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Franco-Moreno A, Muñoz-Rivas N, Torres-Macho J, Bustamante-Fermosel A, Ancos-Aracil CL, Madroñal-Cerezo E. Systematic review of clinical trials on antithrombotic therapy with factor XI inhibitors. Rev Clin Esp 2024; 224:167-177. [PMID: 38309621 DOI: 10.1016/j.rceng.2024.01.006] [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: 02/05/2024]
Abstract
INTRODUCTION AND OBJECTIVE Data from phase 2 clinical trials suggest that factor XI inhibitors may exhibit a more favorable efficacy/safety profile compared to current antithrombotic therapies. The aim of this systematic review is to analyze the available evidence derived from these studies. METHODS A literature search in the PubMed, Cochrane Library, Scopus, EMBASE databases, and clinical trial registration platforms Clinical Trials and Cochrane Central Register of Controlled was conducted. In accordance with the PRISMA statement, results were reported. RESULTS A total of 18 completed or ongoing clinical trials addressing multiple scenarios, including atrial fibrillation, stroke, myocardial infarction, and venous thromboembolism, were identified. Evidence from 8 studies with available results was analyzed. Phase 2 studies with factor XI inhibitors, overall, demonstrated an acceptable efficacy and safety profile. The benefit-risk balance, in terms of reducing venous thromboembolism in patients undergoing total knee arthroplasty, was more favorable. For this scenario, factor XI inhibitors showed a 50% reduction in the overall rate of thrombotic complications and a 60% reduction in the rate of bleeding compared to enoxaparin. Modest results in studies involving patients with atrial fibrillation, stroke, and myocardial infarction were observed. CONCLUSIONS Factor XI inhibitors offer new prospects in antithrombotic treatment and prophylaxis. Ongoing phase 3 studies will help define the most suitable drugs and indications.
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Affiliation(s)
- A Franco-Moreno
- Servicio de Medicina Interna, Unidad de Tromboembolismo Venoso, Hospital Universitario Infanta Leonor-Virgen de la Torre, Madrid, Spain.
| | - N Muñoz-Rivas
- Servicio de Medicina Interna, Unidad de Tromboembolismo Venoso, Hospital Universitario Infanta Leonor-Virgen de la Torre, Madrid, Spain
| | - J Torres-Macho
- Servicio de Medicina Interna, Hospital Universitario Infanta Leonor-Virgen de la Torre, Madrid, Spain
| | - A Bustamante-Fermosel
- Servicio de Medicina Interna, Hospital Universitario Infanta Leonor-Virgen de la Torre, Madrid, Spain
| | - C L Ancos-Aracil
- Servicio de Medicina Interna, Unidad de Tromboembolismo Venoso, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - E Madroñal-Cerezo
- Servicio de Medicina Interna, Unidad de Tromboembolismo Venoso, Hospital Universitario de Fuenlabrada, Madrid, Spain
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2
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Paszek E, Malinowski KP, Ząbczyk M, Butenas S, Undas A. Elevated factor XIa as a modulator of plasma fibrin clot properties in coronary artery disease. Eur J Clin Invest 2023; 53:e14007. [PMID: 37042848 DOI: 10.1111/eci.14007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/12/2023] [Accepted: 04/11/2023] [Indexed: 04/13/2023]
Abstract
INTRODUCTION Patients with coronary artery disease (CAD) display a prothrombotic fibrin clot phenotype, involving low permeability and resistance to lysis. The determinants of this phenotype remain elusive. Circulating tissue factor (TF) and activated factor XI (FXIa) are linked to arterial thromboembolism. We investigated whether detectable active TF and FXIa influence fibrin clot properties in CAD. METHODS In 118 CAD patients (median age 65 years, 78% men), we assessed Ks, an indicator of clot permeability, and clot lysis time (CLT) in plasma-based assays, along with the presence of active TF and FXIa. We also analysed proteins involved in clotting and thrombolysis, including fibrinogen, plasminogen activator inhibitor-1 (PAI-1) and thrombin activatable thrombolysis inhibitor (TAFI). During a median 106 month (interquartile range 95-119) follow-up, myocardial infarction (MI), stroke, systemic thromboembolism (SE) and cardiovascular (CV) death were recorded. RESULTS Circulating TF and FXIa, detected in 20.3% and 39.8% of patients, respectively, were associated with low Ks and prolonged CLT. Solely FXIa remained an independent predictor of low Ks and high CLT on multivariable analysis. Additionally, fibrinogen and PAI-1 were associated with low Ks, while PAI-1 and TAFI-with prolonged CLT. During follow-up low Ks and prolonged CLT increased the risk of MI and the latter also a composite endpoint of MI, stroke/SE or CV death. CONCLUSIONS To our knowledge, this study is the first to show that circulating FXIa is associated with prothrombotic fibrin clot properties in CAD, suggesting additional mechanisms through which FXIa inhibitors could act as novel antithrombotic agents in CAD.
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Affiliation(s)
- Elżbieta Paszek
- Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Krzysztof P Malinowski
- Department of Bioinformatics and Telemedicine, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
- Center for Digital Medicine and Robotics, Jagiellonian University Medical College, Krakow, Poland
| | - Michał Ząbczyk
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Krakow Center for Medical Research and Technologies, John Paul II Hospital, Krakow, Poland
| | - Saulius Butenas
- Department of Biochemistry, University of Vermont, Burlington, Vermont, USA
| | - Anetta Undas
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Krakow Center for Medical Research and Technologies, John Paul II Hospital, Krakow, Poland
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3
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Hassan N, Efing J, Kiesel L, Bendas G, Götte M. The Tissue Factor Pathway in Cancer: Overview and Role of Heparan Sulfate Proteoglycans. Cancers (Basel) 2023; 15:cancers15051524. [PMID: 36900315 PMCID: PMC10001432 DOI: 10.3390/cancers15051524] [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: 01/30/2023] [Revised: 02/24/2023] [Accepted: 02/26/2023] [Indexed: 03/05/2023] Open
Abstract
Historically, the only focus on tissue factor (TF) in clinical pathophysiology has been on its function as the initiation of the extrinsic coagulation cascade. This obsolete vessel-wall TF dogma is now being challenged by the findings that TF circulates throughout the body as a soluble form, a cell-associated protein, and a binding microparticle. Furthermore, it has been observed that TF is expressed by various cell types, including T-lymphocytes and platelets, and that certain pathological situations, such as chronic and acute inflammatory states, and cancer, may increase its expression and activity. Transmembrane G protein-coupled protease-activated receptors can be proteolytically cleaved by the TF:FVIIa complex that develops when TF binds to Factor VII (PARs). The TF:FVIIa complex can activate integrins, receptor tyrosine kinases (RTKs), and PARs in addition to PARs. Cancer cells use these signaling pathways to promote cell division, angiogenesis, metastasis, and the maintenance of cancer stem-like cells. Proteoglycans play a crucial role in the biochemical and mechanical properties of the cellular extracellular matrix, where they control cellular behavior via interacting with transmembrane receptors. For TFPI.fXa complexes, heparan sulfate proteoglycans (HSPGs) may serve as the primary receptor for uptake and degradation. The regulation of TF expression, TF signaling mechanisms, their pathogenic effects, and their therapeutic targeting in cancer are all covered in detail here.
