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Pablo-Moreno JAD, Serrano LJ, Revuelta L, Sánchez MJ, Liras A. The Vascular Endothelium and Coagulation: Homeostasis, Disease, and Treatment, with a Focus on the Von Willebrand Factor and Factors VIII and V. Int J Mol Sci 2022; 23:ijms23158283. [PMID: 35955419 PMCID: PMC9425441 DOI: 10.3390/ijms23158283] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/22/2022] [Accepted: 07/23/2022] [Indexed: 11/27/2022] Open
Abstract
The vascular endothelium has several important functions, including hemostasis. The homeostasis of hemostasis is based on a fine balance between procoagulant and anticoagulant proteins and between fibrinolytic and antifibrinolytic ones. Coagulopathies are characterized by a mutation-induced alteration of the function of certain coagulation factors or by a disturbed balance between the mechanisms responsible for regulating coagulation. Homeostatic therapies consist in replacement and nonreplacement treatments or in the administration of antifibrinolytic agents. Rebalancing products reestablish hemostasis by inhibiting natural anticoagulant pathways. These agents include monoclonal antibodies, such as concizumab and marstacimab, which target the tissue factor pathway inhibitor; interfering RNA therapies, such as fitusiran, which targets antithrombin III; and protease inhibitors, such as serpinPC, which targets active protein C. In cases of thrombophilia (deficiency of protein C, protein S, or factor V Leiden), treatment may consist in direct oral anticoagulants, replacement therapy (plasma or recombinant ADAMTS13) in cases of a congenital deficiency of ADAMTS13, or immunomodulators (prednisone) if the thrombophilia is autoimmune. Monoclonal-antibody-based anti-vWF immunotherapy (caplacizumab) is used in the context of severe thrombophilia, regardless of the cause of the disorder. In cases of disseminated intravascular coagulation, the treatment of choice consists in administration of antifibrinolytics, all-trans-retinoic acid, and recombinant soluble human thrombomodulin.
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Affiliation(s)
- Juan A. De Pablo-Moreno
- Department of Genetics, Physiology and Microbiology, School of Biology, Complutense University, 28040 Madrid, Spain; (J.A.D.P.-M.); (L.J.S.)
| | - Luis Javier Serrano
- Department of Genetics, Physiology and Microbiology, School of Biology, Complutense University, 28040 Madrid, Spain; (J.A.D.P.-M.); (L.J.S.)
| | - Luis Revuelta
- Department of Physiology, School of Veterinary Medicine, Complutense University of Madrid, 28040 Madrid, Spain;
| | - María José Sánchez
- Centro Andaluz de Biología del Desarrollo (CABD), Consejo Superior de Investigaciones Científicas (CSIC), Junta de Andalucía, Pablo de Olavide University, 41013 Sevilla, Spain;
| | - Antonio Liras
- Department of Genetics, Physiology and Microbiology, School of Biology, Complutense University, 28040 Madrid, Spain; (J.A.D.P.-M.); (L.J.S.)
- Correspondence:
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Rey Y Formoso V, Barreto Mota R, Soares H. Developmental hemostasis in the neonatal period. World J Pediatr 2022; 18:7-15. [PMID: 34981411 DOI: 10.1007/s12519-021-00492-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/17/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The hemostatic system is complex and evolves continuously since gestation and well into the adult years, in a process known as "developmental hemostasis." DATA SOURCES A comprehensive review was performed after an extensive literature search on PubMed/MEDLINE concerning developmental hemostasis during the neonatal period. Relevant cross references were also included. RESULTS Although part of a system, each component of the hemostatic system evolves differently, with many displaying both quantitative and qualitative age-related differences. This leads to drastic disparities between the coagulation system of neonates and both other children's and adults', while still maintaining a generally balanced and physiological hemostasis. The motives behind this process remain to be fully elucidated but may be, at least in part, related to non-hemostatic factors. CONCLUSIONS Knowledge regarding "developmental hemostasis" is essential for everyone caring for newborns or even children in general and in this review, we describe each hemostatic system component's neonatal characteristics and age-related progression as well as explore some of the possible physiological motives behind the process.
