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Ichinose A, Osaki T, Souri M. Diagnosis and Treatment of Autoimmune Acquired Coagulation Factor Deficiencies: An Evidence-Based Review of Japanese Practice. Semin Thromb Hemost 2024. [PMID: 38866039 DOI: 10.1055/s-0044-1787188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
Among the acquired coagulation factor deficiencies, autoimmune coagulation factor deficiencies (AiCFD) are rare and result from autoantibody production against coagulation factors. In Japan, a nationwide survey on AiCFD has been conducted since 2009. Autoimmune factor XIII, factor VIII, von Willebrand factor, factor V, and factor X deficiencies (AiF13D, AiF8D, AiVWFD, AiF5D, and AiF10D, respectively) have been enacted as "designated intractable disease-282." The incidence of AiF8D, AiF13D, and AiF5D was 1.83, 0.044, and 0.038 per million people/year, respectively, whereas that of AiVWFD and AiF10D was not calculable owing to the small number of patients. AiF13D and AiF8D were often idiopathic, whereas AiVWFD was often associated with plasma cell neoplasms. Epistaxis was a characteristic symptom of AiVWFD, intramuscular bleeding was frequent in AiF13D and AiF8D, and subcutaneous bleeding (purpura) was frequent in AiF13D and AiF10D, although none were specific to any one disease. Differential diagnosis cannot be made based on bleeding symptoms alone; therefore, rapid and accurate testing is mandatory. Definitive diagnosis of AiCFD necessitates identifying the presence of coagulation factor "inhibitors" and/or "autoantibodies." Therefore, these tests should be performed upon unexplained severe acquired coagulation factor deficiencies. The mainstay of treatment for AiCFD was hemostatic therapy and autoantibody eradication therapy, which included the replacement of coagulation factors or "bypass" agents and administration of immunosuppressants. The rate of hemorrhagic death was high in AiF13D (13%), followed by AiF5D (7%) and Ai10D (5%); therefore, early diagnosis and optimal treatment are essential for AiCFDs. Given the unknown long-term prognosis, "intractable disease platform registries" have begun to accumulate in Japan.
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Affiliation(s)
- Akitada Ichinose
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Yamagata, Japan
- The Japanese Collaborative Research Group on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare, Yamagata University School of Medicine, Yamagata, Japan
| | - Tsukasa Osaki
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Yamagata, Japan
- The Japanese Collaborative Research Group on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare, Yamagata University School of Medicine, Yamagata, Japan
- Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Yamagata, Japan
| | - Masayoshi Souri
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Yamagata, Japan
- The Japanese Collaborative Research Group on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare, Yamagata University School of Medicine, Yamagata, Japan
- Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Yamagata, Japan
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A novel F13A1 gene mutation (Arg208Pro) in a Chinese patient with factor XIII deficiency. Blood Coagul Fibrinolysis 2022; 33:337-341. [PMID: 35981255 DOI: 10.1097/mbc.0000000000001143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The objective of the study was to analyse a novel F13A1 gene mutation in a Chinese patient with factor XIII (FXIII) deficiency and explore the molecular mechanism. Pedigree investigation, clinical diagnosis, phenotypic and genetic analysis were conducted. The F13A1 gene was amplified by PCR and directly sequenced. Online bioinformatics software was needed to analyse the mutation. A novel mutation c.515G>C (p.Arg208Pro) in exon 4 was found in the proband. Protein Arg208 is conserved highly among homologous species. Bioinformatics software showed that Arg208Pro mutation might affect the protein function. We preliminarily believed the mutation Arg208Pro was responsible for the decrease FXIII level. We reported a novel mutation in the F13A1 gene, which can flesh out the mutant library.
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Wolberg AS, Sang Y. Fibrinogen and Factor XIII in Venous Thrombosis and Thrombus Stability. Arterioscler Thromb Vasc Biol 2022; 42:931-941. [PMID: 35652333 PMCID: PMC9339521 DOI: 10.1161/atvbaha.122.317164] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
As the third most common vascular disease, venous thromboembolism is associated with significant mortality and morbidity. Pathogenesis underlying venous thrombosis is still not fully understood. Accumulating data suggest fibrin network structure and factor XIII-mediated crosslinking are major determinants of venous thrombus mass, composition, and stability. Understanding the cellular and molecular mechanisms mediating fibrin(ogen) and factor XIII production and function and their ability to influence venous thrombogenesis and resolution may inspire new anticoagulant strategies that target these proteins to reduce or prevent venous thrombosis in certain at-risk patients. This article summarizes fibrinogen and factor XIII biology and current knowledge of their function during venous thromboembolism.
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Affiliation(s)
- Alisa S Wolberg
- Department of Pathology and UNC Blood Research Center, University of North Carolina, Chapel Hill
| | - Yaqiu Sang
- Department of Pathology and UNC Blood Research Center, University of North Carolina, Chapel Hill
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Measuring Factor XIII Inhibitors in Patients with Factor XIII Deficiency: A Case Report and Systematic Review of Current Practices in Japan. J Clin Med 2022; 11:jcm11061699. [PMID: 35330024 PMCID: PMC8955945 DOI: 10.3390/jcm11061699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/12/2022] [Accepted: 03/15/2022] [Indexed: 11/17/2022] Open
Abstract
Factor XIII (FXIII) deficiency is a rare but serious coagulopathy. FXIII is critical in blood coagulation, and FXIII deficiencies can lead to uncontrolled or spontaneous bleeding. FXIII deficiencies can be congenital or acquired; acquired FXIII deficiency can be categorized as autoimmune and non-autoimmune. Immunological tests to measure FXIII inhibitors are required to diagnose acquired FXIII deficiency; however, appropriate test facilities are limited, which increases the turnaround time of these tests. In the case of critical bleeding, delayed test results may worsen prognosis due to delayed treatment. Here, we report a case of acquired FXIII deficiency, followed by a review of FXIII deficiency cases in Japan. We performed a systematic review to investigate the present conditions of the diagnosis and treatment of FXIII deficiency, including the measurement of FXIII inhibitors in Japan. FXIII inhibitor testing was only performed in 29.7 of acquired FXIII deficiency cases. Clinical departments other than internal medicine and pediatrics were often involved in medical treatment at the time of onset. Therefore, it is important for doctors in clinical departments other than internal medicine and pediatrics to consider FXIII deficiency and perform FXIII inhibitor testing when examining patients with prolonged bleeding of unknown cause or persistent bleeding after trauma.
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Kattula S, Sang Y, de Ridder G, Silver AC, Bouck EG, Cooley BC, Wolberg AS. Novel venous thromboembolism mouse model to evaluate the role of complete and partial factor XIII deficiency in pulmonary embolism risk. J Thromb Haemost 2021; 19:2997-3007. [PMID: 34431201 PMCID: PMC8605765 DOI: 10.1111/jth.15510] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/19/2021] [Accepted: 08/23/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Venous thrombosis (VT) and pulmonary embolism (PE), collectively venous thromboembolism (VTE), cause high mortality and morbidity. Factor XIII (FXIII) crosslinks fibrin to enhance thrombus stability and consequently may influence PE risk. Elucidating mechanisms contributing to PE is limited by a lack of models that recapitulate human PE characteristics. OBJECTIVE We aimed to develop a mouse model that permits embolization of red blood cell (RBC)- and fibrin-rich VT and determine the contribution of FXIII to PE risk. METHODS AND RESULTS In a thrombin-infusion PE model, F13a+/+ , F13a+/- , and F13a-/- mice had similar incidence of microthrombi in the lungs; however, thrombi were small, with low RBC content (≤7%), unlike human PEs (~70%). To identify a model producing PE consistent with histological characteristics of human PE, we compared mouse femoral vein electrolytic injury, femoral vein FeCl3 injury, and infrarenal vena cava (IVC) stasis models of VT. Electrolytic and FeCl3 models produced small thrombi with few RBCs (5% and 4%, respectively), whereas IVC stasis produced large thrombi with higher RBC content (68%) that was similar to human PEs. After IVC stasis and ligature removal (de-ligation) to permit thrombus embolization, compared to F13a+/+ mice, F13a+/- and F13a-/- mice had similar and increased PE incidence, respectively. CONCLUSIONS Compared to thrombin infusion-, electrolytic injury-, and FeCl3 -based models, IVC stasis produces thrombi that are more histologically similar to human thrombi. IVC stasis followed by de-ligation permits embolization of existing RBC- and fibrin-rich thrombi. Complete FXIII deficiency increases PE incidence, but partial deficiency does not.
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Affiliation(s)
- Sravya Kattula
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, USA
| | - Yaqiu Sang
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, USA
| | - Gustaaf de Ridder
- Department of Pathology and Laboratory Medicine, Transfusion Medicine, University of North Carolina at Chapel Hill, USA
| | - Anna C. Silver
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, USA
| | - Emma G. Bouck
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, USA
| | - Brian C. Cooley
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, USA
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, USA
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Schmitt FCF, von der Forst M, Miesbach W, Casu S, Weigand MA, Alesci S. Mild Acquired Factor XIII Deficiency and Clinical Relevance at the ICU-A Retrospective Analysis. Clin Appl Thromb Hemost 2021; 27:10760296211024741. [PMID: 34286623 PMCID: PMC8299891 DOI: 10.1177/10760296211024741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Acquired FXIII deficiency is a relevant complication in the perioperative setting; however, we still have little evidence about the incidence and management of this rarely isolated coagulopathy. This study aims to help find the right value for the substitution of patients with an acquired mild FXIII deficiency. In this retrospective single-center cohort study, we enrolled critically ill patients with mild acquired FXIII deficiency (>5% and ≤70%) and compared clinical and laboratory parameters, as well as pro-coagulatory treatments. The results of the present analysis of 104 patients support the clinical relevance of FXIII activity out of the normal range. Patients with lower FXIII levels, beginning at <60%, had lower minimum and maximum hemoglobin values, corresponding to the finding that patients with a minimum FXIII activity of <50% needed significantly more packed red blood cells. FXIII activity correlated significantly with general coagulation markers such as prothrombin time, activated partial thromboplastin time, and fibrinogen. Nevertheless, comparing the groups with a cut-off of 50%, the amount of fresh frozen plasma, thrombocytes, PPSB, AT-III, and fibrinogen given did not differ. These results indicate that a mild FXIII deficiency occurring at any point of intensive care unit stay is also probably relevant for the total need of packed red blood cells, independent of pro-coagulatory management. In alignment with the ESAIC guidelines, the measurement of FXIII in critically ill patients with the risk of bleeding and early management, with the substitution of FXIII at levels <50%-60%, could be suggested.
