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Saito T, Hayakawa M, Kumano O, Honma Y, Murashita M, Kato J, Fukui S, Takahashi M, Takahashi Y, Tsuchida T, Mizugaki A, Takauji S, Hayamizu M, Yoshida T, Katabami K, Wada T, Maekawa K. Variation in coagulation factor activity levels cause discrepancies between activated partial thromboplastin time and anti-Xa activity for heparin monitoring: a retrospective observational study. J Intensive Care 2023; 11:54. [PMID: 37974289 PMCID: PMC10652491 DOI: 10.1186/s40560-023-00701-3] [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: 09/20/2023] [Accepted: 11/03/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Unfractionated heparin (UFH) is primarily monitored using activated partial thromboplastin time (APTT). However, the recent introduction of anti-activated factor X (anti-Xa) activity testing has provided a direct evaluation of Xa inhibition by anticoagulants. This study aimed to investigate discrepancies between APTT and anti-Xa activity during UFH monitoring in critically ill patients and explore their underlying causes. METHODS This study analyzed 271 pairs of laboratory test results from blood samples of 99 critically ill patients receiving continuous intravenous UFH. Theoretical APTT values were calculated using fitted curve equations from spiked sample measurements with anti-Xa activity. Samples were categorized into three groups based on the measurement of the APTT/theoretical APTT ratio: the lower group (< 80%), the concordant group (80-120%), and the upper group (> 120%). RESULTS The overall concordance rate between APTT and anti-Xa activity was 45%, with a 55% discrepancy rate. The lower group frequently showed apparent heparin overdoses, while coagulation factor activities in the lower and upper groups were higher and lower, respectively, than those in the concordant group. Particularly, the lower group exhibited higher factor VIII activity levels than the upper and concordant groups. CONCLUSIONS Discrepancies between APTT and anti-Xa activity were frequently observed, influenced by changes in coagulation factors activity levels. The lower and upper groups were classified as pseudo-heparin-resistant and coagulopathy types, respectively. Accurate monitoring of heparin in critically ill patients is crucial, especially in cases of pseudo-heparin resistance, where APTT values may wrongly indicate inadequate heparin dosing despite sufficient anti-Xa activity. Understanding these discrepancies is important for managing heparin therapy in critically ill patients. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Tomoyo Saito
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Mineji Hayakawa
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan.
| | - Osamu Kumano
- Health and Medical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Takamatsu, Japan
| | - Yoshinori Honma
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Mone Murashita
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Jun Kato
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Syouki Fukui
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Masaki Takahashi
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Yuki Takahashi
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Takumi Tsuchida
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Asumi Mizugaki
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Shuhei Takauji
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Mariko Hayamizu
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Tomonao Yoshida
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Kenichi Katabami
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Takeshi Wada
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Kunihiko Maekawa
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
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Sun H, Yang S, Li P, Shang X, Wang P, Zhang J, Yuan L, Yin R, Gao N, Zhao J. Comparative Assessment of APTT Reagents for Evaluating Anticoagulant Sensitivity of Fucosylated Glycosaminoglycans (FGs) Derived from Sea Cucumbers. Mar Drugs 2023; 21:568. [PMID: 37999392 PMCID: PMC10672211 DOI: 10.3390/md21110568] [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: 10/10/2023] [Revised: 10/26/2023] [Accepted: 10/28/2023] [Indexed: 11/25/2023] Open
Abstract
Fucosylated glycosaminoglycans (FGs) derived from sea cucumbers exhibit potent intrinsic Xase (iXase) inhibition, anticoagulation, and antithrombosis. Plasma activated partial thromboplastin time (APTT), a widely used screening test worldwide, is crucial for evaluating anticoagulant efficacy. However, the applicability of these commercially available APTT reagents for assessing anticoagulation of FGs remains unreported. In this study, we investigated the disparity between ellagic acid and colloidal silica APTT reagents in evaluating anticoagulation of dHG-5 and dHLFG-4, two depolymerized FGs, and elucidated the underlying rationale. The results demonstrated that dHG-5 and dHLFG-4 exhibited heightened sensitivity to the ellagic acid APTT reagent both in vitro and in vivo, and did not significantly affect the activation of APTT reagents for plasma. In addition, both ellagic acid and colloidal silica APTT reagents inhibited the anti-iXase of dHG-5 and dHLFG-4, and the inhibition of the ellagic acid APTT reagent was less pronounced compared to the colloidal silica APTT reagent. These findings suggest that the reduced impact of the ellagic acid APTT reagent on the anti-iXase activity of dHG-5 and dHLFG-4 is responsible for the increased sensitivity in plasma APTT analysis. This study offers valuable insights into the characteristics of two APTT reagents applied for assessing the anticoagulant activity of FG-related compounds.
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Affiliation(s)
- Huifang Sun
- School of Chemistry and Materials Science, South-Central University for Nationalities, Wuhan 430074, China;
| | - Shasha Yang
- School of Pharmaceutical Sciences, South-Central University for Nationalities, Wuhan 430074, China; (S.Y.); (P.L.); (X.S.); (P.W.); (J.Z.); (L.Y.); (R.Y.)
| | - Pengfei Li
- School of Pharmaceutical Sciences, South-Central University for Nationalities, Wuhan 430074, China; (S.Y.); (P.L.); (X.S.); (P.W.); (J.Z.); (L.Y.); (R.Y.)
| | - Xiaolei Shang
- School of Pharmaceutical Sciences, South-Central University for Nationalities, Wuhan 430074, China; (S.Y.); (P.L.); (X.S.); (P.W.); (J.Z.); (L.Y.); (R.Y.)
| | - Pin Wang
- School of Pharmaceutical Sciences, South-Central University for Nationalities, Wuhan 430074, China; (S.Y.); (P.L.); (X.S.); (P.W.); (J.Z.); (L.Y.); (R.Y.)
| | - Jiali Zhang
- School of Pharmaceutical Sciences, South-Central University for Nationalities, Wuhan 430074, China; (S.Y.); (P.L.); (X.S.); (P.W.); (J.Z.); (L.Y.); (R.Y.)
| | - Lin Yuan
- School of Pharmaceutical Sciences, South-Central University for Nationalities, Wuhan 430074, China; (S.Y.); (P.L.); (X.S.); (P.W.); (J.Z.); (L.Y.); (R.Y.)
| | - Ronghua Yin
- School of Pharmaceutical Sciences, South-Central University for Nationalities, Wuhan 430074, China; (S.Y.); (P.L.); (X.S.); (P.W.); (J.Z.); (L.Y.); (R.Y.)
| | - Na Gao
- School of Pharmaceutical Sciences, South-Central University for Nationalities, Wuhan 430074, China; (S.Y.); (P.L.); (X.S.); (P.W.); (J.Z.); (L.Y.); (R.Y.)
| | - Jinhua Zhao
- School of Pharmaceutical Sciences, South-Central University for Nationalities, Wuhan 430074, China; (S.Y.); (P.L.); (X.S.); (P.W.); (J.Z.); (L.Y.); (R.Y.)
