrysanthopoulou A, Pneumatikos
I. Autophagy mediates the delivery of thrombogenic tissue factor to neutrophil
extracellular traps in human sepsis. PLoS One 2012;7:e45427.
[21] Semeraro N, Ammollo CT, Semeraro F, Colucci M. Sepsis, thrombosis and organ
dysfunction. Thromb Res 2012;129:2905.
[22] Xu J, Zhang X, Pelayo R, Monestier M, Ammollo CT, Semeraro F, et al. Extracellular
histones are major mediators of death in sepsis. Nat Med 2009;15:131821.
[23] Kidokoro A, Iba T, Hong J. Role of DIC in multiple organ failure. Int J Surg Investig
2000;2:7380.
[24] Emonts M, de Bruijne EL, Guimares AH, Declerck PJ, Leebeek FW, de Maat MP,
et al. Thrombin-activatable brinolysis inhibitor is associated with severity and
outcome of severe meningococcal infection in children. J Thromb Haemost 2008;6:
26876.
[25] Taylor FBJ, Chang A, Esmon CT, D'Angelo A, Vigano-D'Angelo S, Blick KE. Protein C
prevents the coagulopathic and lethal effects of Escherichia coli infusion in the
baboon. J Clin Invest 1987;79:91825.
[26] Murakami K, Okajima K, Uchiba M, Johno M, Nakagaki T, Okabe H, et al. Activated
protein C attenuates endotoxin-induced pulmonary vascular injury by inhibiting
activated leukocytes in rats. Blood 1996;87:6427.
[27] White B, Schmidt M, Murphy C, Livingstone W, O'Toole D, Lawler M, et al. Activated
protein C inhibits lipopolysaccharide-induced nuclear translocation of nuclear factor
kappaB (NF-kappaB) and tumour necrosis factor alpha (TNF-alpha) production in
the THP-1 monocytic cell line. Br J Haematol 2000;110:1304.
[28] Levi M, Dorfer-Melly J, Reitsma PH, Buller HR, Florquin S, Poll T, et al. Aggravation of endotoxin-induced disseminated intravascular coagulation and cytokine
activation in heterozygous protein C decient mice. Blood 2003;101:48237.
[29] Esmon CT. New mechanisms for vascular control of inammation mediated by
natural anticoagulant proteins. J Exp Med 2002;196:5614.
[30] Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, et al. Surviving
Sepsis Campaign: international guidelines for management of severe sepsis and
septic shock: 2008. Crit Care Med 2008;36:296327.
[31] Esmon CT, Schwarz HP. An update on clinical and basic aspects of the protein C
anticoagulant pathway. Trends Cardiovasc Med 1995;5:1418.
[32] Vervloet MG, Thijs LG, Hack CE. Derangements of coagulation and brinolysis in
critically ill patients with sepsis and septic shock. Semin Thromb Hemost 1998;24:
3344.
[33] Shorr AF, Bernard GR, Dhainaut JF, Russell JR, Macias WL, Nelson DR, et al. Protein
C concentrations in severe sepsis: an early directional change in plasma levels
predicts outcome. Crit Care 2006;10:R929.

