1
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Barg AA, Livnat T, Kenet G. Factor XI deficiency: phenotypic age-related considerations and clinical approach towards bleeding risk assessment. Blood 2024; 143:1455-1464. [PMID: 38194679 DOI: 10.1182/blood.2023020721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 12/22/2023] [Accepted: 12/29/2023] [Indexed: 01/11/2024] Open
Abstract
ABSTRACT Factor XI (FXI) deficiency is a rare bleeding disorder that presents complex challenges in patient assessment and bleeding risk management. Despite generally causing mild to moderate bleeding symptoms, clinical manifestations can vary, and bleeding tendency does not always correlate with FXI plasma levels or genotype. Our manuscript delves into the age-related nuances of FXI deficiency across an individual's lifespan. We emphasize issues faced by specific groups, including neonates and females of reproductive age experiencing abnormal uterine bleeding and postpartum hemorrhage. Older patients present unique challenges and concerns related to the management of bleeding as well as thrombotic complications. The current assortment of diagnostic laboratory assays shows limited success in predicting bleeding risk in the perisurgical setting of patients with FXI deficiency. This review explores the intricate interplay between individual bleeding profiles, surgical sites, and FXI activity levels. We also evaluate the accuracy of existing laboratory assays in predicting bleeding and discuss the potential role of investigational global assays in perioperative assessment. Furthermore, we outline our suggested diagnostic approach to refine treatment strategies and decision making. Available treatment options are presented, including antifibrinolytics, replacement products, and recombinant activated FVII. Finally, we discuss promising nonreplacement therapies for the treatment of rare bleeding disorders that can potentially address the challenges faced when managing FXI deficiency-related bleeding complications.
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Affiliation(s)
- Assaf Arie Barg
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institution of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tami Livnat
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institution of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gili Kenet
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institution of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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2
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Sucker C, Geisen C, Litmathe J, Schmitt U. Concomitant hypofibrinogenemia and factor XI deficiency as rare cause of bleeding during urgent dentistry: case report and short review of the literature. Arch Clin Cases 2023; 10:110-113. [PMID: 37405328 PMCID: PMC10315684 DOI: 10.22551/2023.39.1002.10253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023] Open
Abstract
Hypofibrinogenemia and Factor XI deficiency are rare defects of hemostasis, potentially leading to spontaneous bleeding manifestations and increased bleeding risk during surgery, dentistry, and interventions. Due to the different mode of inheritance, the concomitance of both defects is extremely rare and the clinical management of combined hypofibrinogenemia and factor XI deficiency is not standardized. Here, we report a rare case of concomitant genetically determined hypofibrinogenemia and factor XI deficiency as a cause of increased spontaneous bleeding and bleeding complications during dentistry. The diagnostic procedure including screening assays, single clotting factor determinations, genetic analyses, and also use of thrombin generation assays (TGA) are described. Also, we present our considerations regarding the development of an adequate prophylaxis of bleeding with fibrinogen concentrate in this case. The literature regarding the issue is briefly discussed.
