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Foret T, Dufrost V, Lagrange J, Costa P, Mourey G, Lecompte T, Magy-Bertrand N, Regnault V, Zuily S, Wahl D. Thrombin Generation Assay in Antiphospholipid Antibodies Positive Subjects as a Personalized Thrombotic Risk Assessment: State of the Art and Perspectives. Curr Rheumatol Rep 2024; 26:178-187. [PMID: 38372872 DOI: 10.1007/s11926-024-01140-1] [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] [Accepted: 02/05/2024] [Indexed: 02/20/2024]
Abstract
PURPOSE OF THE REVIEW Thrombotic risk assessment in antiphospholipid positive (aPL +) subjects is a major challenge, and the study of in vitro thrombin generation (thrombin generation assays (TGA)) could provide useful information. Activated protein C (APC) sensitivity is involved in thrombotic events in antiphospholipid syndrome patients. We summarized methods used to assess APC sensitivity with TGA and evaluated the prognostic role of APC resistance through literature search. RECENT FINDINGS APC resistance induced by aPL is a complex pathway. Several cross-sectional studies assessed APC sensitivity to understand thrombotic event mechanisms in aPL + subjects. Only one prospective cohort had investigated the prognostic impact of APC resistance in aPL + subjects, with a positive and significant correlation between APC sensitivity and the risk of thrombosis during the follow up (hazard ratio, 6.07 [95% CI, 1.69-21.87]). APC resistance assessed with TGA could be associated with thrombotic events in aPL + subjects.
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Affiliation(s)
- Thomas Foret
- Vascular Medicine Unit, Vascular and Endovascular Surgery Department, CHU-Besancon, 3 BD Alexandre Fleming, F-25000, Besancon, France.
- Université de Franche-Comté, SINERGIES, F-25000, Besancon, France.
| | - Virginie Dufrost
- Université de Lorraine, INSERM, DCAC, F-54000, Nancy, France
- Vascular Medicine Division and National Referral Center for Rare Vascular and Systemic Autoimmune Diseases, CHRU-Nancy, F-54000, Nancy, France
| | - Jeremy Lagrange
- Université de Lorraine, INSERM, DCAC, F-54000, Nancy, France
- CHRU-Nancy, F-54000, Nancy, France
| | - Patricia Costa
- Vascular Medicine Unit, Vascular and Endovascular Surgery Department, CHU-Besancon, 3 BD Alexandre Fleming, F-25000, Besancon, France
| | - Guillaume Mourey
- Université de Franche-Comté, SINERGIES, F-25000, Besancon, France
- Medical Biology Laboratory, Biological Haemostasis Department, CHU Besançon, F-25000, Besançon, France
| | - Thomas Lecompte
- Vascular Medicine Division and National Referral Center for Rare Vascular and Systemic Autoimmune Diseases, CHRU-Nancy, F-54000, Nancy, France
- Université de Lorraine, Nancy, France
| | | | - Veronique Regnault
- Université de Lorraine, INSERM, DCAC, F-54000, Nancy, France
- CHRU-Nancy, F-54000, Nancy, France
| | - Stéphane Zuily
- Université de Lorraine, INSERM, DCAC, F-54000, Nancy, France
- Vascular Medicine Division and National Referral Center for Rare Vascular and Systemic Autoimmune Diseases, CHRU-Nancy, F-54000, Nancy, France
| | - Denis Wahl
- Université de Lorraine, INSERM, DCAC, F-54000, Nancy, France
- Vascular Medicine Division and National Referral Center for Rare Vascular and Systemic Autoimmune Diseases, CHRU-Nancy, F-54000, Nancy, France
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Gehlen R, Vandevelde A, de Laat B, Devreese KMJ. Application of the thrombin generation assay in patients with antiphospholipid syndrome: A systematic review of the literature. Front Cardiovasc Med 2023; 10:1075121. [PMID: 37057100 PMCID: PMC10089302 DOI: 10.3389/fcvm.2023.1075121] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 02/20/2023] [Indexed: 03/30/2023] Open
Abstract
BackgroundThe antiphospholipid syndrome (APS) is classified by the presence of antiphospholipid antibodies (aPL) and thrombotic and/or adverse obstetric outcomes. The diagnosis and risk assessment of APS is challenging. This systematic review investigated if the thrombin generation (TG) assay could be helpful for APS diagnosis and risk assessment.MethodsA systemic review was performed by searching two databases (MEDLINE and Embase) until March 31, 2022, using a search strategy with two concepts: APS and TG, and related keywords. Two reviewers independently screened the articles based on predefined inclusion and exclusion criteria. Data extraction and quality assessment with the Newcastle-Ottawa Scale (NOS) were performed independently. Synthesis Without Meta-analysis guidelines were followed for data synthesis reporting.ResultsFourteen studies with 677 APS and 1,349 control subjects were included with variable quality according to the NOS. Twelve studies measured TG via the calibrated automated thrombogram (CAT) method using a fluorogenic substrate, whereas two used a chromogenic substrate-based TG assay. One study compared the CAT assay to the fully-automated ST Genesia® (Stago, France). Two studies initiated TG using platelet-rich plasma, whereas the rest of the studies used platelet-poor plasma. Resistance to activated protein C (aPC) was examined in ten studies. They reported a significant increase in aPC-resistance in APS patients compared to healthy controls, aPL-carriers, and thrombotic controls. Based on two studies, the prevalence of aPC-resistance was higher in APS patients compared to healthy controls and thrombotic controls with odds ratios of 5.9 and 6.8–12.8, respectively (p < 0.05). In contrast, no significant difference in aPC-resistance was found between APS patients and autoimmune disease controls. Furthermore, 7/14 studies reported TG-parameters including peak height, endogenous thrombin potential, lag time, and time to peak, but these outcomes were highly variable between studies. Furthermore, TG methodology between studies differed greatly, impacting the comparability of the studies.ConclusionaPC-resistance measured with TG was increased in APS patients compared to healthy and thrombotic controls, but the diagnostic and prognostic value is unclear compared to current diagnostic strategies. Studies of other TG-parameters were heterogeneous and more research is needed to identify their potential added value in APS diagnosis.Systematic Review Registrationhttps://www.PROSPERO/, identifier: CRD42022308363
