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Holle LA, Pantazis JC, Turecek PL, Wolberg AS. Clot formation and fibrinolysis assays reveal functional differences among hemostatic agents in hemophilia A plasma. Res Pract Thromb Haemost 2024; 8:102337. [PMID: 38426025 PMCID: PMC10901841 DOI: 10.1016/j.rpth.2024.102337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 12/21/2023] [Accepted: 01/16/2024] [Indexed: 03/02/2024] Open
Abstract
Background Measuring the activity of hemostatic agents used to treat hemophilia A often requires drug-specific assays. In vitro assays show hemophilic clots have abnormal characteristics, including prolonged clotting time and decreased resistance to fibrinolysis. The ability of certain agents to correct these parameters in vitro is associated with hemostatic efficacy in vivo. Objectives To compare effects of established and emerging hemostatic agents on clot formation and fibrinolysis in hemophilia A plasma. Methods Pooled and individual hemophilia A platelet-poor plasmas were spiked with replacement (recombinant factor VIII [rFVIII], PEGylated rFVIII, polysialylated rFVIII, and porcine rFVIII) or bypassing (emicizumab, rFVIIa, and activated prothrombin complex concentrate) products. Effects on tissue factor-initiated clot formation and fibrinolysis were measured by turbidity. Results Compared to normal pooled plasma, hemophilia-pooled plasma showed reduced clot formation and increased fibrinolysis, and all replacement agents improved these characteristics. rFVIII and PEGylated rFVIII produced similar effects at similar concentrations, whereas polysialylated rFVIII produced slightly higher and porcine rFVIII slightly lower effects at these concentrations. Bypassing agents enhanced clot formation and stability, but patterns differed from replacement agents. The clotting rate showed a concentration-response relationship for all agents. High concentrations of all products produced effects that exceeded the normal range in at least some parameters. Responses of individual donors varied, but all agents improved clot formation and stability in all donors tested. Conclusion Clotting and fibrinolysis assays reveal hemostatic effects of replacement and bypassing therapies at clinically relevant concentrations. These assays may help characterize hemostatic agents and optimize dosing.
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Affiliation(s)
- Lori A. Holle
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jacob C. Pantazis
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Peter L. Turecek
- Plasma-Derived Therapies R&D, Baxalta Innovations GmbH – Takeda, Vienna, Austria
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
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2
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Binder NB, Depasse F, Mueller J, Wissel T, Schwers S, Germer M, Hermes B, Turecek PL. Clinical use of thrombin generation assays. J Thromb Haemost 2021; 19:2918-2929. [PMID: 34592058 PMCID: PMC9292855 DOI: 10.1111/jth.15538] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 09/24/2021] [Accepted: 09/28/2021] [Indexed: 11/29/2022]
Abstract
Determining patient's coagulation profile, i.e. detecting a bleeding tendency or the opposite, a thrombotic risk, is crucial for clinicians in many situations. Routine coagulation assays and even more specialized tests may not allow a relevant characterization of the hemostatic balance. In contrast, thrombin generation assay (TGA) is a global assay allowing the dynamic continuous and simultaneous recording of the combined effects of both thrombin generation and thrombin inactivation. TGA thus reflects the result of procoagulant and anticoagulant activities in blood and plasma. Because of this unique feature, TGA has been widely used in a wide array of settings from both research, clinical and pharmaceutical perspectives. This includes diagnosis, prognosis, prophylaxis, and treatment of inherited and acquired bleeding and thrombotic disorders. In addition, TGA has been shown to provide relevant information for the diagnosis of coagulopathies induced by infectious diseases, comprising also disturbance of the coagulation system in COVID-19, or for the assessment of early recurrence in breast cancer. This review article aims to document most clinical applications of TGA.