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Affiliation(s)
- Vicente Rey Y Formoso
- Neonatology Department (Reference Center for Congenital Heart Diseases), São João University Hospital Center, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.
| | - Ricardo Barreto Mota
- Neonatology Department (Reference Center for Congenital Heart Diseases), São João University Hospital Center, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Henrique Soares
- Neonatology Department (Reference Center for Congenital Heart Diseases), São João University Hospital Center, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.,Faculty of Medicine, Porto University, Porto, Portugal
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Robinson V, Achey MA, Nag UP, Reed CR, Pahl KS, Greenberg RG, Clark RH, Tracy ET. Thrombosis in infants in the neonatal intensive care unit: Analysis of a large national database. J Thromb Haemost 2021; 19:400-407. [PMID: 33075167 DOI: 10.1111/jth.15144] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 10/11/2020] [Accepted: 10/13/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Thrombosis in the neonatal population is rare, but increasing. Its incidence and management are not well understood. OBJECTIVES To investigate the incidence, associated factors, and management of thrombosis in the neonatal intensive care unit (NICU) population. PATIENTS/METHODS We performed a retrospective cohort study of infants admitted to a Pediatrix Medical Group-affiliated NICU from 1997 through 2015. We determined the prevalence of venous and arterial thrombosis, and assessed demographic characteristics and known risk factors. Categorical variables were compared with the Pearson χ2 test and continuous variables with Wilcoxon rank-sum tests. Stepwise logistic regression was used to identify associated factors. The primary outcome was incidence of thrombosis. Secondary analyses investigated correlations between clinical and demographic characteristics and thrombosis. RESULTS Among 1 158 755 infants, we identified 2367 (0.20%) diagnosed with thrombosis. In a multivariable regression analysis, prematurity, male sex, congenital heart disease, sepsis, ventilator support, vasopressor receipt, central venous catheter, invasive procedures, and receipt of erythropoietin were associated with increased risk of thrombosis, while Black race and Hispanic ethnicity were associated with reduced risk. The majority of infants diagnosed with thrombosis (73%) received no anticoagulation, but anticoagulant use in infants with thrombosis was higher than those without (27% versus 0.2%, P < .001). Thrombosis in infants was associated with higher mortality (11% versus 2%, P < .001) and longer hospital stays (57 days, [interquartile range (IQR) 28--100] versus 10 days, [IQR 6--22], P < .001). CONCLUSIONS In the largest national study to date, we found that thrombosis in NICU patients is associated with prematurity, low birth weight, sepsis, and invasive procedures.
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Affiliation(s)
| | | | - Uttara P Nag
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Kristy S Pahl
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Rachel G Greenberg
- Division of Neonatology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - Elisabeth T Tracy
- Division of Pediatric Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Achey MA, Nag UP, Robinson VL, Reed CR, Arepally GM, Levy JH, Tracy ET. The Developing Balance of Thrombosis and Hemorrhage in Pediatric Surgery: Clinical Implications of Age-Related Changes in Hemostasis. Clin Appl Thromb Hemost 2020; 26:1076029620929092. [PMID: 32584601 PMCID: PMC7427005 DOI: 10.1177/1076029620929092] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/14/2020] [Accepted: 04/30/2020] [Indexed: 12/17/2022] Open
Abstract
Bleeding and thrombosis in critically ill infants and children is a vexing clinical problem. Despite the relatively low incidence of bleeding and thrombosis in the overall pediatric population relative to adults, these critically ill children face unique challenges to hemostasis due to extreme physiologic derangements, exposure of blood to foreign surfaces and membranes, and major vascular endothelial injury or disruption. Caring for pediatric patients on extracorporeal support, recovering from solid organ transplant or invasive surgery, and after major trauma is often complicated by major bleeding or clotting events. As our ability to care for the youngest and sickest of these children increases, the gaps in our understanding of the clinical implications of developmental hemostasis have become increasingly important. We review the current understanding of the development and function of the hemostatic system, including the complex and overlapping interactions of coagulation proteins, platelets, fibrinolysis, and immune mediators from the neonatal period through early childhood and to young adulthood. We then examine scenarios in which our ability to effectively measure and treat coagulation derangements in pediatric patients is limited. In these clinical situations, adult therapies are often extrapolated for use in children without taking age-related differences in pediatric hemostasis into account, leaving clinicians confused and impacting patient outcomes. We discuss the limitations of current coagulation testing in pediatric patients before turning to emerging ideas in the measurement and management of pediatric bleeding and thrombosis. Finally, we highlight opportunities for future research which take into account this developing balance of bleeding and thrombosis in our youngest patients.