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Affiliation(s)
- Nourhan Hassan
- Department of Gynecology and Obstetrics, Münster University Hospital, Domagkstrasse 11, 48149 Münster, Germany
- Biotechnology/Biomolecular Chemistry Program, Faculty of Science, Cairo University, Giza 12613, Egypt
| | - Janes Efing
- Department of Gynecology and Obstetrics, Münster University Hospital, Domagkstrasse 11, 48149 Münster, Germany
| | - Ludwig Kiesel
- Department of Gynecology and Obstetrics, Münster University Hospital, Domagkstrasse 11, 48149 Münster, Germany
| | - Gerd Bendas
- Pharmaceutical Department, University Bonn, An der Immenburg 4, 53225 Bonn, Germany
| | - Martin Götte
- Department of Gynecology and Obstetrics, Münster University Hospital, Domagkstrasse 11, 48149 Münster, Germany
- Correspondence:
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4
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Paszek E, Pociask E, Ząbczyk M, Butenas S, Undas A. Activated factor XI is associated with increased factor VIIa - Antithrombin complexes in stable coronary artery disease: Impact on cardiovascular outcomes. Eur J Clin Invest 2022; 52:e13857. [PMID: 35996895 DOI: 10.1111/eci.13857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/05/2022] [Accepted: 08/18/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Coronary artery disease (CAD) is associated with a prothrombotic tendency including increased factor (F) VIIa-antithrombin (FVIIa-AT) complexes, a measure of tissue factor (TF) exposure, and activated FXI (FXIa). We investigated whether increased FVIIa-AT complexes are associated with FXIa and active TF and if major adverse clinical outcomes are predicted by the complexes in CAD. METHODS In 120 CAD patients, we assessed FVIIa-AT complex concentrations and the presence of circulating FXIa and active TF. Levels of 8-iso-prostaglandin F2α (8-iso-PGF2α), interleukin-6, high-sensitivity C reactive protein, prothrombin fragment 1 + 2, and free Tissue Factor Pathway Inhibitor were determined. Myocardial infarction (MI), ischemic stroke, systemic thromboembolism (SE), and cardiovascular (CV) death were recorded separately and as a composite endpoint, during follow-up. RESULTS FVIIa-AT complexes were positively associated with current smoking and multivessel CAD. Elevated FVIIa-AT complexes characterized patients with circulating FXIa and/or active TF in association with increased plasma isoprostanes but not with thrombin generation or inflammatory markers. During a median follow-up of 106 months (interquartile range 95-119), high baseline levels of FVIIa-AT complexes predicted ischemic stroke/SE (HR 4.61 [95% CI 1.48-18.42]) and a composite endpoint of MI, stroke/SE, and CV death (HR 7.47 [95% CI 2.81-19.87]). CONCLUSIONS This study is the first to show that high FVIIa-AT complexes characterize advanced CAD patients with detectable FXIa and active TF, which is, in part, driven by oxidative stress. High FVIIa-AT complexes were associated with the risk of ischemic stroke/SE during long-term follow-up, highlighting the need for effective antithrombotic agents in CAD.
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Affiliation(s)
- Elżbieta Paszek
- Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland.,Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Elżbieta Pociask
- Department of Biocybernetics and Biomedical Engineering, AGH University of Science and Technology, Krakow, Poland
| | - Michał Ząbczyk
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland.,Krakow Center for Medical Research and Technologies, John Paul II Hospital, Krakow, Poland
| | - Saulius Butenas
- Department of Biochemistry, University of Vermont, Burlington, Vermont, USA
| | - Anetta Undas
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland.,Krakow Center for Medical Research and Technologies, John Paul II Hospital, Krakow, Poland
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5
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Ząbczyk MT, Hanarz M, Malinowski KP, Pociask E, Butenas S, Gajos G, Undas A. Active FXI Can Independently Predict Ischemic Stroke in Anticoagulated Atrial Fibrillation Patients: A Cohort Study. Thromb Haemost 2022; 122:1397-1406. [PMID: 35158400 DOI: 10.1055/s-0042-1742366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is associated with a prothrombotic state. Presence of active tissue factor (TF), activated factor IX (FIXa) and FXIa in circulating blood contributes to thrombosis. We investigated a prognostic value of these factors in AF patients. METHODS In this cohort study, 284 AF patients (aged 63.3 ± 8.8 years) treated with oral anticoagulants were enrolled. Plasma levels of active coagulation factors were evaluated using thrombin generation assay. Concentrations of fibrinogen, D-dimer, interleukin-6 (IL-6), and endothelial damage markers, including von Willebrand factor (VWF) and soluble (s)E-selectin, were also measured. Ischemic stroke and cardiovascular death, analyzed separately or as a composite endpoint, were recorded during a mean follow-up of 47 months. RESULTS Cerebrovascular events were observed in 20 patients (1.8%/year) who had at baseline higher fibrinogen, D-dimer, and VWF levels. Active TF and FXIa at enrollment were detectable in 12 (60%) and 15 (75%) patients who experienced ischemic stroke during follow-up. The composite endpoint observed in 23 patients (2.1%/year) was associated with increased concentrations of the above laboratory variables, along with 26% higher IL-6 levels. sE-selectin did not differ between the studied groups. On multivariable regression analysis, advanced age, anticoagulation discontinuation, and detectable FXIa, but not active TF, independently predicted the composite endpoint. No associations of FIXa with the study endpoints were observed. CONCLUSION FXIa present in circulating blood is associated with increased risk of ischemic stroke and cardiovascular death in anticoagulated AF patients during long-term follow-up. FXIa inhibition could be useful in cardiovascular prevention in AF beyond the current oral anticoagulation.
