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Yan J, Liao L, Deng D, Zhou W, Cheng P, Xiang L, Luo M, Lin F. Guideline for diagnosis and management of congenital dysfibrinogenemia. Clin Chim Acta 2024; 561:119680. [PMID: 38642629 DOI: 10.1016/j.cca.2024.119680] [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: 10/22/2023] [Revised: 04/17/2024] [Accepted: 04/17/2024] [Indexed: 04/22/2024]
Abstract
INTRODUCTION Congenital dysfibrinogenemia (CD) is characterized by dysfunction induced by an abnormal fibrinogen molecule structure that results in blood coagulation dysfunction. The clinical manifestations of CD patients are asymptomatic, bleeding and thrombosis. The majority of patient are asymptomatic. However, the single fibrinogen detection method is easy to cause missed diagnosis or misdiagnosis of CD patients. The treatment strategies of CD patients with different clinical manifestations are also different. METHODS Combing the existing experimental diagnosis technology, literature and our research results, a simple and practical CD diagnostic criteria was proposed. And based on the relevant literature and existing treatment guidelines, more comprehensive treatment recommendations are summarized. RESULTS In this new criteria, combination Clauss method and PT derived method was proposed to detect fibrinogen and its ratio was used to diagnose for CD. Diagnosis also needs to be combined the clinical manifestations, family investigation and genetic testing. According to different clinical manifestation (bleeding, thrombosis or asymptomatic), treatment methods and strategies are different. The treatment of CD patients should consider the patient's personal and family history of bleeding or thrombosis. Treatment of thrombosis and pregnancy may be more challenging. The risk of bleeding and thrombosis should be evaluated and balanced at all times during clinical treatment. These detailed treatment recommendations can provide reference for patients with different clinical manifestations of CD. CONCLUSIONS The new CD diagnosis criteria and comprehensive treatment recommendations can effectively improve the diagnosis and treatment of CD.
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Affiliation(s)
- Jie Yan
- Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China; Key Laboratory of Clinical Laboratory Medicine of Guangxi, Department of Education, China
| | - Lin Liao
- Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China; Key Laboratory of Clinical Laboratory Medicine of Guangxi, Department of Education, China; Guangxi Medical Doctor Association-Laboratory Medicine, China
| | - Donghong Deng
- Department of Hematology, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Weijie Zhou
- Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China; Key Laboratory of Clinical Laboratory Medicine of Guangxi, Department of Education, China; Guangxi Medical Doctor Association-Laboratory Medicine, China; Clinical Laboratory, Baise People's Hospital, Baise, China
| | - Peng Cheng
- Department of Hematology, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Liqun Xiang
- Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China; Key Laboratory of Clinical Laboratory Medicine of Guangxi, Department of Education, China
| | - Meiling Luo
- Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China; Key Laboratory of Clinical Laboratory Medicine of Guangxi, Department of Education, China
| | - Faquan Lin
- Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China; Key Laboratory of Clinical Laboratory Medicine of Guangxi, Department of Education, China; Guangxi Medical Doctor Association-Laboratory Medicine, China.
