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Sidonio RF, Hoffman M, Kenet G, Dargaud Y. Thrombin generation and implications for hemophilia therapies: A narrative review. Res Pract Thromb Haemost 2022; 7:100018. [PMID: 36798897 PMCID: PMC9926221 DOI: 10.1016/j.rpth.2022.100018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 10/24/2022] [Accepted: 11/09/2022] [Indexed: 01/07/2023] Open
Abstract
Thrombin plays an essential role in achieving and maintaining effective hemostasis and stable clot formation. In people with hemophilia, deficiency of procoagulant factor (F)VIII or FIX results in insufficient thrombin generation, leading to reduced clot stability and various bleeding manifestations. A correlation has been found between the bleeding phenotype of people with hemophilia and the extent of thrombin generation, with individuals with increased thrombin generation being protected from bleeding and those with lower thrombin generation having increased bleeding tendency. The amount, location, and timing of thrombin generation have been found to affect the formation and stability of the resulting clot. The goal of all therapies for hemophilia is to enhance the generation of thrombin with the aim of restoring effective hemostasis and preventing or controlling bleeding; current treatment approaches rely on either replacing or mimicking the missing procoagulant (ie, FVIII or FIX) or rebalancing hemostasis through lowering natural anticoagulants, such as antithrombin. Global coagulation assays, such as the thrombin generation assay, may help guide the overall management of hemostasis by measuring and monitoring the hemostatic potential of patients and, thus, assessing the efficacy of treatment in people with hemophilia. Nevertheless, standardization of the thrombin generation assay is needed before it can be adopted in routine clinical practice.
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Affiliation(s)
- Robert F. Sidonio
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia, USA,Department of Pediatrics, Emory University, Atlanta, Georgia, USA,Correspondence Robert F Sidonio, Aflac Cancer and Blood Disorders Center Children’s Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA 30322, USA. @nashgreenie
| | - Maureane Hoffman
- Department of Pathology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Gili Kenet
- The Israeli National Hemophilia Center and Thrombosis Unit, Sheba Medical Center, Tel Hashomer, Israel,The Amalia Biron Thrombosis Research Institute, Tel Aviv University, Tel Aviv, Israel
| | - Yesim Dargaud
- Unité d’Hémostase Clinique, Centre National de Reference de l'Hemophilie, Hôpital Cardiologique Louis Pradel, Université Lyon, Lyon, France
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Ninivaggi M, de Laat‐Kremers RMW, Carlo A, de Laat B. ST Genesia reference values of 117 healthy donors measured with STG-BleedScreen, STG-DrugScreen and STG-ThromboScreen reagents. Res Pract Thromb Haemost 2021; 5:187-196. [PMID: 33537543 PMCID: PMC7845068 DOI: 10.1002/rth2.12455] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/06/2020] [Accepted: 10/10/2020] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION The ST Genesia is a benchtop, fully automated thrombin generation (TG) device. It is completely standardized and ensures a uniform heat distribution throughout the measurement. We aimed to determine reference values and to compare TG in men and women with and without the use of oral contraceptives (OCs). MATERIALS AND METHODS Plasma from 117 healthy donors was measured on the ST Genesia with the available reagent kits: STG-BleedScreen, STG-DrugScreen, and STG-ThromboScreen. All kits include at least two quality controls and a reference plasma to normalize data. STG-ThromboScreen has a second trigger containing thrombomodulin (TM) to include the effect on the protein C pathway. Means were compared with one-way analysis of variance and reference ranges were established with 2.5th to 97.5th percentiles on absolute TG parameters. RESULTS Mean age of the donors was 35 years (SD ± 12); 49.6% were men, 37.6% women without OCs, and 12.8% women with OCs. Men and women without OCs had, respectively, a mean peak height of 167 nM and 164 nM with STG-BleedScreen, 335 nM and 351 nM with STG-DrugScreen, and 192 nM and 198 nM with STG-ThromboScreen. Women taking OCs had a mean peak height of 263 nM, 473 nM, and 312nM, respectively (P < .05 compared to men/women without OCs). TM decreased endogenous thrombin potential by 54% in men, 47% in women without OCs, and only 25% in women with OCs (P < .05 compared to men/women without OCs). CONCLUSIONS TG in men and women without OCs was similar; however, women taking OCs had significantly higher TG values, and the effect of TM was also less pronounced in these women.
