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Casini A, Al-Samkari H, Hayward C, Peyvandi F. Rare bleeding disorders: Advances in management. Haemophilia 2024; 30 Suppl 3:60-69. [PMID: 38494995 DOI: 10.1111/hae.14986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/28/2024] [Accepted: 02/28/2024] [Indexed: 03/19/2024]
Abstract
Inherited factor coagulation deficiencies and vascular bleeding disorders, associated with bleeding of various severity, are often classified as rare bleeding disorders (RBDs). These include inherited fibrinogen disorders, inherited platelet function disorders (IPFD) and hereditary haemorrhagic telangiectasia (HHT). In the last decades, there have been large increases in knowledge on the epidemiology, genetics, physiopathology, clinical features, and diagnosis of RBDs, but improvements in management have been more limited and remain challenging. The treatment mainstay of RBDs is based only on replacement of a few available coagulation factor concentrates or cryoprecipitates. There is growing interest in therapeutic agents that enhance coagulation or inhibiting anticoagulant pathways in RBDs. In severe IPFD, the optimal platelet transfusion strategy is not yet established. Moreover, data is scarce on the effectiveness and safety of desmopressin and/or antifibrinolytic drugs often used for milder IPFD treatment. The best fibrinogen replacement strategy (prophylaxis vs. on demand) in afibrinogenemia is still debated. Similarly, the optimal trough fibrinogen target level for treatment of acute bleeding, and the role of fibrinogen replacement during pregnancy in mild hypofibrinogenemia and dysfibrinogenemia, have not been properly evaluated. The therapeutic arsenal in HHT includes antifibrinolytics and a series of antiangiogenic agents whose potential efficacy has been tested in small studies or are under investigation for treatment of bleeding. However, there is need to address several issues, including the optimal dosing strategies, the potential emergent toxicity of longer-term use, and the impact of systemic antiangiogenic treatment on visceral arteriovenous malformations.
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Affiliation(s)
- Alessandro Casini
- Division of Angiology and Hemostasis, University Hospitals of Geneva and Faculty of Medicine of Geneva, Geneva, Switzerland
| | - Hanny Al-Samkari
- Division of Hematology Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Catherine Hayward
- Departments of Pathology and Molecular Medicine, and Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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2
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Mohsenian S, Palla R, Menegatti M, Cairo A, Lecchi A, Casini A, Neerman-Arbez M, Asselta R, Scardo S, Siboni SM, Blatny J, Zapletal O, Schved JF, Giansily-Blaizot M, Halimeh S, Daoud MA, Platokouki H, Pergantou H, Schutgens REG, Van Haaften-Spoor M, Brons P, Laros-van Gorkom B, Van Pinxten E, Borhany M, Fatima N, Mikovic D, Saracevic M, Özdemir GN, Ay Y, Makris M, Lockley C, Mumford A, Harvey A, Austin S, Shapiro A, Williamson A, McGuinn C, Goldberg I, De Moerloose P, Peyvandi F. Congenital fibrinogen disorders: a retrospective clinical and genetic analysis of the Prospective Rare Bleeding Disorders Database. Blood Adv 2024; 8:1392-1404. [PMID: 38286442 PMCID: PMC10950829 DOI: 10.1182/bloodadvances.2023012186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/11/2024] [Accepted: 01/13/2024] [Indexed: 01/31/2024] Open
Abstract
ABSTRACT Congenital fibrinogen deficiency (CFD) is a rare bleeding disorder caused by mutations in FGA, FGB, and FGG. We sought to comprehensively characterize patients with CFD using PRO-RBDD (Prospective Rare Bleeding Disorders Database). Clinical phenotypes, laboratory, and genetic features were investigated using retrospective data from the PRO-RBDD. Patients were classified from asymptomatic to grade 3 based on their bleeding severity. In addition, FGA, FGB, and FGG were sequenced to find causative variants. A total of 166 CFD cases from 16 countries were included, of whom 123 (30 afibrinogenemia, 33 hypofibrinogenemia, 55 dysfibrinogenemia, and 5 hypodysfibrinogenemia) were well characterized. Considering the previously established factor activity and antigen level thresholds, bleeding severity was correctly identified in 58% of the cases. The rates of thrombotic events among afibrinogenemic and hypofibrinogenemic patients were relatively similar (11% and 10%, respectively) and surprisingly higher than in dysfibrinogenemic cases. The rate of spontaneous abortions among 68 pregnancies was 31%, including 86% in dysfibrinogenemic women and 14% with hypofibrinogenemia. Eighty-six patients received treatment (69 on-demand and/or 17 on prophylaxis), with fibrinogen concentrates being the most frequently used product. Genetic analysis was available for 91 cases and 41 distinct variants were identified. Hotspot variants (FGG, p.Arg301Cys/His and FGA, p.Arg35Cys/His) were present in 51% of dysfibrinogenemia. Obstetric complications were commonly observed in dysfibrinogenemia. This large multicenter study provided a comprehensive insight into the clinical, laboratory, and genetic history of patients with CFDs. We conclude that bleeding severity grades were in agreement with the established factor activity threshold in nearly half of the cases with quantitative defects.
