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Leblanc Y, Chapuis V, Faid V, Seifert A. Characterization of antithrombin isoforms and latent forms by ion exchange chromatography coupled to mass spectrometry. Anal Biochem 2023; 668:115088. [PMID: 36878338 DOI: 10.1016/j.ab.2023.115088] [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: 09/12/2022] [Revised: 01/16/2023] [Accepted: 02/21/2023] [Indexed: 03/07/2023]
Abstract
Antithrombin is a key protein of the coagulation system belonging to the serine protease inhibitor family. Antithrombin preparations are used as a therapeutic treatment for patients with decreased antithrombin activity. Elucidating the structural features of this protein is an important part of the control strategy to assure a high quality. This study presents an ion exchange chromatographic method coupled to mass spectrometry capable of characterizing antithrombin post-translational modifications such as N-glycosylation, phosphorylation or deamidation. Furthermore, the method was successfully used to evidence irreversible/inactive conformers of antithrombin which are commonly observed for serine protease inhibitors and referred to as latent forms.
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Affiliation(s)
- Yann Leblanc
- Analytical Department of LFB Biotechnologies, 3 Avenue des Tropiques, 91958, Courtabœuf, France.
| | - Violaine Chapuis
- Analytical Department of LFB Biotechnologies, 3 Avenue des Tropiques, 91958, Courtabœuf, France
| | - Valegh Faid
- Analytical Department of LFB Biotechnologies, 3 Avenue des Tropiques, 91958, Courtabœuf, France
| | - Alexander Seifert
- Analytical Department of LFB Biotechnologies, 3 Avenue des Tropiques, 91958, Courtabœuf, France.
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2
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Abstract
Commercially available products used for antithrombin supplementation, for example, in extracorporeal life support, may contain latent antithrombin, a hyper-stable strongly procoagulative and anti-angiogenic residue. Latent antithrombin is associated with severe thrombosis in the critically ill. In the manufacturing process of fractionated antithrombin from plasma, heat treatment, citrate, and freeze drying speed up the transformation of native antithrombin to latent antithrombin. Manufacturers are not required to assess and report the latent antithrombin content of their products. When reported, the latent antithrombin fractions in their product range from <1% to 40% of total antithrombin compared with <3% in the healthy adult and less in children. The aims of this work were (1) to convey increased awareness to clinicians who may experience defaulted, expected effect after antithrombin supplementation in, for example, heparin anticoagulation during extracorporeal life support and (2) to urge manufacturers to assess and disclose latent antithrombin content in their products.
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Affiliation(s)
- Lars Mikael Broman
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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3
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Moynihan KM, Johnson K, Rane M, Norman A, Humphreys S, Stocker C, Gibbons K, Roy J. Pediatric Thromboelastograph 6s and Laboratory Coagulation Reference Values. Arch Pathol Lab Med 2021; 145:1413-1423. [PMID: 33503231 DOI: 10.5858/arpa.2020-0647-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2020] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Specific reference intervals (RIs) facilitate accurate interpretation of results. Coagulation assay results may vary by demographics and also between reagents and analyzers used. Current Thromboelastograph 6s (TEG 6s) Hemostasis Analyzer RIs were generated from adult samples. OBJECTIVE.— To generate reagent analyzer-specific pediatric RIs for TEG 6s and coagulation parameters. DESIGN.— A prospective, observational, single-center study of healthy children undergoing general anesthesia (January 3, 2017 to January 3, 2019). Venous blood samples were obtained for TEG 6s (Kaolin, Kaolin-Heparinase, Rapid and Functional Fibrinogen assays) and coagulation parameters (activated partial thromboplastin time, prothrombin time, thrombin clotting time, Echis time, antithrombin activity, and fibrinogen concentration using Instrumentation Laboratory ACL-TOP analyzers). Differences between activated partial thromboplastin time and prothrombin time reagents were investigated using mixed-effects regression, comparing maximum coefficients-of-variation with assay-specific allowable variation. RIs (lower/upper limits 2.5th of 97.5th percentiles) were generated using the following 2 methods: within discrete age-groups (neonates [<1 month], infants [1 month-1 year], young children [1-5 years], older children [6-10 years], and adolescents [11-16 years]), and modeled as functions of age and/or sex using quantile regression, including significant fractional polynomial and interaction terms. RESULTS.— Variation between prothrombin time and activated partial thromboplastin time assays using different reagents was clinically significant. Reagent-analyzer specific pediatric RIs were generated using data from 254 children. Discrete and model-based RIs varied by age for all coagulation parameters and TEG 6s variables in all assays. CONCLUSIONS.— We report reagent-analyzer specific pediatric RIs for TEG 6s and coagulation parameters. Observed variation reinforces recommendations for laboratory-specific RIs. These findings improve accuracy of interpretation of clinical results, provide a foundation for comparison and validation of tests in pathology and illustrate feasibility and advantages of model-based RI approaches.