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Affiliation(s)
| | | | | | - Bas de Laat
- Synapse Research InstituteMaastrichtThe Netherlands
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Bosch YPJ, Bloemen S, de Laat B, Weerwind PW, Mochtar B, Maessen JG, Wagenvoord RJ, Al Dieri R, Coenraad Hemker H, Kremers RMW. A reduction of prothrombin conversion by cardiac surgery with cardiopulmonary bypass shifts the haemostatic balance towards bleeding. Thromb Haemost 2017; 116:442-51. [DOI: 10.1160/th16-02-0094] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 03/31/2016] [Indexed: 11/05/2022]
Abstract
SummaryCardiac surgery with cardiopulmonary bypass (CPB) is associated with blood loss and post-surgery thrombotic complications. The process of thrombin generation is disturbed during surgery with CPB because of haemodilution, coagulation factor consumption and heparin administration. We aimed to investigate the changes in thrombin generation during cardiac surgery and its underlying pro- and anticoagulant processes, and to explore the clinical consequences of these changes using in silico experimentation. Plasma was obtained from 29 patients undergoing surgery with CPB before heparinisation, after heparinisation, after haemodilution, and after protamine administration. Thrombin generation was measured and prothrombin conversion and thrombin inactivation were quantified. In silico experimentation was used to investigate the reaction of patients to the administration of procoagulant factors and/or anticoagulant factors. Surgery with CPB causes significant coagulation factor consumption and a reduction of thrombin generation. The total amount of prothrombin converted and the rate of prothrombin conversion decreased during surgery. As the surgery progressed, the relative contribution of α2-macroglobulin-dependent thrombin inhibition increased, at the expense of antithrombin-dependent inhibition. In silico restoration of post-surgical prothrombin conversion to pre-surgical levels increased thrombin generation excessively, whereas co-administration of antithrombin resulted in the normalisation of post-surgical thrombin generation. Thrombin generation is reduced during surgery with cardiopulmonary bypass because of a balance shift between prothrombin conversion and thrombin inactivation. According to in silico predictions of thrombin generation, this new balance increases the risk of thrombotic complications with prothrombin complex concentrate administration, but not if antithrombin is co-administered.
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Ninivaggi M, Kuiper G, Marcus M, Cate HT, Lancé M, Feijge M, Baaten C, Heemskerk J, van der Meijden P. Additive roles of platelets and fibrinogen in whole-blood fibrin clot formation upon dilution as assessed by thromboelastometry. Thromb Haemost 2017; 111:447-57. [DOI: 10.1160/th13-06-0493] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 10/13/2013] [Indexed: 11/05/2022]
Abstract
SummaryBlood dilution after transfusion fluids leads to diminished coagulant activity monitored by rotational thromboelastometry, assessing elastic fibrin clot formation, or by thrombin generation testing. We aimed to determine the contributions of blood cells (platelets, red blood cells) and plasma factors (fibrinogen, prothrombin complex concentrate) to fibrin clot formation under conditions of haemodilution in vitro or in vivo. Whole blood or plasma diluted in vitro was supplemented with platelets, red cells, fibrinogen or prothrombin complex concentrate (PCC). Thromboelastometry was measured in whole blood as well as plasma; thrombin generation was determined in parallel. Similar tests were performed with blood from 48 patients, obtained before and after massive fluid infusion during cardiothoracic surgery. Addition of platelets or fibrinogen, in additive and independent ways, reversed the impaired fibrin clot formation (thromboelastometry) in diluted whole blood. In contrast, supplementation of red blood cells or prothrombin complex concentrate was ineffective. Platelets and fibrinogen independently restored clot formation in diluted plasma, resulting in thromboelastometry curves approaching those in whole blood. In whole blood from patients undergoing dilution during surgery, elastic clot formation was determined by both the platelet count and the fibrinogen level. Thrombin generation in diluted (patient) plasma was not changed by fibrinogen, but improved markedly by prothrombin complex concentrate. In conclusion, in dilutional coagulopathy, platelets and fibrinogen, but not red blood cells or vitamin K-dependent coagulation factors, independently determine thromboelastometry parameters measured in whole blood and plasma. Clinical decisions for transfusion based on thromboelastometry should take into account the platelet concentration.
