【在线速递】重组人可溶性血栓调节蛋白对脓毒症相关凝血障碍患者死亡率的影响——SCARLET随机临床试验

IMPORTANCE  重点

Previous research suggested that soluble human recombinant thrombomodulin

may reduce mortality among patients with sepsis-associated coagulopathy

先前的研究表明，重组人可溶性血栓调节蛋白可能降低脓毒症相关凝血障碍患者的死亡率。

OBJECTIVE  目的

To determine the effect of human recombinant thrombomodulin vs placebo on 28-day all-cause mortality among patients with sepsis-associated coagulopathy

研究重组人血栓调节蛋白与安慰剂对比对脓毒症相关凝血障碍患者28天全因死亡率的影响。

DESIGN,SETTING,AND PARTICIPANTS  设计、设置和参与者

The SCARLET trial was a randomized, double-blind,placebo-controlled, multinational, multicenter phase 3 study conducted in intensive care units at 159 sites in 26 countries. All adult patients admitted to one of the participating intensive care units between October 2012 and March 2018 with sepsis-associated coagulopathy and concomitant cardiovascular and/or respiratory failure, defined as an international normalized ratio greater than 1.40 without other known etiology and a platelet count in the range of 30 to 150X109/L or a greater than 30% decrease in platelet count within 24 hours, were considered for inclusion. The final date of follow-up was February 28, 2019.

SCARLET试验是在26个国家/地区的159个重症监护室进行的一项随机，双盲，安慰剂对照，多国多中心的3期研究。在2012年10月至2018年3月期间入住重症监护病房患有脓毒症相关凝血障碍疾病并伴有循环和/或呼吸衰竭的所有成年患者中，国际标准化比值大于1.40，而没有其他已知病因和血小板计数在30-150×109 / L或24小时内下降超过30％。随访的最后日期是2019年2月28日。

INTERVENTIONS  干预措施

Patients with sepsis-associated coagulopathy were randomized and treated with an intravenous bolus or a 15-minute infusion of thrombomodulin (0.06 mg/kg/d [maximum, 6 mg/d]; n = 395) or matching placebo (n = 405) once daily for 6 days.

脓毒症相关凝血障碍患者被随机分配并静脉推注或15分钟输注血栓调节蛋白（0.06 mg / kg / d [最大，6 mg / d]；n = 395）或匹配的安慰剂（n = 405） 每天一次，持续6天。

MAIN OUTCOME AND MEASURES  主要结果及指标

The primary end point was 28-day all-cause mortality

主要终点是28天全因死亡率。

RESULTS  结果

Among 816 randomized patients, 800 (mean age, 60.7 years; 437 [54.6%] men)

completed the study and were included in the full analysis set. In these patients, the 28-day

all-cause mortality rate was not statistically significantly different between the thrombomodulin group and the placebo group (106 of 395 patients [26.8%] vs 119 of 405 patients [29.4%], respectively;P = .32). The absolute risk difference was 2.55% (95% CI,−3.68% to 8.77%). The incidence of serious major bleeding adverse events (defined as any intracranial hemorrhage; life-threatening bleeding; or bleeding event classified as serious by the investigator, with administration of at least 1440 mL [typically 6 units] of packed red blood cells over 2 consecutive days) was 23 of 396 patients (5.8%) in thethrombomodulin group and 16 of 404 (4.0%) in the placebo group.

在816名随机分组的患者中，有800名（平均年龄60.7岁；437名[54.6％]男性）完成了研究，并纳入了完整的分析组。在这些患者中，血栓调节蛋白组和安慰剂组的28天全因死亡率无统计学差异（分别为395例患者中的106例[26.8％]和405例患者中的119例[29.4％]；P =.32）。绝对风险差异为2.55％（95％CI，−3.68％至8.77％）。严重出血不良事件的发生率(定义为任何颅内出血;危及生命的出血;或研究者将出血事件归类为严重出血，在396名患者中，血栓调节蛋白组有23名患者(5.8%)连续2天给予至少1440毫升(通常为6个单位)的红细胞，安慰剂组的404名患者中有16名（4.0％）。

CONCLUSIONS AND RELEVANCE  结论及相关性

Among patients with sepsis-associated coagulopathy,

administration of a human recombinant thrombomodulin, compared with placebo, did not significantly reduce 28-day all-cause mortality.

在脓毒症相关凝血障碍患者中，与安慰剂组相比，给予人重组血栓调节蛋白并没有显著降低28天全因死亡率。

TRIAL REGISTRATION  试验注册

ClinicalTrials.gov Identifier:NCT01598831

ClinicalTrials.gov Identifier:NCT01598831

Sepsis, defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, remains the most common cause of death in critically ill patients.1Numerous therapies intended to target the various biological pathways of sepsis have been tested in large randomized studies, but none have shown a significant benefit on mortality.

脓毒症，由于宿主对感染的反应失调而导致危及生命的器官功能障碍，仍然是危重病人最常见的死亡原因。大量针对脓毒症各种生物途径的治疗方法已经在大量的随机研究中进行了测试，但没有一种方法显示对死亡率有显著的益处。

Sepsis-associated coagulopathy, defined by a prolonged international normalized ratio (INR) and reduced platelet count, is highly predictive of 28-day mortality.5The most notable benefit on mortality by an anticoagulant agent for patients with sepsis with overt disseminated intravascular coagulation was observed with drotrecogin α (activated),a recombinant human activated protein C,6which was withdrawn from the market in 2011.