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Affiliation(s)
| | | | | | | | | | | | - Björn Hermes
- DIN e.V. – DIN Standards Committee Medicine (NAMed)
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3
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Abstract
Snake venoms have evolved primarily to immobilize and kill prey, and consequently, they contain some of the most potent natural toxins. Part of that armory is a range of hemotoxic components that affect every area of hemostasis, which we have harnessed to great effect in the study and diagnosis of hemostatic disorders. The most widely used are those that affect coagulation, such as thrombin-like enzymes unaffected by heparin and direct thrombin inhibitors, which can help confirm or dispute their presence in plasma. The liquid gold of coagulation activators is Russell's viper venom, since it contains activators of factor X and factor V. It is used in a range of clotting-based assays, such as assessment of factor X and factor V deficiencies, protein C and protein S deficiencies, activated protein C resistance, and probably the most important test for lupus anticoagulants, the dilute Russell's viper venom time. Activators of prothrombin, such as oscutarin C from Coastal Taipan venom and ecarin from saw-scaled viper venom, are employed in prothrombin activity assays and lupus anticoagulant detection, and ecarin has a valuable role in quantitative assays of direct thrombin inhibitors. Snake venoms affecting primary hemostasis include botrocetin from the jararaca, which can be used to assay von Willebrand factor activity, and convulxin from the cascavel, which can be used to detect deficiency of the platelet collagen receptor, glycoprotein VI. This article takes the reader to every area of the diagnostic hemostasis laboratory to appreciate the myriad applications of snake venoms available in diagnostic practice.
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Affiliation(s)
- Gary William Moore
- Department of Haematology, Specialist Haemostasis Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.,Faculty of Science and Technology, Middlesex University London, London, United Kingdom
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4
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Wilmot HV, Rakowski K, Gray E. The traceability of commercial plasma calibrators to the plasma International Standards for factor VIII and factor IX. Int J Lab Hematol 2020; 42:810-818. [PMID: 32638532 PMCID: PMC7754292 DOI: 10.1111/ijlh.13277] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/03/2020] [Accepted: 06/05/2020] [Indexed: 01/19/2023]
Abstract
Accurate measurement of coagulation factors is essential, especially for diagnosis of deficiency. Clinical laboratories use commercially available plasma calibrators, which should be traceable to the relevant plasma International Standard (IS). This study assessed the relationship between the plasma IS for factors IX (FIX) and VIII (FVIII) and some commonly used commercial calibrators. Calibrators from seven manufacturers were assayed for FIX and FVIII activity by one‐stage clotting assay (OSCA) using different activated partial thromboplastin time (APTT) reagents and deficient plasmas, or chromogenic assay (CA). Results were calculated relative to the 4th IS Factors II,VII,IX,X, Plasma or the 6th IS Factor VIII/VWF, Plasma. Results for each calibrator were similar across the APTT reagents and deficient plasmas used. All calibrators showed a recovery of 90%‐111% of the manufacturers’ values, except calibrator C, which had recovery of around 85%. CA gave similar results, with good recovery for all but calibrator C. Similar low recoveries for OSCA and CA were found for a different lot of calibrator C and for a different calibrator product from manufacturer C. When all calibrators from manufacturer C were assayed by OSCA using the manufacturer's own deficient plasmas and APTT reagents, the mean recovery was still below 90%. Overall, there was good traceability of the international unit between the IS and commercial calibrator plasmas. Calibrators from one manufacturer consistently yielded lower than expected values for FIX and FVIII. This could lead to an over‐estimation of the coagulation factor content in patient samples and demonstrates the importance of careful choice of calibrator.
