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Nakajima Y, Oda A, Baatartsogt N, Kashiwakura Y, Ohmori T, Nogami K. The combination of Asp519Val/Glu665Val and Lys1813Ala mutations in FVIII markedly increases coagulation potential. Blood Adv 2024; 8:3929-3940. [PMID: 38820442 PMCID: PMC11321387 DOI: 10.1182/bloodadvances.2023012391] [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: 12/12/2023] [Revised: 05/06/2024] [Accepted: 05/18/2024] [Indexed: 06/02/2024] Open
Abstract
ABSTRACT A2 domain dissociation in activated factor VIII (FVIIIa) results in reduced activity. Previous studies demonstrated that some FVIII mutants (D519V/E665V and K1813A) with delayed A2 dissociation enhanced coagulation potential. We speculated, therefore, that FVIII encompassing a combination of these mutations might further enhance coagulant activity. The aim was to assess the D519V/E665V/K1813A-FVIII mutation as a gain of function. The FVIII mutants, D519V/E665V/K1813A, D519V/E665V, and K1813A were expressed in a baby hamster kidney cell system, and global coagulation potential of these mutants was compared with wild-type (WT) FVIII in vitro and in hemophilia A mice in vivo. Kinetic analyses indicated that the apparent Kd for FIXa on the tenase assembly with D519V/E665V and D519V/E665V/K1813A mutants were lower, and that the generated FXa for D519V/E665V/K1813A was significantly greater than WT-FVIII. WT-FVIII activity after thrombin activation increased by ∼12-fold within 5 minutes, and returned to initial levels within 30 minutes. In contrast, The FVIII-related activity of D519V/E665V/K1813A increased further with time after thrombin activation, and showed an ∼25-fold increase at 2 hours. The A2 dissociation rate of D519V/E665V/K1813A was ∼50-fold slower than the WT in a 1-stage clotting assay. Thrombin generation assays demonstrated that D519V/E665V/K1813A (0.125 nM) exhibited coagulation potential comparable with that of the WT (1 nM). In animal studies, rotational thromboelastometry and tail-clip assays showed that the coagulation potential of D519V/E665V/K1813A (0.25 μg/kg) was equal to that of the WT (2 μg/kg). FVIII-D519V/E665V/K1813A mutant could provide an approximately eightfold increase in hemostatic function of WT-FVIII because of increased FVIIIa stability and the association between FVIIIa and FIXa.
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Affiliation(s)
- Yuto Nakajima
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara City, Japan
| | - Akihisa Oda
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | | | - Yuji Kashiwakura
- Department of Biochemistry, Jichi Medical University School of Medicine, Shimotsuke, Japan
| | - Tsukasa Ohmori
- Department of Biochemistry, Jichi Medical University School of Medicine, Shimotsuke, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
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Moore GW. Thrombophilia Screening: Not So Straightforward. Semin Thromb Hemost 2024. [PMID: 38733983 DOI: 10.1055/s-0044-1786807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2024]
Abstract
Although inherited thrombophilias are lifelong risk factors for a first thrombotic episode, progression to thrombosis is multifactorial and not all individuals with inherited thrombophilia develop thrombosis in their lifetimes. Consequently, indiscriminate screening in patients with idiopathic thrombosis is not recommended, since presence of a thrombophilia does not necessarily predict recurrence or influence management, and testing should be selective. It follows that a decision to undertake laboratory detection of thrombophilia should be aligned with a concerted effort to identify any significant abnormalities, because it will inform patient management. Deficiencies of antithrombin and protein C are rare and usually determined using phenotypic assays assessing biological activities, whereas protein S deficiency (also rare) is commonly detected with antigenic assays for the free form of protein S since available activity assays are considered to lack specificity. In each case, no single phenotypic assay is capable of detecting every deficiency, because the various mutations express different molecular characteristics, rendering thrombophilia screening repertoires employing one assay per potential deficiency, of limited effectiveness. Activated protein C resistance (APCR) is more common than discrete deficiencies of antithrombin, protein C, and protein S and also often detected initially with phenotypic assays; however, some centres perform only genetic analysis for factor V Leiden, as this is responsible for most cases of hereditary APCR, accepting that acquired APCR and rare F5 mutations conferring APCR will go undetected if only factor V Leiden is evaluated. All phenotypic assays have interferences and limitations, which must be factored into decisions about if, and when, to test, and be given consideration in the laboratory during assay performance and interpretation. This review looks in detail at performance and limitations of routine phenotypic thrombophilia assays.
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Affiliation(s)
- Gary W Moore
- Specialist Haemostasis Laboratory, Cambridge Haemophilia and Thrombophilia Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Department of Natural Sciences, Middlesex University, London, United Kingdom
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Nakajima Y, Osuna M, Mizumachi K, Shimonishi N, Furukawa S, Ogiwara K, Nogami K. Activated protein C resistance in the copresence of emicizumab and activated prothrombin complex concentrates. Res Pract Thromb Haemost 2024; 8:102479. [PMID: 39114481 PMCID: PMC11305313 DOI: 10.1016/j.rpth.2024.102479] [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] [Received: 03/23/2024] [Revised: 05/11/2024] [Accepted: 06/12/2024] [Indexed: 08/10/2024] Open
Abstract
Background Venous thromboembolic events have been reported in persons with hemophilia A who received emicizumab and activated prothrombin complex concentrate (APCC) concomitantly, but the relevant mechanism(s) remains unclear. We speculated that activated protein C (APC) and antithrombin (AT) resistance might be associated with these adverse events. Objectives To investigate APC and AT resistance in factor (F)VIII-deficient (FVIIIdef) plasma in the presence of emicizumab and APCC. Methods In pooled normal plasma or FVIIIdef plasma samples mixed with emicizumab (50 μg/mL) and FVIII-bypassing agents, including recombinant FVIIa (2.2 μg/mL), APCC (1.3 IU/mL), or plasma-derived FVIIa/FX (1.5 μg/mL), the suppression effect of AT (0-2.4 μM) and APC (0-16 nM) was assessed by tissue factor-triggered thrombin generation assay. The APC effects in FVIIIdef plasma with the copresence of emicizumab, FII (1.3 μM), and/or FIXa (280 pM) were also examined. Results The AT resistance in emicizumab and each bypassing agent was not observed. Moreover, APC dose-dependent suppression effect was observed in pooled normal plasma or FVIIIdef plasma mixed with emicizumab and recombinant FVIIa or plasma-derived FVIIa/FX. However, APC-catalyzed inactivation had little effect on thrombin generation assay potential in FVIIIdef plasma spiked with emicizumab and APCC. The addition of FIXa to emicizumab in FVIIIdef plasma could lead to partial APC resistance. Furthermore, FVIIIdef plasma spiked with emicizumab, FIXa, and FII was markedly resistant to APC-mediated inactivation. Conclusion FII and FIXa in APCCs were key clotting factors for APC resistance in FVIIIdef plasma supplemented with emicizumab and APCCs. The APC resistance in persons with hemophilia A receiving emicizumab and APCC may contribute to venous thromboembolic events.
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Affiliation(s)
- Yuto Nakajima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Nara, Japan
| | - Mitsumasa Osuna
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | | | - Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Nara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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Hugon-Rodin J, Fontana P, Poncet A, Streuli I, Casini A, Blondon M. Longitudinal profile of estrogen-related thrombotic biomarkers after cessation of combined hormonal contraceptives. Blood 2024; 143:70-78. [PMID: 37939264 DOI: 10.1182/blood.2023021717] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/28/2023] [Accepted: 09/13/2023] [Indexed: 11/10/2023] Open
Abstract
ABSTRACT The persistence of risk of venous thromboembolism (VTE) due to combined hormonal contraceptives (CHCs), after their cessation, is unknown but important to guide clinical practice. The objective of this prospective cohort study was to define the time until normalization of estrogen-related thrombotic biomarkers after CHC cessation. We enrolled women aged 18 to 50 years who had decided to stop their CHC, excluding those with a personal history of VTE, anticoagulation, or pregnancy. The study started before cessation of CHC, with 6 visits afterwards (at 1, 2, 4, 6, and 12 weeks after cessation). Primary outcomes were normalized sensitivity ratios to activated protein C (nAPCsr) and to thrombomodulin (nTMsr), with sex hormone-binding globulin (SHBG) as a secondary end point. We also included control women without CHC. Among 66 CHC users, from baseline until 12 weeks, average levels of nAPCsr, nTMsr, and SHBG decreased from 4.11 (standard deviation [SD], 2.06), 2.53 (SD, 1.03), and 167 nmol/L (SD, 103) to 1.27 (SD, 0.82), 1.11 (SD, 0.58), and 55.4 nmol/L (SD, 26.7), respectively. On a relative scale, 85.8%, 81.3%, and 76.2% of the decrease from baseline until 12 weeks was achieved at 2 weeks and 86.7%, 85.5%, and 87.8% at 4 weeks after CHC cessation, respectively. Levels were not meaningfully modified throughout the study period among 28 control women. In conclusion, CHC cessation is followed by a rapid decrease in estrogen-related thrombotic biomarkers. Two to 4 weeks of cessation before planned major surgery or withdrawal of anticoagulants in patients with VTE appears sufficient for the majority of women. The trial is registered at www.clinicaltrials.gov as #NCT03949985.
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Affiliation(s)
- Justine Hugon-Rodin
- Division of Gynecology, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
- Gynecology Department, Gynecological Endocrinology Unit, Hospital Saint Joseph, INSERM Unité Mixte de Recherche 1153, Équipe de Recherche en Épidémiologie Obstétricale Périnatale et Pédiatrique, Paris, France
| | - Pierre Fontana
- Division of Angiology and Hemostasis, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Antoine Poncet
- Center for Clinical Research, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Isabelle Streuli
- Division of Gynecology, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Alessandro Casini
- Division of Angiology and Hemostasis, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Marc Blondon
- Division of Angiology and Hemostasis, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
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Nakajima Y, Ogiwara K, Inaba K, Kitazawa T, Nogami K. NXT007-mediated hemostatic potential is suppressed by activated protein C-catalyzed inactivation of activated factor V. Res Pract Thromb Haemost 2024; 8:102271. [PMID: 38115953 PMCID: PMC10727940 DOI: 10.1016/j.rpth.2023.102271] [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] [Received: 08/03/2023] [Revised: 10/16/2023] [Accepted: 11/09/2023] [Indexed: 12/21/2023] Open
Abstract
Background Activated protein C (APC) inactivates activated factor (F) V (FVa) and FVIIIa. NXT007, an emicizumab-based engineered therapeutic bispecific antibody, enhances the coagulation potential of FVIII-deficient plasma (FVIIIdef-plasma) to near normal levels. However, little is known about the effect of APC-induced inactivation in NXT007-mediated hemostatic function. Objectives To investigate the contribution of APC-mediated reactions to NXT007-driven hemostasis. Methods In pooled normal plasma (PNP) or FVIIIdef-plasma spiked with NXT007 (10 μg/mL), effects of APC (0-16 nM) were measured using a thrombin generation assay (TGA). The direct effects of APC on cofactor activity of NXT007 or FVIIIa in a FXa generation assay were also measured. The FVdef-plasma and FV Leiden plasma (FVLeiden plasma) were preincubated with 2 anti-FVIII monoclonal antibodies (termed FVIII-depleted), and the APC effect in the presence of NXT007 in FVIII-depleted FVdef-plasma with the addition of exogenous FV (7.5-30 nM) or FVIII-depleted FVLeiden plasma was investigated. Results The APC dose-dependent suppression effect in TGA of FVIIIdef-plasma spiked with NXT007 was similar to that of PNP. FXa generation with NXT007 was not impaired by the addition of APC, suggesting that the APC-induced reaction in TGA with NXT007 was attributed to the direct inactivation of FVa. The addition of APC to FVIII-depleted FVdef-plasma, along with NXT007 and various FV concentrations, showed a similar attenuation to PNP. The NXT007-driven thrombin generation in FVIII-depleted FVLeiden plasma was suppressed by APC, similar to the reaction in native FVLeiden plasma. Conclusion NXT007 did not impair APC-mediated downregulation of FVa in FVIIIdef-plasmas, regardless of the presence of FV mutation with APC resistance.
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Affiliation(s)
- Yuto Nakajima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Nara, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keito Inaba
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Japan
| | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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Arafat A, Gennari P, Ignatov A, Tchaikovski S. Role of tissue factor pathway inhibitor in hormone-induced venous thromboembolism. Blood Coagul Fibrinolysis 2023; 34:233-238. [PMID: 37115963 DOI: 10.1097/mbc.0000000000001198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
ABSTRACT Exposure to higher levels of steroid hormones, like that in pregnancy or during combined hormonal contraception, increases the risk of venous thromboembolism. Development of resistance to activated protein C (APC) thought to be the underlying pathomechanism of this prothrombotic state. This coagulation phenomena is largely to be explained by the hormone-induced impairment of the protein S/ tissue factor pathway inhibitor (TFPI) leading to a less efficient inactivation of factor Va and factor VIIIa by APC. APC resistance and decreased protein S/TFPI function were associated with the risk of first as well as recurrent venous thromboembolism. Preexisting disturbances in these pathways are likely to predispose to thrombosis during hormone exposure and can persist over years after the thrombosis event.Further studies are necessary to investigate the predictive value of forgoing APC resistance and decreased protein S/TFPI function or an excessive alteration in these parameters during hormone intake on the development of hormone-induced venous thromboembolism.
