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Li Q, Wang R, Qi X. Systemic Thrombolysis for Isolated Splenic Vein Thrombosis Secondary to Oral Contraceptives: A Case Report. Int J Womens Health 2024; 16:811-818. [PMID: 38765206 PMCID: PMC11100964 DOI: 10.2147/ijwh.s462610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 05/09/2024] [Indexed: 05/21/2024] Open
Abstract
Isolated splenic vein thrombosis (ISVT) is a very rare venous thromboembolism in the absence of pancreatic diseases, which can cause acute abdominal pain and chronic left-side portal hypertension. Herein, we reported a 40-year-old female patient who developed ISVT after taking oral contraceptives. Anticoagulation with oral rivaroxaban was the first-line choice of therapy in this case. Since then, abdominal pain alleviated, but she did not achieve vessel recanalization. Thus, a 7-day systemic thrombolysis with urokinase was given. Abdominal pain disappeared, but ISVT was not significantly improved. During follow-up period, long-term anticoagulation with oral rivaroxaban was given. Collectively, this case indicates the possibility of oral contraceptives as a risk factor of ISVT as well as anticoagulation combined with systemic thrombolysis as a choice of treatment for ISVT. Certainly, long-term follow-up is necessary in this case.
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Affiliation(s)
- Qianqian Li
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, People’s Republic of China
| | - Ran Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, People’s Republic of China
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, People’s Republic of China
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2
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Ząbczyk M, Undas A. Fibrin Clot Properties in Cancer: Impact on Cancer-Associated Thrombosis. Semin Thromb Hemost 2024; 50:402-412. [PMID: 37353045 DOI: 10.1055/s-0043-1770364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2023]
Abstract
Cancer is associated with a high risk of venous thromboembolism (VTE) and its recurrence. There is evidence that the prothrombotic fibrin clot phenotype, involving the formation of denser and stiffer clots relatively resistant to lysis, occurs in cancer patients, which is in part related to enhanced inflammation, oxidative stress, and coagulation activation, along with the release of neutrophil extracellular traps, indicating that fibrin-related mechanisms might contribute to cancer-associated thrombosis (CAT). Multiple myeloma and its therapy have been most widely explored in terms of altered fibrin characteristics, but prothrombotic fibrin clot features have also been reported in patients with active solid cancer, including lung cancer and gastrointestinal cancer. Patient-related factors such as advanced age, smoking, and comorbidities might also affect fibrin clot characteristics and the risk of CAT. Prothrombotic fibrin clot features have been shown to predict the detection of cancer in patients following VTE during follow-up. Cancer-specific therapies and anticoagulation can favorably modify the phenotype of a fibrin clot, which may alter the course of CAT. It is unclear whether the fibrin clot phenotype might help identify patients with CAT who are more likely to experience recurrent events. This narrative review summarizes the current knowledge on the role of fibrin clot structure and function in cancer patients in the context of CAT.
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Affiliation(s)
- Michał Ząbczyk
- Thromboembolic Disorders Department, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Krakow Center for Medical Research and Technologies, John Paul II Hospital, Krakow, Poland
| | - Anetta Undas
- Thromboembolic Disorders Department, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Krakow Center for Medical Research and Technologies, John Paul II Hospital, Krakow, Poland
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3
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Ghansah H, Orbán-Kálmándi R, Debreceni IB, Katona É, Rejtő L, Váróczy L, Lóczi L, de Laat B, Huskens D, Kappelmayer J, Bagoly Z. Low factor XIII levels and altered fibrinolysis in patients with multiple myeloma. Thromb Res 2024; 234:12-20. [PMID: 38134612 DOI: 10.1016/j.thromres.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 11/13/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Acquired factor FXIII (FXIII) deficiency can be immune- or non-immune mediated and may cause severe bleeding symptoms. The incidence of acquired FXIII deficiency and its etiology in patients with multiple myeloma (MM) are poorly understood. OBJECTIVES To assess FXIII levels and the balance of fibrinolysis in newly diagnosed, untreated MM and monoclonal gammopathy of undetermined significance (MGUS) patients. METHODS FXIII activity, mixing studies, FXIII-A2B2 antigen, total FXIII-B antigen were measured in platelet-poor plasma from 17 untreated MM patients, 33 untreated MGUS patients, and 30 age and sex-matched healthy controls. Besides routine laboratory measurements, the balance of coagulation and fibrinolysis was evaluated using quantitative fibrin monomer (FM) test, thrombin-antithrombin assay, α2-antiplasmin activity, plasmin-α2-antiplasmin (PAP) complex, D-dimer, plasmin generation assay, clot lysis assay, and ClotPro-TPA test. RESULTS FXIII-A2B2 levels were significantly lower in MM patients compared to controls [median (IQR):14.6 (11.2-19.4) vs. 21.8 (17.1-26.4) mg/L, p = 0.0015], whereas total FXIII-B did not differ between groups. Decrease in FXIII activity was parallel to the decrease in FXIII-A2B2. An immune-mediated inhibitory mechanism was ruled out. Free/total FXIII-B was significantly higher in MM patients compared to MGUS and healthy controls, suggesting an etiology of FXIII-A consumption. In MM and MGUS patients, FM, D-dimer, and PAP complex were significantly elevated compared to controls, indicating hypercoagulability and ongoing fibrinolysis. CONCLUSIONS Low FXIII levels due to consumption were observed in MM patients at diagnosis. Hypercoagulability and ongoing fibrinolysis were detected in MM and MGUS, indicating that a disturbed hemostasis balance is already present in the latter benign condition.
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Affiliation(s)
- Harriet Ghansah
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary; Kálmán Laki Doctoral School, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Rita Orbán-Kálmándi
- Department of Laboratory Medicine, Faculty of Medicine, Division of Clinical Laboratory Sciences, University of Debrecen, Debrecen, Hungary
| | - Ildikó Beke Debreceni
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Éva Katona
- Department of Laboratory Medicine, Faculty of Medicine, Division of Clinical Laboratory Sciences, University of Debrecen, Debrecen, Hungary
| | - László Rejtő
- Department of Hematology, Jósa András Teaching Hospital, Nyíregyháza, Hungary
| | - László Váróczy
- Department of Internal Medicine, Division of Hematology, University of Debrecen, Debrecen, Hungary
| | - Linda Lóczi
- Department of Laboratory Medicine, Faculty of Medicine, Division of Clinical Laboratory Sciences, University of Debrecen, Debrecen, Hungary
| | - Bas de Laat
- Synapse Research Institute, Maastricht, the Netherlands
| | - Dana Huskens
- Synapse Research Institute, Maastricht, the Netherlands
| | - János Kappelmayer
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zsuzsa Bagoly
- Department of Laboratory Medicine, Faculty of Medicine, Division of Clinical Laboratory Sciences, University of Debrecen, Debrecen, Hungary; Hungarian Research Network (HUN-REN-DE) Cerebrovascular Research Group, Debrecen, Hungary.
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4
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van den Boom BP, Stamouli M, Timon J, Bernal W, Blasi A, Adelmeijer J, Fernandez J, Lisman T, Patel VC. Von Willebrand factor is an independent predictor of short-term mortality in acutely ill patients with cirrhosis. Liver Int 2023; 43:2752-2761. [PMID: 37715606 DOI: 10.1111/liv.15728] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 07/25/2023] [Accepted: 08/30/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND AND AIMS Levels of von Willebrand factor (VWF) are elevated in patients with cirrhosis, and correlate well with disease severity. In patients with decompensated cirrhosis (DC), plasma VWF is associated with mortality. The value of VWF in predicting short-term mortality risk in patients with acute-on-chronic liver failure (ACLF) is, however, unclear. METHODS We included patients with DC (n = 111) and ACLF (n = 105). We measured VWF levels and correlated these with other laboratory parameters and prediction models for mortality. Also, we assessed the predictive value of VWF in the prediction of 90- and 30-day mortality in patients with DC and ACLF, respectively, and compared this to the predictive value of clinically used prediction models. Finally, we determined the optimal cut-off value for VWF in patients with ACLF. RESULTS Sixteen of 111 (14%) patients with DC and 35 of 105 (33%) with ACLF died within 90 and 30 days, respectively. VWF was associated with mortality and correlated closely with other prediction models. In patients with ACLF, VWF levels had a discrimination for 30-day mortality comparable with these models and accurately identified ACLF patients with high 30-day mortality risk. CONCLUSIONS Levels of VWF associate closely with risk of mortality in patients with DC and ACLF, and may have predictive utility as a laboratory marker of prognosis. Further research is warranted to assess the additional value of VWF in the prediction of mortality and associated complications in chronic liver failure syndromes.
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Affiliation(s)
- Bente P van den Boom
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Marilena Stamouli
- The Roger Williams Institute of Hepatology, Foundation for Liver Research, London, UK
| | - Jennifer Timon
- Institute of Liver Studies & Transplantation, King's College Hospital, NHS Foundation Trust, London, UK
| | - William Bernal
- Institute of Liver Studies & Transplantation, King's College Hospital, NHS Foundation Trust, London, UK
| | - Annabel Blasi
- Anesthesia Department, Hospital Clinic, IDIBAPS, Barcelona, Spain
| | - Jelle Adelmeijer
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Vishal C Patel
- The Roger Williams Institute of Hepatology, Foundation for Liver Research, London, UK
- Institute of Liver Studies & Transplantation, King's College Hospital, NHS Foundation Trust, London, UK
- Liver Sciences, School of Immunology & Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
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5
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Zheng Z, Mukhametova L, Boffa MB, Moore EE, Wolberg AS, Urano T, Kim PY. Assays to quantify fibrinolysis: strengths and limitations. Communication from the International Society on Thrombosis and Haemostasis Scientific and Standardization Committee on fibrinolysis. J Thromb Haemost 2023; 21:1043-1054. [PMID: 36759279 PMCID: PMC10109242 DOI: 10.1016/j.jtha.2023.01.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 01/04/2023] [Accepted: 01/06/2023] [Indexed: 01/15/2023]
Abstract
Fibrinolysis is a series of enzymatic reactions that degrade insoluble fibrin. Plasminogen activators convert the zymogen plasminogen to the active serine protease plasmin, which cleaves and solubilizes crosslinked fibrin clots into fibrin degradation products. The quantity and quality of fibrinolytic enzymes, their respective inhibitors, and clot structure determine overall fibrinolysis. The quantity of protein can be measured by antigen-based assays, and both quantity and quality can be assessed using functional assays. Furthermore, variations of commonly used assays have been reported, which are tailored to address the role(s) of specific fibrinolytic factors and cellular elements (eg, platelets, neutrophils, and red blood cells). Although the concentration and/or activity of a protein can be quantified, how these individual components contribute to the overall fibrinolysis outcome can be challenging to determine. This difficulty is due to temporal changes within and around the thrombi during the clot breakdown, particularly the fibrin matrix structure, and composition. Furthermore, terms such as "fibrinolytic activity/potential," "plasminogen activation," and "plasmin activity" are often used interchangeably despite having different definitions. The purpose of this review is to 1) summarize the assays measuring fibrinolysis activity and potential, 2) facilitate the interpretation of data generated by these assays, and 3) summarize the strengths and limitations of these assays.
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Affiliation(s)
- Ze Zheng
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA; Blood Research Institute, Versiti Blood Center of Wisconsin, Milwaukee, Wisconsin, USA
| | - Liliya Mukhametova
- Chemical Enzymology Department, Chemistry Faculty, Lomonosov Moscow State University, Moscow, Russia
| | - Michael B Boffa
- Department of Biochemistry and Robarts Research Institute, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Ernest E Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, Colorado, USA
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Tetsumei Urano
- Department of Medical Physiology, Hamamatsu University School of Medicine and Shizuoka Graduate University of Public Health, Hamamatsu, Japan
| | - Paul Y Kim
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada.