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Affiliation(s)
| | - Maik von der Forst
- Department of Anaesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Wolfgang Miesbach
- Haemostaseology, Department of Internal Medicine II, Institute of Transfusion Medicine, University Hospital, Goethe University Frankfurt am Main, Frankfurt, Germany
| | - Sebastian Casu
- Department of Emergency Medicine, Asklepios Klinik Wandsbek, Hamburg, Germany
| | | | - Sonja Alesci
- Institute of IMD Blood Coagulation Centre, Frankfurt/Bad Homburg, Germany
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7
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Duque P, Chasco-Ganuza M, Ortuzar A, Almaraz C, Terradillos E, Perez-Rus G, Pascual C. Acquired FXIII Deficiency is Associated with High Morbidity. Thromb Haemost 2021; 122:48-56. [PMID: 33851388 DOI: 10.1055/a-1481-2733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND A factor XIII (FXIII) level >30% is considered necessary to prevent spontaneous bleeding. Bleeding is also a risk in patients with acquired FXIII deficiency, but the hemostatic level of FXIII in this context remains to be determined. METHODS We retrospectively analyzed all patients diagnosed with acquired FXIII deficiency at a large hospital over 3 years (study ID NCT04416594, http://www.clinicaltrials.gov) and assessed clinical data to identify the best cut-off point for FXIII activity to distinguish between low and high risk of major bleeding in a mixed medical and surgical population. RESULTS Of the 97 patients who experienced bleeding despite a normal coagulation test, 43.2% had FXIII activity <70%. FXIII activity was significantly lower in surgical patients and patients admitted to the intensive care unit (ICU). Low FXIII activity was significantly associated with long ICU stays and a high incidence of major bleeding. CONCLUSION Acquired FXIII deficiency is associated with high morbidity. The hemostatic level of FXIII in the setting of acquired FXIII deficiency might be above 30%.
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Affiliation(s)
- Patricia Duque
- Anesthesiology and Critical Care Department, Gregorio Marañon Hospital, Madrid, Spain.,Gregorio Marañon Health Research Institute, Gregorio Marañon Hospital, Madrid, Spain
| | - Maite Chasco-Ganuza
- Anesthesiology and Critical Care Department, Gregorio Marañon Hospital, Madrid, Spain
| | - Ariana Ortuzar
- Department of Hematology, Gregorio Marañon Hospital, Madrid, Spain
| | - Carolina Almaraz
- Anesthesiology and Critical Care Department, Gregorio Marañon Hospital, Madrid, Spain
| | - Estrella Terradillos
- Anesthesiology and Critical Care Department, Gregorio Marañon Hospital, Madrid, Spain
| | - Gloria Perez-Rus
- Department of Hematology, Gregorio Marañon Hospital, Madrid, Spain.,Internal Medicine Department, Complutense University, Madrid, Spain
| | - Cristina Pascual
- Department of Hematology, Gregorio Marañon Hospital, Madrid, Spain.,Gregorio Marañon Health Research Institute, Gregorio Marañon Hospital, Madrid, Spain
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Clinical Validation of an Automated Fluorogenic Factor XIII Activity Assay Based on Isopeptidase Activity. Int J Mol Sci 2021; 22:ijms22031002. [PMID: 33498248 PMCID: PMC7863959 DOI: 10.3390/ijms22031002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/14/2021] [Accepted: 01/18/2021] [Indexed: 02/06/2023] Open
Abstract
Hereditary factor XIII (FXIII) deficiency is a rare autosomal bleeding disorder which can cause life-threatening bleeding. Acquired deficiency can be immune-mediated or due to increased consumption or reduced synthesis. The most commonly used screening test is insensitive, and widely used quantitative assays have analytical limitations. The present study sought to validate Technofluor FXIII Activity, the first isopeptidase-based assay available on a routine coagulation analyser, the Ceveron s100. Linearity was evidenced throughout the measuring range, with correlation coefficients of >0.99, and coefficients of variation for repeatability and reproducibility were <5% and <10%, respectively. A normally distributed reference range of 47.0–135.5 IU/dL was derived from 154 normal donors. Clinical samples with Technofluor FXIII Activity results between 0 and 167.0 IU/dL were assayed with Berichrom® FXIII Activity, a functional ammonia release assay, and the HemosIL™ FXIII antigen assay, generating correlations of 0.950 and 0.980, respectively. Experiments with a transglutaminase inhibitor showed that Technofluor FXIII Activity can detect inhibition of enzymatic activity. No interference was exhibited by high levels of haemolysis and lipaemia, and interference by bilirubin was evident at 18 mg/dL, a level commensurate with severe liver disease. Technofluor FXIII Activity is a rapid, accurate and precise assay suitable for routine diagnostic use with fewer interferents than ammonia release FXIII activity assays.
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Abstract
Coagulation factor XIII (FXIII) is a fibrin-stabilizing factor with additional roles in wound healing and interactions between the decidua and fetus. Congenital FXIII deficiency is rare bleeding disorder. Inhibitor development against FXIII in inherited FXIII deficency is also uncommon, but may cause severe, life-threatening bleeding. FXIII is the last step in the coagulation cascade with normal coagulation paramaters (PT, aPTT), the detection of inhibitor to FXIII is quite difficult. The treatment of inhibitor-positive congenital FXIII deficiency is challenging due to the lack of a role of by-pass agents such as FVII. The best known ways of treatment in these cases are the use of high-dose FXIII concentrates and immunosuppression. Herein, we report the management of postoperative bleeding diathesis in a patient with FXIII deficiency who developed inhibitors, and to follow the clinical course of the disease with FXIII concentrate and immunosuppression.
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Chuliber FA, Penchasky D, Santoro DM, Viñuales S, Otero V, Villagra Iturre M, Privitera V, Mezzarobba D, Burgos Pratx L, López MS, Barrera L, Schutz N, Arbelbide J, Martinuzzo M. Acquired factor XIII deficiency in patients under therapeutic plasma exchange: A poorly explored etiology. J Clin Apher 2020; 36:59-66. [PMID: 32942343 DOI: 10.1002/jca.21840] [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: 05/16/2020] [Revised: 08/19/2020] [Accepted: 09/02/2020] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Factor XIII (FXIII) deficiency may cause bleeding under certain clinical circumstances. Therapeutic plasma exchange (TPE) may lead to a transient deficiency. OBJECTIVES To describe the clinical evolution of patients with acquired FXIII deficiency secondary to TPE. METHODS We respectively studied a cohort of consecutive patients from 2014 to 2019 who were treated with TPE with FXIII levels <50%. The FXIII was measured after the start of the TPE course, on days between the TPE sessions, due to suspected acquired deficiency. All TPE were performed using continuous flow cell separator. In all cases, the initial replacement fluid applied was albumin. Apheresis procedures were held at 24to 48 hours intervals. RESULTS Eighteen patients were included, 13 of them were recipients of kidney transplants. The main TPE prescription was humoral rejection. Median FXIII at diagnosis (measured on days between sessions of the TPE course) was 19%(IQR17-25). The median of apheresis procedures before measurement of FXIII was 3(IQR2-4). Among the total cohort, 10 patients suffered hemorrhages. None of the patients without history of kidney transplants had bleeding (n = 5), however, 10/13 with kidney transplants did. Five kidney transplant patients received therapy with FXIII concentrate because of life-threatening bleeding. In all cases, the bleeding stopped within the first 24 hours. All patients had their FXIII levels measured again after finishing the TPE course, with normal results. CONCLUSIONS TPE is an under-diagnosed cause of acquired FXIII deficiency since routine coagulation tests remain unaltered. It might cause major bleeding, particularly in patients with a recent history of surgery like kidney transplants.
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Affiliation(s)
| | - Diana Penchasky
- Section of Hematology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Diego Mario Santoro
- Service of Transfusion Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Susana Viñuales
- Section of Hematology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Victoria Otero
- Section of Hematology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Verónica Privitera
- Section of Hematology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Daniela Mezzarobba
- Section of Hematology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Leandro Burgos Pratx
- Service of Transfusion Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Marina Sol López
- Department of Applied Biochemistry, Section of Hematology and Hemostasis, Central Laboratory, Hospital Italiano de Buenos Aires. Instituto Universitario del Hospital Italiano, Buenos Aires, Argentina
| | - Luis Barrera
- Department of Applied Biochemistry, Section of Hematology and Hemostasis, Central Laboratory, Hospital Italiano de Buenos Aires. Instituto Universitario del Hospital Italiano, Buenos Aires, Argentina
| | - Natalia Schutz
- Section of Hematology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Jorge Arbelbide
- Section of Hematology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Marta Martinuzzo
- Department of Applied Biochemistry, Section of Hematology and Hemostasis, Central Laboratory, Hospital Italiano de Buenos Aires. Instituto Universitario del Hospital Italiano, Buenos Aires, Argentina
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Cai R, Li Y, Wang W, Feng Q. A novel Cys328-terminator mutant implicated in severe coagulation factor XIII deficiency: a case report. BMC MEDICAL GENETICS 2020; 21:175. [PMID: 32883222 PMCID: PMC7650518 DOI: 10.1186/s12881-020-01111-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 08/27/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Factor XIII (FXIII) deficiency is an extremely rare bleeding disorder that is commonly due to mutations in the FXIIIA subunit gene (F13A1), and it has been reported to have a prevalence of one per 2 million. We describe a new genetic variant in the F13A1 gene that caused a patient to suffer from lifelong hemorrhagic diathesis. CASE PRESENTATION We evaluated a 20-year-old female with umbilical cord bleeding after birth, an intracerebral hemorrhage at age 6, and other bleeding episodes, including hematuria and cephalohematoma, who suffered from a lifelong hemorrhagic diathesis. The clot solubility test showed that the clot of the patient was dissolved in urea solution at 10 h. Genetic testing identified a novel homozygous mutation, c.984C > A(p. Cys328stop), resulting in a premature stop codon in exon 8 of the F13A1 gene. The results obtained with ClusterX software showed that Cys328 of exon 8 in the F13A1 gene is highly conserved among species. CONCLUSION We reported a novel homozygous mutation in the F13A1 gene in a factor XIII (FXIII)-deficient patient, which adds a new point mutation to the mutant library. In this paper, we discuss other aspects of the disease, including laboratory examination, homogeneous sequence alignment and molecular modeling.