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Affiliation(s)
- Amina Arafat
- Department of Obstetrics and Gynecology, Otto von Guericke University Clinic, Magdeburg, Germany
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Wójcik K, Bazan-Socha S, Celejewska-Wójcik N, Górka K, Lichołai S, Polok K, Stachura T, Zaręba L, Dziedzic R, Gradzikiewicz A, Sanak M, Musiał J, Sładek K, Iwaniec T. Decreased protein C activity, lower ADAMTS13 antigen and free protein S levels accompanied by unchanged thrombin generation potential in hospitalized COVID-19 patients. Thromb Res 2023; 223:80-86. [PMID: 36709678 PMCID: PMC9872442 DOI: 10.1016/j.thromres.2023.01.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 12/27/2022] [Accepted: 01/16/2023] [Indexed: 01/26/2023]
Abstract
INTRODUCTION COVID-19 is associated with an increased thromboembolic risk. However, the mechanisms triggering clot formation in those patients remain unknown. PATIENTS AND METHODS In 118 adult Caucasian severe but non-critically ill COVID-19 patients (median age 58 years; 73 % men) and 46 controls, we analyzed in vitro plasma thrombin generation profile (calibrated automated thrombogram [CAT assay]) and investigated thrombophilia-related factors, such as protein C and antithrombin activity, free protein S level, presence of antiphospholipid antibodies and factor V Leiden R506Q and prothrombin G20210A mutations. We also measured circulating von Willebrand factor (vWF) antigen and a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) antigen and activity. In patients, blood samples were collected on admission to the hospital before starting any therapy, including heparin. Finally, we examined the relationship between observed alterations and disease follow-up, such as thromboembolic complications. RESULTS COVID-19 patients showed 17 % lower protein C activity, 22 % decreased free protein S levels, and a higher prevalence of positive results for IgM anticardiolipin antibodies. They also had 151 % increased vWF, and 27 % decreased ADAMTS13 antigens compared with controls (p < 0.001, all). On the contrary, thrombin generation potential was similar to controls. In the follow-up, pulmonary embolism (PE) occurred in thirteen (11 %) patients. They were characterized by a 55 % elevated D-dimer (p = 0.04) and 2.7-fold higher troponin I (p = 0.002) during hospitalization and 29 % shorter time to thrombin peak in CAT assay (p = 0.009) compared to patients without PE. CONCLUSIONS In COVID-19, we documented prothrombotic abnormalities of peripheral blood. PE was characterized by more dynamic thrombin generation growth in CAT assay performed on admittance to the hospital.
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Affiliation(s)
- Krzysztof Wójcik
- Jagiellonian University Medical College, Faculty of Medicine, Department of Internal Medicine, 30-688 Krakow, Poland
| | - Stanisława Bazan-Socha
- Jagiellonian University Medical College, Faculty of Medicine, Department of Internal Medicine, 30-688 Krakow, Poland.
| | - Natalia Celejewska-Wójcik
- Jagiellonian University Medical College, Faculty of Medicine, Department of Internal Medicine, 30-688 Krakow, Poland
| | - Karolina Górka
- Jagiellonian University Medical College, Faculty of Medicine, Department of Internal Medicine, 30-688 Krakow, Poland
| | - Sabina Lichołai
- Jagiellonian University Medical College, Faculty of Medicine, Department of Internal Medicine, 30-688 Krakow, Poland
| | - Kamil Polok
- Jagiellonian University Medical College, Faculty of Medicine, Department of Internal Medicine, 30-688 Krakow, Poland
| | - Tomasz Stachura
- Jagiellonian University Medical College, Faculty of Medicine, Department of Internal Medicine, 30-688 Krakow, Poland
| | - Lech Zaręba
- University of Rzeszow, College of Natural Sciences, Interdisciplinary Center for Computational Modelling, 35-310 Rzeszow, Poland
| | - Radosław Dziedzic
- Jagiellonian University Medical College, Students' Scientific Group of Immune Diseases and Hypercoagulation, 30-688 Krakow, Poland; Jagiellonian University Medical College, Doctoral School of Medical and Health Sciences, Łazarza 16, 31-530 Krakow, Poland
| | - Ada Gradzikiewicz
- Jagiellonian University Medical College, Students' Scientific Group of Immune Diseases and Hypercoagulation, 30-688 Krakow, Poland
| | - Marek Sanak
- Jagiellonian University Medical College, Faculty of Medicine, Department of Internal Medicine, 30-688 Krakow, Poland
| | - Jacek Musiał
- Jagiellonian University Medical College, Faculty of Medicine, Department of Internal Medicine, 30-688 Krakow, Poland
| | - Krzysztof Sładek
- Jagiellonian University Medical College, Faculty of Medicine, Department of Internal Medicine, 30-688 Krakow, Poland
| | - Teresa Iwaniec
- Jagiellonian University Medical College, Department of Haematology, 31-501 Krakow, Poland
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Dahlbäck B. Natural anticoagulant discovery, the gift that keeps on giving: finding FV-Short. J Thromb Haemost 2023; 21:716-727. [PMID: 36746318 DOI: 10.1016/j.jtha.2023.01.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 01/24/2023] [Accepted: 01/24/2023] [Indexed: 02/05/2023]
Abstract
The complex reactions of blood coagulation are balanced by several natural anticoagulants resulting in tuned hemostasis. During several decades, the knowledge base of the natural anticoagulants has greatly increased and we have also learned about antiinflammatory and cytoprotective activities expressed by antithrombin and activated protein C (APC). Some coagulation proteins have also been found to function as anticoagulants; e.g., thrombin when bound to thrombomodulin activates protein C. Another example is factor V (FV), which in addition to being a procofactor to FVa has emerged as an anticoagulant. The discovery of APC resistance, caused by FVLeiden, as a thrombosis risk factor resulted in the identification of FV as an APC cofactor working in synergy with protein S in the regulation of FVIIIa in the Xase complex. More recently, a natural anticoagulant FV splice isoform (FV-Short) was discovered when investigating the East Texas bleeding disorder. In FV-Short, the truncated B domain exposes a high-affinity binding site for tissue factor pathway inhibitor alpha (TFPIα), and together with protein S a high-affinity trimolecular complex is generated. The FXa-inhibitory activity of TFPIα is synergistically stimulated by FV-Short and protein S. The circulating FV-Short/protein S/TFPIα complex concentration is normally low (≈0.2 nM) but provides an anticoagulant threshold. In the East Texas bleeding, the concentration of the complex, and thus the threshold, is increased 10-fold, which results in bleeding manifestations. The anticoagulant properties of FV were discovered during investigations of individual patients and follow the great tradition of bed-to-bench and bench-to-bed research in the coagulation field.
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Affiliation(s)
- Björn Dahlbäck
- Department of Translational Medicine, University Hospital, Lund University, 21428 Malmö, Sweden.
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Moore GW, Castoldi E, Teruya J, Morishita E, Adcock DM. Factor V Leiden-independent activated protein C resistance: Communication from the plasma coagulation inhibitors subcommittee of the International Society on Thrombosis and Haemostasis Scientific and Standardisation Committee. JOURNAL OF THROMBOSIS AND HAEMOSTASIS : JTH 2023; 21:164-174. [PMID: 36695379 DOI: 10.1016/j.jtha.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/30/2022] [Accepted: 10/06/2022] [Indexed: 01/09/2023]
Abstract
Activated protein C resistance (APC-R) due to the single-nucleotide polymorphism factor V Leiden (FVL) is the most common cause of hereditary thrombophilia. It is found predominantly in Caucasians and is uncommon or absent in other populations. Although FVL is responsible for >90% of cases of hereditary APC-R, a number of other F5 variants that also confer various degrees of APC-R and thrombotic risk have been described. Acquired APC-R due to increased levels of coagulation factors, reduced levels of inhibitors, or the presence of autoantibodies occurs in a variety of conditions and is an independent risk factor for thrombosis. It is common for thrombophilia screening protocols to restrict assessment for APC-R to demonstrating the presence or absence of FVL. The aim of this Scientific and Standardisation Committee communication is to detail the causes of FVL-independent APC-R to widen the diagnostic net, particularly in situations in which in vitro APC-R is encountered in the absence of FVL. Predilution clotting assays are not FVL specific and are used to detect clinically significant F5 variants conferring APC-R, whereas different forms of acquired APC-R are preferentially detected using the classical activated partial thromboplastin time-based APC-R assay without predilution and/or endogenous thrombin potential APC-R assays. Resource-specific recommendations are given to guide the detection of FVL-independent APC-R.
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Affiliation(s)
- Gary W Moore
- Department of Haematology, Specialist Haemostasis Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; Faculty of Science and Technology, Middlesex University, London, UK.
| | - Elisabetta Castoldi
- Department of Biochemistry, CARIM, Maastricht University, Maastricht, the Netherlands
| | - Jun Teruya
- Department of Pathology & Immunology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA; Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA; Department of Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Eriko Morishita
- Department of Hematology, Kanazawa University Hospital, Kanazawa, Japan
| | - Dorothy M Adcock
- Laboratory Corporation of America Holdings, Burlington, North Carolina, USA
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10
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Kriegshäuser G, Braunsteiner A. Temporal Association between Hampton's Hump Pulmonary Embolism and First-Dose ChAdOx1 nCov-19 Vaccine in a Patient with Activated Protein C Resistance. Vaccines (Basel) 2022; 10:vaccines10101659. [PMID: 36298523 PMCID: PMC9609840 DOI: 10.3390/vaccines10101659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/18/2022] [Accepted: 09/28/2022] [Indexed: 11/07/2022] Open
Abstract
A 58-year-old man presented to his practitioner with right-sided pleuritic chest pain, dyspnea, and fatigue 18 days following the first dose of the ChAdOx1 nCov-19 vaccine. Chest radiography showed a basal wedge-shaped consolidation indicative of a Hampton’s hump in the right lower lobe, which was confirmed by subsequent computed tomography pulmonary angiography. The major laboratory abnormalities were a markedly elevated D-dimer level of 7.53 µg/mL (normal range < 0.5 µg/mL), a CRP level of 62.8 mg/L (normal range < 5 mg/L), and a previously unknown activated protein C resistance of 1.3 (normal range ≥ 1.8). Genetic analysis identified the patient to be heterozygous for the FVLeiden mutation. Neither other errors of hemostasis nor antibodies against platelet factor 4-polyanion complexes could be observed. Moreover, we failed to demonstrate Severe Acute Respiratory Syndrome Coronavirus-2 infection. The patient fully recovered with no sequelae but is being continued on long-term anticoagulation given his risk of recurrent venous thromboembolism. Here we report on the temporal association between the first dose of the ChAdOx1 nCov-19 vaccine and extensive pulmonary embolism in an otherwise healthy patient with activated protein C resistance, however, further investigation is needed to prove causality.
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Affiliation(s)
- Gernot Kriegshäuser
- IHR LABOR Medical Diagnostic Laboratories, Wagramer Straße 144, 1220 Vienna, Austria
- School of Management, University of Applied Sciences BFI, 1020 Vienna, Austria
- Correspondence: ; Tel.: +43-1-8906701; Fax: +43-1-8906701-85
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11
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Morimont L, Donis N, Bouvy C, Mullier F, Dogné JM, Douxfils J. Laboratory Testing for the Evaluation of Phenotypic Activated Protein C Resistance. Semin Thromb Hemost 2022. [PMID: 36063850 DOI: 10.1055/s-0042-1757136] [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
Activated protein C (APC) resistance (APCR) is considered a risk factor of venous thromboembolism (VTE). The most common genetic disorder conferring APCR is a factor (F) V Leiden mutation, but many other factors are also implicated, such as other F5 mutations (e.g., FV Hong-Kong and FV Cambridge), protein S deficiency, elevated factor VIII, exogenous hormone use, pregnancy and postpartum, depending on how APCR is defined. Considering the large population affected, the detection of this phenotype is crucial. Two types of tests are currently available: clotting time-based assays (with several versions) and thrombin generation-based assays with the endogenous thrombin potential (ETP)-based assay. The purpose of this review is therefore to discuss the performances of these tests and the cases in which it would be appropriate to use one over the other. Initially, as APCR was thought to be solely related to the FV Leiden mutation, the objective was to obtain a 100% specific assay. Clotting-time based assays were thus specifically designed to detect this inherited condition. Later on, an APCR condition without a FV Leiden mutation was identified and highlighted as an independent risk factor of VTE. Therefore, the development of a less specific assay was needed and a global coagulation test was proposed, known as the ETP-based APCR assay. In light of the above, these tests should not be used for the same purpose. Clotting time-based assays should only be recommended as a screening test for the detection of FV mutations prior to confirmation by genetic testing. On the other hand, the ETP-based APC resistance assay, in addition to being able to detect any type of APCR, could be proposed as a global screening test as it assesses the entire coagulation process.
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Affiliation(s)
- Laure Morimont
- Department of Research, Qualiblood Sa, Namur, Belgium.,Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | | | - Céline Bouvy
- Department of Research, Qualiblood Sa, Namur, Belgium
| | - François Mullier
- Hematology Laboratory, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Jean-Michel Dogné
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Jonathan Douxfils
- Department of Research, Qualiblood Sa, Namur, Belgium.,Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
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Gemzell-Danielsson K, Cagnacci A, Chabbert-Buffet N, Douxfils J, Foidart JM, Kubba A, Lasa LIL, Mansour D, Neulen J, Neves J, Palma F, Römer T, Ski RS, Tóth V. A novel estetrol-containing combined oral contraceptive: European expert panel review. CESKA GYNEKOLOGIE 2022; 87:440-452. [PMID: 36543594 DOI: 10.1080/13625187.2022.2093850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE Despite considerable advances in recently developed combined oral contraceptives (COCs), resulting in lower rates of adverse events while maintaining contraceptive efficacy, there is interest in further innovation. MATERIALS AND METHODS Estetrol (E4), a native oestrogen, and progestin drospirenone (DRSP) were combined in a new COC. A European expert panel reviewed the pharmacology, efficacy, and safety and tolerability of this combination. Their findings are presented as a narrative review. RESULTS E4 15mg/DRSP 3 mg in a 24/4 regimen provided effective contraception with good cycle control, characterised by a predictable regular bleeding pattern and minimal unscheduled bleeding, together with a good safety profile. The combination was associated with high user satisfaction, wellbeing, and minimal changes in body weight. The effects on endocrine and metabolic parameters were limited, and the combination was found to have a limited impact on liver function and lipid and carbohydrate metabolism. Moreover, its effect on several haemostatic parameters was lower than that of comparators containing ethinyl oestradiol (EE) 20mg/DRSP 3 mg and EE 30mg/levonorgestrel 150mg. CONCLUSION E4 15 mg/DRSP 3 mg provides safe and effective contraception, with high user satisfaction and predictable bleeding. Further research will evaluate the long-term safety of the COC.