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Links MH, Lefrandt JD, Lisman T, van der Boom T, Lukens MV, Meijer K, Links TP, Zandee WT. Fluctuations in Thyroid Hormone Levels During Initial Treatment for Differentiated Thyroid Carcinoma are Associated with Changes in Hemostasis: A Prospective Cohort Study. Thyroid 2023; 33:203-213. [PMID: 36322715 DOI: 10.1089/thy.2022.0299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background: During treatment for differentiated thyroid carcinoma (DTC), patients go from euthyroidism to severe hypothyroidism to subclinical hyperthyroidism induced by thyroid hormone suppression therapy (THST). Severe hypothyroidism may induce a tendency toward bleeding, whereas hyperthyroidism is thrombogenic. Therefore, treatment for DTC may increase the risk of bleeding during thyroid hormone withdrawal, and thrombosis during THST. This study aims to provide prospective analysis of changes in the hemostatic system from euthyroidism to hypothyroidism, and during THST, in patients treated for DTC. Methods: This is a secondary study in a larger Dutch prospective cohort. Consecutive samples were obtained from 20 patients (18 female [90%]; median age 48 [interquartile range 35.8-56.5] years) throughout their treatment for DTC during euthyroidism (n = 5), severe hypothyroidism (n = 20), and THST (n = 20). We measured selected hemostatic proteins and C-reactive protein (CRP), performed functional tests of hemostasis (a thrombin generation test and a plasma-based clot lysis test), and assessed markers of in vivo activation of hemostasis (thrombin-antithrombin complexes, plasmin-antiplasmin [PAP] complexes, and D-dimer levels). Results: During hypothyroidism, the majority of measured parameters did not change. During THST, plasma levels of nearly all measured hemostatic proteins were higher than during hypothyroidism. Additionally, CRP significantly increased from 1.3 (0.5-3.3) to 3.2 (1.3-5.1) mg/L during THST (p < 0.01). Ex vivo thrombin generation increased from 626.0 (477.0-836.3) to 876.0 (699.0-1052.0) nM × min (p = 0.02), and ex vivo clot lysis time increased from 60.6 (55.6-67.4) to 76.0 (69.7-95.0) minutes during THST (p < 0.01). PAP levels reduced from 266.5 (211.8-312.0) to 192.0 (161.0-230.0) μg/L during THST (p < 0.01); other markers of in vivo activation of coagulation remained unaffected. Conclusions: During THST-induced hyperthyroidism, a shift toward a more hypercoagulable and hypofibrinolytic state occurred. However, in vivo activation of hemostasis did not increase. The rise in CRP levels suggests the presence of a low-grade inflammation in patients during THST. Both a hypercoagulable and hypofibrinolytic state and a low-grade inflammation are associated with an increased risk of cardiovascular diseases (CVD). Therefore, the subtle changes found during THST could potentially play a role in the pathogenesis of CVD as observed in DTC patients. Clinical Trial Registration: This study is part of a larger clinical trial registered at the Netherlands Trial Register (NTR ID 7228).
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Affiliation(s)
- Mirthe H Links
- Division of Endocrinology, Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Joop D Lefrandt
- Division of Vascular Medicine, Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Trynke van der Boom
- Division of Endocrinology, Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Michaël V Lukens
- Department of Laboratory Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Karina Meijer
- Department of Hematology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Thera P Links
- Division of Endocrinology, Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Wouter T Zandee
- Division of Endocrinology, Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
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7
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Yap ES, Lijfering WM, Timp JF, Rosendaal FR, Cannegieter SC, Scheres LJJ. Procoagulant factors and future risk of arterial cardiovascular disease in patients with prior venous thrombosis: A cohort study. EJHAEM 2023; 4:3-12. [PMID: 36819164 PMCID: PMC9928659 DOI: 10.1002/jha2.618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/31/2022] [Accepted: 11/03/2022] [Indexed: 01/18/2023]
Abstract
Patients with venous thrombosis (VT) are at increased risk of future arterial cardiovascular disease (CVD) (i.e., myocardial infarction, ischemic stroke or peripheral artery disease). We investigated whether shared risk factors for VT and CVD are associated with the levels of procoagulant factors (fibrinogen, factor VIII, and von Willebrand factor), and whether the relationship between these risk factors and subsequent CVD was mediated through these procoagulant factors in patients with VT. In a follow-up study consisting of 4956 patients with VT, 2176 patients (44%) provided blood samples and were linked to the Dutch Hospital registry of Statistics Netherlands to identify hospital admissions or procedures for subsequent CVD. In total, 52 CVD events occurred over a follow-up of 11,124 years, with an incidence rate of 4.7 per 1000 patient years (95% confidence intervals 3.5-6.1). Increasing age, male sex, smoking history, major illnesses, dyslipidemia, and impaired fasting glucose levels were associated with increased CVD risk. Procoagulant factor levels were also associated with CVD risk. When adjusted for these procoagulant factors, the association between the risk factors and CVD attenuated partially. This study provides evidence that procoagulant factors can partially explain the association between increased risks of subsequent CVD in patients with previous VT.
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Affiliation(s)
- Eng Soo Yap
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands,Department of Laboratory MedicineNational University HospitalSingaporeSingapore
| | - Willem M. Lijfering
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands,Kennisinstituut, Federatie Medisch SpecialistenUtrechtThe Netherlands
| | - Jasmijn F. Timp
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Frits R. Rosendaal
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands,Einthoven Laboratory for Experimental Vascular MedicineLeiden University Medical CenterLeidenThe Netherlands
| | - Suzanne C. Cannegieter
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands,Department of Internal MedicineSection of Thrombosis and HaemostasiasLeiden University Medical CenterLeidenThe Netherlands
| | - Luuk J. J. Scheres
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands,Department of Internal MedicineRadboud University Medical CenterNijmegenThe Netherlands
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8
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Humphreys SJ, Whyte CS, Mutch NJ. "Super" SERPINs-A stabilizing force against fibrinolysis in thromboinflammatory conditions. Front Cardiovasc Med 2023; 10:1146833. [PMID: 37153474 PMCID: PMC10155837 DOI: 10.3389/fcvm.2023.1146833] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/31/2023] [Indexed: 05/09/2023] Open
Abstract
The superfamily of serine protease inhibitors (SERPINs) are a class of inhibitors that utilise a dynamic conformational change to trap and inhibit their target enzymes. Their powerful nature lends itself well to regulation of complex physiological enzymatic cascades, such as the haemostatic, inflammatory and complement pathways. The SERPINs α2-antiplasmin, plasminogen-activator inhibitor-1, plasminogen-activator inhibitor-2, protease nexin-1, and C1-inhibitor play crucial inhibitory roles in regulation of the fibrinolytic system and inflammation. Elevated levels of these SERPINs are associated with increased risk of thrombotic complications, obesity, type 2 diabetes, and hypertension. Conversely, deficiencies of these SERPINs have been linked to hyperfibrinolysis with bleeding and angioedema. In recent years SERPINs have been implicated in the modulation of the immune response and various thromboinflammatory conditions, such as sepsis and COVID-19. Here, we highlight the current understanding of the physiological role of SERPINs in haemostasis and inflammatory disease progression, with emphasis on the fibrinolytic pathway, and how this becomes dysregulated during disease. Finally, we consider the role of these SERPINs as potential biomarkers of disease progression and therapeutic targets for thromboinflammatory diseases.
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9
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Blasi A, Patel VC, Spanke ENHE, Adelmeijer J, Stamouli M, Zamalloa A, Corcoran E, Calvo A, Fernandez J, Bernal W, Lisman T. Fibrin clot quality in acutely ill cirrhosis patients: Relation with outcome and improvement with coagulation factor concentrates. Liver Int 2022; 42:435-443. [PMID: 34894081 PMCID: PMC9299765 DOI: 10.1111/liv.15132] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/13/2021] [Accepted: 12/02/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND & AIMS Patients with liver disease may acquire substantial changes in their hemostatic system, which are most pronounced in patients who are critically ill. Changes in the quality of the fibrin clot in critically ill patients have not been studied in detail. Here we assessed markers of fibrin clot quality and effects of coagulation factor concentrates in patients with acutely decompensated (AD) cirrhosis and acute on chronic liver failure (ACLF). METHODS We measured plasma levels of fibrinogen, factor XIII, prothrombin and performed thrombin generation assays in 52 AD patients, 58 ACLF patients and 40 controls. In addition, we examined the effects of coagulation factor concentrates on functional assays of fibrin quality. RESULTS We found increased thrombin generating capacity in both AD and ACLF in comparison with healthy controls. Plasma levels of prothrombin, fibrinogen, and factor XIII were lower in patients compared to controls, appeared lower in ACLF compared to AD patients, and were related to clinical outcomes. Fibrinogen concentrate, but not factor XIII or prothrombin complex concentrate, improved clot quality in vitro. Prothrombin complex concentrate increased the resistance of the clot to break down. CONCLUSIONS We have demonstrated elevated thrombin generation but decreased plasma levels of prothrombin, fibrinogen and FXIII in acutely ill patients with cirrhosis. In addition, we showed that fibrinogen concentrate and PCCs, but not factor XIII concentrate, improve clot properties in patient plasma. Whether there is true clinical benefit from coagulation factor concentrates in prevention or treatment of bleeding requires further study. LAY SUMMARY Patients with liver diseases are at risk of bleeding, but mechanisms involved in this bleeding risk are incompletely understood. We studied components that determine the stability of the blood clot and found that concentrations of certain proteins involved in clot stability are present in low levels in acutely ill patients with liver disease. We furthermore demonstrated that some clinically available drugs improve the stability of blood clots from these patients in a test tube.
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Affiliation(s)
- Annabel Blasi
- Anesthesiology DepartmentHospital Clínic and University of BarcelonaBarcelonaSpain,Institute d'Investigacions Biomèdica Agustí Pi i Sunyer (IDIBAPS)BarcelonaSpain
| | - Vishal C. Patel
- Institute of Liver Studies & TransplantationKing's College HospitalNHS Foundation TrustLondonUK,Liver SciencesSchool of Immunology & Microbial SciencesKing's College LondonUK,Institute of HepatologyFoundation for Liver ResearchLondonUK
| | - Eva N. H. E. Spanke
- Surgical Research LaboratoryDepartment of SurgeryUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Jelle Adelmeijer
- Surgical Research LaboratoryDepartment of SurgeryUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | | | - Ane Zamalloa
- Institute of Liver Studies & TransplantationKing's College HospitalNHS Foundation TrustLondonUK
| | - Eleanor Corcoran
- Department of Critical CareKing's College Hospital NHS Foundation TrustLondonUK
| | - Andrea Calvo
- Anesthesiology DepartmentHospital Clínic and University of BarcelonaBarcelonaSpain,Institute d'Investigacions Biomèdica Agustí Pi i Sunyer (IDIBAPS)BarcelonaSpain
| | - Javier Fernandez
- Liver UnitInstitut de Malalties Digestives i MetabòliquesHospital Clínic and University of BarcelonaBarcelonaSpain
| | - William Bernal
- Institute of Liver Studies & TransplantationKing's College HospitalNHS Foundation TrustLondonUK
| | - Ton Lisman
- Surgical Research LaboratoryDepartment of SurgeryUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands,Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
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10
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Ishikawa T, Nakajima Y, Omae T, Ogiwara K, Nogami K. Comprehensive coagulation and fibrinolytic potential in the acute phase of pediatric patients with idiopathic nephrotic syndrome evaluated by whole blood-based rotational thromboelastometry. Pediatr Nephrol 2022; 37:1605-1614. [PMID: 34997323 PMCID: PMC8741554 DOI: 10.1007/s00467-021-05366-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 11/09/2021] [Accepted: 11/09/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Venous thromboembolism is a rare, serious complication of idiopathic nephrotic syndrome (INS) in childhood. The mechanisms responsible for the hypercoagulable state in the acute phase of INS are poorly understood, however. This study aimed to assess overall coagulation and fibrinolytic function in pediatric patients with INS. METHODS Global coagulation and fibrinolysis were examined in whole blood samples from 22 children with initial onset INS (initial-group), 22 children with relapsed INS (relapse-group), and 15 control pediatric patients using rotational thromboelastometry (ROTEM®). In the initial-group, blood samples were obtained before (week 0) and 1-4 weeks after initiation of corticosteroid therapy. EXTEM and FIBTEM were used to assess coagulation and fibrinolysis, respectively. Clot time (CT), clot formation time (CFT), maximum clot firmness (MCF), and α-angle were determined as coagulation parameters, and lysis index at 30 and 60 min (LI30 and LI60, respectively) were assessed as fibrinolytic parameters. RESULTS CT was significantly shortened, and MCF and α-angle were significantly greater than controls at week 0 and week 1 both in the initial-group and the relapse-group. MCF correlated with serum albumin (r = 0.70, p < 0.001) and fibrinogen level (r = 0.68, p < 0.001). The fibrinolytic parameters (LI30 and LI60) in the initial-group were stable and higher than those in controls at all time points (p < 0.01). CONCLUSIONS We have shown that the hypofibrinolytic defect did not improve with effective NS treatment at the early 4-week time-point. Additionally, a likely pre-thrombotic state was evident in the period before initial onset and 1 week after corticosteroid therapy in pediatric INS.
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Affiliation(s)
- Tomoaki Ishikawa
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522 Japan
| | - Yuto Nakajima
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522 Japan ,Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Nara Japan
| | - Takashi Omae
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522 Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522 Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
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11
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Assessment of fibrinolytic markers in patients with deep vein thrombosis. Blood Coagul Fibrinolysis 2021; 33:113-118. [DOI: 10.1097/mbc.0000000000001114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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Bryk-Wiązania AH, Undas A. Hypofibrinolysis in type 2 diabetes and its clinical implications: from mechanisms to pharmacological modulation. Cardiovasc Diabetol 2021; 20:191. [PMID: 34551784 PMCID: PMC8459566 DOI: 10.1186/s12933-021-01372-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 08/25/2021] [Indexed: 12/19/2022] Open
Abstract
A prothrombotic state is a typical feature of type 2 diabetes mellitus (T2DM). Apart from increased platelet reactivity, endothelial dysfunction, hyperfibrinogenemia, and hypofibrinolysis are observed in T2DM. A variety of poorly elucidated mechanisms behind impaired fibrinolysis in this disease have been reported, indicating complex associations between platelet activation, fibrin formation and clot structure, and fibrinolysis inhibitors, in particular, elevated plasminogen antigen inhibitor-1 levels which are closely associated with obesity. Abnormal fibrin clot structure is of paramount importance for relative resistance to plasmin-mediated lysis in T2DM. Enhanced thrombin generation, a proinflammatory state, increased release of neutrophil extracellular traps, elevated complement C3, along with posttranslational modifications of fibrinogen and plasminogen have been regarded to contribute to altered clot structure and impaired fibrinolysis in T2DM. Antidiabetic agents such as metformin and insulin, as well as antithrombotic agents, including anticoagulants, have been reported to improve fibrin properties and accelerate fibrinolysis in T2DM. Notably, recent evidence shows that hypofibrinolysis, assessed in plasma-based assays, has a predictive value in terms of cardiovascular events and cardiovascular mortality in T2DM patients. This review presents the current data on the mechanisms underlying arterial and venous thrombotic complications in T2DM patients, with an emphasis on hypofibrinolysis and its impact on clinical outcomes. We also discuss potential modulators of fibrinolysis in the search for optimal therapy in diabetic patients.
