出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2018/03/30 11:48:41」(JST)
| Disseminated intravascular coagulation | |
|---|---|
| Synonyms | Disseminated intravascular coagulopathy, consumptive coagulopathy, defibrination syndrome[1] |
| Micrograph showing acute thrombotic microangiopathy due to DIC in a kidney biopsy. A clot is present in the hilum of the glomerulus (center of image). | |
| Specialty | Haematology |
| Symptoms | Chest pain, shortness of breath, leg pain, problems speaking, problems moving part of the body, bleeding[1] |
| Complications | Organ failure[2] |
| Types | Acute, chronic[1] |
| Causes | Sepsis, surgery, major trauma, cancer, complications of pregnancy, snake bites, frostbite, burns[1] |
| Diagnostic method | Blood tests[2] |
| Similar conditions | Thrombotic thrombocytopenic purpura, hemolytic-uremic syndrome[1] |
| Treatment | Directed at the underlying condition[3] |
| Medication | Platelets, cryoprecipitate, fresh frozen plasma, heparin[2] |
| Prognosis | 20-50% risk of death[4] |
| Frequency | 1% of people admitted to hospital[4] |
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Disseminated intravascular coagulation (DIC) is a condition in which blood clots form throughout the body blocking small blood vessels.[1] Symptoms may include chest pain, shortness of breath, leg pain, problems speaking, or problems moving parts of the body.[1] As clotting factors and platelets are used up, bleeding may occur.[1] This may include blood in the urine, blood in the stool, or bleeding into the skin.[1] Complications may include organ failure.[2]
Relatively common causes include sepsis, surgery, major trauma, cancer, and complications of pregnancy.[1] Less common causes include snake bites, frostbite, and burns.[1] There are two main types acute (rapid onset) and chronic (slow onset).[1] Diagnosis is typically based on blood tests.[2] Findings may include low platelets, low fibrinogen, high INR, or high D-dimer.[2]
Treatment is mainly directed towards the underlying condition.[3][2] Other measures may include giving platelets, cryoprecipitate, or fresh frozen plasma.[2] Evidence to support these treatments, however, is poor. Heparin may be useful in the chronic form.[2] About 1% of people admitted to hospital are affected by the condition.[4] In those with sepsis rates are between 20% and 50%.[4] The risk of death among those affected varies from 20 to 50%.[4]
In DIC, the underlying cause usually leads to symptoms and signs, and DIC is discovered on laboratory testing. The onset of DIC can be sudden, as in endotoxic shock or amniotic fluid embolism, or it may be insidious and chronic, as in cancer. DIC can lead to multiorgan failure and widespread bleeding.[5]
DIC can occur in the following conditions:[6][7][5][8]
Liver disease, HELLP syndrome, thrombotic thrombocytopenic purpura/Haemolytic uremic syndrome, and malignant hypertension may mimic DIC but do not occur via the same pathways.[citation needed]
Under homeostatic conditions, the body is maintained in a finely tuned balance of coagulation and fibrinolysis. The activation of the coagulation cascade yields thrombin that converts fibrinogen to fibrin; the stable fibrin clot being the final product of hemostasis. The fibrinolytic system then functions to break down fibrinogen and fibrin. Activation of the fibrinolytic system generates plasmin (in the presence of thrombin), which is responsible for the lysis of fibrin clots. The breakdown of fibrinogen and fibrin results in polypeptides called fibrin degradation products (FDPs) or fibrin split products (FSPs). In a state of homeostasis, the presence of plasmin is critical, as it is the central proteolytic enzyme of coagulation and is also necessary for the breakdown of clots, or fibrinolysis.[citation needed]
In DIC, the processes of coagulation and fibrinolysis are dysregulated, and the result is widespread clotting with resultant bleeding. Regardless of the triggering event of DIC, once initiated, the pathophysiology of DIC is similar in all conditions. One critical mediator of DIC is the release of a transmembrane glycoprotein called tissue factor (TF). TF is present on the surface of many cell types (including endothelial cells, macrophages, and monocytes) and is not normally in contact with the general circulation, but is exposed to the circulation after vascular damage. For example, TF is released in response to exposure to cytokines (particularly interleukin 1), tumor necrosis factor, and endotoxin.[9] This plays a major role in the development of DIC in septic conditions. TF is also abundant in tissues of the lungs, brain, and placenta. This helps to explain why DIC readily develops in patients with extensive trauma. Upon exposure to blood and platelets, TF binds with activated factor VIIa (normally present in trace amounts in the blood), forming the extrinsic tenase complex. This complex further activates factor IX and X to IXa and Xa, respectively, leading to the common coagulation pathway and the subsequent formation of thrombin and fibrin.[7]