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Bowyer AE, Gosselin RC. Factor VIII and Factor IX Activity Measurements for Hemophilia Diagnosis and Related Treatments. Semin Thromb Hemost 2023; 49:609-620. [PMID: 36473488 PMCID: PMC10421651 DOI: 10.1055/s-0042-1758870] [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] [Indexed: 12/12/2022]
Abstract
Accurate measurement of clotting factors VIII (FVIII) or IX (FIX) is vital for comprehensive diagnosis and management of patients with hemophilia A or B. The one-stage activated partial thromboplastin time (aPTT)-based clotting assay is the most commonly used method worldwide for testing FVIII or FIX activities. Alternatively, FVIII and FIX chromogenic substrate assays, which assess the activation of factor X, are available in some specialized laboratories. The choice of reagent or methodology can strongly influence the resulting activity. Variation between one-stage FVIII or FIX activities has been reported in the measurement of some standard and extended half-life factor replacement therapies and gene therapy for hemophilia B using different aPTT reagents. Discrepancy between one-stage and chromogenic reagents has been demonstrated in some patients with mild hemophilia A or B, the measurement of some standard and extended half-life factor replacement therapies, and the transgene expression of hemophilia A and B patients who have received gene therapy. Finally, the measurement of bispecific antibody therapy in patients with hemophilia A has highlighted differences between chromogenic assays. It is imperative that hemostasis laboratories evaluate how suitable their routine assays are for the accurate measurement of the various hemophilia treatment therapies.
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Affiliation(s)
- Annette E. Bowyer
- Department of Coagulation, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Robert C. Gosselin
- Hemostasis and Thrombosis Center, University of California, Davis Health System, Sacramento, California
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Perrin KL. Coagulation Disorders, Testing, and Treatment in Exotic Animal Critical Care. Vet Clin North Am Exot Anim Pract 2023:S1094-9194(23)00024-5. [PMID: 37321935 DOI: 10.1016/j.cvex.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Despite poor recognition in the literature, exotic companion animals are affected by many diseases that can result in disordered coagulation and fibrinolysis. This article outlines current knowledge of hemostasis, common diagnostic tests and reviews reported diseases associated with coagulopathy in small mammals, bird and reptiles. A range of conditions affect platelets and thrombocytes, endothelium and blood vessels, and plasma clotting factors. Improved recognition and monitoring of hemostatic disorders will enable targeted therapy and improved case outcomes.
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Affiliation(s)
- Kathryn L Perrin
- San Diego Zoo Wildlife Alliance, Veterinary Services, 15500 San Pasqual Valley Road, Escondido, CA 92027, USA.
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Bauça JM, Ajzner É, Cadamuro J, Hillarp A, Kristoffersen AH, Meijer P. An international study on activated partial thromboplastin time prolongation. Part 1: Analytical results. Clin Chim Acta 2022; 535:167-173. [PMID: 36041550 DOI: 10.1016/j.cca.2022.08.024] [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: 05/31/2022] [Revised: 07/28/2022] [Accepted: 08/23/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Unexpected prolongation of first-line coagulation tests, including activated partial thromboplastin time (APTT), should trigger further work-up by performing mixing tests to elucidate the underlying cause, direct further specific testing and clarify their possible clinical impact. The aim of our study was to assess whether methodological diversity has any impact on the APTT mixing test results and their interpretation. MATERIAL AND METHODS Two lyophilized plasma samples (case 1: heparin contamination [0.5 IU/mL]; case 2: factor VIII deficiency [0.13 IU/mL]) and their respective fictional clinical cases were sent to European laboratories for APTT measurement and performance of mixing tests. Participants were surveyed about the methodology (reagents, analytical platform, reference ranges), APTT results, mixing test conditions, their classification (normal, equivocal, prolonged) and categorization of the sample (factor deficiency, presence of inhibitor, anticoagulant, unknown). RESULTS A total of 269 responses were included. For case 1, all participants reported a prolonged APTT, and 91% obtained no correction in the mixing test, without differences among reagents or analytical platforms. Only 15% of them selected the presence of an anticoagulant as the single cause for the prolongation. For case 2, 99% of participants reported a prolonged APTT, while some heterogeneity in the mixing test results was found. Eighty-six percent of participants selected factor deficiency as the cause for APTT prolongation. CONCLUSIONS Most European laboratories obtained valid results for APTT and the subsequent mixing tests, despite using different methodologies. However, their classification could be improved. Therefore, more training and periodic evaluations are recommended to harmonize protocols and ensure proper result classification and categorization.
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Affiliation(s)
- Josep Miquel Bauça
- Department of Laboratory Medicine, Hospital Universitari Son Espases, Palma, Spain.
| | - Éva Ajzner
- Central Laboratory, András Jósa University Hospital, Nyíregyháza, Hungary
| | - Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Andreas Hillarp
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Ann Helen Kristoffersen
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway; Norwegian Organization for Quality Improvement of Laboratory Examinations (Noklus), Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Piet Meijer
- ECAT Foundation (External Quality Control for Assays and Tests), Voorschoten, Netherlands
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Pontara E, Cattini MG, Bison E, Cheng C, Denas G, Pengo V. Antiphospholipid syndrome: Reversal of antiphosphatidylserine/prothrombin-induced activated protein C resistance. Thromb Res 2022; 218:17-23. [PMID: 35973396 DOI: 10.1016/j.thromres.2022.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/28/2022] [Accepted: 08/08/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Anti-phosphatidylserine/prothrombin (aPS/PT) antibodies are the major contributor to activated Protein C resistance (APC-R) in tetra-positive thrombotic high-risk patients with Antiphospholipid Syndrome (APS). OBJECTIVES To evaluate the role of phospholipids (PL) on aPS/PT mediated APC-R. PATIENTS/METHODS Total IgG were purified from plasma of 6 tetra-positive patients and IgG aPS/PT were affinity-purified from 3 of these patients. Purified material was spiked into Normal Pooled Plasma (NPP) and tested for APC-R in thrombin generation assay and in Factor Va inactivation assay using increasing amounts of phospholipids. RESULTS AND CONCLUSIONS Total IgG showed APC-R at low PL concentration (1.5 μg/mL) that disappeared at increasing PL concentrations (5.8, 11.6 and 46.6 μg/mL). In the same way, affinity purified aPS/PT showed a robust (59 %, 52 %, 36 %) APC-R in patients #4, #5 and #6, respectively at low PL concentration (1.5 μg/mL) that was completely reversed at higher concentration (11.6 μg/mL). The inactivation of FVa by activated Protein C (aPC) was impaired in the presence of aPS/PT at low aPL concentration and reversed by increasing amounts of PL. These data point out the relevance of PL in reversing APC-R in this 'in vitro' system. The mechanism for reversal might be explained by loss of PL availability for aPC. These results may give some insight into the pathogenesis of thrombosis or suggestions for alternative treatments.
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Affiliation(s)
- Elena Pontara
- Thrombosis Research Laboratory, University of Padova, Padova, Italy
| | | | - Elisa Bison
- Thrombosis Research Laboratory, University of Padova, Padova, Italy
| | - Chunyan Cheng
- Thrombosis Research Laboratory, University of Padova, Padova, Italy
| | - Gentian Denas
- Thrombosis Research Laboratory, University of Padova, Padova, Italy
| | - Vittorio Pengo
- Thrombosis Research Laboratory, University of Padova, Padova, Italy; Arianna Foundation on Anticoagulation, Bologna, Italy.