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Affiliation(s)
- Agata Hanna Bryk-Wiązania
- Department of Endocrinology, Jagiellonian University Medical College, Kraków, Poland.,University Hospital, Kraków, Poland
| | - Anetta Undas
- Institute of Cardiology, Jagiellonian University Medical College, 80 Prądnicka St., 31-202, Kraków, Poland. .,John Paul II Hospital, Kraków , Poland.
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13
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Lisman T, Adelmeijer J, Huskens D, Meijers JCM. Aprotinin Inhibits Thrombin Generation by Inhibition of the Intrinsic Pathway, but is not a Direct Thrombin Inhibitor. TH OPEN 2021; 5:e363-e375. [PMID: 34485811 PMCID: PMC8407936 DOI: 10.1055/s-0041-1735154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/29/2021] [Indexed: 12/01/2022] Open
Abstract
Background
Aprotinin is a broad-acting serine protease inhibitor that has been clinically used to prevent blood loss during major surgical procedures including cardiac surgery and liver transplantation. The prohemostatic properties of aprotinin likely are related to its antifibrinolytic effects, but other mechanisms including preservation of platelet function have been proposed.
Aim
Here we assessed effects of aprotinin on various hemostatic pathways in vitro, and compared effects to tranexamic acid(TXA), which is an antifibrinolytic but not a serine protease inhibitor.
Methods
We used plasma-based clot lysis assays, clotting assays in whole blood, plasma, and using purified proteins, and platelet activation assays to which aprotinin or TXA were added in pharmacological concentrations.
Results
Aprotinin and TXA dose-dependently inhibited fibrinolysis in plasma. Aprotinin inhibited clot formation and thrombin generation initiated via the intrinsic pathway, but had no effect on reactions initiated by tissue factor. However, in the presence of thrombomodulin, aprotinin enhanced thrombin generation in reactions started by tissue factor. TXA had no effect on coagulation. Aprotinin did not inhibit thrombin, only weakly inhibited the TF-VIIa complex and had no effect on platelet activation and aggregation by various agonists including thrombin. Aprotinin and TXA inhibited plasmin-induced platelet activation.
Conclusion
Pharmacologically relevant concentrations of aprotinin inhibit coagulation initiated via the intrinsic pathway. The antifibrinolytic activity of aprotinin likely explains the prohemostatic effects of aprotinin during surgical procedures. The anticoagulant properties may be beneficial during surgical procedures in which pathological activation of the intrinsic pathway, for example by extracorporeal circuits, occurs.
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Affiliation(s)
- Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jelle Adelmeijer
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dana Huskens
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Synapse Research Institute, Maastricht, The Netherlands
| | - Joost C M Meijers
- Department of Molecular Hematology, Sanquin Research, Amsterdam, The Netherlands.,Department of Experimental Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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14
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Rivas G, Hummer-Bair B, Bezinover D, Kadry Z, Stine J. Plasminogen activator inhibitor is significantly elevated in liver transplant recipients with decompensated NASH cirrhosis. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000683. [PMID: 34341018 PMCID: PMC8330585 DOI: 10.1136/bmjgast-2021-000683] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/12/2021] [Indexed: 12/16/2022] Open
Abstract
Background Non-alcoholic fatty liver disease is a prohaemostatic state with abnormal primary, secondary and tertiary haemostasis. Plasminogen activator inhibitor (PAI)-1 is the best-established marker for prohaemostasis in non-alcoholic fatty liver disease. While epidemiological studies demonstrate decompensated non-alcoholic steatohepatitis (NASH) cirrhosis patients have increased rates of venous thromboembolism, including portal vein thrombosis, mechanistic studies have focused exclusively on patients without or with compensated cirrhosis. We aimed to characterizecharacterise PAI-1 levels in decompensated NASH cirrhosis. Methods PAI-1 level was measured in consecutive adult liver transplant recipients immediately prior to liver transplantation. Multivariable models were constructed using linear regression to assess factors related to PAI-1 level. Results Forty-six subjects with mean age 57 (IQR 53–62) years and Model for Endstage Liver Disease (MELD) score of 34 (IQR 30–40) were enrolled. Baseline characteristics were similar between NASH (n=10) and non-NASH (n=36) subjects except for rates of diabetes and hyperlipidaemia. Mean PAI-1 level was greater in NASH (53.9, 95% CI 33.3 to 74.5 mg/mL) when compared with non-NASH (36.1, 95% CI 28.7 to 43.5), p=0.040. NASH remained independently predictive of PAI-1 level prior to transplant on adjusted multivariable modelling (β 40.13, 95% CI 14.41 to 65.86, p=0.003). Conclusions: PAI-1 level is significantly elevated in decompensated NASH cirrhosis independent of other pro-haemostatic factors. This may explain the greater rates of venous thromboembolism in decompensated NASH cirrhosis. Future study focusing on prevention of venous thromboembolism in this population is paramount to improve patient-oriented outcomes given the high morbidity and mortality of venous thromboembolism and the significant impact it has on transplant candidacy.
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Affiliation(s)
- Gloriany Rivas
- Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | | | - Dmitri Bezinover
- Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Zakiyah Kadry
- Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Jonathan Stine
- Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
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15
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Fassel H, Chen H, Ruisi M, Kumar N, DeSancho M, Hajjar KA. Reduced expression of annexin A2 is associated with impaired cell surface fibrinolysis and venous thromboembolism. Blood 2021; 137:2221-2230. [PMID: 33512476 PMCID: PMC8063089 DOI: 10.1182/blood.2020008123] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 12/03/2020] [Indexed: 01/04/2023] Open
Abstract
Reduced plasma fibrinolysis has been identified as a potential risk factor for venous thromboembolism (VTE), but the role of cell surface fibrinolysis in VTE is unknown. The annexin A2/S100A10 complex serves as a coreceptor for plasminogen and tissue plasminogen activator (tPA), augmenting plasmin generation by 60-fold on the endothelial cell surface. Several studies in both mice and humans support the concept that A2 regulates fibrin homeostasis and intravascular thrombosis in vivo. Here, we examined A2 protein expression and function in 115 adult subjects with VTE and 87 healthy controls. Using peripheral blood mononuclear cells as a surrogate for endothelial cells, we found a 41% mean decrease in cell surface tPA-dependent fibrinolytic activity in subjects who had a positive personal and family history of VTE but tested negative for known inherited thrombophilias (ITs). A2 protein was reduced on average by 70% and messenger RNA levels by 30%, but neither decrease correlated with anticoagulant therapy. Neither cell A2 protein nor cell surface plasmin generation correlated with plasma-based clot lysis times, suggesting that the plasma and cell surface fibrinolytic systems operate independently of one another. These data suggest that reduced expression of annexin A2 protein is associated with cell surface hypofibrinolysis and may represent a novel risk factor for IT.
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Affiliation(s)
| | | | | | | | - Maria DeSancho
- Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Katherine A Hajjar
- Department of Pediatrics and
- Department of Medicine, Weill Cornell Medicine, New York, NY
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16
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Abstract
Fibrinolysis is of paramount importance in maintaining or regaining the patency of veins and pulmonary arteries obstructed by thrombi. Growing experimental and clinical evidence indicates that impaired fibrinolysis mediated by multiple complex mechanisms is involved in venous thromboembolism (VTE). Global plasma fibrin clot lysis markers, especially clot lysis time, have been reported to predict recurrent deep-vein thrombosis and pulmonary embolism. The current overview summarizes available data linking fibrinolysis to VTE and its long-term sequelae.
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Affiliation(s)
- Anetta Undas
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland.,Krakow Centre for Medical Research and Technologies, John Paul II Hospital, Krakow, Poland
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17
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Kanji R, Kubica J, Navarese EP, Gorog DA. Endogenous fibrinolysis-Relevance to clinical thrombosis risk assessment. Eur J Clin Invest 2021; 51:e13471. [PMID: 33296082 DOI: 10.1111/eci.13471] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/05/2020] [Accepted: 12/06/2020] [Indexed: 12/11/2022]
Abstract
The development of an obstructive luminal thrombus is pathological and considered a failure of endogenous fibrinolysis. The consequences may be fatal, or result in lasting downstream organ damage. Therefore, assessment of endogenous fibrinolytic status in an individual may identify those at risk of occlusive thrombus formation and provide prognostic information. Arterial thrombi are more platelet rich and more resistant to fibrinolysis than venous thrombi. Several recent studies using global tests of fibrinolysis in patients with acute coronary syndromes (ACS) have shown that despite dual antiplatelet therapy, patients with impaired fibrinolytic status have an increased risk of adverse cardiovascular events, compared with those with effective fibrinolytic function. Such data add significantly to the predictive value of established cardiovascular risk factors and conventional biomarkers. Most data reported have been obtained with the Global Thrombosis Test and the turbidimetric plasma clot lysis assay. A few small studies in patients with ischaemic stroke suggest a similar predictive role of fibrinolytic status assessment in these patients. Studies reporting an association between impaired fibrinolysis and future venous thrombotic events are limited, and in the form of case-control studies. Viscoelastic assays may have a role in the prediction of venous thromboembolic risk. Assays of fibrinolytic function should be used to obtain a more accurate risk of future thrombotic events, particularly in the setting of ACS. The availability of point-of-care tests helps facilitate this and should encourage future studies to assess personalised antithrombotic treatment combinations to optimise fibrinolytic status and reduce thrombosis risk.
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Affiliation(s)
- Rahim Kanji
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK.,Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Eliano P Navarese
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland.,Faculty of Medicine, University of Alberta, Edmonton, Canada
| | - Diana A Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK.,Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, UK.,School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Stevenage, UK
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18
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Memtsas VP, Arachchillage DRJ, Gorog DA. Role, Laboratory Assessment and Clinical Relevance of Fibrin, Factor XIII and Endogenous Fibrinolysis in Arterial and Venous Thrombosis. Int J Mol Sci 2021; 22:ijms22031472. [PMID: 33540604 PMCID: PMC7867291 DOI: 10.3390/ijms22031472] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 02/06/2023] Open
Abstract
Diseases such as myocardial infarction, ischaemic stroke, peripheral vascular disease and venous thromboembolism are major contributors to morbidity and mortality. Procoagulant, anticoagulant and fibrinolytic pathways are finely regulated in healthy individuals and dysregulated procoagulant, anticoagulant and fibrinolytic pathways lead to arterial and venous thrombosis. In this review article, we discuss the (patho)physiological role and laboratory assessment of fibrin, factor XIII and endogenous fibrinolysis, which are key players in the terminal phase of the coagulation cascade and fibrinolysis. Finally, we present the most up-to-date evidence for their involvement in various disease states and assessment of cardiovascular risk.
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Affiliation(s)
- Vassilios P. Memtsas
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire SG1 4AB, UK;
| | - Deepa R. J. Arachchillage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London SW7 2AZ, UK;
- Department of Haematology, Imperial College Healthcare NHS Trust, London W2 1NY, UK
- Department of Haematology, Royal Brompton Hospital, London SW3 6NP, UK
| | - Diana A. Gorog
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire SG1 4AB, UK;
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hertfordshire AL10 9AB, UK
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London SW3 6LY, UK
- Correspondence: ; Tel.: +44-207-0348841
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19
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Rosell A, Havervall S, von Meijenfeldt F, Hisada Y, Aguilera K, Grover SP, Lisman T, Mackman N, Thålin C. Patients With COVID-19 Have Elevated Levels of Circulating Extracellular Vesicle Tissue Factor Activity That Is Associated With Severity and Mortality-Brief Report. Arterioscler Thromb Vasc Biol 2021; 41:878-882. [PMID: 33267656 PMCID: PMC7837685 DOI: 10.1161/atvbaha.120.315547] [Citation(s) in RCA: 151] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/15/2020] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Patients with coronavirus disease 2019 (COVID-19) have a high rate of thrombosis. We hypothesized that severe acute respiratory syndrome coronavirus 2 infection leads to induction of TF (tissue factor) expression and increased levels of circulating TF-positive extracellular vesicles (EV) that may drive thrombosis. Approach and Results: We measured levels of plasma EV TF activity in 100 patients with COVID-19 with moderate and severe disease and 28 healthy controls. Levels of EV TF activity were significantly higher in patients with COVID-19 compared with controls. In addition, levels of EV TF activity were associated with disease severity and mortality. Finally, levels of EV TF activity correlated with several plasma markers, including D-dimer, which has been shown to be associated with thrombosis in patients with COVID-19. CONCLUSIONS Our results indicate that severe acute respiratory syndrome coronavirus 2 infection induces the release of TF-positive EVs into the circulation that are likely to contribute to thrombosis in patients with COVID-19. EV TF activity was also associated with severity and mortality.