脓毒症相关凝血障碍的定义是国际标准化比值(INR)延长和血小板计数下降，可高度预测28天死亡率。抗凝剂对明显弥散性血管内凝血的脓毒症患者的死亡率具有最显著的益处，它是重组人活化蛋白C drotrecoginα（活化的），于2011年退出市场。

ART-123 is a recombinant human soluble thrombomodulin (rhsTM; thrombomodulin α) composed of 498 amino acids (64 kDa) from the soluble and active extracellular domains of thrombomodulin. The primary mechanism of protection afforded by rhsTM is derived from its capacity to bind circulating thrombin molecules and serve as an activation complex to convert protein C to activated protein C.7,8In addition, rhsTM inhibits inflammation and organ injury caused by damage-associated molecular patterns, such as high mobility group box protein 1 and histones.9-11

ART-123是一种重组人可溶性血栓调节蛋白（rhsTM;血栓调节蛋白α），由来自血栓调节蛋白的可溶性和活性胞外域的498个氨基酸（64 kDa）组成。rhsTM提供的主要保护机制来自其结合循环凝血酶分子的能力，并充当将C蛋白转化为活化C蛋白的激活复合物。此外，rhsTM还可以抑制与损伤相关的分子模式引起的炎症和器官损伤， 例如高迁移率的基盒蛋白1和组蛋白。

Post hoc analysis of a phase 2b randomized clinical trial of patients with sepsis and suspected disseminated intravascular coagulation suggested that reduced mortality associated with rhsTM administration was best predicted when the following 3 factors were present: infection, at least 1 sepsis-associated organ dysfunction (cardiovascular and/or respiratory), and coagulopathy indicated by prolongation of the INR and reduction of platelet count.12The hypothesis was that rhsTM can reduce 28-day mortality in patients with sepsis-associated coagulopathy. This double-blind, placebo-controlled, multinational, multicenter phase 3 study was conducted to determine the adverse effects and efficacy of rhsTM in addition to standard care in patients with sepsis-associated coagulopathy.

对脓毒症和疑似弥散性血管内凝血的2b期随机临床试验的事后分析表明，当出现以下三个因素时，可以最好预测比rhsTM给药相关的死亡率降低：感染，至少1个与脓毒症相关的器官功能障碍（心血管疾病和/或呼吸道），INR的延长和血小板计数的下降指示的凝血功能障碍。假说是rhsTM可以降低脓毒症相关的凝血功能障碍患者的28天死亡率。这项双盲，安慰剂对照，多国，多中心3期研究旨在确定脓毒症相关的凝血病患者除常规治疗外的rhsTM不良反应和疗效。

Study Design  研究设计

The SCARLET (Sepsis Coagulopathy Asahi Recombinant LE Thrombomodulin) trial was a randomized, double-blind,placebo-controlled, multinational, multicenter, parallelgroup phase 3 study with 319 sites in 27 countries (enrollment by 159 sites) in North America, Europe (including Israel), South America, Asia-Pacific, and Russia. The study protocol (Supplement 1) and informed consent form were reviewed and approved by the institutional review board or independent ethics committee at each participating site.Informed consent was obtained, as detailed in the protocol (Supplement 1), before any study-specific procedures were performed in accordance with all applicable ethical, regulatory, and local requirements. Patients were enrolled from October 2012 to March 2018.

SCARLET（脓毒症凝血病Asahi重组LE血栓调节蛋白）试验是一项随机，双盲，安慰剂对照，跨国，多中心，平行组的3期研究，在北美，欧洲（包括以色列），南美，亚太地区和俄罗斯在内的27个国家，319个研究点（注册的有159个）。研究方案（补充1）和知情同意书在每个参与地点均经过机构审查委员会或独立伦理委员会的审查和批准。在进行任何特定研究程序之前按照所有适用的伦理、监管和当地要求，获得知情同意，详见方案(补充1)。患者登记时间为2012年10月至2018年3月。

Key Points  要点

Question  Does administration of a recombinant human soluble thrombomodulin reduce mortality of critically ill patients with sepsis-associated coagulopathy?

问题 重组人可溶性血栓调节蛋白能否降低重症患者脓毒症相关凝血障碍患者的死亡率?

Findings  In this randomized clinical trial that included 800 patients with sepsis-associated coagulopathy, treatment with thrombomodulin, compared with placebo, did not significantly

reduce 28-day all-cause mortality (26.8% in the thrombomodulin group vs 29.4% in the placebo group).

研究发现 在这项随机临床试验中，包括800名脓毒症相关凝血障碍患者，与安慰剂相比，使用血栓调节蛋白治疗并没有显著降低28天全因死亡率(血栓调节蛋白组26.8% vs安慰剂组29.4%)。

Meaning  Use of a recombinant human soluble thrombomodulin did not significantly reduce 28-day all-cause mortality in critically ill patients with sepsis-associated coagulopathy.