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Rahe-Meyer N, Neumann G, Schmidt DS, Downey LA. Long-Term Safety Analysis of a Fibrinogen Concentrate (RiaSTAP ®/Haemocomplettan ® P). Clin Appl Thromb Hemost 2024; 30:10760296241254106. [PMID: 38803191 PMCID: PMC11135097 DOI: 10.1177/10760296241254106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 04/03/2024] [Accepted: 04/22/2024] [Indexed: 05/29/2024] Open
Abstract
Fibrinogen concentrate treatment is recommended for acute bleeding episodes in adult and pediatric patients with congenital and acquired fibrinogen deficiency. Previous studies have reported a low risk of thromboembolic events (TEEs) with fibrinogen concentrate use; however, the post-treatment TEE risk remains a concern. A retrospective evaluation of RiaSTAP®/Haemocomplettan® P (CSL Behring, Marburg, Germany) post-marketing data was performed (January 1986-June 2022), complemented by a literature review of published studies. Approximately 7.45 million grams of fibrinogen concentrate was administered during the review period. Adverse drug reactions (ADRs) were reported in 337 patients, and 81 (24.0%) of these patients experienced possible TEEs, including 14/81 (17.3%) who experienced fatal outcomes. Risk factors and the administration of other coagulation products existed in most cases, providing alternative explanations. The literature review identified 52 high-ranking studies with fibrinogen concentrate across various clinical areas, including 26 randomized controlled trials. Overall, a higher number of comparative studies showed lower rates of ADRs and/or TEEs in the fibrinogen group versus the comparison group(s) compared with those that reported higher rates or no differences between groups. Post-marketing data and clinical studies demonstrate a low rate of ADRs, including TEEs, with fibrinogen concentrate treatment. These findings suggest a favorable safety profile of fibrinogen concentrate, placing it among the first-line treatments effective for managing intraoperative hemostatic bleeding.
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Affiliation(s)
- Niels Rahe-Meyer
- Department for Anaesthesiology and Intensive Care Medicine, Franziskus Hospital Bielefeld, Bielefeld, Germany
- Department for Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | | | | | - Laura A Downey
- Department of Anaesthesiology, Emory University Medical School, Atlanta, GA, USA
- Department of Paediatric Cardiac Anaesthesiology, Children's Healthcare of Atlanta, Atlanta, GA, USA
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3
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Özay M, Kara M, Keskin Z. Congenital afibrinogenemia in a newborn. SANAMED 2022. [DOI: 10.5937/sanamed0-40292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Introduction: Congenital afibrinogenemia is a rare coagulation disorder characterized by a deficiency in the fibrinogen molecule. Fibrinogen is a hexameric glycoprotein consisting of a polypeptide chain encoded by FGB, FGA, and FGG and is required for normal hemostasis. Changes in FGA, FGB, and FGG may affect fibrinogen at different levels. As a result of these changes, fibrinogen cannot be detected in the blood. Clinical manifestations of such changes range from asymptomatic to life-threatening bleeding or thromboembolic events. Since it is an autosomal recessive disease, the risk is higher in children whose parents are related. Therefore, the disease is more common in regions where consanguineous marriage rates are high. Diagnosis is made by laboratory tests that show the absence of fibrinogen. These patients need to be treated with fibrinogen replacement therapy. Case presentation: This study reports the case of a newborn with congenital afibrinogenemia. The baby born from a first-degree consanguineous marriage was referred to our hospital due to bleeding and ecchymosis, and afibrinogenemia was diagnosed after coagulation tests were performed. Blood samples of the patient and his parents were sent to the Genetic Diseases Diagnosis Center for a genetic diagnosis of afibrinogenemia. A new homozygous mutation of FGB exon 7: c.1220c > t (p.t407 m) (p.thr407 met) was identified in the patient. The patients' parents were heterozygous for the same mutation. Prophylaxis was not recommended for our patient who was asymptomatic in the follow-up. Conclusions: We present the case of a hemorrhagic neonatal patient diagnosed with congenital afibrinogenemia and emphasize that fibrinogen testing should be included in the evaluation of such patients. Furthermore, congenital fibrinogen disorders may be more severe when caused due to unknown specific mutation genes. Therefore, a more center-involved genetic analysis is required to identify undiagnosed fibrinogen and fibrinogen mutations.
