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Bavinck AP, Heerde WV, Schols SEM. Point-of-Care Testing in Patients with Hereditary Disorders of Primary Hemostasis: A Narrative Review. Semin Thromb Hemost 2024. [PMID: 38950596 DOI: 10.1055/s-0044-1787976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
Inherited disorders of primary hemostasis, such as von Willebrand disease and congenital platelet disorders, can cause extensive, typically mucocutaneous bleeding. Assays to diagnose and monitor these disorders, such as von Willebrand factor activity assays and light transmission aggregometry, are performed in specialized hemostasis laboratories but are commonly not available in local hospitals. Due to the complexity and relative scarcity of these conventional assays, point-of-care tests (POCT) might be an attractive alternative in patients with hereditary bleeding disorders. POCTs, such as thromboelastography, are increasingly used to assess hemostasis in patients with acquired hemostatic defects, aiding clinical decision-making in critical situations, such as during surgery or childbirth. In comparison, the use of these assays in patients with hereditary hemostasis defects remains relatively unexplored. This review aims to give an overview of point-of-care hemostasis tests in patients with hereditary disorders of primary hemostasis. A summary of the literature reporting on the performance of currently available and experimental POCTs in these disorders is given, and the potential utility of the assays in various use scenarios is discussed. Altogether, the studies included in this review reveal that several POCTs are capable of identifying and monitoring severe defects in the primary hemostasis, while a POCT that can reliably detect milder defects of primary hemostasis is currently lacking. A better understanding of the strengths and limitations of POCTs in assessing hereditary defects of primary hemostasis is needed, after which these tests may become available for clinical practice, potentially targeting a large group of patients with milder defects of primary hemostasis.
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Affiliation(s)
- Aernoud P Bavinck
- Department of Hematology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Waander van Heerde
- Department of Hematology, Radboud University Medical Centre, Hemophilia Treatment Centre Nijmegen-Eindhoven-Maastricht, Nijmegen, The Netherlands
| | - Saskia E M Schols
- Department of Hematology, Radboud University Medical Centre, Hemophilia Treatment Centre Nijmegen-Eindhoven-Maastricht, Nijmegen, The Netherlands
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2
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Introna M, Broggi M, Ferroli P, Martino D, Pinto C, Carpenedo M, Gemma M. Perioperative ROTEM® evaluation in a patient affected by severe VII factor deficiency undergoing microvascular decompression craniotomy for hemifacial spasm. J Clin Monit Comput 2024:10.1007/s10877-024-01183-w. [PMID: 38850455 DOI: 10.1007/s10877-024-01183-w] [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: 04/05/2024] [Accepted: 05/28/2024] [Indexed: 06/10/2024]
Abstract
The potential use of TEG/ROTEM® in evaluating the bleeding risk for rare coagulation disorders needs to be assessed, considering the common mismatch among laboratory tests and the clinical manifestations. As a result, there is currently no published data on the use of viscoelastic tests to assess coagulation in FVII deficient patients undergoing elective neurosurgery. We describe the case of a patient affected by severe FVII deficiency who underwent microvascular decompression (MVD) craniotomy for hemifacial spasm (HFS). The ROTEM® did not show a significant coagulopathy according to the normal ranges, before and after the preoperative administration of the recombinant activated FVII, but a substantial reduction in EXTEM and FIBTEM Clotting Times was noted. The values of coagulation in standard tests, on the contrary, were indicative of a coagulopathy, which was corrected by the administration of replacement therapy. Whether this difference between ROTEM® and standard tests is due to the inadequacy of thromboelastographic normal ranges in this setting, or to the absence of clinically significant coagulopathy, has yet to be clarified. Neurosurgery is a typical high bleeding risk surgery; additional data is required to clarify the potential role for thromboelastographic tests in the perioperative evaluation of the FVII deficient neurosurgical patients.
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Affiliation(s)
- Michele Introna
- Neurointensive Care Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy.
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Morgan Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Paolo Ferroli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Donato Martino
- Neurointensive Care Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Carmela Pinto
- Neurointensive Care Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Monica Carpenedo
- Hematology Unit, ASST Fatebenefratelli-Sacco, Ospedale L. Sacco, Polo Didattico Università degli Studi di Milano, Milano, Italy
| | - Marco Gemma
- Neurointensive Care Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
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3
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López AA, Cohen CT, Small A, Lam FW, Bachim AN. Traumatic intracranial hemorrhage in pediatrics: Implications of factor XIII deficiency and consumptive coagulopathy in abusive head trauma evaluation. CHILD ABUSE & NEGLECT 2024; 149:106651. [PMID: 38325162 DOI: 10.1016/j.chiabu.2024.106651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 12/28/2023] [Accepted: 01/10/2024] [Indexed: 02/09/2024]
Abstract
For infants that present with intracranial hemorrhage in the setting of suspected abusive head trauma (AHT), the standard recommendation is to perform an evaluation for a bleeding disorder. Factor XIII (FXIII) deficiency is a rare congenital bleeding disorder associated with intracranial hemorrhages in infancy, though testing for FXIII is not commonly included in the initial hemostatic evaluation. The current pediatric literature recognizes that trauma, especially traumatic brain injury, may induce coagulopathy in children, though FXIII is often overlooked as having a role in pediatric trauma-induced coagulopathy. We report an infant that presented with suspected AHT in whom laboratory workup revealed a decreased FXIII level, which was later determined to be caused by consumption in the setting of trauma induced coagulopathy, rather than a congenital disorder. Within the Child Abuse Pediatrics Research Network (CAPNET) database, 85 out of 569 (15 %) children had FXIII testing, 3 of those tested (3.5 %) had absent FXIII activity on qualitative testing, and 2 (2.4 %) children had activity levels below 30 % on quantitative testing. In this article we review the literature on the pathophysiology and treatment of low FXIII in the setting of trauma. This case and literature review demonstrate that FXIII consumption should be considered in the setting of pediatric AHT.
