Is small volume, up to 2 red blood cell units transfusion required and redeemable in cardiac surgery? / Szükséges-e, kiváltható-e a kis volumenu vörösvértest-koncentrátum transzfúziója a szívmutétekben? Befolyásoló tényezok

Introduction: Low-volume (1-2 U) transfusion affects more than a quarter of cardiac surgical patients. This may increase the incidence of complications, mortality, and blood use, even in low-risk patients. Objective: By analyzing risk factors, we searched for measures to reduce the frequency of low-volume transfusions. Method: The risk factors for transfusion of up to 2 U red blood cells were examined in 1011 patients. We compared data from 276 (27.3%) patients who received low-volume transfusion (study group) with 448 (44.3%) patients who received no transfusion (control group). 287 patients (28,4%), who received more than 2 U red blood cells, were excluded. Multivariate logistic regression analysis of data was performed. Results: The factors affecting low-volume transfusion were female gender (OR= 2.048; p = 0.002), age (OR= 1.033; p = 0.002), body weight (OR= 0.954; p<0.001), preoperative hemoglobin value of <130 g/l (OR = 3.185; p<0.001), preoperative glomerular filtration rate <60 ml/min/1.73 m(2) (OR = 1.750; p = 0.026), off-pump coronary artery bypass surgery (OR = 0.371; p<0.001), combined procedures (OR = 2.432; p = 0.015), perioperative fluid balance (OR = 1.227; p = 0.005), intraoperative bleeding and preoperative clopidogrel treatment (OR = 1.002; p<0.001), postoperative bleeding >1200 ml/24 hours (OR= 2.438; p<0.005). Conclusion: Screening and treatment of preoperative anemia, decreasing operative hemodilution, increasing the number of minimally invasive and off-pump procedures as well as applying a surgical hemostasis protocol could be a solution to avoid low-volume transfusion in cardiac surgery.

Crosslinked Hyaluronic Acid Gels with Blood-Derived Protein Components for Soft Tissue Regeneration.

Hyaluronic acid (HA) is an ideal initial material for preparing hydrogels, which may be used as scaffolds in soft tissue engineering based on their advantageous physical and biological properties. In this study, two crosslinking agents, divinyl sulfone (DVS) and butanediol diglycidyl ether, were used to investigate their effect on the properties of HA hydrogels. As HA hydrogels alone do not promote cell adhesion on the scaffold, fibrin and serum from platelet-rich fibrin (SPRF) were combined with the scaffold; the aim was to create a material intended to be used as soft tissue implant that facilitates new tissue formation, and degrades over time. The chemical changes were characterized and cell attachment capacity of the protein-containing gels was examined using human mesenchymal stem cells, and viability was assessed using live-dead staining. Fourier-transform infrared measurements revealed that linking fibrin into the gel was more effective than linking SPRF. The scaffolds were found to be able to support cell adherence onto the hydrogels, and the best result was achieved when HA was crosslinked with DVS and contained fibrin. The most promising derivative, 5% DVS-crosslinked fibrin-containing hydrogel, was injected subcutaneously into C57BL/6 mice for 12 weeks. The scaffold was proven to be biocompatible, remodeling, and vascularization occurred, while shape and integrity were maintained. Impact statement Fibrin was combined with crosslinked hyaluronic acid (HA) for regenerative application, the structure of the combination of crosslinked HA with blood-derived protein was analyzed and effective coating was proven. It was observed that the fibrin content led to better mesenchymal stem cell attachment in vitro. The compositions showed biocompatibility, connective tissue and vascularization took place when implanted in vivo. Thus, a biocompatible, injectable gel was produced, which is a potential candidate for soft tissue implantation.

A Reconfigurable In Vitro Model for Studying the Blood-Brain Barrier.

Much of what is currently known about the role of the blood-brain barrier (BBB) in regulating the passage of chemicals from the blood stream to the central nervous system (CNS) comes from animal in vivo models (requiring extrapolation to human relevance) and 2D static in vitro systems, which fail to capture the rich cell-cell and cell-matrix interactions of the dynamic 3D in vivo tissue microenvironment. In this work we have developed a BBB platform that allows for a high degree of customization in cellular composition, cellular orientation, and physiologically-relevant fluid dynamics. The system characterized and presented in this study reproduces key characteristics of a BBB model (e.g. tight junctions, efflux pumps) allowing for the formation of a selective and functional barrier. We demonstrate that our in vitro BBB is responsive to both biochemical and mechanical cues. This model further allows for culture of a CNS-like space around the BBB. The design of this platform is a valuable tool for studying BBB function as well as for screening of novel therapeutics.