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Morimont L, Donis N, Bouvy C, Mullier F, Dogné JM, Douxfils J. Laboratory Testing for the Evaluation of Phenotypic Activated Protein C Resistance. Semin Thromb Hemost 2022; 48:680-689. [PMID: 36055270 DOI: 10.1055/s-0042-1753511] [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
Activated protein C (APC) resistance (APCR) is considered a risk factor of venous thromboembolism (VTE). The most common genetic disorder conferring APCR is a factor (F) V Leiden mutation, but many other factors are also implicated, such as other F5 mutations (e.g., FV Hong-Kong and FV Cambridge), protein S deficiency, elevated factor VIII, exogenous hormone use, pregnancy and postpartum, depending on how APCR is defined. Considering the large population affected, the detection of this phenotype is crucial. Two types of tests are currently available: clotting time-based assays (with several versions) and thrombin generation-based assays with the endogenous thrombin potential (ETP)-based assay. The purpose of this review is therefore to discuss the performances of these tests and the cases in which it would be appropriate to use one over the other. Initially, as APCR was thought to be solely related to the FV Leiden mutation, the objective was to obtain a 100% specific assay. Clotting-time based assays were thus specifically designed to detect this inherited condition. Later on, an APCR condition without a FV Leiden mutation was identified and highlighted as an independent risk factor of VTE. Therefore, the development of a less specific assay was needed and a global coagulation test was proposed, known as the ETP-based APCR assay. In light of the above, these tests should not be used for the same purpose. Clotting time-based assays should only be recommended as a screening test for the detection of FV mutations prior to confirmation by genetic testing. On the other hand, the ETP-based APC resistance assay, in addition to being able to detect any type of APCR, could be proposed as a global screening test as it assesses the entire coagulation process.
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Affiliation(s)
- Laure Morimont
- Department of Research, Qualiblood Sa, Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | | | - Céline Bouvy
- Department of Research, Qualiblood Sa, Namur, Belgium
| | - François Mullier
- Hematology Laboratory, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Jean-Michel Dogné
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Jonathan Douxfils
- Department of Research, Qualiblood Sa, Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
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14
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Morimont L, Donis N, Bouvy C, Mullier F, Dogné JM, Douxfils J. Laboratory Testing for the Evaluation of Phenotypic Activated Protein C Resistance. Semin Thromb Hemost 2022; 48:680-689. [DOI: 10.1055/s-0042-1758162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractActivated protein C (APC) resistance (APCR) is considered a risk factor of venous thromboembolism (VTE). The most common genetic disorder conferring APCR is a factor (F) V Leiden mutation, but many other factors are also implicated, such as other F5 mutations (e.g., FV Hong-Kong and FV Cambridge), protein S deficiency, elevated factor VIII, exogenous hormone use, pregnancy and postpartum, depending on how APCR is defined. Considering the large population affected, the detection of this phenotype is crucial. Two types of tests are currently available: clotting time-based assays (with several versions) and thrombin generation-based assays with the endogenous thrombin potential (ETP)-based assay. The purpose of this review is therefore to discuss the performances of these tests and the cases in which it would be appropriate to use one over the other. Initially, as APCR was thought to be solely related to the FV Leiden mutation, the objective was to obtain a 100% specific assay. Clotting-time based assays were thus specifically designed to detect this inherited condition. Later on, an APCR condition without a FV Leiden mutation was identified and highlighted as an independent risk factor of VTE. Therefore, the development of a less specific assay was needed and a global coagulation test was proposed, known as the ETP-based APCR assay. In light of the above, these tests should not be used for the same purpose. Clotting time-based assays should only be recommended as a screening test for the detection of FV mutations prior to confirmation by genetic testing. On the other hand, the ETP-based APC resistance assay, in addition to being able to detect any type of APCR, could be proposed as a global screening test as it assesses the entire coagulation process.
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Affiliation(s)
- Laure Morimont
- Department of Research, Qualiblood Sa, Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | | | - Céline Bouvy
- Department of Research, Qualiblood Sa, Namur, Belgium
| | - François Mullier
- Hematology Laboratory, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Jean-Michel Dogné
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Jonathan Douxfils
- Department of Research, Qualiblood Sa, Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
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15
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Falkner F, Thomas B, Aman M, Risse EM, Wittenberg G, Gazyakan E, Harhaus L, Bigdeli AK, Kneser U, Radu CA. The prognostic role of extended preoperative hypercoagulability work-up in high-risk microsurgical free flaps: a single-center retrospective case series of patients with heterozygotic factor V Leiden thrombophilia. BMC Surg 2022; 22:190. [PMID: 35568862 PMCID: PMC9107705 DOI: 10.1186/s12893-022-01639-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 05/05/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Hypercoagulability is associated with an increased risk of microvascular complications and free flap failures. The authors present their experience and approach to diagnosing and treating patients with heterozygotic factor V Leiden (hFVL) thrombophilia undergoing free flap reconstruction. METHODS Between November 2009 and June 2018, 23 free flap surgeries were performed in 15 hypercoagulable patients with hFVL. According to the timing of perioperative hypercoagulability work-up, they were grouped into flaps with established diagnoses prior to surgery (Group A) versus flaps with unknown diagnoses prior to surgery (Group B). Baseline characteristics and perioperative complications were compared between both groups, including revision surgeries due to microvascular thromboses, acute bleedings, hematomas, flap necroses, and reconstructive failures. RESULTS HFVL mutations had been confirmed preoperatively in 14 free flap surgeries (61%, Group A), whereas in 9 free flap surgeries (39%, Group B), mutations were only diagnosed postoperatively after the occurrence of microvascular thromboses had warranted extended hypercoagulability work-up. The overall rate of intraoperative flap thromboses was 9% (n = 2), whereas the overall rate of postoperative flap thromboses was 43% (n = 10). The corresponding salvage rates were 100% (n = 2/2) for intraoperative and 40% (n = 4/10) for postoperative pedicle thromboses. A total of five free flaps were lost (22%). Upon comparison, flaps with an unconfirmed diagnosis prior to surgery were at ten times higher risk for developing total necroses (flaps lost in Group B = 4/9 versus Group A = 1/14; OR: 10.4; 95% CI 1.0, 134.7; p = 0.03). CONCLUSION Meticulous preoperative work-up of patients with any history of hypercoagulability can help reduce free flap loss rates, thus improving surgical outcomes and increasing patient safety.
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Affiliation(s)
- Florian Falkner
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Benjamin Thomas
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Martin Aman
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Eva-Maria Risse
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Gerhard Wittenberg
- Department of Anesthesiology, Intensive Care Medicine and Pain Management, BG Trauma Clinic Ludwigshafen, Ludwigshafen, Germany
| | - Emre Gazyakan
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Leila Harhaus
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Amir K Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Christian A Radu
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany.
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16
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Stacey D, Chen L, Stanczyk PJ, Howson JMM, Mason AM, Burgess S, MacDonald S, Langdown J, McKinney H, Downes K, Farahi N, Peters JE, Basu S, Pankow JS, Tang W, Pankratz N, Sabater-Lleal M, de Vries PS, Smith NL, Gelinas AD, Schneider DJ, Janjic N, Samani NJ, Ye S, Summers C, Chilvers ER, Danesh J, Paul DS. Elucidating mechanisms of genetic cross-disease associations at the PROCR vascular disease locus. Nat Commun 2022; 13:1222. [PMID: 35264566 PMCID: PMC8907312 DOI: 10.1038/s41467-022-28729-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 02/08/2022] [Indexed: 02/05/2023] Open
Abstract
Many individual genetic risk loci have been associated with multiple common human diseases. However, the molecular basis of this pleiotropy often remains unclear. We present an integrative approach to reveal the molecular mechanism underlying the PROCR locus, associated with lower coronary artery disease (CAD) risk but higher venous thromboembolism (VTE) risk. We identify PROCR-p.Ser219Gly as the likely causal variant at the locus and protein C as a causal factor. Using genetic analyses, human recall-by-genotype and in vitro experimentation, we demonstrate that PROCR-219Gly increases plasma levels of (activated) protein C through endothelial protein C receptor (EPCR) ectodomain shedding in endothelial cells, attenuating leukocyte-endothelial cell adhesion and vascular inflammation. We also associate PROCR-219Gly with an increased pro-thrombotic state via coagulation factor VII, a ligand of EPCR. Our study, which links PROCR-219Gly to CAD through anti-inflammatory mechanisms and to VTE through pro-thrombotic mechanisms, provides a framework to reveal the mechanisms underlying similar cross-phenotype associations.
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Affiliation(s)
- David Stacey
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Lingyan Chen
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Paulina J Stanczyk
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- National Institute for Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Joanna M M Howson
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Department of Genetics, Novo Nordisk Research Centre Oxford, Innovation Building, Old Road Campus, Roosevelt Drive, Oxford, UK
| | - Amy M Mason
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephen Burgess
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Stephen MacDonald
- Specialist Haemostasis Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jonathan Langdown
- Specialist Haemostasis Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Harriett McKinney
- Department of Haematology, University of Cambridge, Cambridge, UK
- National Health Service Blood and Transplant, Cambridge, UK
| | - Kate Downes
- Department of Haematology, University of Cambridge, Cambridge, UK
- National Health Service Blood and Transplant, Cambridge, UK
- National Institute for Health Research BioResource, University of Cambridge, Cambridge, UK
| | - Neda Farahi
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - James E Peters
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, UK
- Health Data Research UK London, London, UK
| | - Saonli Basu
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - James S Pankow
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Weihong Tang
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Nathan Pankratz
- Department of Laboratory Medicine and Pathology, School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Maria Sabater-Lleal
- Genomics of Complex Diseases Group, Sant Pau Biomedical Research Institute, IIB-Sant Pau, Barcelona, Spain
- Cardiovascular Medicine Unit, Department of Medicine, Karolinska Institutet, Center for Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Paul S de Vries
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences; School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Nicholas L Smith
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, WA, USA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | | | | | - Nilesh J Samani
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- National Institute for Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Shu Ye
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- National Institute for Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | | | - Edwin R Chilvers
- National Heart and Lung Institute, Imperial College London, London, UK
| | - John Danesh
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, UK
- National Institute for Health Research Blood and Transplant Research Unit in Donor Health and Genomics, University of Cambridge, Cambridge, UK
- Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, UK
- Department of Human Genetics, Wellcome Sanger Institute, Hinxton, UK
| | - Dirk S Paul
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
- British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, UK.
- Department of Human Genetics, Wellcome Sanger Institute, Hinxton, UK.
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17
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Brouns SLN, Tullemans BME, Bulato C, Perrella G, Campello E, Spiezia L, Geffen J, Kuijpers MJE, Oerle R, Spronk HH, Meijden PEJ, Simioni P, Heemskerk JWM. Protein C or Protein S deficiency associates with paradoxically impaired platelet‐dependent thrombus and fibrin formation under flow. Res Pract Thromb Haemost 2022; 6:e12678. [PMID: 35284776 PMCID: PMC8900581 DOI: 10.1002/rth2.12678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 01/05/2022] [Accepted: 01/07/2022] [Indexed: 12/01/2022] Open
Abstract
Background Low plasma levels of protein C or protein S are associated with venous thromboembolism rather than myocardial infarction. The high coagulant activity in patients with thrombophilia with a (familial) defect in protein C or S is explained by defective protein C activation, involving thrombomodulin and protein S. This causes increased plasmatic thrombin generation. Objective Assess the role of platelets in the thrombus‐ and fibrin‐forming potential in patients with familial protein C or protein S deficiency under high‐shear flow conditions. Patients/Methods Whole blood from 23 patients and 15 control subjects was perfused over six glycoprotein VI–dependent microspot surfaces. By real‐time multicolor microscopic imaging, kinetics of platelet thrombus and fibrin formation were characterized in 49 parameters. Results and Conclusion Whole‐blood flow perfusion over collagen, collagen‐like peptide, and fibrin surfaces with low or high GPVI dependency indicated an unexpected impairment of platelet activation, thrombus phenotype, and fibrin formation but unchanged platelet adhesion, observed in patients with protein C deficiency and to a lesser extent protein S deficiency, when compared to controls. The defect extended from diminished phosphatidylserine exposure and thrombus contraction to delayed and suppressed fibrin formation. The mechanism was thrombomodulin independent, and may involve negative platelet priming by plasma components. ![]()
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Affiliation(s)
- Sanne L. N. Brouns
- Departments of Biochemistry and Internal Medicine CARIM Maastricht University Medical Centre Maastricht The Netherlands
| | - Bibian M. E. Tullemans
- Departments of Biochemistry and Internal Medicine CARIM Maastricht University Medical Centre Maastricht The Netherlands
| | - Cristiana Bulato
- Department of Medicine University of Padua Medical School Padova Italy
| | - Gina Perrella
- Departments of Biochemistry and Internal Medicine CARIM Maastricht University Medical Centre Maastricht The Netherlands
- Institute of Cardiovascular Sciences University of Birmingham Birmingham UK
| | - Elena Campello
- Department of Medicine University of Padua Medical School Padova Italy
| | - Luca Spiezia
- Department of Medicine University of Padua Medical School Padova Italy
| | - Johanna P. Geffen
- Departments of Biochemistry and Internal Medicine CARIM Maastricht University Medical Centre Maastricht The Netherlands
| | - Marijke J. E. Kuijpers
- Departments of Biochemistry and Internal Medicine CARIM Maastricht University Medical Centre Maastricht The Netherlands
| | - René Oerle
- Departments of Biochemistry and Internal Medicine CARIM Maastricht University Medical Centre Maastricht The Netherlands
| | - Henri M. H. Spronk
- Departments of Biochemistry and Internal Medicine CARIM Maastricht University Medical Centre Maastricht The Netherlands
| | - Paola E. J. Meijden
- Departments of Biochemistry and Internal Medicine CARIM Maastricht University Medical Centre Maastricht The Netherlands
| | - Paolo Simioni
- Department of Medicine University of Padua Medical School Padova Italy
| | - Johan W. M. Heemskerk
- Departments of Biochemistry and Internal Medicine CARIM Maastricht University Medical Centre Maastricht The Netherlands
- Synapse Research Institute Maastricht The Netherlands
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18
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Wan J, Vadaq N, Konings J, Jaeger M, Kumar V, de Laat B, Joosten L, Netea MG, van der Ven AJ, de Groot PG, de Mast Q, Roest M. Kallikrein augments the anticoagulant function of the protein C system in thrombin generation. J Thromb Haemost 2022; 20:48-57. [PMID: 34532976 PMCID: PMC9293419 DOI: 10.1111/jth.15530] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 09/13/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Genetics play a significant role in coagulation phenotype and venous thromboembolism risk. Resistance to the anticoagulant activated protein C (APC) is an established risk for thrombosis. Herein, we explored the genetic determinants of thrombin generation (TG) and thrombomodulin (TM)-modulated TG using plasma from the Human Functional Genomics Project. METHODS Calibrated TG was measured both in absence and presence of TM using tissue factor as trigger. Genetic determinants of TG parameters and protein C pathway function were assessed using genome-wide single-nucleotide polymorphism (SNP) genotyping. Plasma samples were supplemented with purified apolipoprotein A-IV, prekallikrein, or kallikrein to test their influence on the anticoagulant function of TM and APC in TG. RESULTS Thrombin generation data from 392 individuals were analyzed. Genotyping showed that the KLKB1 gene (top SNP: rs4241819) on chromosome 4 was associated with the normalized sensitivity ratio of endogenous thrombin potential to TM at genome-wide level (nETP-TMsr, P = 4.27 × 10-8 ). In vitro supplementation of kallikrein, but not prekallikrein or apolipoprotein A-IV, into plasma dose-dependently augmented the anticoagulant effect of TM and APC in TG. Variations of rs4241819 was not associated with the plasma concentration of prekallikrein. Association between rs4241819 and nETP-TMsr was absent when TG was measured in presence of a contact pathway inhibitor corn trypsin inhibitor. CONCLUSIONS Our results suggest that kallikrein plays a role in the regulation of the anticoagulant protein C pathway in TG, which may provide a novel mechanism for the previously observed association between the KLKB1 gene and venous thrombosis.