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Affiliation(s)
- Arianexys Aquino López
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States of America; Division of Hematology and Oncology, Department of Pediatrics, United States of America
| | - Clay T Cohen
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States of America; Division of Hematology and Oncology, Department of Pediatrics, United States of America
| | - Amanda Small
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States of America; Division of Public Health Pediatrics, Department of Pediatrics, United States of America
| | - Fong Wilson Lam
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States of America; Division of Pediatric Critical Care Medicine, Department of Pediatrics, United States of America
| | - Angela N Bachim
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States of America; Division of Public Health Pediatrics, Department of Pediatrics, United States of America.
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4
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Tang N, Li D. A screening method of factor XIII inhibitor based on thromboelastography. Clin Chim Acta 2023; 551:117626. [PMID: 37923105 DOI: 10.1016/j.cca.2023.117626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/28/2023] [Accepted: 10/31/2023] [Indexed: 11/07/2023]
Affiliation(s)
- Ning Tang
- Clinical Laboratory, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Dengju Li
- Hematology Department, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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5
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Ramanujam V, DiMaria S, Varma V. Thromboelastography in the Perioperative Period: A Literature Review. Cureus 2023; 15:e39407. [PMID: 37362492 PMCID: PMC10287184 DOI: 10.7759/cureus.39407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2023] [Indexed: 06/28/2023] Open
Abstract
Assessing coagulation status is essential for prompt intervention to reduce morbidity and mortality related to bleeding and thrombotic complications during the perioperative period. Traditional coagulation tests such as platelet count, activated partial thromboplastin time (aPTT), prothrombin time (PT), international normalized ratio (INR), and activated clotting time (ACT) provide only static evaluation. These tests are not designed for assessment of dynamically changing coagulation conditions during the perioperative time. However, viscoelastic coagulation testing such as thromboelastography (TEG) produces a rapid numerical and graphical representation that helps to detect and direct targeted hemostatic therapy. Searching the literature through PubMed, Medline, Ovid, CINAHL, and ClinicalTrials.gov we retrieved 210 studies, which represent the use of TEG in the perioperative period. The included studies were categorized under various settings such as trauma, obstetrics, orthopedics, intensive care unit (ICU), cardiovascular, transplant, and miscellaneous scenarios. TEG showed promising results in trauma surgeries in predicting mortality, hypercoagulability, and bleeding even when it was compared to conventional methods. TEG was also useful in monitoring anticoagulant therapy in orthopedic and obstetric surgeries; however, its role in predicting thrombotic events, hypercoagulability, or complications was questionable. In ICU patients, it showed promising results, especially in the prediction or improvement of sepsis, coagulopathy, thrombotic events, ICU duration, hospital stay, and ventilator duration. TEG parameters effectively predicted hypercoagulation in transplant surgeries. Regarding cardiovascular surgeries, they were effective in the prediction of the need for blood products, coagulopathy, thrombotic events, and monitoring anticoagulation therapy. More randomized clinical trials comparing TEG parameters with standardized tools are needed to produce robust results to standardize its use in different perioperative settings.
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Affiliation(s)
- Vendhan Ramanujam
- Department of Anesthesiology, Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, USA
| | - Stephen DiMaria
- Department of Anesthesiology, Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, USA
| | - Vivek Varma
- Department of Anesthesiology, Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, USA
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Bruno L, Lenberg J, Le D, Dimmock D, Thornburg CD, Briggs B. Novel Approach to Improve the Identification of the Bleeding Phenotype in Noonan Syndrome and Related RASopathies. J Pediatr 2023:S0022-3476(23)00019-7. [PMID: 36646249 DOI: 10.1016/j.jpeds.2022.12.036] [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: 09/27/2022] [Revised: 11/10/2022] [Accepted: 12/01/2022] [Indexed: 01/14/2023]
Abstract
OBJECTIVES To characterize bleeding phenotype in Noonan Syndrome, to test the utility of following national guidelines in detecting this phenotype, to evaluate thromboelastography (TEG) as a diagnostic tool and to evaluate the cohort for genotype-phenotype correlations. STUDY DESIGN Participants with a clinical diagnosis NS or related RASopathy were enrolled in a cohort study. Study procedures included clinical bleeding assessment, coagulation testing per guidelines and hematology consultation. TEG was completed in a subset and genetic testing was conducted for those without a molecular diagnosis. International Society of Haemostasis and Thrombosis Bleeding Assessment Tool (ISTH-BAT) scores were calculated with hematology consultation. Bleeding phenotype was defined as abnormal bleeding score. RESULTS Twenty participants enrolled; 12completed clinical and laboratory evaluation, five of whom met the definition for bleeding phenotype. Four of the five participants with a bleeding phenotype had platelet aggregation defects and at least one additional coagulation defect. TEG was performed in nine participants, four with bleeding phenotype and five without, and results were normal in all cases. No genotype-phenotype correlation was found. CONCLUSION Five of 20 participants had a bleeding phenotype identified. Based on available data we do not recommend incorporating TEG into clinical practice for NS patients. Platelet aggregation defects were the most common abnormalities, which would not be detected on Tier 1 testing of current guidelines, therefore we propose a new algorithm.
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Affiliation(s)
- Leah Bruno
- Department of Pediatrics, Division of Hematology and Oncology, University of California San Diego, La Jolla, California; Rady Children's Institute of Genomic Medicine, San Diego, California
| | - Jerica Lenberg
- Rady Children's Institute of Genomic Medicine, San Diego, California
| | - Dzung Le
- Department of Pathology, University of California San Diego, La Jolla, California
| | - David Dimmock
- Rady Children's Institute of Genomic Medicine, San Diego, California
| | - Courtney D Thornburg
- Department of Pediatrics, Division of Hematology and Oncology, University of California San Diego, La Jolla, California; Hemophilia and Thrombosis Treatment Center, Rady Children's Hospital San Diego, San Diego, California
| | - Benjamin Briggs
- Rady Children's Institute of Genomic Medicine, San Diego, California.