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Moore GW, Jones PO, Platton S, Hussain N, White D, Thomas W, Rigano J, Pouplard C, Gray E, Devreese KMJ. International multicenter, multiplatform study to validate Taipan snake venom time as a lupus anticoagulant screening test with ecarin time as the confirmatory test: Communication from the ISTH SSC Subcommittee on Lupus Anticoagulant/Antiphospholipid Antibodies. J Thromb Haemost 2021; 19:3177-3192. [PMID: 34192404 DOI: 10.1111/jth.15438] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/08/2021] [Accepted: 06/28/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Lupus anticoagulant (LA) assays are compromised in anticoagulated patients, and existing strategies to overcome the interferences have limitations. The prothrombin-activating Taipan snake venom time (TSVT) screening test and ecarin time (ET) confirmatory test are innately insensitive to vitamin K antagonists (VKA) and direct factor Xa inhibitors (DFXaI). OBJECTIVES Validate standardized TSVT/ET reagents for LA detection, in a multicenter, multiplatform study. PATIENTS/METHODS Six centers from four countries analyzed samples with TSVT/ET from 81 nonanticoagulated patients with LA, patients with established antiphospholipid syndrome (APS), and proven persistent LA who were either not anticoagulated (n = 120) or were anticoagulated with VKAs (n = 180) or DFXaIs (n = 71). Additionally, 339 nonanticoagulated LA-negative patients, and 575 anticoagulated non-APS patients (172 VKA, 403 DFXaI) were tested. Anticoagulant spiking experiments were performed and 112 samples containing potential interferences (i.e., direct thrombin inhibitors) were tested. Results were evaluated against locally derived cutoffs. Imprecision was evaluated. RESULTS Cutoffs were remarkably similar despite use of different analyzers and donor populations. Cutoffs for TSVT ratio, ET ratio, percent correction, and normalized TSVT ratio/ET ratio ranged between 1.08 and 1.10, 1.09 and 1.12, 9.3% and 14.8%, and 1.10 and 1.15, respectively. Coefficients of variation for TSVT and ET ratios were ≤5.0%. TSVT/ET exhibited sensitivity, specificity, and negative and positive predictive values of 78.2%/95.0%/86.3%/91.5%, respectively, with established APS as the LA-positive population, and 86.9%/95.0%/76.8%/97.4%, respectively, with triple-positive APS. Interference was seen with direct thrombin inhibitors, unfractionated heparin, and low molecular weight heparins, but not VKAs or DFXaIs. CONCLUSIONS TSVT/ET are validated for LA detection in nonanticoagulated patients and those on VKAs or DFXaIs.
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Affiliation(s)
- Gary W Moore
- Department of Haemostasis and Thrombosis, Viapath Analytics, Guy's & St. Thomas' Hospitals, London, UK
- Specialist Haemostasis Unit, Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Faculty of Science and Technology, Middlesex University, London, UK
| | - Paul O Jones
- Department of Haemostasis and Thrombosis, Viapath Analytics, Guy's & St. Thomas' Hospitals, London, UK
| | - Sean Platton
- The Royal London Hospital Haemophilia Centre, Barts Health NHS Trust, London, UK
| | - Nadia Hussain
- Clinical Biochemistry Department, Barts Health NHS Trust, London, UK
| | - Danielle White
- Specialist Haemostasis Unit, Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Will Thomas
- Specialist Haemostasis Unit, Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Joseph Rigano
- Haematology Department, Alfred Health, Melbourne, Vic., Australia
| | - Claire Pouplard
- Department of Hemostasis, University Hospital of Tours, University of Tours, Tours, France
| | - Elaine Gray
- Haemostasis Section, The National Institute for Biological Standards and Control, Potters Bar, UK
| | - Katrien M J Devreese
- Coagulation Laboratory, Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
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Kumano O, Akatsuchi K, Amiral J. Updates on Anticoagulation and Laboratory Tools for Therapy Monitoring of Heparin, Vitamin K Antagonists and Direct Oral Anticoagulants. Biomedicines 2021; 9:biomedicines9030264. [PMID: 33799956 PMCID: PMC7998518 DOI: 10.3390/biomedicines9030264] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/24/2021] [Accepted: 03/03/2021] [Indexed: 01/08/2023] Open
Abstract
Anticoagulant drugs have been used to prevent and treat thrombosis. However, they are associated with risk of hemorrhage. Therefore, prior to their clinical use, it is important to assess the risk of bleeding and thrombosis. In case of older anticoagulant drugs like heparin and warfarin, dose adjustment is required owing to narrow therapeutic ranges. The established monitoring methods for heparin and warfarin are activated partial thromboplastin time (APTT)/anti-Xa assay and prothrombin time – international normalized ratio (PT-INR), respectively. Since 2008, new generation anticoagulant drugs, called direct oral anticoagulants (DOACs), have been widely prescribed to prevent and treat several thromboembolic diseases. Although the use of DOACs without routine monitoring and frequent dose adjustment has been shown to be safe and effective, there may be clinical circumstances in specific patients when measurement of the anticoagulant effects of DOACs is required. Recently, anticoagulation therapy has received attention when treating patients with coronavirus disease 2019 (COVID-19). In this review, we discuss the mechanisms of anticoagulant drugs—heparin, warfarin, and DOACs and describe the methods used for the measurement of their effects. In addition, we discuss the latest findings on thrombosis mechanism in patients with COVID-19 with respect to biological chemistry.
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Affiliation(s)
- Osamu Kumano
- Research Department, HYPHEN BioMed, 155 Rue d’Eragny, 95000 Neuville sur Oise, France;
- Protein Technology, Engineering 1, Sysmex Corporation, Kobe 651-2271, Japan
- Correspondence: ; Tel.: +81-78-991-2203
| | - Kohei Akatsuchi
- R&D Division, Sysmex R&D Center Americas, Inc., Mundelein, IL 60060, USA;
| | - Jean Amiral
- Research Department, HYPHEN BioMed, 155 Rue d’Eragny, 95000 Neuville sur Oise, France;
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Chatterjee M, Meeks S, Novakovic VA, Gilbert GE. Discordance between platelet-supported and vesicle-supported factor VIII activity in the presence of anti-C2 domain inhibitory antibodies. J Thromb Haemost 2020; 18:3184-3193. [PMID: 32558078 DOI: 10.1111/jth.14961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/14/2020] [Accepted: 06/05/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND We recently reported that factor VIII (FVIII) binds to a macromolecular complex including fibrin on thrombin-stimulated platelets and that two antibodies against FVIII diminish platelet-supported FVIII activity more than vesicle-supported activity. The C2 domain of FVIII is known to bind to phospholipid membrane and also binds fibrin. OBJECTIVES We asked whether the degree of inhibition by anti-C2 antibodies would show differences between platelet-supported and the standard activated partial thromboplastin time (aPTT) assay. METHODS We evaluated the inhibition by a well-defined panel of monoclonal anti-C2 domain antibodies encompassing the major epitopes of the C2 domain. Activity was measured in an activated platelet time (aPT) assay containing fresh, density gradient-purified human platelets. RESULTS The aPT exhibited a log-linear relationship between FVIII and time to fibrin formation over a 4-log range, encompassing 0.01% to 100% plasma FVIII. Nine of 10 mAbs inhibited 89% to 96% of FVIII activity, whereas mAb F85 did not. There was no correlation between the degree of inhibition in the aPTT-based assay and the platelet assay. In particular, four mAbs did not inhibit the aPTT assay, yet inhibited 90% of platelet-based activity. Residual FVIII activity in purified-protein assays, relying on platelets, correlated with the aPT assay. CONCLUSIONS The degree of FVIII impairment by some inhibitor antibodies is substantially different on platelet membranes vs synthetic vesicles. Thus, current inhibitor assays may underestimate the frequency of significant inhibitors, and a platelet-based assay may more accurately assess bleeding risk.