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Affiliation(s)
- Christoph Sucker
- Coagumed Coagulation Center, Berlin, Germany
- Medical School Brandenburg, Brandenburg an der Havel, Germany
| | - Christof Geisen
- Institute of Transfusion Medicine and Immunohaematology, German Red Cross Blood Transfusion Service Baden-Württemberg-Hessen gGmbH, Goethe University Hospital Frankfurt/Main, Frankfurt am Main, Germany
| | - Jens Litmathe
- Emergency Department, Wesel Protestant Medical Center, Wesel, Germany
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3
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Reitsma SE, Holle LA, Bouck EG, Monroe DM, Mast AE, Burthem J, Bolton-Maggs PHB, Gidley GN, Wolberg AS. Tissue factor pathway inhibitor is a potential modifier of bleeding risk in factor XI deficiency. J Thromb Haemost 2023; 21:467-479. [PMID: 36696199 PMCID: PMC10111213 DOI: 10.1016/j.jtha.2022.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/26/2022] [Accepted: 10/06/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Factor (F) XI deficiency is associated with increased bleeding risk in some individuals. Neither FXI levels nor clinical clotting assays predict the bleeding risk. Compared with controls, FXI-deficient bleeders have reduced clot formation, decreased fibrin network density, and increased susceptibility to fibrinolysis. Tissue factor pathway inhibitor (TFPI) was recently implicated as a modifying factor in individuals with bleeding of unknown cause. OBJECTIVES To determine the potential of TFPI in modifying the bleeding risk in FXI-deficient individuals. METHODS The effects of TFPI on thrombin generation and clot formation, structure, and fibrinolysis in FXI-deficient plasma were measured in vitro in the absence or presence of inhibitory anti-TFPI antibody or exogenous recombinant TFPIα. Total plasma TFPI concentration was measured in 2 independent cohorts of controls and FXI-deficient individuals classified as bleeders or nonbleeders (cohort 1: 10 controls and 16 FXI-deficient individuals; cohort 2: 48 controls and 57 FXI-deficient individuals) and correlated with ex vivo plasma clot formation and fibrinolysis parameters associated with bleeding risk. RESULTS In an in vitro FXI deficiency model, inhibition of TFPI enhanced thrombin generation and clot formation, increased the network density, and decreased fibrinolysis, whereas an increase in TFPI had the opposite effects. Compared with controls, plasma from FXI-deficient bleeders had higher TFPI concentration. Total plasma TFPI concentrations correlated with parameters from ex vivo clotting and fibrinolysis assays that differentiate FXI-deficient bleeders and nonbleeders. CONCLUSION Coagulation and fibrinolysis parameters that differentiate FXI-deficient nonbleeders and bleeders were altered by plasma TFPIα. Total plasma TFPI was increased in FXI-deficient bleeders. TFPI may modify the bleeding risk in FXI-deficient individuals.
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Affiliation(s)
- Stéphanie E Reitsma
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Lori A Holle
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Emma G Bouck
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Dougald M Monroe
- Department of Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, North Carolina, USA
| | - Alan E Mast
- Versiti Blood Research Institute, Milwaukee, Wisconsin, USA
| | - John Burthem
- Department of Haematology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK; Institute of Cancer Sciences, The University of Manchester, Manchester, UK
| | | | - Gillian N Gidley
- Institute of Cancer Sciences, The University of Manchester, Manchester, UK; Department of Haematology, St James' Hospital, Leeds Teaching Hospitals Trust, UK
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA.
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4
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Association of FXI activity with thrombo-inflammation, extracellular matrix, lipid metabolism and apoptosis in venous thrombosis. Sci Rep 2022; 12:9761. [PMID: 35697739 PMCID: PMC9192691 DOI: 10.1038/s41598-022-13174-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 02/17/2022] [Indexed: 12/31/2022] Open
Abstract
Animal experiments and early phase human trials suggest that inhibition of factor XIa (FXIa) safely prevents venous thromboembolism (VTE), and specific murine models of sepsis have shown potential efficacy in alleviating cytokine storm. These latter findings support the role of FXI beyond coagulation. Here, we combine targeted proteomics, machine learning and bioinformatics, to discover associations between FXI activity (FXI:C) and the plasma protein profile of patients with VTE. FXI:C was measured with a modified activated partial prothrombin time (APTT) clotting time assay. Proximity extension assay-based protein profiling was performed on plasma collected from subjects from the Genotyping and Molecular Phenotyping of Venous Thromboembolism (GMP-VTE) Project, collected during an acute VTE event (n = 549) and 12-months after (n = 187). Among 444 proteins investigated, N = 21 and N = 66 were associated with FXI:C during the acute VTE event and at 12 months follow-up, respectively. Seven proteins were identified as FXI:C-associated at both time points. These FXI-related proteins were enriched in immune pathways related to causes of thrombo-inflammation, extracellular matrix interaction, lipid metabolism, and apoptosis. The results of this study offer important new avenues for future research into the multiple properties of FXI, which are of high clinical interest given the current development of FXI inhibitors.