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Bunch CM, Berquist M, Ansari A, McCoy ML, Langford JH, Brenner TJ, Aboukhaled M, Thomas SJ, Peck E, Patel S, Cancel E, Al-Fadhl MD, Zackariya N, Thomas AV, Aversa JG, Greene RB, Seder CW, Speybroeck J, Miller JB, Kwaan HC, Walsh MM. The Choice between Plasma-Based Common Coagulation Tests and Cell-Based Viscoelastic Tests in Monitoring Hemostatic Competence: Not an either-or Proposition. Semin Thromb Hemost 2022; 48:769-784. [PMID: 36174601 DOI: 10.1055/s-0042-1756302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
There has been a significant interest in the last decade in the use of viscoelastic tests (VETs) to determine the hemostatic competence of bleeding patients. Previously, common coagulation tests (CCTs) such as the prothrombin time (PT) and partial thromboplastin time (PTT) were used to assist in the guidance of blood component and hemostatic adjunctive therapy for these patients. However, the experience of decades of VET use in liver failure with transplantation, cardiac surgery, and trauma has now spread to obstetrical hemorrhage and congenital and acquired coagulopathies. Since CCTs measure only 5 to 10% of the lifespan of a clot, these assays have been found to be of limited use for acute surgical and medical conditions, whereby rapid results are required. However, there are medical indications for the PT/PTT that cannot be supplanted by VETs. Therefore, the choice of whether to use a CCT or a VET to guide blood component therapy or hemostatic adjunctive therapy may often require consideration of both methodologies. In this review, we provide examples of the relative indications for CCTs and VETs in monitoring hemostatic competence of bleeding patients.
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Affiliation(s)
- Connor M Bunch
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Margaret Berquist
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Aida Ansari
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Max L McCoy
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Jack H Langford
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Toby J Brenner
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Michael Aboukhaled
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Samuel J Thomas
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Ethan Peck
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Shivani Patel
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Emily Cancel
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Mahmoud D Al-Fadhl
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Nuha Zackariya
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Anthony V Thomas
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - John G Aversa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ryan B Greene
- Department of Interventional Radiology, St. Joseph Regional Medical Center, Mishawaka, Indiana
| | - Christopher W Seder
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Jacob Speybroeck
- Department of Orthopedic Surgery, Case Western Medical Center, Cleveland, Ohio
| | - Joseph B Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Hau C Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mark M Walsh
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana.,Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
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8
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Haas T, Faraoni D. Viscoelastic testing in pediatric patients. Transfusion 2021; 60 Suppl 6:S75-S85. [PMID: 33089938 DOI: 10.1111/trf.16076] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/04/2020] [Accepted: 06/14/2020] [Indexed: 12/18/2022]
Abstract
A tailored transfusion algorithm based on viscoelastic testing in the perioperative period or in trauma patients is recommended by guidelines for bleeding management. Bleeding management strategies in neonates and children are mostly extrapolated from the adult experience, as published evidence in the youngest age group is scarce. This manuscript is intended to give a structured overview of what has been published on the use of viscoelastic testing to guide bleeding management in neonates and children. Several devices that use either the traditional viscoelastic method or resonance viscoelastography technology are on the market. Reference ranges for children have been evaluated in only some of them. As most of the hemostasis maturation processes can be observed during the first year of life, adult reference ranges for viscoelastic testing could be applied over the age of 1 year. The majority of the published trials in children are based on retrospective analyses describing the correlation between viscoelastic testing and standard laboratory testing or focusing on the prediction of bleeding. Clinically more relevant studies in pediatric patients undergoing cardiac surgery have demonstrated that the implementation of a transfusion algorithm based on viscoelastic testing has significantly reduced transfusion requirements and that this approach has enabled a rapid detection of coagulation disorders in the presence of excessive bleeding. Although further studies are urgently needed, experts have reviewed the use of a transfusion algorithm based on viscoelastic testing in children as a feasible approach, as it has been shown to improve bleeding management and rationalize blood product transfusion.
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Affiliation(s)
- Thorsten Haas
- Department of Pediatric Anesthesia, Zurich University Children's Hospital, Zurich, Switzerland
| | - David Faraoni
- Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Speybroeck J, Marsee M, Shariff F, Zackariya N, Grisoli A, Lune SV, Larson EE, Hatch J, McCauley R, Shariff F, Aversa JG, Son M, Agostini V, Campello E, Simioni P, Scărlătescu E, Kwaan H, Hartmann J, Fries D, Walsh M. Viscoelastic testing in benign hematologic disorders: Clinical perspectives and future implications of point-of-care testing to assess hemostatic competence. Transfusion 2021; 60 Suppl 6:S101-S121. [PMID: 33089936 DOI: 10.1111/trf.16088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 09/04/2020] [Accepted: 09/05/2020] [Indexed: 01/04/2023]
Abstract
Viscoelastic tests (VETs) have been used routinely for liver transplantation, cardiac surgery, and trauma, but only recently have found clinical utility in benign hematologic disorders. Therefore, guidelines for diagnosis and treatment of these disorders based on viscoelastic variables have been adapted from the existing transplant, cardiothoracic surgery, and trauma resuscitation literature. As a result, diagnostic and therapeutic strategies for benign hematologic disorders utilizing VETs are not uniform. Accordingly, even though there has been a recent increase in the utilization of VET for the diagnosis and treatment of such disorders, the literature is still in its early stages. Analysis of point-of-care viscoelastic tracings from benign hematologic disorders has the potential to allow prompt recognition of disease and to guide patient-specific intervention. Here we present a review describing the application of VETs to benign hematologic disorders.