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Affiliation(s)
- Helen V Wilmot
- Haemostasis Section, Biotherapeutics Group, National Institute for Biological Standards and Control (NIBSC), Potters Bar, Hertfordshire, United Kingdom
| | - Kajetan Rakowski
- Haemostasis Section, Biotherapeutics Group, National Institute for Biological Standards and Control (NIBSC), Potters Bar, Hertfordshire, United Kingdom
| | - Elaine Gray
- Haemostasis Section, Biotherapeutics Group, National Institute for Biological Standards and Control (NIBSC), Potters Bar, Hertfordshire, United Kingdom
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5
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Peyvandi F, Kenet G, Pekrul I, Pruthi RK, Ramge P, Spannagl M. Laboratory testing in hemophilia: Impact of factor and non-factor replacement therapy on coagulation assays. J Thromb Haemost 2020; 18:1242-1255. [PMID: 32115865 DOI: 10.1111/jth.14784] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/20/2020] [Accepted: 02/20/2020] [Indexed: 02/06/2023]
Abstract
The advent of extended half-life (EHL) recombinant clotting factors and innovative non-factor replacement therapeutics, such as emicizumab, offers several advantages over existing products for the prophylactic treatment of people living with hemophilia (PwH). These include low annual bleeding rates with less frequent dosing, higher trough plasma concentrations, and a more convenient route of administration. However, increasing use of these therapies poses challenges to clinicians and coagulation laboratories due to the lack of standardized assays for monitoring of hemostatic parameters, and the potential for misinterpretation of test results, which may jeopardize patient safety. Definitive diagnosis of hemophilia and treatment monitoring is reliant on demonstrating factor VIII (FVIII; hemophilia A) or factor IX (FIX; hemophilia B) deficiency using a functional coagulation assay. The most frequently used assays are based on activated partial thromboplastin time, using a one-stage or two-stage process. While one-stage and chromogenic assays have performed well with human-derived FVIII and FIX and full-length recombinant products, EHL recombinant factors are heterogeneous in structure and mode of action and therefore show wide variation in activity levels between different one-stage assays, and between one-stage and chromogenic assays. In the context of the recommended stepwise approach for laboratory diagnosis of hemophilia, we examine the diagnostic challenges associated with the use of EHL factors and novel non-factor therapeutics and consider the optimal diagnostic approach in PwH who are receiving these treatments. Ultimately, accurate diagnostic solutions are a prerequisite for personalized therapy to minimize treatment burden and improve quality of life in PwH.
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Affiliation(s)
- Flora Peyvandi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gili Kenet
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Israeli National Hemophilia Center and Thrombosis Unit, The Amalia Biron Thrombosis Research Institute, Sheba Medical Center, Tel Hashomer, Israel
| | - Isabell Pekrul
- Hämostaseologie, Campus Innenstadt, Klinikum der Universität München, München, Germany
| | - Rajiv K Pruthi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, MN, USA
- Division of Hematopathology and Laboratory Genetics, Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, Rochester, MN, USA
| | - Peter Ramge
- Roche Diagnostics International Ltd, Rotkreuz, Switzerland
| | - Michael Spannagl
- Hämostaseologie, Campus Innenstadt, Klinikum der Universität München, München, Germany
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6
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Peyvandi F, Berger K, Seitz R, Hilger A, Hecquet ML, Wierer M, Buchheit KH, O'Mahony B, Bok A, Makris M, Mansmann U, Schramm W, Mannucci PM. Kreuth V initiative: European consensus proposals for treatment of hemophilia using standard products, extended half-life coagulation factor concentrates and non-replacement therapies. Haematologica 2020; 105:2038-2043. [PMID: 32467138 PMCID: PMC7395279 DOI: 10.3324/haematol.2019.242735] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 05/20/2020] [Indexed: 12/30/2022] Open
Abstract
This report contains the updated consensus recommendations for optimal hemophilia care produced in 2019 by three Working Groups (WG) on behalf of the European Directorate for Quality of Medicines and Healthcare in the frame of the Kreuth V Initiative. WG1 recommended access to prophylaxis for all patients, the achievement of plasma factor trough levels of at least 3-5% when extended half-life factor VIII (FVIII) and FIX products are used, a personalized treatment regimen, and a choice of chromogenic assays for treatment monitoring. It was also emphasized that innovative therapies should be supervised by hemophilia comprehensive care centers. WG2 recommended mandatory collection of postmarketing data to assure the long-term safety and efficacy of new hemophilia therapies, the establishment of national patient registries including the core data recommended by the European Medicines Agency and the International Society on Thrombosis and Haemostasis, with adequate support under public control, and greater collaboration to facilitate a comprehensive data evaluation throughout Europe. WG3 discussed methodological aspects of hemophilia care in the context of access decisions, particularly for innovative therapies, and recommended that clinical studies should be designed to provide the quality of evidence needed by regulatory authorities, HTA bodies and healthcare providers. The dialogue between all stakeholders in hemophilia care and patient organizations should be fostered to implement these recommendations.
