1
|
Ariëns S, Huisman A, Hovinga ICLK, Urbanus RT, van Galen KPM, van Vulpen LFD, Fischer K, Schutgens REG. Limited value of testing for factor XIII and α2-antiplasmin deficiency in patients with a bleeding disorder of unknown cause. Haemophilia 2024; 30:998-1002. [PMID: 38812123 DOI: 10.1111/hae.15059] [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: 03/18/2024] [Revised: 05/14/2024] [Accepted: 05/20/2024] [Indexed: 05/31/2024]
Abstract
INTRODUCTION In patients with an increased bleeding tendency, extensive diagnostic blood testing is often performed. When results of tier 1 assays of primary haemostasis are normal, protocols recommend additional testing to rule out rare disorders including coagulation factor XIII (FXIII) and α2-antiplasmin (α2AP) deficiency. AIM To evaluate the added diagnostic value of FXIII and α2AP levels in patients with a bleeding disorder of unknown cause (BDUC). METHODS A retrospective monocentre cohort study between August 2011 and August 2023 was conducted. In all patients with bleeding tendencies and normal diagnostic tests for von Willebrand disease and platelet function, FXIII and α2AP were measured. RESULTS We included 158 consecutive patients; mean ISTH-BAT scores were 8.2 (SD ± 3.7) in children, 6.2 (SD ± 2.1) in men and 10.6 (SD ± 3.3) in women. Median age was 37 (range 5-79) years, 88.6% of patients were female. Patients displayed median FXIII activity of 111% (IQR = 97-131) and median α2AP activity of 112% (IQR = 103-119). Three (1.9%) patients had FXIII levels < 50%, respectively 43%, 45% and 46%. Corresponding ISTH-BAT scores were 7, 12 and 14. No α2AP levels < 60% was observed. No significant association was found between FXIII levels and ISTH-BAT scores. CONCLUSION In our cohort of BDUC patients, no clinical relevant FXIII deficiencies were detected; absolute values were well above the 30% cutoff considered adequate for normal haemostasis. No α2AP deficiencies were detected. These data suggest that in BDUC patients, measuring FXIII or AP activity is of limited value.
Collapse
Affiliation(s)
- Sander Ariëns
- Center for Benign Haematology, Thrombosis and Haemostasis, van Creveldkliniek, Utrecht, the Netherlands
| | - Albert Huisman
- Central Diagnostic Laboratory, University Medical Center Utrecht and University Utrecht, Utrecht, the Netherlands
| | - Idske C L Kremer Hovinga
- Center for Benign Haematology, Thrombosis and Haemostasis, van Creveldkliniek, Utrecht, the Netherlands
| | - Rolf T Urbanus
- Center for Benign Haematology, Thrombosis and Haemostasis, van Creveldkliniek, Utrecht, the Netherlands
| | - Karin P M van Galen
- Center for Benign Haematology, Thrombosis and Haemostasis, van Creveldkliniek, Utrecht, the Netherlands
| | - Lize F D van Vulpen
- Center for Benign Haematology, Thrombosis and Haemostasis, van Creveldkliniek, Utrecht, the Netherlands
| | - Kathelijn Fischer
- Center for Benign Haematology, Thrombosis and Haemostasis, van Creveldkliniek, Utrecht, the Netherlands
| | - Roger E G Schutgens
- Center for Benign Haematology, Thrombosis and Haemostasis, van Creveldkliniek, Utrecht, the Netherlands
| |
Collapse
|
2
|
Snow EE, Wyatt-Thompson KE. The perioperative implications of factor XIII deficiency: A pediatric perspective. J Clin Anesth 2024; 94:111369. [PMID: 38199034 DOI: 10.1016/j.jclinane.2023.111369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/05/2023] [Accepted: 12/21/2023] [Indexed: 01/12/2024]
Affiliation(s)
- Erica E Snow
- Department of Anesthesiology, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, United States of America
| | - Karla E Wyatt-Thompson
- Department of Anesthesiology, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, United States of America; Department of Perioperative and Pain Medicine, Texas Children's Hospital, 6621 Fannin St, Ste A3300, Houston, TX 77030, United States of America.