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Affiliation(s)
- Ruimin Cai
- Department of Clinical Laboratory, Taian City Central Hospital, No. 29, Longtan Road, Taishan District, Taian, 271000, Shandong Province, China
| | - Yi Li
- Department of Clinical Laboratory, Taian City Central Hospital, No. 29, Longtan Road, Taishan District, Taian, 271000, Shandong Province, China
| | - Wenyang Wang
- Department of Clinical Laboratory, Taian City Central Hospital, No. 29, Longtan Road, Taishan District, Taian, 271000, Shandong Province, China
| | - Qiang Feng
- Department of Clinical Laboratory, Taian City Central Hospital, No. 29, Longtan Road, Taishan District, Taian, 271000, Shandong Province, China.
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A case of life-threatening small intestinal bleeding accompanied by lower coagulation factor XIII activity. Clin J Gastroenterol 2020; 13:1178-1182. [DOI: 10.1007/s12328-020-01195-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 07/10/2020] [Indexed: 01/29/2023]
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Zanon E, Pasca S, Radu C, Scattolo N, Spiezia L, Simioni P. Tailored prophylaxis with rFXIII (NovoThirteen ® ) in a young girl with severe FXIII deficiency and previous cephalohaematoma. Haemophilia 2019; 25:e206-e208. [PMID: 30888101 DOI: 10.1111/hae.13723] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 01/31/2019] [Accepted: 02/12/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Ezio Zanon
- Department of Medicine - DIMED, Thrombotic and Haemorrhagic and Coagulation Diseases Unit, Veneto Regional Centre for Haemophilia and Thrombophilia, Padova University Hospital, Padova, Italy
| | - Samantha Pasca
- Department of Medicine - DIMED, Thrombotic and Haemorrhagic and Coagulation Diseases Unit, Veneto Regional Centre for Haemophilia and Thrombophilia, Padova University Hospital, Padova, Italy
| | - Claudia Radu
- Department of Medicine - DIMED, Thrombotic and Haemorrhagic and Coagulation Diseases Unit, Veneto Regional Centre for Haemophilia and Thrombophilia, Padova University Hospital, Padova, Italy
| | | | - Luca Spiezia
- Department of Medicine - DIMED, Thrombotic and Haemorrhagic and Coagulation Diseases Unit, Veneto Regional Centre for Haemophilia and Thrombophilia, Padova University Hospital, Padova, Italy
| | - Paolo Simioni
- Department of Medicine - DIMED, Thrombotic and Haemorrhagic and Coagulation Diseases Unit, Veneto Regional Centre for Haemophilia and Thrombophilia, Padova University Hospital, Padova, Italy
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14
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Abstract
Factor XIII, a heterotetrameric proenzyme, is converted to an activated transglutaminase by thrombin and calcium in the final phases of coagulation. Factor XIII catalyzes the formation of crosslinks between fibrin monomers and between α2-antiplasmin and fibrin. These crosslinks mechanically stabilize fibrin against shear stress, enable red cell retention within the clot, and protect the clot from premature degradation. Congenital factor XIII deficiency is caused by autosomal recessive mutations, presenting early in life with a severe bleeding diathesis. Acquired deficiency may be caused by autoimmunity. Currently available assays for laboratory diagnosis of factor XIII deficiency include clot solubility assays, quantitative factor XIII activity assays, factor XIII antigen assays, and genetic testing. The International Society on Thrombosis and Haemostasis Scientific and Standardization Committee has recommended an algorithm for the laboratory diagnosis and differentiation of the different forms of factor XIII deficiency. However, implementation of this algorithm has been limited by technical and budgetary challenges associated with the currently available factor XIII-specific assays. The purpose of this review is to discuss the advantages and limitations of the currently available assays employed for the laboratory diagnosis of factor XIII deficiency.
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Affiliation(s)
- Michael A Durda
- The Ohio State University College of Medicine, Columbus, OH, United States
| | - Alisa S Wolberg
- University of North Carolina at Chapel Hill, Department of Pathology and Laboratory Medicine, Chapel Hill, NC, United States.
| | - Bryce A Kerlin
- Nationwide Children's Hospital, Division of Hematology/Oncology/Blood and Marrow Transplantation, Columbus, OH, United States; The Research Institute at Nationwide Children's Hospital, Center for Clinical & Translational Research, Columbus, OH, United States; The Ohio State University College of Medicine, Department of Pediatrics, Columbus, OH, United States
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15
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Factor XIII in plasma, but not in platelets, mediates red blood cell retention in clots and venous thrombus size in mice. Blood Adv 2018; 2:25-35. [PMID: 29344582 DOI: 10.1182/bloodadvances.2017011890] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 11/29/2017] [Indexed: 01/08/2023] Open
Abstract
The transglutaminase factor XIII (FXIII) stabilizes clots against mechanical and biochemical disruption and is essential for hemostasis. In vitro and in vivo models of venous thrombosis demonstrate that FXIII mediates clot size by promoting red blood cell (RBC) retention. However, the key source of FXIII and whether FXIII activity can be reduced to suppress thrombosis without imposing deleterious hemostatic consequences are 2 critical unresolved questions. FXIII is present in multiple compartments, including plasma (FXIIIplasma) as a heterotetramer of A2 and B2 subunits and platelets (FXIIIplt) as an A2 homodimer. We determined the role of the FXIII compartment and level in clot contraction, composition, and size in vitro and using in vivo models of hemostasis and venous thrombosis. Reducing overall FXIII levels decreased whole blood clot weight but did not alter thrombin generation or contraction of platelet-rich plasma clots. In reconstituted platelet-rich plasma and whole blood clot contraction assays, FXIIIplasma, but not FXIIIplt, produced high-molecular-weight fibrin crosslinks, promoted RBC retention, and increased clot weights. Genetically imposed reduction of FXIII delayed FXIII activation and fibrin crosslinking, suggesting FXIII levels mediate the kinetics of FXIII activation and activity and that the timing of these processes is a critical determinant of RBC retention during clot formation and contraction. A 50% reduction in FXIIIplasma produced significantly smaller venous thrombi but did not increase bleeding in tail transection or saphenous vein puncture models in vivo. Collectively, these findings suggest that partial FXIII reduction may be a therapeutic strategy for reducing venous thrombosis.
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Beckman JD, Holle LA, Wolberg AS. Factor XIII cotreatment with hemostatic agents in hemophilia A increases fibrin α-chain crosslinking. J Thromb Haemost 2018; 16:131-141. [PMID: 29080382 PMCID: PMC5802369 DOI: 10.1111/jth.13887] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Indexed: 01/19/2023]
Abstract
Essentials Factor XIII (FXIII)-mediated fibrin crosslinking is delayed in hemophilia. We determined effects of FXIII cotreatment with hemostatic agents on clot parameters. FXIII cotreatment accelerated FXIII activation and crosslinking of fibrin and α2 -antiplasmin. These data provide biochemical rationale for FXIII cotreatment in hemophilia. SUMMARY Background Hemophilia A results from the absence, deficiency or inhibition of factor VIII. Bleeding is treated with hemostatic agents (FVIII, recombinant activated FVII [rFVIIa], anti-inhibitor coagulation complex [FEIBA], or recombinant porcine FVIII [rpFVIII]). Despite treatment, some patients have prolonged bleeding. FXIII-A2 B2 (FXIII) is a protransglutaminase. During clot contraction, thrombin-activated FXIII (FXIIIa) crosslinks fibrin and α2 -antiplasmin, which promotes red blood cell retention and increases clot stability and weight. We hypothesized that FXIII cotreatment in hemophilia would accelerate FXIII activation, leading to increased fibrin crosslinking. Methods FVIII-deficient plasma and whole blood were clotted with or without hemostatic agents (FVIII, rFVIIa, FEIBA, or recombinant B-domain-deleted porcine FVIII [rpFVIII]) and/or FXIII. The effects on FXIII activation, thrombin generation, fibrin and α2 -antiplasmin crosslinking, clot formation and clot weight were measured by western blotting, calibrated automated thrombography, thromboelastography, and clot contraction assays. Results As compared with FVIII-treated hemophilic plasma, FVIII + FXIII cotreatment accelerated FXIIIa formation without increasing thrombin generation. As compared with buffer-treated or FXIII-treated hemophilic plasma, FVIII treatment and FVIII + FXIII cotreatment increased the generation and amount of crosslinked fibrin, including α-chain-rich high molecular weight species and crosslinked α2 -antiplasmin. In the presence of FVIII inhibitors, as compared with hemostatic treatments (rFVIIa, FEIBA, or rpFVIII) alone, FXIII cotreatment increased whole blood clot weight. Conclusion In hemophilia A plasma and whole blood, FXIII cotreatment with hemostatic agents accelerated FXIIIa formation, increased the generation and amount of fibrin α-chain crosslinked species, accelerated α2 -antiplasmin crosslinking, and increased clot weight. FXIII cotreatment with hemostatic therapy may augment hemostasis through increased crosslinking of fibrin and α2 -antiplasmin.