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Affiliation(s)
| | - Uttara P. Nag
- Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | | | | | - Gowthami M. Arepally
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jerrold H. Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Elisabeth T. Tracy
- Division of Pediatric Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC, USA
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Patino M, Chandrakantan A. Midgestational Fetal Procedures. CASE STUDIES IN PEDIATRIC ANESTHESIA 2019:197-201. [DOI: 10.1017/9781108668736.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Sokou R, Konstantinidi A, Stefanaki C, Tsantes AG, Parastatidou S, Lampropoulou K, Katsaras G, Tavoulari E, Iacovidou N, Kyriakou E, Gounaris A, Bonovas S, Tsantes AE. Thromboelastometry: studying hemostatic profile in small for gestational age neonates-a pilot observational study. Eur J Pediatr 2019; 178:551-557. [PMID: 30707363 DOI: 10.1007/s00431-019-03331-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/24/2019] [Accepted: 01/25/2019] [Indexed: 12/23/2022]
Abstract
Scarce data exists about the hemostatic status of small for gestational age (SGA) neonates. We aimed at evaluating the hemostatic profile of SGA neonates, using thromboelastometry (TEM). This is an observational study performed in a Greek tertiary General Hospital during an 18-month period. Ninety-three neonates were included in the study: 48 appropriate for gestational age weight (AGA) neonates and 45 SGA neonates Extrinsically activated TEM (ex-TEM) parameters, such as clotting time, clot formation time, amplitude recorded at 5 and 10 min, a angle, maximum clot firmness, lysis index at 60 min, and also platelet count, were used for the evaluation of the hemostatic profile in all neonates. No statistically significant differences were noticed regarding all ex-TEM parameters between AGA and SGA neonates, while no event of hemorrhage or thrombosis was noticed in the study population.Conclusions: The coagulation system of SGA neonates seems to be fully functional, with no evident tendency toward coagulopathy or thrombosis, when compared with AGA neonates. TEM seems to provide a promising and valid assessment of coagulation and fibrinolysis systems and may be used as a valuable biomarker, in the future. Further studies, with large samples, are necessary to confirm our results. What is Known: • SGA neonates may present coagulation disorders mainly due to hepatic dysfunction, polycythemia, and thrombocytopenia owing to long-term intrauterine hypoxia. • In the literature, despite the statistically significant differences in laboratory results between SGA and AGA neonates, no clinical manifestations of significantly altered hemostasis were recorded. Data of TEM interpretation of hemostasis in SGA neonates are not available. What is New: • TEM seems to interpret coagulation mechanism of preterm and full-term SGA neonates and confirm previous relevant literature findings regarding hemostasis in these neonates.