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Affiliation(s)
- Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy .,Università degli Studi di Milano, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Karin Berger
- University Hospital, Ludwig-Maximilian University, Department of Medicine III, Munich, Germany.,Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Ludwig-Maximilian-University, Munich, Germany
| | | | | | - Marie-Laure Hecquet
- European Directorate for the Quality of Medicines and Healthcare, Strasbourg, France
| | - Michael Wierer
- European Directorate for the Quality of Medicines and Healthcare, Strasbourg, France
| | - Karl-Heinz Buchheit
- European Directorate for the Quality of Medicines and Healthcare, Strasbourg, France
| | - Brian O'Mahony
- Trinity College, Dublin, Ireland.,European Haemophilia Consortium, Brussels, Belgium
| | - Amanda Bok
- European Haemophilia Consortium, Brussels, Belgium
| | - Mike Makris
- Sheffield Haemophilia and Thrombosis Centre, Sheffield, UK
| | - Ulrich Mansmann
- Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Ludwig-Maximilian-University, Munich, Germany
| | - Wolfgang Schramm
- Department of Transfusion Medicine and Haemostasis, Ludwig-Maximilians-University, Munich, Germany
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
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Türkantoz H, Königs C, Knöbl P, Klamroth R, Holstein K, Huth-Kühne A, Heinz J, Eichler H, Tiede A. Cross-reacting inhibitors against recombinant porcine factor VIII in acquired hemophilia A: Data from the GTH-AH 01/2010 Study. J Thromb Haemost 2020; 18:36-43. [PMID: 31448877 DOI: 10.1111/jth.14618] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/22/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Recombinant porcine factor VIII (rpFVIII, OBI-1, susoctocog alfa) is used for the treatment of acute bleeds in patients with acquired hemophilia A (AHA). Inhibitors in AHA can sometimes cross-react with rpFVIII. OBJECTIVES To assess the frequency, strength, and determinants of cross-reactivity. PATIENTS/METHODS Baseline samples from 70 patients of the prospective, observational cohort study GTH-AH 01/2010 were assessed for anti-human FVIII and anti-rpFVIII inhibitors using modified Nijmegen-Bethesda assays, as well as anti-human FVIII domain reactivity using enzyme-linked immunoassay (ELISA). RESULTS Anti-human FVIII inhibitors were present in all samples ranging between 0.7 and 3891 Bethesda Units (BU)/mL. Inhibitors from 31 of 70 patients (44%) partially inhibited rpFVIII with anti-rpFVIII titers ranging between 0.5 and 471 BU/mL. Anti-rpFVIII titers were ≤5 BU in most patients. Patients with cross-reacting inhibitors, as compared to patients without, had significantly higher anti-human FVIII titers (27.8 versus 5.4 BU/mL) and lower baseline FVIII activity (<1 versus 2.6 IU/dL). The ratio between anti-rpFVIII to anti-human titers was highest for inhibitors involving the C1 domain. Cross-reactivity was very rare, if inhibitors reacted only with the C2 domain of FVIII (6%). An anti-human FVIII titer of >100 BU/mL predicted cross-reactivity with 97% likelihood, whereas an anti-human FVIII titer of <3.8 BU/mL predicted absent cross-reactivity with 90% likelihood. CONCLUSION Cross-reacting inhibitors should be considered when choosing a treatment for bleeding patients with AHA. Cross-reactivity is frequent in patients with anti-human FVIII titers of >100 BU/mL.
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Affiliation(s)
- Halet Türkantoz
- Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Christoph Königs
- Department of Pediatrics, Clinical and Molecular Hemostasis, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Paul Knöbl
- Hematology and Hemostasis, Vienna Medical University, Vienna, Austria
| | - Robert Klamroth
- Internal Medicine, Vivantes Clinic Friedrichshain, Berlin, Germany
| | - Katharina Holstein
- Hematology and Clinical Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Angela Huth-Kühne
- Hemophilia Care Center, SRH Kurpfalzkrankenhaus Heidelberg, Heidelberg, Germany
| | - Jürgen Heinz
- Hematology and Oncology, Freiburg University Hospital, Freiburg, Germany
| | - Hermann Eichler
- Institute of Clinical Hemostaseology and Transfusion Medicine, Saarland University and Saarland University Hospital, Homburg/Saar, Germany
| | - Andreas Tiede
- Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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8
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Pipe SW. New treatment paradigm for hemophilia poses challenges for legacy bioassays. J Thromb Haemost 2019; 17:1446-1448. [PMID: 31479189 DOI: 10.1111/jth.14550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 06/17/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Steven W Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan
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