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Affiliation(s)
- J D Beckman
- Department of Medicine, Division of Hematology and Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - L A Holle
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - A S Wolberg
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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17
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Karimi M, Peyvandi F, Naderi M, Shapiro A. Factor XIII deficiency diagnosis: Challenges and tools. Int J Lab Hematol 2017; 40:3-11. [PMID: 29027765 DOI: 10.1111/ijlh.12756] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 09/06/2017] [Indexed: 01/06/2023]
Abstract
Factor XIII deficiency (FXIIID) is a rare hereditary bleeding disorder arising from heterogeneous mutations, which can lead to life-threatening hemorrhage. The diagnosis of FXIIID is challenging due to normal standard coagulation assays requiring specific FXIII assays for diagnosis, which is especially difficult in developing countries. This report presents an overview of FXIIID diagnosis and laboratory methods and suggests an algorithm to improve diagnostic efficiency and prevent missed or delayed FXIIID diagnosis. Assays measuring FXIII activity: The currently available assays utilized to diagnose FXIIID, including an overview of their complexity, reliability, sensitivity, and specificity, as well as mutational analysis are reviewed. The use of a FXIII inhibitor assay is described. Diagnostic tools in FXIIID: Many laboratories are not equipped with quantitative FXIII activity assays, and if available, limitations in lower activity ranges are important to consider. Clot solubility tests are not standardized, have a low sensitivity, and are therefore not recommended as routine screening test; however, they are the first screening test in almost all coagulation laboratories in developing countries. To minimize the number of patients with undiagnosed FXIIID, test quality should be improved in less well-equipped laboratories. Common country-specific mutations may facilitate diagnosis through targeted genetic analysis in reference laboratories in suspected cases. However, genetic analysis may not be feasible in every country and may miss spontaneous mutations. Centralized FXIII activity measurements should also be considered. An algorithm for diagnosis of FXIIID including different approaches dependent upon laboratory capability is proposed.
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Affiliation(s)
- M Karimi
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Indiana Hemophilia & Thrombosis Center, Indianapolis, IN, USA
| | - F Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - M Naderi
- Department Of Pediatrics Hematology and Oncology, Ali Ebn-e Abitaleb Hospital Research Centre for Children and Adolescents Health [RCCAH], Zahedan University Of Medical Sciences, Zahedan, Iran
| | - A Shapiro
- Indiana Hemophilia & Thrombosis Center, Indianapolis, IN, USA
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18
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Jennings I, Kitchen S, Menegatti M, Palla R, Walker I, Makris M, Peyvandi F. Detection of Factor XIII deficiency: data from multicentre exercises amongst UK NEQAS and PRO-RBDD project laboratories. Int J Lab Hematol 2017; 39:350-358. [PMID: 28406553 DOI: 10.1111/ijlh.12633] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 11/25/2016] [Indexed: 11/30/2022]
Abstract
INTRODUCTION FXIII deficiency is a rare bleeding disorders, and specific FXIII assays are recommended to detect this deficiency. We investigated the performance and accuracy of FXIII investigations in two exercises, comparing centres enrolled in the PRO-RBDD project (prospective data collection on patients with fibrinogen and Factor XIII deficiencies), and UK NEQAS BC centres. METHODS Samples from a FXIII deficient subject and a normal donor were sent to participating centres, to investigate for FXIII deficiency, and interpret their results. Median, coefficient of variation and range were determined. RESULTS Results were returned from 98 UK NEQAS BC and 28 PRO-RBDD centres. Up to 40% of UK NEQAS BC and 52% of PRO-RBDD centres reported clot solubility results - with diagnostic errors by two NEQAS BC centres (false negatives for the FXIII deficient sample) and one PRO-RBDD centre (false positive for the normal sample). Over 70% of UK NEQAS BC centres and PRO-RBDD centres performed FXIII assays. Median results were similar between the two groups, with the exception of sample 3 in survey 2 (5.5 vs. 14.0 μ/dl for UK NEQAS BC and PRO-RBDD centres respectively, P < 0.001). Diagnostic errors were made by 2 UK NEQAS BC centres. CONCLUSION Approximately 70% of centres now employ FXIII assays, complying with international recommendations. However, solubility tests continue to be used. Our data show this can be successful, depending on the sensitivity of the method in use. Diagnostic errors are made by centres using both solubility screens and FXIII assays, and laboratories should ensure good quality assurance procedures to improve diagnostic accuracy.
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Affiliation(s)
- I Jennings
- UK NEQAS (Blood Coagulation), Sheffield, UK
| | - S Kitchen
- UK NEQAS (Blood Coagulation), Sheffield, UK.,Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK
| | - M Menegatti
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano and Fondazione Luigi Villa, Milan, Italy
| | - R Palla
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano and Fondazione Luigi Villa, Milan, Italy
| | - I Walker
- UK NEQAS (Blood Coagulation), Sheffield, UK
| | - M Makris
- Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK
| | - F Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano and Fondazione Luigi Villa, Milan, Italy
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19
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von Rappard S, Hinnen C, Lussmann R, Rechsteiner M, Korte W. Factor XIII Deficiency and Thrombocytopenia Are Frequent Modulators of Postoperative Clot Firmness in a Surgical Intensive Care Unit. Transfus Med Hemother 2017; 44:85-92. [PMID: 28503124 DOI: 10.1159/000468946] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 03/06/2017] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE Fibrinogen and factor XIII (FXIII) have been shown to critically influence clot firmness in the intraoperative setting and thus likely influence intraoperative bleeding. We were interested to identify potential modulators of postoperative clot firmness in a tertiary care hospital surgical intensive care unit setting, independent of their clinical course during surgery. METHODS 272 day-shift consecutive patients were evaluated for whole blood clot firmness evaluated by the ROTEM® EXTEM thrombelastometric assay and various potential modulators of clot firmness upon arrival at the surgical intensive care unit (SICU). RESULTS Maximum clot firmness on the SICU was found to be independently influenced by the amount of colloids given during surgery as well as by platelet count, fibrinogen concentration, and FXIII activity at the time of SICU admission. In patients with lowest clot firmness, FXIII activity was the most important independent modulator of clot firmness; in patients with the highest clot firmness, platelet count and fibrinogen concentration were the most important modulators of clot firmness. Deficiencies (i.e., results below normal range) of these modulators of clot firmness were most prevalent for FXIII (activity < 70%: 45% of cases), which was significantly more frequent than thrombocytopenia (<150 × 109/l: 32%) or fibrinogen deficiency (<1.5 g/l: 6%). CONCLUSIONS Postoperative clot firmness as evaluated by whole blood thrombelastometry (ROTEM EXTEM assay) is independently and frequently modulated though FXIII activity and the platelet count, while fibrinogen concentration is also an independent but much less frequent modulator. Different modulators show different influences, depending on the clot firmness being present. Colloids infused during surgery also independently modulate postoperative clot firmness. Based on our data, strategies can be developed to improving postoperative care of patients with bleedings or at risk for bleeding.
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Affiliation(s)
- Sarah von Rappard
- Department of Anesthesiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Corina Hinnen
- Department of Anesthesiology, Intensive Care, Rescue and Pain Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Roger Lussmann
- Institute for Anesthesiology and Intensive Care, Klinik Hirslanden, Zurich, Switzerland
| | - Manuela Rechsteiner
- Center for Laboratory Medicine and Hemostasis; and Hemophilia Center, St. Gallen, Switzerland
| | - Wolfgang Korte
- Center for Laboratory Medicine and Hemostasis; and Hemophilia Center, St. Gallen, Switzerland
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20
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Caron C, Meley R, Le Cam Duchez V, Aillaud MF, Lavenu-Bombled C, Dutrillaux F, Flaujac C, Ryman A, Ternisien C, Lasne D, Galinat H, Pouplard C. Agreement between factor XIII activity and antigen assays in measurement of factor XIII: A French multicenter study of 147 human plasma samples. Int J Lab Hematol 2017; 39:279-285. [PMID: 28318109 DOI: 10.1111/ijlh.12621] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 12/02/2016] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Factor XIII (FXIII) deficiency is a rare hemorrhagic disorder whose early diagnosis is crucial for appropriate treatment and prophylactic supplementation in cases of severe deficiency. International guidelines recommend a quantitative FXIII activity assay as first-line screening test. FXIII antigen measurement may be performed to establish the subtype of FXIII deficiency (FXIIID) when activity is decreased. METHODS The aim of this multicenter study was to evaluate the analytical and diagnostic levels of performance of a new latex immunoassay, K-Assay® FXIII reagent from Stago, for first-line measurement of FXIII antigen. Results were compared to those obtained with the Berichrom® FXIII chromogenic assay for measurement of FXIII activity. Of the 147 patient plasma samples, 138 were selected for analysis. RESULTS The accuracy was very good, with intercenter reproducibility close to 7%. Five groups were defined on FXIII activity level (<5% (n = 5), 5%-30% (n = 23), 30%-60% (n = 17), 60%-120% (n = 69), above 120% (n = 24)), without statistical differences between activity and antigen levels (P value >0.05). Correlation of the K-Assay® with the Berichrom® FXIII activity results was excellent (r = 0.919). Good agreement was established by the Bland and Altman method, with a bias of +9.4% on all samples, and of -1.4% for FXIII levels lower than 30%. One patient with afibrinogenemia showed low levels of Berichrom® FXIII activity but normal antigen level and clot solubility as expected. CONCLUSIONS The measurement of FXIII antigen using the K-Assay® is a reliable first-line tool for detection of FXIII deficiency when an activity assay is not available.
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Affiliation(s)
- C Caron
- Laboratoire d'Hématologie-Hémostase, CHU Lille, Lille, France
| | - R Meley
- Laboratoire d'Hématologie-Hémostase, CHU Saint-Etienne, Saint-Etienne, France
| | - V Le Cam Duchez
- Laboratoire d'Hématologie-Hémostase, CHU Rouen, Rouen, France
| | - M F Aillaud
- Laboratoire d'Hématologie-Hémostase, CHU Marseille, Marseille, France
| | - C Lavenu-Bombled
- Laboratoire d'Hématologie-Hémostase, CHU Le Kremlin-Bicêtre, Le Kremlin-Bicêtre, France
| | - F Dutrillaux
- Laboratoire d'Hématologie-Hémostase, CHU Dijon, Dijon, France
| | - C Flaujac
- Laboratoire d'Hématologie-Hémostase, CHU Paris Cochin, Paris, France
| | - A Ryman
- Laboratoire d'Hématologie-Hémostase, CHU Bordeaux, Bordeaux, France
| | - C Ternisien
- Laboratoire d'Hématologie-Hémostase, CHU Nantes, Nantes, France
| | - D Lasne
- Laboratoire d'Hématologie-Hémostase, CHU Paris-Necker, Paris, France
| | - H Galinat
- Laboratoire d'Hématologie-Hémostase, CHU Brest, Brest, France
| | - C Pouplard
- Laboratoire d'Hématologie-Hémostase, CHU Tours, Tours, France
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21
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Abstract
Factor XIII (FXIII) deficiency is an extremely rare hemorrhagic disorder with an approximate worldwide incidence of one per two million. With current tests, diagnosis of this disease can be made more precisely. However, factors such as the number of patients with FXIII deficiency (FXIIID), available diagnostic coagulation tests and the number of molecular studies have affected the diagnosis of FXIIID in different parts of the world. Various laboratory approaches can be used, including screening and diagnosis of the disorder in countries with a relatively high rate of FXIIID and recurrent mutation(s) with a simple polymerase chain reaction-restriction fragment length polymorphism analysis or polymerase chain reaction-sequencing for detection of one or a few specific mutations. In other countries, two different laboratory approaches can be used, depending on available coagulation tests. In less-equipped coagulation laboratories, the clot solubility test remains the only diagnostic test for FXIIID. Even in these countries, at least one referral laboratory should perform FXIII activity and, if possible, confirmation of FXIIID by molecular analysis. In countries with well equipped coagulation laboratories, FXIII activity should be used to screen suspected FXIIID patients; more specific tests such as molecular analysis should be used for confirmation. This study suggests a simple, reliable and flexible algorithm for early diagnosis of FXIIID, and may, with one-time diagnosis of FXIIID, reduce the rate of morbidity and mortality in patients with the disorder.