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John MJ, Byreddy P, Modak K, Makkar M. Congenital Fibrinogen Deficiency in India and Role of Human Fibrinogen Concentrate. Acta Haematol 2021; 144:595-602. [PMID: 34091452 DOI: 10.1159/000516339] [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: 02/25/2021] [Accepted: 03/25/2021] [Indexed: 11/19/2022]
Abstract
Congenital fibrinogen deficiency is an inherited disorder due to genetic mutations with diverse presentations arising from reduced fibrinogen levels (hypofibrinogenemia), absence of fibrinogen in circulation (afibrinogenemia), abnormal functioning (dysfibrinogenemia) or both reduced levels and abnormal functioning (hypodysfibrinogenemia) of fibrinogen. The decreased fibrinogen concentration in congenital fibrinogen deficiency necessitates fibrinogen replacement therapy with fresh frozen plasma, cryoprecipitate, or human fibrinogen concentrate. However, the use of fresh frozen plasma and cryoprecipitate is limited owing to their longer transfusion time, requirement of high doses, volume overload, risk of viral transmission, and other safety concerns. The availability of human fibrinogen concentrate has made it the preferred replacement alternative due to its reduced risk of viral transmission, smaller infusion volume, and accurate dosing. The hemostatic efficacy and safety of human fibrinogen concentrate in congenital fibrinogen deficiency is well established in the literature. We review the prevalence of congenital fibrinogen deficiency in India and the current role of human fibrinogen concentrate in its management.
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Affiliation(s)
- M Joseph John
- Department of Clinical Haematology, Haemato-Oncology and Bone Marrow (Stem Cell) Transplantation, Christian Medical College, Ludhiana, India
| | - Poojitha Byreddy
- Department of Clinical Haematology, Haemato-Oncology and Bone Marrow (Stem Cell) Transplantation, Christian Medical College, Ludhiana, India
| | - Ketan Modak
- Department of Clinical Haematology, Haemato-Oncology and Bone Marrow (Stem Cell) Transplantation, Christian Medical College, Ludhiana, India
| | - Mridul Makkar
- Department of Clinical Haematology, Haemato-Oncology and Bone Marrow (Stem Cell) Transplantation, Christian Medical College, Ludhiana, India
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Pharmacokinetics, surrogate efficacy and safety evaluations of a new human plasma-derived fibrinogen concentrate (FIB Grifols) in adult patients with congenital afibrinogenemia. Thromb Res 2021; 199:110-118. [PMID: 33486319 DOI: 10.1016/j.thromres.2020.12.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 12/04/2020] [Accepted: 12/29/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND AIMS Congenital afibrinogenemia is a rare coagulation disorder resulting from a deficiency in fibrinogen. This study assessed the pharmacokinetics, surrogate efficacy and safety of FIB Grifols, a new human plasma-derived fibrinogen concentrate, to treat congenital afibrinogenemia. METHODS Eleven adult patients from a multinational, phase 1-2, prospective, open-label, single-arm, uncontrolled clinical study received a single infusion of FIB Grifols, 70 mg/kg bw. Fibrinogen pharmacokinetics (fibrinogen activity: Clauss method; antigen plasma concentrations: ELISA) and efficacy parameters were determined over 14 days after infusion. Efficacy endpoints were the mean change on plasma maximum clot firmness (MCF) on viscoelastic testing and coagulation tests 1-hour post-infusion, and correlation with fibrinogen levels throughout. Safety parameters were also assessed. RESULTS For the Clauss method, (mean [standard deviation]) baseline adjusted Cmax was 1.99 (0.40) g/L, reached 1.76 (1.00) h after infusion, and half-life was 76.94 (20.21) h. Using ELISA, Cmax after FIB Grifols infusion was 2.88 (0.86) mg/mL, with a tmax of 3.06 (2.24) h. Fibrinogen activity and antigen concentrations showed statistically significant correlation of 0.9120 (P < 0.001). Surrogate efficacy was demonstrated by a significant increase of 12.35 (3.85) mm in MCF. Prothrombin time, activated partial thromboplastin time and thrombin time, returned to normal ranges over time, indicating restoration of functionally active fibrinogen. There were no treatment-related adverse events, allergic reactions, serious adverse events, or discontinuations. CONCLUSIONS The pharmacokinetic profile of functionally active FIB Grifols was established, hemostasis was restored, and FIB Grifols was safe and well tolerated in fibrinogen-deficient patients.
