Involvement of blood coagulation factor XIII in burn healing in the carbon tetrachloride-induced hepatic injury model in rats

Refractory Duodenal Bleeding Ulcers Successfully Treated with Factor XIII Transfusion

A 67-year-old woman with a history of autoimmune hepatitis was admitted for fever, acute hepatic dysfunction, and acute kidney injury. She was diagnosed with multiple duodenal ulcers. Despite the administration of proton pump inhibitor and red blood cells, her black stool and anemia progressed, and she was therefore transferred to our hospital. Despite hemostatic treatments, she continued to bleed. On the 21st day of admission, an endoscopic examination showed the oozing of blood from the duodenal mucosa. A low factor XIII (FXIII) activity level was detected, and she was administered FXIII concentrate. The bleeding stopped and she was thereafter discharged.

Dynamics of coagulation factor XIII activity after video-assisted thoracoscopic lobectomy for non-small cell lung cancer

Background

The present study was performed to investigate the perioperative dynamics of coagulation factor XIII (FXIII) in patients with non-small cell lung cancer undergoing video-assisted thoracoscopic surgery (VATS) lobectomy compared with open lobectomy.

Methods

Perioperative coagulation factors including FXIII were analyzed in 30 patients who underwent VATS lobectomy and 10 patients who underwent open lobectomy at Teikyo University Hospital from December 2017 to April 2019.

Results

Patients in the VATS lobectomy group showed higher FXIII activity on postoperative day (POD) 5 than patients in the open lobectomy group (P=0.028). The FXIII activity was significantly lower on POD3, POD5, and POD7 than that in the preoperative period and on POD1, even in patients who had undergone VATS lobectomy (P<0.001). No factors were found to affect the maintenance of FXIII in the VATS lobectomy group.

Conclusion

The postoperative decrease of FXIII activity differed between patients who underwent VATS lobectomy and those who underwent open lobectomy. Based on the characteristics of FXIII, the FXIII activity may be a good marker of the invasiveness of VATS lobectomy versus open lobectomy.

Systemic and intestinal levels of factor XIII-A: the impact of inflammation on expression in macrophage subtypes

BACKGROUND

Subunit A of coagulation factor XIII (FXIII-A) is important for clot stability and acts in the subsequent wound healing process. Loss of plasma FXIII-A has been reported after surgery, sepsis, and inflammatory conditions. In the intestinal mucosa, FXIII-A is expressed by macrophages and cellular FXIII-A has been associated with phagocytosis and migration of macrophages. The objective was to evaluate the consequences of intestinal inflammation on resident mucosal macrophages, focusing on the level and distribution of FXIII-A.

METHODS

Plasma and colonic biopsies were collected from 67 patients with ulcerative colitis and controls. Intestinal samples were stained using immunohistochemistry for FXIII-A and macrophages (CD68, CD163 and iNOS). In situ hybridization were used to assess the intestinal expression of FXIII-A. FXIII-A antigen and activity levels were measured in plasma.

RESULTS

Increased infiltration of CD68 positive macrophages in the inflamed mucosa coincided with increased extracellular deposited FXIII-A and decreased expression and intracellular protein levels of FXIII-A. A decreased proportion of FXIII-A/CD68/CD163 triple-positive macrophages was observed in inflamed mucosa, indicating a reduction of the M2 phenotype with consequent loss of FXIII-A. No induction of iNOS positive macrophages was observed. Stimulation of naïve monocytes with physiological concentrations of pro-inflammatory mediators negatively affected the expression of FXIII-A. Measurements in plasma confirmed the loss of both FXIII antigen and activity during active disease.

CONCLUSIONS

Intestinal inflammation in UC induces loss of M2 macrophages with subsequent loss of FXIII-A synthesis. The loss of cellular FXIII-A may impact migration and phagocytosis, and hence limit pathogen eradication in UC.

Nonclinical analysis of the safety, pharmacodynamics, and pharmacokinetics of plasma-derived human FXIII concentrate in animals

Factor XIII (FXIII) is a coagulation protein which plays a major role in hemostasis by covalently cross‐linking fibrin molecules, thereby stabilizing the blood clot and increasing resistance to fibrinolysis. FXIII deficiency, either congenital or acquired, is associated with spontaneous bleeding, increased bleeding time, and poor wound healing. Purified plasma‐derived human FXIII concentrate (pd hFXIII) has been available since 1993 for therapeutic use in congenital FXIII deficiency. This set of nonclinical investigations aimed to evaluate the pharmacodynamic effects and assess the safety profile of pd hFXIII. The efficacy and safety of pd hFXIII were evaluated by pharmacodynamic, pharmacokinetic, and toxicity studies in mice and rats, safety pharmacology studies in dogs, neoantigenicity study, local tolerance, and thrombogenicity tests in rabbits. Administration of pd hFXIII resulted in the correction of deficits in clot formation kinetics and strength as measured by thromboelastometry, and was not associated with thrombus formation up to 350 IU/kg in FXIII knockout mice. There was no production of neoantigens resulting from the viral elimination manufacturing steps detected, and no adverse reactions were observed in toxicity studies with single doses up to 3550 IU/kg in mice and 1420 IU/kg in rats; nor from repeat doses of 350 IU/kg in rats. In addition, local tolerance tests revealed a good tolerability profile in rabbits. Overall, this data showed that pd hFXIII was well tolerated and pharmacodynamically active in preclinical animal models, supporting pd hFXIII as a therapy for FXIII deficiency.