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Affiliation(s)
- Samin Mohsenian
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Roberta Palla
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Marzia Menegatti
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
| | - Andrea Cairo
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
| | - Anna Lecchi
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
| | - Alessandro Casini
- Division of Angiology and Hemostasis, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Marguerite Neerman-Arbez
- Department of Genetic Medicine and Development, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Rosanna Asselta
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - Sara Scardo
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
| | - Simona Maria Siboni
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
| | - Jan Blatny
- Department of Paediatrics Haematology and Biochemistry, University Hospital Brno and Masaryk University, Brno, Czech Republic
| | - Ondrej Zapletal
- Department of Paediatrics Haematology and Biochemistry, University Hospital Brno and Masaryk University, Brno, Czech Republic
| | - Jean-Francois Schved
- Department of Biological Hematology, CHU Montpellier, Université de Montpellier, Montpellier, France
| | - Muriel Giansily-Blaizot
- Department of Biological Hematology, CHU Montpellier, Université de Montpellier, Montpellier, France
| | | | | | - Helen Platokouki
- Haemophilia-Centre-Haemostasis Unit, Aghia Sophia Children’s Hospital, Athens, Greece
| | - Helen Pergantou
- Haemophilia-Centre-Haemostasis Unit, Aghia Sophia Children’s Hospital, Athens, Greece
| | - Roger E. G. Schutgens
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Monique Van Haaften-Spoor
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Paul Brons
- Department of Pediatric Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Elise Van Pinxten
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Munira Borhany
- Clinical Hematology, National Institute of Blood Diseases and Bone Marrow Transplantation, Karachi, Pakistan
| | - Naveena Fatima
- Clinical Hematology, National Institute of Blood Diseases and Bone Marrow Transplantation, Karachi, Pakistan
| | - Danijela Mikovic
- Hemostasis Department, Blood Transfusion Institute of Serbia, Belgrade, Serbia
| | - Marko Saracevic
- Hemostasis Department, Blood Transfusion Institute of Serbia, Belgrade, Serbia
| | - Gül Nihal Özdemir
- Pediatric Hematology Department, Istinye University, Istanbul, Turkey
| | - Yılmaz Ay
- University of Health Sciences Kartal Health Application and Research Center, Pediatric Hematology and Oncology Clinic, Istanbul, Turkey
| | - Michael Makris
- Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Caryl Lockley
- Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Andrew Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
| | - Andrew Harvey
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
| | - Steve Austin
- Department of Haematology, Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Amy Shapiro
- Indiana Hemophilia and Thrombosis Center, Indianapolis, IN
| | | | | | - Ilene Goldberg
- Division of Pediatric Hematology Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY
| | - Philippe De Moerloose
- Division of Angiology and Hemostasis, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Flora Peyvandi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
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3
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Moazzeni A, Naderi M, Dorgalaleh A, Alizadeh S. Fibrinogen Aα gene genotyping in patients with inherited afibrinogenemia deficiency; a novel mutation in Iranian afibrinogenemia patients. Blood Coagul Fibrinolysis 2023; 34:517-522. [PMID: 37823427 DOI: 10.1097/mbc.0000000000001260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
BACKGROUND Congenital fibrinogen deficiencies (CFD) are a group of rare bleeding disorders (RBD). Afibrinogenemia as a subclass of these disorders would occurs as a result of mutations in fibrinogen gene. Here in, the sequences of Aα chain of fibrinogen (FGA) in patients with inherited afibrinogenemia disorder in south-eastern of Iran were analysed. METHODS The FGA gene exons were amplified using PCR method and the DNA sequences were analysed to study the mutations in Aα chain of Fibrinogen. RESULTS Results showed that there was no large deletion in FGA gene. Although a frame shift mutation: c.196_197insT p.Ser66PhefsX10 in a patient and a novel mutation of IVS2-1G>A in two other patients were detected which were different from those detected in European population. CONCLUSION Different mutations are responsible of afibrinogenemia deficiency which requires more relevant studies for confirmation. The type and distribution of mutations in fibrinogen gene in Iranian patients is significantly different with reported mutations in European patients.