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Affiliation(s)
- Katie M Moynihan
- From the Department of Cardiology, Division of Cardiovascular Critical Care, Boston Children's Hospital, Massachusetts (Moynihan).,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts (Moynihan).,Pediatric Critical Care Research Group at Child Health Research Centre (Moynihan, Johnson, Humphreys, Stocker, Gibbons).,Faculty of Medicine (Moynihan), The University of Queensland, Australia
| | - Kerry Johnson
- Pediatric Critical Care Research Group at Child Health Research Centre (Moynihan, Johnson, Humphreys, Stocker, Gibbons).,Pediatric Intensive Care Unit (Johnson, Stocker)
| | - Mark Rane
- Pathology Queensland, Queensland Health - Queensland Children's Laboratory, Brisbane, Australia (Rane, Norman)
| | - Andrew Norman
- Pathology Queensland, Queensland Health - Queensland Children's Laboratory, Brisbane, Australia (Rane, Norman)
| | - Susan Humphreys
- Pediatric Critical Care Research Group at Child Health Research Centre (Moynihan, Johnson, Humphreys, Stocker, Gibbons).,Department of Anesthesia (Humphreys)
| | - Christian Stocker
- Pediatric Critical Care Research Group at Child Health Research Centre (Moynihan, Johnson, Humphreys, Stocker, Gibbons).,Pediatric Intensive Care Unit (Johnson, Stocker)
| | - Kristen Gibbons
- Pediatric Critical Care Research Group at Child Health Research Centre (Moynihan, Johnson, Humphreys, Stocker, Gibbons)
| | - John Roy
- Hematology Department (Roy), Queensland Children's Hospital, Brisbane, Australia
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Sniderman J, Monagle P, Annich GM, MacLaren G. Hematologic concerns in extracorporeal membrane oxygenation. Res Pract Thromb Haemost 2020; 4:455-468. [PMID: 32548547 PMCID: PMC7292669 DOI: 10.1002/rth2.12346] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/27/2020] [Accepted: 03/31/2020] [Indexed: 12/16/2022] Open
Abstract
This ISTH "State of the Art" review aims to critically evaluate the hematologic considerations and complications in extracorporeal membrane oxygenation (ECMO). ECMO is experiencing a rapid increase in clinical use, but many questions remain unanswered. The existing literature does not address or explicitly state many pertinent details that may influence hematologic complications and, ultimately, patient outcomes. This review aims to broadly introduce modern ECMO practices, circuit designs, circuit materials, hematologic complications, transfusion-related considerations, age- and size-related differences, and considerations for choosing outcome measures. Relevant studies from the 2019 ISTH Congress in Melbourne, which further advanced our understanding of these processes, will also be highlighted.
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Affiliation(s)
| | - Paul Monagle
- Department of PaediatricsDepartment of HaematologyUniversity of MelbourneThe Royal Children's HospitalHaematology Research Murdoch Children’s Research InstituteMelbourneVic.Australia
| | - Gail M. Annich
- Department of Critical Care MedicineThe Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
| | - Graeme MacLaren
- Paediatric ICURoyal Children’s HospitalMelbourneVic.Australia
- Department of PaediatricsUniversity of MelbourneParkvilleVic.Australia
- Cardiothoracic ICUNational University Health SystemSingapore CitySingapore
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Bleeding and Thrombosis in the Future of Pediatric Extracorporeal Life Support: A Roadmap From the Pediatric Cardiac Intensive Care Society. Pediatr Crit Care Med 2019; 20:1089-1091. [PMID: 31688679 DOI: 10.1097/pcc.0000000000002139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Downey L, Faraoni D. Antithrombin Supplementation in Infants Undergoing Cardiac Surgery: A New Piece of a Complex Puzzle. J Cardiothorac Vasc Anesth 2019; 33:403-405. [DOI: 10.1053/j.jvca.2018.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Indexed: 11/11/2022]
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Newall F, Branchford B, Male C. Anticoagulant prophylaxis and therapy in children: current challenges and emerging issues. J Thromb Haemost 2018; 16:196-208. [PMID: 29316202 DOI: 10.1111/jth.13913] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
This review is aimed at describing the unique challenges of anticoagulant prophylaxis and treatment in children, and highlighting areas for research for improving clinical outcomes of children with thromboembolic disease. The evidence presented demonstrates the challenges of advancing the evidence base informing optimal management of thromboembolic disease in children. Recent observational studies have identified risk factors for venous thromboembolism in children, but there are few interventional studies assessing the benefit-risk balance of using thromboprophylaxis in risk-stratified clinical subgroups. A risk level-based framework is proposed for administering mechanical and pharmacological thromboprophylaxis. More research is required to refine the assignment of risk levels. The anticoagulants currently used predominantly in children are unfractionated heparin, low molecular weight heparin, and vitamin K antagonists. There is a paucity of robust evidence on the age-specific pharmacology of these agents, and their efficacy and safety for prevention and treatment of thrombosis in children. The available literature is heterogeneous, reflecting age-specific differences, and the various clinical settings for anticoagulation in children. Monitoring assays and target ranges are not well established. Nevertheless, weight-based dosing appears to achieve acceptable outcomes in most indications. Given the limitations of the classical anticoagulants for children, there is great interest in the direct oral anticoagulants (DOACs), whose properties appear to be particularly suitable for children. All DOACs currently approved for adults have Pediatric Investigation Plans ongoing or planned. These are generating age-specific formulations and systematic dosing information. The ongoing pediatric studies still have to establish whether DOACs have a positive benefit-risk balance in the various pediatric indications and age groups.