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Affiliation(s)
- Rozeta Sokou
- Neonatal Intensive Care Unit, Nikaia General Hospital "Aghios Panteleimon", Piraeus, Greece.
| | | | - Charikleia Stefanaki
- Neonatal Intensive Care Unit, Nikaia General Hospital "Aghios Panteleimon", Piraeus, Greece
| | - Andreas G Tsantes
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Stavroula Parastatidou
- Neonatal Intensive Care Unit, Nikaia General Hospital "Aghios Panteleimon", Piraeus, Greece
| | - Katerina Lampropoulou
- Neonatal Intensive Care Unit, Nikaia General Hospital "Aghios Panteleimon", Piraeus, Greece
| | - George Katsaras
- Neonatal Intensive Care Unit, Nikaia General Hospital "Aghios Panteleimon", Piraeus, Greece
| | - Evagelia Tavoulari
- Neonatal Intensive Care Unit, Nikaia General Hospital "Aghios Panteleimon", Piraeus, Greece
| | - Nicoletta Iacovidou
- Neonatal Department, Aretaeio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Elias Kyriakou
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonios Gounaris
- Neonatal Intensive Care Unit, University Hospital of Larissa, Larissa, Greece
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Humanitas Clinical and Research Center, Milan, Italy
| | - Argirios E Tsantes
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Abstract
BACKGROUND Thromboelastography (TEG) is utilized as a point-of-care test of coagulation function to improve evidence-based blood product replacement in adults. In contrast to standard indices of coagulation, TEG reflects the dynamic interactions among the elements involved in hemostasis, including fibrinolysis. Although normal adult values and various abnormalities have been characterized, normative values for term neonates have not been described. Studies of neonatal TEG remain limited and have small sample sizes with inconsistent methodology. The aim of this study is to provide normative data on healthy term neonates, and to assess the impact of mode of delivery on TEG parameters at term. METHODS Venous umbilical blood was obtained from the placenta within 10 min of delivery. TEG analysis of citrated kaolin-activated samples was performed for 50 healthy term vaginal and 50 cesarean deliveries. Samples collected for cesarean sections were from scheduled cases or unscheduled ones due to failure of progression of labor. RESULTS Healthy neonates with uncomplicated vaginal term deliveries resulted in the following TEG parameters: R: 5.41 ± 1.34 (mean ± SD) min; K: 1.62 ± 0.75 min; α-angle: 65.39 ± 8.77°; MA: 65.86 ± 5.81 mm; and LY30: 1.40 ± 1.18%. Results for the cesarean delivery neonatal TEG assays showed: R: 5.51 ± 1.74 (mean ± SD) min; K: 1.52 ± 0.47 min; α-angle: 64.15 ± 4.61°; MA: 64.15 ± 4.61 mm; and LY30: 2.44 ± 3.51%. Of note, no statistical differences were observed (p < .01) between the groups. CONCLUSION TEG measurements from term neonates were no different when the neonates were delivered vaginally or by cesarean section. Labor had no effect on neonatal TEG levels. Neonatal TEG values may therefore serve as insight for fetal values at the appropriate postconceptional age.
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Affiliation(s)
- Nicholas J Schott
- a Department of Anesthesiology , University of Pittsburgh , Pittsburgh , PA , USA
| | - Stephen P Emery
- b Department of Obstetrics, Gynecology & Reproductive Sciences, Division of Ultrasound , University of Pittsburgh , Pittsburgh , PA , USA
| | - Courtney Garbee
- a Department of Anesthesiology , University of Pittsburgh , Pittsburgh , PA , USA
| | - Jonathan Waters
- c Department of Anesthesiology and Bioengineering , Magee Womens Hospital of UPMC , Pittsburgh , PA , USA
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Circuncisión neonatal con anestesia local. Resultados de un protocolo estandarizado. ACTA ACUST UNITED AC 2016; 87:175-9. [DOI: 10.1016/j.rchipe.2015.06.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 06/10/2015] [Accepted: 06/22/2015] [Indexed: 11/19/2022]
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Piccione G, Arfuso F, Quartuccio M, Di Pietro S, Giudice E. Age-Related Developmental Clotting Profile and Platelet Aggregation in Foals Over the First Month of Life. J Equine Vet Sci 2015. [DOI: 10.1016/j.jevs.2014.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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