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Affiliation(s)
- Axel Rosell
- Division of Internal Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden (A.R., S.H., K.A., C.T.)
| | - Sebastian Havervall
- Division of Internal Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden (A.R., S.H., K.A., C.T.)
| | - Fien von Meijenfeldt
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, the Netherlands (F.v.M., T.L.)
| | - Yohei Hisada
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill (Y.H., S.P.G., N.M.)
| | - Katherina Aguilera
- Division of Internal Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden (A.R., S.H., K.A., C.T.)
| | - Steven P. Grover
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill (Y.H., S.P.G., N.M.)
| | - Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, the Netherlands (F.v.M., T.L.)
| | - Nigel Mackman
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill (Y.H., S.P.G., N.M.)
| | - Charlotte Thålin
- Division of Internal Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden (A.R., S.H., K.A., C.T.)
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20
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Individualised Risk Assessments for Recurrent Venous Thromboembolism: New Frontiers in the Era of Direct Oral Anticoagulants. HEMATO 2021. [DOI: 10.3390/hemato2010003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Venous thromboembolism (VTE) is a leading cause of morbidity and mortality and is associated with high recurrence rates. The introduction of direct oral anticoagulants (DOACs) in the 2010s has changed the landscape of VTE management. DOACs have become the preferred anticoagulant therapy for their ease of use, predictable pharmacokinetics, and improved safety profile. Increasingly, guidelines have recommended long term anticoagulation for some indications such as following first unprovoked major VTE, although an objective individualised risk assessment for VTE recurrence remains elusive. The balance of preventing VTE recurrence needs to be weighed against the not insignificant bleeding risk, which is cumulative with prolonged use. Hence, there is a need for an individualised, targeted approach for assessing the risk of VTE recurrence, especially in those patients in whom the balance between benefit and risk of long-term anticoagulation is not clear. Clinical factors alone do not provide the level of discrimination required on an individual level. Laboratory data from global coagulation assays and biomarkers may provide enhanced risk assessment ability and are an active area of research. A review of the prediction models and biomarkers for assessing VTE recurrence risk is provided, with an emphasis on contemporary developments in the era of DOACs and global coagulation assays.
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21
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von Meijenfeldt FA, Havervall S, Adelmeijer J, Lundström A, Rudberg A, Magnusson M, Mackman N, Thalin C, Lisman T. Prothrombotic changes in patients with COVID-19 are associated with disease severity and mortality. Res Pract Thromb Haemost 2021; 5:132-141. [PMID: 33537537 PMCID: PMC7845083 DOI: 10.1002/rth2.12462] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/03/2020] [Accepted: 11/06/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Patients with severe coronavirus disease 2019 (COVID-19) are at significant risk of thrombotic complications. However, their prothrombotic state is incompletely understood. Therefore, we measured in vivo activation markers of hemostasis, plasma levels of hemostatic proteins, and functional assays of coagulation and fibrinolysis in plasma from patients with COVID-19 and determined their association with disease severity and 30-day mortality. METHODS We included 102 patients with COVID-19 receiving various levels of respiratory support admitted to general wards, intermediate units, or intensive care units and collected plasma samples shortly after hospital admission. RESULTS Patients with COVID-19 with higher respiratory support had increased in vivo activation of coagulation and fibrinolysis, as reflected by higher plasma levels of d-dimer, thrombin-antithrombin, and plasmin-antiplasmin complexes as compared to patients with no to minimal respiratory support and healthy controls. Moreover, the patients with COVID-19 with higher respiratory support exhibited substantial ex vivo thrombin generation and lower ex vivo fibrinolytic capacity, despite higher doses of anticoagulant therapy compared to less severely ill patients. Fibrinogen, factor VIII, and von Willebrand factor levels increased, and ADAMTS13 levels decreased with increasing respiratory support in patients with COVID-19. Low platelet count; low levels of prothrombin, antithrombin, and ADAMTS13; and high levels of von Willebrand factor were associated with short-term mortality. CONCLUSIONS Severe COVID-19 is associated with prothrombotic changes with increased in vivo activation of coagulation and fibrinolysis, despite anticoagulant therapy.
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Affiliation(s)
- Fien A. von Meijenfeldt
- Surgical Research LaboratoryDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Sebastian Havervall
- Division of Internal MedicineDepartment of Clinical SciencesKarolinska InstitutetDanderyd HospitalStockholmSweden
| | - Jelle Adelmeijer
- Surgical Research LaboratoryDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Annika Lundström
- Division of Internal MedicineDepartment of Clinical SciencesKarolinska InstitutetDanderyd HospitalStockholmSweden
| | - Ann‐Sofie Rudberg
- Department of NeurologyDanderyd HospitalStockholmSweden
- Department of Clinical NeurosciencesKarolinska InstitutetStockholmSweden
| | - Maria Magnusson
- Clinical Chemistry and Blood Coagulation ResearchMMKDepartment of PediatricsDepartment of HematologyCLINTECKarolinska InstitutetKarolinska University HospitalStockholmSweden
| | - Nigel Mackman
- UNC Blood Research CenterDivision of HematologyDepartment of MedicineUniversity of North Carolina at Chapel HillNCUSA
| | - Charlotte Thalin
- Division of Internal MedicineDepartment of Clinical SciencesKarolinska InstitutetDanderyd HospitalStockholmSweden
| | - Ton Lisman
- Surgical Research LaboratoryDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
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22
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Lisman T, Arefaine B, Adelmeijer J, Zamalloa A, Corcoran E, Smith JG, Bernal W, Patel VC. Global hemostatic status in patients with acute-on-chronic liver failure and septics without underlying liver disease. J Thromb Haemost 2021; 19:85-95. [PMID: 33006808 PMCID: PMC7839476 DOI: 10.1111/jth.15112] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/28/2020] [Accepted: 09/22/2020] [Indexed: 12/12/2022]
Abstract
Essentials Liver diseases are associated with profound hemostatic changes proportional to severity of illness. Hemostatic changes in acute-on-chronic liver failure (ACLF) may in part reflect critical illness. Hemostatic changes in ACLF partly overlap with those in sepsis, with rebalanced hemostasis in both. Patients with sepsis had hyperfibrinogenemia, associated with a thrombogenic clot structure. ABSTRACT: Background Even the sickest patients with chronic liver disease (CLD), such as those with acute-on-chronic liver failure (ACLF) remain in hemostatic balance due to a concomitant decline in pro- and antihemostatic factors. Objectives We aimed to study whether the hemostatic status in ACLF is merely an exaggeration from the status in patients with compensated and acutely decompensated cirrhosis, or whether sepsis-associated hemostatic changes contribute. Methods We performed extensive hemostatic profiling in 31 adult patients with ACLF, 20 patients with sepsis without underlying CLD, and 40 healthy controls. Results We found similarly elevated plasma levels of the platelet adhesive protein von Willebrand factor (VWF) and decreased levels of the VWF-regulating protease ADAMTS13 in both groups compared to healthy controls. In vivo markers of activation of coagulation (thrombin-antithrombin III, D-dimer) were similarly elevated in both groups compared to controls, but ex vivo thrombin-generating capacity was similar between patients and controls, despite a much more profound international normalized ratio elevation in ACLF. Plasma fibrinogen levels were much higher in septics, which was accompanied by a decreased ex vivo clot permeability and an increase in ex vivo resistance to clot lysis. All hemostatic parameters were remarkably stable over the first 10 days after admission. Conclusions We have found hemostatic changes in ACLF to partially overlap with that of patients with sepsis, and evidence of preserved hemostatic capacity in both patient groups. The notable difference was a profound hyperfibrinogenemia, associated with a thrombogenic clot structure and a marked ex vivo resistance to fibrinolysis in patients with sepsis.
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Affiliation(s)
- Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | | | - Jelle Adelmeijer
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Ane Zamalloa
- Institute of Liver StudiesKing’s College Hospital NHS Foundation TrustLondonUK
| | - Eleanor Corcoran
- Department of Critical CareKing’s College Hospital NHS Foundation TrustLondonUK
| | - John G. Smith
- Department of Critical CareKing’s College Hospital NHS Foundation TrustLondonUK
| | - William Bernal
- Institute of Liver StudiesKing’s College Hospital NHS Foundation TrustLondonUK
| | - Vishal C. Patel
- Institute of Hepatology LondonFoundation for Liver ResearchLondonUK
- Institute of Liver StudiesKing’s College Hospital NHS Foundation TrustLondonUK
- School of Immunology and Microbial SciencesFaculty of Life Sciences and MedicineKing’s College LondonLondonUK
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23
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Spinosa M, Stine JG. Nonalcoholic Fatty Liver Disease-Evidence for a Thrombophilic State? Curr Pharm Des 2020; 26:1036-1044. [PMID: 32003679 DOI: 10.2174/1381612826666200131101553] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 12/16/2019] [Indexed: 02/06/2023]
Abstract
Nonalcoholic fatty liver disease is the leading cause of liver disease worldwide. It has expansive extrahepatic morbidity and mortality including increased rates of both cardiovascular disease and venous thromboembolism. Derangements in primary, secondary and tertiary hemostasis are found in nonalcoholic fatty liver disease independent of those ascribed to end-stage liver disease. The abnormalities across all stages of hemostasis explain the increased rates of clinically relevant thrombotic events, including pulmonary embolism, deep vein thrombosis and portal vein thrombosis, which on an epidemiologic basis appears to be independent of obesity and other traditional venous thromboembolic risk factors. However, given the complex interaction between obesity, body composition and nonalcoholic fatty liver disease and the potential for exercise to benefit all three, more research is needed to further define the role of each in contributing to the prohemostatic state of nonalcoholic fatty liver disease in order to improve patient oriented outcomes.
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Affiliation(s)
- Margaret Spinosa
- Department of Medicine, Pennsylvania State University Milton S. Hershey Medical Center, PA 17033, United States
| | - Jonathan G Stine
- Division of Gastroenterology & Hepatology, Department of Medicine, Pennsylvania State University Milton S. Hershey Medical Center, United States.,Department of Public Health Sciences, Pennsylvania State University Milton S. Hershey Medical Center, PA 17033, United States
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Stewart LK, Kline JA. Fibrinolytics for the treatment of pulmonary embolism. Transl Res 2020; 225:82-94. [PMID: 32434005 PMCID: PMC7487055 DOI: 10.1016/j.trsl.2020.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 04/07/2020] [Accepted: 05/05/2020] [Indexed: 12/15/2022]
Abstract
The use of fibrinolytic agents in acute pulmonary embolism (PE), first described over 50 years ago, hastens the resolution of RV stain, leading to earlier hemodynamic improvement. However, this benefit comes at the increased risk of bleeding. The strongest indication for fibrinolysis is in high-risk PE, or that characterized by sustained hypotension, while its use in patients with intermediate-risk PE remains controversial. Fibrinolysis is generally not recommended for routine use in intermediate-risk PE, although most guidelines advise that it may be considered in patients with signs of acute decompensation and an overall low bleeding risk. The efficacy of fibrinolysis often varies significantly between patients, which may be at least partially explained by several factors found to promote resistance to fibrinolysis. Ultimately, treatment decisions should carefully weigh the risks and benefits of the individual clinical scenario at hand, including the overall severity, the patient's bleeding risk, and the presence of factors known to promote resistance to fibrinolysis. This review aims to further explore the use of fibrinolytic agents in the treatment of PE including specific indications, outcomes, and special considerations.
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Affiliation(s)
- Lauren K Stewart
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana.
| | - Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana
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25
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Blasi A, von Meijenfeldt FA, Adelmeijer J, Calvo A, Ibañez C, Perdomo J, Reverter JC, Lisman T. In vitro hypercoagulability and ongoing in vivo activation of coagulation and fibrinolysis in COVID-19 patients on anticoagulation. J Thromb Haemost 2020; 18:2646-2653. [PMID: 32762118 PMCID: PMC7436627 DOI: 10.1111/jth.15043] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/08/2020] [Accepted: 08/03/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND COVID-19 is associated with a substantial risk of venous thrombotic events, even in the presence of adequate thromboprophylactic therapy. OBJECTIVES We aimed to better characterize the hypercoagulable state of COVID-19 patients in patients receiving anticoagulant therapy. METHODS We took plasma samples of 23 patients with COVID-19 who were on prophylactic or intensified anticoagulant therapy. Twenty healthy volunteers were included to establish reference ranges. RESULTS COVID-19 patients had a mildly prolonged prothrombin time, high von Willebrand factor levels and low ADAMTS13 activity. Most rotational thromboelastometry parameters were normal, with a hypercoagulable maximum clot firmness in part of the patients. Despite detectable anti-activated factor X activity in the majority of patients, ex vivo thrombin generation was normal, and in vivo thrombin generation elevated as evidenced by elevated levels of thrombin-antithrombin complexes and D-dimers. Plasma levels of activated factor VII were lower in patients, and levels of the platelet activation marker soluble CD40 ligand were similar in patients and controls. Plasmin-antiplasmin complex levels were also increased in patients despite an in vitro hypofibrinolytic profile. CONCLUSIONS COVID-19 patients are characterized by normal in vitro thrombin generation and enhanced clot formation and decreased fibrinolytic potential despite the presence of heparin in the sample. Anticoagulated COVID-19 patients have persistent in vivo activation of coagulation and fibrinolysis, but no evidence of excessive platelet activation. Ongoing activation of coagulation despite normal to intensified anticoagulant therapy indicates studies on alternative antithrombotic strategies are urgently required.