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Affiliation(s)
- Michał Tomasz Ząbczyk
- Department of Experimental Cardiac Surgery, Anesthesiology and Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland.,Krakow Centre for Medical Research and Technologies, John Paul II Hospital, Krakow, Poland
| | - Maksymilian Hanarz
- Department of Experimental Cardiac Surgery, Anesthesiology and Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Krzysztof P Malinowski
- Department of Bioinformatics and Telemedicine, Jagiellonian University Medical College, Krakow, Poland
| | - Elżbieta Pociask
- Department of Biocybernetics and Biomedical Engineering, AGH University of Science and Technology, Krakow, Poland
| | - Saulius Butenas
- Department of Biochemistry, University of Vermont, Burlington, Vermont, United States
| | - Grzegorz Gajos
- Department of Coronary Disease and Heart Failure, John Paul II Hospital, Krakow, Poland.,Department of Coronary Disease and Heart Failure, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Anetta Undas
- Department of Experimental Cardiac Surgery, Anesthesiology and Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland.,Krakow Centre for Medical Research and Technologies, John Paul II Hospital, Krakow, Poland
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6
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Paszek E, Pociask E, Ząbczyk M, Piórkowski A, Butenas S, Legutko J, Undas A. Active factor XI is associated with the risk of cardiovascular events in stable coronary artery disease patients. Atherosclerosis 2022; 346:124-132. [DOI: 10.1016/j.atherosclerosis.2022.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/20/2022] [Accepted: 02/09/2022] [Indexed: 01/03/2023]
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7
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Gerber GF, Klute KA, Chapin J, Bussel J, DeSancho MT. Peri- and Postpartum Management of Patients With Factor XI Deficiency. Clin Appl Thromb Hemost 2020; 25:1076029619880262. [PMID: 31595781 PMCID: PMC6900674 DOI: 10.1177/1076029619880262] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Factor XI (FXI) deficiency is an uncommon autosomal disorder with variable bleeding phenotype, making peripartum management challenging. We describe our experience in pregnant women with FXI deficiency and identify strategies to minimize the use of hemostatic agents and increase utilization of neuraxial anesthesia. Electronic records of 28 pregnant women with FXI deficiency seen by a hematology service in an academic medical center from January 2006 to August 2018 were reviewed. Data on bleeding, obstetric history, peripartum management, and FXI activity were collected. Partial FXI deficiency was defined as >20 IU/dL and severe <20 IU/dL. Median FXI activity was 42 IU/dL (range <1-73 IU/dL), and median activated partial thromboplastin time was 32.2 seconds (range: 27.8-75 seconds). There were 64 pregnancies: 53 (83%) live births and 11 (17%) pregnancy losses. Postpartum hemorrhage occurred in 9 (17%) pregnancies. Antifibrinolytic agents and fresh frozen plasma were used only in women with severe deficiency (42% with bleeding and 17% with no bleeding phenotype, respectively). Neuraxial anesthesia was successfully administered in 32 (59%) deliveries. Most women with FXI deficiency have uncomplicated pregnancies and deliveries with minimal hemostatic support. Neuraxial anesthesia can be safely administered in most women.
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Affiliation(s)
- Gloria F Gerber
- Department of Medicine, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA
| | - Kelsey A Klute
- Division of Oncology and Hematology, University of Nebraska Medical Center, Omaha, NE, USA
| | - John Chapin
- Clinical Development, CRISPR Therapeutics, Cambridge, MA, USA
| | - James Bussel
- Division of Hematology-Oncology, Department of Pediatrics, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA
| | - Maria T DeSancho
- Division of Hematology-Oncology, Department of Medicine, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA
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8
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Prior SM, Park MS, Mann KG, Butenas S. Endogenous Procoagulant Activity in Trauma Patients and Its Relationship to Trauma Severity. TH OPEN 2019; 3:e10-e19. [PMID: 31249976 PMCID: PMC6524897 DOI: 10.1055/s-0038-1677030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 11/27/2018] [Indexed: 12/13/2022] Open
Abstract
Background
It has been observed that trauma patients have elevated plasma procoagulant activity that could be assigned to an elevated concentration of tissue factor (TF). However, in many instances there is a discrepancy between the levels of TF and the procoagulant activity observed. We hypothesized that factor XIa (FXIa) could be responsible for this additional activity and that the presence and levels of both proteins could correlate with trauma severity.
Methods
Citrate plasma from 98 trauma patients (47 blunt, 17 penetrating, and 34 thermal) were evaluated in clotting assays for the presence of FXIa and TF activity using respective inhibitory antibodies.
Results
When the three trauma patient groups were divided into two cohorts (Injury Severity Score [ISS] > 25 and ISS ≤ 25), higher frequencies and concentrations of both TF and FXIa were observed for all the more severe injury subgroups.
Conclusions
The majority of trauma patients have active FXIa in their plasma, with a significant fraction having active TF as well. Additionally, both TF and FXIa frequency and concentration directly relate to trauma severity. These data suggest the use of these two proteins as potential markers for the stratification of trauma patients.
