Disseminated intravascular coagulation pathophysiology: Difference between revisions
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==Overview== | ==Overview== | ||
DIC is a hemorrhagic syndrome originating in the small blood vessels. DIC is caused by uncontrolled activation of clotting factors and fibrinolytic enzymes. Tissue necrosis and bleeding are results of | DIC is a hemorrhagic syndrome originating in the small blood vessels. DIC is caused by uncontrolled activation of [[clotting factors]] and [[fibrinolytic]] [[enzymes]]. Tissue [[necrosis]] and [[bleeding]] are consequences of DIC. Under [[Homeostasis|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 [[Fibrinolysis|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 [[thrombin]] is critical, as it is the central [[proteolytic]] [[enzyme]] of coagulation and is also necessary for the breakdown of clots, or [[fibrinolysis]]. | ||
==Pathophysiology== | ==Pathophysiology== | ||
Under [[Homeostasis|homeostatic]] conditions, the body is maintained in a | DIC is an acquired syndrome characterized by the intravascular activation of coagulation due to sepsis, trauma, malignancy, liver disease, obstetric disorders, envenomation, vascular anomalies and major transfusion reactions. It can originate from and cause damage to the microvasculature, which may eventually lead to organ dysfunction. Under [[Homeostasis|homeostatic]] conditions, the body is maintained in a state of [[hematological]] equilibrium of [[coagulation]] and [[fibrinolysis]] termed as [[hemostasis]]. The activation of the [[coagulation]] cascade yields [[thrombin]] that converts [[fibrinogen]] to [[fibrin]]; the stable [[fibrin]] clot being the final product of coagulation cascade. The fibrinolytic system then functions to break down [[fibrinogen]] and fibrin. Activation of the [[Fibrinolysis|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). | ||
=== '''DIC as a disease process''' === | |||
* DIC occurs secondary to a clinical disorder. The clinical spectrum includes sepsis, trauma, malignancy, liver disease, obstetric disorders, envenomation, vascular anomalies and major transfusion reactions. | |||
* Ocurrence of DIC in a patient should always be seen as an indicator of another life-threatening condition and warrants thorough diagnostic evaluation. | |||
=== '''Mediators of induction of DIC''' === | |||
* DIC may be induced by either or both of the following mechanisms: | |||
** As a consequence of systemic inflammatory response, there is activation of cytokine network and thereby coagulation system as in sepsis or polytrauma and/or | |||
** Release of pro-coagulant products into the blood stream such as in malignancies or obstetrical cases. | |||
In [[DIC]], the processes of [[coagulation]] and [[fibrinolysis]] lose control, 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.<ref name="pmid24366358">{{cite journal |vauthors=Martinod K, Wagner DD |title=Thrombosis: tangled up in NETs |journal=Blood |volume=123 |issue=18 |pages=2768–76 |date=May 2014 |pmid=24366358 |pmc=4007606 |doi=10.1182/blood-2013-10-463646 |url=}}</ref> 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]], [[Macrophage|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]]), tumor necrosis factor, and [[endotoxin]]. 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 activation, TF binds with [[coagulation]] factors that then trigger both the intrinsic and the extrinsic pathways of [[coagulation]].<ref name="pmid24423888">{{cite journal |vauthors=Hellum M, Øvstebø R, Brusletto BS, Berg JP, Brandtzaeg P, Henriksson CE |title=Microparticle-associated tissue factor activity correlates with plasma levels of bacterial lipopolysaccharides in meningococcal septic shock |journal=Thromb. Res. |volume=133 |issue=3 |pages=507–14 |date=March 2014 |pmid=24423888 |doi=10.1016/j.thromres.2013.12.031 |url=}}</ref> | * In [[DIC]], the processes of [[coagulation]] and [[fibrinolysis]] lose control, 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.