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Affiliation(s)
- Ali Moazzeni
- Hematology department, Allied medical school, Tehran University of Medical Sciences
| | - Majid Naderi
- Non-Communicable Disease Research Center, Zahedan University of Medical Sciences
| | - Akbar Dorgalaleh
- Department of Hematology and Blood Transfusion, School of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Shaban Alizadeh
- Hematology department, Allied medical school, Tehran University of Medical Sciences
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4
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Garyfallogiannis K, Ramanujam RK, Litvinov RI, Yu T, Nagaswami C, Bassani JL, Weisel JW, Purohit PK, Tutwiler V. Fracture toughness of fibrin gels as a function of protein volume fraction: Mechanical origins. Acta Biomater 2023; 159:49-62. [PMID: 36642339 DOI: 10.1016/j.actbio.2022.12.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 12/09/2022] [Accepted: 12/15/2022] [Indexed: 01/15/2023]
Abstract
The mechanical stability of blood clots necessary for their functions is provided by fibrin, a fibrous gel. Rupture of clots leads to life-threatening thrombotic embolization, which is little understood. Here, we combine experiments and simulations to determine the toughness of plasma clots as a function of fibrin content and correlate toughness with fibrin network structure characterized by confocal and scanning electron microscopy. We develop fibrin constitutive laws that scale with fibrin concentration and capture the force-stretch response of cracked clot specimens using only a few material parameters. Toughness is calculated from the path-independent J* integral that includes dissipative effects due to fluid flow and uses only the constitutive model and overall stretch at crack propagation as input. We show that internal fluid motion, which is not directly measurable, contributes significantly to clot toughness, with its effect increasing as fibrin content increases, because the reduced gel porosity at higher density results in greater expense of energy in fluid motion. Increasing fibrin content (1→10mg/mL) results in a significant increase in clot toughness (3→15 N/m) in accordance with a power law relation reminiscent of cellular solids and elastomeric gels. These results provide a basis for understanding and predicting the tendency for thrombotic embolization. STATEMENT OF SIGNIFICANCE: Fibrin, a naturally occurring biomaterial, is the major determinant of the structural and mechanical integrity of blood clots. We determined that increasing the fibrin content in clots, as in some thrombi and fibrin-based anti-bleeding sealants, results in an increase in clot toughness. Toughness corresponds to the ability to resist rupturing in the presence of a defect. We couple bulk mechanical testing, microstructural measurements, and finite element modeling to capture the force-stretch response of fibrin clots and compute toughness. We show that increased fibrin content in clots reduces porosity and limits fluid motion and that fluid motion drastically alters the clot toughness. These results provide a fundamental understanding of blood clot rupture and could help in rational design of fibrin-containing biomaterials.
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Affiliation(s)
| | - Ranjini K Ramanujam
- Department of Biomedical Engineering, Rutgers University, Piscataway, NJ, USA
| | - Rustem I Litvinov
- Department of Cell and Developmental Biology, University of Pennsylvania, Philadelphia, PA, USA
| | - Tony Yu
- Department of Biomedical Engineering, Rutgers University, Piscataway, NJ, USA
| | | | - John L Bassani
- Department of Mechanical Engineering and Applied Mechanics, University of Pennsylvania, Philadelphia, PA, USA
| | - John W Weisel
- Department of Cell and Developmental Biology, University of Pennsylvania, Philadelphia, PA, USA
| | - Prashant K Purohit
- Department of Mechanical Engineering and Applied Mechanics, University of Pennsylvania, Philadelphia, PA, USA
| | - Valerie Tutwiler
- Department of Biomedical Engineering, Rutgers University, Piscataway, NJ, USA.