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Affiliation(s)
- Jacob Speybroeck
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Mathew Marsee
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Faadil Shariff
- Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Nuha Zackariya
- Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Anne Grisoli
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Stefani Vande Lune
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Emilee E Larson
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Jordan Hatch
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Ross McCauley
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Faisal Shariff
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - John G Aversa
- Department of General Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Michael Son
- Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Vanessa Agostini
- Department of Transfusion Medicine, IRCC Polyclinic Hospital San Marino, Genoa, Italy
| | - Elena Campello
- Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padua University Hospital, Padua, Italy
| | - Paolo Simioni
- Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padua University Hospital, Padua, Italy
| | - Escaterina Scărlătescu
- Department of Anaesthesia and Intensive Care, Fundeni Clinical Institute, Bucharest, Romania
| | - Hau Kwaan
- Department of Hematology Oncology, Northwestern University School of Medicine, Chicago, Illinois
| | - Jan Hartmann
- Department of Medical Affairs, Haemonetics Corporation, Boston, Massachusetts
| | - Dietmar Fries
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Mark Walsh
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana.,Saint Joseph Regional Medical Center, Mishawaka, Indiana
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Evaluation of Bleeding Phenotype of Inherited Factor VII Deficiency in Children With a Bleeding Assessment Tool and Global Assays. J Pediatr Hematol Oncol 2020; 42:e527-e530. [PMID: 31343480 DOI: 10.1097/mph.0000000000001564] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Inherited factor VII (FVII) deficiency is the most common of the rare bleeding disorders and shows a heterogenous distribution of bleeding phenotypes independent of factor activity level. The bleeding score (BS) evaluates the phenotype of patients with rare bleeding disorders. Thromboelastography (TEG) and thrombin generation assays (TGAs) are 2 methods to evaluate global hemostasis, and controversially both tests are useful for identifying different bleeding tendency phenotypes. The purpose of this study was to investigate the use of the BS and global assays (TEG and TGAs) to predict the bleeding phenotype of inherited FVII deficiency. MATERIALS AND METHODS A total of 27 patients with FVII deficiency were evaluated with the BS and global hemostasis assays. RESULTS The BS was compatible with disease severity according to the FVII activity level (P<0.05) but the BS and bleeding grade of patients did not show a statistically significant correlation with factor activity level (P>0.05). No significant correlation was observed between the factor activity level and any TEG parameter (P>0.05). The factor activity level was negatively correlated with the lag time of the TGA on the contrary positively correlated with the peak thrombin time of the TGA (P<0.05). CONCLUSIONS The global assays do not successfully predict the bleeding phenotype. The BS is a more suitable tool than conventional and global assays for predicting the bleeding phenotype.
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11
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Rigouzzo A, Louvet N, Favier R, Ore MV, Piana F, Girault L, Farrugia M, Sabourdin N, Constant I. Assessment of Coagulation by Thromboelastography During Ongoing Postpartum Hemorrhage. Anesth Analg 2020; 130:416-425. [DOI: 10.1213/ane.0000000000004422] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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12
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Devata S, Angelini DE, Blackburn S, Hawley A, Myers DD, Schaefer JK, Hemmer M, Magnani JL, Thackray HM, Wakefield TW, Sood SL. Use of GMI-1271, an E-selectin antagonist, in healthy subjects and in 2 patients with calf vein thrombosis. Res Pract Thromb Haemost 2020; 4:193-204. [PMID: 32110749 PMCID: PMC7040550 DOI: 10.1002/rth2.12279] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/13/2019] [Accepted: 10/14/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND There is an unmet need for antithrombotic treatments for venous thromboembolic disease that do not increase bleeding risk. Selectins are cell adhesion molecules that augment thrombosis by activating immune cells to initiate the coagulation cascade. GMI-1271, a potent small-molecule E-selectin antagonist, has been shown in mouse models to decrease thrombus burden with a low risk of bleeding. METHODS A first-in-human study of GMI-1271 was conducted to assess its safety, tolerability, and pharmacokinetic (PK) profile. As a secondary end point, biomarkers of coagulation, cell adhesion, and leukocyte/platelet activation were evaluated. Aims 1 and 2 were performed in healthy volunteers and evaluated single and multiple doses of the study drug, respectively. Aim 3 included 2 patients with isolated calf-level deep vein thrombosis (DVT). RESULTS GMI-1271 showed consistent PK parameters for doses ranging from 2 to 40 mg/kg. Plasma levels increased in a linear manner with respect to dose, while clearance, volume of distribution, and half-life were not dose dependent. No accumulation was seen with multiple consecutive doses. No serious adverse events (grade 3 or 4) were reported. Biomarker analysis demonstrated a trend in reduction of soluble E-selectin (sEsel) levels with GMI-1271 exposure, while exposure did not impact laboratory testing of coagulation. Two patients with calf vein DVT were treated with GMI-1271 and demonstrated rapid improvement of symptoms after 48 hours, with repeat ultrasound showing signs of clot resolution. CONCLUSIONS We demonstrate that GMI-1271 is safe in healthy volunteers and provide proof of concept that an E-selectin antagonist is a potential therapeutic approach to treat venous thrombosis.