<ref name="pmid24366358">{{cite journal |vauthors=Martinod K, Wagner DD |title=Thrombosis: tangled up in NETs |journal=Blood |volume=123 |issue=18 |pages=2768–76 |date=May 2014 |pmid=24366358 |pmc=4007606 |doi=10.1182/blood-2013-10-463646 |url=}}</ref> 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]], [[Macrophage|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]]), tumor necrosis factor, and [[endotoxin]]. 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 activation, TF binds with [[coagulation]] factors that then trigger both the intrinsic and the extrinsic pathways of [[coagulation]].<ref name="pmid24423888">{{cite journal |vauthors=Hellum M, Øvstebø R, Brusletto BS, Berg JP, Brandtzaeg P, Henriksson CE |title=Microparticle-associated tissue factor activity correlates with plasma levels of bacterial lipopolysaccharides in meningococcal septic shock |journal=Thromb. Res. |volume=133 |issue=3 |pages=507–14 |date=March 2014 |pmid=24423888 |doi=10.1016/j.thromres.2013.12.031 |url=}}</ref> | |||
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 bed|microvascular]] and [[Macrovascular disease|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]].<ref name="pmid234638">{{cite journal |vauthors=Gordon SG, Franks JJ, Lewis B |title=Cancer procoagulant A: a factor X activating procoagulant from malignant tissue |journal=Thromb. Res. |volume=6 |issue=2 |pages=127–37 |date=February 1975 |pmid=234638 |doi= |url=}}</ref><ref name="pmid23650392">{{cite journal |vauthors=Martinod K, Demers M, Fuchs TA, Wong SL, Brill A, Gallant M, Hu J, Wang Y, Wagner DD |title=Neutrophil histone modification by peptidylarginine deiminase 4 is critical for deep vein thrombosis in mice |journal=Proc. Natl. Acad. Sci. U.S.A. |volume=110 |issue=21 |pages=8674–9 |date=May 2013 |pmid=23650392 |pmc=3666755 |doi=10.1073/pnas.1301059110 |url=}}</ref><ref name="pmid834136">{{cite journal |vauthors=Sack GH, Levin J, Bell WR |title=Trousseau's syndrome and other manifestations of chronic disseminated coagulopathy in patients with neoplasms: clinical, pathophysiologic, and therapeutic features |journal=Medicine (Baltimore) |volume=56 |issue=1 |pages=1–37 |date=January 1977 |pmid=834136 |doi= |url=}}</ref> | === '''Activation of coagulation cascade''' === | ||
* 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 bed|microvascular]] and [[Macrovascular disease|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]].<ref name="pmid234638">{{cite journal |vauthors=Gordon SG, Franks JJ, Lewis B |title=Cancer procoagulant A: a factor X activating procoagulant from malignant tissue |journal=Thromb. Res. |volume=6 |issue=2 |pages=127–37 |date=February 1975 |pmid=234638 |doi= |url=}}</ref><ref name="pmid23650392">{{cite journal |vauthors=Martinod K, Demers M, Fuchs TA, Wong SL, Brill A, Gallant M, Hu J, Wang Y, Wagner DD |title=Neutrophil histone modification by peptidylarginine deiminase 4 is critical for deep vein thrombosis in mice |journal=Proc. Natl. Acad. Sci. U.S.A. |volume=110 |issue=21 |pages=8674–9 |date=May 2013 |pmid=23650392 |pmc=3666755 |doi=10.1073/pnas.1301059110 |url=}}</ref><ref name="pmid834136">{{cite journal |vauthors=Sack GH, Levin J, Bell WR |title=Trousseau's syndrome and other manifestations of chronic disseminated coagulopathy in patients with neoplasms: clinical, pathophysiologic, and therapeutic features |journal=Medicine (Baltimore) |volume=56 |issue=1 |pages=1–37 |date=January 1977 |pmid=834136 |doi= |url=}}</ref> | |||