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Affiliation(s)
- Madhumouli Chatterjee
- Departments of Medicine & Research, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Shannon Meeks
- Department of Pediatrics, Children's Healthcare Atlanta/Aflac Cancer and Blood Disorder Center, Emory University, Atlanta, Georgia, USA
| | - Valerie A Novakovic
- Departments of Medicine & Research, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Gary E Gilbert
- Departments of Medicine & Research, VA Boston Healthcare System, Boston, Massachusetts, USA
- Departments of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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10
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Overview and Practical Application of Coagulation Assays in Managing Anticoagulation with Direct Oral Anticoagulants (DOACs). ACTA ACUST UNITED AC 2020. [DOI: 10.1007/s40495-020-00232-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Kostousov V, Devaraj S, Bruzdoski K, Hensch L, Hui SK, Teruya J. C-reactive protein-induced activated partial thromboplastin time prolongation in heparinized samples is attenuated by elevated factor VIII. Int J Lab Hematol 2020; 43:139-142. [PMID: 32812381 DOI: 10.1111/ijlh.13314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/07/2020] [Accepted: 07/26/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Activated partial thromboplastin time (aPTT) and antifactor Xa (anti-Xa) activity are used to monitor unfractionated heparin therapy in children on extracorporeal membrane oxygenation (ECMO). Elevated C-reactive protein (CRP) can prolong aPTT and cause discrepancy between these two assays. We aimed to evaluate CRP effect on aPTT and anti-Xa assays in the presence of heparin and to determine whether elevated CRP affects laboratory monitoring in pediatric ECMO patients. MATERIALS AND METHODS Citrated normal specimens were spiked with CRP, heparin, and recombinant factor VIII (FVIII) and followed by measurement of aPTT and anti-Xa activity. Additionally, aPTT, anti-Xa activity, FVIII, fibrinogen, and CRP were measured in 18 ECMO specimens. RESULTS Elevated CRP prolonged aPTT in normal specimens with or without heparin, but did not affect anti-Xa assay. In contrast, ECMO specimens showed similar aPTT and anti-Xa values regardless of CRP level. Elevated CRP in specimens was accompanied by increased fibrinogen and FVIII activity. Additional in vitro experiments confirmed that FVIII spiked simultaneously with CRP attenuated CRP-induced aPTT prolongation in heparinized specimens. CONCLUSION In vitro CRP-induced aPTT prolongation is not observed in pediatric ECMO samples due to concomitant FVIII increase. Discordant changes of CRP and FVIII in plasma could contribute to aPTT/anti-Xa discrepancies observed during heparin therapy in the pediatric population. The anti-Xa assay is preferable for heparin monitoring in pediatric ECMO settings.
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Affiliation(s)
- Vadim Kostousov
- Departments of Pathology & Immunology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Sridevi Devaraj
- Departments of Pathology & Immunology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Karen Bruzdoski
- Departments of Pathology & Immunology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Lisa Hensch
- Departments of Pathology & Immunology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Shiu-Ki Hui
- Departments of Pathology & Immunology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.,Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Jun Teruya
- Departments of Pathology & Immunology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.,Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.,Department of Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
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Van den Bossche D, Peerlinck K, Jacquemin M. New challenges and best practices for the laboratory monitoring of factor VIII and factor IX replacement. Int J Lab Hematol 2018; 40 Suppl 1:21-29. [PMID: 29741261 DOI: 10.1111/ijlh.12813] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 02/07/2018] [Indexed: 11/29/2022]
Abstract
Several recombinant factor VIII and factor IX concentrates with extended half-life (EHL) have recently been validated by clinical studies. The availability of these novel concentrates is expected to significantly facilitate the treatment of patients with hemophilia A and B. However, the modification applied to these molecules has introduced variations in their activity measurement in routine coagulation assays. Depending on the assays, underestimations of up to 10-fold or overestimations of up to approximately 30-fold in the measurements of the recovery have been reported in some factor concentrates. Such biases in monitoring may lead to major under- or overtreatment, as well as unnecessary searching for inhibitor antibodies. In this review, we discuss the guidelines and recommendations that allow the selection of optimal strategies to monitor patients treated with these novel factor concentrates. Based on the specificities of the assays and on local regulations, different chromogenic substrate assays in addition to one-stage clotting assays may be validated to allow the accurate measurement of all novel products. An efficient communication between the clinical laboratory and the clinicians is essential to ensure that the appropriate assays are carried out in laboratories and that the clinicians correctly evaluate the data. Further laboratory and clinical studies are still required for the optimization of the laboratory assays that can be used in the measurement of novel factor VIII and factor IX concentrates with EHL.
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Affiliation(s)
- D Van den Bossche
- Department of Laboratory Medicine, University Hospitals of Leuven, Leuven, Belgium
| | - K Peerlinck
- Center for Molecular and Vascular Biology, University of Leuven, Leuven, Belgium.,Department of Vascular Medicine and Hemostasis, University Hospitals Leuven, Leuven, Belgium.,National Coordinating Hemophilia Center, University Hospitals Leuven, Leuven, Belgium
| | - M Jacquemin
- Department of Laboratory Medicine, University Hospitals of Leuven, Leuven, Belgium.,Center for Molecular and Vascular Biology, University of Leuven, Leuven, Belgium.,Department of Vascular Medicine and Hemostasis, University Hospitals Leuven, Leuven, Belgium.,National Coordinating Hemophilia Center, University Hospitals Leuven, Leuven, Belgium
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13
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Santos García A, Millán Del Valle I, Cruzado Vega L, Ruiz Ferrús R, Tordera Fuentes D, Sabater Belmar A, Valenciano Moreno R, Mompel Sanjuan A. Prolonged Activated partial thromboplastin time without coagulopathy in peritoneal dialysis. Nefrologia 2018; 39:210-211. [PMID: 30245139 DOI: 10.1016/j.nefro.2018.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/15/2018] [Accepted: 07/01/2018] [Indexed: 11/26/2022] Open
Affiliation(s)
- Alba Santos García
- Servicio de Nefrología, Hospital General Universitario de Elche, Elche, Alicante, España.