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Affiliation(s)
- Sumana Devata
- Department of Internal MedicineDivision of Hematology/OncologyUniversity of MichiganAnn ArborMIUSA
| | - Dana E. Angelini
- Department of Hematology and Medical OncologyTaussig Cancer InstituteCleveland Clinic FoundationClevelandOHUSA
| | - Susan Blackburn
- Conrad Jobst Vascular Research LaboratoriesSection of Vascular SurgeryUniversity of Michigan Medical CenterAnn ArborMIUSA
| | - Angela Hawley
- Conrad Jobst Vascular Research LaboratoriesSection of Vascular SurgeryUniversity of Michigan Medical CenterAnn ArborMIUSA
| | - Daniel D. Myers
- Conrad Jobst Vascular Research LaboratoriesSection of Vascular SurgeryUniversity of Michigan Medical CenterAnn ArborMIUSA
| | - Jordan K. Schaefer
- Department of Internal MedicineDivision of Hematology/OncologyUniversity of MichiganAnn ArborMIUSA
| | | | | | | | - Thomas W. Wakefield
- Conrad Jobst Vascular Research LaboratoriesSection of Vascular SurgeryUniversity of Michigan Medical CenterAnn ArborMIUSA
| | - Suman L. Sood
- Department of Internal MedicineDivision of Hematology/OncologyUniversity of MichiganAnn ArborMIUSA
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13
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Clinico-hematological and thromboelastographic profiles in glanzmann's thrombasthenia. Blood Coagul Fibrinolysis 2020; 31:29-34. [DOI: 10.1097/mbc.0000000000000870] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Al-Horani RA, Abdelfadiel EI, Afosah DK, Morla S, Sistla JC, Mohammed B, Martin EJ, Sakagami M, Brophy DF, Desai UR. A synthetic heparin mimetic that allosterically inhibits factor XIa and reduces thrombosis in vivo without enhanced risk of bleeding. J Thromb Haemost 2019; 17:2110-2122. [PMID: 31397071 PMCID: PMC6893084 DOI: 10.1111/jth.14606] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 07/15/2019] [Accepted: 08/07/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Human factor XIa (FXIa) is an actively pursued target for development of safer anticoagulants. Our long-standing hypothesis has been that allosterism originating from heparin-binding site(s) on coagulation enzymes is a promising approach to yield safer agents. OBJECTIVES To develop a synthetic heparin mimetic as an inhibitor of FXIa so as to reduce clot formation in vivo but not carry high bleeding risk. METHODS We employed a gamut of methods involving synthetic chemistry, biophysical biochemistry, enzyme assays, blood and plasma coagulation assays, and in vivo thrombosis models in this work. RESULTS Sulfated chiro-inositol (SCI), a non-saccharide mimetic of heparin, was synthesized in three steps in overall yields of >50%. SCI inhibited FXIa with potency of 280 nmol/L and preferentially engaged FXIa's heparin-binding site to conformationally alter its active site. SCI inhibition of FXIa could be rapidly reversed by common antidotes, such as protamine. SCI preferentially prolonged plasma clotting initiated with recalcification, rather than thromboplastin, alluding to its intrinsic pathway-based mechanism. Human blood thromboelastography indicated good ex vivo anticoagulation properties of SCI. Rat tail bleeding and maximum-dose-tolerated studies indicated that no major bleeding or toxicity concerns for SCI suggesting a potentially safer anticoagulation outcome. FeCl3 -induced arterial and thromboplastin-induced venous thrombosis model studies in the rat showed reduced thrombus formation by SCI at 250 μg/animal, which matched enoxaparin at 2500 μg/animal. CONCLUSIONS Overall, SCI is a highly promising, allosteric inhibitor of FXIa that induces potent anticoagulation in vivo. Further studies are necessary to assess SCI in animal models mimicking human clinical indications.
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Affiliation(s)
- Rami A. Al-Horani
- Department of Medicinal Chemistry, Virginia Commonwealth University, Richmond, VA 23298
- Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, VA 23219
| | - Elsamani I. Abdelfadiel
- Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, VA 23219
- Department of Biochemistry, Virginia Commonwealth University, Richmond, VA 23298
| | - Daniel K. Afosah
- Department of Medicinal Chemistry, Virginia Commonwealth University, Richmond, VA 23298
- Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, VA 23219
| | - Shravan Morla
- Department of Medicinal Chemistry, Virginia Commonwealth University, Richmond, VA 23298
- Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, VA 23219
| | - Jyothi C. Sistla
- Department of Medicinal Chemistry, Virginia Commonwealth University, Richmond, VA 23298
- Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, VA 23219
| | - Bassem Mohammed
- Department of Pharmacotherapy and Outcomes Sciences, Virginia Commonwealth University, Richmond, VA 23298
| | - Erika J. Martin
- Department of Pharmacotherapy and Outcomes Sciences, Virginia Commonwealth University, Richmond, VA 23298
| | - Masahiro Sakagami
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, VA 23298
| | - Donald F. Brophy
- Department of Pharmacotherapy and Outcomes Sciences, Virginia Commonwealth University, Richmond, VA 23298
| | - Umesh R. Desai
- Department of Medicinal Chemistry, Virginia Commonwealth University, Richmond, VA 23298
- Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, VA 23219
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15
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Wang P, Yang H, Wang G, Tian J. Predictive value of thromboelastography parameters combined with antithrombin III and D-Dimer in patients with recurrent spontaneous abortion. Am J Reprod Immunol 2019; 82:e13165. [PMID: 31283067 DOI: 10.1111/aji.13165] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 06/02/2019] [Accepted: 06/22/2019] [Indexed: 12/29/2022] Open
Abstract
PROBLEM To investigate the value of thromboelastography (TEG) combined with antithrombin III (AT-III) and D-Dimer in predicting the occurrence of recurrent spontaneous abortion (RSA). METHOD OF STUDY One hundred and five RSA patients and 40 fertile women were enrolled. The subjects were subjected into four groups: group 1 (40 fertile women), group 2 (58 women with 2 abortions), group 3 (30 women with 3 abortions), and group 4 (17 women with four abortions). TEG was conducted on all subjects. Clotting time, reaction time, angle degree, coagulation index, and maximum amplitude were measured. The levels AT-III, D-Dimer, platelet counts, and fibrinogen concentration were determined. The ROC curve analysis was done using MedCalc software to analyse the diagnosis accuracy of the parameters of interest and the combined approach. RESULTS The AT-III level in all group 4 was significantly lower than in fertile women. The D-Dimer concentration, platelet count, and MA in patients with four prior abortions were significantly higher than the other three groups. CI and fibrinogen concentration in patients with four prior pregnancy losses were significantly higher than group 1. The ROC curves suggested that combined use of CI, MA, AT-III, and D-Dimer was with the highest accuracy 92.8%, thus predicting the most accurate diagnosis for RSA. CONCLUSION Recurrent spontaneous abortion is associated with abnormal coagulation and anticoagulation. TEG combined with detection of AT-III and D-Dimer levels can distinguish patient with RSA from those with normal fertility and highly possibly predict the occurrence of RSA.