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22
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Abstract
Blood coagulation factor XIII (FXIII) is essential for maintaining hemostasis. The absence of FXIII results in severe bleeding diathesis, which without prophylaxis frequently leads to fatal bleeding. As the usual hemostasis screening tests remain normal, the diagnosis of FXIII deficiency needs specific tests. Here, we describe FXIII activity determination by the ammonia release assay, which is the first-line test in the diagnostic algorithm for FXIII deficiency. The method for another activity test, the undeservedly rarely used fibrin cross-linking assay, is also presented. Further tests used for the classification of FXIII deficiencies, measurement of FXIII activity in platelets, ELISAs for the measurement of complex plasma FXIII (FXIII-A2B2) antigen and for FXIII-A2 in plasma and platelets are also included. Detailed description of the methods for the detection and measurement of neutralizing auto- and alloantibodies is also provided.
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Affiliation(s)
- László Muszbek
- Division of Clinical Laboratory Science, Faculty of Medicine, University of Debrecen, Nagyerdei krt. 98, Debrecen, Hungary.
| | - Éva Katona
- Division of Clinical Laboratory Science, Faculty of Medicine, University of Debrecen, Nagyerdei krt. 98, Debrecen, Hungary
| | - Adrienne Kerényi
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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23
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Mohammed H, ALtamimi ZAR, Sheikh R, Al Taweel H, Ganesan S. Recurrent Post Tonsillectomy Secondary Hemorrhage in Patients with Factor XIII Deficiency: A Case Series and Review of Literature. AMERICAN JOURNAL OF CASE REPORTS 2016; 17:850-854. [PMID: 27843132 PMCID: PMC5111571 DOI: 10.12659/ajcr.900391] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Case series Patients: Male, 20 • Male, 4 • Male, 27 • Male, 25 • Female, 5 • Female, 26 Final Diagnosis: Post tonsillectomy secondary hemorrhage Symptoms: Bleeding • bleeding per oral Medication: — Clinical Procedure: Control of post tonsillectomy secondary hemorrhage Specialty: Otolaryngology
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Affiliation(s)
- Hassen Mohammed
- Department of Otorhinolaryngology and Head & Neck Surgery (ORL-HNS), Rumailah Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Zaid Abu Rajab ALtamimi
- Department of Otorhinolaryngology and Head & Neck Surgery (ORL-HNS), Rumailah Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Rashid Sheikh
- Department of Otorhinolaryngology and Head & Neck Surgery (ORL-HNS), Rumailah Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Hayam Al Taweel
- Department of Otorhinolaryngology and Head & Neck Surgery (ORL-HNS), Rumailah Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Shanmugam Ganesan
- Department of Otorhinolaryngology and Head & Neck Surgery (ORL-HNS), Rumailah Hospital, Hamad Medical Corporation, Doha, Qatar
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24
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Abstract
Factor XIII (FXIII) has an important role in the control of bleeding through fibrin cross-linking; however, its effect within the menstrual cycle is not fully understood. The aim of this study was to examine changes in FXIII activity during the normal menstrual cycle and correlate FXIII activity with menstrual blood loss. A total of 32 healthy normal women of reproductive age were recruited. Menstrual blood loss was measured using the pictorial blood-assessment chart (PBAC). A bleeding score questionnaire was also completed. Blood samples were taken during the menstrual, proliferative, periovulatory, secretory and premenstrual phase for assessment of FXIII level. The mean ± SD FXIII level was lowest during menstrual and periovulatory phases (114 ± 23 and 114 ± 21 IU/dl, respectively). Mean FXIII level during the secretory and premenstrual phases were higher than the menstrual phase (P = 0.036). Mean secretory phase FXIII was also significantly higher compared with the periovulatory phase (P = 0.02). There was no significant correlation between FXIII level during the menstrual phase and age (P = 0.53) or PBAC score (P = 0.53). There were no significant differences in FXIII level during the menstrual phase between women with PBAC scores of at least 100 (n = 14; mean 116 IU/dl) and women with PBAC scores less than 100 (n = 18; mean 113 IU/dl). There was no correlation between FXIII level and bleeding score. FXIII activity was lower during menstrual and periovulatory phases of the cycle. However, the small difference between mean values (8 IU/dl) would be unlikely to have a significant impact on diagnosis of FXIII deficiency and clinical management.
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Effects of Factor XIII Deficiency on Thromboelastography. Thromboelastography with Calcium and Streptokinase Addition is more Sensitive than Solubility Tests. Mediterr J Hematol Infect Dis 2016; 8:e2016037. [PMID: 27648200 PMCID: PMC5016016 DOI: 10.4084/mjhid.2016.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 07/05/2016] [Indexed: 11/29/2022] Open
Abstract
Background Homozygous or double heterozygous factor XIII (FXIII) deficiency is characterized by soft tissue hematomas, intracranial and delayed spontaneous bleeding. Alterations of thromboelastography (TEG) parameters in these patients have been reported. The aim of the study was to show results of TEG, TEG Lysis (Lys 60) induced by subthreshold concentrations of streptokinase (SK), and to compare them to the clot solubility studies results in samples of a 1-year-old girl with homozygous or double heterozygous FXIII deficiency. Case A year one girl with a history of bleeding from the umbilical cord. During her first year of life, several hematomas appeared in soft upper limb tissue after punctures for vaccination and a gluteal hematoma. One additional sample of a heterozygous patient and three samples of acquired FXIII deficiency were also evaluated. Materials and Methods Clotting tests, von Willebrand factor (vWF) antigen and activity, plasma FXIII-A subunit (pFXIII-A) were measured by an immunoturbidimetric assay in a photo-optical coagulometer. Solubility tests were performed with Ca2+-5 M urea and thrombin-2% acetic acid. Basal and post-FXIII concentrate infusion samples were studied. TEG was performed with CaCl2 or CaCl2 + SK (3.2 U/mL) in a Thromboelastograph. Results Prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time, fibrinogen, factor VIIIc, vWF, and platelet aggregation were normal. Antigenic pFXIII-A subunit was < 2%. TEG, evaluated at diagnosis and post FXIII concentrate infusion (pFXIII-A= 37%), presented a normal reaction time (R), 8 min, prolonged k (14 and 11min respectively), a low Maximum-Amplitude (MA) ( 39 and 52 mm respectively), and Clot Lysis (Lys60) slightly increased (23 and 30% respectively). In the sample at diagnosis, clot solubility was abnormal, 50 and 45 min with Ca-Urea and thrombin-acetic acid, respectively, but normal (>16 hours) 1-day post-FXIII infusion. Analysis of FXIII deficient and normal plasma mixtures (< 2–102% of pFXIII-A), showed that Ca-urea solubility was abnormal at pFXIII-A < 9%, thrombin-acetic acid at pFXIII-A<18%, but TEG MA and elasticity at 23% and Lys60 with SK at pFXIII-A< 40%. Conclusions TEG parameters MA and elasticity, and Lys 60 in TEG either with Ca2+ or Ca2+ and SK are more sensitive to low levels of pFXIII than solubility tests. The increased Lys60 induced by a subthreshold concentration of SK could probably reflect the clot characteristics “in vivo” in many patients with pFXIII levels between 5–40% and could be potentially considered as screening test.
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Autoimmune acquired factor XIII deficiency due to anti-factor XIII/13 antibodies: A summary of 93 patients. Blood Rev 2016; 31:37-45. [PMID: 27542511 DOI: 10.1016/j.blre.2016.08.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/14/2016] [Accepted: 08/02/2016] [Indexed: 11/22/2022]
Abstract
Autoimmune acquired factor XIII (F13) deficiency or autoimmune hemophilia-like disease (hemorrhaphilia) resulted from the generation of anti-F13 antibodies (AH13) is a severe bleeding disorder that occurs mainly in the elderly. Although rare, the number of patients diagnosed with AH13 has recently increased. To improve understanding of this disease, the author summarized 93 ever reported/diagnosed AH13 cases. About 50% of cases were idiopathic. In the remaining half of the patients, autoimmune diseases and malignancies were the most common underlying diseases. Intramuscular and subcutaneous bleeding were the most frequently reported symptoms. Hemorrhage was the cause of death in 13 patients. In 4 patients, the diagnosis was established after hemorrhagic death. Therefore, physicians/hematologists must raise the awareness of AH13 as a life-threatening disease. Most patients were treated with F13 concentrates to arrest bleeding and with prednisolone and cyclophosphamide to eradicate anti-F13 autoantibodies. AH13 cases tend to become chronic and intractable and require close follow-up over an extended period.