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Lasky J, Teitel J, Wang M, Dalton D, Schmidt DS, Brainsky A. Fibrinogen concentrate for bleeding in patients with congenital fibrinogen deficiency: Observational study of efficacy and safety for prophylaxis and treatment. Res Pract Thromb Haemost 2020; 4:1313-1323. [PMID: 33313470 PMCID: PMC7695557 DOI: 10.1002/rth2.12433] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 08/25/2020] [Accepted: 08/27/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Congenital fibrinogen deficiency (CFD) is a rare bleeding disorder characterized by reduced levels (afibrinogenemia, hypofibrinogenemia) or dysfunctional fibrinogen (dysfibrinogenemia), for which fibrinogen supplementation is the mainstay treatment. OBJECTIVES To assess the efficacy and safety of human fibrinogen concentrate (FCH) in patients with CFD. METHODS This was a multicenter, noninterventional, retrospective cohort study with a 12-month prospective follow-up period in the United States and Canada. Individuals with CFD who received FCH for the treatment of bleeding, perioperative hemostasis, or prophylaxis were included. Data were collected retrospectively from medical records and every 3 months during the prospective period. Hemostatic efficacy was rated by the investigators as effective or ineffective using a 4-point efficacy scale. Annualized bleeding rate (ABR) was summarized for patients who received FCH for routine prophylaxis. RESULTS Twenty-two patients were enrolled. FCH treatment was rated effective in treating ≥97.0% of bleeding events, in the retrospective and prospective periods. FCH was effective for perioperative hemostasis in ≥97.5% of minor and major surgeries across both periods. In patients treated with FCH for routine prophylaxis, the median ABRs for the retrospective and prospective period were 1.4 and 1.3, respectively. One adverse event (AE), thrombosis of the right cephalic vein, was reported as related to FCH treatment and resolved with a short course of anticoagulant. No serious AEs related to FCH or deaths were reported. CONCLUSIONS In patients with CFD, FCH is a well-tolerated and effective treatment to achieve hemostasis during bleeding events and surgery and associated with infrequent bleeding events when used prophylactically.
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Affiliation(s)
- Joseph Lasky
- Cure 4 The Kids FoundationRoseman University of Health SciencesLas VegasNVUSA
| | - Jerome Teitel
- St Michael’s Hospital, University of TorontoTorontoONCanada
| | - Michael Wang
- University of Colorado Anschutz Medical CampusAuroraCOUSA
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7
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Zhang Y, Zuo X, Teng Y. Women With Congenital Hypofibrinogenemia/Afibrinogenemia: From Birth to Death. Clin Appl Thromb Hemost 2020; 26:1076029620912819. [PMID: 32233805 PMCID: PMC7288827 DOI: 10.1177/1076029620912819] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Congenital fibrinogen disorders are a group of most frequent rare coagulation disorder, characterized by deficiency and/or defects in the fibrinogen molecule. Quantitative disorders include hypofibrinogenemia and afibrinogenemia. Due to their specific physiological characteristics, female patients tend to have congenital hypofibrinogenemia/afibrinogenemia, such as spontaneous recurrent abortion, menorrhagia, infertility, antepartum and postpartum hemorrhage, and so on. Current studies of congenital hypofibrinogenemia/afibrinogenemia mainly focus on different types of fibrinogen mutations, etiology/pathogenesis, and some rare case reports of the diseases. So far, there is no study available to systematically review the specific features of female patients with congenital bleeding disorders. This review aims to deal with hematological, gynecologic and obstetric issues, and relevant clinical management of congenital hypofibrinogenemia/afibrinogenemia at different life stages of female patients. We believe this review provides valuable reference for clinicians in the field of hematology, obstetrics, as well as gynecology.