| |
Collapse
|
3
|
Wiszniewska M, Włodarczyk U, Sury M, Słomka A, Piekuś-Słomka N, Żdanowicz A, Żekanowska E. The Usefulness of Factor XIII Concentration Assessment in Patients in the Acute Phase of Ischaemic Stroke Treated with Thrombolysis. Neurol Int 2024; 16:551-560. [PMID: 38804480 PMCID: PMC11130863 DOI: 10.3390/neurolint16030041] [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: 04/10/2024] [Revised: 05/05/2024] [Accepted: 05/08/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND AND AIMS In recent years, there has been a growing interest in factor XIII in ischaemic stroke. The study's main aim was to assess the usefulness of factor XIII concentration determination in patients with acute ischaemic stroke (AIS) treated with thrombolysis with recombinant tissue plasminogen activator (t-PA). METHODS The study was conducted in two groups of 84 patients with AIS: group I-with thrombolytic therapy and group II-without thrombolysis. A physical examination, neurological status (using the National Institutes of Health Stroke Scale, NIHSS), daily patients' activities measured with the Barthel Index and Modified Rankin Scale (mRS), and blood parameters were conducted on day 1 and day 7. The following parameters were assessed: highly sensitive C-reaction protein (CRP), fibrinogen, D-dimers (DD), neutrophil-lymphocyte ratio (NLR index), and the concentration of factor XIII-A. RESULTS In group I, the concentration of XIII-A decreased significantly between day 1 and 7 (p < 0.001). In group I, the concentration of XIII-A on day 7 in Total Anterior Circulation Infarct (TACI) was significantly lower than in non-TACI stroke. XIII-A concentration in group I was significantly lower in patients < 31 points with Acute Stroke Registry and Analysis of Lausanne (ASTRAL). A greater decrease in XIII-A between the first sampling on day 1 and the second sampling on day 7 was associated with a worse patient neurological state in group I. CONCLUSIONS In patients with AIS treated with t-PA, factor XIII concentrations decrease in the acute phase of stroke, and the largest decrease occurs in the TACI stroke. Determination of factor XIII concentration in patients with AIS can be used in clinical practice as an additional parameter supporting the assessment of stroke severity and may play a role in the prognosis; lower factor XIII-A activity may be a predictor of a worse prognosis.
Collapse
Affiliation(s)
- Małgorzata Wiszniewska
- Emergency Medical Services, University of Applied Sciences, 64-920 Piła, Poland
- Neurological Department with Stroke Unit, Specialist Hospital, 64-920 Piła, Poland
| | - Urszula Włodarczyk
- Neurological Department with Stroke Unit, Specialist Hospital, 64-920 Piła, Poland
| | - Magdalena Sury
- Neurological Department with Stroke Unit, Specialist Hospital, 64-920 Piła, Poland
| | - Artur Słomka
- Department of Pathophysiology, Nicolaus Copernicus University in Torun, Ludwik Rydygier Collegium Medicum, Faculty of Pharmacy, 85-067 Bydgoszcz, Poland; (A.S.)
| | - Natalia Piekuś-Słomka
- Department of Inorganic and Analytical Chemistry, Nicolaus Copernicus University in Toruń, Ludwik Rydygier Collegium Medicum, 85-067 Bydgoszcz, Poland;
| | - Anna Żdanowicz
- Department of Nursing, Stanislaw Staszic State University of Applied Science, 64-920 Piła, Poland
| | - Ewa Żekanowska
- Department of Pathophysiology, Nicolaus Copernicus University in Torun, Ludwik Rydygier Collegium Medicum, Faculty of Pharmacy, 85-067 Bydgoszcz, Poland; (A.S.)