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27
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Tone KJ, James TE, Fergusson DA, Tinmouth A, Tay J, Avey MT, Kilty S, Lalu MM. Acquired Factor XIII Inhibitor in Hospitalized and Perioperative Patients: A Systematic Review of Case Reports and Case Series. Transfus Med Rev 2016; 30:123-31. [DOI: 10.1016/j.tmrv.2016.04.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 04/15/2016] [Indexed: 10/21/2022]
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Dorgalaleh A, Tabibian S, Shams M, Tavasoli B, Gheidishahran M, Shamsizadeh M. Laboratory Diagnosis of Factor XIII Deficiency in Developing Countries: An Iranian Experience. Lab Med 2016; 47:220-6. [PMID: 27346867 DOI: 10.1093/labmed/lmw021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Factor XIII (FXIII) deficiency is an extremely rare bleeding disorder with an approximately 12-times higher than the rest of the world. The International Society for Thrombosis and Hemostasis (ISTH) suggested a standard algorithm for precise diagnosis and classification of FXIII deficiency (FXIIID). However, due to lack of investment in proper equipment and procedures in Iran, almost no part of this algorithm can be used to diagnose Iranian patients. Thus, this study proposes a guideline for accurate molecular and laboratory diagnosis of FXIIID based on the available tools. Because this study suggests a simple and reliable algorithm for early diagnosis, it can therefore, reduce the rates of morbidity and mortality of FXIIID patients with this condition.
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Affiliation(s)
- Akbar Dorgalaleh
- Department of Hematology and Blood Transfusion, School of Allied Medical Science, Iran University of Medical Sciences, Tehran,
| | - Shadi Tabibian
- Department of Hematology and Blood Transfusion, School of Allied Medical Science, Iran University of Medical Sciences, Tehran
| | - Mahmood Shams
- Department of Hematology and Blood Transfusion, School of Allied Medical Science, Iran University of Medical Sciences, Tehran, Department of Laboratory Sciences, Paramedical Faculty, Babol University of Medical Sciences, Babol, and
| | - Behnaz Tavasoli
- Department of Hematology and Blood Transfusion, School of Allied Medical Science, Iran University of Medical Sciences, Tehran
| | - Maryam Gheidishahran
- Department of Hematology and Blood Transfusion, School of Allied Medical Science, Iran University of Medical Sciences, Tehran
| | - Morteza Shamsizadeh
- School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran
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29
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Blood coagulation factor XIII and factor XIII deficiency. Blood Rev 2016; 30:461-475. [PMID: 27344554 DOI: 10.1016/j.blre.2016.06.002] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 06/01/2016] [Accepted: 06/10/2016] [Indexed: 11/20/2022]
Abstract
Factor XIII (FXIII) is a multifunctional pro-γ-transglutaminase that, in addition to its well-known role in hemostasis, has a crucial role in angiogenesis, maintenance of pregnancy, wound healing, bone metabolism, and even cardio protection. FXIII deficiency (FXIIID) is a rare bleeding disorder (RBD) with an estimated incidence of one per two million that is accompanied by life-threatening bleeding such as umbilical cord bleeding, recurrent spontaneous miscarriage, and intracranial hemorrhage (ICH). Today, the disease is successfully managed by FXIII concentrate and recombinant FXIII for prophylaxis, management of minor and major bleeding, treatment of ICH, and successful delivery in women with recurrent pregnancy loss. Molecular analysis of patients with FXIIID revealed a wide spectrum of mutations, most frequently missense mutations in the FXIII-A subunit, with a few recurrent mutations observed worldwide. In vitro expression studies revealed that most of the missense mutations cause intracellular instability of the FXIII protein and, subsequently, FXIIID.
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Dorgalaleh A, Tabibian S, Hosseini MS, Farshi Y, Roshanzamir F, Naderi M, Kazemi A, Zaker F, Aghideh AN, Shamsizadeh M. Diagnosis of factor XIII deficiency. Hematology 2016; 21:430-9. [DOI: 10.1080/10245332.2015.1101975] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Affiliation(s)
- Akbar Dorgalaleh
- Department of Hematology and Blood Transfusion, School of Allied Medical Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Shadi Tabibian
- Department of Hematology and Blood Transfusion, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Sadat Hosseini
- Department of Hematology and Blood Transfusion, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Yadolla Farshi
- Department of Hematology and Blood Transfusion, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Fateme Roshanzamir
- Department of Hematology and Blood Transfusion, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Majid Naderi
- Department of Pediatrics Hematology & Oncology, Ali Ebn-e Abitaleb Hospital Research Center for Children and Adolescents Health [RCCAH], Zahedan University of Medical Sciences, Zahedan, Iran
| | - Ahmad Kazemi
- Department of Hematology and Blood Transfusion, School of Allied Medical Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Farhad Zaker
- Cellular and Molecular Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Noroozi Aghideh
- Department of Hematology and Blood Transfusion, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Morteza Shamsizadeh
- School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran
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Green L, Backholer L, Wiltshire M, Platton S, Stanworth SJ, Cardigan R. The hemostatic properties of thawed pooled cryoprecipitate up to 72 hours. Transfusion 2016; 56:1356-61. [DOI: 10.1111/trf.13571] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 01/27/2016] [Accepted: 01/28/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Laura Green
- NHS Blood and Transplant
- Barts Health NHS Trust UK
- Blizzard Institute; Queen Mary University of London; London UK
| | - Lucy Backholer
- Component Development Laboratory; NHS Blood and Transplant; Cambridge UK
| | - Mike Wiltshire
- Component Development Laboratory; NHS Blood and Transplant; Cambridge UK
| | | | - Simon J. Stanworth
- NHS Blood and Transplant; and Oxford University Hospitals NHS Trust; Oxford UK
| | - Rebecca Cardigan
- Component Development Laboratory; NHS Blood and Transplant; Cambridge UK
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Cini M, Legnani C, Frascaro M, Pancani C, Cappelli C, Rodorigo G, Valdrè L, Cosmi B. Measurement of factor XIII (FXIII) activity by an automatic ammonia release assay using iodoacetamide blank-procedure: no more overestimation in the low activity range and better detection of severe FXIII deficiencies. ACTA ACUST UNITED AC 2016; 54:805-9. [DOI: 10.1515/cclm-2015-0547] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 09/10/2015] [Indexed: 11/15/2022]
Abstract
AbstractBackground:Laboratory investigation with specific factor XIII (FXIII) assays plays a crucial role in diagnosis of FXIII deficiency. According to the International Society on Thrombosis and Hemostasis (ISTH), it is necessary a blank sample with iodoacetamide, provided by the kit or locally prepared, when the ammonia release assays are used, to avoid FXIII activity overestimation.Methods:In this study we set up a modification of the Berichrom FXIII chromogenic assay, in which iodoacetamide was added by the BCS analyzer in the reaction mixture of the blank sample, without modifications of the original reagents. We analyzed 100 plasma samples of outpatients with clinical symptoms suggestive of a bleeding diathesis (20 samples had FXIII activity <20%).Results:In all samples blank subtraction significantly reduced FXIII activity, mostly in the low activity range group (from 10.1% to 2.4%, p<0.0001). In this group correction with iodoacetamide also increased the agreement with the immunoassay and allowed FXIII activity measure up to 0%.Conclusions:Despite the low number of samples included in the study, the described automatic procedure seemed to decrease FXIII activity overestimation and, especially for low activity range samples (<20%), to improve the agreement between FXIII activity and concentration. Our data suggested that iodoacetamide correction could allow the detection of severe FXIII deficiencies (activity <5%) otherwise undiagnosed using the original method.
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Chandrawati R, Stevens MM. Controlled assembly of peptide-functionalized gold nanoparticles for label-free detection of blood coagulation Factor XIII activity. Chem Commun (Camb) 2015; 50:5431-4. [PMID: 24618788 DOI: 10.1039/c4cc00572d] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A highly sensitive label-free assay for the determination of blood coagulation Factor XIII activity is demonstrated through the controlled assembly of peptide-functionalized gold nanoparticles (AuNPs). Activated Factor XIII catalyzes the formation of covalent crosslinking between peptide chains through ε-(γ-glutamyl)-lysine bonds leading to the aggregation of the AuNPs and consequently a red-shift of the localized surface plasmon resonance. The selective engineering of nanoscale order over AuNP crosslinking via the formation of isopeptide bonds provides a new approach toward the design of nanoassemblies with precise control on the molecular level. The colorimetric assay reported here provides direct qualitative and quantitative analysis of Factor XIII activity with a limit of detection of 0.01 U mL(-1).
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Affiliation(s)
- Rona Chandrawati
- Department of Materials, Department of Bioengineering and Institute for Biomedical Engineering, Imperial College London, London SW7 2AZ, UK.
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Kerlin B, Brand B, Inbal A, Halimeh S, Nugent D, Lundblad M, Tehranchi R. Pharmacokinetics of recombinant factor XIII at steady state in patients with congenital factor XIII A-subunit deficiency. J Thromb Haemost 2014; 12:2038-43. [PMID: 25263390 DOI: 10.1111/jth.12739] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 09/21/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND The use of monthly recombinant factor XIII (rFXIII) recently demonstrated favorable safety and efficacy for congenital FXIII A-subunit deficiency patients aged ≥ 6 years (mentor(™) 1 trial), although the pharmacokinetics (PK) were not fully evaluated. OBJECTIVES To comprehensively evaluate the steady-state PK of rFXIII in patients aged ≥ 6 years with congenital FXIII A-subunit deficiency. PATIENTS/METHODS mentor(™) 2 is an ongoing, multinational safety and efficacy trial in which patients are receiving monthly rFXIII (35 IU kg(-1) ) for ≥ 52 weeks. For this 28-day PK analysis, blood samples were collected immediately predosing, and 1 h, 2 h, 3, 7, 14, 21, and 28 days postdosing. FXIII activity was measured and PK parameters were calculated using non-compartmental analysis, without prior baseline adjustment. Information regarding adverse events and bleeding was collected at each visit. Antibody assessments were performed predosing and at day 28. RESULTS PK analysis in 23 patients revealed first-order elimination of rFXIII with a geometric mean half-life of 13.6 days. Mean FXIII activity was > 0.1 IU mL(-1) throughout the 28-day period, with a geometric mean peak activity of 0.87 IU mL(-1) and trough of 0.16 IU mL(-1) . The geometric mean clearance was 0.15 mL h(-1) kg(-1) . No bleeding episodes occurred during the PK session, and no anti-rFXIII antibodies were detected. Peak and trough FXIII activities were constant over time, compared with previous activities (≥ 10 rFXIII doses) in the same patients. CONCLUSIONS Clearance of rFXIII is unaffected over time, and monthly prophylaxis with 35 IU kg(-1) rFXIII provides FXIII activity > 0.1 IU mL(-1) throughout the dosing interval in patients with congenital FXIII A-subunit deficiency.