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Affiliation(s)
- Shannon M Prior
- Department of Biochemistry, University of Vermont, Colchester, Vermont, United States
| | - Myung S Park
- Division of Trauma, Critical Care, and General Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Kenneth G Mann
- Department of Biochemistry, University of Vermont, Colchester, Vermont, United States
| | - Saulius Butenas
- Department of Biochemistry, University of Vermont, Colchester, Vermont, United States
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9
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Goldman S, Prior SM, Bembenek JP, Niewada M, Broniatowska E, Członkowska A, Butenas S, Undas A. Activation of blood coagulation and thrombin generation in acute ischemic stroke treated with rtPA. J Thromb Thrombolysis 2018; 44:362-370. [PMID: 28879581 PMCID: PMC5617868 DOI: 10.1007/s11239-017-1544-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The impact of thrombolysis with recombinant tissue plasminogen activator (rtPA) on blood coagulation in acute ischemic stroke (AIS) patients is not completely understood. We studied the effect of thrombolysis on the thrombin generation (TG) profile as well as coagulant activity of activated factors IX (FIXa), XI (FXIa) and tissue factor (TF) in AIS patients. In a case-control study, TG parameters as well as FIXa, FXIa and TF levels were assessed in 95 AIS patients, including individuals receiving rtPA treatment within 4.5 h since AIS onset (n = 71, 74.7%) and those ineligible for thrombolysis (n = 24, 25.3%). Blood samples were collected at baseline and after 24 h since admission. The two groups were similar with regard to demographics and clinical factors. In thrombolysed patients, all TG parameters measured after 24 h were markedly decreased, with strongest impact on lag time (LT), when compared with the baseline values (81.3% longer LT, p < 0.0001), as well as when compared to the non-thrombolysed group (86% longer LT, p = 0.002). In non-thrombolysed AIS patients the TG remained unaltered. Logistic regression adjusted for potential confounders showed that high baseline ETP value (the top quartile) was solely predicted by the presence of circulating FIXa, whereas after 24 h FXIa predicted high ETP in the subgroup of thrombolysed and in all AIS patients. Thrombolysis in AIS patients markedly attenuates the TG. Elevated FXIa contributes to thrombin formation capacity after 24 h, highlighting a role of this factor in the regulation of blood coagulation in AIS.
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Affiliation(s)
- Sarah Goldman
- Krakow Center for Medical Research and Technology, John Paul II Hospital, Krakow, Poland
| | - Shannon M Prior
- Department of Biochemistry, University of Vermont, Colchester, VT, USA
| | - Jan P Bembenek
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Maciej Niewada
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Elżbieta Broniatowska
- Department of Bioinformatics and Telemedicine, Jagiellonian University Medical College, Krakow, Poland
| | - Anna Członkowska
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Saulius Butenas
- Department of Biochemistry, University of Vermont, Colchester, VT, USA
| | - Anetta Undas
- Krakow Center for Medical Research and Technology, John Paul II Hospital, Krakow, Poland. .,Institute of Cardiology, Jagiellonian University Medical College, 80 Pradnicka St., 31-202, Krakow, Poland.
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10
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Ades S, Douce D, Holmes CE, Cory S, Prior S, Butenas S, Callas P, Cushman M. Effect of rosuvastatin on risk markers for venous thromboembolism in cancer. J Thromb Haemost 2018; 16:1099-1106. [PMID: 29575637 DOI: 10.1111/jth.14004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Indexed: 12/21/2022]
Abstract
Essentials Statins lower venous thromboembolism risk in general but have not been studied in cancer patients. We completed a randomized trial of rosuvastatin vs. placebo among cancer patients on chemotherapy. Rosuvastatin did not significantly lower prothrombotic biomarkers including D-dimer. The role of statins in venous thrombosis prevention in cancer patients remains unknown. SUMMARY Background Statin therapy is associated with lower risk of venous thromboembolism (VTE) but has not been prospectively evaluated in patients with advanced cancer. Objectives We determined if statin administration in this high-risk population reduces the risk of VTE, based on established and emerging biomarkers. Patients/Methods This double-blind, crossover, randomized controlled trial among patients with advanced cancer receiving systemic therapy allocated participants to rosuvastatin 20 mg daily or placebo for 3-4 weeks prior to crossover to the alternative therapy, with a 3-5-week washout. D-dimer, C-reactive protein (CRP), soluble (s)P-selectin, factor VIII (FVIII), thrombin generation and exploratory biomarkers focusing on endogenous thrombin potential, including tissue factor (TF), activated factor IX (FIXa) and activated factor XI (FXIa), were measured at the start and end of both treatment periods. The primary outcome was change in D-dimer with rosuvastatin compared with placebo. Results Of 38 enrolled participants, 24 (63%) completed the study. Rosuvastatin did not cause statistically significant changes in D-dimer levels or any other biomarker. CRP levels decreased by 40%; 4.3 mg L-1 (95% confidence interval, -11.0 to +2.5 mg L-1 ) compared with placebo. In post-hoc analysis, participants who received rosuvastatin initially during their first line of treatment had a 13% decrease in D-dimer. Circulating TF, FIXa and FXIa were detected in 26%, 68% and 71% of cancer patients despite not being found in healthy individuals. Conclusions Rosuvastatin did not cause favorable changes in biomarkers of VTE risk in advanced cancer patients receiving chemotherapy. The role of statin therapy as thromboprophylaxis in the cancer population remains uncertain.
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Affiliation(s)
- S Ades
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - D Douce
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - C E Holmes
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - S Cory
- Department of Graduate Entry Medicine, Royal College of Surgeons, Dublin, Ireland
| | - S Prior
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - S Butenas
- Department of Biochemistry, Larner College of Medicine, University of Vermont, Colchester, VT, USA
| | - P Callas
- Department of Medical Biostatistics, University of Vermont, Burlington, VT, USA
| | - M Cushman
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, VT, USA
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11
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Prior SM, Mann KG, Freeman K, Butenas S. Continuous thrombin generation in whole blood: New applications for assessing activators and inhibitors of coagulation. Anal Biochem 2018; 551:19-25. [PMID: 29746819 DOI: 10.1016/j.ab.2018.05.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 04/14/2018] [Accepted: 05/03/2018] [Indexed: 11/25/2022]
Abstract
Hemostatic tests have been utilized to clarify the blood coagulation potential. The novel thrombin generation (TG) assay of this study provides explicit information and is the most physiologically-relevant hemostatic test ex vivo. We describe how this assay allows for TG under a number of relevant circumstances. First, whole blood (WB) from healthy individuals was analyzed ± 5 pM tissue factor (TF) and ± contact pathway inhibition. Without an exogenous initiator TG was decreased and delayed, but addition of 5 pM TF shortened the lag phase and increased peak thrombin. Additional experiments included fresh WB from a trauma patient analyzed for endogenous activity and TG from healthy donors subjected to TG antagonists which prolonged the lag phase whereas TG agonists consistently shortened the lag phase in a dose dependent manner. Lastly, platelet-poor plasma was reconstituted with packed red blood cells and TG was monitored in the presence and absence of both TF as an activator and PCPS as a phospholipid surface. Our data illustrate the potential that this continuous TG assay has in the evaluation of disorders relevant to blood coagulation and in the monitoring of treatments administered in response to these disorders.