意义 应用重组人可溶性血栓调节蛋白并没有显著降低脓毒症相关凝血障碍危重症患者28天全因死亡率。

Study Patients  研究患者

Critically ill patients who were aged at least 18 years with clinical objective evidence of bacterial infection and a known site of infection, systemic inflammatory response syndrome criteria of white blood cell count and temperature, coagulopathy due to sepsis, and a concurrent diagnosis of cardiovascular and/or respiratory dysfunction requiring mechanical ventilation for hypoxemia were eligible for inclusion (Supplement 1). Cardiovascular dysfunction was defined as a requirement for vasopressors to maintain mean arterial pressure of at least 65 mmHg after adequate fluid resuscitation. Adequate fluid resuscitation was defined as intravenous administration of at least 20 mL/kg crystalloid or 10 mL/kg colloid infusion within 6 hours and/or a central venous pressure greater than 8 mmHg or a pulmonary artery occlusion pressure greater than 12 mmHg. Respiratory dysfunction was defined as an acute need for (invasive) mechanical ventilation and partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio of less than 250 (or <200 when the lung was the site of infection). Coagulopathy was characterized by (1) an INR greater than 1.40 without other known etiology (eg, anticoagulant therapy, chronic liver disease) and (2) a platelet count in the range of 30 to 150 × 109/L or a decrease in platelet count greater than 30% within 24 hours. Patients with a platelet count of 30 × 109/L or less were not eligible for inclusion.

年龄在18岁以上、有细菌感染的临床客观证据、已知感染部位、白细胞计数和体温达到全身炎症反应综合征的标准、脓毒症引起的凝血功能障碍、同时诊断为循环和/或呼吸功能障碍因低氧血症需要机械通气的患者符合纳入标准(补充1)。循环功能障碍被定义为经过充分的液体复苏后需要血管升压药维持平均动脉压65mmHg以上。充分的液体复苏被指在6小时内静脉注射至少20ml /kg晶体或10ml /kg胶体和/或中心静脉压力大于8mmHg或肺动脉闭塞压力大于12mmHg。呼吸功能障碍是指急需(有创)机械通气和氧合指数(PaO2/FiO2)小于250(或肺部感染时小于200)。凝血障碍的特点是(1)INR大于1.40，无其他已知病因(如抗凝治疗、慢性肝病);(2)血小板计数在30 ~ 150×109/L，或24小时内血小板计数下降大于30%。血小板计数小于或等于30×109/L的患者不符合纳入标准。

The time limit for the confirmation of inclusion criteria was modified during the study after protocol version 4.0 was implemented, substantially lengthening the maximum time between the first qualifying INR measure and the first dose of rhsTM or placebo from 15 hours to 40 hours. The purpose of this change was to provide more time for investigators to enroll participants because the 15-hour restriction affected the ability to identify and enroll patients in a timely manner. The study protocol including amendments is available in Supplement 1. The eligibility of each patient was discussed by telephone with a physician from one of the 2 regional clinical coordinating centers to confirm the presence of infection, organ dysfunction, coagulopathy, and all other inclusion and exclusion criteria before randomization.

在实施方案4.0版本后，研究中修改了确认纳入标准的时间限制，从而将首次合格的INR值与rhsTM或安慰剂的首次剂量之间的最长时间从15小时延长至40小时。进行此更改的目的是为研究人员提供更多的时间招募参与者，因为15个小时的限制影响了及时识别和招募患者的能力。包括修订的研究方案可在补充1中获得。在随机分组之前，通过电话与来自两个区域临床协调中心之一的医生讨论以确认每个患者是否符合感染、器官功能障碍、凝血功能障碍以及所有其他纳入和排除标准。

Randomization and Intervention  随机化和干预

Randomization was stratified by site with a block size of 4 patients using an interactive voice/web response system,which linked patient randomization numbers to treatment codes. At randomization, patients who met all inclusion criteria and no exclusion criteria were assigned randomly, in a 1:1 ratio, to receive rhsTM at a dose of 0.06 mg/kg/d (maximum dose of 6 mg/d) or matching placebo once daily for 6 consecutive days. These interventions were administered by a dedicated study nurse or trained intensive care unit nurse as an intravenous bolus injection or diluted in 50 mL of 0.9% saline for a 15-minute infusion. Placebo and rhsTM were supplied in identically labeled, individual glass ampules.

使用交互式语音/网络响应系统，将患者的随机编号与治疗代码相关联，按4位患者为一组进行随机分组。随机分组时，以1：1的比例将所有符合入选标准且无排除标准的患者随机分配，接受剂量为0.06 mg/kg/d(最大剂量为6 mg/d)的rhsTM或安慰剂，每日一次，连续6天。这些干预措施由专门的研究护士或经训练过的重症监护室护士执行，药物给患者静脉推注或在50mL 0.9％盐水中的稀释后在15分钟内滴注。安慰剂和rhsTM存放在有着相同标签的独立玻璃安瓿瓶里。

Study Outcomes  研究结果

The primary efficacy end point was all-cause mortality 28 days after the start of the intervention. Secondary efficacy end points were all-cause mortality at 3 months and resolution of organ dysfunction through day 28, measured by shock-free and alive days, ventilator-free and alive days, and dialysis-free and alive days. Follow-up was complete on February 28, 2019, so analyses for secondary end points have not yet been completed and results are therefore not reported.