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5
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Désage S, Dargaud Y, Meunier S, Le Quellec S, Lienhart A, Negrier C, Nougier C, Rugeri L. Report of surgeries, their outcome and the thrombin generation assay in patients with Factor XI deficiency: A retrospective single-centre study. Haemophilia 2022; 28:301-307. [PMID: 35122661 DOI: 10.1111/hae.14506] [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: 10/02/2021] [Revised: 01/12/2022] [Accepted: 01/26/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND In patients with FXI deficiency, the risk of surgery-related bleeding is poorly correlated with plasma FXI activity (FXI:C); the latter can therefore not be used as a reliable predictor of bleeding in surgeries. OBJECTIVES The aim of this retrospective study was to determine whether thrombin generation assay (TGA) could be used to evaluate the risk of surgery-related bleeding in FXI-deficient patients. TGA parameters were compared to FXI:C values, haemostatic treatments and surgical outcomes. PATIENTS All patients followed at the haemophilia treatment care centre (Lyon, France) with a FXI:C < 50IU/dL, and for whom a baseline TGA was performed between January 2014 and December 2019, were included. RESULTS Among the 175 surgeries reported herein in 49 patients, FXI concentrates were used for 11 (6%) surgeries and fresh frozen plasma was used for five (3%) surgeries; these surgeries were performed in patients with two or three impaired TGA parameters. No haemostatic treatment was prescribed for 119 (68%) surgeries. A surgery-related bleeding occurred in 12 patients during 21 (12%) surgeries. Thrombin generation was significantly reduced or delayed in patients who reported surgery related-bleeding. Among the 34 (68%) surgeries performed without haemostatic treatment in patients with three impaired TGA parameters, a surgery-related bleeding was reported in 44% of cases (15 surgeries out of 34). CONCLUSION The present study confirmed that TGA is an interesting laboratory test in FXI deficiency, for determining the bleeding risk and guiding the haemostatic management of surgeries, while taking into account the surgical bleeding risk and the history of bleeding.
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Affiliation(s)
- Stéphanie Désage
- Unité d'Hémostase Clinique, Hôpital Cardiologique Louis Pradel, Hospices Civils de Lyon, Bron, France.,Laboratoire d'hémostase, Centre de Biologie et de Pathologie Est, Hospices Civils de Lyon, Lyon, France
| | - Yesim Dargaud
- Unité d'Hémostase Clinique, Hôpital Cardiologique Louis Pradel, Hospices Civils de Lyon, Bron, France.,Laboratoire d'hémostase, Centre de Biologie et de Pathologie Est, Hospices Civils de Lyon, Lyon, France.,Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France
| | - Sandrine Meunier
- Unité d'Hémostase Clinique, Hôpital Cardiologique Louis Pradel, Hospices Civils de Lyon, Bron, France
| | - Sandra Le Quellec
- Unité d'Hémostase Clinique, Hôpital Cardiologique Louis Pradel, Hospices Civils de Lyon, Bron, France.,Laboratoire d'hémostase, Centre de Biologie et de Pathologie Est, Hospices Civils de Lyon, Lyon, France.,Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France
| | - Anne Lienhart
- Unité d'Hémostase Clinique, Hôpital Cardiologique Louis Pradel, Hospices Civils de Lyon, Bron, France
| | - Claude Negrier
- Unité d'Hémostase Clinique, Hôpital Cardiologique Louis Pradel, Hospices Civils de Lyon, Bron, France.,Laboratoire d'hémostase, Centre de Biologie et de Pathologie Est, Hospices Civils de Lyon, Lyon, France.,Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France
| | - Christophe Nougier
- Laboratoire d'hémostase, Centre de Biologie et de Pathologie Est, Hospices Civils de Lyon, Lyon, France
| | - Lucia Rugeri
- Unité d'Hémostase Clinique, Hôpital Cardiologique Louis Pradel, Hospices Civils de Lyon, Bron, France
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Bertaggia Calderara D, Zermatten MG, Aliotta A, Alberio L. How to Capture the Bleeding Phenotype in FXI-Deficient Patients. Hamostaseologie 2020; 40:491-499. [DOI: 10.1055/a-1227-8122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
AbstractFactor XI (FXI) is a serine protease involved in the propagation phase of coagulation and in providing clot stability. Several mutations in the F11 gene lead to FXI deficiency, a rare mild bleeding disorder. Current laboratory methods are unable to assess bleeding risk in FXI-deficient patients, because the degree of bleeding tendency does not correlate with plasma FXI activity as measured by routine coagulometric aPTT–based assays. Bleeding manifestations are highly variable among FXI-deficient patients and FXI replacement therapy can be associated with an increased thrombotic risk. A correct evaluation of the patient hemostatic potential is crucial to prevent under- or overtreatment. In recent years, different research groups have investigated the use of global coagulation assays as alternative for studying the role of FXI in hemostasis and identifying the clinical phenotype of FXI deficiency. This brief review article summarizes the main features of coagulation factor XI and its deficiency and resumes the principle axes of research and methods used to investigate FXI functions.