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Affiliation(s)
- Yan Zhang
- Nursing Department, Baoji Maternal and Child Health Hospital, Baoji, China
| | | | - Yue Teng
- Nursing Department, Baoji Maternal and Child Health Hospital, Baoji, China.,Department of Obstetrics and Gynecology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, China
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8
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Bellon A, Fuseau E, Roumanie O, Lamazure J, Stevens W, Dahmane A, Barthez-Toullec M, Golly D, Henriet C, Bridey F. Population pharmacokinetics of a triple-secured fibrinogen concentrate administered to afibrinogenaemic patients: Observed age- and body weight-related differences and consequences for dose adjustment in children. Br J Clin Pharmacol 2020; 86:329-337. [PMID: 31658379 PMCID: PMC7015754 DOI: 10.1111/bcp.14147] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 09/09/2019] [Accepted: 09/21/2019] [Indexed: 11/28/2022] Open
Abstract
Aims The pharmacokinetics (PK) of a triple‐secured fibrinogen concentrate (FC) was assessed in patients ≥40 kg by noncompartmental analysis over a period of 14 days with multiple blood samples. Limited PK time point assessments in children lead to consideration of using Bayesian estimation for paediatric data. The objectives were (i) to define the population PK of FC in patients with afibrinogenaemia; (ii) to detect age‐ and body weight‐related differences and consequences for dose adjustment. Methods A population PK model was built using plasma fibrinogen activity data collected in 31 patients aged 1 to 48 years who had participated in a single‐dose PK study with FC 0.06 g kg–1. Results A 1‐compartment model with allometric scaling accounting for body weight was found to best describe the kinetics of FC. Addition of age and sex as covariates did not improve the model. Incremental in vivo recovery assessed at the end of infusion with the predicted maximal concentrations was lower, weight‐adjusted clearance was higher, and fibrinogen elimination half‐life was shorter in patients <40 kg than patients ≥40 kg. Interpatient variability was similar in both groups. Conclusion Dosing in patients ≥40 kg based on the previous empirical finding using noncompartmental analysis where FC 1 g kg–1 raises the plasma fibrinogen activity by 23 g L–1 was confirmed. In patients <40 kg, (covering the age range from birth up to about 12 years old) FC 1 g kg–1 raises the plasma fibrinogen by 19 g L–1. Dosing should be adapted accordingly unless therapy is individualized.
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Affiliation(s)
- Anne Bellon
- Clinical Development, Laboratoire français du Fractionnement et des Biotechnologies (LFB), Les Ulis, France
| | | | | | - Jennifer Lamazure
- Clinical Development, Laboratoire français du Fractionnement et des Biotechnologies (LFB), Les Ulis, France
| | - Wil Stevens
- Clinical Development, Laboratoire français du Fractionnement et des Biotechnologies (LFB), Les Ulis, France
| | - Amel Dahmane
- Clinical Development, Laboratoire français du Fractionnement et des Biotechnologies (LFB), Les Ulis, France
| | - Malika Barthez-Toullec
- Clinical Development, Laboratoire français du Fractionnement et des Biotechnologies (LFB), Les Ulis, France
| | - Dominique Golly
- Clinical Development, Laboratoire français du Fractionnement et des Biotechnologies (LFB), Les Ulis, France
| | - Céline Henriet
- Clinical Development, Laboratoire français du Fractionnement et des Biotechnologies (LFB), Les Ulis, France
| | - Françoise Bridey
- Clinical Development, Laboratoire français du Fractionnement et des Biotechnologies (LFB), Les Ulis, France
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9
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Hu Z, Lavik KI, Liu Y, Vo AH, Richter CE, Di Paola J, Shavit JA. Loss of fibrinogen in zebrafish results in an asymptomatic embryonic hemostatic defect and synthetic lethality with thrombocytopenia. J Thromb Haemost 2019; 17:607-617. [PMID: 30663848 PMCID: PMC6443434 DOI: 10.1111/jth.14391] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Indexed: 12/17/2022]
Abstract