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Affiliation(s)
- Jun Wan
- Synapse Research InstituteCardiovascular Research Institute MaastrichtMaastricht University Medical CenterMaastrichtthe Netherlands
| | - Nadira Vadaq
- Department of Internal MedicineRadboud Center for Infectious DiseasesRadboud University Medical CenterNijmegenthe Netherlands
- Dr. Kariadi Hospital; Center for Tropical and Infectious Diseases (CENTRID)Faculty of MedicineDiponegoro UniversitySemarangIndonesia
| | - Joke Konings
- Synapse Research InstituteCardiovascular Research Institute MaastrichtMaastricht University Medical CenterMaastrichtthe Netherlands
| | - Martin Jaeger
- Department of Internal MedicineRadboud Center for Infectious DiseasesRadboud University Medical CenterNijmegenthe Netherlands
| | - Vinod Kumar
- Department of Internal MedicineRadboud Center for Infectious DiseasesRadboud University Medical CenterNijmegenthe Netherlands
- Department of GeneticsUniversity Medical Centre GroningenGroningenthe Netherlands
- Nitte (Deemed to be University)Nitte University Centre for Science Education and Research (NUCSER)Medical Sciences ComplexDeralakatte, MangaloreIndia
| | - Bas de Laat
- Synapse Research InstituteCardiovascular Research Institute MaastrichtMaastricht University Medical CenterMaastrichtthe Netherlands
| | - Leo Joosten
- Department of Internal MedicineRadboud Center for Infectious DiseasesRadboud University Medical CenterNijmegenthe Netherlands
| | - Mihai G. Netea
- Department of Internal MedicineRadboud Center for Infectious DiseasesRadboud University Medical CenterNijmegenthe Netherlands
- Department for Immunology and Metabolism, Life and Medical Sciences Institute (LIMES)University of BonnBonnGermany
| | - Andre J. van der Ven
- Department of Internal MedicineRadboud Center for Infectious DiseasesRadboud University Medical CenterNijmegenthe Netherlands
| | - Philip G. de Groot
- Synapse Research InstituteCardiovascular Research Institute MaastrichtMaastricht University Medical CenterMaastrichtthe Netherlands
| | - Quirijn de Mast
- Department of Internal MedicineRadboud Center for Infectious DiseasesRadboud University Medical CenterNijmegenthe Netherlands
| | - Mark Roest
- Synapse Research InstituteCardiovascular Research Institute MaastrichtMaastricht University Medical CenterMaastrichtthe Netherlands
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19
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Morimont L, Haguet H, Dogné JM, Gaspard U, Douxfils J. Combined Oral Contraceptives and Venous Thromboembolism: Review and Perspective to Mitigate the Risk. Front Endocrinol (Lausanne) 2021; 12:769187. [PMID: 34956081 PMCID: PMC8697849 DOI: 10.3389/fendo.2021.769187] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/08/2021] [Indexed: 12/02/2022] Open
Abstract
Many factors must be considered and discussed with women when initiating a contraceptive method and the risk of venous thromboembolism (VTE) is one of them. In this review, we discuss the numerous strategies that have been implemented to reduce the thrombotic risk associated with combined oral contraceptives (COCs) from their arrival on the market until today. Evidences suggesting that COCs were associated with an increased risk of VTE appeared rapidly after their marketing. Identified as the main contributor of this risk, the dosage of the estrogen, i.e., ethinylestradiol (EE), was significantly reduced. New progestins were also synthetized (e.g., desogestrel or gestodene) but their weak androgenic activity did not permit to counterbalance the effect of EE as did the initial progestins such as levonorgestrel. Numerous studies assessed the impact of estroprogestative combinations on hemostasis and demonstrated that women under COC suffered from resistance towards activated protein C (APC). Subsequently, the European Medicines Agency updated its guidelines on clinical investigation of steroid contraceptives in which they recommended to assess this biological marker. In 2009, estradiol-containing COCs were marketed and the use of this natural form of estrogen was found to exert a weaker effect on the synthesis of hepatic proteins compared to EE. In this year 2021, a novel COC based on a native estrogen, i.e., estetrol, will be introduced on the market. Associated with drospirenone, this preparation demonstrated minor effects on coagulation proteins as compared with other drospirenone-containing COCs. At the present time, the standard of care when starting a contraception, consists of identifying the presence of hereditary thrombophilia solely on the basis of familial history of VTE. This strategy has however been reported as poorly predictive of hereditary thrombophilia. One rationale and affordable perspective which has already been considered in the past could be the implementation of a baseline screening of the prothrombotic state to provide health care professionals with objective data to support the prescription of the more appropriate contraceptive method. While this strategy was judged too expensive due to limited laboratory solutions, the endogenous thrombin potential-based APC resistance assay could now represent an interesting alternative.
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Affiliation(s)
- Laure Morimont
- Research Department, Qualiblood s.a., Namur, Belgium
- Faculty of Medicine, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), University of Namur, Namur, Belgium
| | - Hélène Haguet
- Research Department, Qualiblood s.a., Namur, Belgium
- Faculty of Medicine, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), University of Namur, Namur, Belgium
| | | | - Ulysse Gaspard
- Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium
| | - Jonathan Douxfils
- Research Department, Qualiblood s.a., Namur, Belgium
- Faculty of Medicine, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), University of Namur, Namur, Belgium
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20
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Castoldi E, Hézard N, Mourey G, Wichapong K, Poggi M, Ibrahim-Kosta M, Thomassen MCLGD, Fournel A, Hayward CPM, Alessi MC, Hackeng TM, Rosing J, Morange PE. Severe thrombophilia in a factor V-deficient patient homozygous for the Ala2086Asp mutation (FV Besançon). J Thromb Haemost 2021; 19:1186-1199. [PMID: 33605529 DOI: 10.1111/jth.15274] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/04/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Coagulation factor V (FV), present in plasma and platelets, has both pro- and anticoagulant functions. OBJECTIVE We investigated an FV-deficient patient (FV:C 3%, FV:Ag 4%) paradoxically presenting with recurrent venous thrombosis (11 events) instead of bleeding. METHODS/RESULTS Thrombophilia screening revealed only heterozygosity for the F2 20210G>A mutation. Although thrombin generation in the patient's platelet-poor plasma was suggestive of a hypocoagulable state, thrombin generation in the patient's platelet-rich plasma (PRP) was higher than in control PRP and extremely resistant to activated protein C (APC). This was partially attributable to the complete abolition of the APC-cofactor activity of FV and a marked reduction of plasma tissue factor pathway inhibitor antigen and activity. The patient was homozygous for a novel missense mutation (Ala2086Asp, FVBesançon ) that favors a "closed conformation" of the C2 domain, predicting impaired binding of FV(a) to phospholipids. Recombinant FVBesançon was hardly secreted, indicating that this mutation is responsible for the patient's FV deficiency. Model system experiments performed using highly diluted plasma as a source of FV showed that, compared with normal FVa, FVaBesançon has slightly (≤1.5-fold) unfavorable kinetic parameters (Km , Vmax ) of prothrombin activation, but also a lower rate of APC-catalyzed inactivation in the presence of protein S. CONCLUSIONS FVBesançon induces a hypercoagulable state via quantitative (markedly decreased FV level) and qualitative (phospholipid-binding defect) effects that affect anticoagulant pathways (anticoagulant activities of FV, FVa inactivation, tissue factor pathway inhibitor α level) more strongly than the prothrombinase activity of FVa. A possible specific role of platelet FV cannot be excluded.
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Affiliation(s)
- Elisabetta Castoldi
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Nathalie Hézard
- Laboratory of Haematology, La Timone Hospital, Marseille, France
| | - Guillaume Mourey
- Department of Clinical Hemostasis, University Hospital of Besançon, Besançon, France
| | - Kanin Wichapong
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Marjorie Poggi
- C2VN, INSERM, INRA, Aix Marseille University, Marseille, France
| | | | | | - Alexandra Fournel
- Department of Clinical Hemostasis, University Hospital of Besançon, Besançon, France
| | | | | | - Tilman M Hackeng
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Jan Rosing
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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21
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Zhao R, Lang TC, Kim A, Wijewardena A, Vandervord J, McGrath R, Fulcher G, Xue M, Jackson C. Early protein C activation is reflective of burn injury severity and plays a critical role in inflammatory burden and patient outcomes. Burns 2021; 48:91-103. [PMID: 34175158 DOI: 10.1016/j.burns.2021.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 02/17/2021] [Accepted: 03/09/2021] [Indexed: 11/02/2022]
Abstract
BACKGROUND Navigating the complexities of a severe burn injury is a challenging endeavour where the natural course of some patients can be difficult to predict. Straddling both the coagulation and inflammatory cascades that feature strongly in the burns systemic pathophysiology, we propose the pleiotropic protein C (PC) system may produce a viable biomarker to assist traditional evaluation methods for diagnostic and prognostic purposes. METHODS We enrolled 86 patients in a prospective observational cohort study. Over three weeks, serial blood samples were taken and measured for PC, activated (A)PC, their receptor endothelial protein C receptor (EPCR), and a panel of inflammatory cytokines including C-reactive protein (CRP), tumour necrosis factor-α, interleukin (IL)-1β, IL-6, IL-8, and IL-17. Their temporal trends were analysed alongside clinical factors including burn size, burn depth, presence of inhalational injury, and a composite outcome of requiring increased support. RESULTS (i) APC increased from a nadir on Day 3 (2.3±2.1ng/mL vs 4.1±2.5ng/mL by Day 18, p<0.0005), only becoming appropriately correlated to PC from Day 6 onwards (r=0.412-0.721, p<0.05 for all Days 6-21). (ii) This early disturbance in the PC system was amplified in the more severe burns (≥30% total body surface area, predominantly full thickness, or with inhalational injury), which were characterised by a marked fall in PC activation (approximated by APC/PC ratio) and APC levels during Days 0-3 with low unchanged PC levels. Critically low levels of this cytoprotective agent was associated with greater inflammatory burden, as reflected by significantly elevated CRP, IL-6, and IL-8 levels in the more severe compared to less severe burns, and by negative correlations between both PC and APC with most inflammatory cytokines. (iii) Alongside clinical markers of severity at admission (burn size, burn depth, and presence of inhalational injury), only Day 0 APC/PC ratio (OR 1.048 (1.014-1.083), p=0.006), APC (OR 1.364 (1.032-1.803), p=0.029), PC (OR 0.899 (0.849-0.953), p<0.0005), and not any inflammatory cytokines were predictive markers of requiring increased support. Uniquely, decreased Day 0 PC was further individually associated with each increased total length of stay, ICU length of stay, intravenous fluid resuscitation, and total surgeries, as well as possibly mortality. CONCLUSION An early functional depletion of the cytoprotective PC system provides a physiological link between severe burns and the cytokine storm, likely contributing to worse outcomes. Our findings on the changes in APC, PC and PC activation during this pathological state support APC and PC as early diagnostic and prognostic biomarkers, and provides a basis for their therapeutic potential in severe burn injuries.