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Affiliation(s)
- Debora Bertaggia Calderara
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Maxime G. Zermatten
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Alessandro Aliotta
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Lorenzo Alberio
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
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7
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Billoir P, Feugray G, Chrétien MH, Duchez VLC. Thrombin generation assay is a useful pre‐operative tool to predict non‐bleeding risk in a patient with mild factor V deficiency. Transfus Med 2020; 30:408-409. [DOI: 10.1111/tme.12680] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 03/16/2020] [Accepted: 03/18/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Paul Billoir
- Vascular Hemostasis Unit, Normandie Univ, UNIROUEN, INSERM U1096, Rouen University Hospital Rouen France
| | | | | | - Véronique Le Cam Duchez
- Vascular Hemostasis Unit, Normandie Univ, UNIROUEN, INSERM U1096, Rouen University Hospital Rouen France
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8
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Clinical and laboratory diagnosis of rare coagulation disorders (RCDs). Thromb Res 2019; 196:603-608. [PMID: 31515069 DOI: 10.1016/j.thromres.2019.09.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/04/2019] [Accepted: 09/05/2019] [Indexed: 12/17/2022]
Abstract
Rare coagulation disorders (RCDs) are a group of diseases due to coagulation factors deficiency leading to life-long bleeding diathesis. The diagnosis of RCDs is challenging due to the limited knowledge of these disorders and the large heterogeneity of their bleeding patterns. The clinical symptoms of RCDs are extremely diverse in terms of bleeding type, site, severity, age at onset, and duration. The strength of the association between clotting factor activity level in plasma and clinical symptoms is also variable within each RCD. The clinical evaluation of RCDs starts with a detailed collection of clinical history and has been facilitated by bleeding assessment tools, however their effectiveness in diagnosing RCDs requires further investigation. The following laboratory diagnosis of RCDs involves coagulation screening tests, including activated partial thromboplastin time, prothrombin time, and thrombin time. After ruling out the presence of an inhibitor by mixing studies, in case of abnormal results, the specific deficiency is identified by performing one-stage clotting assays using the specific factor-depleted plasmas as substrate. In fibrinogen and FXIII deficiencies coagulation screening tests are not informative, therefore additional tests are needed. Global assays have been developed and are thought to aid in patient management, however, they are not well standardized yet. In addition to outlining the principles of clinical and laboratory diagnosis, this review explores molecular basis of RCDs and laboratory techniques for genetic analysis, and discusses the importance and effectiveness of quality control programs to ensure standardized laboratory results.
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9
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Negrier C, Shima M, Hoffman M. The central role of thrombin in bleeding disorders. Blood Rev 2019; 38:100582. [PMID: 31164248 DOI: 10.1016/j.blre.2019.05.006] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 05/10/2019] [Accepted: 05/20/2019] [Indexed: 01/25/2023]
Abstract
Maintaining normal hemostasis relies on a regulated system of procoagulant and anticoagulant pathways, and disruption of these processes leads to the loss of hemostatic control, with the potential for excessive bleeding or thrombosis. Evaluation of bleeding disorders has conventionally been achieved by laboratory assays that measure the activity of individual coagulation factors. While such assays have proven effective for detecting abnormalities of the coagulation system and aiding diagnosis, inherent limitations prevent them from capturing a complete picture of hemostatic function. An improved understanding of thrombin activity and its central role in hemostasis and bleeding disorders has led to the clinical development of global assays that are more physiologically relevant than traditional assays; furthermore, these global assays are able to monitor responses to therapy. In this review, we provide an overview of the role of thrombin in hemostasis, and describe the clinical benefits of thrombin monitoring in patients with bleeding disorders. Moreover, we discuss recent advances in thrombin-targeting therapeutic strategies that aim to correct thrombin deficiency and prevent bleeding in patients with hemophilia and other rare bleeding disorders.