主要疗效终点是干预开始后28天的全因死亡率。次要疗效终点是3个月时的全因死亡率，以及直到28天时器官功能障碍的缓解情况，以无休克和存活天数，无呼吸机和存活天数以及无透析和存活天数来衡量。随访已于2019年2月28日完成，因此尚未完成对次要终点的分析，故未报告结果。

The primary safety end points included adverse events and major bleeding events through day 28 (defined as any intracranial hemorrhage; life-threatening bleeding; or bleeding event classified as serious by the investigator, with administration of at least 1440 mL [typically 6 units] of packed red blood cells over 2 consecutive days). The secondary safety end point was antidrug antibodies to rhsTM.

主要安全终点包括至第28天的不良事件和重大出血事件（定义为任何颅内出血；威胁生命的出血；或研究者认为严重的出血事件，连续2天给予至少注射1440 mL [通常6个单位]的红血细胞）。次要安全终点是rhsTM的抗药抗体。

Prespecified exploratory laboratory tests were performed to assess differences in coagulation parameters (the plasma concentrations of D-dimer, prothrombin fragment F1.2, and thrombin-antithrombin complex), inflammation parameters (C-reactive protein level, the presence of microparticles or C5a), rhsTM plasma concentration, organ dysfunction (hepatic dysfunction, bilirubin concentration ≥2.0 mg/dL; renal dysfunction, creatinine concentration ≥2.0 mg/dL), and adverse event parameters between baseline (ie, after randomization and before receiving the intervention) and day 28.

指定实验室探索性测试以评估凝血参数(血浆d-二聚体浓度,凝血酶原片段f1.2,和凝血酶-抗凝血酶复合物),炎症参数(c反应蛋白水平,微粒或C5a的存在), rhsTM血浆浓度,器官功能障碍(肝功能障碍,胆红素浓度≥2.0 mg / dL;肾功能障碍，肌酐浓度≥2.0 mg/dL)，以及初始(即随机化后和干预前)和第28天之间的不良事件参数。

Post hoc analyses were performed among subgroups of patients based on baseline thrombin-antithrombin complex concentration, baseline protein C, Acute Physiology and Chronic Health Evaluation (APACHE) II scores, number of baseline organ dysfunctions, arterial lactate concentration, and maintenance of the protocol-specified coagulopathy criteria (INR >1.4 and platelet count >30 × 109/L) at baseline.

根据凝血酶-抗凝血酶复合物基线浓度，蛋白C基线浓度，急性生理学和慢性健康评估（APACHE）II评分，出现功能障碍器官的基线数目，动脉血乳酸浓度以及规定的基线凝血标准（INR> 1.4，血小板计数> 30×109 / L），各组患者进行事后分析。

Statistical Analysis  统计分析

The study was powered for the 28-day all-cause mortality end point. For sample size and power calculations, a χ2test was used. A sample size of 800 patients provided 80% power at a 5% 2-sided α level based on an assumption of an absolute risk reduction of 8% in mortality (24% in the placebo group vs 16% in the rhsTM group). This sample size assumption was based on the results of the previous phase 2b study.12

此项研究以28天全因死亡率为终点。应用χ2检验计算样本量及其功效。假设死亡率绝对风险降低8%（安慰剂组为24％，而rhsTM组为16％），则800名患者的样本量在5％双面α水平下提供了80％的功效。该样本量假设是基于先前2b期研究的结果。

The efficacy end points were analyzed in the full analysis set, which included all patients who consented and were randomly assigned to treatment and received at least 1 dose of the study drug. Patients were analyzed according to the treatment group they were randomized to, regardless of the study drug received. The adverse event end points were analyzed in the safety population, which included all patients who received at least 1 dose of the study treatment. Patients were analyzed based on the study intervention received. One patient received both rhsTM and placebo and was included in the rhsTM group for the adverse event analysis.

在完整分析中对疗效终点进行了分析，包括所有自愿并随机分配到治疗组并接受至少1剂研究药物的患者。无论接受何种研究药物，研究对象根据随机分组进行分析。在安全人群中进行了不良事件的终点的分析，其中包括所有接受至少1剂研究治疗的患者。根据接受的研究干预对患者进行分析。同时接受了rhsTM和安慰剂治疗的患者，则纳入rhsTM组进行不良事件分析。

The primary efficacy analysis for this study was based on a Cochran-Mantel-Haenszel test stratified by pooled sites at a 5% 2-sided α level. Individual sites that enrolled fewer than 8 patients were pooled together by region (North America, Western Europe [including Israel] combined with Australia and New Zealand, and Eastern Europe combined with the rest of world). Descriptive statistics were used to summarize. Survival time was summarized using KaplanMeier methods. Analysis of the difference between the treatment groups has not yet been conducted because, at the time of writing this article, the 12-month end point had not been reached. Prespecified subgroup analyses were performed per the statistical analysis plan (Supplement 2).Post hoc sensitivity analyses were conducted using generalized linear mixed models with pooled site as a random effect. Post hoc subgroup analyses of the patients who maintained the protocol-specified coagulopathy criteria (INR >1.4 and platelet count >30 × 109 /L) at baseline and,according to baseline thrombin-antithrombin complex concentration, baseline protein C, APACHE II score, number of baseline organ dysfunctions, and arterial lactate concentration were conducted in the same way as for the prespecified subgroup analyses. The change of the plasma concentrations of D-dimer, prothrombin fragment F1.2, and thrombin-antithrombin complex from baseline were compared between the 2 groups using a Wilcoxon rank sum test in a post hoc analysis. No adjustment for multiple comparisons was made and thus results of secondary analyses should be interpreted as exploratory.