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Affiliation(s)
- B Kerlin
- Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
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35
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Aleman MM, Byrnes JR, Wang JG, Tran R, Lam WA, Di Paola J, Mackman N, Degen JL, Flick MJ, Wolberg AS. Factor XIII activity mediates red blood cell retention in venous thrombi. J Clin Invest 2014; 124:3590-600. [PMID: 24983320 DOI: 10.1172/jci75386] [Citation(s) in RCA: 152] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 05/21/2014] [Indexed: 11/17/2022] Open
Abstract
Venous thrombi, fibrin- and rbc-rich clots triggered by inflammation and blood stasis, underlie devastating, and sometimes fatal, occlusive events. During intravascular fibrin deposition, rbc are thought to become passively trapped in thrombi and therefore have not been considered a modifiable thrombus component. In the present study, we determined that activity of the transglutaminase factor XIII (FXIII) is critical for rbc retention within clots and directly affects thrombus size. Compared with WT mice, mice carrying a homozygous mutation in the fibrinogen γ chain (Fibγ390-396A) had a striking 50% reduction in thrombus weight due to reduced rbc content. Fibrinogen from mice harboring the Fibγ390-396A mutation exhibited reduced binding to FXIII, and plasma from these mice exhibited delayed FXIII activation and fibrin crosslinking, indicating these residues mediate FXIII binding and activation. FXIII-deficient mice phenocopied mice carrying Fibγ390-396A and produced smaller thrombi with fewer rbc than WT mice. Importantly, FXIII-deficient human clots also exhibited reduced rbc retention. The addition of FXIII to FXIII-deficient clots increased rbc retention, while inhibition of FXIII activity in normal blood reduced rbc retention and produced smaller clots. These findings establish the FXIII-fibrinogen axis as a central determinant in venous thrombogenesis and identify FXIII as a potential therapeutic target for limiting venous thrombosis.
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36
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Sharief LT, Lawrie AS, Mackie IJ, Smith C, Peyvandi F, Kadir RA. Changes in factor XIII level during pregnancy. Haemophilia 2013; 20:e144-8. [DOI: 10.1111/hae.12345] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2013] [Indexed: 11/27/2022]
Affiliation(s)
- L. T. Sharief
- Institute of Women's Health; University College London; London UK
- Obstetrics and Gynaecology Department; Haemophilia centre and Thrombosis Unit; Royal Free Hospital NHS Foundation Trust; London UK
| | - A. S. Lawrie
- Haemostasis Research Unit; Department of Haematology; University College London; London UK
| | - I. J. Mackie
- Haemostasis Research Unit; Department of Haematology; University College London; London UK
| | - C. Smith
- Institute of Epidemiology & Health; University College London; London UK
| | - F. Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis; Centre Fondazione IRCCS Ca' Granda; Ospedale Maggiore Policlinico; Milan Italy
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center; Università degli Studi di Milano; Milan Italy
| | - R. A. Kadir
- Obstetrics and Gynaecology Department; Haemophilia centre and Thrombosis Unit; Royal Free Hospital NHS Foundation Trust; London UK
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37
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Katona É, Muszbek L, Devreese K, Kovács KB, Bereczky Z, Jonkers M, Shemirani AH, Mondelaers V, Ermens AAM. Factor XIII deficiency: complete phenotypic characterization of two cases with novel causative mutations. Haemophilia 2013; 20:114-20. [PMID: 24118344 DOI: 10.1111/hae.12267] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2013] [Indexed: 11/29/2022]
Abstract
Coagulation factor XIII (FXIII) exists as heterotetramer (FXIII-A₂B₂) in the plasma and as dimer (FXIII-A₂) in cells. Activated FXIII mechanically stabilizes fibrin and protects it from fibrinolysis by cross-linking fibrin chains and α₂-plasmin inhibitor to fibrin. FXIII is essential to maintaining haemostasis, and its deficiency causes severe bleeding diathesis. Due to improper laboratory practices, FXIII deficiency is considered the most under-diagnosed bleeding disorder. The aim of this study was to demonstrate in two cases how FXIII deficiency is properly diagnosed and classified, and to compare results of laboratory analysis and clinical symptoms. FXIII activity from plasma and platelets was measured by a modified ammonia release assay, while FXIII-A₂B₂, FXIII-A and FXIII-B antigens were determined by ELISA. The exon-intron boundaries and the promoter region of F13A1 gene were amplified by PCR and the amplified products were analysed by direct fluorescent sequencing. FXIII-A mRNA in platelets was determined by RT-qPCR. Two children with severe bleeding symptoms were investigated. In both cases FXIII activity and FXIII-A antigen were undetectable in the plasma and platelet lysate. In the plasma no FXIII-A₂B₂ antigen was found, while FXIII-B antigen was >30% in both cases. Proband1 was a compound heterozygote possessing a known missense mutation (c.980G>A, p.Arg326Gln) and a novel splice-site mutation (c.1112+2T>C). Proband2 was homozygote for a novel single nucleotide deletion (c.212delA) leading to early stop codon. The discovered mutations explain the severity of clinical symptoms and the laboratory data. Methods precise in the low activity/antigen range are required to draw valid conclusion on phenotype-genotype relationship.
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Affiliation(s)
- É Katona
- Clinical Research Center, University of Debrecen, Medical and Health Science Center, Debrecen, Hungary
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38
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Hanna J, Winstedt D, Schött U. Fibrinogen and FXIII dose response effects on albumin-induced coagulopathy. Scandinavian Journal of Clinical and Laboratory Investigation 2013; 73:553-62. [DOI: 10.3109/00365513.2013.821710] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Fadoo Z, Merchant Q, Rehman KA. New developments in the management of congenital Factor XIII deficiency. J Blood Med 2013; 4:65-73. [PMID: 23761984 PMCID: PMC3674014 DOI: 10.2147/jbm.s32693] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Congenital Factor XIII (FXIII) deficiency is a rare, inherited, autosomal recessive coagulation disorder. Most mutations of this condition are found in the A-subunit with almost half these being missense mutations. Globally, approximately one in three million people suffer from this deficiency. Factor XIII deficiency is associated with severe life threatening bleeding, intracranial hemorrhage, impaired wound healing, and recurrent pregnancy losses. FXIII is known to have a potential role in mediating inflammatory processes, insulin resistance, bone metabolism, neoplasia, and angiogenesis. The algorithm provided for FXIII diagnosis and classification will enable prompt identification and early intervention for controlling potential life threatening complications. Prophylactic replacement therapy using blood products containing FXIII such as fresh frozen plasma, cryoprecipitate, or using FXIII concentrate remains the mainstay for the management of FXIII deficiency. In most parts of the world, cryoprecipitate and plasma transfusions are the only treatments available. Management developments have revealed the effectiveness and safety of recombinant FXIII concentrate for prophylaxis and treatment. The aim of this review is to provide an overview of advancements made in the management of FXIII deficiency from the time it was first detected, highlighting novel developments made in recent years. Greater research is warranted in identifying novel approaches to manage FXIII deficiency in light of its underlying pathophysiology.
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Affiliation(s)
- Zehra Fadoo
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
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40
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Kessel R, Hu C, Shore-Lesserson L, Rand J, Manwani D. A child with acquired factor XIII deficiency: case report and literature review. Haemophilia 2013; 19:814-26. [PMID: 23607876 DOI: 10.1111/hae.12145] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2013] [Indexed: 11/30/2022]
Abstract
Factor XIII (FXIII) deficiency is a rare bleeding disorder, which can result in life threatening hemorrhage. Rarer still is acquired FXIII deficiency, in which the disorder is due to autoantibodies that inhibit the factor. To describe one of the youngest reported patients with this condition. To discuss the challenges we encountered in monitoring response with the available assays. To review the literature and provide a review of all acquired FXIII cases. We present the case of our patient, a 9-year-old girl with acquired FXIII deficiency. We present a comprehensive review of all acquired FXIII deficiency cases reported globally in English, with focus on clinical presentation, diagnostic assays, treatment and prognosis. There is no current standard for therapy and measuring response to therapy can be complicated by limitations of assays in the presence of inhibitors. Clinicians should be aware of acquired FXIII deficiency as a potentially life threatening bleeding disorder even in young children. The case presented illustrates a young patient with acquired FXIII deficiency with a good clinical response to cryoprecipitate and difficulty in hemostasis monitoring utilizing clinically available assays.
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Affiliation(s)
- R Kessel
- Division of Pediatric Hematology/Oncology, Children's Hospital at Montefiore, Bronx, NY, USA
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41
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Hayward CPM, Moffat KA. Laboratory testing for bleeding disorders: strategic uses of high and low-yield tests. Int J Lab Hematol 2013; 35:322-33. [PMID: 23480172 DOI: 10.1111/ijlh.12077] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 02/04/2013] [Indexed: 11/26/2022]
Abstract
Laboratory testing is essential for diagnosing bleeding disorders. The tests and panels that laboratories currently use for bleeding disorder evaluation are not standardized, although most offer coagulation screening tests in bleeding disorder panels. Some tests for bleeding disorders, including von Willebrand factor multimer assays and tests for rarer disorders, are not widely available. Accordingly, clinicians and laboratories need tailored strategies for evaluating common and rare bleeding disorders. Coagulation screening tests have high specificity, however, false positives and false negatives do occur among subjects evaluated for bleeding disorders and more specific tests (e.g., factor assays) are required to further assess abnormalities. Tests for defects in primary hemostasis have similar high specificity but much greater sensitivity for common bleeding disorders than coagulation screening tests. Nonetheless, extensive testing fails to establish a diagnosis in a significant number of individuals considered to have significant bleeding problems. Rare bleeding disorder investigations are important to diagnose some conditions, particularly those with delayed-onset bleeding, such as factor XIII deficiency, α2 antiplasmin deficiency, plasminogen activator inhibitor-1 deficiency, and Quebec platelet disorder. These issues need careful consideration when assessing patients for congenital and acquired bleeding problems.