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Affiliation(s)
- Ruilong Zhao
- Sutton Arthritis Research Laboratory, Kolling Institute of Medical Research, University of Sydney at Royal North Shore Hospital, St Leonards, NSW 2065, Australia; Royal North Shore Hospital, St Leonards, NSW 2065, Australia.
| | - Thomas Charles Lang
- Sutton Arthritis Research Laboratory, Kolling Institute of Medical Research, University of Sydney at Royal North Shore Hospital, St Leonards, NSW 2065, Australia; Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | - Albert Kim
- Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | | | - John Vandervord
- Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | - Rachel McGrath
- Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | - Gregory Fulcher
- Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | - Meilang Xue
- Sutton Arthritis Research Laboratory, Kolling Institute of Medical Research, University of Sydney at Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | - Christopher Jackson
- Sutton Arthritis Research Laboratory, Kolling Institute of Medical Research, University of Sydney at Royal North Shore Hospital, St Leonards, NSW 2065, Australia
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22
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Ward MP, Saadeh FA, O'Toole SA, O'Leary JJ, Gleeson N, Norris LA. Procoagulant activity in high grade serous ovarian cancer patients following neoadjuvant chemotherapy-The role of the activated protein C pathway. Thromb Res 2021; 200:91-98. [PMID: 33571724 DOI: 10.1016/j.thromres.2021.01.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 01/11/2021] [Accepted: 01/14/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Ovarian cancer patients are at high risk of thrombosis particularly during chemotherapy treatment however the mechanism is not understood. The aim of this study is to investigate the role of the activated protein C (aPC) pathway in the procoagulant activity observed in ovarian cancer patients undergoing neoadjuvant chemotherapy. PATIENTS AND METHODS Thrombin generation was determined before and after addition of thrombomodulin (TM) in high grade serous ovarian cancer (HGSOC) patients treated with neoadjuvant chemotherapy (n = 29) compared with HGSOC patients who were chemo naïve (n = 23) and patients with benign tumours (n = 29). Plasma expression of proteins from the aPC pathway was analysed. mRNA expression was determined in endothelial (EA.hy926) and ovarian (OAW42) cell lines following addition of carboplatin and paclitaxel. RESULTS Lower levels of ETP (p < 0.007; p < 0.003) and peak thrombin (p < 0.0008; p < 0.0018) were found in the neoadjuvant group compared with both chemo naïve and benign groups. Following addition of TM, ETP (p < 0.0005) and peak thrombin (p < 0.0049) were higher in the neoadjuvant group compared with the benign controls indicating an increase in aPC resistance. Increased TM and lower levels of protein S were found in the neoadjuvant group compared with benign controls (p < 0.05; p < 0.003). Factor V levels were increased in the neoadjuvant group compared with the chemo naïve group (p < 0.05). Carboplatin and paclitaxel altered the expression of EPCR and thrombomodulin in OAW42 cells with a modest effect on EA.hy926 cells. CONCLUSION Chemotherapy induced procoagulant activity in HGSOC is associated with an alteration in expression of key members of the aPC pathway. This acquired aPC resistance may explain the procoagulant phenotype associated with ovarian cancer patients undergoing chemotherapy.
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Affiliation(s)
- Mark P Ward
- Coagulation Research Laboratory, Department of Obstetrics and Gynaecology, Trinity College Dublin, Ireland; Trinity St James's Cancer Institute, St. James's Hospital, Dublin 8, Ireland.
| | - Feras Abu Saadeh
- Coagulation Research Laboratory, Department of Obstetrics and Gynaecology, Trinity College Dublin, Ireland; Trinity St James's Cancer Institute, St. James's Hospital, Dublin 8, Ireland; Department of Gynae-oncology, St. James's Hospital, Dublin 8, Ireland
| | - Sharon A O'Toole
- Coagulation Research Laboratory, Department of Obstetrics and Gynaecology, Trinity College Dublin, Ireland; Trinity St James's Cancer Institute, St. James's Hospital, Dublin 8, Ireland; Department of Histopathology, Trinity College Dublin, Ireland
| | - John J O'Leary
- Trinity St James's Cancer Institute, St. James's Hospital, Dublin 8, Ireland; Department of Histopathology, Trinity College Dublin, Ireland; Molecular Pathology Research Laboratory, Coombe Women and Infants University Hospital, Dublin 8, Ireland
| | - Noreen Gleeson
- Coagulation Research Laboratory, Department of Obstetrics and Gynaecology, Trinity College Dublin, Ireland; Trinity St James's Cancer Institute, St. James's Hospital, Dublin 8, Ireland; Department of Gynae-oncology, St. James's Hospital, Dublin 8, Ireland
| | - Lucy A Norris
- Coagulation Research Laboratory, Department of Obstetrics and Gynaecology, Trinity College Dublin, Ireland; Trinity St James's Cancer Institute, St. James's Hospital, Dublin 8, Ireland
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23
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Ladeira VS, de Oliveira Toledo SL, Ferreira LGR, Oliveira MM, Silva APF, de Oliveira WV, Duarte RCF, Renó CDO, Dusse LMS, Dos Santos HL, Carvalho MDG, Pinheiro MDB, Rios DRA. Thrombin generation in vivo and ex vivo in sickle cell disease patients. Thromb Res 2020; 197:165-171. [PMID: 33221576 DOI: 10.1016/j.thromres.2020.10.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/26/2020] [Accepted: 10/29/2020] [Indexed: 12/18/2022]
Abstract
Activation of coagulation is an important hallmark of sickle cell disease (SCD) and it is believed that hypercoagulability plays a role to the disease pathophysiology. Studies have sought to identify how hemostatic biomarkers are expressed in SCD, however, the results are inconclusive. In this context, our objective was to evaluate the thrombin generation in vivo and ex vivo in SCD patients and the association between these biomarkers and the use of HU. This cross-sectional study was carried out with patients diagnosed with SCD, users or not of Hydroxyurea (HU), and healthy individuals as controls. D dimer (D-Di) was evaluated by ELISA and (TGT) thrombin generation test by CAT method. D-Di plasma levels were significantly higher in SCD patients when compared to the controls. TGT parameters such as peak, ETP and normalized ETP at low TF concentration and time-to-peak, peak, ETP and normalized ETP values at high TF concentration were lower in SCD patients than in controls. In contrast, the normalized activated protein C sensitivity ratio (nAPCsr) was higher in patients compared to controls, indicating resistance to the action of this natural anticoagulant. Regarding the use of HU, comparing users and non-users of this drug, no difference was observed in D-Di levels and in most TGT parameters. Our data analyzed together allow us to conclude that patients with SCD present a state of hypercoagulability in vivo due to the higher levels of D-Di and resistance to APC assessed ex vivo which is consistent with the coagulation imbalance described in SCD patients.
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Affiliation(s)
- Valéria Sutana Ladeira
- Universidade Federal de São João del-Rei, Campus Centro Oeste Dona Lindu, Brazil; Fundação Hemominas, Minas Gerais, Brazil
| | | | | | - Marina Mendes Oliveira
- Universidade Federal de São João del-Rei, Campus Centro Oeste Dona Lindu, Brazil; Fundação Hemominas, Minas Gerais, Brazil
| | | | | | | | | | | | | | - Maria das Graças Carvalho
- Universidade Federal de São João del-Rei, Campus Centro Oeste Dona Lindu, Brazil; Faculdade de Farmácia, Universidade Federal de Minas Gerais, Brazil
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24
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Velasco-Rodríguez D, Laso RV, García-Raso A, Mahíllo-Fernández I, Guzmán-López K, Martín-Herrero S, Barral EJ, Vegas-Sánchez MDC, Martínez-Becerra MJ, de la Plaza R, Romero LFL, Mínguez D, Alonso-Domínguez JM, López CB, López AG, Fernández MSS, Llamas-Sillero P. Thrombin generation in subjects with lupus anticoagulant without prior thrombosis or gestational morbidities. Thromb Res 2020; 196:425-431. [PMID: 33038586 DOI: 10.1016/j.thromres.2020.09.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 04/27/2020] [Accepted: 09/17/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Lupus anticoagulant (LA) can be a cause of thrombosis and/or pregnancy morbidities, producing antiphospholipid syndrome (APS). An increase in thrombin generation (TG) is correlated with prothrombotic status. Several changes in TG-derived parameters have been reported in APS patients. OBJECTIVES Evaluate whether the TG phenotype of APS can also be described in LA subjects without clinical manifestations of APS, and to investigate the possible influence of both LA potency and antiphospholipid (aPL) profile on it. RESULTS TG was analyzed in 153 cases of LA and 41 healthy controls. We have observed prolongation of both lag time (3.7 min vs 2.32 min, p < 0.001) and time to peak (6.48 min vs 5.27 min, p < 0.001), increased peak height (221.7 nM vs 182.7 nM, p < 0.001), slightly higher ETP (221.7 nM·min vs 182.7 nM·min, p = 0.041), and higher velocity index (100.7 nM/min vs 74.53 nM/min, p = 0.001) in LA subjects compared to controls. After adding thrombomodulin (TM), ETP%inh was significantly lower in LA group (37.90% vs 59.90%, p < 0.001) showing resistance to TM/activated protein C (APC). Significant differences were found in lag time, time to peak and ETP%inh according to the potency and aPL profile. CONCLUSIONS Previously described differences in TG-derived parameters in APS patients have been confirmed in incidental LA subjects: prolonged lag time and time to peak, slightly higher ETP, higher peak height, and less sensitivity to TM/APC. High LA potency and triple-positive aPL profile enhance differences in lag time, time to peak and, especially, increase APC resistance, but no effect in ETP was observed.
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Affiliation(s)
- Diego Velasco-Rodríguez
- Department of Hematology, Hospital Universitario Fundación Jiménez Díaz, IIS-FJD, Madrid, Spain.
| | - Rosa Vidal Laso
- Department of Hematology, Hospital Universitario Fundación Jiménez Díaz, IIS-FJD, Madrid, Spain
| | - Aránzazu García-Raso
- Department of Hematology, Hospital Universitario Fundación Jiménez Díaz, IIS-FJD, Madrid, Spain
| | | | - Karina Guzmán-López
- Department of Immunology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Sara Martín-Herrero
- Department of Hematology, Hospital Universitario Fundación Jiménez Díaz, IIS-FJD, Madrid, Spain
| | - Elena Jiménez Barral
- Department of Hematology, Hospital Universitario Fundación Jiménez Díaz, IIS-FJD, Madrid, Spain
| | | | | | - Reyes de la Plaza
- Department of Hematology, Hospital Universitario Fundación Jiménez Díaz, IIS-FJD, Madrid, Spain
| | | | - Dolores Mínguez
- Department of Hematology, Hospital Universitario Fundación Jiménez Díaz, IIS-FJD, Madrid, Spain
| | | | - Carlos Blas López
- Department of Hematology, Hospital Universitario Fundación Jiménez Díaz, IIS-FJD, Madrid, Spain
| | - Amanda García López
- Department of Hematology, Hospital Universitario Fundación Jiménez Díaz, IIS-FJD, Madrid, Spain
| | | | - Pilar Llamas-Sillero
- Department of Hematology, Hospital Universitario Fundación Jiménez Díaz, IIS-FJD, Madrid, Spain; Department of Hematology, Hospitales Quirón públicos, IIS-FJD, Universidad Autónoma de Madrid, Madrid, Spain
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25
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Brouns SLN, van Geffen JP, Campello E, Swieringa F, Spiezia L, van Oerle R, Provenzale I, Verdoold R, Farndale RW, Clemetson KJ, Spronk HMH, van der Meijden PEJ, Cavill R, Kuijpers MJE, Castoldi E, Simioni P, Heemskerk JWM. Platelet-primed interactions of coagulation and anticoagulation pathways in flow-dependent thrombus formation. Sci Rep 2020; 10:11910. [PMID: 32680988 PMCID: PMC7368055 DOI: 10.1038/s41598-020-68438-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 06/17/2020] [Indexed: 12/13/2022] Open
Abstract
In haemostasis and thrombosis, platelet, coagulation and anticoagulation pathways act together to produce fibrin-containing thrombi. We developed a microspot-based technique, in which we assessed platelet adhesion, platelet activation, thrombus structure and fibrin clot formation in real time using flowing whole blood. Microspots were made from distinct platelet-adhesive surfaces in the absence or presence of tissue factor, thrombomodulin or activated protein C. Kinetics of platelet activation, thrombus structure and fibrin formation were assessed by fluorescence microscopy. This work revealed: (1) a priming role of platelet adhesion in thrombus contraction and subsequent fibrin formation; (2) a surface-independent role of tissue factor, independent of the shear rate; (3) a mechanism of tissue factor-enhanced activation of the intrinsic coagulation pathway; (4) a local, suppressive role of the anticoagulant thrombomodulin/protein C pathway under flow. Multiparameter analysis using blood samples from patients with (anti)coagulation disorders indicated characteristic defects in thrombus formation, in cases of factor V, XI or XII deficiency; and in contrast, thrombogenic effects in patients with factor V-Leiden. Taken together, this integrative phenotyping approach of platelet–fibrin thrombus formation has revealed interaction mechanisms of platelet-primed key haemostatic pathways with alterations in patients with (anti)coagulation defects. It can help as an important functional add-on whole-blood phenotyping.
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Affiliation(s)
- Sanne L N Brouns
- Departments of Biochemistry and Internal Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
| | - Johanna P van Geffen
- Departments of Biochemistry and Internal Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
| | - Elena Campello
- Department of Medicine, University of Padua Medical School, Padua, Italy
| | - Frauke Swieringa
- Departments of Biochemistry and Internal Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.,Department of Protein Dynamics, Leibniz Institute for Analytical Sciences, ISAS, Dortmund, Germany
| | - Luca Spiezia
- Department of Medicine, University of Padua Medical School, Padua, Italy
| | - René van Oerle
- Departments of Biochemistry and Internal Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
| | - Isabella Provenzale
- Departments of Biochemistry and Internal Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
| | - Remco Verdoold
- Departments of Biochemistry and Internal Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
| | | | - Kenneth J Clemetson
- Department of Haematology, Inselspital, University of Berne, Berne, Switzerland
| | - Henri M H Spronk
- Departments of Biochemistry and Internal Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
| | - Paola E J van der Meijden
- Departments of Biochemistry and Internal Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
| | - Rachel Cavill
- Department of Data Science and Knowledge Engineering, Maastricht University, Maastricht, The Netherlands
| | - Marijke J E Kuijpers
- Departments of Biochemistry and Internal Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
| | - Elisabetta Castoldi
- Departments of Biochemistry and Internal Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
| | - Paolo Simioni
- Department of Medicine, University of Padua Medical School, Padua, Italy.
| | - Johan W M Heemskerk
- Departments of Biochemistry and Internal Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.