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5
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Abdelwahab M, de Moerloose P, Casini A. High incidence of intracranial haemorrhage in Egyptian children with congenital afibrinogenaemia. Haemophilia 2023; 29:572-577. [PMID: 36585888 DOI: 10.1111/hae.14738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Intracerebral hemorrhage (ICH) is associated with high morbidity and mortality in patients with congenital afibrinogenaemia. Details on location of cerebral haemorrhage, management and neurological outcomes are lacking. METHODS We performed a retrospective study on Egyptian children with congenital afibrinogenaemia who experienced ICH, in order to estimate frequency, symptoms and neurological outcomes. RESULTS Among 58 children with congenital afibrinogenaemia treated on demand, 18 (31%) had an history of ICH (28 episodes). The first ICH occurred at a median age of 1 year (Q1-Q3 1-7 years). Impaired consciousness level, vomiting and seizures were the most common presenting symptoms. Spontaneous bleeding was associated with a more severe clinical presentation and worse neurological outcomes, including hydrocephaly and impaired cognitive development. Only half of ICH events (n = 14) were treated in less than 24 h from the onset of symptoms. Fibrinogen replacement by Fresh Frozen Plasma (FFP), cryoprecipitate or fibrinogen concentrates was administered in seven (25%), 19 (68%) and three (10%) ICH events, respectively. Overall, seven (25%) ICH occurring in four patients required a surgical intervention. After the ICH, six patients started secondary prophylaxis. The cumulative incidence of ICH at 10 years was 35% (95% CI 23-51) and at 20 years was 40% (95 CI% 26.7-58.8). CONCLUSION In our cohort of children with congenital afibrinogenaemia, ICH was very frequent and associated with adverse neurological outcomes and death. Further studies are required to determine whether primary prophylaxis starting early in childhood is indicated after diagnosis.
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Affiliation(s)
- Magy Abdelwahab
- Paediatric and Paediatric Haematology Department, Cairo University Paediatric Hospital, Social and Preventive medicine, Kasralainy Hospital, Cairo, Egypt
| | | | - A Casini
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Division of Angiology and Haemostasis, University Hospitals of Geneva, Geneva, Switzerland
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6
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Son JW, Son JM, Hur KH, Lee W, Song I, Na DH. Application of isothermal chemical denaturation to early‐stage formulation development of fibrinogen. B KOREAN CHEM SOC 2022. [DOI: 10.1002/bkcs.12664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Jae Woon Son
- GC Biopharma Yongin Republic of Korea
- College of Pharmacy Kyungpook National University Daegu Republic of Korea
| | - Jong Mun Son
- GC Biopharma Yongin Republic of Korea
- College of Pharmacy Chung‐Ang University Seoul Republic of Korea
| | - Ki Ho Hur
- GC Biopharma Yongin Republic of Korea
- College of Pharmacy Chungbuk National University Cheongju South Korea
| | - Wonhwa Lee
- Department of Chemistry Sungkyunkwan University Suwon Republic of Korea
| | - Im‐Sook Song
- College of Pharmacy Kyungpook National University Daegu Republic of Korea
| | - Dong Hee Na
- College of Pharmacy Chung‐Ang University Seoul Republic of Korea
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7
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Diagnosis and classification of hereditary fibrinogen disorders. ACTA MEDICA MARTINIANA 2022. [DOI: 10.2478/acm-2022-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Abstract
Hereditary fibrinogen disorders (HFDs) are rare bleeding disorders with a wide spectrum of biological and clinical features. While most patients with HFDs are at risk to suffer from mild to severe, sometimes life-threatening bleeding, thrombotic events are also common. Therefore, an appropriate diagnosis is needed to offer the optimal treatment. Diagnosis of HFDs can be challenging and plenty of pitfalls. The sensitivity and specificity of hemostasis routine test are depending on the reagents, the methods, and the fibrinogen variants. To distinguish subtypes of HFDs additional tests are often required. Historically based on the assessment of fibrinogen levels, a recent classification also considers the clinical phenotype and the genotype. In this short review, diagnosis strategies and HFDs classification are reviewed.