Investigation of Cytokine Changes in Osteoarthritic Knee Joint Tissues in Response to Hyperacute Serum Treatment.

One option to fight joint degradation and inflammation in osteoarthritis is the injection of activated blood products into the synovial space. It has been demonstrated that hyperacute serum is the most proliferative among plasma products, so we investigated how the cytokine milieu of osteoarthritic knee joint reacts to hyperacute serum treatment in vitro. Cartilage, subchondral bone, and synovial membrane explanted from osteoarthritic knees were stimulated by interleukin-1 beta (IL-1ß) and the concentration of 39 biomarkers was measured in the co-culture supernatant after hyperacute serum treatment. The IL-1ß stimulation triggered a strong inflammatory response and enhanced the concentrations of matrix metalloproteinase 3 and 13 (MMP-3 and MMP-13), while hyperacute serum treatment reduced inflammation by decreasing the concentrations of IL-1ß, tumor necrosis factor alpha (TNF-α), interleukin-6 receptor alpha (IL-6Rα), and by increasing the level of interleukin-1 antagonist (IL-1RA) Cell viability increased by day 5 in the presence of hyperacute serum. The level of MMPs-1, 2, and 9 were higher on day 3, but did not increase further until day 5. The concentrations of collagen 1 alpha 1 (COL1A1) and osteonectin were increased and receptor activator of nuclear factor kappa-B ligand (RANKL) was reduced in response to hyperacute serum. We concluded that hyperacute serum treatment induces cell proliferation of osteoarthritic joint tissues and affects the cytokine milieu towards a less inflamed state.

The Composition of Hyperacute Serum and Platelet-Rich Plasma Is Markedly Different despite the Similar Production Method.

Autologous blood derived products, such as platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) are widely applied in regenerative therapies, in contrast to the drawbacks in their application, mainly deriving from the preparation methods used. Eliminating the disadvantages of both PRP and PRF, hyperacute serum (HAS) opens a new path in autologous serum therapy showing similar or even improved regenerative potential at the same time. Despite the frequent experimental and clinical use of PRP and HAS, their protein composition has not been examined thoroughly yet. Thus, we investigated and compared the composition of HAS, serum, PRP and plasma products using citrate and EDTA by simple laboratory tests, and we compared the composition of HAS, serum, EDTA PRP and plasma by Proteome Profiler and ELISA assays. According to our results the natural ionic balance was upset in both EDTA and citrate PRP as well as in plasma. EDTA PRP contained significantly higher level of growth factors and cytokines, especially platelet derived angiogenic and inflammatory proteins, that can be explained by the significantly higher number of platelets in EDTA PRP. The composition analysis of blood derivatives revealed that although the preparation method of PRP and HAS were similar, the ionic and protein composition of HAS could be advantageous for cell function.

Biological and Mechanical Properties of Platelet-Rich Fibrin Membranes after Thermal Manipulation and Preparation in a Single-Syringe Closed System.

Platelet-rich fibrin (PRF) membrane is a three-dimensional biodegradable biopolymer, which consists of platelet derived growth factors enhancing cell adhesion and proliferation. It is widely used in soft and hard tissue regeneration, however, there are unresolved problems with its clinical application. Its preparation needs open handling of the membranes, it degrades easily, and it has a low tensile strength which does not hold a suture blocking wider clinical applications of PRF. Our aim was to produce a sterile, suturable, reproducible PRF membrane suitable for surgical intervention. We compared the biological and mechanical properties of PRF membranes created by the classical glass-tube and those that were created in a single-syringe closed system (hypACT Inject), which allowed aseptic preparation. HypACT Inject device produces a PRF membrane with better handling characteristics without compromising biological properties. Freeze-thawing resulted in significantly higher tensile strength and higher cell adhesion at a lower degradation rate of the membranes. Mesenchymal stem cells seeded onto PRF membranes readily proliferated on the surface of fresh, but even better on freeze/thawed or freeze-dried membranes. These data show that PRF membranes can be made sterile, more uniform and significantly stronger which makes it possible to use them as suturable surgical membranes.

Hyperacute serum has markedly better regenerative efficacy than platelet-rich plasma in a human bone oxygen-glucose deprivation model.