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26
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Hansen RS, Nybo M. The association between activated protein C ratio and Factor V Leiden are gender-dependent. Clin Chem Lab Med 2020; 57:1229-1234. [PMID: 30903752 DOI: 10.1515/cclm-2018-1382] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 02/22/2019] [Indexed: 11/15/2022]
Abstract
Background The most common cause of activated protein C (aPC) resistance is a missense substitution (Arg506Gln), known as Factor V Leiden (FVL). Due to its low cost, many laboratories use the aPC ratio as a primary test with a unisex cut-off. However, the association between the aPC ratio and FVL including any relation to gender has been sparsely investigated. Methods Results of the aPC ratio and FVL analyses from 1081 patients referred to the Thrombophilia Clinic at Odense University Hospital were compared. Results In 153 FVL positive patients, the mean aPC ratio was 2.1 ± 0.3, which differed from 2.7 ± 0.4 in FVL negative individuals (p < 0.01). The receiver operating characteristics (ROC), with area under the curve (AUC) of 0.93, indicated the optimal aPC cut-off at 2.3-2.4, with sensitivity 89%-94%, specificity 71%-84%, positive predictive value 35%-48% and negative predictive value 98%-99%. In FVL positive females, the mean aPC ratio was 2.0 ± 0.3, which differed from males (2.1 ± 0.3, p < 0.05). In FVL negative females, the mean aPC ratio was 2.6 ± 0.4, also different from males (2.8 ± 0.5, p < 0.01). Of note, 35% of FVL negative females had an aPC ratio ≤2.4 against 18% in males (p < 0.01). Conclusions Our results indicate that the aPC ratio is lower in females than in males. Due to a high negative predictive value the aPC ratio can be used as a first line test for FVL, but those found positive must be confirmed with a DNA test.
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Affiliation(s)
- Rasmus Søgaard Hansen
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Mads Nybo
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
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Li X, Li X, Li X, Zhuang Y, Kang L, Ju X. Genotypic and phenotypic character of Chinese neonates with congenital protein C deficiency: a case report and literature review. Thromb J 2019; 17:19. [PMID: 31592240 PMCID: PMC6774216 DOI: 10.1186/s12959-019-0208-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 09/06/2019] [Indexed: 12/31/2022] Open
Abstract
Background Our objective was to study the phenotype of and molecular genetic mechanisms underlying congenital protein C (PC) deficiency in Chinese neonates. We report the case of a neonate who presented 4 h after birth with purpura fulminans of the skin and thrombosis in the kidney. We also carried out a through literature review to study the genotype and phenotype, relevance, diagnosis, management, and prognosis of neonates with congenital PC deficiency in China. Case presentation and literature review Following a septic work-up and check of PC and protein S (PS) levels that showed PC deficiency, we investigated the patient’s and her parents’ genotypes. Our patient was found to have a plasma PC level of 0.8%. Molecular testing revealed a compound heterozygous mutation of the PROC gene: From the father, a c._262 G > T p. ASP88Tyr mutation in exon 4; from the mother, a C. 400 + 5G mutation in intron 5 that had been previously reported as likely pathogenic. Both parents were found to have heterozygous mutations for PC deficiency. In China, 5 other cases of congenital PC deficiency in the neonatal period were reported in the literature. In those cases, purpura fulminans and thrombosis were the main symptoms, and homozygous or compound heterozygous mutations of the PROC gene were identified. Conclusion Congenital PC deficiency should be ruled out for neonates presenting with purpura fulminans and thrombosis.
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Affiliation(s)
- Xiaoying Li
- 1Qilu Children's Hospital of Shandong University, Jinan, Shandong China
| | - Xiaoyan Li
- 2People's Hospital of Rongcheng, Weihai, Shandong China
| | - Xiao Li
- 1Qilu Children's Hospital of Shandong University, Jinan, Shandong China
| | - Yuanhua Zhuang
- 1Qilu Children's Hospital of Shandong University, Jinan, Shandong China
| | - Lili Kang
- 1Qilu Children's Hospital of Shandong University, Jinan, Shandong China
| | - Xiuli Ju
- 3Qilu Hospital of Shandong University, No107, Cultural west Road, Lixia District, Jinan, Shandong China
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Rühl H, Berens C, Winterhagen FI, Reda S, Müller J, Oldenburg J, Pötzsch B. Increased Activated Protein C Response Rates Reduce the Thrombotic Risk of Factor V Leiden Carriers But Not of Prothrombin 20210G>A Carriers. Circ Res 2019; 125:523-534. [PMID: 31314700 DOI: 10.1161/circresaha.119.315037] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
RATIONALE Carriers of the most common prothrombotic mutations FVL (factor V Leiden) and FII (prothrombin) 20210G>A show a highly variable clinical phenotype. Using standardized in vivo coagulation activation followed by activity pattern analysis we have recently shown, that the FVL mutation accelerates thrombin and APC (activated protein C) formation in carriers without a history of venous thromboembolism (VTE). OBJECTIVE The aim of this prospective cohort study was to investigate, if the FII 20210G>A mutation induces a similar reaction pattern, and if the response rates differ in FVL and FII 20210G>A mutation carriers with prior VTE (VTE+). METHODS AND RESULTS We comparatively analyzed 30 FVL carriers, 28 FII 20210G>A carriers (thereof 13 VTE+ each) and 15 healthy controls. Changes in plasma levels of thrombin, prothrombin activation fragment 1+2 (F1+2), TAT (thrombin-antithrombin complex), APC, and D-dimer were monitored over 8 hours after infusion of recombinant factor VIIa (15 µg/kg). An increase of F1+2 and TAT levels was observed, that did neither differ between FVL and FII 20210G>A carriers nor between asymptomatic and VTE+ carriers of these mutations. Median plasma levels of APC increased more (P=0.008) in FVL carriers (from 1.39 to 7.79 pmol/L) than in FII 20210G>A carriers (from 1.03 to 5.79 pmol/L), and more in FII 20210G>A carriers (P=2×10-4) than in healthy controls (from 0.86 to 3.00 pmol/L). Most importantly, however, the APC response was greater (P=0.015) in asymptomatic (n=13) than in VTE+ (n=12) heterozygous FVL carriers, with an increase of APC levels from 1.44 to 8.11 pmol/L versus 1.27 to 5.62 pmol/L. CONCLUSIONS These in vivo data demonstrate that the FII 20210G>A and FVL mutations share an intermediate phenotype that is characterized by increased thrombin formation after coagulation activation. Furthermore, our data support the conclusion that the APC activating capacity of FVL carriers modifies the thrombotic risk of this common prothrombotic mutation.
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Affiliation(s)
- Heiko Rühl
- From the Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Germany
| | - Christina Berens
- From the Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Germany
| | - Franziska I Winterhagen
- From the Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Germany
| | - Sara Reda
- From the Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Germany
| | - Jens Müller
- From the Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Germany
| | - Johannes Oldenburg
- From the Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Germany
| | - Bernd Pötzsch
- From the Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Germany
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Abstract
INTRODUCTION Fifty-three years after the first description of an inherited prothrombotic condition (antithrombin deficiency), our knowledge on hereditary and acquired causes of hypercoagulability that can predispose carriers to venous thromboembolism (VTE) has greatly improved. Areas covered: Main causes of hereditary thrombophilia are summarized alongside new prothrombotic mutations recently discovered. The main causes of acquired thrombophilia, and namely, antiphospholipid antibody syndrome and hyperhomocysteinemia, are also discussed together with other common acquired prothrombotic states characterized by an increase of procoagulant factors and/or a decrease of natural anticoagulants. Finally, suggestions for thromboprophylaxis in carriers of hereditary thrombophilia according to current guidelines/evidence are made for the most challenging high-risk situations (i.e. surgery, pregnancy, contraception, cancer, economy class syndrome) as well as for the prevention of post-thrombotic syndrome. Expert opinion: A carrier of inherited thrombophilia should be evaluated in the framework of other (genetic and/or acquired) coexisting risk factors for first or recurrent VTE when assessing the need and duration of prevention (primary prophylaxis). Prevention strategies should be tailored to each patient and every situational risk factor. The knowledge of the carriership status of severe thrombophilia in the proband can be important to provide asymptomatic relatives with adequate counseling on thrombophilia screening or primary thromboprophylaxis.
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Affiliation(s)
- Elena Campello
- a Haemorrhagic and Thrombotic Diseases Unit, Department of Medicine (DIMED) , Padova University Hospital , Padova , Italy
| | - Luca Spiezia
- a Haemorrhagic and Thrombotic Diseases Unit, Department of Medicine (DIMED) , Padova University Hospital , Padova , Italy
| | - Angelo Adamo
- a Haemorrhagic and Thrombotic Diseases Unit, Department of Medicine (DIMED) , Padova University Hospital , Padova , Italy
| | - Paolo Simioni
- a Haemorrhagic and Thrombotic Diseases Unit, Department of Medicine (DIMED) , Padova University Hospital , Padova , Italy
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Estrella MM, Parekh RS. The Expanding Role of APOL1 Risk in Chronic Kidney Disease and Cardiovascular Disease. Semin Nephrol 2018; 37:520-529. [PMID: 29110759 DOI: 10.1016/j.semnephrol.2017.07.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Variants of the APOL1 gene, found primarily in individuals of African descent, are associated with various forms of kidney disease and kidney disease progression. Recent studies evaluating the association of APOL1 with cardiovascular disease have yielded conflicting results, and the potential role in cardiovascular disease remains unclear. In this review, we summarize the observational studies linking the APOL1 risk variants with chronic kidney and cardiovascular disease among persons of African descent.
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Affiliation(s)
- Michelle M Estrella
- Kidney Health Research Collaborative, Department of Medicine, University of California San Francisco, San Francisco, CA; Department of Medicine, San Francisco VA Medical Center, San Francisco, CA
| | - Rulan S Parekh
- Division of Nephrology, Departments of Pediatrics and Medicine, The Hospital for Sick Children, SickKids Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Sinegre T, Duron C, Lecompte T, Pereira B, Massoulier S, Lamblin G, Abergel A, Lebreton A. Increased factor VIII plays a significant role in plasma hypercoagulability phenotype of patients with cirrhosis. J Thromb Haemost 2018; 16:1132-1140. [PMID: 29577605 DOI: 10.1111/jth.14011] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Indexed: 12/14/2022]
Abstract
Essentials The role of increased factor VIII in cirrhosis-induced hypercoagulability has never been demonstrated. Factor VIII and protein C effects were characterized by thrombin generation with thrombomodulin. Factor VIII elevation plays a significant role in cirrhosis-induced plasma hypercoagulability. Only protein C and factor VIII normalization led to thrombin generation similar to controls. SUMMARY Background In cirrhosis, thrombin generation (TG) studied in the presence of thrombomodulin (TM) indicates plasma hypercoagulability. Although the role of protein C (PC) deficiency has been investigated, the influence of an increase in the factor VIII level has never been addressed. Objectives We investigated the roles of high FVIII and low PC levels in increased TG in the presence of TM. Methods Blood samples were prospectively collected from 35 healthy controls and 93 patients with cirrhosis (Child-Turcotte-Pugh [CTP]-A, n = 61; CTP-B, n = 19; and CTP-C, n = 13) and FVIII levels > 150% (n = 48) and/or PC levels < 70% (n = 88). TG was performed with tissue factor (5 pm), phospholipids, and TM (4 nm). FVIII and PC levels were normalized by adding an inhibitory anti-FVIII antibody and exogenous PC, respectively. Results The endogenous thrombin potential (ETP) in the presence of TM was higher in patients than in controls. After FVIII normalization, the ETP (median) decreased from 929 nm min to 621 nm min (CTP-A), 1122 nm min to 1082 nm min (CTP-B), and 1221 nm min to 1143 nm min (CTP-C); after PC normalization, it decreased from 776 nm min to 566 nm min (CTP-A), 1120 nm min to 790 nm min (CTP-B), and 995 nm min to 790 nm min (CTP-C). The ETP was reduced by 17% and 30%, respectively, but normal TG was not restored. When both FVIII and PC levels were normalized, the ETP decreased from 929 nm min to 340 nm min (CTP-A), 1122 nm min to 506 nm min (CTP-B), and 1226 nm min to 586 nm min (CTP-C), becoming similar to control levels. Conclusion Cirrhosis-induced plasma hypercoagulability, as demonstrated in these experimental conditions, can be partly explained by opposite changes in two factors: PC level (decrease) and FVIII level (increase).
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Affiliation(s)
- T Sinegre
- Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, INRA, UMR 1019, Clermont-Ferrand, France
| | - C Duron
- Service d'Hépato-Gastro-Entérologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, CNRS, UMR 6284, Clermont-Ferrand, France
| | - T Lecompte
- Hôpitaux Universitaires de Genève, Unité d'hémostase, Département des spécialités de médecine, Geneva, Switzerland
- Université de Genève, GpG, Geneva, Switzerland
| | - B Pereira
- CHU Clermont-Ferrand, Unité de Biostatistiques (Direction de la recherche clinique et de l'innovation), Clermont-Ferrand, France
| | - S Massoulier
- Service d'Hépato-Gastro-Entérologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - G Lamblin
- Service d'Hépato-Gastro-Entérologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - A Abergel
- Service d'Hépato-Gastro-Entérologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, CNRS, UMR 6284, Clermont-Ferrand, France
| | - A Lebreton
- Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, INRA, UMR 1019, Clermont-Ferrand, France
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In vivo thrombin generation and subsequent APC formation are increased in factor V Leiden carriers. Blood 2018; 131:1489-1492. [DOI: 10.1182/blood-2017-12-823831] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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34
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Angchaisuksiri P. Venous thromboembolism in Asia – an unrecognised and under-treated problem? Thromb Haemost 2017; 106:585-90. [DOI: 10.1160/th11-03-0184] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Accepted: 06/29/2011] [Indexed: 11/05/2022]
Abstract
SummaryVenous thromboembolism (VTE) has been perceived for a long time to be less common in Asian populations, particularly in the Far East, than in Western populations. Generally, thromboprophylaxis is not implemented as frequently as it should be in high-risk patients. However, recent prospective studies undertaken in Asian countries have demonstrated higher rates of VTE after major surgery and in medical wards, approaching those observed in Western populations. Risk factors for VTE are not different in Asian patients from those of Western patients with the exception of thrombophilic mutations. Deficiencies of the natural anticoagulants (protein S, protein C, and antithrombin) are the predominant thrombophilias in Asia whereas factor V Leiden and prothrombin G20210A gene mutation are not found or rarely reported. Further large well-designed clinical studies are needed to evaluate the magnitude of the risk of VTE and the appropriate use of thromboprophylaxis in different clinical situations.
