key: cord-0717766-c4cw7nx1
authors: Trimaille, Antonin; Marchandot, Benjamin; Oulehri, Walid; Carmona, Adrien; Vollmer, Olivier; Poindron, Vincent; Matsushita, Kensuke; Sattler, Laurent; Grunebaum, Lelia; Korganow, Anne-Sophie; Schini-Kerth, Valerie; Morel, Olivier
title: Transient endothelial injury and release of lupus anticoagulant in COVID-19
date: 2021-05-28
journal: J Thromb Thrombolysis
DOI: 10.1007/s11239-021-02485-5
sha: 63afb135f72b95b6a1ee4ffc6ebee7e695bad2ca
doc_id: 717766
cord_uid: c4cw7nx1

nan

performed, were considered as confirmed COVID-19 cases by a multidisciplinary team. Medical management was left at the discretion of the treating physician. When decided, thromboprophylaxis was achieved with Enoxaparin at 4000 international units (IU)/24 h, Fondaparinux at 2.5 mg/24 h or unfractionated heparin at 4800 IU/24 h (standard preventive treatment), with Enoxaparin at 4000 IU twice /24 h (reinforced preventive treatment) or with Enoxaparin 100 IU/kg twice /24 h (therapeutic).

Blood samples were collected in 0.109 M sodium citrate tubes during acute phase and at least 12 weeks after COVID-19 diagnosis. Fibrinogen, activated partial thromboplastin time (aPTT), D-dimer and von Willebrand factor antigen (vWF:Ag) were determined in plasma immediately after a single centrifugation (2500 g for 10 min). Assays were delayed for LA detection. Platelet-poor plasma (PPP) was obtained by double centrifugation (2 × 2500×g for 10 min), then frozen at − 80 °C until use. PPP was thawed for 4 min in a 37 °C water bath just before the assays. All haemostasis assays (fibrinogen, aPTT, D-Dimer, vWF:Ag, LA detection) were analysed on STA-R® Evolution (Diagnostica Stago ®, Asnières-sur-Seine, France) with standard commercial reagents and protocols. LA detection was based on several tests. First, two screening tests were performed, respectively a Diluted Russel Viper Venom Time (dRVVT screen) made with the STA®-Staclot dRVV Screen reagent (Stago), and an aPTT performed with the STA®-PPT A reagent (Stago). Positivity of one or both screening tests induced a mixing test at 1:1 proportion with a commercial frozen PNP (Cryo-check™ Pooled Normal Plasma, Cryocheck, Montpellier, France). Moreover, a positive dRVVT screen induced a confirmatory test with an increased concentration of phospholipids (dRVVT confirm), performed with the STA®-Staclot dRVV Confirm reagent (Stago). dRVVT screen, DRVVT confirm and aPTT results were expressed as a ratio of patient-to-PNP. Mixing tests results were expressed as an index of circulating anticoagulant (ICA). LA was considered as positive only if the normalized dRVVT ratio (screen ratio/ confirm ratio) was > 1.2 and all causes of false positive were excluded (i.e. anticoagulation conditions).

The study was approved by the national agency for the safety of medicines (Number 2020-A01500-39). Written informed consent was obtained from all study participants.

LA assays were performed in 262 patients hospitalized for COVID-19 in 10 departments of Strasbourg University Hospital, France between March 3 and May 5, 2020 and 56 had positive LA. Five patients were excluded from the analysis because of direct oral anticoagulant treatment at the time of follow-up. A total of 51 patients were included in the final analysis. The main results are shown in the Table 1 . The mean age was 61 years and 39 patients (76.5%) were male.

During the acute phase of COVID-19, 38 patients (74.5%) required mechanical ventilation and 10 patients (19.7%) presented a venous thrombotic event. Mean von Willebrand factor antigen (vWF:Ag) level was 409.5%. As previously mentioned, all patients were positive for LA.

Follow-up visit was performed at a median of 144 (interquartile range 129-179) days after COVID-19 diagnosis. LA detection was positive only in three patients (5.9%) and mean level of vWF:Ag was 158.0% at the time of followup (Fig. 1) . Clinical and biological characteristics of these three patients are described in the Supplementary Table I. Of note, two young male patients required mechanic ventilation at the acute phase and none of the three had venous thromboembolism.

Acute COVID-19 is characterized by an endothelial injury secondary to endothelial cells viral invasion and cytokine storm [1] . As admitted in antiphospholipid syndrome pathophysiology [5] , our work suggest that the subsequent plasma membrane remodeling is susceptible to expose intracellular phospholipid to extracellular environment leading to LA formation. In addition, the loss of endothelium antithrombotic effects associated with coagulation abnormalities may expose patients to a higher risk of thrombosis [1, 6, 7] . This pathophysiologic hypothesis is consistent with the increased levels of vWF:Ag in our cohort and the high frequency of venous thrombosis at the acute phase.

As described in other viral diseases [8] , we showed disappearance of LA in a large majority of patients. In addition, the drastic decrease of vWF:Ag levels suggests an endothelial injury recovery at distance from acute COVID-19, clinically translated by the absence of thrombosis event during the follow-up. Although our observational data do not prove causation, they suggest that endothelial dysfunction is transient in COVID-19 patients and therefore associated to a potential temporary and limited pathophysiological effect. Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. 

COVID-19 is, in the end, an endothelial disease

Lupus anticoagulant and abnormal coagulation tests in patients with Covid-19

Are antiphospholipid antibodies associated with thrombotic complications in critically ill COVID-19 patients?

Circulating Von Willebrand factor and high molecular weight multimers as markers of endothelial injury predict COVID-19 in-hospital mortality

The antiphospholipid syndrome

Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia

Confirmation of the high cumulative incidence of thrombotic complications in critically ill ICU patients with COVID-19: An updated analysis

Systematic review of case reports of antiphospholipid syndrome following infection

The authors would like to formally acknowledge the commitment of all front-line healthcare workers during the COVID-19 crisis in the University Hospital of Strasbourg as they commit themselves to difficult work and also put themselves at risk of infection. Strasbourg's University Hospital is proud of the commitment of all nurses, including newly graduated nurses, medical students, health support staff and volunteers.Funding This work was supported by GERCA (Groupe pour l'Enseignement, la prévention et la Recherche Cardiologique en Alsace) and Fondation Coeur et Recherche.

The author declares that they have no conflict of interest.