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Lancé MD. A general review of major global coagulation assays: thrombelastography, thrombin generation test and clot waveform analysis. Thromb J 2015; 13:1. [PMID: 25937820 PMCID: PMC4417204 DOI: 10.1186/1477-9560-13-1] [Citation(s) in RCA: 131] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 06/16/2014] [Indexed: 01/08/2023] Open
Abstract
Thrombosis and hemorrhage are major contributors to morbidity and mortality. The traditional laboratory tests do not supply enough information to diagnose and treat patients timely and according to their phenotype. Global hemostasis tests might improve this circumstance. The viscoelastic tests (ROTEM/TEG) demonstrated to ameliorate treatment of acute hemorrhage in terms of decreased amount of transfusion and lowered costs. Thrombin generation measurement is indicative for thrombosis and might also become an important tool in managing hemorrhage. While the clot waveform analysis is less well known it could be of worth in staging sepsis patients, early detection of DIC and also in diagnosis and treatment monitoring of hemophiliac patients. Although in different degree all three methods still need more background, standardization and acceptance before a wide clinical application.
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Affiliation(s)
- Marcus D Lancé
- Department of Anesthesiology and Pain Treatment, Maastricht University Medical Center, P. Debyelaan 25, PO box 5800, 6202 AZ Maastricht, The Netherlands
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Mitrophanov AY, Wolberg AS, Reifman J. Kinetic model facilitates analysis of fibrin generation and its modulation by clotting factors: implications for hemostasis-enhancing therapies. MOLECULAR BIOSYSTEMS 2014; 10:2347-57. [PMID: 24958246 PMCID: PMC4128477 DOI: 10.1039/c4mb00263f] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Current mechanistic knowledge of protein interactions driving blood coagulation has come largely from experiments with simple synthetic systems, which only partially represent the molecular composition of human blood plasma. Here, we investigate the ability of the suggested molecular mechanisms to account for fibrin generation and degradation kinetics in diverse, physiologically relevant in vitro systems. We represented the protein interaction network responsible for thrombin generation, fibrin formation, and fibrinolysis as a computational kinetic model and benchmarked it against published and newly generated data reflecting diverse experimental conditions. We then applied the model to investigate the ability of fibrinogen and a recently proposed prothrombin complex concentrate composition, PCC-AT (a combination of the clotting factors II, IX, X, and antithrombin), to restore normal thrombin and fibrin generation in diluted plasma. The kinetic model captured essential features of empirically detected effects of prothrombin, fibrinogen, and thrombin-activatable fibrinolysis inhibitor titrations on fibrin formation and degradation kinetics. Moreover, the model qualitatively predicted the impact of tissue factor and tPA/tenecteplase level variations on the fibrin output. In the majority of considered cases, PCC-AT combined with fibrinogen accurately approximated both normal thrombin and fibrin generation in diluted plasma, which could not be accomplished by fibrinogen or PCC-AT acting alone. We conclude that a common network of protein interactions can account for key kinetic features characterizing fibrin accumulation and degradation in human blood plasma under diverse experimental conditions. Combined PCC-AT/fibrinogen supplementation is a promising strategy to reverse the deleterious effects of dilution-induced coagulopathy associated with traumatic bleeding.