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Affiliation(s)
- Annabel Blasi
- Anesthesiology Department, Hospital Clínic, Institute d'Investigacions Biomèdica Agustí Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Fien A von Meijenfeldt
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jelle Adelmeijer
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Andrea Calvo
- Anesthesiology Department, Hospital Clínic, Institute d'Investigacions Biomèdica Agustí Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Cristina Ibañez
- Anesthesiology Department, Hospital Clínic, Institute d'Investigacions Biomèdica Agustí Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Juan Perdomo
- Anesthesiology Department, Hospital Clínic, Institute d'Investigacions Biomèdica Agustí Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Juan C Reverter
- Department of Hemostasis, Hospital Clínic, Agustí Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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26
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Larsen JB, Hvas AM. Fibrin Clot Formation and Lysis in Plasma. Methods Protoc 2020; 3:mps3040067. [PMID: 32993011 PMCID: PMC7712220 DOI: 10.3390/mps3040067] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 09/21/2020] [Accepted: 09/23/2020] [Indexed: 12/20/2022] Open
Abstract
Disturbance in the balance between fibrin formation and fibrinolysis can lead to either bleeding or thrombosis; however, our current routine coagulation assays are not sensitive to altered fibrinolysis. The clot formation and lysis assay is a dynamic plasma-based analysis that assesses the patient’s capacity for fibrin formation and fibrinolysis by adding an activator of coagulation as well as fibrinolysis to plasma and measuring ex vivo fibrin clot formation and breakdown over time. This assay provides detailed information on the fibrinolytic activity but is currently used for research only, as the assay is prone to inter-laboratory variation and as it demands experienced laboratory technicians as well as specialized personnel to validate and interpret the results. Here, we describe a protocol for the clot formation and lysis assay used at our research laboratory.
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Affiliation(s)
- Julie Brogaard Larsen
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark;
- Correspondence: ; Tel.: +45-4046-5766
| | - Anne-Mette Hvas
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark;
- Department of Clinical Medicine, Health, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus, Denmark
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27
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Stine JG, Schreibman I, Navabi S, Kang M, Dahmus J, Soriano C, Rivas G, Hummer B, Beyer M, Tressler H, Kimball SR, Patterson AD, Schmitz K, Sciamanna C. Nonalcoholic steatohepatitis Fitness Intervention in Thrombosis (NASHFit): Study protocol for a randomized controlled trial of a supervised aerobic exercise program to reduce elevated clotting risk in patients with NASH. Contemp Clin Trials Commun 2020; 18:100560. [PMID: 32309672 PMCID: PMC7154986 DOI: 10.1016/j.conctc.2020.100560] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/17/2020] [Accepted: 03/28/2020] [Indexed: 02/07/2023] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) is the leading cause of chronic liver disease worldwide affecting upwards of one third the global population. For reasons not fully understood, individuals with NAFLD and its more severe variant, nonalcoholic steatohepatitis (NASH), are at increased risk for venous thromboembolism which significantly increases morbidity and mortality. Lifestyle changes centering around exercise training are the mainstay of treatment for NAFLD/NASH. While exercise training can lessen venous thromboembolic risk in healthy persons and those with cardiovascular disease, whether or not this benefit is seen in patients with NAFLD/NASH remains unknown. In order to better understand how exercise training impacts thrombosis risk in NAFLD, we present the design of a thirty-two week randomized controlled clinical trial of 42 sedentary subjects age 18-69 with biopsy proven NASH. The main aim is to determine the impact of an aerobic exercise training program on the abnormal hemostatic system unique to NAFLD/NASH. The main outcome is change in plasminogen activator inhibitor one level, an established marker for venous thromboembolism. Secondary outcomes include body composition, cardiorespiratory fitness, control of comorbid metabolic conditions (e.g., obesity, hypertension, hyperlipidemia, diabetes), dietary composition, health related quality of life, liver enzymes and histology, NAFLD/NASH disease activity (e.g., biomarkers, clinical decision aids), microbiome, other markers of hemostasis, and PNPLA3 gene expression. The study represents the first clinical trial of an exercise training program to reduce elevated clotting risk in subjects with NAFLD/NASH.
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Affiliation(s)
- Jonathan G. Stine
- Division of Gastroenterology and Hepatology, Department of Medicine, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey, PA, USA
- Department of Public Health Sciences, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey, PA, USA
- Liver Center, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey, PA, USA
- Cancer Institute, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Ian Schreibman
- Division of Gastroenterology and Hepatology, Department of Medicine, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey, PA, USA
- Liver Center, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Seyedehsan Navabi
- Division of Gastroenterology and Hepatology, Department of Medicine, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Mitchell Kang
- Division of Gastroenterology and Hepatology, Department of Medicine, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Jessica Dahmus
- Division of Gastroenterology and Hepatology, Department of Medicine, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Christopher Soriano
- Department of Medicine, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Gloriany Rivas
- Division of Gastroenterology and Hepatology, Department of Medicine, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Breianna Hummer
- Division of Gastroenterology and Hepatology, Department of Medicine, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Megan Beyer
- Division of Gastroenterology and Hepatology, Department of Medicine, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Heather Tressler
- Division of Gastroenterology and Hepatology, Department of Medicine, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Scot R. Kimball
- Department of Physiology, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Andrew D. Patterson
- Department of Biochemistry and Molecular Biology, The Pennsylvania State University, University Park, PA, USA
| | - Kathryn Schmitz
- Department of Public Health Sciences, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey, PA, USA
- Cancer Institute, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey, PA, USA
- Department of Kinesiology, The Pennsylvania State University- College of Medicine, Hershey, PA, USA
- Department of Physical Medicine & Rehabilitation, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Christopher Sciamanna
- Department of Public Health Sciences, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey, PA, USA
- Cancer Institute, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey, PA, USA
- Department of Medicine, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey, PA, USA
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Schol-Gelok S, de Maat MPM, Biedermann JS, van Gelder T, Leebeek FWG, Lijfering WM, van der Meer FJM, Rijken DC, Versmissen J, Kruip MJHA. Rosuvastatin use increases plasma fibrinolytic potential: a randomised clinical trial. Br J Haematol 2020; 190:916-922. [PMID: 32301122 PMCID: PMC7539918 DOI: 10.1111/bjh.16648] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/16/2020] [Indexed: 12/14/2022]
Abstract
We conducted a study to assess the effect of rosuvastatin use on fibrinolysis in patients with previous venous thromboembolism (VTE). This was a post hoc analysis within the STAtins Reduce Thrombophilia (START) study (NCT01613794). Plasma fibrinolytic potential, fibrinogen, plasmin inhibitor, plasminogen activator inhibitor‐1 (PAI‐1) and thrombin‐activatable fibrinolysis inhibitor (TAFI) were measured before and after four weeks of rosuvastatin or no treatment in participants with prior confirmed VTE, after ending anticoagulant therapy. In the non‐rosuvastatin group (n = 121), plasma fibrinolytic potential and individual fibrinolysis parameters did not change at the end of the study versus the baseline, whereas in the rosuvastatin group (n = 126), plasma fibrinolytic potential increased: the mean clot lysis time decreased by 8·75 min (95% CI −13·8 to −3·72), and plasmin inhibitor levels and TAFI activity were lower at the end of the study (−0·05 U/ml; 95% CI −0·07 to −0·02 and −4·77%; 95% CI −6·81 to −2·73, respectively). PAI‐1 levels did not change and fibrinogen levels were 0·17 g/l (95% CI 0·04–0·29) higher. In participants with prior VTE, rosuvastatin use led to an increased fibrinolytic potential compared with non‐statin use. Our findings support the need for further studies on the possible role for statins in the secondary prevention of VTE.
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Affiliation(s)
- Suzanne Schol-Gelok
- Departments of Hospital Pharmacy and Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Moniek P M de Maat
- Department of Haematology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Joseph S Biedermann
- Department of Haematology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Teun van Gelder
- Departments of Hospital Pharmacy and Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Frank W G Leebeek
- Department of Haematology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Willem M Lijfering
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Felix J M van der Meer
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Dingeman C Rijken
- Department of Haematology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Jorie Versmissen
- Departments of Hospital Pharmacy and Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Marieke J H A Kruip
- Department of Haematology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands.,Thrombosis Service Star-shl, Rotterdam, the Netherlands
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Blasi A, Patel VC, Adelmeijer J, Azarian S, Hernandez Tejero M, Calvo A, Fernández J, Bernal W, Lisman T. Mixed Fibrinolytic Phenotypes in Decompensated Cirrhosis and Acute-on-Chronic Liver Failure with Hypofibrinolysis in Those With Complications and Poor Survival. Hepatology 2020; 71:1381-1390. [PMID: 31465557 PMCID: PMC7187291 DOI: 10.1002/hep.30915] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 08/22/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Patients with liver disease acquire complex changes in their hemostatic system, which results in a fragile rebalanced status. The status of the fibrinolytic system is controversial, as is the role of fibrinolytic dysfunction in bleeding and thrombosis in patients with cirrhosis. Here, we aimed to determine fibrinolytic status and its relationship with outcome in acutely ill patients with cirrhosis. APPROACH AND RESULTS We assessed plasma fibrinolytic potential in a large cohort of patients with acutely decompensated cirrhosis (AD, n = 52) or acute-on-chronic liver failure (ACLF, n = 57). Compared with 40 healthy volunteers, median clot lysis times (CLTs) were shorter in patients with AD but comparable to controls in patients with ACLF. However, the variability in CLTs in patients was much larger than in healthy controls, and in both patient groups, a proportion of patients had clearly prolonged or shortened CLTs. The variability in CLTs in patients was not readily explained by variations in plasma levels of key fibrinolytic proteins. However, CLTs were clearly related to clinical characteristics, with longer CLTs in patients with sepsis and patients with any organ failure (as defined by the European Foundation for the Study of Chronic Liver Disease organ failure scores). CLTs were not different between patients that did or did not experience bleeding or a thrombotic event during follow-up. Baseline CLTs were substantially longer in patients that died within 30 days of admission. CONCLUSIONS Our study demonstrates a mixed fibrinolytic phenotype in acutely ill patients with cirrhosis with baseline hypofibrinolysis associated with sepsis, organ failure, and short-term mortality. These associations may be explained by defective clearance of intraorgan microthrombi that have been proposed to drive organ failure.