AIM: Platelet-rich plasma (PRP) and hyperacute serum (HAS) were compared in a novel human model of ex vivo bone damage induced by oxygen-glucose deprivation (OGD). MATERIALS & METHODS: Osteoarthritic subchondral bone pieces were harvested from discarded femoral heads during hip replacement surgery and subjected to transient OGD. RESULTS: Proteome profiling revealed that PRP is more angiopoietic, whereas HAS is more antiangiopoietic in composition. However, treatment of OGD-exposed bone with multiple PRP preparations had no effect on cell counts, whereas HAS restored cell proliferation capacity and rescued viable cell number following OGD. CONCLUSION: A similar pro-proliferation effect was observed with recombinant growth factors, indicating that HAS may be an alternative agent for enhancing the regeneration of damaged bone cells.

The Effects of Hyperacute Serum on the Elements of the Human Subchondral Bone Marrow Niche.

Mesenchymal stem cells (MSCs) are widely used in laboratory experiments as well as in human cell therapy. Their culture requires animal sera like fetal calf serum (FCS) as essential supplementation; however, animal sera pose a risk for clinical applications. Human blood derivatives, for example, platelet-rich plasma (PRP) releasates, are potential replacements of FCS; however, it is unclear which serum variant has the best effect on the given cell or tissue type. Additionally, blood derivatives are commonly used in musculoskeletal diseases like osteoarthritis (OA) or osteonecrosis as "proliferative agents" for the topical MSC pool. Hyperacute serum (HAS), a new serum derivative, has been designed to approximate the natural coagulation cascade with a single-step, additive-free preparation method. We investigated the effects of HAS on monolayer MSC cultures and in their natural niche, in 3D subchondral bone and marrow explants. Viability measurements, RT-qPCR evaluation for gene expression and flow cytometry for cell surface marker analysis were performed to compare the effects of FCS-, PRP-, or HAS-supplemented culture media. Monolayer MSCs showed significantly higher metabolic activity following 5 days' incubation in HAS, and osteoblast-specific mRNA expression was markedly increased, while cells also retained their MSC-specific cell surface markers. A similar effect was observed on bone and marrow explants, which was further confirmed with confocal microscopy analysis. Moreover, markedly higher bone marrow preservation was observed with histology in case of HAS supplementation compared to FCS. These findings indicate possible application of HAS in regenerative solutions of skeletal diseases like OA or osteonecrosis.

The Effects of Hyperacute Serum on Adipogenesis and Cell Proliferation of Mesenchymal Stromal Cells.

Fat tissue, due to its high concentration of stem cells, has a role in aesthetic medicine and reconstructive surgery. However, poor survival of the transplanted cells still limits the usefulness of this material in regenerative medicine. Several studies indicated that platelet-rich plasma (PRP) may improve adipose tissue viability due to its growth factor content. This study aimed at investigating the effects of PRP and hyperacute serum (HAS) on the adipogenic lineage in vitro. PRP was prepared by using two centrifugation steps in the presence of anticoagulants, and HAS was isolated from activated platelet-rich fibrin within 10 min of blood drawing to prevent the propagation of inflammatory cascades. Metabolic activity and proliferation rate of human bone marrow-derived mesenchymal stem cells (hMSCs) cultivated in media supplemented with three types of serum additives (fetal calf serum [FCS], human PRP, or HAS) was determined by using a tetrazolium assay. Adipogenesis was evaluated in standard and pro-adipogenic media and tested by oil red staining, triglyceride content, and expression of specific genes. Adipogenic regulators in the sera were measured by multiplex ELISA assays. We observed that proliferation of hMSCs was supported by both FCS and HAS in a time-dependent manner, but surprisingly, PRP had a much weaker effect (change in proliferation rate after 5 days relative to metabolic activity on day 0-FCS: 5.4-fold change, HAS: 5.8-fold change, serum free 1.9-fold change, PRP: 3.0-fold change, p < 0.05). Lipogenesis was only observed in groups with adipogenic differentiation medium, with HAS showing a significantly stronger effect than PRP. This was confirmed by intensive accumulation of lysochrome dye in lipid droplets, higher triglyceride concentration, and elevated expression of specific adipogenic genes. Measurement of lipogenic proteins in the sera revealed that both PRP and HAS are abundant in them; however, PRP also contains anti-adipogenic factors, which explains its weaker and less reliable effect. The results of this study suggest that HAS provides more robust support than PRP in hMSCs proliferation as well as lipogenic differentiation, indicating that it may be a better adjuvant in fat grafting procedures.