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Affiliation(s)
- Shannon M Prior
- University of Vermont, Department of Biochemistry, 360 South Park Drive, Colchester, VT 05446, USA.
| | - Kenneth G Mann
- University of Vermont, Department of Biochemistry, 360 South Park Drive, Colchester, VT 05446, USA.
| | - Kalev Freeman
- University of Vermont, Department of Surgery, 89 Beaumont Avenue, Burlington, VT 05405, USA.
| | - Saulius Butenas
- University of Vermont, Department of Biochemistry, 360 South Park Drive, Colchester, VT 05446, USA.
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12
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Shupp JW, Prior SM, Jo DY, Moffatt LT, Mann KG, Butenas S. Analysis of factor XIa, factor IXa and tissue factor activity in burn patients. Burns 2017; 44:436-444. [PMID: 29032977 DOI: 10.1016/j.burns.2017.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 06/15/2017] [Accepted: 08/08/2017] [Indexed: 12/31/2022]
Abstract
INTRODUCTION An elevated procoagulant activity observed in trauma patients is, in part, related to tissue factor (TF) located on blood cells and microparticles. However, analysis of trauma patient plasma indicates that there are other contributor(s) to the procoagulant activity. We hypothesize that factor (F)XIa and FIXa are responsible for an additional procoagulant activity in burn patients. METHODS Multiple time-point plasma samples from 56 burn patients (total number of samples was 471; up to 20 time-points/patient collected in 3 weeks following admission) were evaluated in a thrombin generation assay using inhibitory antibodies to TF, FIXa and FXIa. RESULTS Due to the limited volume of some samples, not all were analyzed for all three proteins. At admission, 10 of 53 patients (19%) had active TF, 53 of 55 (96%) had FXIa and 48 of 55 (87%) had FIXa in their plasma. 34 patients of 56 enrolled (61%) showed TF activity at one or more time-points. All patients had FXIa and 96% had FIXa at one or more time-points. Overall, TF was observed in 99 of 455 samples analyzed (22%), FXIa in 424 of 471 (90%) and FIXa in 244 of 471 (52%). The concentration of TF was relatively low and varied between 0 and 2.1pM, whereas that of FXIa was higher, exceeding 100pM in some samples. The majority of samples with FIXa had it at sub-nanomolar concentrations. No TF, FXIa and FIXa activity was detected in plasma from healthy individuals. CONCLUSIONS For the first time reported, the majority of plasma samples from burn patients have active FXIa and FIXa, with a significant fraction of them having active TF. The concentration of all three proteins varies in a wide range.
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Affiliation(s)
- Jeffrey W Shupp
- Department of Surgery, MedStar Washington Hospital Center, Washington, DC, United States.
| | - Shannon M Prior
- University of Vermont, Department of Biochemistry, Burlington, VT, United States.
| | - Daniel Y Jo
- Department of Surgery, MedStar Washington Hospital Center, Washington, DC, United States.
| | - Lauren T Moffatt
- Department of Surgery, MedStar Washington Hospital Center, Washington, DC, United States.
| | - Kenneth G Mann
- Haematologic Technologies, Inc., Essex Junction, VT, United States.
| | - Saulius Butenas
- University of Vermont, Department of Biochemistry, Burlington, VT, United States.
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Valga F, Monzón T, Henriquez Palop F, Antón G. Alargamiento del tiempo de hemostasia en hemodiálisis. Déficit del factor xi (hemofilia C). A propósito de un caso. Nefrologia 2017; 37:544-545. [DOI: 10.1016/j.nefro.2016.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 08/31/2016] [Accepted: 10/16/2016] [Indexed: 10/19/2022] Open
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Correlation between factor (F)XIa, FIXa and tissue factor and trauma severity. J Trauma Acute Care Surg 2017; 82:1073-1079. [PMID: 28328676 DOI: 10.1097/ta.0000000000001449] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND It has been observed that trauma patients often display elevated procoagulant activity that could be caused, in part, by tissue factor (TF). We previously observed that trauma patients with thermal, blunt, and penetrating injuries have active FIXa and FXIa in their plasma. In the current study, we evaluated the effect of injury severity, with or without accompanying shock, on the frequency and concentration of TF, FIXa, and FXIa in plasma from trauma patients. METHODS Eighty trauma patients were enrolled and divided equally into four groups based on their Injury Severity Score and base deficit:Blood was collected at a 0 time-point (first blood draw upon arrival at hospital) and citrate plasma was prepared, frozen, and stored at -80 °C. FXIa, FIXa, and TF activity assays were based on a response of thrombin generation to corresponding monoclonal inhibitory antibodies. RESULTS The frequency and median concentrations of TF were relatively low in non-severe injury groups (17.5% and 0 pM, respectively) but were higher in those with severe injury (65% and 0.5 pM, respectively). Although FXIa was observed in 91% of samples and was high across all four groups, median concentrations were highest (by approximately fourfold) in groups with shock. FIXa was observed in 80% of plasma samples and concentrations varied in a relatively narrow range between all four groups. No endogenous activity was observed in plasma from healthy individuals. CONCLUSIONS (1) Frequency and concentration of TF is higher in patients with a higher trauma severity. (2) Concentration of FXIa is higher in patients with shock. (3) For the first time reported, the vast majority of plasma samples from trauma patients contain active FIXa and FXIa. LEVEL OF EVIDENCE Prognostic/epidemiological study, level II.