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8
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Kangro K, Wolberg AS, Flick MJ. Fibrinogen, Fibrin, and Fibrin Degradation Products in COVID-19. Curr Drug Targets 2022; 23:1593-1602. [PMID: 36029073 DOI: 10.2174/1389450123666220826162900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/31/2022] [Accepted: 06/15/2022] [Indexed: 01/25/2023]
Abstract
Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) is the highly pathogenic and highly transmissible human coronavirus that is the causative agent for the worldwide COVID-19 pandemic. COVID-19 manifests predominantly as a respiratory illness with symptoms consistent with viral pneumonia, but other organ systems (e.g., kidney, heart, brain) can also become perturbed in COVID-19 patients. Accumulating data suggest that significant activation of the hemostatic system is a common pathological manifestation of SARS-CoV-2 infection. The clotting protein fibrinogen is one of the most abundant plasma proteins. Following activation of coagulation, the central coagulation protease thrombin converts fibrinogen to fibrin monomers, which selfassemble to form a matrix, the primary structural component of the blood clot. Severe COVID-19 is associated with a profound perturbation of circulating fibrinogen, intra- and extravascular fibrin deposition and persistence, and fibrin degradation. Current findings suggest high levels of fibrinogen and the fibrin degradation product D-dimer are biomarkers of poor prognosis in COVID-19. Moreover, emerging studies with in vitro and animal models indicate fibrin(ogen) as an active player in COVID-19 pathogenesis. Here, we review the current literature regarding fibrin(ogen) and COVID-19, including possible pathogenic mechanisms and treatment strategies centered on clotting and fibrin(ogen) function.
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Affiliation(s)
- Kadri Kangro
- Department of Pathology and Laboratory Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Matthew J Flick
- Department of Pathology and Laboratory Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
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9
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Wei L, Tang Y, Wu Z, Xu P, Mo M. A case of congenital afibrinogenemia with multiple thrombotic and hemorrhagic disorders. Clin Case Rep 2022; 10:e6395. [PMID: 36276905 PMCID: PMC9582684 DOI: 10.1002/ccr3.6395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/04/2022] [Accepted: 09/20/2022] [Indexed: 11/06/2022] Open
Abstract
This is a case of congenital afibrinogenemia with multiple thrombotic and hemorrhagic events. His fibrinogen concentration was negatively correlated with thrombin time and prothrombin time and abnormally negatively correlated with plasma D-dimer levels. The individualized standard for fibrinogen concentration may help to balance thrombotic and hemorrhagic events for this disease.
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Affiliation(s)
- Lijian Wei
- Department of Neurologythe First Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
| | - Yuting Tang
- Department of Neurologythe First Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
| | - Zhuohua Wu
- Department of Neurologythe First Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
| | - Pingyi Xu
- Department of Neurologythe First Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
| | - Mingshu Mo
- Department of Neurologythe First Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
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10
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Casini A, Moerloose PD, Neerman-Arbez M. One Hundred Years of Congenital Fibrinogen Disorders. Semin Thromb Hemost 2022; 48:880-888. [PMID: 36055263 DOI: 10.1055/s-0042-1756187] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Congenital fibrinogen disorders encompass a broad range of fibrinogen defects characterized by a wide molecular and clinical spectrum. From the first clinical description of afibrinogenemia in 1920, many major achievements have contributed to a better understanding of these complex disorders. The finding of causative mutations in all three fibrinogen genes has contributed to reveal the molecular mechanisms involved in biosynthesis of the fibrinogen molecule and to clarify the basic processes of fibrin polymerization and fibrinolysis. The compilation of abundant cases with detailed genetic, biological, and clinical features has enabled the classification of congenital fibrinogen disorders into several types and subtypes. Thus, the recent classification of congenital fibrinogen disorder is based not only on the clottable and antigenic fibrinogen levels but also on the patient's clinical phenotype and genotype. Fibrinogen supplementation is the cornerstone of bleeding management in fibrinogen disorders. Since the discovery of blood fractionation, the method of production of fibrinogen concentrate has been progressively modified to significantly improve purity and safety. Nevertheless, the availability of such products is still limited to a few countries and the optimal threshold of fibrinogen to target is still not established. In this review, we describe the major advances that have characterized 100 years of congenital fibrinogen disorders, focusing on afibrinogenemia and dysfibrinogenemia.