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Affiliation(s)
- C P M Hayward
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON,
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42
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The effect of fibrinogen concentrate and factor XIII on thromboelastometry in 33% diluted blood with albumin, gelatine, hydroxyethyl starch or saline in vitro. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2012; 11:510-7. [PMID: 23245725 DOI: 10.2450/2012.0171-12] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Accepted: 09/25/2012] [Indexed: 01/02/2023]
Abstract
BACKGROUND Fluid replacement results in dilutional coagulopathy. We investigated the potential role of fibrinogen, factor XIII and a combination of both to reverse dilutional coagulopathy, assessed by thromboelastometry (ROTEM(®)). MATERIAL AND METHODS Blood samples from healthy volunteers were analysed undiluted and after 33% dilution in vitro with albumin, gelatine, 130/0.4 hydroxyethyl starch or saline. Diluted samples were incubated with fibrinogen (3 g/70 kg bodyweight equivalent), factor XIII (10,000 IU/70 kg bodyweight equivalent), or a combination of both. Measurements were performed using an extrinsic activated assay (EXTEM(®)) and a functional fibrin polymerisation test (FIBTEM(®)). RESULTS Compared with baseline, EXTEM clotting time increased with hydroxyethyl starch, exceeding the upper limit of the reference value. Albumin prolonged clotting time within normal limits. Gelatine did not change clotting time, and saline reduced clotting time. Clot formation time increased in colloids only. Maximum clot firmness of both EXTEM and FIBTEM decreased with all fluids, but was less pronounced in saline. Incubation with fibrinogen had no effect on EXTEM maximum clot firmness but improved FIBTEM maximum clot firmness in saline (P <0.001) and albumin (P <0.05), but not gelatine and hydroxyethyl starch). Factor XIII had no effect on any EXTEM and FIBTEM maximum clot firmness results. Fibrinogen and factor XIII combined did not improve EXTEM maximum clot firmness. Fibrinogen and factor XIII did not change FIBTEM maximum clot firmness in hydroxyethyl starch but improved FIBTEM maximum clot firmness in albumin (P <0.001), gelatine (P <0.01) and saline (P <0.001). DISCUSSION ROTEM parameters in dilutional coagulopathy in vitro cannot be improved with factor XIII alone in any tested diluent. The combination of fibrinogen and factor XIII is highly effective in raising FIBTEM maximum clot firmness after dilution with albumin, gelatine and saline back to normal values, but is ineffective in 130/0.4 hydroxyethyl starch.
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Abstract
Abstract
Congenital mild bleeding disorders (MBDs) are very prevalent and are the source of frequent diagnostic problems. Most MBDs are categorized as disorders of primary hemostasis (ie, type 1 VWD and platelet function disorders), but mild or moderate deficiencies of clotting factors and some rare hyperfibrinolytic disorders are also included. These patients have abnormal bleeding from the skin and mucous membranes, menorrhagia, and disproportionate hemorrhages after trauma, invasive procedures, and surgery. This review addresses the main problems that physicians and hemostasis laboratories confront with the diagnosis of these patients, including: discerning normal/appropriate from pathological bleeding, the role and yield of screening tests, the lack of distinctive bleeding pattern among the different diseases, the inherent difficulties in the diagnosis of type 1 VWD and the most common platelet functional disorders, improvements in assays to measure platelet aggregation and secretion, and the evidence that most of the patients with MBDs end up without a definite diagnosis after exhaustive and repeated laboratory testing. Much research is needed to determine the pathogenesis of bleeding in MBD patients. Better standardization of current laboratory assays, progress in the knowledge of fibrinolytic mechanisms and their laboratory evaluation, and new understanding of the factors contributing to platelet-vessel wall interaction, along with the corresponding development of laboratory tools, should improve our capacity to diagnose a greater proportion of patients with MBDs.
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44
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Lodemann P, Kolbeck H, Held TK, Ivaskevicius V, Oldenburg J, Schweigerer L, Ludwig WD, Peetz D. Acquired deficiency of coagulation factor XIII—possible evidence for a new link between coagulation and infection from a case. Ann Hematol 2012; 92:427-9. [DOI: 10.1007/s00277-012-1582-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Accepted: 09/16/2012] [Indexed: 10/27/2022]
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Mackie I, Cooper P, Lawrie A, Kitchen S, Gray E, Laffan M. Guidelines on the laboratory aspects of assays used in haemostasis and thrombosis. Int J Lab Hematol 2012; 35:1-13. [DOI: 10.1111/ijlh.12004] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 08/06/2012] [Indexed: 11/30/2022]
Affiliation(s)
- I. Mackie
- Haemostasis Research Unit; Department of Haematology; University College London; London; UK
| | - P. Cooper
- Department of Coagulation; Royal Hallamshire Hospital; Sheffield; UK
| | - A. Lawrie
- Haemostasis Research Unit; Department of Haematology; University College London; London; UK
| | - S. Kitchen
- Department of Coagulation; Royal Hallamshire Hospital; Sheffield; UK
| | - E. Gray
- Haemostasis Section; Biotherapeutics Group; National Institute for Biological Standards and Control; Potters Bar; UK
| | - M. Laffan
- Department of Haematology; Imperial College at Hammersmith Hospital; London; UK
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46
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Levy JH, Greenberg C. Biology of Factor XIII and clinical manifestations of Factor XIII deficiency. Transfusion 2012; 53:1120-31. [DOI: 10.1111/j.1537-2995.2012.03865.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Abstract
Congenital factor XIII (FXIII) deficiency is a rare, autosomal-recessive disorder, with most patients having an A-subunit (FXIII-A) deficiency. Patients experience life-threatening bleeds, impaired wound healing, and spontaneous abortions. In many countries, only plasma or cryoprecipitate treatments are available, but these carry a risk for allergic reactions and infection with blood-borne pathogens. The present study was a multinational, open-label, single-arm, phase 3 prophylaxis trial evaluating the efficacy and safety of a novel recombinant FXIII (rFXIII) in congenital FXIII-A subunit deficiency. Forty-one patients ≥ 6 years of age (mean, 26.4; range, 7-60) with congenital FXIII-A subunit deficiency were enrolled. Throughout the rFXIII prophylaxis, only 5 bleeding episodes (all trauma induced) in 4 patients were treated with FXIII-containing products. The crude mean bleeding rate was significantly lower than the historic bleeding rate (0.138 vs 2.91 bleeds/patient/year, respectively) for on-demand treatment. Transient, non-neutralizing, low-titer anti-rFXIII Abs developed in 4 patients, none of whom experienced allergic reactions, any bleeds requiring treatment, or changes in FXIII pharmacokinetics during the trial or follow-up. These non-neutralizing Abs declined below detection limits in all 4 patients despite further exposure to rFXIII or other FXIII-containing products. We conclude that rFXIII is safe and effective in preventing bleeding episodes in patients with congenital FXIII-A subunit deficiency. This study is registered at http://www..clinicaltrials.gov as number NCT00713648.
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Management of pregnancy and delivery in women with inherited bleeding disorders. Semin Fetal Neonatal Med 2011; 16:311-7. [PMID: 21852211 DOI: 10.1016/j.siny.2011.07.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Women with inherited bleeding disorders present a wide spectrum of clinical symptoms that vary from mild or moderate bleeding tendency to severe episodes. Monthly haemostatic changes affect these women during menstruation and ovulation. These events may be associated with significant bleeding and pain leading to the limitations in conducting daily activities and adverse effect on quality of life. Likewise, pregnancy and delivery are critical times for affected women. During pregnancy, they may be at greater risk of miscarriage and bleeding complications. In particular, recurrent miscarriage was observed in women with type 3 von Willebrand disease, afibrinogenaemia and severe factor XIII deficiency, and an optimal therapeutic plan is required during their pregnancy. Precautions must be taken at delivery in these women, since they could be at risk of bleeding. The lack of adequate information makes it very difficult to prepare evidence-based guidelines for the prevention of bleedings in affected women and their treatment. A multidisciplinary team of obstetricians, haematologists and paediatricians is required with a good knowledge of these disorders and an awareness of the potential maternal neonatal complications.
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Biswas A, Ivaskevicius V, Seitz R, Thomas A, Oldenburg J. An update of the mutation profile of Factor 13 A and B genes. Blood Rev 2011; 25:193-204. [PMID: 21640452 DOI: 10.1016/j.blre.2011.03.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Mutational reports over the past two decades have accumulated an immense amount of literature for inherited Factor XIII deficiency. However, the genotype and phenotype correlations for inherited Factor XIII deficiency are complicated. While many studies clearly prove a cause and effect relationship for the reported mutations, others are lacking in this regard. The F13B gene remains an elusive component as far as inherited Factor XIII deficiencies are concerned. Also, an in-depth analysis into the heterozygous state of this deficiency is also lacking. In this review we have tried to analyze and present an exhaustive amount of mutational data from the past three decades. The source of our mutational data is our website dedicated to Factor XIII deficiencies (www.F13-database.de) as well as literature search done on the Pubmed (www.ncbi.nlm.nih.gov/pubmed).
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Affiliation(s)
- Arijit Biswas
- Institute of Experimental Hematology and Transfusion Medicine, University Clinic Bonn, Germany.
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Taeumer T, de Greiff A, Scharrer I, Papaspyrou K, Mewes T, Mann W. [The significance of bleeding disorders in patients with epistaxis]. HNO 2011; 59:582-7. [PMID: 21424138 DOI: 10.1007/s00106-010-2245-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Epistaxis can have a variety of different local or systemic causes. It is the cardinal symptom of von Willebrand disease (VWD), the most frequent congenital bleeding disorder with a prevalence of approximately 1%. The usual routine coagulation screening tests (PT, APTT, platelet count) are not sufficient to diagnose VWD, factor XIII (FXIII)-deficiency or platelet dysfunction. METHOD A prospective study was conducted implementing enhanced coagulation screening for bleeding disorders in a total of 100 inpatients admitted for epistaxis. RESULTS A bleeding disorder was found in 13%. In eight patients VWD was diagnosed, in six patients FXIII-deficiency was found, and in one patient both. CONCLUSION The prevalence of bleeding disorders in patients with epistaxis is higher than in the general population. Epistaxis can be the primary symptom of chronic inflammatory disease or malignant disease. A thorough anamnesis is necessary and in cases of doubt additional testing for underlying disorders is recommended.
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Affiliation(s)
- T Taeumer
- Klinik für Hals-, Nasen-, Ohrenheilkunde, Universitätsmedizin Mainz, Langenbeckstrasse 1, 55131, Mainz, Deutschland.
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