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Terada R, Mishima Y, Le B, Butt AL, Levy JH, Tanaka KA. Evaluation of Thrombin and Plasmin Generation Velocity Ratios during Progressive Plasma Dilution. Anesth Analg 2024; 139:449-451. [PMID: 39008978 DOI: 10.1213/ane.0000000000006946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Affiliation(s)
- Rui Terada
- From the Department of Anesthesiology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Yuko Mishima
- From the Department of Anesthesiology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - BreAnna Le
- From the Department of Anesthesiology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Amir L Butt
- From the Department of Anesthesiology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University Medical Center, Durham, North Carolina
| | - Kenichi A Tanaka
- From the Department of Anesthesiology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
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Mehic D, Assinger A, Gebhart J. Utility of Global Hemostatic Assays in Patients with Bleeding Disorders of Unknown Cause. Hamostaseologie 2024. [PMID: 38950624 DOI: 10.1055/a-2330-9112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024] Open
Abstract
Bleeding disorder of unknown cause (BDUC) is a diagnosis of exclusion after exhaustive evaluation of plasmatic coagulation and platelet function. This review explores the utility of global hemostatic assays as confirmatory tests and in elucidating the pathophysiology of BDUC. Unlike traditional hemostatic tests that focus on coagulation factors, global assays are conducted both in plasma and also whole blood. These assays provide a more comprehensive understanding of the cell-based model of coagulation, aid in the identification of plasmatic factor abnormalities that may reduce hemostatic capacity, and allow for the assessment of impaired platelet-endothelial interactions under shear stress, as well as hyperfibrinolytic states. While clinical tests such as skin bleeding time and global assays such as PFA-100 exhibit limited diagnostic capacity, the role of viscoelastic testing in identifying hemostatic dysfunction in patients with BDUC remains unclear. Thrombin generation assays have shown variable results in BDUC patients; some studies demonstrate differences compared with healthy controls or reference values, whereas others question its clinical utility. Fibrinolysis assessment in vitro remains challenging, with studies employing euglobulin clot lysis time, plasma clot lysis time, and fluorogenic plasmin generation yielding inconclusive or conflicting results. Notably, recent studies suggest that microfluidic analysis unveils shear-dependent platelet function defects in BDUC patients, undetected by conventional platelet function assays. Overall, global assays might be helpful for exploring underlying hemostatic impairments, when conventional hemostatic laboratory tests yield no results. However, due to limited data and/or discrepant results, further research is needed to evaluate the utility of global assays as screening tools.
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Affiliation(s)
- Dino Mehic
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Alice Assinger
- Institute of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Johanna Gebhart
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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Giordano P, Pollio B, Sottilotta G, Biasoli C, Daniele F, De Cristofaro R, Peyvandi F, Villa MR, Castaman G. Pattern of use and clinical outcomes with rIX-FP in pediatric/adolescent patients with haemophilia B in Italy: Results from IDEAL real-world study. Eur J Haematol 2024; 112:765-775. [PMID: 38223989 DOI: 10.1111/ejh.14168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/21/2023] [Accepted: 12/27/2023] [Indexed: 01/16/2024]
Abstract
OBJECTIVES To evaluate pattern of use and clinical outcomes in pediatric/adolescent patients enrolled in the IDEAL study. METHODS This post-hoc analysis of IDEAL retrospective-prospective observational study focused on patients <18 years, 100% on prophylaxis during the entire observation period. RESULTS Thirteen subjects (median age 10.0 years; 61.5% ≤ 11 years) were analyzed. The infusion frequency changed from 2/week in 84.6% (N = 11) of patients with previous rFIX, to less than 1/weekly in 76.9% (N = 9) with rIX-FP and the annualized number of infusions reduced of 57% (p = .002), from a mean ± SD of 95.1 ± 22.77 to 40.4 ± 6.79, respectively. Annualized mean consumption decreased of about 56% (p = .001), from 3748.4 ± 1155.40 IU/kg with previous rFIX, to 1656.8 ± 456.63 IU/kg of rIX-FP. Mean FIX trough level changed from 3.0% ± 1.98% to 10.92% ± 3.6%. Low mean Annualized Bleeding Rate was maintained across all prophylaxis regimens (0.8 ± 1.69 vs. 0.3 ± 0.89) and zero bleeding patients moved from 69.2% (N = 9) with previous rFIX to 84.6% (N = 11) with rIX-FP (p = .63). Two adverse events, none related to rIX-FP, occurred in two patients. No inhibitors development was reported. CONCLUSIONS The results in this pediatric/adolescent subgroup support rIX-FP prophylaxis may reduce infusion frequency, while providing high FIX trough levels, stable annualized bleeding rate and a good safety profile.