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Affiliation(s)
- Alessandro Casini
- Division of Angiology and Hemostasis, University Hospitals of Geneva, Geneva, Switzerland.,Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Philippe de Moerloose
- Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Marguerite Neerman-Arbez
- Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Department of Genetic Medicine and Development, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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11
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Wolberg AS, Sang Y. Fibrinogen and Factor XIII in Venous Thrombosis and Thrombus Stability. Arterioscler Thromb Vasc Biol 2022; 42:931-941. [PMID: 35652333 PMCID: PMC9339521 DOI: 10.1161/atvbaha.122.317164] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
As the third most common vascular disease, venous thromboembolism is associated with significant mortality and morbidity. Pathogenesis underlying venous thrombosis is still not fully understood. Accumulating data suggest fibrin network structure and factor XIII-mediated crosslinking are major determinants of venous thrombus mass, composition, and stability. Understanding the cellular and molecular mechanisms mediating fibrin(ogen) and factor XIII production and function and their ability to influence venous thrombogenesis and resolution may inspire new anticoagulant strategies that target these proteins to reduce or prevent venous thrombosis in certain at-risk patients. This article summarizes fibrinogen and factor XIII biology and current knowledge of their function during venous thromboembolism.
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Affiliation(s)
- Alisa S Wolberg
- Department of Pathology and UNC Blood Research Center, University of North Carolina, Chapel Hill
| | - Yaqiu Sang
- Department of Pathology and UNC Blood Research Center, University of North Carolina, Chapel Hill
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12
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CD44-fibrinogen binding promotes bleeding in acute promyelocytic leukemia by in situ fibrin(ogen) deposition. Blood Adv 2022; 6:4617-4633. [PMID: 35511736 DOI: 10.1182/bloodadvances.2022006980] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/26/2022] [Indexed: 11/20/2022] Open
Abstract
Early haemorrhagic death is still the main obstacle for the successful treatment of acute promyelocytic leukaemia (APL). However, the mechanisms underlying haemostatic perturbations in APL have not been fully elucidated. Here, we report that CD44 on the membrane of APL blasts and NB4 cells ligated bound fibrinogen, resulting in in situ deposition of fibrin and abnormal fibrin distribution. Clots formed by leukaemic cells in response to CD44 and fibrinogen interaction exhibited low permeability and resistance to fibrinolysis. Using flow cytometry and confocal microscopy, we found that CD44 was also involved in platelet and leukaemic cell adhesion. CD44 bound activated platelets but not resting platelets through interaction with P-selectin. APL cell-coated fibrinogen-activated platelets directly induce enhanced procoagulant activity of platelets. In vivo studies revealed that CD44 knockdown shortened bleeding time, increased the level of fibrinogen, and elevated the number of platelets by approximately 2-fold in an APL mouse model. Moreover, CD44 expression on leukaemic cells in an APL mouse model was not only associated with bleeding complications but was also related to the wound healing process and the survival time of APL mice. Collectively, our results suggest that CD44 may be a potential intervention target for preventing bleeding complications in APL.
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13
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EASL Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis. J Hepatol 2022; 76:1151-1184. [PMID: 35300861 DOI: 10.1016/j.jhep.2021.09.003] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 09/13/2021] [Indexed: 12/11/2022]
Abstract
The prevention and management of bleeding and thrombosis in patients with cirrhosis poses several difficult clinical questions. These Clinical Practice Guidelines have been developed to provide practical guidance on debated topics, including current views on haemostasis in liver disease, controversy regarding the need to correct thrombocytopenia and abnormalities in the coagulation system in patients undergoing invasive procedures, and the need for thromboprophylaxis in hospitalised patients with haemostatic abnormalities. Multiple recommendations in this document are based on interventions that the panel feels are not useful, even though widely applied in clinical practice.