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Kusak P, Czarnecka D, Gissel M, Plens K, Butenas S, Undas A. Activated factor IX, factor XI and tissue factor identify patients with permanent atrial fibrillation treated with warfarin who are at risk of ischemic stroke. Arch Med Sci 2016; 12:1000-1007. [PMID: 27695490 PMCID: PMC5016572 DOI: 10.5114/aoms.2015.54791] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 03/12/2015] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Previously, we have demonstrated that significant proportions of patients with various cardiovascular diseases have active tissue factor and active factor XIa in their plasma. In the current study, we evaluated active tissue factor and active factors (F)XI and FIX in plasma from patients with atrial fibrillation. MATERIAL AND METHODS In 110 consecutive patients with permanent atrial fibrillation receiving warfarin, we determined active tissue factor, together with plasma FIXa and FXIa, using clotting assays by measuring the response to inhibitory monoclonal antibodies. RESULTS Sixteen (14.5%) patients had detectable active tissue factor and active FXIa, including 11 subjects with both factors, while FIXa was observed in 28 (25.7%) patients. The three positive groups did not differ from the patients without these factors with regard to demographic and clinical characteristics. Von Willebrand factor was higher in the active tissue factor-positive group (p < 0.0001) and FXIa-positive group (p = 0.0037). Individuals positive for active tissue factor and FXIa had higher plasma interleukin-6 levels (p = 0.0014 and 0.0322, respectively). The presence of active tissue factor, FXIa and FIXa in anticoagulated patients with permanent atrial fibrillation correlated with elevated von Willebrand factor and interleukin-6. During a 3-year follow-up, ischemic stroke (n = 12, 10.9%) occurred more commonly among atrial fibrillation patients who had circulating TF (p = 0.002) or FXIa (p = 0.013). CONCLUSIONS These data suggest that circulating active coagulation factors, in particular TF and FXIa, can be detected despite oral anticoagulation in a significant proportion of patients with atrial fibrillation, and could represent novel markers of persistent prothrombotic alterations predisposing to ischemic stroke.
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Affiliation(s)
- Piotr Kusak
- Institute of Cardiology, Jagiellonian University School of Medicine, Krakow, Poland
| | - Danuta Czarnecka
- Institute of Cardiology, Jagiellonian University School of Medicine, Krakow, Poland
| | - Matthew Gissel
- Department of Biochemistry, University of Vermont, Burlington, Vermont, USA
| | | | - Saulius Butenas
- Department of Biochemistry, University of Vermont, Burlington, Vermont, USA
| | - Anetta Undas
- Institute of Cardiology, Jagiellonian University School of Medicine, Krakow, Poland
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Aleshnick M, Foley JH, Keating FK, Butenas S. Procoagulant activity in stored units of red blood cells. Biochem Biophys Res Commun 2016; 474:680-685. [PMID: 27150627 DOI: 10.1016/j.bbrc.2016.05.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 05/01/2016] [Indexed: 01/08/2023]
Abstract
The procoagulant activity (PA) of stored units of red blood cells (RBC) increases over time, which is related to the expression/exposure of tissue factor (TF). However, there is a discrepancy between the TF measured and changes in PA observed, suggesting that other blood components contribute to this activity. Our goal was to evaluate changes in PA of stored RBCs and to determine possible contributors to it. RBC units from 4 healthy donors were prepared and stored at 4 °C. On selected days, RBC aliquots were reconstituted with autologous plasma and tested in the thromboelastography assay. Corresponding supernatants were tested in a clotting assay. For all donors, the clotting time (CT) of reconstituted RBC units decreased from ∼3000-4000s on day 1 to ∼1000-1600s on day 30, with the most dramatic changes occurring between days 1 and 5. Anti-TF antibody slightly prolonged the CT. The concentration of TF did not change significantly over time and was within the range of 0.3-2.3 pM. Bovine lactadherin (LTD) prolonged the CT of the RBC (by 2.4-3.4-fold in days 3-5 and by 1.3-1.8-fold at day 30). Anti-TF antibody together with LTD had a cumulative effect on the CT prolongation. CT of supernatants responded to both anti-TF and anti-FXIa antibodies. Three contributors to the PA of stored RBC were identified, i.e. FXIa in solution and phosphatidylserine and TF exposed on blood cells and microparticles. Failure of LTD and antibodies to completely eliminate PA suggests that other components of blood could contribute to it.
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Affiliation(s)
- Maya Aleshnick
- Department of Biochemistry, University of Vermont, 360 South Park Drive, Room 235A, Colchester, VT 05446, USA.
| | - Jonathan H Foley
- Department of Biochemistry, University of Vermont, 360 South Park Drive, Room 235A, Colchester, VT 05446, USA.
| | - Friederike K Keating
- Department of Medicine, University of Vermont, 360 South Park Drive, Room 235A, Colchester, VT 05446, USA.
| | - Saulius Butenas
- Department of Biochemistry, University of Vermont, 360 South Park Drive, Room 235A, Colchester, VT 05446, USA.
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Hansson KM, Nielsen S, Elg M, Deinum J. The effect of corn trypsin inhibitor and inhibiting antibodies for FXIa and FXIIa on coagulation of plasma and whole blood. J Thromb Haemost 2014; 12:1678-86. [PMID: 25142753 DOI: 10.1111/jth.12707] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 08/10/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Corn trypsin inhibitor (CTI), an inhibitor of FXIIa, is used to prevent plasma coagulation by contact activation, to specifically investigate tissue factor (TF)-initiated coagulation. OBJECTIVE In the present work the specificity of CTI for factor (F) XIIa is questioned. METHODS AND RESULTS In the commercial available plasma coagulation assays CTI was found to double activated partial thromboplastin time (APTT) at a plasma concentration of 7.3 ± 1.5 μm CTI (assay concentration 2.4 μm). No effect was found on the prothrombin time (PT) when high TF concentrations were used. Also, with specific antibodies for FXIIa and for FXIa only APTT was found to be extended but not PT. With specific enzyme assays using chromogenic substrates CTI was shown to be a strong inhibitor of FXIIa and a competitive inhibitor of FXIa with Ki = 8.1 ± 0.3 μm, without effect on the coagulation factors FVIIa, FIXa, FXa and thrombin. In thrombin generation and coagulation (free oscillation rheometry, FOR) assays, initiated with low TF concentrations, no effect of CTI (plasma concentrations of 4.4 and 13.6 μm CTI, 25 resp. 100 mg L(-1) in blood) was found with ≥ 1 pm TF. At ≤ 0.1 pm TF in the FOR whole blood assay the coagulation time (CT) concentration dependently increased while the plasma CT became longer than the observation time. CONCLUSION To avoid inhibition of FXIa and the thrombin feedback loop we recommend that for coagulation assays the concentration of CTI in blood should be below 20 mg L(-1) (1.6 μm) and in plasma below 3 μm.