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Tchaikovski S, Holmström M, Rosing J, Bremme K, Lärfars G, Sonnevi K. Thrombin generation and activated protein C resistance in the absence of factor V Leiden correlates with the risk of recurrent venous thromboembolism in women aged 18–65 years. Thromb Haemost 2017; 106:901-7. [DOI: 10.1160/th11-04-0254] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 07/29/2011] [Indexed: 11/05/2022]
Abstract
SummaryIdentification of patients at high risk of recurrence after a first event of venous thromboembolism (VTE) remains difficult. Resistance to activated protein C (APC) is a known risk factor for VTE, but data on the risk of recurrence is controversial. We wanted to investigate whether APC resistance in the absence of factor V Leiden, determined with global coagulation test such as the thrombin generation assay, could be used as a marker for increased risk of recurrent VTE among women 18–65 years old after a first event of VTE. In a cohort of 243 women with a first event of VTE, plasma was collected after discontinuation of anticoagulant treatment and the patients were followed up for 46 months (median). Thrombin generation was measured via calibrated automated thrombography, at 1 pM and 10 pM of tissue factor (TF). In women without factor V Leiden (n=117), samples were analysed in the absence and in the presence of APC. Increase in ETP (endogenous thrombin potential) and peak height analysed in the presence of APC correlated significantly with higher risk of recurrence. At 1 pM, peak height correlated with increased risk of recurrence. In conclusion, high thrombin generation in the presence of APC, in women after a first event of VTE is indicative for an increased risk of a recurrence. We also found that thrombin generation at low TF (1 pM) is correlated with the risk of recurrence. Our data suggest that APC resistance in the absence of factor V Leiden is a risk factor for recurrent VTE.
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36
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Primary Thrombophilia in México XI: Activated Protein C Resistance Phenotypes are Multifactorial. Indian J Hematol Blood Transfus 2017; 33:375-379. [DOI: 10.1007/s12288-016-0767-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 12/15/2016] [Indexed: 10/20/2022] Open
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37
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Dahlbäck B. Novel insights into the regulation of coagulation by factor V isoforms, tissue factor pathway inhibitorα, and protein S. J Thromb Haemost 2017; 15:1241-1250. [PMID: 28671348 DOI: 10.1111/jth.13665] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Factor V (FV) is a regulator of both pro- and anticoagulant pathways. It circulates as a single-chain procofactor, which is activated by thrombin or FXa to FVa that serves as cofactor for FXa in prothrombin activation. The cofactor function of FVa is regulated by activated protein C (APC) and protein S. FV can also function as an anticoagulant APC cofactor in the inhibition of FVIIIa in the membrane-bound tenase complex (FIXa/FVIIIa). In recent years, it has become clear that FV also functions in multiple ways in the tissue factor pathway inhibitor (TFPI) anticoagulant pathway. Of particular importance is a FV splice variant (FV-Short) that serves as a carrier and cofactor to TFPIα in the inhibition of FXa. FV-Short is generated through alternative splicing of exon 13 that encodes the large activation B domain. A highly negatively charged binding site for TFPIα is exposed in the C-terminus of the FV-Short B domain, which binds the positively charged C-terminus of TFPIα, thus keeping TFPIα in circulation. The binding of TFPIα to FV-Short is also instrumental in localizing the inhibitor to the surface of negatively charged phospholipids, where TFPIα inhibits FXa in process that is stimulated by protein S. Plasma FV activation intermediates and partially proteolyzed platelet FV similarly bind TFPIα with high affinity and regulate formation of prothrombinase. The novel insights gained into the interaction between FV isoforms, TFPIα, and protein S have opened a new avenue for research about the mechanisms of coagulation regulation and also for future development of therapeutics aimed at modulating coagulation.
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Affiliation(s)
- B Dahlbäck
- Department of Translational Medicine, Lund University, University Hospital SUS, Malmö, Sweden
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38
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Ten Cate H, Hackeng TM, García de Frutos P. Coagulation factor and protease pathways in thrombosis and cardiovascular disease. Thromb Haemost 2017; 117:1265-1271. [PMID: 28594052 DOI: 10.1160/th17-02-0079] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 04/27/2017] [Indexed: 02/06/2023]
Abstract
The biochemical characterisation of the proteolytic pathways that constitute blood coagulation was one of the most relevant achievements in biomedical research during the second half of the 20th century. Understanding these pathways was of crucial importance for improving global health through application in haemostasis and thrombosis pathologies. Immediately after the cloning of the genes corresponding to these proteins, mutations were discovered in them that were associated with imbalances in haemostasis. Later, the importance of coagulation pathways in other pathological processes was demonstrated, such as in atherosclerosis and inflammation, both essential processes involved in vascular disease. In the present review we evaluate the concepts that have allowed us to reach the integrated vision on coagulation that we have today. The thrombo-inflammation model encompassing these aspects includes a pivotal role for the proteases of the coagulation pathway as well as the regulatory proteins thereof. These concepts illustrate the importance of the coagulation cascade in cardiovascular pathology, not only in thrombotic processes, but also in atherosclerotic processes and in the response to ischaemia-reperfusion injury, making it a central mechanism in cardiovascular disease.
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Affiliation(s)
| | | | - Pablo García de Frutos
- Dr. Pablo García de Frutos, Institute of Biomedical Research of Barcelona (IIBB-CSIC), C/Roselló 161, 08036 Barcelona, Spain, Tel.: +34 933632382, E-mail:
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Lebreton A, Sinegre T, Pereira B, Lamblin G, Duron C, Abergel A. Plasma hypercoagulability in the presence of thrombomodulin but not of activated protein C in patients with cirrhosis. J Gastroenterol Hepatol 2017; 32:916-924. [PMID: 27421039 DOI: 10.1111/jgh.13493] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 07/03/2016] [Accepted: 07/07/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Cirrhosis significantly changes all hemostasis steps. Recent studies suggest that cirrhosis is associated with a coagulopathy leading to a hypercoagulable state. The underlying mechanisms are not fully understood, but protein C deficiency is probably a major determinant of this phenotype. The aim of this study was to compare the results of thrombin generation assays performed with addition of thrombomodulin or activated protein C to assess the effect of by-passing the protein C activation step in cirrhotic patients and healthy controls. METHODS Fifty-eight patients with cirrhosis and 26 healthy controls were prospectively included in this study. Thrombin generation was determined in platelet-poor plasma using 5 pM of tissue factor and 4 nM of phospholipids, without and with external addition of 1 nM thrombomodulin or 4 nM activated protein C. All results were normalized with the values of a pool of normal plasma samples to limit inter-plate variability. RESULTS When thrombin generation assays were performed in the presence of thrombomodulin, endogenous thrombin potential (ETP) and ETP with/ETP without TM ratio were significantly higher in cirrhotic patients than in healthy controls (P < 0.0001). Moreover, these values progressively increased with cirrhosis severity. When thrombin generation assays were performed with activated protein C, all thrombin generation parameters were comparable between healthy controls and cirrhotic patients, despite an acquired protein S deficiency. CONCLUSION In the presence of activated protein C, no hypercoagulability was observed, adding to the current evidence that acquired protein C deficiency plays a key role in the coagulation imbalance.
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Affiliation(s)
- Aurélien Lebreton
- CHU Clermont-Ferrand, Service d'Hématologie Biologique, Clermont-Ferrand, France.,INRA-Université d'Auvergne, UMR1019, Unité de nutrition humaine, Clermont-Ferrand, France
| | - Thomas Sinegre
- CHU Clermont-Ferrand, Service d'Hématologie Biologique, Clermont-Ferrand, France.,INRA-Université d'Auvergne, UMR1019, Unité de nutrition humaine, Clermont-Ferrand, France
| | - Bruno Pereira
- CHU Clermont-Ferrand, Unité de Biostatistiques (Direction de la Recherche Clinique et de L'innovation), Clermont-Ferrand, France
| | - Géraldine Lamblin
- CHU Clermont-Ferrand, Service d'Hépato-Gastro-Entérologie, Clermont-Ferrand, France
| | - Cédric Duron
- CHU Clermont-Ferrand, Service d'Hépato-Gastro-Entérologie, Clermont-Ferrand, France.,Université d'Auvergne, UMR CNRS 6284, Clermont-Ferrand, France
| | - Armand Abergel
- CHU Clermont-Ferrand, Service d'Hépato-Gastro-Entérologie, Clermont-Ferrand, France.,Université d'Auvergne, UMR CNRS 6284, Clermont-Ferrand, France
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Sharma A, Singh K, Biswas A, Ranjan R, Kishor K, Kumar R, Pandey H, Kamal VK, Saxena R. Evaluation of role of FV, FVIII and APLAs in the pathogenesis of APCR in FV Leiden negative DVT patients: a study in India. J Thromb Thrombolysis 2017; 43:217-223. [DOI: 10.1007/s11239-016-1469-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
INTRODUCTION The discovery of the factor V Leiden (FVL) missense mutation (Arg506Gln) causing factor V resistance to the anticoagulant action of activated protein C was a landmark that allowed a better understanding of the basis of inherited thrombotic risk. FVL mutation is currently the most common known hereditary defect predisposing to venous thrombosis. Areas covered: Novel data-driven FVL diagnosis and therapeutic approaches in the management of FVL carriers in various clinical settings. Brief conclusions on topics of direct clinical relevance including currently available indications for primary and secondary prophylaxis, the management of female, pediatric carriers and asymptomatic relatives. Latest evidence on the association between FVL and cancer, as well as the possible use of direct oral anticoagulant therapy. Expert commentary: Although FVL diagnosis nowadays is highly accurate, many doubts remain regarding the best management and therapeutic protocols. The main role of clinicians is to tailor therapeutic strategies to carriers and their relatives. High familial penetrance, distinctive aspects of the first thrombotic event (provoked/unprovoked, age, etc.) and laboratory biomarkers can guide the optimal management of secondary antithrombotic prophylaxis, primary prophylaxis in asymptomatic individuals, and whether to screen relatives.
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Affiliation(s)
- Elena Campello
- a Hemorrhagic and Thrombotic Diseases Unit, Department of Medicine (DIMED) , University of Padua Medical School , Padua , Italy
| | - Luca Spiezia
- a Hemorrhagic and Thrombotic Diseases Unit, Department of Medicine (DIMED) , University of Padua Medical School , Padua , Italy
| | - Paolo Simioni
- a Hemorrhagic and Thrombotic Diseases Unit, Department of Medicine (DIMED) , University of Padua Medical School , Padua , Italy
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Pezeshkpoor B, Castoldi E, Mahler A, Hanel D, Müller J, Hamedani NS, Biswas A, Oldenburg J, Pavlova A. Identification and functional characterization of a novel F5 mutation (Ala512Val, FVB onn ) associated with activated protein C resistance. J Thromb Haemost 2016; 14:1353-63. [PMID: 27090446 DOI: 10.1111/jth.13339] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Indexed: 11/29/2022]
Abstract
UNLABELLED Essentials Activated protein C (APC) resistance is a prevalent risk factor for venous thrombosis. A novel missense mutation (Ala512Val - FVBonn ) was characterized in vitro and in silico. FVBonn is a new cause of APC resistance and venous thrombosis. FVBonn expresses additionally enhanced procoagulant activity in the absence of APC. SUMMARY Background Activated protein C (APC) resistance is a prevalent risk factor for venous thrombosis. This phenotype is most commonly associated with the factor V Arg506Gln mutation (FV Leiden), which impairs the APC-mediated inactivation of both activated FV (FVa) and activated FVIII (FVIIIa). Objectives Here, we report the identification and characterization of a novel FV mutation (Ala512Val, FVBonn ) in six patients with APC resistance and venous thrombosis or recurrent abortions. Methods FVBonn was expressed in a recombinant system and compared with recombinant wild-type (WT) FV and FV Leiden in several functional assays. Results FVBonn conferred APC resistance to FV-depleted plasma, both in the activated partial thromboplastin time (APTT)-based test (APC sensitivity ratio [APCsr] of 1.98 for FVBonn versus 4.31 for WT FV and 1.59 for FV Leiden) and in the thrombin generation-based test (normalized APCsr of 5.41 for FVBonn versus 1.00 for WT FV and 8.99 for FV Leiden). The APC-mediated inactivation of FVaBonn was slower than that of WT FVa (mainly because of delayed cleavage at Arg506), but was greatly stimulated by protein S. The APC cofactor activity of FVBonn in FVIIIa inactivation was ~ 24% lower than that of WT FV. In line with these findings, an in silico analysis showed that the Ala512Val mutation is located in the same loop as the Arg506 APC cleavage site and might hamper its interaction with APC. Moreover, FVBonn was more procoagulant than WT FV and FV Leiden in the absence of APC, because of an increased activation rate and, possibly, an enhanced interaction with activated FX. Conclusions FVBonn induces hypercoagulability via a combination of increased activation/procoagulant activity, decreased susceptibility to APC-mediated inactivation, and slightly reduced APC cofactor activity.