Essentials Loss of fibrinogen in zebrafish has been previously shown to result in adult onset hemorrhage Hemostatic defects were discovered in early fga-/- embryos but well tolerated until adulthood Afibrinogenemia and thrombocytopenia results in synthetic lethality in zebrafish. Testing human FGA variants of uncertain significance in zebrafish identified causative mutations SUMMARY: Background Mutations in the alpha chain of fibrinogen (FGA), such as deficiencies in other fibrinogen subunits, lead to rare inherited autosomal recessive hemostatic disorders. These range from asymptomatic to catastrophic life-threatening bleeds and the molecular basis of inherited fibrinogen deficiencies is only partially understood. Zinc finger nucleases have been used to produce mutations in zebrafish fga, resulting in overt adult-onset hemorrhage and reduced survival. Objectives To determine the age of onset of hemostatic defects in afibrinogenemic zebrafish and model human fibrinogen deficiencies. Methods TALEN genome editing (transcription activator-like effector nucleases) was used to generate a zebrafish fga mutant. Hemostatic defects were assessed through survival, gross anatomical and histological observation and laser-induced endothelial injury. Human FGA variants with unknown pathologies were engineered into the orthologous positions in zebrafish fga. Results Loss of Fga decreased survival and resulted in synthetic lethality when combined with thrombocytopenia. Zebrafish fga mutants exhibit a severe hemostatic defect by 3 days of life, but without visible hemorrhage. Induced thrombus formation through venous endothelial injury was completely absent in mutant embryos and larvae. This hemostatic defect was restored by microinjection of wild-type fga cDNA plasmid or purified human fibrinogen. This system was used to determine whether unknown human variants were pathological by engineering them into fga. Conclusions These studies confirm that loss of fibrinogen in zebrafish results in the absence of hemostasis from the embryonic period through adulthood. When combined with thrombocytopenia, zebrafish exhibit synthetic lethality, demonstrating that thrombocytes are necessary for survival in response to hemorrhage.
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Affiliation(s)
- Zhilian Hu
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Kari I Lavik
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Yang Liu
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Andy H Vo
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | | | - Jorge Di Paola
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jordan A Shavit
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
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Young GA, Carmona R, Cano Garcia V. Thromboelastography and thrombin generation assay in inherited afibrinogenemia. Haemophilia 2018; 24:e410-e416. [DOI: 10.1111/hae.13620] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/13/2018] [Accepted: 09/24/2018] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Viridiana Cano Garcia
- Children’s Hospital Los Angeles; Los Angeles California
- University of Southern California Keck School of Medicine; Los Angeles California
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11
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Franchini M, Marano G, Pupella S, Vaglio S, Masiello F, Veropalumbo E, Piccinini V, Pati I, Catalano L, Liumbruno GM. Rare congenital bleeding disorders. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:331. [PMID: 30306070 DOI: 10.21037/atm.2018.08.34] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The rare congenital bleeding disorders are a heterogeneous group of diseases which include deficiencies of fibrinogen, prothrombin and factors V, V + VIII, VII, X, XI and XIII. They are usually transmitted as autosomal recessive disorders, and the prevalence of the severe forms ranges from one case in 500,000 for factor VII up to one in 2,000,000 for factor XIII in the general population. Patients with rare congenital bleeding disorders may have a broad spectrum of clinical symptoms, ranging from mucocutaneous bleeding to life-threatening haemorrhages, such as those occurring in the central nervous system. The treatment of these disorders is based principally on the replacement of the deficient factor using, when available, specific plasma-derived or recombinant products. The aim of this narrative review is to summarise current knowledge about these rare bleeding conditions.