[[Coagulation]] inhibitors are also consumed in this process. Decreased inhibitor levels will permit more [[clotting]] so that a feedback system develops in which increased clotting leads to more [[clotting]]. At the same time, [[thrombocytopenia]] occurs because of the entrapment of [[platelets]]. [[Clotting]] factors are consumed in the development of multiple clots, which contributes to the bleeding seen with [[DIC]].<ref name="pmid9518049">{{cite journal |vauthors=Gordon SG, Mielicki WP |title=Cancer procoagulant: a factor X activator, tumor marker and growth factor from malignant tissue |journal=Blood Coagul. Fibrinolysis |volume=8 |issue=2 |pages=73–86 |date=March 1997 |pmid=9518049 |doi= |url=}}</ref> | === Consumptive coagulopathy and bleeding sequelae === | ||
* [[Coagulation]] inhibitors are also consumed in this process. Decreased inhibitor levels will permit more [[clotting]] so that a feedback system develops in which increased clotting leads to more [[clotting]]. At the same time, [[thrombocytopenia]] occurs because of the entrapment of [[platelets]]. [[Clotting]] factors are consumed in the development of multiple clots, which contributes to the bleeding seen with [[DIC]].<ref name="pmid9518049">{{cite journal |vauthors=Gordon SG, Mielicki WP |title=Cancer procoagulant: a factor X activator, tumor marker and growth factor from malignant tissue |journal=Blood Coagul. Fibrinolysis |volume=8 |issue=2 |pages=73–86 |date=March 1997 |pmid=9518049 |doi= |url=}}</ref> | |||
* Simultaneously, excess circulating [[thrombin]] assists in the conversion of [[plasminogen]] to [[plasmin]], resulting in [[fibrinolysis]]. The breakdown of clots results in excess amounts of FDPs, which have powerful [[anticoagulant]] properties, contributing to [[hemorrhage]]. | |||
* The excess [[plasmin]] also activates the [[complement]] and [[kinin]] systems.<ref name="pmid19855397">{{cite journal |vauthors=Xu J, Zhang X, Pelayo R, Monestier M, Ammollo CT, Semeraro F, Taylor FB, Esmon NL, Lupu F, Esmon CT |title=Extracellular histones are major mediators of death in sepsis |journal=Nat. Med. |volume=15 |issue=11 |pages=1318–21 |date=November 2009 |pmid=19855397 |pmc=2783754 |doi=10.1038/nm.2053 |url=}}</ref> | |||
* 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. | |||
=== Summary === | |||
As a summary:<ref name="pmid7770905">{{cite journal |vauthors=Capon SM, Goldfinger D |title=Acute hemolytic transfusion reaction, a paradigm of the systemic inflammatory response: new insights into pathophysiology and treatment |journal=Transfusion |volume=35 |issue=6 |pages=513–20 |date=June 1995 |pmid=7770905 |doi= |url=}}</ref><ref name="pmid19222477">{{cite journal |vauthors=Levi M, Toh CH, Thachil J, Watson HG |title=Guidelines for the diagnosis and management of disseminated intravascular coagulation. British Committee for Standards in Haematology |journal=Br. J. Haematol. |volume=145 |issue=1 |pages=24–33 |date=April 2009 |pmid=19222477 |doi=10.1111/j.1365-2141.2009.07600.x |url=}}</ref><ref name="pmid25843168">{{cite journal |vauthors=Kim JE, Lee N, Gu JY, Yoo HJ, Kim HK |title=Circulating levels of DNA-histone complex and dsDNA are independent prognostic factors of disseminated intravascular coagulation |journal=Thromb. Res. |volume=135 |issue=6 |pages=1064–9 |date=June 2015 |pmid=25843168 |doi=10.1016/j.thromres.2015.03.014 |url=}}</ref> | |||
* It seems that the formation of both [[thrombin]] and [[plasmin]] are required for the development of [[DIC]]. | * It seems that the formation of both [[thrombin]] and [[plasmin]] are required for the development of [[DIC]]. | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Omer Kamal, M.D.[2]
Overview
DIC is a hemorrhagic syndrome originating in the small blood vessels. DIC is caused by uncontrolled activation of clotting factors and fibrinolytic enzymes. Tissue necrosis and bleeding are consequences of DIC. 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 thrombin is critical, as it is the central proteolytic enzyme of coagulation and is also necessary for the breakdown of clots, or fibrinolysis.