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Affiliation(s)
- Alexander Y. Mitrophanov
- DoD Biotechnology High-Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, U.S. Army Medical Research and Materiel Command, Ft. Detrick, MD 21702
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC 27599
| | - Jaques Reifman
- DoD Biotechnology High-Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, U.S. Army Medical Research and Materiel Command, Ft. Detrick, MD 21702
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van der Meijden PEJ, Heemskerk JWM. Polyphosphates: a link between platelet activation, intrinsic coagulation and inflammation? Expert Rev Hematol 2014; 3:269-72. [DOI: 10.1586/ehm.10.26] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Extracorporeal life support associated with hypothermia and normoxemia in refractory cardiac arrest. Resuscitation 2013; 84:1519-24. [DOI: 10.1016/j.resuscitation.2013.06.016] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 05/30/2013] [Accepted: 06/21/2013] [Indexed: 11/21/2022]
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Case scenario: management of trauma-induced coagulopathy in a severe blunt trauma patient. Anesthesiology 2013; 119:191-200. [PMID: 23514719 DOI: 10.1097/aln.0b013e31828fc627] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Girardis M, Marietta M. Hemostasis in acute liver and kidney failure: nothing is as it seems. Kidney Int 2013; 84:22-4. [PMID: 23812363 DOI: 10.1038/ki.2013.121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Very little is known about the behavior of the hemostatic system in patients with acute kidney injury (AKI) associated with acute liver failure (ALF). Agarwal and colleagues show that patients who suffer from both ALF and AKI exhibit a higher degree of hemostasis impairment than those with normal renal function. Both anticoagulant and procoagulant factors were impaired. The development of AKI appears to displace the hemostatic equilibrium toward a more prothrombotic pattern.
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Affiliation(s)
- Massimo Girardis
- Intensive Care Unit, Department of Anaesthesiology and Intensive Care, University Hospital of Modena, Modena, Italy.
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Thiolliere F, Serre-Sapin AF, Reignier J, Benedit M, Constantin JM, Lebert C, Guélon D, Timsit JF, Souweine B. Epidemiology and outcome of thrombocytopenic patients in the intensive care unit: results of a prospective multicenter study. Intensive Care Med 2013; 39:1460-8. [DOI: 10.1007/s00134-013-2963-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 05/09/2013] [Indexed: 12/17/2022]
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Diagnostic et prise en charge de la coagulopathie post-traumatique. Transfus Clin Biol 2012; 19:165-73. [DOI: 10.1016/j.tracli.2012.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 07/21/2012] [Indexed: 11/21/2022]
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Utility of a point-of-care device for rapid determination of prothrombin time in trauma patients: a preliminary study. J Trauma Acute Care Surg 2012; 72:703-7. [PMID: 22491557 DOI: 10.1097/ta.0b013e31822c884d] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Rapid and accurate determination of prothrombin time in trauma patients may help to faster control of bleeding induced coagulopathy. The goal of this prospective observational study was to investigate the accuracy of bedside measurements of prothrombin time by the mean of a point-of-care device (INRatio) in trauma patients. METHODS Fifty blood samples were drawn at admission and during the acute care phase for standard coagulation assays (prothrombin time, International Normalized Ratio [INR], and fibrinogen) and INRatio testing (INR(A)) from 48 trauma patients. RESULTS Standard coagulation assays were available after a mean of 66 minutes. Median Injury Severity Score was 18, and 16 patients (33%) had a coagulopathy. Significant correlation was found between INR and INR(A) (r: 0.93, 95% confidence interval: 0.87-0.96). The mean difference (bias) for INR was 0.00, and standard deviation (precision) of the difference was 0.78. However, in cases where there was decreased hemoglobin (<10 gr · L(-1)) and fibrinogen (<1.5 gr · L(-1)), bias and precision were increased. To predict the need for fresh frozen plasma transfusion (INR > 1.5), INR(A) cutoff value of 1.3 resulted in a sensitivity of 92% and a specificity of 79%. The area under the receiver operating characteristic curve was 0.946 (95% confidence interval: 0,845-0,982). CONCLUSION INRatio may be a useful device in the management of trauma patients with ongoing or suspected coagulopathy that may help to save at least 60 minutes in the process of obtaining a prothrombin time result. It may allow earlier detection of coagulopathy and, together with vital sign and hemoglobin, may help to guide fresh frozen plasma transfusion.