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Affiliation(s)
- K M Hansson
- CVMD iMED, AstraZeneca R&D Mölndal, Mölndal, Sweden
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Haynes LM, Dubief YC, Mann KG. Membrane binding events in the initiation and propagation phases of tissue factor-initiated zymogen activation under flow. J Biol Chem 2011; 287:5225-34. [PMID: 22187432 DOI: 10.1074/jbc.m111.302075] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
This study investigates the dynamics of zymogen activation when both extrinsic tenase and prothrombinase are assembled on an appropriate membrane. Although the activation of prothrombin by surface-localized prothrombinase is clearly mediated by flow-induced dilutional effects, we find that when factor X is activated in isolation by surface-localized extrinsic tenase, it exhibits characteristics of diffusion-mediated activation in which diffusion of substrate to the catalytically active region is rate-limiting. When prothrombin and factor X are activated coincident with each other, competition for available membrane binding sites masks the diffusion-limiting effects of factor X activation. To verify the role of membrane binding in the activation of factor X by extrinsic tenase under flow conditions, we demonstrate that bovine lactadherin competes for both factor X and Xa binding sites, limiting factor X activation and forcing the release of bound factor Xa from the membrane at a venous shear rate (100 s(-1)). Finally, we present steady-state models of prothrombin and factor X activation under flow showing that zymogen and enzyme membrane binding events further regulate the coagulation process in an open system representative of the vasculature geometry.
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Affiliation(s)
- Laura M Haynes
- Department of Biochemistry, University of Vermont College of Medicine, Colchester, Vermont 05446, USA
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Szlam F, Sreeram G, Solomon C, Levy JH, Molinaro RJ, Tanaka KA. Elevated factor VIII enhances thrombin generation in the presence of factor VIII-deficiency, factor XI-deficiency or fondaparinux. Thromb Res 2010; 127:135-40. [PMID: 21144556 DOI: 10.1016/j.thromres.2010.10.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Revised: 09/02/2010] [Accepted: 10/19/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Increased levels of factor VIII occur as a response to vascular injury and/or inflammation, and may increase thrombotic risks. In contrast, factor VIII deficiency poses a major hemostatic challenge. The role of factor VIII in modulating hemostasis/thrombosis was investigated in plasma models of hypocoagulable and hypercoagulable state using thrombin generation (TG) assay. METHODS TG was performed in undiluted/diluted control, FVIII-deficient, FVIII-deficient with low antithrombin (AT activity, ~59%), and factor XI-deficient plasma samples using relipidated tissue factor (TF, 2 pM) or dilute Actin as activators. The impact of elevated FVIII on TG was simulated by adding Humate-P (0 to 3 U/ml) to the above plasma samples. In fondaparinux (1 μg/ml) treated plasma with normal or lower AT activity effects of Humate-P vs. 60 nM of recombinant activated factor VII (rFVIIa) were also evaluated. RESULTS Humate-P increased TG concentration dependently in undiluted and diluted control plasma with TF activation. With Actin activation, only the concentration dependent shortening of lag time, but no change in peak thrombin was observed. In FVIII-deficient, FVIII-deficient with low AT, and FXI-deficient samples, 3 U/ml of Humate-P increased TG, and decreased its onset with either activator. The reduced peak thrombin due to fondaparinux was reversed with Humate-P (3 U/ml) more than with rFVIIa. Elevated FVIII levels seem to favor intrinsic tenase formation and antagonize fondaparinux because anti-FIXa aptamer added to fondaparinux effectively attenuated TG. CONCLUSION Elevated FVIII supports the propagation of TG via intrinsic tenase formation under low TF condition, factor XI deficiency or in the presence of fondaparinux.
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Affiliation(s)
- Fania Szlam
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia 30322, USA
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20
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RUGERI L, QUÉLIN F, CHATARD B, DE MAZANCOURT P, NEGRIER C, DARGAUD Y. Thrombin generation in patients with factor XI deficiency and clinical bleeding risk. Haemophilia 2010; 16:771-7. [DOI: 10.1111/j.1365-2516.2010.02246.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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21
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Abstract
SUMMARY BACKGROUND In the extrinsic pathway, the essential procofactors factor (F) V and FVIII are activated to FVa and FVIIIa by thrombin. In the contact pathway and its clinical diagnostic test, the activated partial thromboplastin time (APTT) assay, the sources of procofactor activation are unknown. In the APTT assay, FXII is activated on a negatively charged surface and proceeds to activate FXI, which activates FIX upon the addition of Ca(2+). FIXa feeds thrombin generation through activation of FX. FIXa is an extremely poor catalyst in the absence of its FVIIIa cofactor, which, in the intrinsic FXase complex, increases FXa generation by approximately 10(7). One potential APTT procofactor activator in this setting is FXIa. OBJECTIVE To test the hypothesis that FXIa can activate FVIII and FV. METHODS Recombinant FVIII and plasma FV were treated with FXIa, and the activities and integrities of each procofactor were measured using commercial clotting assays and sodium dodecylsulfate polyacrylamide gel electrophoresis (SDS-PAGE). RESULTS Kinetic analyses of FXIa-catalyzed activation and inactivation of FV and FVIII are reported, and the the timing and sites of cleavage are defined. CONCLUSIONS FXIa activates both procofactors at plasma protein concentrations, and computational modeling suggests that procofactor activation during the preincubation phase of the APTT assay is critical to the performance of the assay. As the APTT assay is the primary tool for the diagnosis and management of hemophilias A and B, as well as in the determination of FVIII inhibitors, these findings have potential implications in the clinical setting.
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Affiliation(s)
- M F Whelihan
- Department of Biochemistry, University of Vermont College of Medicine, Burlington, VT, USA
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Duncan EM, Casey GJ, Fenech MP, Lerda NV, Casey CR, Rodgers SE, Lee SH, Chunilal S, Robinson K, Lloyd JV. Partial and severe factor XI deficiency in South Australia and the usefulness of factor XI mutation analysis for diagnosis. Pathology 2008; 40:401-6. [DOI: 10.1080/00313020801911462] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Szlam F, Taketomi T, Sheppard CA, Kempton CL, Levy JH, Tanaka KA. Antithrombin Affects Hemostatic Response to Recombinant Activated Factor VII in Factor VIII Deficient Plasma. Anesth Analg 2008; 106:719-24, table of contents. [DOI: 10.1213/ane.0b013e3181618702] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Although factor XI (FXI) deficiency has a particularly high incidence in Ashkenazi Jews, it is now frequently diagnosed in other ethnic groups. This review gives an overview of the basic pathophysiology, clinical manifestations, and management of FXI deficiency. The correlation between FXI levels and the bleeding phenotype is much less clear than in the haemophilias, and consequently the bleeding risk can be difficult to predict. Two well-characterized mutations in the F11 gene are responsible for the majority of Jewish cases, but new mutations are becoming increasingly recognized. The publication of the crystal structure has greatly enhanced our understanding of the structure-function relationship in FXI. The impact of recent studies on our understanding of the role of FXI in coagulation is discussed.