| | | | - Leonidas Cruzado Vega
- Servicio de Nefrología, Hospital General Universitario de Elche, Elche, Alicante, España
| | - Rosalía Ruiz Ferrús
- Servicio de Nefrología, Hospital General Universitario de Elche, Elche, Alicante, España
| | - Diana Tordera Fuentes
- Servicio de Nefrología, Hospital General Universitario de Elche, Elche, Alicante, España
| | | | | | - Angela Mompel Sanjuan
- Servicio de Hematología, Hospital General Universitario de Elche, Elche, Alicante, España
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Jennings I, Kitchen D, Kitchen S, Woods T, Walker I. The importance of commutability in material used for quality control purposes. Int J Lab Hematol 2018; 41:39-45. [PMID: 30184324 DOI: 10.1111/ijlh.12918] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 07/13/2018] [Accepted: 07/25/2018] [Indexed: 11/29/2022]
Abstract
External Quality Assessment (EQA) is an important part of laboratory quality assurance. Spiking of normal plasma is sometimes employed to mimic clinical samples. It is important that spiked material gives similar results to clinical samples (ie, is commutable) to ensure appropriate conclusions can be drawn from EQA exercises. We describe here data from UK National External Quality Assessment Scheme for Blood Coagulation (NEQAS BC) exercises where spiked samples were tested alongside samples from patients to explore commutability of artificial material. Normal plasma was spiked with unfractionated heparin (UFH), low molecular weight heparin (LMWH), Dabigatran or Rivaroxaban. Factor VIII (FVIII) deficient plasma was spiked with FVIII concentrate. Spiked samples and ex vivo patient material were sent to laboratories for testing. For LMWH, good agreement was seen between results for samples from patient plasma and plasma spiked with heparin. For UFH, APTT ratios differed between spiked and patient samples for the same drug concentration, with no correlation in ranking of reagents. Precision for patient and spiked material for Rivaroxaban and Dabigatran assays was comparable. However, the pattern of results for some Dabigatran assay kits differed between spiked and patient samples. For FVIII assays, results obtained with spiked and postinfusion samples gave comparable results. Spiked material is suitable for EQA if commutability is demonstrated. Our data show commutability for plasma spiked with Rivaroxaban, LWMH and some FVIII concentrates. For some tests, notably APTT for UFH, marked differences between patient and spiked samples indicate not all tests can be evaluated using artificial samples.
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Thom I, Cameron G, Robertson D, Watson HG. Measurement of rivaroxaban concentrations demonstrates lack of clinical utility of a PT, dPT and APTT test in estimating levels. Int J Lab Hematol 2018; 40:493-499. [PMID: 29718586 DOI: 10.1111/ijlh.12846] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 03/14/2018] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Rivaroxaban concentrations were measured in 127 inpatient samples using an HPLC-MS/MS assay. METHODS We compared this measurement with a calibrated anti-Xa assay and performed PT, aPTT and dilute PT tests to assess the value of clot-based assays in clinical decision-making. RESULTS The correlation between the anti-Xa assay and the HPLC-MS/MS at therapeutic concentrations was strong (R2 = 0.98). The PT, RecombiPlasTin 2G, and aPTT, Actin FS, showed a linear dose-response but poor correlation (R2 = 0.32 and 0.44, respectively) and at dilutions of 1 in 150 to 1 in 750 the dilute PT assay also showed poor correlation with rivaroxaban concentrations measured by specific assays. A normal PT or aPTT alone did not identify a likely safe rivaroxaban concentration to allow surgery or invasive procedures, but the combination of normal PT and aPTT identified a group of patients with rivaroxaban levels less than 90 ng/mL. Combined normal PT and aPTT had specificity and sensitivity of 0.97 (95% CI 0.92-0.99) and 0.37 (95% CI 0.1-0.74) for a rivaroxaban concentration < 32 ng/mL. CONCLUSIONS The PT and aPTT show poor correlation with rivaroxaban levels measured by calibrated anti-Xa and HPLC-MS/MS assays. A normal combined PT and APTT identified low rivaroxaban levels with high specificity but lacked sensitivity. The dPT assay at several dilutions could not be used to quantify rivaroxaban in clinical samples. The utility of these PT, aPTT and dilute PT assays in a clinical setting is very limited, and results generated must be interpreted with caution.
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Affiliation(s)
- I Thom
- Department of Haematology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - G Cameron
- Rowett Institute, University of Aberdeen, Aberdeen, UK
| | - D Robertson
- Laboratory Medicine IT Department, Aberdeen Royal Infirmary, Aberdeen, UK
| | - H G Watson
- Department of Haematology, Aberdeen Royal Infirmary, Aberdeen, UK
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16
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Bailleul E, Chatelain B, Demulder A, Devreese K, Douxfils J, Jochmans K, Mullier F, Wijns W, Soumali MR, Coucke W, Vernelen K, Walle PVD, Blerk MV. Influence of dabigatran and rivaroxaban on routine coagulation assays. Thromb Haemost 2017; 113:154-64. [DOI: 10.1160/th14-02-0161] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 08/02/2014] [Indexed: 11/05/2022]
Abstract
SummaryThe Belgian national External Quality Assessment Scheme performed a nationwide survey using lyophilised plasma samples spiked with dabigatran or rivaroxaban to demonstrate to the Belgian clinical laboratories how these drugs affect their routine coagulation assays prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen and antithrombin. Virtually all Belgian laboratories performing routine coagulation testing (189/192) participated in the survey. Both, dabigatran and rivaroxaban significantly prolonged the PT and aPTT in a concentration- and reagent-dependent manner. PT reagents were more influenced by rivaroxaban than by dabigatran and aPTT reagents more influenced by dabigatran than by rivaroxaban. Among PT reagents, Neoplastin R® was the most sensitive to rivaroxaban and Innovin ® and Thromborel S® the least sensitive. Converting PT results to INR only increased the variability between reagents. Among aPTT reagents, Actin FSL® was the least sensitive to dabigatran while the other aPTT reagents showed slightly higher sensitivities. The presence of dabigatran led to falsely reduced fibrinogen concentrations when measured with a low thrombin concentration reagent. The presence of dabigatran caused an overestimation of the antithrombin level when measured with a thrombin-based activity assay and the presence of rivaroxaban an overestimation of the antithrombin level when measured with a FXa-based assay. Instrument-related differences were found for all tested parameters. In conclusion, this paper provides detailed information on the effect of dabigatran and rivaroxaban on routine coagulation assays as performed with a large number of reagent/instrument combinations.
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17
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Toh CH, Alhamdi Y, Abrams ST. Current Pathological and Laboratory Considerations in the Diagnosis of Disseminated Intravascular Coagulation. Ann Lab Med 2017; 36:505-12. [PMID: 27578502 PMCID: PMC5011102 DOI: 10.3343/alm.2016.36.6.505] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 06/21/2016] [Accepted: 07/22/2016] [Indexed: 01/06/2023] Open
Abstract
Systemically sustained thrombin generation in vivo is the hallmark of disseminated intravascular coagulation (DIC). Typically, this is in response to a progressing disease state that is associated with significant cellular injury. The etiology could be infectious or noninfectious, with the main pathophysiological mechanisms involving cross-activation among coagulation, innate immunity, and inflammatory responses. This leads to consumption of both pro- and anticoagulant factors as well as endothelial dysfunction and disrupted homeostasis at the blood vessel wall interface. In addition to the release of tissue plasminogen activator (tPA) and soluble thrombomodulin (sTM) following cellular activation and damage, respectively, there is the release of damage-associated molecular patterns (DAMPs) such as extracellular histones and cell-free DNA. Extracellular histones are increasingly recognized as significantly pathogenic in critical illnesses through direct cell toxicity, the promotion of thrombin generation, and the induction of neutrophil extracellular trap (NET) formation. Clinically, high circulating levels of histones and histone–DNA complexes are associated with multiorgan failure, DIC, and adverse patient outcomes. Their measurements as well as that of other DAMPs and molecular markers of thrombin generation are not yet applicable in the routine diagnostic laboratory. To provide a practical diagnostic tool for acute DIC, a composite scoring system using rapidly available coagulation tests is recommended by the International Society on Thrombosis and Haemostasis. Its usefulness and limitations are discussed alongside the advances and unanswered questions in DIC pathogenesis.