Serum albumin as a local therapeutic agent in cell therapy and tissue engineering.

Albumin is a major plasma protein that has become ubiquitous in regenerative medicine research. As such, many studies have examined its structure and advantageous properties. However, a systematic and comprehensive understanding of albumin's role, capabilities and therapeutic potential still eludes the field. In the present work, we review how albumin is applied in tissue engineering, including cell culture and storage, in vitro fertilization and transplantation. Furthermore, we discuss how albumin's physiological role extends beyond a carrier for metal ions, fatty acids, pharmacons and growth factors. Albumin acts as a bacteriostatic coating that simultaneously promotes attachment and proliferation of eukaryotic cells. These properties with the combination of free radical scavenging, neutrophil activation and as a buffer molecule already make the albumin protein beneficial in healing processes supporting functional tissue remodeling. Nevertheless, recent data revealed that albumin can be synthesized by osteoblasts and its local concentration is raised after bone trauma. Interestingly, by increasing the local albumin concentration in vivo, faster bone healing is achieved, possibly because albumin recruits endogenous stem cells and promotes the growth of new bone. These data also suggest an active role of albumin, even though a specific receptor has not yet been identified. Together, this discussion sheds light on why the extravascular use of the albumin molecule is in the scope of scientific investigations and why it should be considered as a local therapeutic agent in regenerative medicine. © 2016 BioFactors, 43(3):315-330, 2017.

Cavity-induced microstreaming for simultaneous on-chip pumping and size-based separation of cells and particles.

We present a microfluidic platform for simultaneous on-chip pumping and size-based separation of cells and particles without external fluidic control systems required for most existing platforms. The device utilizes an array of acoustically actuated air/liquid interfaces generated using dead-end side channels termed Lateral Cavity Acoustic Transducers (LCATs). The oscillating interfaces generate local streaming flow while the angle of the LCATs relative to the main channel generates a global bulk flow from the inlet to the outlet. The interaction of these two competing velocity fields (i.e. global bulk velocity vs. local streaming velocity) is responsible for the observed separation. It is shown that the separation of 5 µm and 10 µm polystyrene beads is dependent on the ratio of these two competing velocity fields. The experimental and simulation results suggest that particle trajectories based only on Stokes drag force cannot fully explain the separation behavior and that the impact of additional forces due to the oscillating flow field must be considered to determine the trajectory of the beads and ultimately the separation behavior of the device. To demonstrate an application of this separation platform with cellular components, smaller red blood cells (7.5 ± 0.8 µm) are separated from larger K562 cells (16.3 ± 2.0 µm) with viabilities comparable to those of controls based on a trypan blue exclusion assay.

TGFß activated kinase 1 (TAK1) at the crossroad of B cell receptor and Toll-like receptor 9 signaling pathways in human B cells.

B cell development and activation are regulated by combined signals mediated by the B cell receptor (BCR), receptors for the B-cell activating factor of the tumor necrosis factor family (BAFF-R) and the innate receptor, Toll-like receptor 9 (TLR9). However, the underlying mechanisms by which these signals cooperate in human B cells remain unclear. Our aim was to elucidate the key signaling molecules at the crossroads of BCR, BAFF-R and TLR9 mediated pathways and to follow the functional consequences of costimulation.Therefore we stimulated purified human B cells by combinations of anti-Ig, B-cell activating factor of the tumor necrosis factor family (BAFF) and the TLR9 agonist, CpG oligodeoxynucleotide. Phosphorylation status of various signaling molecules, B cell proliferation, cytokine secretion, plasma blast generation and the frequency of IgG producing cells were investigated. We have found that BCR induced signals cooperate with BAFF-R- and TLR9-mediated signals at different levels of cell activation. BCR and BAFF- as well as TLR9 and BAFF-mediated signals cooperate at NFκB activation, while BCR and TLR9 synergistically costimulate mitogen activated protein kinases (MAPKs), ERK, JNK and p38. We show here for the first time that the MAP3K7 (TGF beta activated kinase, TAK1) is responsible for the synergistic costimulation of B cells by BCR and TLR9, resulting in an enhanced cell proliferation, plasma blast generation, cytokine and antibody production. Specific inhibitor of TAK1 as well as knocking down TAK1 by siRNA abrogates the synergistic signals. We conclude that TAK1 is a key regulator of receptor crosstalk between BCR and TLR9, thus plays a critical role in B cell development and activation.