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Affiliation(s)
- K Gomez
- Haemophilia Centre and Thrombosis Unit, Royal Free Hospital, Hampstead, London, UK.
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Butenas S, Orfeo T, Brummel-Ziedins KE, Mann KG. Influence of bivalirudin on tissue factor-triggered coagulation. Blood Coagul Fibrinolysis 2007; 18:407-14. [PMID: 17581314 DOI: 10.1097/mbc.0b013e32814fcdb8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Bivalirudin, a synthetic analog of the carboxy-terminus of hirudin, is a reversible thrombin inhibitor used during coronary balloon angioplasty. The objective of this study was to evaluate the influence of bivalirudin on thrombin generation. Three in-vitro models (numerical simulations, synthetic coagulation proteome and whole blood) of contact pathway-independent blood coagulation triggered with tissue factor were used in this study. Increasing concentrations of bivalirudin prolong the initiation phase of thrombin generation in a concentration-dependent manner. At subpharmacologic bivalirudin concentrations (0.5-2 micromol/l), total thrombin generation was significantly increased. At a pharmacologic concentration (5 micromol/l), bivalirudin suppressed thrombin generation in the synthetic coagulation proteome; in numerical simulations and contact pathway-inhibited whole blood, no thrombin generation was detected over 1200-2000 s and platelet activation was inhibited by 80%. The addition of a pharmacologic concentration (9 micromol/l) of a naturally occurring protease inhibitor aprotinin in the presence of at least 0.5 micromol/l bivalirudin provided limited enhancement of the bivalirudin inhibitory effect. In conclusion, bivalirudin at pharmacologic concentrations is an efficient inhibitor of thrombin generation, platelet activation and clot formation, which acts not as a modulator but as an 'on-off' switch of blood coagulation.
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Affiliation(s)
- Saulius Butenas
- Department of Biochemistry, University of Vermont, College of Medicine, Burlington, Vermont, USA
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Abstract
The limitations of the vitamin K antagonists have prompted the development of new oral anticoagulants that target specific clotting enzymes. Most of the novel agents currently under development target either thrombin or factor Xa. As the final effector of blood coagulation and the most potent platelet agonist, thrombin is a logical target for new oral anticoagulants. Clinical trials with parenteral direct thrombin inhibitors revealed that the therapeutic window is wider with reversible inhibitors than with irreversible inhibitors. The results of clinical trials with ximelagatran, an orally active prodrug of melagatran, a reversible direct thrombin inhibitor, validate thrombin as a target. Although ximelagatran was withdrawn from the market because of hepatotoxicity, newer oral thrombin inhibitors, such as dabigatran etexilate, are filling the void. Several oral factor Xa inhibitors also are being tested. Is thrombin a better target for new oral anticoagulants than factor Xa? Only time will tell!
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Affiliation(s)
- J I Weitz
- Henderson Research Centre and McMaster University, Hamilton, ON, Canada.
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Butenas S, Bouchard BA, Brummel-Ziedins KE, Parhami-Seren B, Mann KG. Tissue factor activity in whole blood. Blood 2004; 105:2764-70. [PMID: 15604222 DOI: 10.1182/blood-2004-09-3567] [Citation(s) in RCA: 214] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Tissue factor (TF) is an integral membrane protein essential for hemostasis. During the past several years, a number of studies have suggested that physiologically active TF circulates in blood at concentrations greater than 30 pM either as a component of blood cells and microparticles or as a soluble plasma protein. In our studies using contact pathway-inhibited blood or plasma containing activated platelets, typically no clot is observed for 20 minutes in the absence of exogenous TF. An inhibitory anti-TF antibody also has no effect on the clotting time in the absence of exogenous TF. The addition of TF to whole blood at a concentration as low as 16 to 20 fM results in pronounced acceleration of clot formation. The presence of potential platelet TF activity was evaluated using ionophore-treated platelets and employing functional and immunoassays. No detectable TF activity or antigen was observed on quiescent or ionophore-stimulated platelets. Similarly, no TF antigen was detected on mononuclear cells in nonstimulated whole blood, whereas in lipopolysaccharide (LPS)-stimulated blood a significant fraction of monocytes express TF. Our data indicate that the concentration of physiologically active TF in non-cytokine-stimulated blood from healthy individuals cannot exceed and is probably lower than 20 fM.
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Affiliation(s)
- Saulius Butenas
- University of Vermont, Department of Biochemistry, Given Building, 89 Beaumont Ave, Burlington, VT 05405-0068, USA.
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Affiliation(s)
- U Hedner
- Professor of Clinical Coagulation Research, Lund University, Sweden.
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Abstract
Tissue factor (TF) is best known as the primary cellular initiator of blood coagulation. After vessel injury, the TF:FVIIa complex activates the coagulation protease cascade, which leads to fibrin deposition and activation of platelets. TF deficiency causes embryonic lethality in the mouse and there have been no reports of TF deficiency in humans. These results indicate that TF is essential for life, most likely because of its central role in hemostasis. In addition, aberrant TF expression within the vasculature initiates life-threatening thrombosis in various diseases, such as sepsis, atherosclerosis, and cancer. Finally, recent studies have revealed a nonhemostatic role of TF in the generation of coagulation proteases and subsequent activation of protease activated receptors (PARs) on vascular cells. This TF-dependent signaling contributes to a variety of biological processes, including inflammation, angiogenesis, metastasis, and cell migration. This review focuses on the roles of TF in hemostasis, thrombosis, and vascular development.
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Affiliation(s)
- Nigel Mackman
- The Scripps Research Institute, Department of Immunology, 10550 North Torrey Pines Road, La Jolla, Calif 92037, USA.
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