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Affiliation(s)
- Cheng Hock Toh
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom.,Roald Dahl Haemostasis & Thrombosis Centre, Royal Liverpool University Hospital, Liverpool, United Kingdom.
| | - Yasir Alhamdi
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Simon T Abrams
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
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18
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Bowyer AE, Hillarp A, Ezban M, Persson P, Kitchen S. Measuring factor IX activity of nonacog beta pegol with commercially available one-stage clotting and chromogenic assay kits: a two-center study. J Thromb Haemost 2016; 14:1428-35. [PMID: 27107268 DOI: 10.1111/jth.13348] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 04/02/2016] [Indexed: 08/31/2023]
Abstract
UNLABELLED Essentials Validated assays are required to precisely measure factor IX (FIX) activity in FIX products. N9-GP and two other FIX products were assessed in various coagulation assay systems at two sites. Large variations in FIX activity measurements were observed for N9-GP using some assays. One-stage and chromogenic assays accurately measuring FIX activity for N9-GP were identified. SUMMARY Background Measurement of factor IX activity (FIX:C) with activated partial thromboplastin time-based one-stage clotting assays is associated with a large degree of interlaboratory variation in samples containing glycoPEGylated recombinant FIX (rFIX), i.e. nonacog beta pegol (N9-GP). Validation and qualification of specific assays and conditions are necessary for the accurate assessment of FIX:C in samples containing N9-GP. Objectives To assess the accuracy of various one-stage clotting and chromogenic assays for measuring FIX:C in samples containing N9-GP as compared with samples containing rFIX or plasma-derived FIX (pdFIX) across two laboratory sites. Methods FIX:C, in severe hemophilia B plasma spiked with a range of concentrations (from very low, i.e. 0.03 IU mL(-1) , to high, i.e. 0.90 IU mL(-1) ) of N9-GP, rFIX (BeneFIX), and pdFIX (Mononine), was determined at two laboratory sites with 10 commercially available one-stage clotting assays and two chromogenic FIX:C assays. Assays were performed with a plasma calibrator and different analyzers. Results A high degree of variation in FIX:C measurement was observed for one-stage clotting assays for N9-GP as compared with rFIX or pdFIX. Acceptable N9-GP recovery was observed in the low-concentration to high-concentration samples tested with one-stage clotting assays using SynthAFax or DG Synth, or with chromogenic FIX:C assays. Similar patterns of FIX:C measurement were observed at both laboratory sites, with minor differences probably being attributable to the use of different analyzers. Conclusions These results suggest that, of the reagents tested, FIX:C in N9-GP-containing plasma samples can be most accurately measured with one-stage clotting assays using SynthAFax or DG Synth, or with chromogenic FIX:C assays.
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Affiliation(s)
- A E Bowyer
- Coagulation Department, Sheffield Teaching Hospitals, Sheffield, UK
| | - A Hillarp
- Department of Clinical Chemistry, Skåne University Hospital, Malmö, Sweden
| | - M Ezban
- Novo Nordisk A/S, Novo Nordisk Park, Måløv, Denmark
| | | | - S Kitchen
- Coagulation Department, Sheffield Teaching Hospitals, Sheffield, UK
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19
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Kitchen S, Jennings I, Makris M, Kitchen DP, Woods TAL, Walker ID. Factor VIII assay variability in postinfusion samples containing full length and B-domain deleted FVIII. Haemophilia 2016; 22:806-12. [PMID: 27217329 DOI: 10.1111/hae.12962] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2016] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Although the variability in factor VIII (FVIII):C measurement is well recognized, this has not been widely reported for post-FVIII infusion samples. AIM/METHODS Three samples from haemophilia A patients were distributed in a UK National External Quality Assessment Scheme survey, each after treatment with either ReFacto AF, Kogenate FS or Advate. Fifty-two UK haemophilia centres performed FVIII assays using one-stage (n = 46) and chromogenic (n = 10) assays. Centres calibrated assays with the local plasma standard and with ReFacto AF laboratory standard for the ReFacto AF sample. RESULTS/CONCLUSIONS Chromogenic assays gave significantly higher results than one-stage assays (P < 0.0001, 32% difference) in the post-Kogenate sample but not in the post-ReFacto AF (11% higher by chromogenic assay, ns) or post-Advate samples (3% lower by chromogenic, ns) when assays were calibrated with plasma standards. Twenty centres used all Instrumentation Laboratory (IL)-activated partial thromboplastin time reagents (Synthasil)/IL deficient plasma/reference plasma) in the one-stage assay and 15 used all Siemens reagents (Actin FS/Siemens deficient plasma/reference plasma); this made a significant difference to results post-ReFacto AF (41% higher by IL reagents, P < 0.0001) and Advate (39% higher by IL reagents, P < 0.0001), but not Kogenate (7% higher by IL, ns) when calibrated with plasma standards. Differences between results obtained with different one-stage assay reagents for monitoring Advate have implications for dosing patients. Furthermore, there was considerable inter-laboratory variation as indicated by CVs in the range 15-26% for chromogenic assay and 12-19% for one-stage assay results. This study suggests that external quality assessment schemes should offer participation in post-FVIII infusion schemes where haemophilic patients are monitored.
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Affiliation(s)
- S Kitchen
- UK NEQAS Blood Coagulation, Sheffield, UK. .,Sheffield Haemophilia and Thrombosis Centre, Sheffield, UK.
| | - I Jennings
- UK NEQAS Blood Coagulation, Sheffield, UK
| | - M Makris
- UK NEQAS Blood Coagulation, Sheffield, UK.,Department of Cardiovascular Science, University of Sheffield, Sheffield, UK
| | | | | | - I D Walker
- UK NEQAS Blood Coagulation, Sheffield, UK
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20
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Ustyuzhanina NE, Bilan MI, Gerbst AG, Ushakova NA, Tsvetkova EA, Dmitrenok AS, Usov AI, Nifantiev NE. Anticoagulant and antithrombotic activities of modified xylofucan sulfate from the brown alga Punctaria plantaginea. Carbohydr Polym 2016; 136:826-33. [PMID: 26572418 DOI: 10.1016/j.carbpol.2015.09.102] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 09/23/2015] [Accepted: 09/26/2015] [Indexed: 01/08/2023]
Abstract
Selectively and totally sulfated (1 → 3)-linked linear homofucans bearing ∼ 20 monosaccharide residues on average have been prepared from the branched xylofucan sulfate isolated from the brown alga Punctaria plantaginea. Anticoagulant and antithrombotic properties of the parent biopolymer and its derivatives were assessed in vitro. Highly sulfated linear fucan derivatives were shown to inhibit clot formation in APTT assay and ristocetin induced platelets aggregation, while the partially sulfated analogs were inactive. In the experiments with purified proteins, fucan derivatives with degree of sulfation of ∼ 2.0 were found to enhance thrombin and factor Xa inhibition by antithrombin III. The effect of sulfated fucans on thrombin inhibition, which was similar to those of heparinoid Clexane(®) (enoxaparin) and of a fucoidan from the brown alga Saccharina latissima studied previously, can be explained by the multicenter interaction and formation of a ternary complex thrombin-antithrombin III-polysaccharide. The possibility of such complexation was confirmed by computer docking study.