| |
Collapse
|
4
|
Matsuda T, Haga T, Sakaguchi T, Kan T, Otsuka Y. A case of anti-NPX-2 antibody-positive dermatomyositis resulting in massive haemothorax with acquired factor XIII deficiency. Mod Rheumatol Case Rep 2023; 8:91-94. [PMID: 37606624 DOI: 10.1093/mrcr/rxad049] [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: 06/01/2023] [Revised: 07/24/2023] [Accepted: 08/09/2023] [Indexed: 08/23/2023]
Abstract
Autoimmune diseases, including dermatomyositis, can be complicated by an acquired autoimmune coagulation factor XIII deficiency, which sometimes results in fatal bleeding. Here, we report the case of a young woman with anti-NPX-2 antibody-positive dermatomyositis who developed massive haemothorax with acquired factor XIII deficiency during treatment, including plasma exchange therapy. Emergency transcatheter arterial embolisation was performed and coagulation factor XIII concentrates (Fibrogammin P® 240 U/day for 5 days) were supplemented. Subsequently, the patient was discharged and managed with oral prednisolone and tacrolimus. Coagulation system test results were followed up regularly and remained within normal limits and the patient progressed without recurrence of bleeding symptoms. Coagulation factor XIII deficiency cannot be assessed without measuring coagulation factor XIII activity because common coagulation-fibrinolytic system test results are not abnormal. The measurement of factor XIII activity should be performed when autoimmune diseases are complicated by unexplained bleeding.
Collapse
Affiliation(s)
| | - Taiki Haga
- Department of Critical Care Medicine, Osaka City General Hospital, Osaka, Japan
| | - Takaaki Sakaguchi
- Department of Critical Care Medicine, Osaka City General Hospital, Osaka, Japan
| | - Toshiaki Kan
- Department of Critical Care Medicine, Osaka City General Hospital, Osaka, Japan
| | - Yasunori Otsuka
- Department of Critical Care Medicine, Osaka City General Hospital, Osaka, Japan
| |
Collapse
|
5
|
Tran MH, Mathur G, Barnhard S, Schwartz J. Historic and emerging trends in transfusion medicine: Maintaining relevance as a specialty. Transfusion 2023; 63:2341-2350. [PMID: 37921092 DOI: 10.1111/trf.17588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/05/2023] [Accepted: 10/08/2023] [Indexed: 11/04/2023]
Affiliation(s)
- Minh-Ha Tran
- Department of Pathology and Laboratory Medicine, Irvine School of Medicine, University of California, Irvine, California, USA
| | - Gagan Mathur
- Department of Pathology and Laboratory Medicine, Irvine School of Medicine, University of California, Irvine, California, USA
| | - Sarah Barnhard
- Department of Pathology and Laboratory Medicine, Davis School of Medicine, University of California, Sacramento, California, USA
| | - Joseph Schwartz
- Department of Pathology, Moffitt Cancer Center, Tampa, Florida, USA
| |
Collapse
|
6
|
Bannow BS, Konkle BA. How I approach bleeding in hospitalized patients. Blood 2023; 142:761-768. [PMID: 36652635 PMCID: PMC10562531 DOI: 10.1182/blood.2021014766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 01/05/2023] [Accepted: 01/11/2023] [Indexed: 01/20/2023] Open
Abstract
Excessive bleeding is relatively common in adult inpatients, whether as the primary reason for admission or as a development during the hospital stay. Common causes include structural issues, medication effects, and systemic illnesses; occasionally, unexpected bleeding can develop as a result of an undiagnosed or newly acquired bleeding disorder. The first step in caring for the inpatient who is bleeding is to determine whether the bleeding symptom is truly new or whether the patient has a history of abnormal bleeding. Patients with a history of abnormal bleeding may warrant evaluation for inherited bleeding disorders, such as platelet function disorders, von Willebrand disease, hemophilia, or rare factor deficiencies. Patients with no history of bleeding, for whom other causes, such as liver dysfunction, medication effect, disseminated intravascular coagulation, or certain vitamin deficiencies have been ruled out may require evaluation for acquired coagulopathies, such as acquired hemophilia or acquired von Willebrand disease. Here, we present 3 cases to discuss the diagnosis and management of the 2 most common acquired bleeding disorders as well as a patient with a congenital bleeding disorder with a historical diagnosis.