Coagulation factor XIII: a multifunctional transglutaminase with clinical potential in a range of conditions

Coagulation factor XIII (FXIII), a plasma transglutaminase, is best known as the final enzyme in the coagulation cascade, where it is responsible for cross-linking of fibrin. However, a growing body of evidence has demonstrated that FXIII targets a wide range of additional substrates that have important roles in health and disease. These include antifibrinolytic proteins, with cross-linking of α2-antiplasmin to fibrin, and potentially fibrinogen, being the principal mechanism(s) whereby plasmin-mediated clot degradation is minimised. FXIII also acts on endothelial cell VEGFR-2 and αvβ3 integrin, which ultimately leads to downregulation of the antiangiogenic protein thrombospondin-1, promoting angiogenesis and neovascularisation. Under infectious disease conditions, FXIII cross-links bacterial surface proteins to fibrinogen, resulting in immobilisation and killing, while during wound healing, FXIII induces cross-linking of the provisional matrix. The latter process has been shown to influence the interaction of leukocytes with the provisional extracellular matrix and promote wound healing. Through these actions, there are good rationales for evaluating the therapeutic potential of FXIII in diseases in which tissue repair is dysregulated or perturbed, including systemic sclerosis (scleroderma), invasive bacterial infections, and tissue repair, for instance healing of venous leg ulcers or myocardial injuries. Adequate levels of FXIII are also required in patients undergoing surgery to prevent or treat perioperative bleeding, and its augmentation in patients with/at risk for perioperative bleeding may also have potential clinical benefit. While there are preclinical and/or clinical data to support the use of FXIII in a range of settings, further clinical evaluation in these underexplored applications is warranted.

Clinical value of exogenous factor XIII for prolonged air leak following pulmonary lobectomy: a case control study

Background

We examined the effect of exogenous factor XIII (FXIII) concentrate in patients with prolonged air leak (PAL) after pulmonary lobectomy for non-small cell lung cancer.

Methods

We performed a retrospective analysis of 297 patients who underwent pulmonary lobectomy between July 2007 and March 2014: 90 had an air leak on the first postoperative day, which resolved spontaneously within 5 days in 53 cases (SR group). FXIII concentrate was administered to the remaining 37 patients (PAL group) for 5 days. This group was subdivided into those in whom the air leak resolved during FXIII treatment (EF group) and those who needed additional intervention (inEF group). The clinical and perioperative characteristics of the groups were compared.

Results

Although plasma FXIII activity did not differ significantly between the SR and PAL groups before surgery or on the fifth postoperative day, the proportional perioperative fall in FXIII activity was significantly greater in the SR group (33%) than the PAL group (22%, p = 0.044) and inEF group (14%, p = 0.048). On the fifth postoperative day, FXIII activity was significantly lower in the EF group than in the inEF group (74% versus 91%, p = 0.030). The optimal cut-off point for postoperative plasma FXIII activity to distinguish between the EF and inEF groups was 86%.

Conclusions

Insufficient plasma FXIII consumption and lower postoperative FXIII activity may play a role in the resolution of PAL, and exogenous FXIII concentrate may be an effective, safe and non-invasive treatment.

Tissue-regenerating functions of coagulation factor XIII

The protransglutaminase factor XIII (FXIII) has recently attracted attention within the field of tissue regeneration, as it has been found that FXIII significantly influences wound healing by exerting a multitude of functions. It supports hemostasis by enhancing platelet adhesion to damaged endothelium, and by its cross-linking activity it stabilizes the formed fibrin clot. Furthermore, FXIII limits bacterial dissemination from the wound and incorporates macromolecules of importance for cellular infiltration, supporting cell migration and survival. FXIII-mediated complex formation of the vascular endothelial growth factor receptor 2 and αV β3 integrin is important for angiogenesis, supporting the formation of granulation tissue. Chronic inflammatory conditions involving bleeding and activation of the coagulation cascade have been shown to lead to reduced FXIII levels in plasma. Of particular importance for this review is the fact that patients suffering from inflammatory bowel disease (IBD) have reduced FXIII antigen levels and activity. Furthermore, these patients show impaired mucosal healing, which supports the inflammatory state of the disease. This review summarizes the role of FXIII in the healing of wounds, and briefly summarizes the previous use of FXIII in clinical settings. Moreover, it addresses the potential role for FXIII as a therapeutic agent in the healing of persistent wounds during chronic conditions, with an emphasis on IBD.