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Affiliation(s)
- Ping Wang
- Department of Reproductive Medicine, Dezhou People's Hospital, Dezhou, China
| | - Hongjun Yang
- Department of Reproductive Medicine, Dezhou People's Hospital, Dezhou, China
| | - Guoying Wang
- Department of Reproductive Medicine, Dezhou People's Hospital, Dezhou, China
| | - Jun Tian
- Inspection Section, Dezhou People's Hospital, Dezhou, China
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16
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Regling K, Kakulavarapu S, Thomas R, Hollon W, Chitlur MB. Utility of thromboelastography for the diagnosis of von Willebrand disease. Pediatr Blood Cancer 2019; 66:e27714. [PMID: 30945453 DOI: 10.1002/pbc.27714] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 02/13/2019] [Accepted: 03/01/2019] [Indexed: 11/10/2022]
Abstract
Von Willebrand disease (VWD) is an inherited bleeding disorder that is caused by a quantitative or qualitative deficiency of von Willebrand factor (VWF). The National Heart, Lung, and Blood Institute (NHLBI) guidelines for the diagnosis of VWD state that a VWF activity (VWF:RCo) of <30 IU/dL or <50 IU/dL with symptoms of clinical bleeding are consistent with the diagnosis of VWD. However, current gold-standard diagnostic testing takes days to have complete results. Thromboelastography (TEG) is a testing method that provides a graphical trace that represents the viscoelastic changes seen with fibrin polymerization in whole blood, therefore providing information on all phases of the coagulation process. This study describes the TEG characteristics in 160 patients who presented for workup of a bleeding disorder and a subset of those were subsequently diagnosed with VWD. The TEG parameters, K-time (representing the dynamics of clot formation) and the maximal rate of thrombus generation (MRTG), were found to be sensitive in detecting patients with VWF:RCo <30 IU/dL. The TEG, unlike VWF:RCo, can be done in real time, and results are available to the clinician within an hour. This will definitely be beneficial in acute situations such as evaluation of and management of acute bleeding in patients with acquired deficiencies of VWF and may play an important role in the surgical management of patients with VWD.
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Affiliation(s)
- Katherine Regling
- Children's Hospital of Michigan, Wayne State University, Pediatric Hematology Oncology, Detroit, Michigan
| | | | - Ronald Thomas
- Children's Hospital of Michigan, Children's Research Center of Michigan, Detroit, Michigan
| | - Wendy Hollon
- Children's Hospital of Michigan, Wayne State University, Detroit, Michigan
| | - Meera B Chitlur
- Children's Hospital of Michigan, Wayne State University, Pediatric Hematology Oncology, Detroit, Michigan
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17
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Thromboelastometry as a diagnostic tool in mild bleeding disorders: A prospective cohort study. Eur J Anaesthesiol 2019; 36:457-465. [PMID: 30950901 DOI: 10.1097/eja.0000000000000985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Major guidelines emphasise the potential of visco-elastic methods to overcome the limitations of conventional laboratory assays in the peri-operative setting. Their sensitivity regarding mild bleeding disorders (MBDs), the most common bleeding disorders in the general population, is however unknown. OBJECTIVE The aim of this study was to investigate the sensitivity of thromboelastometry for diagnosis of MBD. DESIGN A single-centre prospective cohort study. SETTING Haematology outpatient unit of a tertiary general hospital in Central Switzerland. PATIENTS All consecutive patients referred over a 32-month period with a suspected bleeding disorder were included and thromboelastometry was conducted using a ROTEM delta (EXTEM, INTEM and FIBTEM). Diagnostic work-up was performed according to current guidelines including the ISTH bleeding assessment tool (ISTH BAT). MAIN OUTCOME MEASURES Distribution of clotting time (CT) and maximum clot firmness (MCF) results in relation to the presence of MBD. RESULTS Two hundred and seventeen patients were assessed; the median [IQR] age was 39 years [28 to 57]; 151 patients were women (70%). MBD was diagnosed in 97 patients (45%), no MBD was found in 100 patients (46%) and a systemic disorder recognised in 20 patients (9%). Presence of MBD was not associated with a significant difference in thromboelastometry variables (0.2 s in CT EXTEM, 95% CI -2.3 to 2.7; -0.2 mm in MCF EXTEM, 95% CI -1.8 to 1.5; -0.7 s in CT INTEM, 95% CI -12.6 to 11.2; 0.6 mm in MCF INTEM, 95% CI -1.2 to 1.3; 0.8 mm in MCF FIBTEM, 95% CI -1.6 to 1.4) and most results were within the established reference ranges. CONCLUSION Our data did not support the use of thromboelastometry as a diagnostic tool in patients with MBD.
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Abstract
Rare bleeding disorders (RBDs) comprise inherited deficiencies of factors I (fibrinogen), II (prothrombin), V, VII, X, XI, and XIII as well as combined factor V + VIII and vitamin K-dependent factors. They represent 3-5% of all congenital bleeding disorders and are usually transmitted as autosomal recessive traits. These disorders often manifest during childhood and have varied clinical presentations from mucocutaneous bleeding to life-threatening symptoms such as central nervous system and gastrointestinal bleeding. Bleeding manifestations generally vary within the same RBD and may also vary from 1 RBD to the other. Laboratory diagnosis is based on coagulation screening tests and specific factor assays, with molecular techniques providing diagnostic accuracy and enabling prenatal counseling. The approach to treatment of bleeding episodes and invasive procedures needs to be individualized and depends on the severity, frequency and procedure-related risk of bleeding. The first line of treatment of RBDs is replacement of the deficient factor, using specific plasma-derived or recombinant products and using fresh frozen plasma or cryoprecipitate when specific products are not available or in resource-limited countries. Prophylaxis may be considered in individuals with recurrent serious bleeding and especially after life-threatening bleeding episodes. Novel no-replacement strategies promoting hemostasis by through different mechanisms need to be studied in RBDs as alternative therapeutic options.