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Affiliation(s)
- Annabel Blasi
- Anesthesiology DepartmentHospital Clínic and University of BarcelonaBarcelonaSpain,Institute d’Investigacions Biomèdica Agustí Pi i Sunyer (IDIBAPS)BarcelonaSpain
| | - Vishal C. Patel
- Institute of Liver Studies & TransplantationKing’s College HospitalNHS Foundation TrustLondonUnited Kingdom,Liver SciencesSchool of Immunology & Microbial SciencesKing’s College LondonUnited Kingdom,Institute of HepatologyFoundation for Liver ResearchLondonUnited Kingdom
| | - Jelle Adelmeijer
- Surgical Research LaboratoryDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Sarah Azarian
- Institute of HepatologyFoundation for Liver ResearchLondonUnited Kingdom
| | - Maria Hernandez Tejero
- Liver UnitInstitut de Malalties Digestives i MetabòliquesHospital Clínic and University of BarcelonaBarcelonaSpain
| | - Andrea Calvo
- Anesthesiology DepartmentHospital Clínic and University of BarcelonaBarcelonaSpain
| | - Javier Fernández
- Liver UnitInstitut de Malalties Digestives i MetabòliquesHospital Clínic and University of BarcelonaBarcelonaSpain
| | - William Bernal
- Institute of Liver Studies & TransplantationKing’s College HospitalNHS Foundation TrustLondonUnited Kingdom
| | - Ton Lisman
- Surgical Research LaboratoryDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands,Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
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Tavares V, Pinto R, Assis J, Pereira D, Medeiros R. Venous thromboembolism GWAS reported genetic makeup and the hallmarks of cancer: Linkage to ovarian tumour behaviour. Biochim Biophys Acta Rev Cancer 2020; 1873:188331. [DOI: 10.1016/j.bbcan.2019.188331] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 11/01/2019] [Accepted: 11/01/2019] [Indexed: 12/14/2022]
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Plasma Fibrin Clot Properties Are Unfavorably Altered in Women following Venous Thromboembolism Associated with Combined Hormonal Contraception. DISEASE MARKERS 2019; 2019:4923535. [PMID: 31827635 PMCID: PMC6885764 DOI: 10.1155/2019/4923535] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 10/22/2019] [Indexed: 11/17/2022]
Abstract
The use of hormonal contraception is associated with an increased risk of venous thromboembolism (VTE). Unfavorably altered fibrin clot phenotype has been reported in patients following unprovoked VTE who are at risk of recurrences. It remains unknown whether fibrin clot characteristics in women with contraception-related VTE differ from those in unprovoked VTE. We studied three age-matched groups of women: (1) after contraception-related VTE, (n = 48) (2) after unprovoked VTE (n = 48), and (3) controls (n = 48). Plasma fibrin clot permeability (K s), turbidity of clot formation, efficiency of fibrinolysis using clot lysis time (CLT), and rate of increase in D-dimer during lytic clot degradation (D-Drate), along with thrombin generation and fibrinolysis proteins were determined. Compared with the controls, patients following contraception-related and unprovoked VTE formed faster (lag phase, -8.8% and -20.4%, respectively) fibrin clots of increased density (K s , -8.6% and -13.4%, respectively) displaying impaired fibrinolysis as evidenced by prolonged CLT (+11.5% and +14.5%, respectively) and lower D-Drate (-7.1% and -5.6%, respectively), accompanied with higher plasminogen activator inhibitor-1 (PAI-1, +14.9% and +17.8%, respectively) and elevated peak thrombin generation (+63.8% and +36.7%, respectively). The only differences between women with unprovoked and contraception-related VTE were lower fibrin mass in plasma clots (D-Dmax, -8.6%), along with higher peak thrombin generation (+19.8%) and shorter lag phase (-6.8%) in the latter group. This study suggests that women after contraception-related VTE, similar to those following unprovoked VTE, have denser fibrin clot formation and impaired clot lysis. These findings might imply higher risk of VTE recurrence in women with the prothrombotic clot phenotype.
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Undas A, Natorska J. Improving fibrinolysis in venous thromboembolism: impact of fibrin structure. Expert Rev Hematol 2019; 12:597-607. [PMID: 31159611 DOI: 10.1080/17474086.2019.1627193] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction. Fibrinolysis is of key importance in maintaining vessel patency. Impaired fibrinolysis associated with more compact fibrin structure has been shown in patients with venous thromboembolism (VTE), including deep-vein thrombosis and pulmonary embolism (PE). Currently, recombinant or modified plasminogen activators are the only commonly available thrombolytic agents. However, they are fraught with side effects and suboptimal effectiveness. Areas covered. Based on the available literature, the current evidence linking fibrinolysis with VTE and potential therapeutic targets among fibrinolysis proteins are presented. Expert opinion. Prolonged clot lysis time has been reported as a new predictor of first-time and recurrent VTE, including PE. Anticoagulant therapy, including non-vitamin K antagonist oral anticoagulants, has a favorable impact on fibrinolysis in VTE patients. Several VTE risk factors are also related to lower efficiency of fibrinolysis and their treatment improve fibrinolysis, in part by alterations to fibrin properties. There is an increasing number of studies aiming at developing novel profibrinolytic therapeutic agents for treatment of VTE patients, mostly targeting the antifibrinolytic proteins, i.e. antiplasmin, plasminogen activator inhibitor-1 and thrombin-activatable fibrinolysis inhibitor.
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Affiliation(s)
- Anetta Undas
- a Institute of Cardiology, Jagiellonian University Medical College , Kraków , Poland
| | - Joanna Natorska
- a Institute of Cardiology, Jagiellonian University Medical College , Kraków , Poland
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Heubel-Moenen FCJI, Henskens YMC, Verhezen PWM, Wetzels RJH, Schouten HC, Beckers EAM. Fibrinolysis in patients with chemotherapy-induced thrombocytopenia and the effect of platelet transfusion. J Thromb Haemost 2019; 17:1073-1084. [PMID: 31033178 DOI: 10.1111/jth.14465] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 04/04/2019] [Accepted: 04/23/2019] [Indexed: 01/11/2023]
Abstract
Essentials Bleeding in chemotherapy induced thrombocytopenia (CIT) might be influenced by hyperfibrinolysis. t-PA-thromboelastography is a fast and reliable assay for hyperfibrinolysis in CIT patients. Clots of CIT patients are more susceptible to t-PA induced lysis compared to healthy individuals. Besides platelets, other factors are likely to influence clot lysis in CIT patients. BACKGROUND Bleeding events in chemotherapy-induced thrombocytopenic (CIT) patients with similar platelet counts might be influenced by changes in clot lysis potential. OBJECTIVES To investigate, in an observational study, thromboelastographic lysis parameters, alterations in clot strength and susceptibility to clot lysis in CIT patients. To identify factors associated with fibrinolytic profiles, and to evaluate the effects of platelet transfusions. METHODS Independent determinants of tissue-type plasminogen activator (t-PA)-ROTEM lysis parameters were identified with multivariable linear regression. Clot formation, strength and lysis parameters were compared with the results of healthy individuals. Characteristics of CIT patients with and without hyperfibrinolytic profiles were compared. t-PA-ROTEM results before, 1 hour after and 24 hours after platelet transfusion were compared. RESULTS A total of 72 consecutive CIT patients were included. t-PA-ROTEM lysis parameters correlated with changes in fibrinolytic proteins. Clot formation time was longer, maximum clot firmness was weaker and lysis times were shorter than in healthy individuals. CIT patients had low plasminogen activator inhibitor-1 and thrombin-activatable fibrinolysis inhibitor levels, and 40% showed hyperfibrinolytic profiles. Platelet transfusions resulted in less hyperfibrinolytic profiles in many, but not all CIT patients. Patients without hyperfibrinolytic profiles had higher fibrinogen, factor VIII and α2 -antiplasmin levels. CONCLUSIONS t-PA-ROTEM can be used as a fast and reliable assay to detect hyperfibrinolytic profiles in CIT patients. CIT patients have weaker clots, which are more susceptible to clot lysis, than healthy individuals. Besides platelets, other factors are likely to influence clot susceptibility to fibrinolysis in CIT patients. The impact of a hyperfibrinolytic t-PA-ROTEM profile on bleeding remains to be investigated.
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Affiliation(s)
- Floor C J I Heubel-Moenen
- Department of Hematology, Internal Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Yvonne M C Henskens
- Central Diagnostic Laboratory, Unit for Hemostasis and Transfusion, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Paul W M Verhezen
- Central Diagnostic Laboratory, Unit for Hemostasis and Transfusion, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Rick J H Wetzels
- Central Diagnostic Laboratory, Unit for Hemostasis and Transfusion, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Harry C Schouten
- Department of Hematology, Internal Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Erik A M Beckers
- Department of Hematology, Internal Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
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Raveh Y, Souki F, Livingstone J, Beduschi T, Vianna R, Rodriguez Y, Nicolau-Raducu R. Fibrinolytic Shutdown Is Associated With Intraoperative Thrombosis and Hemorrhage During Visceral Transplant. Semin Cardiothorac Vasc Anesth 2019; 23:300-308. [DOI: 10.1177/1089253219848441] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Objective. End-stage liver disease is characterized by a precarious imbalance of hemostasis. Detrimental consequences of hypofibrinolysis, also known as fibrinolytic shutdown, have been recently demonstrated, and its significance in visceral (ie, an allograft that contains the intestine) transplant remains unknown. Design and Setting. To fill this gap, following institutional review board approval, this retrospective study included 49 adult recipients of visceral allografts (14 “visceral allograft without the liver” and 35 “multivisceral” with the liver) transplanted between 2010 and 2018 in a single university hospital, and for whom pre-incisional thromboelastography was available. Based on percent clot lysis 30 minutes after maximal amplitude, patients were stratified into 3 fibrinolysis phenotypes: fibrinolytic shutdown, physiologic fibrinolysis, and hyperfibrinolysis. Results. Fibrinolytic shutdown occurred in 57% of patients, with higher incidence in recipients of multivisceral transplant (69%) compared with visceral allograft without liver (29%) allografts ( P = .04). Fibrinolytic shutdown was associated with an increase in both intraoperative thrombosis and hemorrhage. Intraoperative thrombosis (18%) occurred only with multivisceral transplant, and accounted for 36% of in-hospital mortality. A clinically meaningful reduction in incidence of intraoperative thrombosis was noted in recipients who received intravenous heparin thromboprophylaxis. Logistic regression identified pretransplant platelet count as a risk factor for fibrinolytic shutdown (odds ratio = 0.992, 95% confidence interval = [0.984-0.998]; χ2= 7.8, P = .005). Conclusions. This study highlights fibrinolytic shutdown as a dominant and clinically important feature of the hemostatic imbalance in recipients undergoing visceral transplantation.
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Affiliation(s)
- Yehuda Raveh
- University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - Fouad Souki
- University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | | | - Thiago Beduschi
- University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - Rodrigo Vianna
- University of Miami/Jackson Memorial Hospital, Miami, FL, USA
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Burlage LC, Bos S, Adelmeijer J, Sakai T, Porte RJ, Lisman T. Plasma From Patients Undergoing Liver Transplantation Is Resistant to Anticoagulant Activity of Soluble Thrombomodulin. Liver Transpl 2019; 25:252-259. [PMID: 30067306 PMCID: PMC6590179 DOI: 10.1002/lt.25318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 07/23/2018] [Indexed: 01/13/2023]
Abstract
Recombinant human soluble thrombomodulin (ART-123) is an anticoagulant and anti-inflammatory agent clinically used for treatment of disseminated intravascular coagulation. Preclinical studies have shown that ART-123 reduces hepatic ischemia/reperfusion. Although ART-123 may therefore have clinical benefit in orthotopic liver transplantation, the substantial alterations in the hemostatic system may complicate its use in this setting. Here, we studied the in vitro effect of ART-123 on coagulation of patients with end-stage liver disease undergoing liver transplantation. Ten patients with end-stage liver disease undergoing liver transplantation were included in this study. Plasma samples of 10 healthy individuals were included to establish reference values. Different concentrations of ART-123 were added to plasma samples, and peak thrombin generation and clot lysis times (CLTs) were determined. In patient samples, plasma was profoundly resistant to the anticoagulant action of ART-123, as reflected by significantly higher median inhibitory concentration (IC50 ) values of peak thrombin generation compared with controls. This might be partially explained by low levels of protein C, protein S, and elevated levels of factor VIII during transplantation. Intraoperative levels of thrombin activatable fibrinolysis inhibitor were significantly lower when compared with controls. However, ART-123-dependent prolongation of CLTs was not significantly different from healthy controls. In conclusion, this study suggests that ART-123 is unlikely to provoke bleeding in patients undergoing liver transplantation because proposed clinical dosages have a virtually absent anticoagulant effect in these patients. Clinical studies are required to confirm the safety of ART-123 and efficacy on alleviating ischemia/reperfusion injury during liver transplantation.
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Affiliation(s)
- Laura C. Burlage
- Section of HPB Surgery and Liver Transplantation,Surgical Research Laboratory, Department of SurgeryUniversity Medical Center Groningen, University of GroningenGroningenthe Netherlands
| | - Sarah Bos
- Surgical Research Laboratory, Department of SurgeryUniversity Medical Center Groningen, University of GroningenGroningenthe Netherlands
| | - Jelle Adelmeijer
- Surgical Research Laboratory, Department of SurgeryUniversity Medical Center Groningen, University of GroningenGroningenthe Netherlands
| | - Takumi Sakai
- Development Planning, Clinical Department CenterAsahi Kasei Pharma CorporationTokyoJapan
| | | | - Ton Lisman
- Section of HPB Surgery and Liver Transplantation,Surgical Research Laboratory, Department of SurgeryUniversity Medical Center Groningen, University of GroningenGroningenthe Netherlands
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Sokol J, Timp JF, le Cessie S, van Hylckama-Vlieg A, Rosendaal FR, Kubisz P, Cannegieter SC, Lijfering WM. Mild antithrombin deficiency and risk of recurrent venous thromboembolism: results from the MEGA follow-up study. J Thromb Haemost 2018; 16:680-688. [PMID: 29377625 DOI: 10.1111/jth.13960] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Indexed: 12/21/2022]
Abstract
Essentials Mild antithrombin deficiency may increase the risk of recurrent venous thromboembolism (VTE). In a cohort study, we stratified patients with VTE to various cut-off antithrombin levels. A 1.6-3.7-fold increased risk of recurrent VTE was observed in the lowest antithrombin categories. Mild antithrombin deficiency (activity < 5th percentile of normal) increases recurrent VTE risk. SUMMARY Background Mild antithrombin deficiency (previously defined as antithrombin activity below 70% or 80%) has been associated with a 2.4-3.5-fold increased risk of recurrent venous thromboembolism (VTE). This finding may have implications for duration of antithrombotic therapy in VTE patients with mild antithrombin deficiency. Objectives To externally validate whether mild antithrombin deficiency is a risk factor for recurrent VTE. Methods In a population-based cohort study, patients with a first VTE (n = 2357) were stratified according to percentile cut-off antithrombin levels (< 5th [< 87%], 5-10th [87-92%], > 10th percentile [> 92%]) and functional antithrombin levels (< 70%, 70-80%, > 80%). Results During a median follow-up of 7.4 years, 361 recurrent events occurred (incidence rate, 2.5/100 patient-years). We observed an increased risk of recurrent VTE in the lowest antithrombin activity category (< 5th percentile; < 87%) as compared with antithrombin activity that was > 10th percentile (> 92%), with an adjusted hazard ratio (HR) of 1.5 (95%CI, 1.0-2.3). When analyses were stratified to antithrombin cut-off criteria of< 70% vs. patients with antithrombin activity > 80%, the adjusted HR for venous recurrence was 3.7 (95% CI, 1.4-9.9). Mild antithrombin deficiency was able to predict recurrent VTE over at least 8 years of follow-up and the association remained present when the population was stratified to the presence or absence of thrombosis risk factors. Restriction analyses, where patients who used anticoagulation at time of blood draw and those who reported drinking ≥ 5 glasses alcohol daily were excluded, did not materially affect these outcomes. Conclusion This study confirms that mild antithrombin deficiency is a risk factor for recurrent VTE.