Factor XIII: a coagulation factor with multiple plasmatic and cellular functions

Factor XIII (FXIII) is unique among clotting factors for a number of reasons: 1) it is a protransglutaminase, which becomes activated in the last stage of coagulation; 2) it works on an insoluble substrate; 3) its potentially active subunit is also present in the cytoplasm of platelets, monocytes, monocyte-derived macrophages, dendritic cells, chondrocytes, osteoblasts, and osteocytes; and 4) in addition to its contribution to hemostasis, it has multiple extra- and intracellular functions. This review gives a general overview on the structure and activation of FXIII as well as on the biochemical function and downregulation of activated FXIII with emphasis on new developments in the last decade. New aspects of the traditional functions of FXIII, stabilization of fibrin clot, and protection of fibrin against fibrinolysis are summarized. The role of FXIII in maintaining pregnancy, its contribution to the wound healing process, and its proangiogenic function are reviewed in details. Special attention is given to new, less explored, but promising fields of FXIII research that include inhibition of vascular permeability, cardioprotection, and its role in cartilage and bone development. FXIII is also considered as an intracellular enzyme; a separate section is devoted to its intracellular activation, intracellular action, and involvement in platelet, monocyte/macrophage, and dendritic cell functions.

Factor XIII (FXIII) and angiogenesis

Factor XIII is a plasma transglutaminase that participates in the final stage of the coagulation cascade. Thrombin-activated FXIII (FXIIIa) catalyzes the formation of covalent cross-links between gamma-glutamyl and epsilon-lysyl residues on adjacent fibrin chains in polymerized fibrin to yield the mature clot. In addition to its role in hemostasis, FXIII is known to participate in wound healing and embryo implantation, which are processes involving angiogenesis. In this review, we discuss the role of FXIII in angiogenesis and the molecular mechanisms underlying its proangiogenic effects. The FXIII role in tissue repair and remodeling may at least in part be attributed to its pro-angiogenic activity.

Factor XIII activity levels in patients with allogeneic haematopoietic stem cell transplantation and acute graft-versus-host disease of the gut

Severe graft-versus-host disease (GvHD) of the gut clinically resembles Crohn's disease and ulcerative colitis. As low plasma levels of factor XIII (FXIII) have been described in chronic inflammatory bowel disease (CIBD) and as beneficial effects of FXIII concentrates in CIBD have been reported, we studied the FXIII plasma activity levels in patients undergoing allogeneic stem cell transplantation (SCT). In 20 of 22 patients with an uncomplicated course of SCT, FXIII stayed within the normal range (median 102 iu/dl, range 74-122), but was significantly reduced with the lowest FXIII levels on d 0 and 7 (d 0: median 83 iu/dl, range 55-165, d 7: median 83, range 70-101). In 20 of 22 patients with histologically proven GvHD of the gut, FXIII levels far below the normal range were observed (median 50, range 21-87) with a strong correlation between FXIII activity levels and degree of GvHD (r = -0.908; P < 0.001). We conclude that FXIII is consumed in patients with GvHD of the gut. As FXIII plays a a crucial role in haemostasis and wound healing, a study on the potential benefit of FXIII substitution in patients with severe GvHD of the gut might be rewarding.

Effects of profound hemodilution on small-intestinal wound healing in rabbits

BACKGROUND

Wound healing is influenced by tissue oxygen tension and blood perfusion, but not by moderate anemia or hemodilution. The effect of perioperative profound hemodilution on small-intestinal wound healing remains unclear.

METHODS

We performed jejunectomy followed by end-to-end anastomosis in rabbits subjected to a variety of perioperative hemodilutions: HD((HES)), hemodiluted with hydroxyethylstarch; HD((P+HES)), hemodiluted with autologous plasma and hydroxyethylstarch; HD((HES))/R, hemodiluted with hydroxyethylstarch and retransfused afterward. Intraoperative hemoglobin levels were 5 g 100 ml(-1). On Postoperative Day 5, the tensile strength (TS) of the anastomosis was measured and histological specimen was obtained. The time courses of hemoglobin, serum albumin (Alb), plasma fibrinogen (Fbg), and plasma activity of factor XIII (F XIII) were measured.

RESULTS

TS in HD((HES))/R (236.0 +/- 52.2 gf) was similar to that in control (266.5 +/- 41.6 gf); however, TS in HD((HES)) (179.8 +/- 17.9 gf) and HD((P+HES)) (165.5 +/- 14.7 gf) decreased significantly. The histological findings in HD((HES))/R were similar to those of control, whereas they demonstrated a delayed healing process in HD((HES)) and HD((P+HES)). Hemoglobin levels were still lower on Postoperative Day 5 in HD((HES)) and HD((P+HES)), but increased to 10.0 g 100 ml(-1) after retransfusion in HD((HES))/R. Hemodilution caused significant decreases in Alb, Fbg, and F XIII, but the values after retransfusion in HD((HES))/R were similar to postoperative values in HD((P+HES)).

CONCLUSION

Intraoperative profound hemodilution does not interfere with small-intestinal wound healing as long as postoperative hemoglobin levels were maintained above 10 g 100 ml(-1). Postoperative levels of other plasma constituents may not influence wound healing.