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Affiliation(s)
- Claude Negrier
- Haematology Department, Louis Pradel University Hospital, University Claude Bernard, Lyon, France
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Maureane Hoffman
- Department of Pathology, Duke University Medical Center, Durham, NC, USA.
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10
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Kuprash AD, Shibeko AM, Vijay R, Nair SC, Srivastava A, Ataullakhanov FI, Panteleev MA, Balandina AN. Sensitivity and Robustness of Spatially Dependent Thrombin Generation and Fibrin Clot Propagation. Biophys J 2018; 115:2461-2473. [PMID: 30514632 DOI: 10.1016/j.bpj.2018.11.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 10/25/2018] [Accepted: 11/05/2018] [Indexed: 11/25/2022] Open
Abstract
Blood coagulation is a delicately regulated space- and time-dependent process that leads to the formation of fibrin clots preventing blood loss upon vascular injury. The sensitivity of the coagulation network was previously investigated without accounting for transport processes. To investigate its sensitivity to coagulation factor deficiencies in a spatial reaction-diffusion system, we combined an in vitro experimental design with a computational systems biology model. Clot formation in platelet-free plasma supplemented with phospholipids was activated with identical amounts of tissue factor (TF) either homogeneously distributed (concentration 5 pM, homogeneous model) or immobilized on the surface (surface density 100 pmole/m2, spatially heterogeneous model). Fibrin clot growth and thrombin concentration dynamic in space were observed using video microscopy in plasma of healthy donors or patients with deficiencies in factors (F) II, FV, FVII, FVIII, FIX, FX, or FXI. In the spatially heterogeneous model, near-activator thrombin generation was decreased in FV-, FVII-, and FX-deficient plasma. In the homogeneous model, clotting was not registered in these samples. The simulation and experiment data showed that the coagulation threshold depended on the TF concentration. Our data indicate that the velocity of spatial clot propagation correlates linearly with the concentration of thrombin at the clot wave front but not with the overall thrombin wave amplitude. Spatial clot growth in normal plasma at early stages was neither reaction nor diffusion limited but became diffusion limited later. In contrast, clot growth was always diffusion limited in FV-, FVII-, and FX-deficient plasma and reaction limited in FVIII-, FIX-, and FXI-deficient plasma. We conclude that robustness of the spatially heterogeneous coagulation system was achieved because of the combination of 1) a local high TF surface density that overcomes activation thresholds, 2) diffusion control being shared between different active factors, and 3) an early saturated stimulus-response dependence of fibrin clot formation by thrombin.
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Affiliation(s)
- Anna D Kuprash
- Center for Theoretical Problems of Physicochemical Pharmacology RAS, Moscow, Russia; Department of Biophysics and Systems Biology, National Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Alexey M Shibeko
- Center for Theoretical Problems of Physicochemical Pharmacology RAS, Moscow, Russia; Department of Biophysics and Systems Biology, National Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Ramya Vijay
- Department of Haematology, Christian Medical College, Vellore, India
| | - Sukesh C Nair
- Department of Haematology, Christian Medical College, Vellore, India
| | - Alok Srivastava
- Department of Haematology, Christian Medical College, Vellore, India
| | - Fazoil I Ataullakhanov
- Center for Theoretical Problems of Physicochemical Pharmacology RAS, Moscow, Russia; Department of Biophysics and Systems Biology, National Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia; Department of Physics, Lomonosov Moscow State University, Moscow, Russia; Department of Biological and Medical Physics, Moscow Institute of Physics and Technology, Dolgoprudny, Russia
| | - Mikhail A Panteleev
- Center for Theoretical Problems of Physicochemical Pharmacology RAS, Moscow, Russia; Department of Biophysics and Systems Biology, National Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia; Department of Physics, Lomonosov Moscow State University, Moscow, Russia; Department of Biological and Medical Physics, Moscow Institute of Physics and Technology, Dolgoprudny, Russia.