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Affiliation(s)
- J Sokol
- Department of Hematology and Transfusiology, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - J F Timp
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - S le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - A van Hylckama-Vlieg
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - F R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden, the Netherlands
| | - P Kubisz
- Department of Hematology and Transfusiology, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - S C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - W M Lijfering
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Centre, Leiden, The Netherlands
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A new assay for global fibrinolysis capacity (GFC): Investigating a critical system regulating hemostasis and thrombosis and other extravascular functions. Transfus Apher Sci 2018. [PMID: 29525568 DOI: 10.1016/j.transci.2018.02.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
For many years, the importance of fibrinolysis has been recognized, first for its intravascular antithrombotic action, and more recently for its many extravascular activities, associated with matrix degradation and tissue remodeling. In the blood circulation system, fibrinolysis prevents thrombosis, and is associated with various biological and clinical situations: risk factors for cardio-vascular diseases in high risk clinical situations (type II diabetes, hypertension, triglycerides, high BMI, elevated glucose, etc.), probably resulting from a significant reduction of the fibrinolysis potential, and elevation of PAI-1. Noteworthy, t-PA is mainly present as an inactive complex with PAI-1, and its concentration in plasma tends to follow that of PAI-1, but in a lesser extent. Hypofibrinolysis can favor the occurrence of thrombotic events, and possibly other biological dysfunctions. Fibrinolysis activity is however difficult to evaluate as it has a delayed activity after clot formation, is initiated and regulated after fibrin generation, and conversely to clotting, its action is delayed (long lag phase) and slow, before being dramatically amplified leading to rapid clot dissolution. We have designed a new assay for evaluating the global fibrinolytic capacity (GFC) in the body. Reagents are used in association with a specific instrument, which can be connected to any computer, and dedicated software is used for analyzing clot lysis kinetics. The assay is performed in a micro-cuvette, introduced into one of the instrument wells at 37 °C, and light transmittance is continuously measured. Assayed plasma is first supplemented with a limited and constant amount of t-PA with silica and is then clotted with thrombin and calcium. Clot dissolution (measurement of turbidity change) is recorded over time using the dedicated instrument (Lysis Timer), and clot lysis kinetics are analyzed with the associated software: primary and secondary derivatives of the light transmission curve give information on kinetics and completion of clot dissolution. Total assay time is about 1 h (but in the presence of hypofibrinolysis it can be prolonged). The concentration of t-PA used for the assay has been adjusted (100 ng/ml) to obtain an optimal sensitivity to hypofibrinolysis within a short time interval, and clot dissolution occurs within about 45 min for normal individuals, with a broad range from 30 min to 60 min, with some samples presenting a clot dissolution time >60 min (hypofibrinolysis). This new assay is performed with the tested plasma intrinsic factors, especially its own fibrinogen, and only exogeneous t-PA is added. GFC is highly sensitive to PAI-1 activity, but other factors regulating fibrinolysis contribute to the clot dissolution kinetics. Freshly prepared or frozen and thawed citrated plasma can be used. The usefulness of this assay for clinical applications is under investigation. Although fibrinolysis is mainly initiated in the body upon stimulation or blood clotting, and rapidly diluted and inhibited in the circulation, evaluation of its "residual" activity in plasma is expected to reflect its global body potential.
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Influence of decreased fibrinolytic activity and plasminogen activator inhibitor-1 4G/5G polymorphism on the risk of venous thrombosis. Blood Coagul Fibrinolysis 2018; 29:19-24. [DOI: 10.1097/mbc.0000000000000656] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Jeffery U, Brooks MB, LeVine DN. Development of a fibrinolysis assay for canine plasma. Vet J 2017; 229:19-25. [PMID: 29183569 DOI: 10.1016/j.tvjl.2017.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 07/11/2017] [Accepted: 10/25/2017] [Indexed: 11/28/2022]
Abstract
Unbalanced coagulation and fibrinolysis leads to hemorrhage or thrombosis. Thromboelastography has been used to characterize hypo- and hyper-fibrinolysis in dogs, however the technique requires specialized instrumentation and proprietary reagents that limit its availability. The aim of this study was to develop a simple microplate method for assessment of fibrinolysis in canine plasma. Plasma from healthy dogs was mixed in a microwell plate with tissue factor, calcium, phospholipid and tissue plasminogen activator. Light absorbance was measured at regular intervals until return to baseline. Peak optical density (milli-absorption units, mAU), formation velocity (mAU/s), lysis velocity (mAU/s) and area under the curve (mAU.s) were calculated. The influence of potential interferents, variation in fibrinogen and ex vivo addition of heparin and aminocaproic acid on assay performance was determined. Inter-day coefficients of variation were ≤15% for all variables. Bilirubin≤1.88mg/dL and hemoglobin≤0.09mg/dL did not interfere with assay variables. Aminocaproic acid (40μg/mL) and heparin (0.125U/mL) caused almost complete inhibition of fibrinolysis and coagulation, respectively. All variables except lysis velocity (R2=0.08) were associated with fibrinogen concentration (R2>0.8). This assay showed acceptable performance characteristics for measurement of fibrinolysis in normal canine plasma. The assay utilizes small volume citrate plasma samples and readily available instrumentation and reagents, is not influenced by mild to moderate hemolysis or icterus and detects the presence of fibrinolysis inhibitors.
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Affiliation(s)
- U Jeffery
- Veterinary Microbiology and Preventative Medicine, College of Veterinary Medicine, Iowa State University, Ames, IA 50011, USA.
| | - M B Brooks
- Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA
| | - D N LeVine
- Veterinary Clinical Sciences, College of Veterinary Medicine, Iowa State University, Ames, IA 50011, USA
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Undas A. Fibrin clot properties and their modulation in thrombotic disorders. Thromb Haemost 2017; 112:32-42. [DOI: 10.1160/th14-01-0032] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 02/19/2014] [Indexed: 11/05/2022]
Abstract
SummaryAccumulating evidence indicates that accelerated formation of fibrin clots composed of compact, highly-branched networks with thin fibres which are relatively resistant to plasmin-mediated lysis can be commonly observed in patients with venous or arterial thrombosis. This review discusses characteristics of fibrin clot structure and function in patients with various thromboembolic manifestations, in particular myocardial infarction, ischaemic stroke and venous thromboembolism, based on the publications till December 2013. Moreover, factors will be presented that in vivo unfavourably determine altered fibrin clot properties in thrombotic disorders and modalities that can improve clot phenotype.
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Fisher C, Patel VC, Stoy SH, Singanayagam A, Adelmeijer J, Wendon J, Shawcross DL, Lisman T, Bernal W. Balanced haemostasis with both hypo- and hyper-coagulable features in critically ill patients with acute-on-chronic-liver failure. J Crit Care 2017; 43:54-60. [PMID: 28843665 DOI: 10.1016/j.jcrc.2017.07.053] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 07/13/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Cirrhotic patients have complex haemostatic abnormalities. Current evidence suggests stable cirrhotic (SC) patients have a "re-balanced" haemostatic state. However, limited data exists in acute decompensated (AD) or acute on chronic liver failure (ACLF) patients. METHODS We utilised thrombin generation analysis, fibrinolysis assessment, and evaluation of haemostatic parameters to assess haemostasis in liver disease of progressive severity. RESULTS The study cohorts were comprised of: SC, n=8; AD n=44; ACLF, n=17; and Healthy Control (HC), n=35. There was a progressive increase across the cohorts in INR (p=0.0001), Factor VIII (p=0.0001) and VWF levels (p=0.0001) and a correspondingly decrease in anti-thrombin (p=0.0001), ADAMTS-13 (p=0.01) and fibrinogen levels (p=0.0001). In the presence of thrombomodulin, thrombin generation was equivalent or significantly higher in all the cohorts compared to HC (p=0.0001). Compared to AD, ACLF had a lower ETP (p=0.002) and thrombin peak (p=0.0001). There was no significant difference across the cohorts in clot lysis time (p=0.07), although compared to HC, AD had a significantly shorter lysis time (p=0.001). CONCLUSIONS Our cohorts, despite significant differences in haemostatic parameters, displayed intact thrombin generation but progressive hypo-functional clot stability and potentially but not universal hyper-functional haemostasis.
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Affiliation(s)
- Caleb Fisher
- Liver Intensive Care Unit, Institute of Liver Studies, King College Hospital, London, United Kingdom.
| | - Vishal C Patel
- Liver Intensive Care Unit, Institute of Liver Studies, King College Hospital, London, United Kingdom
| | | | | | - Jelle Adelmeijer
- Surgical Research Laboratory, University Medical Center Groningen, Groningen, Netherlands
| | - Julia Wendon
- Liver Intensive Care Unit, Institute of Liver Studies, King College Hospital, London, United Kingdom
| | - Debbie L Shawcross
- Institute of Liver Studies, Kings College Hospital, London, United Kingdom
| | - Ton Lisman
- Surgical Research Laboratory, University Medical Center Groningen, Groningen, Netherlands
| | - William Bernal
- Liver Intensive Care Unit, Institute of Liver Studies, King College Hospital, London, United Kingdom.
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Affiliation(s)
- Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Undas A. Prothrombotic Fibrin Clot Phenotype in Patients with Deep Vein Thrombosis and Pulmonary Embolism: A New Risk Factor for Recurrence. BIOMED RESEARCH INTERNATIONAL 2017; 2017:8196256. [PMID: 28740853 PMCID: PMC5504927 DOI: 10.1155/2017/8196256] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/27/2017] [Accepted: 05/04/2017] [Indexed: 11/23/2022]
Abstract
Prothrombotic fibrin clot phenotype, involving faster formation of dense meshwork composed of thinner and highly branched fibers that are relatively resistant to plasmin-induced lysis, has been reported in patients with not only myocardial infarction or stroke, but also venous thromboembolism (VTE), encompassing deep vein thrombosis (DVT), and/or pulmonary embolism (PE). Prothrombotic fibrin clot phenotype, in particular prolonged clot lysis time, is considered a novel risk factor for VTE as well as venous thrombosis at unusual location, for example, cerebral sinus venous thrombosis, retinal vein obstruction, and Budd-Chiari syndrome. Growing evidence from observational studies indicates that abnormal fibrin clot properties can predict recurrent DVT and PE and they are involved in serious complications of VTE, for example, thromboembolic pulmonary hypertension and postthrombotic syndrome. The purpose of this article is to review our current understanding of the role of fibrin clot structure and function in venous thrombosis with emphasis on clinical issues ranging from prognosis to therapy.
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Affiliation(s)
- Anetta Undas
- Institute of Cardiology, Jagiellonian University School of Medicine and The John Paul II Hospital, Krakow, Poland
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Changes to fibrinolysis in patients with systemic lupus erythematosus are associated with endothelial cell damage and inflammation, but not antiphospholipid antibodies. Blood Coagul Fibrinolysis 2017; 27:870-875. [PMID: 27167859 DOI: 10.1097/mbc.0000000000000504] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
We investigated whether changes to fibrinolysis were associated with other manifestations of systemic lupus erythematosus (SLE), including antiphospholipid (APL) antibody status, endothelial damage, and inflammation. Ninety-four patients (36 SLE patients, 58 healthy controls) were recruited from Tasmania, Australia. Circulating levels of plasminogen, α2-antiplasmin, tissue-type plasminogen activator, plasminogen activator inhibitor-1, and thrombin-activatable fibrinolysis inhibitor (TAFI) were measured, as well as APL antibodies (including lupus anticoagulant, anticardiolipin, and antibeta-2 glycoprotein-1 antibodies), soluble E-selectin, and interleukin-6. Whereas there was a significant decrease in plasminogen (patient vs. control; median) (210 vs. 444 ng/ml; P < 0.0001) and increase in α2-antiplasmin (0.53 vs. 0.09 μg/ml; P = 0.0007), there was increased t-PA (0.65 vs. 0.40 ng/ml; P = 0.0001) and decreased TAFI (8.8 vs. 10.0 ng/ml; P = 0.002) in SLE patients compared to healthy controls. Plasminogen was significantly associated with α2-antiplasmin (rho = -0.563, P < 0.001); TAFI (rho = 0.410, P = 0.011); soluble E-selectin (rho = 0.531, P = 0.001); and interleukin-6 (rho = 0.489, P = 0.002) in SLE patients; however, APL antibody status was not associated with any of the markers measured. This study has demonstrated that fibrinolysis is significantly altered in patients with SLE compared to controls, and associated with endothelial cell damage and inflammation, but not APL antibody status.