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Affiliation(s)
- Rachel Gehlen
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Arne Vandevelde
- Coagulation Laboratory, Ghent University Hospital, Ghent, Belgium
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - Bas de Laat
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Katrien M. J. Devreese
- Coagulation Laboratory, Ghent University Hospital, Ghent, Belgium
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
- Correspondence: Katrien M. J. Devreese
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Evrard J, Morimont L, Didembourg M, Haguet H, Siriez R, Dogné JM, Douxfils J. Assessment of acquired activated protein C resistance with the FibWave and comparison with the ETP-based APC resistance. Int J Lab Hematol 2020; 43:802-812. [PMID: 33314736 DOI: 10.1111/ijlh.13427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 11/22/2020] [Accepted: 11/23/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Activated protein C (APC) resistance is a major risk factor of venous thrombosis which may be acquired by hormonal therapy or other causes. The FibWave, a sensitive global clot-based assay design to analyze the coagulation kinetics in plasma, may be a good candidate to assess this prothrombotic state. This study aims to assess the suitability of the FibWave to differentiate the coagulation kinetics of women on oral contraceptives. MATERIALS AND METHODS Fifty-four healthy volunteers were divided into 5 groups: men [n = 13], women not using hormonal contraception [n = 12], women using second [n = 12] or third generation [n = 12] combined oral contraceptives, and women using progestin only contraceptive [n = 5]. Patients with coagulation abnormalities were also assessed [n = 8]. The APC resistance was assessed on the FibWave using exogenous APC or Protac, and on the Calibrated Automated Thrombogram using the ETP-based APC resistance assay. RESULTS Either in presence or in absence of APC or Protac, the FibWave was able to detect a hypercoagulable state in plasma samples. All combined oral contraceptives showed a lower FW-Max1 , FW-Max2, and FW-Min2 percentage of inhibition and a lower FW-Ttpeak ratio than the other groups. The sensitivity of the FibWave was similar to the one of the ETP-based APC resistance assay. CONCLUSION The FibWave is able to differentiate APC resistance levels observed in women on combined oral contraceptive. The FW-Max1 , FW-Max2, and to a lesser degree FW-Min2 were identified as the most sensitive parameters with a similar performance to the ETP-based APC resistance assay.
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Affiliation(s)
- Jonathan Evrard
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Laure Morimont
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium.,Qualiblood s.a, Namur, Belgium
| | - Marie Didembourg
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Hélène Haguet
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Romain Siriez
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Jean-Michel Dogné
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium.,Namur Biobank-eXchange (NAB-X), University of Namur, Namur, Belgium
| | - Jonathan Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium.,Qualiblood s.a, Namur, Belgium
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Cardigan R, Green L. Thawed and liquid plasma--what do we know? Vox Sang 2015; 109:1-10. [PMID: 25833464 DOI: 10.1111/vox.12251] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 12/16/2014] [Accepted: 12/16/2014] [Indexed: 12/21/2022]
Abstract
There is increasing interest in the use of liquid or frozen plasma thawed and stored for extended periods (>24 h) to reduce wastage and to improve rapid availability of plasma in massive transfusion protocols advocating the early use of plasma in trauma by some centres. There is now a body of studies that have assessed individual coagulation factors during storage of thawed plasma. These show that factor VIII (FVIII) is the worst affected factor and that its activity is mainly lost during the first 24 h following thawing. However, for most factors studied, there is a continual decline during further storage. The few studies that have assessed thrombin generation in thawed plasma have shown variable results. Extended storage of plasma is associated with an increase in levels of DEHP in the component and could theoretically increase the risk of bacterial contamination, although the latter does not appear to have been an issue in countries that have adopted the use of thawed plasma. There are no clinical studies relating to the efficacy of extended-thawed plasma, and therefore, the potential reduction in its efficacy must be balanced with the clinical need for the component.