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Affiliation(s)
- B Pezeshkpoor
- Institute of Experimental Hematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - E Castoldi
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
| | | | - D Hanel
- Synlab MVZ, Stuttgart, Germany
| | - J Müller
- Institute of Experimental Hematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - N S Hamedani
- Institute of Experimental Hematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - A Biswas
- Institute of Experimental Hematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - J Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - A Pavlova
- Institute of Experimental Hematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
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43
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The Importance of Familiar Thrombophilias in the Clinical Practice. Novel Ways in Anticoagulant Therapy. Neuroophthalmology 2016. [DOI: 10.1007/978-3-319-28956-4_34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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44
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Hotoleanu C. Genetic Risk Factors in Venous Thromboembolism. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 906:253-272. [PMID: 27638626 DOI: 10.1007/5584_2016_120] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Genetic risk factors predispose to thrombophilia and play the most important etiopathogenic role in venous thromboembolism (VTE) in people younger than 50 years old. At least one inherited risk factor could be found in about half of the cases with a first episode of idiopathic VTE.Roughly, genetic risk factors are classified into two main categories: loss of function mutations (such as deficiencies of antithrombin, protein C, protein S) and gain of function mutations, (such as prothrombin mutation G20210A, factor V Leiden). A revolutionary contribution to the genetic background of VTE was brought by the achievements of the genome-wide association studies which analyze the association of a huge number of polymorphisms in large sample size.Hereditary thrombophilia testing should be done only in selected cases. The detection of hereditary thrombophilia has impact on the management of the anticoagulation in children with purpura fulminans, pregnant women at risk of VTE and may be useful in the assessment of the risk for recurrent thrombosis in patients presenting an episode of VTE at a young age (<40 years) and in cases with positive family history regarding thrombosis.
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Affiliation(s)
- Cristina Hotoleanu
- Department 5, Iuliu Hatieganu University of Medicine and Pharmacy, 8, Victor Babes street, 400012, Cluj-Napoca, Romania.
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45
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Sharma A, Bhakuni T, Biswas A, Ranjan R, Kumar R, Kishore K, Mahapatra M, Jairajpuri MA, Saxena R. Prevalence of Factor V Genetic Variants Associated With Indian APCR Contributing to Thrombotic Risk. Clin Appl Thromb Hemost 2015; 23:596-600. [PMID: 26699866 DOI: 10.1177/1076029615623376] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Phenotypic resistance to activated protein C (APC) is a complex mechanism associated with increased thrombosis risk. Activated protein C resistance (APCR) is mainly influenced by FVLeiden mutation, and various other single nucleotide polymorphisms (SNPs) in FV gene are known to be associated with APCR. The aim of present study was to investigate the incidence and assess possible mechanisms of APCR in Indian patients with deep vein thrombosis (DVT). Three hundred and ten Doppler-proven patients with DVT were screened for APCR, and 50 APCR positive patients and 50 controls were typed for FVLeiden, Hong Kong, Cambridge, HR2 haplotype, Glu666Asp, Ala485Lys, and Liverpool using either polymerase chain reaction (PCR)-restriction fragment length polymorphism or allele specific PCR. FVLeiden was commonest cause of APCR (50%) in Indian patients with DVT being statistically significant ( P = .001) compared to controls. FV Liverpool, FV Glu666Asp and FV Ala485Lys were studied for the first time in Indian population. FV Liverpool, FV Glu666Asp, Hong Kong, and Cambridge were found to be absent. High frequency of Ala485Lys in patients shows that it might be a risk factor contributing to APCR in Indian patients with DVT. HR2 haplotype was not associated with APCR; however, presence of homozygous HR2 haplotype in patients only indicates the role it might play in Indian APCR population. In conclusion, contribution of FVLeiden causing APCR in Indian population is not as strong as previously reported in Western countries. The presence of other SNPs observed in the present study requires such studies on larger sample size to understand the molecular basis of defect.
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Affiliation(s)
- Amit Sharma
- 1 Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - Teena Bhakuni
- 2 Protein Conformation and Enzymology Lab, Department of Biosciences, Jamia Millia Islamia, New Delhi, India
| | - Arijit Biswas
- 3 Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Ravi Ranjan
- 1 Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - Ravi Kumar
- 1 Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - Kamal Kishore
- 1 Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - Manoranjan Mahapatra
- 1 Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - Mohamad Aman Jairajpuri
- 2 Protein Conformation and Enzymology Lab, Department of Biosciences, Jamia Millia Islamia, New Delhi, India
| | - Renu Saxena
- 1 Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
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46
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Coagulation factor V mediates inhibition of tissue factor signaling by activated protein C in mice. Blood 2015; 126:2415-23. [PMID: 26341257 DOI: 10.1182/blood-2015-05-644401] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 08/31/2015] [Indexed: 01/20/2023] Open
Abstract
The key effector molecule of the natural protein C pathway, activated protein C (aPC), exerts pleiotropic effects on coagulation, fibrinolysis, and inflammation. Coagulation-independent cell signaling by aPC appears to be the predominant mechanism underlying its highly reproducible therapeutic efficacy in most animal models of injury and infection. In this study, using a mouse model of Staphylococcus aureus sepsis, we demonstrate marked disease stage-specific effects of the anticoagulant and cell signaling functions of aPC. aPC resistance of factor (f)V due to the R506Q Leiden mutation protected against detrimental anticoagulant effects of aPC therapy but also abrogated the anti-inflammatory and mortality-reducing effects of the signaling-selective 5A-aPC variant that has minimal anticoagulant function. We found that procofactor V (cleaved by aPC at R506) and protein S were necessary cofactors for the aPC-mediated inhibition of inflammatory tissue-factor signaling. The anti-inflammatory cofactor function of fV involved the same structural features that govern its cofactor function for the anticoagulant effects of aPC, yet its anti-inflammatory activities did not involve proteolysis of activated coagulation factors Va and VIIIa. These findings reveal a novel biological function and mechanism of the protein C pathway in which protein S and the aPC-cleaved form of fV are cofactors for anti-inflammatory cell signaling by aPC in the context of endotoxemia and infection.
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Moore GW, Chege E, Culhane AP, Hunt BJ. Maximising the diagnostic potential of APTT-based screening assays for activated protein C resistance. Int J Lab Hematol 2015; 37:844-52. [DOI: 10.1111/ijlh.12419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 07/20/2015] [Indexed: 12/01/2022]
Affiliation(s)
- G. W. Moore
- Department of Haemostasis and Thrombosis; Viapath Analytics; Guy's & St. Thomas' Hospitals; London UK
| | - E. Chege
- Department of Haemostasis and Thrombosis; Viapath Analytics; Guy's & St. Thomas' Hospitals; London UK
| | - A. P. Culhane
- Department of Haemostasis and Thrombosis; Viapath Analytics; Guy's & St. Thomas' Hospitals; London UK
| | - B. J. Hunt
- Department of Haemostasis and Thrombosis; Viapath Analytics; Guy's & St. Thomas' Hospitals; London UK
- Centre for Haemostasis and Thrombosis; Guy's & St. Thomas' Hospitals; London UK
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48
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Sharma A, Singh N, Mahapatra M, Ranjan R, Kishor K, Saxena R. Factors contributing to APC-resistance in women with recurrent spontaneous miscarriages: Indian perspective. Blood Cells Mol Dis 2015; 55:213-5. [PMID: 26227848 DOI: 10.1016/j.bcmd.2015.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Accepted: 06/21/2015] [Indexed: 11/29/2022]
Abstract
UNLABELLED Phenotypic resistance to APC is a complex mechanism associated with increased risk of venous thrombosis in women with recurrent spontaneous abortions. The primary aim of this prospective case control study was to find out the frequencies of different congenital and acquired thrombophilic factors predisposing to APC resistance and to evaluate the strength of their association with recurrent pregnancy losses. FV Leiden accounted for around 40% of all APCR positive patients and the difference in the group frequencies compared with controls, was found to be statistically significant (p=0.001). 18.33% (11/60) FV Leiden-negative APC-resistant patients had FVIII c values exceeding 95th percentile of the control population (145IU/dL), as compared to 3% in the control group (p=0.001). Mean FVIII level in control subjects was 118±14.0IUdL(-), compared with 127.7±31.2IUdL(-) in the patient group (p=0.009). Apart from FVIII, only the anti-phospholipid antibodies showed a statistically significant association with APCR phenotype (p=0.028), unlike other thrombophilic factors such as Protein C, Protein S, FV levels, HR2 haplotype or other rarer FV variants. The strong positive association of FVL mutation, anti-phospholipid antibodies and elevated FVIII levels with APCR phenotype calls for incorporating them as first line investigations in patients with recurrent spontaneous miscarriages with APCR positivity.
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Affiliation(s)
- Amit Sharma
- Department of Hematology, All India Institute of Medical Sciences, New Delhi 110029, India.
| | - Neha Singh
- Department of Hematology, All India Institute of Medical Sciences, New Delhi 110029, India.
| | - Manoranjan Mahapatra
- Department of Hematology, All India Institute of Medical Sciences, New Delhi 110029, India.
| | - Ravi Ranjan
- Department of Hematology, All India Institute of Medical Sciences, New Delhi 110029, India.
| | - Kamal Kishor
- Department of Hematology, All India Institute of Medical Sciences, New Delhi 110029, India.
| | - Renu Saxena
- Department of Hematology, All India Institute of Medical Sciences, New Delhi 110029, India.
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49
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Kerschen E, Hernandez I, Zogg M, Maas M, Weiler H. Survival advantage of heterozygous factor V Leiden carriers in murine sepsis. J Thromb Haemost 2015; 13:1073-80. [PMID: 25690763 PMCID: PMC4542152 DOI: 10.1111/jth.12876] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 01/28/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND The high allelic frequency of the prothrombotic Leiden polymorphism in human blood coagulation factor V (FV) has been speculated to reflect positive selection during evolution. Heterozygous Leiden carriers enrolled in the placebo arm of the PROWESS sepsis trial and heterozygous Leiden mice challenged with endotoxin both showed reduced mortality, whereas homozygous Leiden mice were not protected from lethal endotoxemia. Follow-up analyses of clinical outcomes and of mouse models of infection with various pathogens remained inconclusive. OBJECTIVE To establish whether activated protein C resistance of FV Leiden modifies the outcome of bacterial infection in murine sepsis models. METHODS Homozygous and heterozygous FV Leiden mice were subjected to gram-positive (S. aureus) or gram-negative (Y. pestis; E. coli) septic peritonitis or polymicrobial, focal septic peritonitis induced by cecal ligation and puncture. The effect of FV Leiden on 7-day survival and bacterial dissemination was assessed. Outcomes were compared with the sepsis survival of mice with genetically impaired hemostasis (hemophilia A, thrombocytopenia, thrombin receptor PAR4 [protease activated receptor 4] deficiency, endothelial protein C receptor [ProcR/EPCR] deficiency). RESULTS Heterozygous, but not homozygous, Leiden mice were protected from lethal infection with highly virulent S. aureus and Y. pestis strains. FV Leiden did not affect the outcome of sepsis induced by cecal ligation and puncture, staphylokinase-deficient S. aureus, Pla-deficient Y. pestis, or E. coli. Thrombocytopenia, deficiency of PAR1 or PAR4 did not affect S. aureus sepsis survival, whereas hemophilia A increased mortality. ProcR deficiency selectively abolished the survival advantage of heterozygous Leiden mice. CONCLUSIONS In mice, heterozygous FV Leiden carriers are protected from sepsis mortality after infection with clinically relevant human bacterial pathogens.
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Affiliation(s)
- Edward Kerschen
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, 53226, USA
| | - Irene Hernandez
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, 53226, USA
| | - Mark Zogg
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, 53226, USA
| | - Matthias Maas
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, 53226, USA
| | - Hartmut Weiler
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, 53226, USA
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50
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Xue M, Jackson CJ. Extracellular Matrix Reorganization During Wound Healing and Its Impact on Abnormal Scarring. Adv Wound Care (New Rochelle) 2015; 4:119-136. [PMID: 25785236 DOI: 10.1089/wound.2013.0485] [Citation(s) in RCA: 785] [Impact Index Per Article: 87.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Indexed: 12/18/2022] Open
Abstract
Significance: When a cutaneous injury occurs, the wound heals via a dynamic series of physiological events, including coagulation, granulation tissue formation, re-epithelialization, and extracellular matrix (ECM) remodeling. The final stage can take many months, yet the new ECM forms a scar that never achieves the flexibility or strength of the original tissue. In certain circumstances, the normal scar is replaced by pathological fibrotic tissue, which results in hypertrophic or keloid scars. These scars cause significant morbidity through physical dysfunction and psychological stress. Recent Advances and Critical Issues: The cutaneous ECM comprises a complex assortment of proteins that was traditionally thought to simply provide structural integrity and scaffolding characteristics. However, recent findings show that the ECM has multiple functions, including, storage and delivery of growth factors and cytokines, tissue repair and various physiological functions. Abnormal ECM reconstruction during wound healing contributes to the formation of hypertrophic and keloid scars. Whereas adult wounds heal with scarring, the developing foetus has the ability to heal wounds in a scarless fashion by regenerating skin and restoring the normal ECM architecture, strength, and function. Recent studies show that the lack of inflammation in fetal wounds contributes to this perfect healing. Future Directions: Better understanding of the exact roles of ECM components in scarring will allow us to produce therapeutic agents to prevent hypertrophic and keloid scars. This review will focus on the components of the ECM and their role in both physiological and pathological (hypertrophic and keloid) cutaneous scar formation.
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Affiliation(s)
- Meilang Xue
- Sutton Research Laboratories, Institute of Bone and Joint Research, Kolling Institute of Medical Research, The University of Sydney at Royal North Shore Hospital, St. Leonards, Australia
| | - Christopher J. Jackson
- Sutton Research Laboratories, Institute of Bone and Joint Research, Kolling Institute of Medical Research, The University of Sydney at Royal North Shore Hospital, St. Leonards, Australia
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