[34] Levi M. The coagulant response in sepsis. Clin Chest Med 2008;29:62742.
[35] Mosnier LO, Zlokovic BV, Grifn JH. The cytoprotective protein C pathway. Blood
2007;109:316172.
[36] Casserly B, Gerlach H, Phillips GS, Marshall JC, Lemeshow S, Levy MM. Evaluating
the use of recombinant human activated protein C in adult severe sepsis: results
of the Surviving Sepsis Campaign. Crit Care Med 2012;40:141726.
[37] Kalil AC, Larosa SP. Effectiveness and safety of drotrecogin alfa (activated) for severe
sepsis: a meta-analysis and metaregression. Lancet Infect Dis 2012;12:67886.
[38] Iba T, Kidokoro A. High dose antithrombin therapy for sepsis: Mechanism of action.
Shock 2002;18:38994.
[39] Kienast J, Juers M, Wiedermann CJ, Hoffmann JN, Ostermann H, Strauss R, et al.
Treatment effects of high-dose antithrombin without concomitant heparin in patients with severe sepsis with or without disseminated intravascular coagulation.
J Thromb Haemost 2006;4:907.
[40] Hoffmann JN, Muhlbayer D, Jochum M, Inthorn D. Effect of long-term and
high-dose antithrombin supplementation on coagulation and brinolysis in patients
with severe sepsis. Crit Care Med 2004;32:18519.
[41] Roemisch J, Gray E, Hoffmann JN, Wiedermann CJ. Antithrombin. A new look at
the actions of a serine protease inhibitor. Blood Coagul Fibrinolysis 2002;13:
65770.
[42] Iba T, Saito D, Wada H, Asakura H. Efcacy and bleeding risk of antithrombin supplementation in septic disseminated intravascular coagulation: A prospective
multicenter survey. Thromb Res 2012;130:e12933.
[43] Lamy M, Eisele B, Keinecke HO. Antithrombin III in patients with severe sepsis: a
randomized placebo-controlled double blind multicenter trial. Proceedings of the 9th
European Congress on Intensive Care Medicine. Bologna, Italy: Monduzzi Editore;
1996. p. 38590.
[44] Wunderink RG, Laterre PF, Francois B, Perrotin D, Artigas A, Vidal LO, et al. Recombinant tissue factor pathway inhibitor in severe community-acquired pneumonia:
a randomized trial. Am J Respir Crit Care Med 2011;183:15618.
[45] Esmon CT. The regulation of natural anticoagulant pathways. Science 1987;235:
134852.
[46] Iba T, Aihara K, Watanabe S, Yanagawa Y, Takemoto M, Yamada A, et al. Recombinat
thrombomodulin improves the visceral microcirculation by attenuating the
leukocyte-endothelial interaction in a rat LPS model. Thromb Res 2013;131:2959.
[47] Nawroth PP, Stern DM. Modulation of endothelial cell hemostatic properties by
tumor necrosis factor. J Exp Med 1986;163:7405.
[48] Saito H, Maruyama I, Shimazaki S, Yamamoto Y, Aikawa N, Ohno R, et al. Efcacy
and safety of recombinant human soluble thrombomodulin (ART-123) in disseminated intravascular coagulation: results of a phase III, randomized, double-blind
clinical trial. J Thromb Haemost 2007;5:3141.
[49] http://www.artisanpharma.net/news.htm.
[50] http://clinicaltrials.gov/ct2/show/NCT01598831?term=ART-123&rank=2.
[51] Polderman KH, Girbes ARJ. Drug intervention trials in sepsis: divergent results.
Lancet 2004;363:17213.
[52] Sakuragawa N, Hasegawa H, Maki M, Nakagawa M, Nakashima M. Clinical evaluation of low-molecular-weight heparin (FR-860) on disseminated intravascular
coagulation (DIC)-a multicenter co-operative double-blind trial in comparison
with heparin. Thromb Res 1993;72:475500.
[53] Yasunaga K, Ogawa N, Mori K, Aoki N, Matsuda T, Nakagawa M, et al. Evaluation of
clinical effect of danaparoid sodium (KB-101) on disseminated intravascular coagulation (DIC): double blind comparative study. Jpn Pharmacol Ther 1995;23:281534.
[54] Massberg S, Grahl L, von Bruehl ML, Manukyan D, Pfeiler S, Goosmann C, et al.
Reciprocal coupling of coagulation and innate immunity via neutrophil serine proteases. Nat Med 2010:88796.
[55] Iba T, Kidokoro A, Fukunaga M, Nagakari K, Shirahama A, Ida Y. Activated protein
C improves the visceral microcirculation by attenuating the leukocyte-endothelial
interaction in a rat LPS model. Crit Care Med 2005;33:36872.
[56] Nevire R, Tournoys A, Mordon S, Marchal X, Song FL, Jourdain M, et al. Antithrombin reduces mesenteric venular leukocytes interactions and small intestine
injury in endotoxemic rats. Shock 2001;15:2205.
[57] Levi M, Toh CH, Thachil J, Watson HG. Guidelines for the diagnosis and management of disseminated intravascular coagulation. British Committee for Standards
in Haematology. Br J Haematol 2009;145:2433.
[58] Wada H, Asakura H, Okamoto K, Iba T, Uchiyama T, Kawasugi K, et al. Expert
consensus for the treatment of disseminated intravascular coagulation in Japan.
Thromb Res 2010;125:611.
[59] Di Nisio M, Baudo F, Cosmi B, D'Angelo A, De Gasperi A, Malato A, et al. Diagnosis
and treatment of disseminated intravascular coagulation: guidelines of the
Italian Society for Haemostasis and Thrombosis (SISET). Thromb Res 2011;129:
e17784.
[60] Iba T. Japanese Association for Acute Medicine DIC Study Group. The meanings of
DIC diagnostic criteria. Thromb Res 2012;129:e26970.
[61] Iba T, Asakura H. Comparison between British and Japanese guidelines for the
diagnosis and treatment of disseminated intravascular coagulation. Br J Haematol
2010;149:4612.
[62] Gando S, Saitoh D, Ogura H, Mayumi T, Koseki K, Ikeda T, et al. Natural history of
disseminated intravascular coagulation diagnosed based on the newly established
diagnostic criteria for critically ill patients: results of a multicenter, prospective
survey. Crit Care Med 2008;36:14550.
[63] Dhainaut JF, Yan SB, Joyce DE, Pettil V, Basson B, Brandt JT, et al. Treatment effects
of drotrecogin alfa (activated) in patients with severe sepsis with or without overt
disseminated intravascular coagulation. J Thromb Haemost 2004;2:192433.
[64] Iba T, Gando S, Murata A, Kushimoto S, Saitoh D, Eguchi Y, et al. Predicting the
severity of SIRS-associated coagulopathy with hemostatic molecular markers
and vascular endothelial injury markers. J Trauma 2007;63:10938.

Author's personal copy

T. Iba et al. / Thrombosis Research 131 (2013) 383389
[65] Iba T, Yagi Y, Kidokoro A, Fukunaga M, Fukunaga T. Increased plasma levels of soluble
thrombomodulin in patients with sepsis and organ failure. Surg Today 1995;25:58590.
[66] Dhainaut JF, Yan SB, Cariou A, Mira JP. Soluble thrombomodulin, plasma-derived
unactivated protein C, and recombinant human activated protein C in sepsis.
Crit Care Med 2002;30:S31824.

389

[67] Iba T, Nakarai E, Takayama T, Nakajima K, Sasaoka T, Ohno Y. Combination effect

of antithrombin and recombinant human soluble thrombomodulin in an LPS induced rat sepsis model. Crit Care 2009;13:R2039.
[68] Sunden-Cullberg J, Norrby-Teglund A, Treutiger CJ. The role of high mobility
group box-1 protein in severe sepsis. Curr Opin Infect Dis 2006;19:2316.