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Affiliation(s)
| | - L Green
- NHS Blood & Transplant, and Barts Health NHS Trust and Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Cookson P, Lawrie A, Green L, Dent E, Proffitt S, Bashir S, Thomas S, Cardigan R. Thrombin generation and coagulation factor content of thawed plasma and platelet concentrates. Vox Sang 2014; 108:160-8. [DOI: 10.1111/vox.12206] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 08/20/2014] [Accepted: 09/15/2014] [Indexed: 11/28/2022]
Affiliation(s)
- P. Cookson
- Component Development Laboratory; NHS Blood & Transplant; Brentwood UK
| | - A. Lawrie
- Haemostasis Research Unit; Department of Haematology; University College London; London UK
| | - L. Green
- Haemostasis Research Unit; Department of Haematology; University College London; London UK
| | | | - S. Proffitt
- Component Development Laboratory; NHS Blood & Transplant; Brentwood UK
| | - S. Bashir
- Component Development Laboratory; NHS Blood & Transplant; Brentwood UK
| | - S. Thomas
- Component Development Laboratory; NHS Blood & Transplant; Brentwood UK
| | - R. Cardigan
- Component Development Laboratory; NHS Blood & Transplant; Brentwood UK
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Arachchillage DRJ, Efthymiou M, Mackie IJ, Lawrie AS, Machin SJ, Cohen H. Anti-protein C antibodies are associated with resistance to endogenous protein C activation and a severe thrombotic phenotype in antiphospholipid syndrome. J Thromb Haemost 2014; 12:1801-9. [PMID: 25196808 DOI: 10.1111/jth.12722] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 09/01/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND Antiphospholipid antibodies may interfere with the anticoagulant activity of activated protein C (APC) to induce acquired APC resistance (APCr). AIMS To investigate the frequency and characteristics of APCr by using recombinant human APC (rhAPC) and endogenous protein C activation in antiphospholipid syndrome (APS). METHODS APCr was assessed in APS and non-APS venous thromboembolism (VTE) patients on warfarin and normal controls with rhAPC or Protac by thrombin generation. IgG anti-protein C and anti-protein S antibodies and avidity were assessed by ELISA. RESULTS APS patients showed greater resistance to both rhAPC and Protac than non-APS patients and normal controls (median normalized endogenous thrombin potential inhibition): APS patients with rhAPC, 81.3% (95% confidence interval [CI] 75.2-88.3%; non-APS patients with rhAPC, 97.7% (95% CI 93.6-101.8%; APS patients with Protac, 66.0% (95% CI 59.5-72.6%); and non-APS patients with Protac, 80.7 (95% CI 74.2-87.2%). APS patients also had a higher frequency and higher levels of anti-protein C antibodies, with 60% (15/25) high-avidity antibodies. High-avidity anti-protein C antibodies were associated with greater APCr and with a severe thrombotic phenotype (defined as the development of recurrent VTE while patients were receiving therapeutic anticoagulation or both venous and arterial thrombosis). Twelve of 15 (80%) patients with high-avidity anti-protein C antibodies were classified as APS category I. CONCLUSION Thrombotic APS patients showed greater APCr to both rhAPC and activation of endogenous protein C by Protac. High-avidity anti-protein C antibodies, associated with greater APCr, may provide a marker for a severe thrombotic phenotype in APS. However, in patients with category I APS, it remains to be established whether anti-protein C or anti-β2 -glycoprotein I antibodies are responsible for APCr.
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Affiliation(s)
- D R J Arachchillage
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
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Abstract
PURPOSE OF REVIEW This article reviews the current literature dealing with pathophysiology, diagnostics, bleeding management, and thromboprophylaxis in patients with acute and chronic liver dysfunction. RECENT FINDINGS Routine coagulation tests such as prothrombin time and International Normalized Ratio (INR) are not able to define whether a patient with critical liver dysfunction is hypocoagulable or hypercoagulable and are not able to predict the risk of bleeding in patients with liver dysfunction. Therefore, prophylactic transfusion of fresh frozen plasma and platelets in order to correct laboratory values is not appropriate. Notably, patients with liver dysfunction and increased INR are not 'autoanticoagulated'. In contrast, thrombin generation assays in the presence and absence of thrombomodulin or Protac, a snake venom that activates protein C in a manner similar to thrombomodulin, as well as viscoelastic tests (thrombelastography/thromboelastometry) indicate that patients with liver dysfunction are rather hypercoagulable with the inherent risk of thrombosis. SUMMARY Coagulopathy in patients with critical liver dysfunction is complex and can quickly decompensate to bleeding as well as to thrombosis. Both are associated with worse outcome. Hemostatic interventions should only be performed in case of clinically relevant bleeding and thromboprophylaxis should strongly be considered.
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