| | - Anna N Balandina
- Center for Theoretical Problems of Physicochemical Pharmacology RAS, Moscow, Russia; Department of Biophysics and Systems Biology, National Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
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11
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Gidley GN, Holle LA, Burthem J, Bolton-Maggs PHB, Lin FC, Wolberg AS. Abnormal plasma clot formation and fibrinolysis reveal bleeding tendency in patients with partial factor XI deficiency. Blood Adv 2018; 2:1076-1088. [PMID: 29760205 PMCID: PMC5965046 DOI: 10.1182/bloodadvances.2017015123] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 04/06/2018] [Indexed: 11/20/2022] Open
Abstract
Individuals with factor XI (FXI) deficiency have a variable bleeding risk that cannot be predicted from plasma FXI antigen or activity. This limitation can result in under- or overtreatment of patients and risk of bleeding or thrombosis. Previously, plasma clot fibrinolysis assays showed sensitivity to bleeding tendency in a small cohort of patients with severe FXI deficiency. Here, we determined the ability of plasma clot formation, structure, and fibrinolysis assays to predict bleeding tendency in a larger, independent cohort of patients with severe and partial FXI deficiency. Patients were characterized as nonbleeders or bleeders based on bleeding after tonsillectomy and/or dental extraction before diagnosis of FXI deficiency. Blood was collected in the absence or presence of the contact pathway inhibitor corn trypsin inhibitor (CTI). Clotting was triggered in platelet-poor plasma with tissue factor, CaCl2, and phospholipids in the absence and presence of thrombomodulin or tissue plasminogen activator. Clot formation and fibrinolysis were assessed by turbidity and confocal microscopy. CTI-treated plasmas from bleeders showed significantly reduced clot formation and decreased resistance to fibrinolysis compared with plasmas from controls or nonbleeders. Differences were enhanced in the presence of CTI. A model that combines activated partial thromboplastin time with the rate of clot formation and area under the curve in fibrinolysis assays identifies most FXI-deficient bleeders. These results show assays with CTI-treated platelet-poor plasma reveal clotting and clot stability deficiencies that are highly associated with bleeding tendency. Turbidity-based fibrinolysis assays may have clinical utility for predicting bleeding risk in patients with severe or partial FXI deficiency.
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Affiliation(s)
- Gillian N Gidley
- Department of Haematology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Institute of Cancer Sciences, The University of Manchester, Manchester, United Kingdom
| | - Lori A Holle
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - John Burthem
- Department of Haematology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Institute of Cancer Sciences, The University of Manchester, Manchester, United Kingdom
| | - Paula H B Bolton-Maggs
- Institute of Cardiovascular Sciences, The University of Manchester, Manchester, United Kingdom
- Serious Hazards of Transfusion Office, Manchester Blood Centre, Plymouth Grove, Manchester, United Kingdom; and
| | - Feng-Chang Lin
- Department of Biostatistics and
- North Carolina Translational and Clinical Sciences Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
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12
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Ogawa Y, Yanagisawa K, Uchiyama Y, Akashi N, Mieda T, Iizuka H, Inoue M, Shizuka R, Murakami M, Matsumoto N, Handa H. Successful hemostatic management of major surgery for cervical spondylotic myelopathy in a patient with severe factor XI deficiency. Int J Hematol 2018; 108:443-446. [PMID: 29713955 DOI: 10.1007/s12185-018-2462-y] [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: 02/28/2018] [Revised: 04/25/2018] [Accepted: 04/25/2018] [Indexed: 11/30/2022]
Abstract
Factor XI deficiency (FXID) is a rare bleeding disorder caused by mutations in the F11 gene. Spontaneous bleeding in patients with factor XI deficiency is rare, but major bleeding may occur after surgery or trauma. The basic method for hemostatic treatment is replacement of the missing factor using FXI concentrate or fresh frozen plasma (FFP). We report the case of a 72-year-old male with severe FXID who underwent a laminoplasty under sufficient, but minimal, FFP transfusion. Through detailed monitoring of activated partial thromboplastin time (APTT) and FXI activity at the perioperative period, we succeeded in hemostatic management of major surgery without significant blood loss and fluid overload. From the course of this case, we found that measuring FXI activity is superior to measuring APTT. Furthermore, we identified a novel homozygous mutation in F11 [NM_000128.3:c.1041C > A:p.(Tyr347*)] by whole exome sequencing.