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Affiliation(s)
- Shilpa Jain
- Division of Pediatric Hematology-Oncology, Women and Children's Hospital of Buffalo and Hemophilia Center of Western New York, Buffalo, NY, 14209, United States.
| | - Suchitra S Acharya
- Bleeding Disorders and Thrombosis Program, Cohen Children's Medical Center of New York and Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
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19
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Young GA, Carmona R, Cano Garcia V. Thromboelastography and thrombin generation assay in inherited afibrinogenemia. Haemophilia 2018; 24:e410-e416. [DOI: 10.1111/hae.13620] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/13/2018] [Accepted: 09/24/2018] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Viridiana Cano Garcia
- Children’s Hospital Los Angeles; Los Angeles California
- University of Southern California Keck School of Medicine; Los Angeles California
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20
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Kim SY, Gu JY, Yoo HJ, Kim JE, Jang S, Choe S, Koh Y, Kim I, Kim HK. Benefits of Thromboelastography and Thrombin Generation Assay for Bleeding Prediction in Patients With Thrombocytopenia or Hematologic Malignancies. Ann Lab Med 2018; 37:484-493. [PMID: 28840985 PMCID: PMC5587820 DOI: 10.3343/alm.2017.37.6.484] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 03/02/2017] [Accepted: 07/10/2017] [Indexed: 01/19/2023] Open
Abstract
Background Thromboelastography (TEG) provides comprehensive information on the whole blood clot formation phases, whereas thrombin generation assay (TGA) reveals the endogenous thrombin levels in plasma. We investigated the potential significance of TEG and TGA parameters for prediction of clinical bleeding in hematologic patients on the basis of the patient's platelet levels. Methods TEG and TGA were performed in 126 patients with thrombocytopenia or hematologic malignancies. The bleeding tendencies were stratified on the basis of the World Health Organization bleeding grade. Results Maximum amplitude (MA) and clot formation in TEG and endogenous thrombin potential (ETP) in TGA showed significant associations with high bleeding grades (P=0.001 and P=0.011, respectively). In patients with platelet counts ≤10×109/L, low MA values were strongly associated with a high bleeding risk. For bleeding prediction, the area under the curve (AUC) of MA (0.857) and ETP (0.809) in patients with severe thrombocytopenia tended to be higher than that of platelets (0.740) in all patients. Patients with platelet counts ≤10×109/L displayed the highest AUC of the combined MA and ETP (0.929). Conclusions Both TEG and TGA were considered to be good predictors of clinical bleeding in patients with severe thrombocytopenia. Combination of the ETP and MA values resulted in a more sensitive bleeding risk prediction in those with severe thrombocytopenia.
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Affiliation(s)
- Seon Young Kim
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ja Yoon Gu
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea.,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Ju Yoo
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea.,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Eun Kim
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea.,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Seonpyo Jang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sooyeon Choe
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Youngil Koh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Inho Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.
| | - Hyun Kyung Kim
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea.,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea.
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21
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Shropshire S, Olver C, Lappin M. Characteristics of hemostasis during experimental Ehrlichia canis infection. J Vet Intern Med 2018; 32:1334-1342. [PMID: 29704268 PMCID: PMC6060328 DOI: 10.1111/jvim.15130] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 01/09/2018] [Accepted: 03/07/2018] [Indexed: 12/20/2022] Open
Abstract
Background Ehrlichia canis infection in dogs can cause thrombocytopenia and clinical evidence of bleeding. It is unknown why some dogs show signs of bleeding whereas others do not despite clinically relevant thrombocytopenia. Hypothesis/Objectives Activated platelets, decreased fibrinolysis or both mitigate bleeding tendency. Assess standard hemostatic variables, platelet dynamics, and specialized coagulation testing in dogs experimentally infected with E. canis to evaluate this clinical discrepancy. Animals Four healthy laboratory beagles. Methods Dogs were given blood infected with E. canis IV. Platelet indices of activation, platelet aggregometry, antiplatelet antibodies (percent IgG), complete coagulation panel, and thromboelastography (TEG) were measured before inoculation and on weeks 1‐8. Dogs were treated with doxycycline at approximately 5 mg/kg PO q12h between weeks 3 and 4 (day 24). For each variable, 1‐way repeated measures analysis (1‐way ANOVA) with post‐hoc analysis was performed with statistical significance set at P < .05. Results Dogs had significantly lower platelet counts, evidence of activated platelets, and antiplatelet antibodies during E. canis infection. Dogs also appeared hypercoagulable and hypofibrinolytic using TEG as compared with baseline, changes that persisted for variable amounts of time after doxycycline administration. No overt signs of bleeding were noted during the study. Conclusions and Clinical Importance Activated platelets and a hypercoagulable, hypofibrinolytic state could explain the lack of a bleeding phenotype in some dogs despite clinically relevant thrombocytopenia. Findings from our pilot study indicate that additional studies are warranted.