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When fibrin(ogen) is too loud, silence it! Blood 2022; 139:1261-1262. [PMID: 35238891 DOI: 10.1182/blood.2021015215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/04/2022] [Indexed: 11/20/2022] Open
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Djambas Khayat C, Marchi R, Durual S, Lecompte T, Neerman-Arbez M, Casini A. Impact of fibrinogen infusion on thrombin generation and fibrin clot structure in patients with inherited afibrinogenemia. Thromb Haemost 2022; 122:1461-1468. [PMID: 35045578 DOI: 10.1055/a-1745-0420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Inherited afibrinogenemia is a very rare disease characterized by complete absence of fibrinogen in the circulation and an increased risk in both thrombosis and bleeding. Infusion of fibrinogen concentrate (FC) is the main approach for prevention and management of bleeding; however, it has been reported to carry a thrombotic risk. METHODS We investigated the impact of a standard dose (40-100 mg/kg) of FC infusion on the thrombin generation (TG) parameters and the fibrin clot structure formed in plasma samples of patients with afibrinogenemia. Blood samples were collected from 20 patients before (T0) and 1 hour after infusion of FC (T1). TG was studied with Calibrated Automated Thrombography. Fibrin clot structure was assessed with turbidimetry and scanning electron microscopy (SEM). RESULTS FC infusions (mean Clauss fibrinogen plasma level 1.21 g/L at T1) led to a statistically significant increase in endogenous thrombin potentials (ETP) (p<0.0001) and thrombin peaks (p=0.02). Nevertheless, when compared to healthy controls, patients' T1 lag times were longer (p=0.002), ETP values were lower (p=0.0003), and thrombin peaks were lower (p<00001). All fibrin polymerization parameters (turbidimetry) obtained at T1 were comparable to those of patients with inherited hypofibrinogenemia matched for fibrinogen plasma levels. CONCLUSIONS In summary, fibrinogen infusion with a standard dose of FC increased but did not correct TG and led to formation of fibrin clots similar to those of patients with hypofibrinogenemia. All in all, our results do not support to biological evidence of hypercoagulability induced by FC in patients with afibrinogenemia.
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Affiliation(s)
| | - Rita Marchi
- Department of Genetic Medicine and Development, University of Geneva Faculty of Medicine, Geneve, Switzerland
| | - Stéphane Durual
- University clinics of dental medicine, University of Geneva, Geneva, Switzerland
| | - Thomas Lecompte
- Angiology and Haemostasis Division, University Hospitals of Geneva, Geneva, Switzerland
| | - Marguerite Neerman-Arbez
- Dep Of Genetic Medicine and Development, University of Geneva Medical School, Geneva, Switzerland
| | - Alessandro Casini
- Angiology and Haemostasis Division, University Hospitals of Geneva, Geneva, Switzerland
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Abstract
Fibrinogen plays a fundamental role in coagulation through its support for platelet aggregation and its conversion to fibrin. Fibrin stabilizes clots and serves as a scaffold and immune effector before being broken down by the fibrinolytic system. Given its importance, abnormalities in fibrin(ogen) and fibrinolysis result in a variety of disorders with hemorrhagic and thrombotic manifestations. This review summarizes (i) the basic elements of fibrin(ogen) and its role in coagulation and the fibrinolytic system; (ii) the laboratory evaluation for fibrin(ogen) disorders, including the use of global fibrinolysis assays; and (iii) the management of congenital and acquired disorders of fibrinogen and fibrinolysis.
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Affiliation(s)
- Jori E May
- Division of Hematology/Oncology, University of Alabama at Birmingham, 1720 2nd Avenue South, NP 2503, Birmingham, AL 35294, USA
| | - Alisa S Wolberg
- UNC Department of Pathology and Laboratory Medicine, UNC Blood Research Center, 8018A Mary Ellen Jones Building, CB7035, Chapel Hill, NC 27599-7035, USA
| | - Ming Yeong Lim
- Department of Internal Medicine, Division of Hematology and Hematologic Malignancies, University of Utah, 2000 Circle Hope Drive, Room 4126, Salt Lake City, UT 84112, USA.
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Li H, Sun S. Protein Aggregation in the ER: Calm behind the Storm. Cells 2021; 10:cells10123337. [PMID: 34943844 PMCID: PMC8699410 DOI: 10.3390/cells10123337] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 02/06/2023] Open
Abstract
As one of the largest organelles in eukaryotic cells, the endoplasmic reticulum (ER) plays a vital role in the synthesis, folding, and assembly of secretory and membrane proteins. To maintain its homeostasis, the ER is equipped with an elaborate network of protein folding chaperones and multiple quality control pathways whose cooperative actions safeguard the fidelity of protein biogenesis. However, due to genetic abnormalities, the error-prone nature of protein folding and assembly, and/or defects or limited capacities of the protein quality control systems, nascent proteins may become misfolded and fail to exit the ER. If not cleared efficiently, the progressive accumulation of misfolded proteins within the ER may result in the formation of toxic protein aggregates, leading to the so-called “ER storage diseases”. In this review, we first summarize our current understanding of the protein folding and quality control networks in the ER, including chaperones, unfolded protein response (UPR), ER-associated protein degradation (ERAD), and ER-selective autophagy (ER-phagy). We then survey recent research progress on a few ER storage diseases, with a focus on the role of ER quality control in the disease etiology, followed by a discussion on outstanding questions and emerging concepts in the field.