这项研究的主要疗效分析是基于Cochran-Mantel-Haenszel试验，该试验以5％双面α水平的合并位点分层。纳入少于8名患者的个别地点按地区（北美，西欧（包括以色列）与澳大利亚和新西兰合并，以及东欧与世界其他地区合并）汇总在一起。采用描述性统计方法进行汇总。采用Kaplan-Meier法总结生存时间。治疗组之间的差异尚未进行分析，因为在撰写本文时，尚未达到12个月的终点。根据统计分析计划进行预先指定的亚组分析(补充2)。以混合位点为随机效应的广义线性混合模型进行事后敏感性分析。符合方案规定的凝血病标准 (INR >1.4 and platelet count >30 × 109 /L)的患者进行事后亚组分析，根据凝血酶-抗凝血酶复合物浓度、蛋白c、APACHEⅡ评分、功能障碍的器官数量和动脉乳酸浓度，采用相同的预先指定的亚组分析方法。在事后分析中，采用Wilcoxon秩和检验比较两组患者血浆中d -二聚体、凝血酶原片段F1.2和凝血酶-抗凝血酶复合物的变化。没有对多次比较进行调整，因此二级分析的结果应解释为探索性的。

Patients with unknown mortality status at day 28 were imputed for testing of the primary end point. Investigators assessed whether, at the last point they had contact with the patient, the patient’s health was such that it was unlikely that they would be alive at day 28. If so, it would be assumed the patient was dead at day 28. Otherwise, the patient was classified as alive for the primary analysis.

第28天死亡状态不明的患者被估算威威可以检测的主要终点。调查人员评估了最后一次与病人接触时，病人的健康状况是否不太可能存活至第28天。如果是这样的话，则假定患者在第28天死亡。否则，患者则被认为是活着的，并进行初步分析。

This study included unblinded interim analyses performed by an independent data monitoring committee. The futility analyses were conducted using a lower O’Brien-Fleming–type boundary, setting minimum acceptable efficacy to an absolute risk reduction of 6%. This boundary was constructed using a 1-sided α of .20. Early termination of the study for efficacy was not actively pursued. However, the primary efficacy results surpassed an O’Brien-Fleming–type boundary using a 2-sided α of .001. The effect on the final α level at the 0.1% level was very small but was nonzero. The α spent at the interim analysis was approximately .00005.Because of the small size of this α spent, no adjustment to the final α level was made.

本研究包括由独立数据监测委员会进行的非盲中期分析。无效分析采用较低的O ' brien - flming型界限，将最小的可接受的疗效设定为绝对风险降低6%。使用1-sided а .20建成此边界。未积极开展关于疗效早期终止的研究。然而，使用.001的双面α分析，初步疗效超过了O'Brien-Fleming边界。在0.1％的水平上对最终α水平的影响很小，但非零。中期分析中α约为.00005，因为该值所占比例较小，因此没有对最终的а水平进行调整。

Statistical analyses were conducted using SAS version 9.3 or 9.4 (SAS Institute). A 2-sided P value less than .05 was considered statistically significant. The statistical analysis plan is available in Supplement 2.

使用SAS 9.3或9.4版(SAS研究所)进行统计分析。双侧P值小于0.05为有统计学意义。统计分析计划见补充2。

Patient Characteristics  患者特点

Informed consent was obtained from 946 patients, and 816 were authorized as eligible to participate by the clinical coordinating centers. These 816 patients were randomized in a 1:1 ratio to receive rhsTM (n = 402) or a placebo (n = 414). Among these randomized patients, 800 (mean age, 60.7 years; 437 [54.6%] men) received either rhsTM (n = 395) or placebo (n = 405). Sixteen patients did not receive the assigned intervention because of adverse events (n = 5), death (n = 2), withdrawal of consent (n = 1), lack of availability of the study drug (n = 2), or change in eligibility before receiving the intervention (n = 6). One patient randomized to receive the placebo was incorrectly also given rhsTM (Figure 1). This patient was included in the placebo group for the efficacy analyses and in the rhsTM group for the safety analyses, as described in the Methods section.

获得了946名患者的知情同意，临床协调中心授权816名患者参与研究。这816名患者按照1:1的比例随机接受rhsTM (n = 402)或安慰剂(n = 414)。在这些随机患者中，800例(平均年龄60.7岁;437名 [54.6%]男性) 接受了rhsTM (n = 395)或安慰剂(n = 405)。16个病人未接受指定的干预措施：不良事件(n = 5),死亡(n = 2),撤回同意(n = 1),缺乏研究药物(n = 2),或干预前资格改变(n = 6)。一个被随机分配到安慰剂组的病人被误给了rhsTM(图1)。将该患者纳入安慰剂组进行疗效分析，在rhsTM组进行安全分析,如方法部分所述。

Baseline demographics and characteristics were well balanced between the rhsTM and placebo groups (Table). In both groups, the mean baseline INR was 1.8 and the mean baseline platelet count was approximately 120 × 109/L. The mean APACHE II score (range, 0-71; a higher score indicates greater severity of illness and higher risk of death) was approximately 22 in both groups. The rate of cardiovascular dysfunction was 90.9%; respiratory dysfunction, 67.1%; renal dysfunction, 32.8%; and hepatic dysfunction, 21.3%; 604 patients (75.5%) had more than 1 organ dysfunction, with cardiovascular and respiratory dysfunction presenting together in 484 patients (60.5%).