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Affiliation(s)
- Nadezhda E Ustyuzhanina
- N.D. Zelinsky Institute of Organic Chemistry, Russian Academy of Sciences, Leninsky Prospect 47, B-334, 119991 Moscow, Russian Federation
| | - Maria I Bilan
- N.D. Zelinsky Institute of Organic Chemistry, Russian Academy of Sciences, Leninsky Prospect 47, B-334, 119991 Moscow, Russian Federation
| | - Alexey G Gerbst
- N.D. Zelinsky Institute of Organic Chemistry, Russian Academy of Sciences, Leninsky Prospect 47, B-334, 119991 Moscow, Russian Federation
| | - Natalia A Ushakova
- V.N. Orekhovich Institute of Biomedical Chemistry, Russian Academy of Medical Sciences, Pogodinskaya Str. 10, 119121 Moscow, Russian Federation
| | - Eugenia A Tsvetkova
- N.D. Zelinsky Institute of Organic Chemistry, Russian Academy of Sciences, Leninsky Prospect 47, B-334, 119991 Moscow, Russian Federation
| | - Andrey S Dmitrenok
- N.D. Zelinsky Institute of Organic Chemistry, Russian Academy of Sciences, Leninsky Prospect 47, B-334, 119991 Moscow, Russian Federation
| | - Anatolii I Usov
- N.D. Zelinsky Institute of Organic Chemistry, Russian Academy of Sciences, Leninsky Prospect 47, B-334, 119991 Moscow, Russian Federation
| | - Nikolay E Nifantiev
- N.D. Zelinsky Institute of Organic Chemistry, Russian Academy of Sciences, Leninsky Prospect 47, B-334, 119991 Moscow, Russian Federation.
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21
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Addition of prothrombin to plasma can result in a paradoxical increase in activated partial thromboplastin time. Blood Coagul Fibrinolysis 2014; 25:851-5. [DOI: 10.1097/mbc.0000000000000161] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Kumano O, Ieko M, Naito S, Yoshida M, Takahashi N, Suzuki T, Aoki T. Verification of the guidelines for lupus anticoagulant detection: Usefulness of index for circulating anticoagulant in APTT mixing test. Thromb Res 2014; 134:503-9. [DOI: 10.1016/j.thromres.2014.05.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 05/15/2014] [Accepted: 05/22/2014] [Indexed: 11/28/2022]
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23
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Dudek MM, Harris LF, Killard AJ. Evaluation of activated partial thromboplastin time (aPTT) reagents for application in biomedical diagnostic device development. Int J Lab Hematol 2010; 33:272-80. [PMID: 21118388 DOI: 10.1111/j.1751-553x.2010.01283.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The most commonly used test for monitoring heparin therapy is the activated partial thromboplastin time (aPTT). The response of available aPTT reagents to heparin varies significantly. The aim of this study was to highlight the differences between aPTT reagents stored in a dried format to select the most suitable formulations to be used for the development of point-of-care diagnostic devices used for monitoring of unfractionated heparin dose response. METHODS Ten reagents were analysed in terms of their performance in liquid and in dried form after storage for 24 h and 14 days. Performance was assessed by measurement of the clotting time (CT) as evidenced by the onset of thrombin formation using a chromogenic thrombin substrate in plasma samples activated with these formulations. RESULTS Reagents in all of the three forms tested (liquid, 24 h and 14 days) resulted in significant shortening of CTs in comparison with the nonactivated plasma CT. Liquids returned more rapid CTs in comparison with dried reagents. Most of the reagents were more sensitive to heparin in dried, rather than in liquid form. Dried reagents based on kaolin as a surface activator were notably more effective in achieving short CT than others, while dried reagents composed of silica and synthetic phospholipids were the most sensitive to heparin. CONCLUSION Two reagents, namely aPTT-SP and SynthASIL both of which are based on synthetic phospholipids and silica, were identified as promising candidates for incorporation into point-of-care diagnostic device platforms as dried reagents.
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Affiliation(s)
- M M Dudek
- Biomedical Diagnostics Institute, National Centre for Sensor Research, Dublin City University, Dublin, Ireland
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24
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Dudek MM, Kent N, Gustafsson KM, Lindahl TL, Killard AJ. Fluorescence-based blood coagulation assay device for measuring activated partial thromboplastin time. Anal Chem 2010; 83:319-28. [PMID: 21121686 DOI: 10.1021/ac102436v] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The measurement of blood clotting time is important in a range of clinical applications such as assessing coagulation disorders and controlling the effect of various anticoagulant drug therapies. Clotting time tests essentially measure the onset of clot formation which results from the formation of fibrin fibers in the blood sample. However, such assays are inherently imprecise due to the highly variable nature of the clot formation process and the sample matrix. This work describes a clotting time measurement assay which uses a fluorescent probe to very precisely detect the onset of fibrin clot formation. It uses a microstructured surface which enhances the formation of multiple localized clot loci and which results in the abrupt redistribution of the fluorescent label at the onset of clot formation in both whole blood and plasma. This methodology was applied to the development of an activated partial thromboplastin time (aPTT) test in a lateral flow microfluidic platform and used to monitor the effect of heparin dosage where it showed linearity from 0 to 2 U/mL in spiked plasma samples (R(2)=0.996, n = 3), correlation against gold standard coagulometry of 0.9986, and correlation against standard hospital aPTT in 32 patient samples of 0.78.
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Affiliation(s)
- Magdalena M Dudek
- Biomedical Diagnostics Institute, National Centre for Sensor Research, Dublin City University, Dublin 9, Ireland
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25
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BOWYER A, SMITH J, WOOLLEY AM, KITCHEN S, HAMPTON KK, MACLEAN RM, VAN VEEN JJ, MAKRIS M. The investigation of a prolonged APTT with specific clotting factor assays is unnecessary if an APTT with Actin FS is normal. Int J Lab Hematol 2010; 33:212-8. [DOI: 10.1111/j.1751-553x.2010.01266.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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POUPLARD C, TROSSAERT M, LE QUERREC A, DELAHOUSSE B, GIRAUDEAU B, GRUEL Y. Influence of source of phospholipids for APTT-based factor IX assays and potential consequences for the diagnosis of mild haemophilia B. Haemophilia 2009; 15:365-8. [DOI: 10.1111/j.1365-2516.2008.01896.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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27
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Gardiner C, Cohen H, Jenkins A, Machin SJ, Mackie IJ. Detection of acquired resistance to activated protein C associated with antiphospholipid antibodies using a novel clotting assay. Blood Coagul Fibrinolysis 2006; 17:477-83. [PMID: 16905952 DOI: 10.1097/01.mbc.0000240921.50059.f2] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Antiphospholipid antibodies (aPA) frequently interfere with the protein C pathway. This manifests as acquired activated protein C (APC) resistance in the absence of factor V Leiden and has been proposed as a putative mechanism for the pathogenesis of the antiphospholipid syndrome (APS). We have developed a Russell's viper venom test, performed with and without activation of endogenous protein C, which is sensitive to aPA-associated APC resistance. Results were reported as the endogenous APC ratio (EAPCr); the ratio of the two clotting times normalized against pooled normal plasma. Forty-four patients with aPA, anticardiolipin and/or lupus anticoagulant, including 34 with a history of thrombosis or pregnancy morbidity; a control group of aPA-negative patients; and 26 healthy normals were studied. EAPCr (mean, SD) was significantly higher in APS patients (1.94, 0.58) than normals (0.98, 0.12) or controls (1.14, 0.19; P < 0.00001). Elevated EAPCr (> 1.22) occurred in 91% of aPA-positive patients, predominantly due to resistance to APC (87%) rather than prolonged basal clotting times alone (15%). Significant correlation was observed between the EAPCr value and dilute Russell's viper venom time (rs = 0.44, P = 0.003), IgG anticardiolipin (rs = 0.54, P = 0.002), protein S (r = -0.46, P = 0.01) and activated partial thromboplastin time-based APC resistance (r = -0.61, P = 0.001). There was no significant relationship between EAPCr and protein C concentration, anti-beta2-glycoprotein-I (anti-beta2GPI) or IgM anticardiolipin. Purified aPA IgG caused a dose-dependent increase in APC resistance when added to normal plasma. We conclude that aPA-associated acquired APC resistance is a common feature of APS and may be independent of anti-beta2GPI.