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WARMUTH M, MAD P, WILD C. Systematic review of the efficacy and safety of fibrinogen concentrate substitution in adults. Acta Anaesthesiol Scand 2012; 56:539-48. [PMID: 22150561 DOI: 10.1111/j.1399-6576.2011.02586.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2011] [Indexed: 11/29/2022]
Abstract
BACKGROUND A sufficient plasma level of fibrinogen is critical for the formation of a fibrin clot and haemostasis in both the perioperative setting and in massive haemorrhage. We assessed the efficacy and safety of fibrinogen concentrate substitution in the perioperative setting and in massive haemorrhage. METHODS We conducted a systematic literature search for studies conducted on humans and published in either English or German in several databases from 1985 to 2010. In addition, we screened several web sites for assessments on fibrinogen concentrate substitution and conducted a hand search using Scopus. In terms of efficacy, we included all prospective, controlled studies. Concerning safety, we included all prospective studies. RESULTS We identified two randomised controlled trials and two non-randomised controlled studies, which included a total of 74 patients. The studies indicate that the administration of fibrinogen concentrate is associated with improved clot firmness and reduction in the substitution of other blood products such as red blood cells, fresh frozen plasma and platelet concentrates, as well as decreased post-operative bleeding and drainage volume. In addition, fibrinogen concentrate administration has been reported to be safe with regard to thrombosis and thromboembolic complications, as well as mortality. However, the studies identified were of poor quality. CONCLUSION In conclusion, the results of the available controlled trials suggest that the administration of fibrinogen concentrate was effective and safe. However, because all studies identified were of inadequate quality, these findings need to be confirmed by randomised controlled trials of sufficient size and long-term follow-up.
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Affiliation(s)
- M. WARMUTH
- Ludwig Boltzmann Institute for Health Technology Assessment; Vienna; Austria
| | - P. MAD
- Ludwig Boltzmann Institute for Health Technology Assessment; Vienna; Austria
| | - C. WILD
- Ludwig Boltzmann Institute for Health Technology Assessment; Vienna; Austria
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Mitrophanov AY, Rosendaal FR, Reifman J. Computational analysis of intersubject variability and thrombin generation in dilutional coagulopathy. Transfusion 2012; 52:2475-86. [PMID: 22429019 DOI: 10.1111/j.1537-2995.2012.03610.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Blood dilution is a frequent complication of massive transfusion during trauma and surgery. This article investigates the quantitative effects of blood plasma dilution on thrombin generation in the context of intersubject variability. STUDY DESIGN AND METHODS A thoroughly validated computational model was used to simulate thrombin generation curves for 472 healthy subjects in the Leiden Thrombophilia Study. Individual thrombin curves were calculated for undiluted blood and for different dilution scenarios. For every such curve, five standard quantitative parameters of thrombin generation were calculated and analyzed. RESULTS Thrombin generation parameters in diluted blood plasma displayed significant intersubject variability (with a coefficient of variation up to approx. 28%). Nevertheless, dilutional effects in the majority (or all) of the subjects in the study group were characterized by persistent patterns. In particular, the largest dilution-induced change typically occurred in the maximum slope (MS) of the thrombin curve, followed by a change in thrombin peak height (PH), whereas the smallest change often occurred in the area under the curve. The identified patterns demonstrated considerable robustness to variations in dilution scenario and tissue factor concentration. CONCLUSION Dilutional effects on thrombin generation in a human population can be predicted from trends identified for the "average" subject and then refined by performing an analysis of actual subjects in the study group. The MS and PH are dilution indicators that are both sensitive and reliable across a large subject group and could potentially be used as disease markers in the diagnosis of coagulopathic conditions.
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Affiliation(s)
- Alexander Y Mitrophanov
- DoD Biotechnology High-Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, US Army Medical Research and Materiel Command, Ft Detrick, Maryland 21702, USA.
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