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Affiliation(s)
- Haisen Li
- Center for Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, MI 48201, USA;
| | - Shengyi Sun
- Center for Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, MI 48201, USA;
- Department of Biochemistry, Microbiology and Immunology, Wayne State University School of Medicine, Detroit, MI 48201, USA
- Correspondence:
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Simurda T, Asselta R, Zolkova J, Brunclikova M, Dobrotova M, Kolkova Z, Loderer D, Skornova I, Hudecek J, Lasabova Z, Stasko J, Kubisz P. Congenital Afibrinogenemia and Hypofibrinogenemia: Laboratory and Genetic Testing in Rare Bleeding Disorders with Life-Threatening Clinical Manifestations and Challenging Management. Diagnostics (Basel) 2021; 11:2140. [PMID: 34829490 PMCID: PMC8622093 DOI: 10.3390/diagnostics11112140] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/10/2021] [Accepted: 11/15/2021] [Indexed: 12/19/2022] Open
Abstract
Congenital fibrinogen disorders are rare pathologies of the hemostasis, comprising quantitative (afibrinogenemia, hypofibrinogenemia) and qualitative (dysfibrinogenemia and hypodysfibrinogenemia) disorders. The clinical phenotype is highly heterogeneous, being associated with bleeding, thrombosis, or absence of symptoms. Afibrinogenemia and hypofibrinogenemia are the consequence of mutations in the homozygous, heterozygous, or compound heterozygous state in one of three genes encoding the fibrinogen chains, which can affect the synthesis, assembly, intracellular processing, stability, or secretion of fibrinogen. In addition to standard coagulation tests depending on the formation of fibrin, diagnostics also includes global coagulation assays, which are effective in monitoring the management of replacement therapy. Genetic testing is a key point for confirming the clinical diagnosis. The identification of the precise genetic mutations of congenital fibrinogen disorders is of value to permit early testing of other at risk persons and better understand the correlation between clinical phenotype and genotype. Management of patients with afibrinogenemia is particularly challenging since there are no data from evidence-based medicine studies. Fibrinogen concentrate is used to treat bleeding, whereas for the treatment of thrombotic complications, administered low-molecular-weight heparin is most often. This review deals with updated information about afibrinogenemia and hypofibrinogenemia, contributing to the early diagnosis and effective treatment of these disorders.
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Affiliation(s)
- Tomas Simurda
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (J.Z.); (M.B.); (M.D.); (I.S.); (J.H.); (J.S.); (P.K.)
| | - Rosanna Asselta
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy;
- Humanitas Clinical and Research Center IRCCS, 20089 Rozzano, Italy
| | - Jana Zolkova
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (J.Z.); (M.B.); (M.D.); (I.S.); (J.H.); (J.S.); (P.K.)
| | - Monika Brunclikova
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (J.Z.); (M.B.); (M.D.); (I.S.); (J.H.); (J.S.); (P.K.)
| | - Miroslava Dobrotova
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (J.Z.); (M.B.); (M.D.); (I.S.); (J.H.); (J.S.); (P.K.)
| | - Zuzana Kolkova
- Biomedical Center Martin, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, 03601 Martin, Slovakia; (Z.K.); (D.L.)
| | - Dusan Loderer
- Biomedical Center Martin, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, 03601 Martin, Slovakia; (Z.K.); (D.L.)
| | - Ingrid Skornova
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (J.Z.); (M.B.); (M.D.); (I.S.); (J.H.); (J.S.); (P.K.)
| | - Jan Hudecek
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (J.Z.); (M.B.); (M.D.); (I.S.); (J.H.); (J.S.); (P.K.)
| | - Zora Lasabova
- Department of Molecular Biology and Genomics, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, 03601 Martin, Slovakia;
| | - Jan Stasko
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (J.Z.); (M.B.); (M.D.); (I.S.); (J.H.); (J.S.); (P.K.)
| | - Peter Kubisz
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (J.Z.); (M.B.); (M.D.); (I.S.); (J.H.); (J.S.); (P.K.)
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