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Affiliation(s)
- Sarah Shropshire
- Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado, CO
| | - Christine Olver
- Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado, CO
| | - Michael Lappin
- Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado, CO
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22
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Rabik CA, Atkinson MA, Sule S, Strouse JJ. Treatment of an acquired Factor XIII inhibitor in an adolescent with systemic lupus erythematosus and renal failure. Transfusion 2017; 57:2159-2163. [DOI: 10.1111/trf.14185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 04/27/2017] [Accepted: 05/02/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Cara A. Rabik
- Department of Pediatrics, Division of Pediatric Hematology
| | | | - Sangeeta Sule
- Department of Pediatrics, Division of Pediatric Rheumatology; Johns Hopkins University; Baltimore Maryland
| | - John J. Strouse
- Department of Medicine, Division of Hematology; and the Department of Pediatrics, Division of Pediatric Hematology/Oncology; Duke University; Durham North Carolina
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23
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Hutchins K, Rajpurkar M, Stockton DW, Callaghan MU. Factor VII and factor X deficiency in a child with a chromosome 13q duplication and deletion. Haemophilia 2017; 27:e127-e128. [PMID: 28580769 DOI: 10.1111/hae.13065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2016] [Indexed: 11/27/2022]
Affiliation(s)
- K Hutchins
- Carmen and Ann Adams Department of Pediatrics, Division of Hematology/Oncology, Children's Hospital of Michigan, Detroit, MI, USA.,Department of Pediatrics, Wayne State University, Detroit, MI, USA
| | - M Rajpurkar
- Carmen and Ann Adams Department of Pediatrics, Division of Hematology/Oncology, Children's Hospital of Michigan, Detroit, MI, USA.,Department of Pediatrics, Wayne State University, Detroit, MI, USA
| | - D W Stockton
- Department of Pediatrics, Wayne State University, Detroit, MI, USA.,Carmen and Ann Adams Department of Pediatrics, Division of Genetic, Genomic and Metabolic Disorders, Children's Hospital of Michigan, Detroit, MI, USA
| | - M U Callaghan
- Carmen and Ann Adams Department of Pediatrics, Division of Hematology/Oncology, Children's Hospital of Michigan, Detroit, MI, USA.,Department of Pediatrics, Wayne State University, Detroit, MI, USA
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24
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25
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Gendreau JL, Knoll C, Adams RH, Su LL. The Role of Thromboelastography in Pediatric Patients with Sinusoidal Obstructive Syndrome Receiving Defibrotide. Biol Blood Marrow Transplant 2017; 23:707-712. [PMID: 28115278 DOI: 10.1016/j.bbmt.2017.01.074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 01/13/2017] [Indexed: 10/20/2022]
Abstract
Sinusoidal obstructive syndrome (SOS) is a potentially fatal form of hepatic injury after hematopoietic stem cell transplantation. Patients can develop liver dysfunction, portal hypertension, ascites, coagulopathies, and multisystem organ failure. The mortality rate of severe SOS has been reported as high as 98% by day 100 after transplantation. Defibrotide, which is now approved for the treatment of SOS, has significantly decreased mortality. Defibrotide is a polynucleotide with profibrinolytic, anti-ischemic, and anti-inflammatory activity. These properties can increase the risk of life-threatening bleeding in this patient population. Previous protocols have suggested maintaining international normalized ratio ≤ 1.5, platelets > 30 k/uL, and fibrinogen ≥ 150 mg/dL to minimize this risk of bleeding. However, this can be challenging in fluid-sensitive patients with SOS. Thromboelastography (TEG) is a functional assay that evaluates the balance of procoagulant and anticoagulant proteins. In this series, TEG was used to guide defibrotide therapy as well as blood product transfusions in SOS patients with abnormal coagulation studies. Each patient recovered from SOS and had no bleeding complications. A randomized clinical trial is the next step in supporting the use of TEG in SOS patients with abnormal coagulation studies receiving defibrotide therapy.
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Affiliation(s)
- Joanna L Gendreau
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, Arizona.
| | - Christine Knoll
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, Arizona
| | - Roberta H Adams
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, Arizona; Hematology/Oncology, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Leon L Su
- Department of Pathology and Laboratory Medicine, Phoenix Children's Hospital, Phoenix, Arizona
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26
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Nogami K. The utility of thromboelastography in inherited and acquired bleeding disorders. Br J Haematol 2016; 174:503-14. [PMID: 27264484 DOI: 10.1111/bjh.14148] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 03/30/2016] [Indexed: 01/08/2023]
Abstract
Thromboelastography (TEG) was first described by Hartert in 1948, and was designed to monitor viscoelastic clot strength in whole blood in real time. The current TEG method and Rotational Thromboelastometry (ROTEM) were subsequently developed from the original principles. Both of the modern methods provide data by measuring changes in the viscoelastic strength of a small sample of clotting blood in response to a constant rotational force. The important advantage of these techniques is to visually observe and quantify blood coagulation including the propagation, stabilization and dissolution phases of clot formation under low shear conditions. Analysis of the results provides detailed kinetic data on fibrin generation, clot strength and fibrinolysis. These TEG/ROTEM analyses therefore enable evaluation of global clotting function and the monitoring of haemostatic treatment in various clinical situations, not only in patients with genetic bleeding disorders, such as haemophilia, but also in patients undergoing cardiac surgery, liver transplantation or suffering from traumatic injury. Some evidence suggests that haemostatic management using TEG/ROTEM leads to a reduction in total transfusions of whole blood or clotting factors. Wider clinical application of this technology seems likely.
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Affiliation(s)
- Keiji Nogami
- Department of Paediatrics, Nara Medical University, Kashihara, Nara, Japan
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27
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Challenges of diagnosing and managing the adolescent with heavy menstrual bleeding. Thromb Res 2016; 143:91-100. [PMID: 27208978 DOI: 10.1016/j.thromres.2016.05.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/26/2016] [Accepted: 05/01/2016] [Indexed: 11/20/2022]
Abstract
Unpredictable, prolonged or heavy menstrual bleeding (HMB) may be expected for many adolescents soon after menarche. A decade of clinical experience and research has now established firmly that bleeding disorders (BD) are common in adolescents with HMB. Despite these advances, many questions remain, and several aspects of the diagnosis and management of BDs in adolescents are not supported by rigorous clinical trials. In this overview, four major areas will be discussed. First, we will discuss the frequency of BDs in young women with HMB. Up to 20% of older females with HMB are thought to have an underlying BD. Estimates from retrospective studies in adolescents suggest a prevalence that varies anywhere from 10 to 62%. Prospective studies with uniform hemostatic evaluation are needed to answer this question definitively. Second, we will review existing tools that help screen and diagnose adolescents with HMB with an underlying BD. Although identification of an underlying BD in older women with HMB is relatively straight forward, uncertainties remain for adolescents. Heavy menstrual bleeding in this age group may have different pathophysiological underpinnings than those in older women and may often be disregarded as anovulatory. There is an urgent need to develop novel tools, and evaluate existing diagnostic strategies in adolescents. Third, we will discuss the optimal medical management of HMB in young adolescents. As direct evidence is largely lacking, these areas are also subject to extrapolation from older women. Lastly, an important area- prediction, and management of future bleeding in those adolescents who are diagnosed with a mild BD-will be discussed. Throughout, areas of controversy and opportunities for further research are highlighted.
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28
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Lippi G, Pasalic L, Favaloro EJ. Detection of mild inherited disorders of blood coagulation: current options and personal recommendations. Expert Rev Hematol 2015; 8:527-42. [DOI: 10.1586/17474086.2015.1039978] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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