Circulating Nucleosomes Are Elevated In Trauma Patients With Venous Thromboembolism: A Prospective Case-Cohort Study

The identification of reliable biomarkers in trauma patients remains a clinical challenge. Nucleosomes, which are DNAs wrapped around histone protein cores, have been used as reliable markers for quantification in sepsis, acute respiratory distress syndrome, and lymphoma. We hypothesized that: 1) levels of circulating nucleosomes quantified after traumatic injury, specifically histone H3.1 and its citrullinated R8 post-translation modification (H3R8 Cit), would be increased after trauma and 2) that levels of circulating nucleosomes would be further, increased in patients who went on to develop venous thromboembolism (VTE), as these nucleosomes may be clot-enhancing mediators. Methods: Trauma patients (pts) presenting to a Level I trauma center were evaluated for inclusion in a prospective case-cohort study, and citrated blood samples were collected within 12 hours of injury. Pts were followed for up to 90 days and VTE occurrence was confirmed via autopsy or imaging. Pts who developed incident, symptomatic VTE and those who did not develop VTE were selected at a 1:3 ratio. The effect of trauma was assessed by comparison with healthy volunteer samples. Circulating nucleosomes were quantified using Nu.Q® H3.1 and Nu.Q® H3R8 Cit assays. Data are presented as median [IQR] or n (%), with Wilcoxon Rank-Sum or chi-squared test performed between trauma patients who developed symptomatic VTE vs those who did not, with p-value <0.05 as statistically significant. Results: A total of 639 trauma pts were analyzed (51 years [33, 65], 71.0% male, 94.1% blunt, ISS 17 [9, 27]. Both H3.1 (359.7 [58.4, 1769.3] vs 21.5 [15.3, 26.6] ng/mL, p<0.001) and H3R8 Cit levels (209.4 [45.4, 665.5] vs 22.3 [16.2, 28.9] ng/mL, p<0.001) were greater in trauma patients than in 10 healthy volunteers. The 160 pts with VTE were then compared to 479 without VTE. VTE pts had a median time to VTE of 8.5 days, with 91 developing symptomatic deep venous thrombosis (DVT), 48 with pulmonary embolism (PE), and 21 with both DVT and PE. No significant differences were found in age, sex, or mechanism between pts with or without VTE. However, VTE pts had higher Injury Severity Scores (ISS) (24 [14, 34], 14 [9,24], p<0.001) and BMI (29.1 [24.3, 34.2], 27.6 [24.2, 32.0] kg/m2, p=0.037). A greater percentage of VTE pts underwent surgery requiring general anesthesia (53.1%, 34.0%, p<0.001) and received blood transfusions within 24 hours of injury (51.9%, 24.0%, p<0.001). H3.1 levels were significantly greater in trauma patients who developed VTE compared to those who did not (828.4 [112.0, 3186.5], vs 276.7 [50.3, 1237.0] ng/mL, p < 0.001), as were H3R8 Cit levels (350.4 [77.4, 729.5], vs 189.2 [40.8, 632.6] ng/mL, p=0.005). No differences in levels of H3.1 and H3R8 Cit were found between early (diagnosed day 0-7 after injury) and late (diagnosed > day 7) VTE. Conclusions: Levels of the H3.1 and H3R8 Cit nucleosomes are elevated early after traumatic injury, especially in those who developed VTE. These findings underscore the importance of understanding the pathophysiology of nucleosomes in inducing VTE and their role as biomarkers. Study Type: Prospective study with less than large effect and no negative criteria.