The release of endotoxin is the mechanism by which Gram-negative sepsis provokes DIC. In acute promyelocytic leukemia, treatment causes the destruction of leukemic granulocyte precursors, resulting in the release of large amounts of proteolytic enzymes from their storage granules, causing microvascular damage. Other malignancies may enhance the expression of various oncogenes that result in the release of TF and plasminogen activator inhibitor-1 (PAI-1), which prevents fibrinolysis.[10]
Excess circulating thrombin results from the excess activation of the coagulation cascade. The excess thrombin cleaves fibrinogen, which ultimately leaves behind multiple fibrin clots in the circulation. These excess clots trap platelets to become larger clots, which leads to microvascular and macrovascular thrombosis. This lodging of clots in the microcirculation, in the large vessels, and in the organs is what leads to the ischemia, impaired organ perfusion, and end-organ damage that occurs with DIC.[citation needed]
Coagulation inhibitors are also consumed in this process. Decreased inhibitor levels will permit more clotting so that a positive feedback loop develops in which increased clotting leads to more clotting. At the same time, thrombocytopenia occurs and this has been attributed to the entrapment and consumption of platelets. Clotting factors are consumed in the development of multiple clots, which contributes to the bleeding seen with DIC.[citation needed]
Simultaneously, excess circulating thrombin assists in the conversion of plasminogen to plasmin, resulting in fibrinolysis. The breakdown of clots results in an excess of FDPs, which have powerful anticoagulant properties, contributing to hemorrhage. The excess plasmin also activates the complement and kinin systems. Activation of these systems leads to many of the clinical symptoms that patients experiencing DIC exhibit, such as shock, hypotension, and increased vascular permeability. The acute form of DIC is considered an extreme expression of the intravascular coagulation process with a complete breakdown of the normal homeostatic boundaries. DIC is associated with a poor prognosis and a high mortality rate.[citation needed]
There has been a recent challenge however to the basic assumptions and interpretations of the pathophysiology of DIC. A study of sepsis and DIC in animal models has shown that a highly expressed receptor on the surface of hepatocytes, termed the Ashwell-Morell receptor, is responsible for thrombocytopenia in bacteremia and sepsis due to Streptococcus pneumoniae (SPN) and possibly other pathogens. The thrombocytopenia observed in SPN sepsis was not due to increased consumption of coagulation factors such as platelets, but instead was the result of this receptor's activity enabling hepatocytes to ingest and rapidly clear platelets from circulation.[11] By removing pro-thrombotic components before they participate in the coagulopathy of DIC, the Ashwell-Morell receptor lessens the severity of DIC, reducing thrombosis and tissue necrosis, and promoting survival. The hemorrhage observed in DIC and among some tissues lacking this receptor may thereby be secondary to increased thrombosis with loss of the mechanical vascular barrier. This discovery has possible significant clinical implications in devising new approaches to reducing the morbidity and mortality of DIC.[citation needed]
There is activation of intrinsic as well as extrinsic coagulation pathway, this results in excess thrombus formation in the blood vessels. Due to extensive coagulation there is consumption of coagulation factors which causes bleeding.
The diagnosis of DIC is not made on a single laboratory value, but rather the constellation of laboratory markers and a consistent history of an illness known to cause DIC. Laboratory markers consistent with DIC include:[3][7][12]
A diagnostic algorithm has been proposed by the International Society of Thrombosis and Haemostasis. This algorithm appears to be 91% sensitive and 97% specific for the diagnosis of overt DIC. A score of 5 or higher is compatible with DIC and it is recommended that the score is repeated daily, while a score below 5 is suggestive but not affirmative for DIC and it is recommended that it is repeated only occasionally:[12][13] It has been recommended that a scoring system be used in the diagnosis and management of DIC in terms of improving outcome.[14]
Treatment of DIC is centered around treating the underlying condition. Transfusions of platelets or fresh frozen plasma can be considered in cases of significant bleeding, or those with a planned invasive procedure. The target goal of such transfusion depends on the clinical situation. Cryoprecipitate can be considered in those with a low fibrinogen level.