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Affiliation(s)
- Yoshiyuki Ogawa
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan.
| | - Kunio Yanagisawa
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Yuri Uchiyama
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan.,Department of Human Genetics, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Naoki Akashi
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Tokue Mieda
- Department of Orthopaedic Surgery, Gunma University Hospital, Maebashi, Japan
| | - Haku Iizuka
- Department of Orthopaedic Surgery, Gunma University Hospital, Maebashi, Japan
| | - Madoka Inoue
- Clinical Laboratory Center, Gunma University Hospital, Maebashi, Japan
| | - Reiko Shizuka
- Clinical Laboratory Center, Gunma University Hospital, Maebashi, Japan
| | - Masami Murakami
- Department of Clinical Laboratory Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Naomichi Matsumoto
- Department of Human Genetics, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hiroshi Handa
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
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Didelot M, Docq C, Wahl D, Lacolley P, Regnault V, Lagrange J. Platelet aggregation impacts thrombin generation assessed by calibrated automated thrombography. Platelets 2017; 29:156-161. [PMID: 29022492 DOI: 10.1080/09537104.2017.1356452] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
A calibrated automated thrombogram (CAT) is performed usually with human platelet-free plasma (PFP) but may be more relevant with platelet-rich plasma (PRP). In this case, platelets are not stimulated by subendothelial molecules like collagen. Our aim was to assess the consequence of strong (collagen) or weak (ADP) induction of platelet release and aggregation on thrombin generation. Platelet aggregation in PRP was triggered with 10 µg/mL collagen or 10 µM ADP using a lumi-aggregometer. Thrombin generation curves were monitored by CAT in different conditions: PRP, PRP with activated platelets (actPRP), aggregated PRP (agPRP), aggregated platelets resuspended in autologous PFP (resPRP), PFP and PFP obtained after aggregation (agPFP). We found a 3-fold shortening of the lag time and time to peak and a marked increase in velocity and thrombin peak without changes in endogenous thrombin potential (ETP) in agPRP with both agonists compared with PRP. The same holds true in agPFP but with a marked increase in ETP compared with PFP. Similar changes in the kinetics of thrombin generation were observed with actPRP-collagen and to a lesser extent in resPRP-collagen compared with PRP. By contrast, there were no modifications of the thrombin generation curves in actPRP-ADP. Alpha-2-macroglobin-thrombin complexes were unchanged in the different PRP conditions but were increased in PFP prepared from agPFP compared to control PFP. Platelet aggregation during activation by agonists other than thrombin did not increase thrombin generation but accelerated its kinetics mainly via platelet content release and platelet-derived extracellular vesicules formation. In diseases characterized by altered platelet granule content or release as well as altered platelet activation, a platelet aggregation step prior to CAT analysis may be clinically relevant to improve laboratory estimation of the bleeding/thrombotic balance.
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Affiliation(s)
- Mélusine Didelot
- a INSERM, U1116 , Faculté de Médecine , Vandoeuvre-les-Nancy , France.,b Université de Lorraine , Nancy , France
| | - Clémence Docq
- a INSERM, U1116 , Faculté de Médecine , Vandoeuvre-les-Nancy , France.,b Université de Lorraine , Nancy , France
| | - Denis Wahl
- a INSERM, U1116 , Faculté de Médecine , Vandoeuvre-les-Nancy , France.,b Université de Lorraine , Nancy , France.,c CHRU Nancy , Vandœuvre-lès-Nancy , France
| | - Patrick Lacolley
- a INSERM, U1116 , Faculté de Médecine , Vandoeuvre-les-Nancy , France.,b Université de Lorraine , Nancy , France.,c CHRU Nancy , Vandœuvre-lès-Nancy , France
| | - Véronique Regnault
- a INSERM, U1116 , Faculté de Médecine , Vandoeuvre-les-Nancy , France.,b Université de Lorraine , Nancy , France.,c CHRU Nancy , Vandœuvre-lès-Nancy , France
| | - Jérémy Lagrange
- a INSERM, U1116 , Faculté de Médecine , Vandoeuvre-les-Nancy , France.,b Université de Lorraine , Nancy , France.,d Center for Thrombosis and Hemostasis , University Medical Center Mainz , Mainz , Germany
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