rhsTM和安慰剂组之间的基线人口统计学和特征得到了很好的平衡（表）。此两组中，平均基线INR为1.8，平均基线血小板计数约为120×109 / L。这两组的平均APACHEII评分（范围：0-71；较高评分表明疾病的严重程度和死亡风险较高）约为22。循环功能障碍发生率为90.9%；呼吸功能障碍，67.1%；肾功能不全，32.8%；肝功能障碍，21.3%；604例患者（75.5%）1个以上的器官出现功能障碍，484名患者同时具有循环和呼吸功能障碍（60.5%）。

The primary sites of infection at baseline were comparable in the 2 groups (Table). The most common site of infection was intra-abdominal. New infection after enrollment occurred in 99 of 395 patients (25.1%) in the rhsTM group and 100 of 405 patients (24%) in the placebo group.

两组在基线时的主要感染部位相当（表）。最常见是腹腔感染。入组后，rhsTM组的395例患者中有99例出现新发感染（25.1％），安慰剂组的405例患者中有100例。

As a concomitant medication, heparin (low dose for deep vein thrombosis prophylaxis or heparin flushes) was administered to about half of the patients in both groups.

两组中约有半数的患者同时使用肝素（低剂量预防深静脉血栓或肝素冲管）。

Primary Outcome for Efficacy  疗效的初步结果

The 28-day all-cause mortality rate was 106 of 395 patients (26.8%) in the rhsTM group vs 119 of 405 (29.4%) in the placebo group (P = .32, Cochran-Mantel-Haenszel test), a difference of 2.55% (95% CI, −3.68% to 8.77%). The Kaplan-Meier survival curve for the full analysis set is shown in Figure 2A.Two patients (1 in the rhsTM group and 1 in the placebo group) had unknown mortality status at day 28 and were assessed as “assumed alive” by the investigators. In a post hoc sensitivity analysis for the primary outcome that accounted for pooled site as a random effect, the adjusted 28-day all-cause mortality rate was 24.8% in the rhsTM group vs 27.5% in the placebo group (P = .31).

rhsTM组395例患者的28天全因死亡率为106例(26.8%)，而安慰剂组405例患者为119例(29.4%)(P = .32, cochrann - mantel - haenszel检验)，差异为2.55% (95% CI，- 3.68%比8.77%)。完整分析Kaplan-Meier生存曲线如图2A所示。两名患者(1名在rhstm组和1名在安慰剂组)在第28天的死亡状况不明，并被调查人员评为“假定存活”。在对初步结果进行事后敏感性分析后，该结果将合并部分归因于随机效应，调整后的28天全因死亡率在rhsTM组为24.8％，而在安慰剂组为27.5％（P = 0.31）。

Subgroup Analyses  亚组分析

In prespecified subgroup analyses (Supplement 2), the difference in 28-day all-cause mortality rates between the rhsTM and placebo group was 4.66% (95% CI, −3.07% to 12.38%) in the subgroup of patients with baseline APACHE II scores less than 25 (n = 439) and −1.45% (95% CI, −12.69% to 9.80%) in the subgroup of patients with APACHE II scores greater than or equal to 25 (n = 283) (eFigure 1 in Supplement 3). The difference in 28-day all-cause mortality between the rhsTM and placebo group was −0.87% (95% CI, −9.52% to 7.77%) in the subgroup of patients who received heparin (n = 416) and 6.25% (95% CI,−2.72% to 15.22%) in the subgroup of patients who did not receive heparin (n = 384) (eFigure 1 in Supplement 3).

在预先指定的亚组分析中(补充2),rhsTM组和安慰剂组28天全因死亡率差异在基线APACHE II评分低于25分(n = 439)的亚组为4.66%(95%可信区间,−3.07%至12.38%)，评分大于等于25 (n = 283)为−1.45% (95% 可信区间, −12.69% to 9.80%) (eFigure 1补充3)。rhsTM组和安慰剂组28天全因死亡率差异在接受肝素治疗的亚组（n = 416）中为 −0.87% (95% CI, −9.52% to 7.77%)，在未接受肝素治疗的亚组(n = 384) 为 6.25% (95% CI,−2.72% to 15.22%)(eFigure 1 in Supplement 3)。

Coagulation Markers  凝血指标

At day 6, the median plasma concentration of D-dimer was 1129.5 ng/mL in the rhsTM group and 1649 ng/mL in the placebo group, the median plasma concentration of prothrombin fragment F1.2 was 309.6 pmol/L in the rhsTM group and 393.2 pmol/L in the placebo group, and the median plasma concentration of thrombin-antithrombin complex was 5.2 ng/mL in the rhsTM group and 7.8 ng/mL in the placebo group. In the post hoc analysis, the change from baseline of each marker during the treatment period (6 days) was statistically significantly greater (P < .05) in the rhsTM group than in the placebo group (Figure 3).