A microfabricated, optically accessible device to study the effects of mechanical cues on collagen fiber organization.

As the primary structural protein of our bodies, fibrillar collagen and its organizational patterns determine the biomechanics and shape of tissues. While the molecular assembly of individual fibrils is well understood, the mechanisms determining the arrangement of fibers and thus the shape and form of tissues remain largely unknown. We have developed a cell culture model that successfully recapitulates early tissue development and the de novo deposition of collagen fibers to investigate the role of mechanical cues on collagen fiber alignment. The devices used a thin, collagen-coated deformable PDMS membrane inside a tissue culture well built on microscope-grade coverslips. Deformations and strains in the PDMS membrane were quantified by tracking fluorescent bead displacement and through the use of a COMSOL model. Cyclical strains were applied to serum-cultured rabbit corneal cells at 0.5 Hz for 24-48 h and showed a preferred alignment after 36 h of cyclical loading. Cells cultured with ascorbic acid under methylcellulose serum-free conditions deposited a collagenous matrix that was visible under live second harmonic generation microscopy at week 4. Our microfabricated tissue culture system allows for the controllable application of a wide range of stress profiles to cells, and for the observation and quantification of cells and de novo collagen formation in vitro. Future studies will involve the fabrication of models to study the formation and organization of collagen in ocular diseases.

Increasing label-free stem cell sorting capacity to reach transplantation-scale throughput.

Dielectrophoresis (DEP) has proven an invaluable tool for the enrichment of populations of stem and progenitor cells owing to its ability to sort cells in a label-free manner and its biological safety. However, DEP separation devices have suffered from a low throughput preventing researchers from undertaking studies requiring large numbers of cells, such as needed for cell transplantation. We developed a microfluidic device designed for the enrichment of stem and progenitor cell populations that sorts cells at a rate of 150,000 cells/h, corresponding to an improvement in the throughput achieved with our previous device designs by over an order of magnitude. This advancement, coupled with data showing the DEP-sorted cells retain their enrichment and differentiation capacity when expanded in culture for periods of up to 2 weeks, provides sufficient throughput and cell numbers to enable a wider variety of experiments with enriched stem and progenitor cell populations. Furthermore, the sorting devices presented here provide ease of setup and operation, a simple fabrication process, and a low associated cost to use that makes them more amenable for use in common biological research laboratories. To our knowledge, this work represents the first to enrich stem cells and expand them in culture to generate transplantation-scale numbers of differentiation-competent cells using DEP.

Novel on-demand droplet generation for selective fluid sample extraction.

A novel microfluidic device enabling selective generation of droplets and encapsulation of targets is presented. Unlike conventional methods, the presented mechanism generates droplets with unique selectivity by utilizing a K-junction design. The K-junction is a modified version of the classic T-junction with an added leg that serves as the exit channel for waste. The dispersed phase fluid enters from one diagonal of the K and exits the other diagonal while the continuous phase travels in the straight leg of the K. The intersection forms an interface that allows the dispersed phase to be controllably injected through actuation of an elastomer membrane located above the inlet channel near the interface. We have characterized two critical components in controlling the droplet size-membrane actuation pressure and timing as well as identified the region of fluid in which the droplet will be formed. This scheme will have applications in fluid sampling processes and selective encapsulation of materials. Selective encapsulation of a single cell from the dispersed phase fluid is demonstrated as an example of functionality of this design.

A Laplace pressure based microfluidic trap for passive droplet trapping and controlled release.

Here, we present a microfluidic droplet trap that takes advantage of the net Laplace pressure force generated when a droplet is differentially constricted. Mathematical simulations were first used to understand the working range of the component; followed by finite element modeling using the CFD software package to further characterize the behavior of the system. Controlled release of the trapped droplets is also demonstrated through both a mechanical method and a chemical method that manipulates the total pressure exerted on the trapped droplet. The unique design of this trapping device also provides the capability for selection of a single droplet from a train, as well as droplet fusion.

Alteration in the gene encoding protein tyrosine phosphatase nonreceptor type 6 (PTPN6/SHP1) may contribute to neutrophilic dermatoses.