Collapse
Affiliation(s)
- Bethany Samuelson Bannow
- Division of Hematology/Medical Oncology, Department of Medicine, Oregon Health and Science University, Portland, OR
| | - Barbara A Konkle
- Division of Hematology, Department of Medicine, Washington Center for Bleeding Disorders, University of Washington, Seattle, WA
| |
Collapse
|
7
|
Warren BB, Moyer GC, Manco-Johnson MJ. Hemostasis in the Pregnant Woman, the Placenta, the Fetus, and the Newborn Infant. Semin Thromb Hemost 2023; 49:319-329. [PMID: 36750218 DOI: 10.1055/s-0042-1760332] [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: 02/09/2023]
Abstract
The hemostasis system is composed of procoagulant, anticoagulant, and fibrinolytic proteins that interact with endothelial and blood cells and with each other in a complex system of checks and balances to maintain blood flow while preventing both hemorrhage and thrombosis. Pregnancy is a unique physiological state in which biological alterations predispose both mother and fetus to both bleeding and clotting. The placenta is a vascular interface for maternal and fetal blood exchange which predisposes the mother to hemorrhage. Maternal hemostasis presents a compensatory hypercoagulability including elevated factor VIII, von Willebrand factor, fibrinogen and thrombin generation, decreased thrombin regulation with resistance to activated protein C and decreased free protein S, and decreased fibrinolysis with increased plasminogen activator inhibitors. The placental vascular surface is of fetal trophoblastic origin that derives many characteristics of endothelium but differs in that tissue factor is constitutively expressed. Ontogeny of fetal hemostasis is characteristic. Platelets, von Willebrand factor, factor VIII, and fibrinogen are expressed and mature early in gestation, while vitamin K-dependent and contact factors exhibit delayed development. The fetal hemostatic system has a decreased capacity to generate or regulate thrombin, resulting in a fragile balance with little capacity to compensate under stress conditions, particularly in the infant born prematurely. Dysfunction of the maternal/placental/fetal unit gives rise to gestational disorders including preeclampsia, fetal growth restriction, placental abruption, and premature delivery. Knowledge of normal hemostasis levels and function are critical to evaluate bleeding or clotting syndromes in the pregnant woman and her fetus or newborn infant.
Collapse
Affiliation(s)
- Beth Boulden Warren
- University of Colorado Hemophilia and Thrombosis Center, Aurora, Colorado
- Department of Pediatrics, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, Colorado
| | - Genevieve C Moyer
- University of Colorado Hemophilia and Thrombosis Center, Aurora, Colorado
- Department of Pediatrics, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, Colorado
| | - Marilyn J Manco-Johnson
- University of Colorado Hemophilia and Thrombosis Center, Aurora, Colorado
- Department of Pediatrics, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, Colorado
| |
Collapse
|
8
|
Sperry JD, Rose AE, Williams E, Dierks MR, Medow JE. Emergent Reversal of Antithrombotics and Treatment of Life-Threatening Bleeding from Coagulopathies: A Clinical Review. J Emerg Med 2022; 63:17-48. [PMID: 35918220 DOI: 10.1016/j.jemermed.2022.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/29/2022] [Accepted: 05/09/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Reversal of antithrombotic agents and treatment of life-threatening bleeding episodes from coagulopathies can be a stressful scenario for clinicians, especially when the selection of treatment options should occur quickly. Understanding the options available for these agents requires emergency physicians to be familiar with the current data surrounding new therapies and dosing strategies for the treatment of bleeding from reversible and nonreversible antithrombotics and coagulopathic conditions. OBJECTIVE To provide quick resource guides for the reversal of major or life-threatening bleeding caused by antithrombotic agents or in the setting of coagulopathies. METHODS A literature search for articles published through September 2021 related to antithrombotic reversal and treatment of acute bleeding from coagulopathies was conducted using the PubMed clinical database. Selected articles were used to generate 5 guidance tables in this clinical review. DISCUSSION Four guidance tables for how to treat major or life-threatening bleeding from antithrombotic agents and 1 table for how to manage life-threatening bleeding for coagulopathies are presented as a quick reference tool for the emergency physician. Additional information on upcoming reversal agents and possible treatment options are provided herein. CONCLUSIONS In this clinical review, a series of 5 tables were created to provide quick and comprehensive guidance for the emergency physician when treating major or life-threatening bleeding caused by antithrombotic agents or coagulopathies. © 2022 Elsevier Inc.
Collapse
Affiliation(s)
- Jeffrey D Sperry
- Department of Pharmacy, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| | - Anne E Rose
- Department of Pharmacy, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| | - Eliot Williams
- Department of Hematology, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| | - Matthew R Dierks
- Department of Pharmacy, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| | - Joshua Eric Medow
- Department of Neurosurgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| |
Collapse
|