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Affiliation(s)
- F Newall
- Clinical Haematology & Nursing Research, Royal Children's Hospital, Haematology Research Group, Murdoch Childrens Research Institute and Departments of Paediatrics and Nursing, The University of Melbourne, Melbourne, Australia
| | - B Branchford
- Department of Pediatrics, Section of Hematology/Oncology/Bone Marrow Transplant and the Hemophilia and Thrombosis Center, School of Medicine and Center for Cancer and Blood Disorders, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - C Male
- Haemostasis and Thrombosis Unit, Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
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Jones AJ, O'Mara KL, Kelly BJ, Samraj RS. The Impact of Antithrombin III Use in Achieving Anticoagulant Goals in Pediatric Patients. J Pediatr Pharmacol Ther 2017; 22:320-325. [PMID: 29042831 DOI: 10.5863/1551-6776-22.5.320] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To determine the percentage of patients with >10% reduction in heparin infusion rate within 48 hours of antithrombin III (ATIII) administration. Secondary objectives include the achievement of therapeutic anticoagulation and determining the days of subtherapeutic infusion prior to supplementation. METHODS Retrospective chart review of 12 patients younger than 18 years of age who received ATIII concentrate supplementation while on continuous heparin infusion. Specific indications for heparin infusion therapy included extracorporeal membrane oxygenation (ECMO), treatment of thrombus, and post implantation of ventricular assist device(s). RESULTS From time of heparin initiation to ATIII supplementation, patients spent a mean 4.9 ± 2.6 days of subtherapeutic infusion and required uptitration from a mean of 15.3 ± 4.4 units/kg/hr to a mean rate of 40.7 ± 9.5 units/kg/hr. 58.3% of the patients (n = 7) had a ≥10% reduction from the baseline heparin infusion rate within 48 hours of ATIII administration. Those patients considered responders (≥10% reduction from baseline rate) had a slightly higher mean baseline antithrombin level (76.3% ± 22.0% vs. 58.6% ± 2.7% in non-responders, p = 0.1) and were administered comparable doses of ATIII. ATIII supplementation did appear to increase the time of therapeutic anticoagulation within the 48 hours. CONCLUSIONS Administration of ATIII is associated with >10% decrease in heparin requirements in more than half of the patients identified. In those patients deemed non-responders, there was a trend towards lower baseline antithrombin serum levels. Further studies are warranted to determine if the lack of response in some patients is due to inadequate dosing of ATIII or any patient-related factors.
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Affiliation(s)
- Allison J Jones
- Department of Pharmacy (AJJ), Norton Children's Hospital, Louisville, Kentucky, Department of Pharmacy (KLO, BJK) and Department of Pediatrics (RSS), University of Florida Health Shands Hospital, Gainesville, Florida
| | - Keliana L O'Mara
- Department of Pharmacy (AJJ), Norton Children's Hospital, Louisville, Kentucky, Department of Pharmacy (KLO, BJK) and Department of Pediatrics (RSS), University of Florida Health Shands Hospital, Gainesville, Florida
| | - Brian J Kelly
- Department of Pharmacy (AJJ), Norton Children's Hospital, Louisville, Kentucky, Department of Pharmacy (KLO, BJK) and Department of Pediatrics (RSS), University of Florida Health Shands Hospital, Gainesville, Florida
| | - Ravi S Samraj
- Department of Pharmacy (AJJ), Norton Children's Hospital, Louisville, Kentucky, Department of Pharmacy (KLO, BJK) and Department of Pediatrics (RSS), University of Florida Health Shands Hospital, Gainesville, Florida
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Antithrombin Administration in Extracorporeal Membrane Oxygenation Patients: Putting the Cart Before the Horse. Pediatr Crit Care Med 2016; 17:1188-1189. [PMID: 27918392 DOI: 10.1097/pcc.0000000000000988] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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10
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Venous Thromboembolic Disease in Children and Adolescents. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 906:149-165. [DOI: 10.1007/5584_2016_113] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Administration of Antithrombin Concentrate in Infants and Children on Extracorporeal Life Support Improves Anticoagulation Efficacy. ASAIO J 2014; 60:559-63. [DOI: 10.1097/mat.0000000000000099] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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