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Affiliation(s)
- Paola Giordano
- B. Trambusti General and Specialised Paediatrics Unit, Giovanni XXIII Hospital, University of Bari, Bari, Italy
| | - Berardino Pollio
- Regional Reference Centre for Inherited Bleeding and Thrombotic Disorders, Transfusion Medicine, Regina Margherita Children Hospital, Turin, Italy
| | | | - Chiara Biasoli
- Haemophilia and Transfusion Centre, Bufalini Hospital, Cesena, Italy
| | - Filomena Daniele
- Haemostasis and Thrombosis Service, Ospedale Civile dell'Annunziata, Cosenza, Italy
| | - Raimondo De Cristofaro
- Haemorrhagic and Thrombotic Disease Service, Area of Haematological and Oncological Sciences, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi, Haemophilia and Thrombosis Centre, and Università degli Studi di Milano, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Maria Rosaria Villa
- Haemophilia and Thrombosis Centre, Hematology Unit, Ospedale del Mare, Naples, Italy
| | - Giancarlo Castaman
- Centre for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy
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Valke LLFG, Cloesmeijer ME, Mansouritorghabeh H, Barteling W, Blijlevens NMA, Cnossen MH, Mathôt RAA, Schols SEM, van Heerde WL. Pharmacokinetic-Pharmacodynamic Modelling in Hemophilia A: Relating Thrombin and Plasmin Generation to Factor VIII Activity After Administration of a VWF/FVIII Concentrate. Eur J Drug Metab Pharmacokinet 2024; 49:191-205. [PMID: 38367175 PMCID: PMC10904421 DOI: 10.1007/s13318-024-00876-6] [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] [Accepted: 01/16/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND Hemophilia A patients are treated with factor (F) VIII prophylactically to prevent bleeding. In general, dosage and frequency are based on pharmacokinetic measurements. Ideally, an alternative dose adjustment can be based on the hemostatic potential, measured with a thrombin generation assay (TGA), like the Nijmegen hemostasis assay. OBJECTIVE The objective of this study was to investigate the predicted performance of a previously developed pharmacokinetic-pharmacodynamic model for FVIII replacement therapy, relating FVIII dose and FVIII activity levels with thrombin and plasmin generation parameters. METHODS Pharmacokinetic and pharmacodynamic measurements were obtained from 29 severe hemophilia A patients treated with pdVWF/FVIII concentrate (Haemate P®). The predictive performance of the previously developed pharmacokinetic-pharmacodynamic model was evaluated using nonlinear mixed-effects modeling (NONMEM). When predictions of FVIII activity or TGA parameters were inadequate [median prediction error (MPE) > 20%], a new model was developed. RESULTS The original pharmacokinetic model underestimated clearance and was refined based on a two-compartment model. The pharmacodynamic model displays no bias in the observed normalized thrombin peak height and normalized thrombin potential (MPE of 6.83% and 7.46%). After re-estimating pharmacodynamic parameters, EC50 and Emax values were relatively comparable between the original model and this group. Prediction of normalized plasmin peak height was inaccurate (MPE 58.9%). CONCLUSION Our predictive performance displayed adequate thrombin pharmacodynamic predictions of the original model, but a new pharmacokinetic model was required. The pharmacodynamic model is not factor specific and applicable to multiple factor concentrates. A prospective study is needed to validate the impact of the FVIII dosing pharmacodynamic model on bleeding reduction in patients.
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Affiliation(s)
- Lars L F G Valke
- Department of Hematology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
- Hemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, The Netherlands
| | - Michael E Cloesmeijer
- Department of Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Hassan Mansouritorghabeh
- Clinical Research Development Unit, Ghaem Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Wideke Barteling
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Marjon H Cnossen
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ron A A Mathôt
- Department of Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Saskia E M Schols
- Department of Hematology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
- Hemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, The Netherlands
| | - Waander L van Heerde
- Department of Hematology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
- Hemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, The Netherlands.
- Enzyre BV, Novio Tech Campus, Nijmegen, The Netherlands.