Pathophysiology
DIC is an acquired syndrome characterized by the intravascular activation of coagulation due to sepsis, trauma, malignancy, liver disease, obstetric disorders, envenomation, vascular anomalies and major transfusion reactions. It can originate from and cause damage to the microvasculature, which may eventually lead to organ dysfunction. Under homeostatic conditions, the body is maintained in a state of hematological equilibrium of coagulation and fibrinolysis termed as hemostasis. The activation of the coagulation cascade yields thrombin that converts fibrinogen to fibrin; the stable fibrin clot being the final product of coagulation cascade. 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).
DIC as a disease process
- DIC occurs secondary to a clinical disorder. The clinical spectrum includes sepsis, trauma, malignancy, liver disease, obstetric disorders, envenomation, vascular anomalies and major transfusion reactions.
- Ocurrence of DIC in a patient should always be seen as an indicator of another life-threatening condition and warrants thorough diagnostic evaluation.
Mediators of induction of DIC
- DIC may be induced by either or both of the following mechanisms:
- As a consequence of systemic inflammatory response, there is activation of cytokine network and thereby coagulation system as in sepsis or polytrauma and/or
- Release of pro-coagulant products into the blood stream such as in malignancies or obstetrical cases.
- In DIC, the processes of coagulation and fibrinolysis lose control, 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.[1] 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), tumor necrosis factor, and endotoxin. 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 activation, TF binds with coagulation factors that then trigger both the intrinsic and the extrinsic pathways of coagulation.[2]
Activation of coagulation cascade
- 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.[3][4][5]
Consumptive coagulopathy and bleeding sequelae
- Coagulation inhibitors are also consumed in this process. Decreased inhibitor levels will permit more clotting so that a feedback system develops in which increased clotting leads to more clotting. At the same time, thrombocytopenia occurs because of the entrapment of platelets. Clotting factors are consumed in the development of multiple clots, which contributes to the bleeding seen with DIC.[6]
- Simultaneously, excess circulating thrombin assists in the conversion of plasminogen to plasmin, resulting in fibrinolysis. The breakdown of clots results in excess amounts of FDPs, which have powerful anticoagulant properties, contributing to hemorrhage.
- The excess plasmin also activates the complement and kinin systems.[7]
- 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.
Summary
- It seems that the formation of both thrombin and plasmin are required for the development of DIC.
- A variety of triggering events can result in thrombin and plasmin formation, including damage to RBCs, platelets, or the endothelium.
- After the coagulation system has been activated, the pathophysiology of DIC is similar in all disorders.
- Circulating thrombin cleaves fibrinopeptides A and B from fibrinogen resulting in the formation of fibrin monomers.
- These monomers polymerize into a fibrin clot, which traps platelets and results in thrombosis, organ ischemia and thrombocytopenia.
- Thrombin also induces endothelial cells to release:
- endothelin, a potent vasoconstrictor, and,
- E selectin, which binds granulocytes and lymphocytes, resulting in further cytokine release as well as release of platelet activating factor.
- At the same time, plasmin cleaves the carboxy-terminal end of fibrinogen into fibrinogen degradation products, and cleaves fibrin into fibrin degradation products.
- The circulating FDPs (fibrin and fibrinogen) interfere with the polymerization of fibrin monomers, resulting in further hemorrhage.
- Additionally, the fibrinogen degradation products D and E impair platelet function, worsening the bleeding.