在第6天，D-二聚体的中位血浆浓度在rhsTM组和安慰剂组分别为1129.5 ng/mL和1649 ng/mL，凝血酶原片段F1.2的中位血浆浓度在rhsTM组和安慰剂组分别为309.6 pmol/L和393.2 pmol/L，凝血酶-抗凝血酶复合物的中位血浆浓度在rhsTM组和安慰剂组分别为5.2 ng/mL和7.8 ng/mL。在事后分析中，治疗期间(6天)，rhsTM组与安慰剂组相比，各标记物与基线水平的差异有统计学意义(P < .05)(图3)。

Post Hoc Subgroup Analyses  事后亚组分析

Approximately 80% of patients in each of the study groups had an INR greater than 1.4 at baseline, but the baseline INR in the remaining approximately 20% of patients was less than or equal to 1.4 after initial confirmation of eligibility (Table). In post hoc analyses, 28-day all-cause mortality rates in the subgroup of patients with coagulopathy at baseline (n = 634; INR >1.4 and platelet count >30 × 109/L) were 82 of 307 patients (26.7%) in the rhsTM group and 105 of 327 (32.1%) in the placebo group,a difference of 5.40% (95% CI, −1.68% to 12.48%) (eFigure 1 in Supplement 3). For patients with an INR less than or equal to 1.4 (n = 146), mortality rates were 15 of 76 patients (19.7%) in the rhsTM group and 10 of 70 (14.3%) in the placebo group.For patients with baseline platelet counts less than or equal to 30X109/L (n = 24),mortality rates were 9 of 13 patients (69.2%) in the rhsTM group and 4 of 11 (36.4%) in the placebo group.Four patients had an INR less than or equal to 1.4 and platelet counts less than or equal to 30X109/L at baseline. The Kaplan-Meier survival curve for the baseline coagulopathy subgroup is shown in Figure 2B.

每组中80%的患者在基线时的INR大于基线的1.4，而其余约20%的患者在初步确认合格后的INR小于或等于1.4(表)。事后分析中，凝血病患者亚组在基线上(n = 634;INR > 1.4和血小板计数> 30×109 / L)28天全因死亡率在 rhsTM组307名患者中存在82人(26.7%)，而安慰剂组的327名中有105人(32.1%)，差异为5.40% (95% CI,−1.68%到12.48%)(eFigure 1补充3)。血小板计数小于或等于30X109/L (n = 24)的患者中，rhsTM组13例患者中有9例(69.2%)死亡，安慰剂组11例患者中有4例(36.4%)死亡。4例患者的INR小于或等于1.4，血小板计数小于或等于30X109/L的基线水平。凝血功能障碍亚组的Kaplan-Meier生存曲线如图2B所示。

In the subgroup of patients with baseline thrombin-antithrombin complex concentration greater than or equal to 10 ng/mL (n = 489), the 28-day mortality rate was 74 of 248 patients (29.0%) in the rhsTM group vs 82 of 241 (35.7%) in the placebo group, a difference of 6.65% (95% CI, −1.62% to 14.93%) (eFigure 1 in Supplement 3). In the subgroup of patients with baseline thrombin-antithrombin complex concentration less than 10 ng/mL (n = 286), the 28-day mortality rate was 31 of 133 patients (23.3%) in the rhsTM group vs 28 of 153 (18.3%) in the placebo group, a difference of −5.01% (95% CI, −14.45% to 4.44%).

凝血酶-抗凝血酶复合物基线浓度大于或等于10 ng/mL (n = 489)的患者亚组中，rhsTM组248名患者中的74名患者(29.0%)与241名安慰剂组中的82名患者(35.7%)的28天死亡率，差异为6.65% (95% CI， - 1.62%至14.93%)(补充3中的eFigure 1)。凝血酶-抗凝血酶复合物基线浓度低于10 ng/mL的患者亚组中(n = 286)，rhsTM组133名患者中的31名患者 (23.3%) 与153名安慰剂组中的28名患者 (18.3%) ，差异为 −5.01% (95% CI, −14.45% to 4.44%)。

The transition of cumulative 28-day mortality rates throughout the trial was analyzed because of the protracted enrollment (approximately 5.5 years). The cumulative 28-day mortality rate in the full analysis set ranged from 20.0% to 27.9% in the rhsTM group and 26.7% to 33.3% in the placebo group after 2014 (eFigure 2A in Supplement 3). The results for the subgroup of patients with coagulopathy at baseline are shown in eFigure 2B in Supplement 3.

在整个试验过程中，分析累积28天死亡率的变化，因为登记时间过长(大约5.5年)。2014年后，全面分析累计28天死亡率在rhstm组为20.0%至27.9%，安慰剂组为26.7%至33.3%(补编3中图2a)。(eFigure 2补充3)。凝血障碍患者的结果如图2b所示，见补充3。

Adverse Event Analyses  不良事件分析

Overall, 754 patients (94.3%) experienced at least 1 treatment-emergent adverse event (377 patients [95.2%] in the rhsTM group and 377 patients [93.3%] in the placebo group) (eTable 1 in Supplement 3). Overall, 408 patients (51.0%) experienced at least 1 treatment-emergent serious adverse event, including 206 patients (52.0%) in the rhsTM group and 202 patients (50.0%) in the placebo group. A serious major bleeding event occurred in 23 patients (5.8%) in the rhsTM group and 16 patients (4.0%) in the placebo group, which included 2 patients with intracerebral bleeding in the rhsTM group and 1 in the placebo group (eTable 2 in Supplement 3). No antidrug antibodies to rhsTM were reported.

