Erythropoietin-Induced Thrombosis as a Result of Increased Inflammation and Thrombin Activatable Fibrinolytic Inhibitor

Abstract

Chronic inflammation is a major cause of morbidity and mortality in end-stage renal disease. The associated anemia in these patients due to renal cortical atrophy and erythropoietin deficiency is treated with recombinant erythropoietin. Recent reports suggest a growing incidence of symptomatic venous thrombosis in cancer patients treated with recombinant erythropoietin. Several investigators have reported on different mechanisms of thrombosis in these patients. We hypothesize that thrombosis in patients with end-stage renal disease due to increased expression of C-reactive protein (CRP) as a result of chronic inflammation promotes the release of thrombin activatable fibrinolytic inhibitor causing fibrinolytic deficit and eventually thrombosis. Furthermore, because endothelial nitric oxide is responsible for the maintenance of the normal vascular function, the decreased levels of nitric oxide in chronic inflammation cause endothelial damage and result in thrombosis. To test this hypothesis, blood samples were collected from 106 patients (49 male and 57 female, aged 59.8±15.7 years) with end-stage renal disease undergoing hemodialysis and treated with recombinant erythropoietin at a mean dose of 201.8 U/kg/week. Blood samples were drawn in 5-mL tubes containing 3.2% sodium citrate just before the hemodialysis procedure. These blood samples were immediately centrifuged to obtain platelet-poor plasma, which was aliquoted and frozen at -70°C until further analysis. Erytropoietin antibodies were measured using an anti-EPO enzyme-linked immunosorbent assay (ELISA) method developed in our laboratory. Nitric oxide was measured using a NO analyzer (Sievers 280I, Ionics, Boulder, CO). Plasma CRP levels were measured with a highly sensitive ELISA method IMUNOCLONE CRP ELISA (American Diagnostica, Greenwich, CT). TAFI antigen levels in plasma were analyzed with an IMUCLONE TAFI ELISA kit (American Diagnostica, Greenwich, CT). TAFI functional activity was assayed with an ACTICHROME TAFI activity kit. The measured levels of nitric oxide, CRP, TAFI antigen, and TAFI functional were 37.36±36.8 (normal value, 37.49±18.96; range, 19.3-102 μM), 12.27±10.6 (normal value, < 1 μg/mL), 146.9±28.4% NHP (normal, 100% NHP), and 102.55±37% NHP (normal range, 22.3-165.7; mean, 89.5% NHP), respectively. The erythropoietin antibody was detected in 9.4% of the patient group. While 20% of the erythropoietin antibody-positive and 27.1% of the erythropoietin antibody-negative patients experienced chest pain, thrombotic events developed in 9.4% of the erythropoietin antibody-negative patients. These data provide the rationale for a novel mechanism of thrombosis through increased activity of CRP, nitric oxide, and TAFI, leading to fibrinolytic deficit and thrombosis in patients treated with erythropoietin.

Keywords

Nitric oxide Thrombosis Erythropoietin Cytokinesis

References

DeLemos JA , Hillis LD . Diagnosis and management of coronary artery disease in patients with end-stage renal disease on hemodialysis. J Am Soc Nephrol 1996;7:2044.

Stenvinkel P , Heimburger O , Paultre F , et al. Strong association between malnutrition, inflammation and atherosclerosis in chronic renal failure. Kidney Int 1999;55:1899.

Kooistra M , Niemantsverdriet E , Van Es A , et al. Iron absorption in erythropoietin-treated haemodialysis patients: Effects of iron availability, inflammation and aluminum. Nephrol Dial Transplant 1998;13:82.

Allen D , Breen C , Yaqoob M , et al. Inhibition of CFU-E colony formation in uremic patients with inflammatory disease: Role of IFN-γ and TNF-α. J Invest Med 1999;47:204.

Steurer M , Sudmeier I , Stauder R , Gasti G. Thromboembolic events in patients with myelodysplastic syndrome receiving thalidomide in combination with darbepoietin-alpha. Br J Haematol 2003;121:101.

Wun T , Law L , Harvey D , et al. Increased incidence of symptomatic venous thrombosis in patients with cervical carcinoma treated with concurrent chemotherapy, radiation, and erythropoietin. Cancer 2003;98:1514.

Wever R , Boer P , Hijmering M , et al. Nitric oxide production is reduced in patients with chronic renal failure. Circulation 1999;19:1168.

Fuste B , Serradell M , Escolar G , et al. Erythropoietin triggers a signaling pathway in endothelial cells and increases the thrombogenicity of their extracellular matrices in vitro. Thromb Haemost 2002;88:678.

Verma S , Wang CH , Li SH , et al. A self-fulfilling prophecy: C-reactive protein attenuates nitric oxide production and inhibits angiogenesis. Circulation 2002;106:913.

10.

Szmitko PE , Wang CH , Weisel RD , et al. New markers of inflammation and endothelial cell activation: Part I. Circulation 2003;108:1917.

11.

Verma S , Li SH , Badiwala MV , et al. Endothelin antagonism and interleukin-6 inhibition attenuate the proatherogenic effects of C-reactive protein. Circulation 2002;105:1890.

12.

Kaplanski G , Martin V , Fabrigoule M , et al. Thrombin-activated human endothelial cells support monocyte adhesion molecule-1 (ICAM-1; CD54) and vascular cell adhesion molecule-1 (VCAM-1; CD106). Blood 1998;92:1259.