Treatment of thrombosis with anticoagulants such as heparin is rarely used due to the risk of bleeding.
Recombinant human activated protein C was previously recommended in those with severe sepsis and DIC, but drotrecogin alfa has been shown to confer no benefit and was withdrawn from the market in 2011.
Recombinant factor VII has been proposed as a "last resort" in those with severe hemorrhage due to obstetric or other causes, but conclusions about its use are still insufficient.[16]
Prognosis varies depending on the underlying disorder, and the extent of the intravascular thrombosis (clotting). The prognosis for those with DIC, regardless of cause, is often grim: Between 20% and 50% of patients will die.[17] DIC with sepsis (infection) has a significantly higher rate of death than DIC associated with trauma.[17]
DIC is observed in approximately 1% of academic hospital admissions.[18] DIC occurs at higher rates in people with bacterial sepsis (83%),[19] severe trauma (31%),[20] and cancer (6.8%).[21]
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Diseases of the skin and appendages by morphology
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Diseases of clotting (D50–69,74, 280–287)
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| リンク元 | 「播種性血管内凝固症候群」 |
| 関連記事 | 「disseminate」「intravascular」「disseminated」「coagulopathy」「intravascular coagulopathy」 |
| 表1.DIC診断基準 | ||
| 厚労省DIC診断基準 | 急性期DIC診断基準 | |
| 基礎疾患 | 基礎疾患あり：1点 | 基礎疾患は必須項目 |
| 臨床症状 | 出血症状あり：1点 臓器症状あり：1点 |
要除外診断 SIRS（3項目以上）：1点 |
| 血小板数 (X104/μL) |
8＜ ≦12：1点 5＜ ≦ 8：2点 ≦ 5：3点 |
8≦＜12 or 30%以上減少/24h：1点 ＜8 or 50%以上減少/24h：3点 |
| 血清FDP(μg/ml) | 10≦ ＜20：1点 20≦ ＜40：2点 40≦ ：3点 |
10≦ ＜25: 1点 25≦ ：3点 D-dimerもFDPとの換算表により使用可能 |
| フィブリノゲン（mg/dl） | 100＜ ≦150：1点 ≦100：2点 |
― |
| PT比 | 1.25≦ ＜1.67：1点 1.67≦ ：2点 |
1.2≦：1点 |
| DIC診断 | 7点以上 （白血病群では、出血症状と血小板数を除いて、4点以上） |
4点以上 （白血病群には適応できない） |
| 血液マーカー | DIC | DIC | 意義 | 例外 | |
| global coagulation tests | プロトロンビン時間 | PT | ↑ | 肝障害 | |
| フィブリノゲン | ↓or→ | 炎症、肝障害 | |||
| 血小板数 | ↓ | 肝障害、骨髄抑制、血小板抗体 | |||
| フィブリン分解産物 | FDP | ↑ | 線溶亢進 | 炎症で増加が減少 | |
| 止血系分子マーカー | トロンビン・アンチトロンビンIII複合体 | TAT, F1+2 | ↑ | トロンビン生成 | その他の血栓症でも増加 |
| SF, Dダイマー | ↑ | フィブリン生成 | |||
| PPIC, Dダイマー | ↑ | フィブリン分解 | |||
| トロンボモジュリン | TM | ↑ | 血管内皮障害 | 腎障害 | |
| アンチトロンビン | AT | ↓ | 肝障害 | ||
| プロテインC | PC | ↓ | 肝障害 | ||
| プラスミノゲンアクティベーターインヒビター1 | PAI-1 | ↑ | 線溶低下 | 高脂血症 | |
| 組織因子 | TF | ↑ | 外因系の活性化 | 大動脈瘤 | |
| 第VIIa因子 | ＦVIIa | ↑ | |||
| 組織因子経路インヒビター | TFPI | ↑ |