- The fibrin degradation products and D-dimer induce synthesis of IL-1 and IL-6, which cause further endothelial damage, as well as plasminogen activator inhibitor type 1 (PAI-1) which inhibits fibrinolysis resulting in accelerated thrombus formation.
- FDPs also stimulate the release of tissue factor, which accelerates thrombosis via the extrinsic coagulation pathway.
- The release of large amounts of tissue factor (i.e. in obstetrical cases) can also initiate DIC.
- Other effects of plasmin include:
- biodegredation of factors V, VII, IX and XI --> hemorrhage.
- complement activation, which results in RBC lysis --> release of ADP and membrane phospholipids (procoagulant material).
- As can be seen, the above soup results in a mess of thrombosis and hemorrhage.
- DIC is seen in a wide variety of clinical conditions and is most commonly associated with infection (esp. GN org --> endotoxin), malignancy and obstetrical complications.
References
- ↑ Martinod K, Wagner DD (May 2014). "Thrombosis: tangled up in NETs". Blood. 123 (18): 2768–76. doi:10.1182/blood-2013-10-463646. PMC 4007606. PMID 24366358.
- ↑ Hellum M, Øvstebø R, Brusletto BS, Berg JP, Brandtzaeg P, Henriksson CE (March 2014). "Microparticle-associated tissue factor activity correlates with plasma levels of bacterial lipopolysaccharides in meningococcal septic shock". Thromb. Res. 133 (3): 507–14. doi:10.1016/j.thromres.2013.12.031. PMID 24423888.
- ↑ Gordon SG, Franks JJ, Lewis B (February 1975). "Cancer procoagulant A: a factor X activating procoagulant from malignant tissue". Thromb. Res. 6 (2): 127–37. PMID 234638.
- ↑ Martinod K, Demers M, Fuchs TA, Wong SL, Brill A, Gallant M, Hu J, Wang Y, Wagner DD (May 2013). "Neutrophil histone modification by peptidylarginine deiminase 4 is critical for deep vein thrombosis in mice". Proc. Natl. Acad. Sci. U.S.A. 110 (21): 8674–9. doi:10.1073/pnas.1301059110. PMC 3666755. PMID 23650392.
- ↑ Sack GH, Levin J, Bell WR (January 1977). "Trousseau's syndrome and other manifestations of chronic disseminated coagulopathy in patients with neoplasms: clinical, pathophysiologic, and therapeutic features". Medicine (Baltimore). 56 (1): 1–37. PMID 834136.
- ↑ Gordon SG, Mielicki WP (March 1997). "Cancer procoagulant: a factor X activator, tumor marker and growth factor from malignant tissue". Blood Coagul. Fibrinolysis. 8 (2): 73–86. PMID 9518049.
- ↑ Xu J, Zhang X, Pelayo R, Monestier M, Ammollo CT, Semeraro F, Taylor FB, Esmon NL, Lupu F, Esmon CT (November 2009). "Extracellular histones are major mediators of death in sepsis". Nat. Med. 15 (11): 1318–21. doi:10.1038/nm.2053. PMC 2783754. PMID 19855397.
- ↑ Capon SM, Goldfinger D (June 1995). "Acute hemolytic transfusion reaction, a paradigm of the systemic inflammatory response: new insights into pathophysiology and treatment". Transfusion. 35 (6): 513–20. PMID 7770905.
- ↑ Levi M, Toh CH, Thachil J, Watson HG (April 2009). "Guidelines for the diagnosis and management of disseminated intravascular coagulation. British Committee for Standards in Haematology". Br. J. Haematol. 145 (1): 24–33. doi:10.1111/j.1365-2141.2009.07600.x. PMID 19222477.
- ↑ Kim JE, Lee N, Gu JY, Yoo HJ, Kim HK (June 2015). "Circulating levels of DNA-histone complex and dsDNA are independent prognostic factors of disseminated intravascular coagulation". Thromb. Res. 135 (6): 1064–9. doi:10.1016/j.thromres.2015.03.014. PMID 25843168.