总体而言，有754名患者（94.3％）存在至少1种治疗相关的不良事件（rhsTM组为377名患者[95.2％]，而安慰剂组为377名患者[93.3％]）（附表3中的表1）。总体而言，有408名患者（51.0％）存在至少1种治疗相关的严重不良事件，其中rhsTM组为206名患者（52.0％），安慰剂组为202名患者（50.0％）。rhsTM组发生严重出血事件23例（5.8％），安慰剂组发生16例患者（4.0％），其中rhsTM组2例发生脑出血，安慰剂组1例（eTable 2 补编3）。没有针对rhsTM的抗药物抗体的报道。

In this randomized, double-blind, placebo-controlled, multinational, multicenter phase 3 study, rhsTM did not significantly reduce 28-day all-cause mortality in patients with sepsis-associated coagulopathy. Patient heterogeneity has been and continues to be a hallmark of sepsis populations within clinical trials. Therefore, this study was designed to select patients with sepsis-associated coagulopathy based on well-defined markers of coagulation; however, the primary efficacy end point was not achieved.

在这项随机、双盲、安慰剂对照、多国、多中心3期研究中，rhsTM并没有显著降低脓毒症相关凝血障碍患者28天全因死亡率。在临床试验中，患者异质性一直是并继续是脓毒症人群的一个特征。因此，本研究旨在选择有脓毒症相关凝血功能明确的凝血标志物的患者;然而，没有达到主要疗效终点。

There are several possible reasons for this finding. First,approximately 20% of patients did not meet the criteria for coagulopathy as defined by INR and platelet count at baseline.A protocol amendment modifying the inclusion criteria was implemented midway through the study, which substantially lengthened (from 15 to 40 hours) the allowable time from first qualifying INR measurement to receiving the intervention. Thus, although all of the patients included in the study met the criteria of INR greater than 1.4 at some point during screening, some no longer did by the time they received the intervention. Second, the mortality rate in the placebo group was higher than the assumed value used for the sample size calculation prior to the study (24%). Third, the heparin used for prophylaxis of deep vein thrombosis may have attenuated the efficacy of rhsTM because heparin also has anticoagulation activity. Fourth, although the randomization was stratified by site, 55 of 159 clinical sites enrolled only 1 patient, which may have influenced the efficacy results.

这一发现有几个可能的原因。首先，大约20%的患者不符合定义的INR和血小板计数在基线水平上凝血病标准。研究进行到一半时，对纳入标准进行了修订，从首次合格INR测量到接受干预，允许时间大幅延长(从15小时延长到40小时)。因此，尽管所有纳入研究的患者在筛选过程中的某一时刻都符合INR大于1.4的标准，但有些患者在接受干预时不再符合。第二，安慰剂组的死亡率高于研究前用于样本量计算的假设值(24%)。第三，用于预防深静脉血栓形成的肝素可能减弱了rhsTM的疗效，因为肝素也具有抗凝活性。第四，虽然随机化按中心分层，但159个临床中心中的55个仅入组1例，可能影响了疗效结果。

The enrolled patient population represented a typical sepsis patient population in its clinical heterogeneity. The greater proportion of patients with intra-abdominal infection in this study is consistent with previous observations that coagulopathy is more prevalent with intra-abdominal than respiratory infection in sepsis.13

纳入的患者人群在其临床异质性方面代表了一个典型的脓毒症患者群体。本研究中腹腔内感染患者的比例较大，这与先前观察到的脓毒症中腹腔感染的凝血病比呼吸道感染更常见的观点是一致的。

No new adverse event concerns were identified in this study. The incidence of serious major bleeding events was similar to the incidence in the previous phase 2b study12 and was numerically higher in the rhsTM than in the placebo group.

本研究未发现新的不良事件。严重大出血事件的发生率与前一阶段2b研究相似，并且rhsTM组的大出血事件发生率高于安慰剂组。

The study has several limitations. First, the sample size may not have been sufficient for the statistical evaluation of study drug efficacy. The 95% CI is consistent with an effect anywhere between a small harm and a benefit exceeding that used as the basis for the sample size calculation. Second, post hoc analyses performed to investigate the population most likely to respond favorably to rhsTM treatment were not preplanned and should be interpreted with caution. Third, the final follow-up has been completed but data collection is still ongoing; therefore, effects on some of the end points, such as a long-term mortality, have not yet been analyzed.

这项研究有几个局限性。首先，样本量可能不足以对研究药物疗效进行统计评估。95%置信区间与一个小的伤害和一个超出用作样本量计算依据的获益之间的效果是一致的。其次，用于调查最有可能对rhsTM治疗产生良好反应的人群的事后分析并不是预先计划的，因此应谨慎解释。第三，最后的随访已经完成，但数据收集仍在进行;因此，对某些终点的影响，如长期死亡率，尚未进行分析。

Among patients with sepsis-associated coagulopathy,administration of a recombinant human thrombomodulin,compared with placebo, did not significantly reduce 28-day all-cause mortality.

在脓毒症相关凝血障碍患者中，与安慰剂相比，使用重组人血栓调节蛋白并不能显著降低28天全因死亡率。

翻译

李洪雷  主治医师

医学博士，济南市中医医院重症医学科主治医师，山东省医师协会重症医学医师分会秘书，美国范德堡大学医学中心访问学者