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Verhagen MJA, van Balen EC, Blijlevens NMA, Coppens M, van Heerde WL, Leebeek FWG, Rijpma SR, van Vulpen LFD, Gouw SC, Schols SEM. Patients with moderate hemophilia A and B with a severe bleeding phenotype have an increased burden of disease. J Thromb Haemost 2024; 22:152-162. [PMID: 37813197 DOI: 10.1016/j.jtha.2023.09.029] [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: 07/18/2023] [Revised: 09/13/2023] [Accepted: 09/25/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND Patients with moderate hemophilia express varying bleeding phenotypes. OBJECTIVES To assess the burden of disease in patients with moderate hemophilia and a mild or severe phenotype incorporating the thrombin generation profile. METHODS This sub-study of the 6th Hemophilia in the Netherlands study, analyzed data of adults with moderate hemophilia A or B. Patient characteristics and information on bleeding tendency, joint status, and quality of life were obtained from electronic patient files and self-reported questionnaires. A severe bleeding phenotype was defined as an annual bleeding rate ≥5, an annual joint bleeding rate ≥3, and/or the use of secondary/tertiary prophylaxis, and a mild phenotype vice versa. TG was measured with the Nijmegen Hemostasis Assay. RESULTS This study included 116 patients: 21% had a severe phenotype of whom 46% used prophylaxis. Patients with a severe phenotype treated on demand reported a higher median annual bleeding rate (7), annual joint bleeding rate (3), and more frequently an impaired joint (77%) than patients with a severe phenotype on prophylaxis (2; 0; 70%) or patients with a mild phenotype (0; 0; 47%). Furthermore, patients with a severe phenotype treated on demand experienced a more decreased quality of life. Despite similar factor activity levels, patients with a severe phenotype had a lower thrombin peak height and thrombin potential (0.7%; 0.06%) than patients with a mild phenotype (21.3%; 46.8%). CONCLUSION Patients with moderate hemophilia and a severe phenotype treated on demand displayed a high burden of disease as well as a low thrombin generation profile advocating them toward more intensive prophylactic treatment.
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Affiliation(s)
- Marieke J A Verhagen
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands; Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Nijmegen, the Netherlands; Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Erna C van Balen
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Michiel Coppens
- Department of Vascular Medicine and Haemophilia Treatment Center, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Waander L van Heerde
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands; Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Nijmegen, the Netherlands; Enzyre BV, Novio Tech Campus, Nijmegen, the Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Sanna R Rijpma
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Lize F D van Vulpen
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Samantha C Gouw
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands; Amsterdam UMC Location University of Amsterdam, Department of Pediatric Hematology, Meibergdreef 9, Amsterdam, the Netherlands
| | - Saskia E M Schols
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands; Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Nijmegen, the Netherlands.
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de Laat-Kremers R, Zuily S, de Laat B. Editorial: Advances in thrombin generation. Front Cardiovasc Med 2023; 10:1183718. [PMID: 37063969 PMCID: PMC10098350 DOI: 10.3389/fcvm.2023.1183718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/20/2023] [Indexed: 04/03/2023] Open
Affiliation(s)
- Romy de Laat-Kremers
- Department of Data Analysis and Artificial Intelligence, Synapse Research Institute, Maastricht, Netherlands
- Correspondence: Romy de Laat-Kremers
| | | | - Bas de Laat
- Department of Data Analysis and Artificial Intelligence, Synapse Research Institute, Maastricht, Netherlands
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, Netherlands
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De Pablo-Moreno JA, Miguel-Batuecas A, de Sancha M, Liras A. The Magic of Proteases: From a Procoagulant and Anticoagulant Factor V to an Equitable Treatment of Its Inherited Deficiency. Int J Mol Sci 2023; 24:ijms24076243. [PMID: 37047215 PMCID: PMC10093859 DOI: 10.3390/ijms24076243] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/22/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023] Open
Abstract
Proteostasis, i.e., the homeostasis of proteins, responsible for ensuring protein turnover, is regulated by proteases, which also participate in the etiopathogenesis of multiple conditions. The magic of proteases is such that, in blood coagulation, one same molecule, such as coagulation factor V, for example, can perform both a procoagulant and an anticoagulant function as a result of the activity of proteases. However, this magic has an insidious side to it, as it may also prevent the completion of the clinical value chain of factor V deficiency. This value chain encompasses the discovery of knowledge, the transfer of this knowledge, and its translation to clinical practice. In the case of rare and ultra-rare diseases like factor V deficiency, this value chain has not been completed as the knowledge acquisition phase has dragged out over time, holding up the transfer of knowledge to clinical practice. The reason for this is related to the small number of patients afflicted with these conditions. As a result, new indications must be found to make the therapies cost-effective. In the case of factor V, significant research efforts have been directed at developing a recombinant factor V capable of resisting the action of the proteases capable of inactivating this factor. This is where bioethics and health equity considerations come into the equation.
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