We have found a B2 repeat insertion in the gene encoding protein tyrosine phosphatase nonreceptor type 6 (PTPN6) in a mouse that developed a skin disorder with clinical and histopathological features resembling those seen in human neutrophilic dermatoses. Neutrophilic dermatoses are a group of complex heterogeneous autoinflammatory diseases that all demonstrate excessive neutrophil infiltration of the skin. Therefore, we tested the cDNA and genomic DNA sequences of PTPN6 from patients with Sweet's syndrome (SW) and pyoderma gangrenosum and found numerous novel splice variants in different combinations. Isoforms resulting from deletions of exons 2, 5, 11, and 15 and retention of intron 1 or 5 were the most common in a patients with a familial case of SW, who had a neonatal onset of an inflammatory disorder with skin lesions and a biopsy specimen consistent with SW. These isoforms were associated with a heterozygous E441G mutation and a heterozygous 1.7-kbp deletion in the promoter region of the PTPN6 gene. Although full-length PTPN6 was detected in all other patients with either pyoderma gangrenosum or SW, it was always associated with splice variants: a partial deletion of exon 4 with the complete deletion of exon 5, alterations that were not detected in healthy controls. The defect in transcriptional regulation of the hematopoietic PTPN6 appears to be involved in the pathogenesis of certain subsets of the heterogeneous group of neutrophilic dermatoses.

Towards an understanding of the migration of Crimean-Congo hemorrhagic fever virus.

Crimean-Congo haemorrhagic fever (CCHF) is a lethal disease caused by Crimean-Congo hemorrhagic fever virus (CCHFV). It is one of the most widespread medically significant tick-borne pathogens, with a distribution that coincides well with the geographical occurrence of its tick vector, Hyalomma marginatum marginatum. Sporadic outbreaks of CCHF have previously been recognized in Asia, Africa, the Middle East and Europe but, in the 21st century, outbreaks have become more frequent in former Yugoslavia, Turkey and Iran. It has been suggested that CCHFV is a migrating pathogen, but it is not clear to what extent. We have, for the first time, analysed the worldwide migration pattern of CCHFV. Our results showed that Turkey may be a donor in Europe, towards both the east and the west, while the United Arab Emirates acted as a donor in the Middle East, and China was found to be the origin for genotype 2. Finally, we showed that migration of CCHFV was unrestricted between Iran and Pakistan. Considering the distribution and coincidence of the tick vector with CCHFV and CCHF, and the fact that the tick vector is present in western Europe, future outbreaks may extend to include hitherto-naïve areas, suggesting that increased surveillance and geographical mapping of this lethal pathogen are needed.

Microtubule-dependent and microtubule-independent steps in Crimean-Congo hemorrhagic fever virus replication cycle.

Following binding and entry many viruses exploit the host cell cytoskeleton to ensure intracellular transport, assembly or egress. For Crimean-Congo hemorrhagic fever virus (CCHFV), the causative agent of a severe hemorrhagic disease, virus-host interactions are poorly investigated. In this study we demonstrated that drug-induced suppression of microtubule dynamics and especially microtubule disassembly, impaired CCHFV biogenesis. Our results showed that intact microtubules were required early during virus internalization, and late, during virus assembly and egress. Furthermore, disruption of microtubules resulted in reduced levels of viral RNA while preservation of microtubule dynamics was most important during viral egress. Finally, although CCHFV proteins were redistributed in drug-treated cells, the glycoprotein remained associated with the Golgi apparatus, the organelle of virus budding. Taken together, our results suggest that manipulation of microtubules affects CCHFV entry, replication, assembly and egress.

Crimean-Congo hemorrhagic fever virus entry and replication is clathrin-, pH- and cholesterol-dependent.

To date, the entry pathway and replication mechanisms for members of the family Bunyaviridae, and especially for Crimean-Congo hemorrhagic fever virus (CCHFV), are poorly understood. Considering the severity of disease and the widespread geographical occurrence of CCHFV, investigating viral entry is of great value for development of antivirals. In this study, we have shown that knockdown of clathrin by small interfering RNA significantly reduced CCHFV nucleocapsid protein and viral RNA levels, suggesting that CCHFV utilizes clathrin-dependent endocytosis. In contrast, caveolin-1, an important constituent of caveolae endocytosis, is not important in CCHFV infection. Moreover, treatment with drugs that are known to interfere with the formation of clathrin-coated pits (sucrose and chlorpromazine) or endosome acidification (bafilomycin A1 and NH(4)Cl) also supported a clathrin-dependent pathway in the entry process of CCHFV. Finally, we demonstrated that cholesterol depletion in the cell plasma membrane significantly inhibited CCHFV infection. In the presence of exogenous cholesterol, this process was reversed, suggesting that cholesterol is important in the life cycle of CCHFV.