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Affiliation(s)
- Chris Gardiner
- Department of Haematology, University College London, UK.
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Bolton-Maggs PHB, Perry DJ, Chalmers EA, Parapia LA, Wilde JT, Williams MD, Collins PW, Kitchen S, Dolan G, Mumford AD. The rare coagulation disorders - review with guidelines for management from the United Kingdom Haemophilia Centre Doctors' Organisation. Haemophilia 2004; 10:593-628. [PMID: 15357789 DOI: 10.1111/j.1365-2516.2004.00944.x] [Citation(s) in RCA: 399] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The rare coagulation disorders are heritable abnormalities of haemostasis that may present significant difficulties in diagnosis and management. This review summarizes the current literature for disorders of fibrinogen, and deficiencies of prothrombin, factor V, FV + VIII, FVII, FX, the combined vitamin K-dependent factors, FXI and FXIII. Based on both collective clinical experience and the literature, guidelines for management of bleeding complications are suggested with specific advice for surgery, spontaneous bleeding, management of pregnancy and the neonate. We have chosen to include a section on Ehlers-Danlos Syndrome because haematologists may be consulted about bleeding manifestations in such patients.
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Affiliation(s)
- P H B Bolton-Maggs
- Department of Clinical Haematology, Manchester Royal Infirmary, Manchester, UK.
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Abstract
Unfractionated heparin (UFH) has been in clinical use for more than half a century. Despite its undoubted contribution to the treatment and prevention of thrombosis, heparin is significantly limited by its variable biochemical composition and unpredictable pharmacokinetics. The situation is compounded by the fact that methods for monitoring heparin do not necessarily reflect its therapeutic effect. The activated partial thromboplastin time (aPTT) is a method for monitoring heparin therapy that is simple, cheap, and readily available. However, it is also poorly standardized and is affected by numerous factors-both analytic and preanalytic-that are unrelated to the heparin effect. Establishing an appropriate therapeutic range for the aPTT is challenging for smaller clinical laboratories, and the antifactor Xa method of measuring heparin levels is not widely available. The College of American Pathologists published consensus guidelines in an effort to improve the laboratory monitoring of UFH therapy. However, it seems unlikely that the laboratory problems associated with monitoring UFH will be resolved. Unfractionated heparin is highly antigenic and carries a significant risk of heparin-induced thrombocytopenia (HIT). Even in the absence of thrombocytopenia or thrombosis, the presence of heparin-associated antibodies may predict adverse clinical outcomes and strengthen the rationale for the ultimate replacement of UFH. Fortunately, alternatives to UFH, such as low-molecular-weight heparins, direct thrombin inhibitors, and more specific factor Xa inhibitors, are becoming available for clinical use. The pharmacokinetics of these agents are more predictable and rely much less on laboratory monitoring. Nonheparin agents also eliminate the risk of HIT. The emergence of these newer anticoagulants makes the continued use of UFH increasingly difficult to justify.
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Affiliation(s)
- John L Francis
- Florida Hospital Center for Hemostasis and Thrombosis, Orlando, Florida 32804, USA.
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Gaussem P, Dubar M, le Bonniec B, Richard-Lordereau I, Jochemsen R, Aiach M. Dose-effect relationship for several coagulation markers during administration of the direct thrombin inhibitor S 18326 in healthy subjects. Br J Clin Pharmacol 2002; 53:147-54. [PMID: 11851638 PMCID: PMC1874285 DOI: 10.1046/j.0306-5251.2001.01534.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AIMS We conducted a phase I placebo-controlled trial with two i.v. doses (0.5 mg h-1 and 3 mg h-1) of S 18326, a selective thrombin inhibitor that interacts with the catalytic site of thrombin, with the aim to study the relationships between increasing plasma levels of S 18326 and changes in coagulation tests and thrombin generation markers. METHODS Thirty-six healthy male volunteers were divided into three groups. In each group, 10 volunteers were randomly assigned to receive S 18326 and two to receive a placebo. Following a bolus of 4.5 mg, doses were 0.5 mg h-1 in the first group and 3 mg h-1 in the two other groups, administered as an i.v. infusion for 24 h. Blood was drawn repeatedly up to 36 h after the bolus, and tested for the activated clotting time (ACT) and activated partial thromboplastin time (APTT). The APTT reagent was chosen among five commercial reagents to yield a linear increase in the clotting time among possible therapeutic S 18326 concentrations in vitro. To accurately measure the thrombin-inhibiting effects of low doses of S 18326 (< 0.5 microm), we developed a specific chromogenic assay. We also measured F1 + 2 prothrombin fragment levels to assess the effect of S 18326 on thrombin generation in vivo. RESULTS A two-compartment pharmacokinetic model was fitted to the S 18326 plasma concentration vs time data by using population pharmacokinetic methods. Results of the pharmacodynamic-pharmacokinetic relationships showed that both the ACT and APTT methods yielded a linear increase according to the S 18326 concentration measured using a highly sensitive analytical method. At the end of infusion, ACT was prolonged 1.20 and 1.95-fold in the 0.5 mg h-1 and the 3 mg h-1 groups, respectively, and APTT was prolonged 1.27 and 2.75-fold. Thrombin inhibition plateaued above 0.5 microm of S 18326 according to an Emax model, confirming that the test was highly sensitive. F1 + 2 levels fell significantly after the 24 h S 18326 infusion (0.83 nm to 0.6 nm and 0.80 nm to 0.44 nm in the 0.5 mg h-1 and the 3 mg h-1 groups, respectively), but remained stable after the placebo infusion. CONCLUSIONS Our results support specific monitoring of the thrombin inhibitor S 18326 with ACT and APTT to establish the safety range of the drug in further studies. Moreover, the fall in F1 + 2 prothrombin fragments suggests that S 18326 effectively reduces the retroactivation of factors V and VIII by thrombin.
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Affiliation(s)
- Pascale Gaussem
- Unité INSERM 428, Faculté des Sciences Pharmaceutiques et Biologiques, Université Paris V, 4 avenue de l'Observatoire, F-75270 Paris Cedex 06, France.
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Kitchen S. Problems In Laboratory Monitoring Of Heparin Dosage. Br J Haematol 2000. [DOI: 10.1111/j.1365-2141.2000.02308.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Affiliation(s)
- S Kitchen
- Department of Coagulation, Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK.
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