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McCully BH, Connelly CR, Fair KA, Holcomb JB, Fox EE, Wade CE, Bulger EM, Schreiber MA. Onset of Coagulation Function Recovery Is Delayed in Severely Injured Trauma Patients with Venous Thromboembolism. J Am Coll Surg 2017; 225:42-51. [PMID: 28315812 DOI: 10.1016/j.jamcollsurg.2017.03.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 03/06/2017] [Accepted: 03/06/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Altered coagulation function after trauma can contribute to development of venous thromboembolism (VTE). Severe trauma impairs coagulation function, but the trajectory for recovery is not known. We hypothesized that enhanced, early recovery of coagulation function increases VTE risk in severely injured trauma patients. STUDY DESIGN Secondary analysis was performed on data from the Pragmatic Randomized Optimal Platelet and Plasma Ratio (PROPPR) trial, excluding patients who died within 24 hours or were on pre-injury anticoagulants. Patient characteristics, adverse outcomes, and parameters of platelet function and coagulation (thromboelastography) were compared from admission to 72 hours between VTE (n = 83) and non-VTE (n = 475) patients. A p value < 0.05 indicates significance. RESULTS Despite similar patient demographics, VTE patients exhibited hypercoagulable thromboelastography parameters and enhanced platelet function at admission (p < 0.05). Both groups exhibited hypocoagulable thromboelastography parameters, platelet dysfunction, and suppressed clot lysis (low clot lysis at 30 minutes) 2 hours after admission (p < 0.05). The VTE patients exhibited delayed coagulation recovery (a significant change compared with 2 hours) of K-value (48 vs 24 hours), α-angle (no recovery), maximum amplitude (24 vs 12 hours), and clot lysis at 30 minutes (48 vs 12 hours). Platelet function recovery mediated by arachidonic acid (72 vs 4 hours), ADP (72 vs 12 hours), and collagen (48 vs 12 hours) was delayed in VTE patients. The VTE patients had lower mortality (4% vs 13%; p < 0.05), but fewer hospital-free days (0 days [interquartile range 0 to 8 days] vs 10 days [interquartile range 0 to 20 days]; p < 0.05) and higher complication rates (p < 0.05). CONCLUSIONS Recovery from platelet dysfunction and coagulopathy after severe trauma were delayed in VTE patients. Suppressed clot lysis and compensatory mechanisms associated with altered coagulation that can potentiate VTE formation require additional investigation.
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Affiliation(s)
- Belinda H McCully
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR.
| | - Christopher R Connelly
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR
| | - Kelly A Fair
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR
| | - John B Holcomb
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center, Houston, TX
| | - Erin E Fox
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center, Houston, TX
| | - Charles E Wade
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center, Houston, TX
| | - Eileen M Bulger
- Division of Trauma and Critical Care, Department of Surgery, University of Washington, Seattle, WA
| | - Martin A Schreiber
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR
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Potze W, Siddiqui MS, Boyett SL, Adelmeijer J, Daita K, Sanyal AJ, Lisman T. Preserved hemostatic status in patients with non-alcoholic fatty liver disease. J Hepatol 2016; 65:980-987. [PMID: 27302378 DOI: 10.1016/j.jhep.2016.06.001] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 04/29/2016] [Accepted: 06/03/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND & AIMS Non-alcoholic fatty liver disease (NAFLD) is associated with an increased risk of thrombosis. However, it remains unclear if hypercoagulability contributes to this risk. We, therefore, determined an in-depth hemostatic profile in a cohort of well-defined patients with NAFLD. METHODS We drew blood samples from 68 patients with biopsy-proven NAFLD (simple steatosis n=24, NASH n=22, and NASH cirrhosis n=22), 30 lean controls, 30 overweight controls (body mass index (BMI) >25kg/m2), and 15 patients with alcoholic (ASH) cirrhosis, and performed in-depth hemostatic profiling. RESULTS Basal and agonist-induced platelet activation, plasma levels of markers of platelet activation, and plasma levels of the platelet adhesion regulators von Willebrand factor and ADAMTS13 were comparable between patients with non-cirrhotic NAFLD and controls. Agonist-induced platelet activation was decreased in patients with cirrhosis. Thrombomodulin-modified thrombin generation was comparable between all patients and controls, although patients with cirrhosis had a reduced anticoagulant response to thrombomodulin. Thromboelastography test results were comparable between controls and non-cirrhotic NAFLD patients, but revealed moderate hypocoagulability in cirrhosis. Plasma fibrinolytic potential was decreased in overweight controls and non-cirrhotic NAFLD, but accelerated fibrinolysis was observed in ASH cirrhosis. Clot permeability was decreased in overweight controls and patients with NAFLD. CONCLUSIONS The overall hemostatic profile is comparable between patients with non-cirrhotic NAFLD and controls. Additionally, pro-thrombotic features (hypofibrinolysis and a pro-thrombotic structure of fibrin clot) in patients with NAFLD are likely driven by obesity. Our study suggests a limited role for hyperactive hemostasis in the increased thrombotic risk in NAFLD. LAY SUMMARY The combined results of this study show that the overall hemostatic status is comparable between healthy individuals and patients with a fatty liver disease.
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Affiliation(s)
- Wilma Potze
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Mohammad S Siddiqui
- Div. of Gastroenterology, Hepatology and Nutrition, Dept. of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA 23298, United States
| | - Sherry L Boyett
- Div. of Gastroenterology, Hepatology and Nutrition, Dept. of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA 23298, United States
| | - Jelle Adelmeijer
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Kalyani Daita
- Div. of Gastroenterology, Hepatology and Nutrition, Dept. of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA 23298, United States
| | - Arun J Sanyal
- Div. of Gastroenterology, Hepatology and Nutrition, Dept. of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA 23298, United States
| | - Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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Kleiss SF, Adelmeijer J, Meijers JC, Porte RJ, Lisman T. A sustained decrease in plasma fibrinolytic potential following partial liver resection or pancreas resection. Thromb Res 2016; 140:36-40. [DOI: 10.1016/j.thromres.2016.02.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 02/04/2016] [Accepted: 02/11/2016] [Indexed: 11/29/2022]
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Stubblefield WB, Alves NJ, Rondina MT, Kline JA. Variable Resistance to Plasminogen Activator Initiated Fibrinolysis for Intermediate-Risk Pulmonary Embolism. PLoS One 2016; 11:e0148747. [PMID: 26866684 PMCID: PMC4751085 DOI: 10.1371/journal.pone.0148747] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 01/22/2016] [Indexed: 12/23/2022] Open
Abstract
Background We examine the clinical significance and biomarkers of tissue plasminogen activator (tPA)-catalyzed clot lysis time (CLT) in patients with intermediate-risk pulmonary embolism (PE). Methods Platelet-poor, citrated plasma was obtained from patients with PE. Healthy age- and sex-matched patients served as disease-negative controls. Fibrinogen, α2-antiplasmin, plasminogen, thrombin activatable fibrinolysis inhibitor (TAFI), plasminogen activator Inhibitor 1 (PAI-1), thrombin time and D-dimer were quantified. Clotting was induced using CaCl2, tissue factor, and phospholipid. Lysis was induced using 60 ng/mL tPA. Time to 50% clot lysis (CLT) was assessed by both thromboelastography (TEG) and turbidimetry (A405). Results Compared with disease-negative controls, patients with PE exhibited significantly longer mean CLT on TEG (+2,580 seconds, 95% CI 1,380 to 3,720 sec). Patients with PE and a short CLT who were treated with tenecteplase had increased risk of bleeding, whereas those with long CLT had significantly worse exercise tolerance and psychometric testing for quality of life at 3 months. A multivariate stepwise removal regression model selected PAI-1 and TAFI as predictive biomarkers of CLT. Conclusion The CLT from TEG predicted increased risk of bleeding and clinical failure with tenecteplase treatment for intermediate-risk PE. Plasmatic PAI-1 and TAFI were independent predictors of CLT.
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Affiliation(s)
| | - Nathan J. Alves
- Indiana University School of Medicine, Indianapolis, United States of America
| | - Matthew T. Rondina
- University of Utah School of Medicine, Salt Lake City, United States of America
| | - Jeffrey A. Kline
- Department of Emergency Medicine, and Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, IN, United States of America
- * E-mail:
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Karasu A, Baglin TP, Luddington R, Baglin CA, van Hylckama Vlieg A. Prolonged clot lysis time increases the risk of a first but not recurrent venous thrombosis. Br J Haematol 2016; 172:947-53. [PMID: 26773756 DOI: 10.1111/bjh.13911] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 11/09/2015] [Indexed: 11/29/2022]
Abstract
The role of the fibrinolytic system in the development of venous thrombosis (VT) is unclear. We studied the risk of first and recurrent VT associated with reduced fibrinolysis, as measured by clot lysis time (CLT). We also studied the relationship between CLT and thrombin generation to determine if any relationship between CLT and VT was affected by thrombin generation. Analyses were performed in the Thrombophilia Hypercoagulability Environmental risk for Venous Thromboembolism Study, a two-centre population-based case-control study, including 579 patients and 338 controls, with patients followed from the event to determine incidence of recurrent VT. Hypofibrinolysis was associated with a 1·8-fold increased risk of a first VT [95% confidence interval (CI) 1·2-2·7]. Adjustment for sex, age, study location and Endogenous Thrombin Potential (ETP) did not change the result. The risk of VT was 2·9-fold increased when the 90th percentiles of prolonged CLT and high ETP were combined, with the highest risk for unprovoked first events (Odds Ratio = 4·2, 95% CI 1·3-13·5). In the follow-up study the Hazard Ratio for a recurrent VT associated with hypofibrinolysis was 1·5 (95% CI 0·9-2·6). A weak dose response effect was observed in relation to prolongation of CLT and recurrent VT. Although hypofibrinolysis constitutes a risk factor for a first VT, an association with recurrence is, at best, weak.
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Affiliation(s)
- Alev Karasu
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Trevor P Baglin
- Department of Haematology, Addenbrookes hospital, Cambridge, UK
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Timp JF, Lijfering WM, Flinterman LE, van Hylckama Vlieg A, le Cessie S, Rosendaal FR, Cannegieter SC. Predictive value of factor VIII levels for recurrent venous thrombosis: results from the MEGA follow-up study. J Thromb Haemost 2015; 13:1823-32. [PMID: 26270389 DOI: 10.1111/jth.13113] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 08/03/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Prediction of recurrent venous thrombosis remains a challenge in the clinic. OBJECTIVE To investigate the predictive value of coagulation factor VIII (FVIII) levels for recurrent venous thrombosis. PATIENTS/METHODS Patients, aged 18-70 years with a first venous thrombosis, were followed from discontinuation of anticoagulant treatment (1999-2010 MEGA follow-up study). The levels of FVIII activity, FVIII antigen and von Willebrand factor (VWF) antigen were measured at least 3 months after cessation of anticoagulant treatment. RESULTS Of 2242 patients followed for a median of 6.9 years, 343 developed recurrent thrombosis (incidence rate 2.7/100 patient-years; 95% confidence interval [CI] 2.5-3.1). Recurrence rates steadily increased with higher FVIII activity levels, from 1.4 (95% CI 1.0-1.9), 2.3 (95% CI 1.8-2.9), 3.0 (95% CI 2.4-3.7), 3.2 (95% CI 2.5-4.1), 3.9 (95% CI 2.8-5.3) to 5.1 (95% CI 3.8-6.8) per 100 patient-years, for levels ranging from < 100 IU dL(-1) to > 200 IU dL(-1) . Patients in the highest category of FVIII (> 200 IU dL(-1) ) had a three-fold higher recurrence rate than patients in the lowest category (≤ 100 IU dL(-1) ) (hazard ratio 3.4; 95% CI 2.2-5.3). Results were similar for FVIII antigen and VWF antigen levels, in several sensitivity analyses, and FVIII predicted recurrence rates over a long time period. Within subgroups of patients currently assumed to have low recurrence risks, a high level of FVIII was still predictive for recurrences. Adding FVIII to an existing prediction model (DASH score) improved its predictive value, and, after replacement of D-dimer with FVIII, the model performed equally well, if not better. CONCLUSIONS FVIII predicted recurrence in a dose-response fashion, overall and in several subgroups, and is a strong candidate component of recurrence prediction tools.
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Affiliation(s)
- J F Timp
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - W M Lijfering
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - L E Flinterman
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - A van Hylckama Vlieg
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - S le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Medical Statistics, Leiden University Medical Center, Leiden, the Netherlands
| | - F R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - S C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
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