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Affiliation(s)
- Massimo Franchini
- Italian National Blood Centre, National Institute of Health, Rome, Italy.,Department of Haematology and Transfusion Medicine, Carlo Poma Hospital, Mantua, Italy
| | - Giuseppe Marano
- Italian National Blood Centre, National Institute of Health, Rome, Italy
| | - Simonetta Pupella
- Italian National Blood Centre, National Institute of Health, Rome, Italy
| | - Stefania Vaglio
- Italian National Blood Centre, National Institute of Health, Rome, Italy
| | - Francesca Masiello
- Italian National Blood Centre, National Institute of Health, Rome, Italy
| | - Eva Veropalumbo
- Italian National Blood Centre, National Institute of Health, Rome, Italy
| | - Vanessa Piccinini
- Italian National Blood Centre, National Institute of Health, Rome, Italy
| | - Ilaria Pati
- Italian National Blood Centre, National Institute of Health, Rome, Italy
| | - Liviana Catalano
- Italian National Blood Centre, National Institute of Health, Rome, Italy
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12
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Korte W, Poon MC, Iorio A, Makris M. Thrombosis in Inherited Fibrinogen Disorders. Transfus Med Hemother 2017; 44:70-76. [PMID: 28503122 DOI: 10.1159/000452864] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 10/26/2016] [Indexed: 12/17/2022] Open
Abstract
Although inherited fibrinogen disorders (IFD) are primarily considered to be bleeding disorders, they are associated with a higher thrombotic complication risk than defects in other clotting factors. Managing IFD patients with thrombosis is challenging as anticoagulant treatment may exacerbate the underlying bleeding risk which can be life-threatening. Due to the low prevalence of IFD, there is little information on pathophysiology or optimal treatment of thrombosis in these patients. We searched the literature for cases of thrombosis among IFD patients and identified a total of 128 patient reports. In approximately half of the cases, thromboses were spontaneous, while in the others trauma, surgery, and parturition contributed to the risk. The true mechanism(s) of thrombosis in IFD patients remain to be elucidated. A variety of anticoagulant treatments have been used in the treatment or prevention of thrombosis, sometimes with concurrent fibrinogen replacement therapy. There is no definite evidence that fibrinogen supplementation increases the risk of thrombosis, and it may potentially be effective in the treatment and prevention of both thrombosis and hemorrhage in IFD patients.
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Affiliation(s)
- Wolfgang Korte
- Center for Laboratory Medicine; and Hemostasis and Hemophilia Center St. Gallen, Switzerland
| | - Man-Chiu Poon
- Department of Medicine, Pediatrics and Oncology, University of Calgary, Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Hospital, Calgary, AB, Canada
| | - Alfonso Iorio
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Michael Makris
- Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK.,Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
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13
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Casini A, de Moerloose P. Factor concentrates for rare congenital coagulation disorders: where are we now? Expert Opin Orphan Drugs 2015. [DOI: 10.1517/21678707.2016.1108188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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14
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Casini A, Neerman-Arbez M, Ariëns RA, de Moerloose P. Dysfibrinogenemia: from molecular anomalies to clinical manifestations and management. J Thromb Haemost 2015; 13:909-19. [PMID: 25816717 DOI: 10.1111/jth.12916] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Indexed: 12/14/2022]
Abstract
Congenital dysfibrinogenemia is a qualitative congenital fibrinogen disorder characterized by normal antigen levels of a dysfunctional fibrinogen. The diagnosis is usually based on discrepancies between fibrinogen activity and antigen levels, but could require more specialized techniques for the assessment of fibrinogen function, owing to some limitations in routine assays. Molecular abnormalities, which are frequently heterozygous missense mutations localized in exon 2 of FGA and exon 8 of FGG, lead to defects in one or more phases of fibrinogen to fibrin conversion, fibrin network formation, and other important functions of fibrinogen. The clinical phenotype is highly heterogeneous, from no manifestations to bleeding and/or thrombotic events. Asymptomatic propositi and relatives with the predisposing genotype are at risk of developing adverse outcomes during the natural course of the disease. Correlations between genotype and phenotype have not yet been clearly established, with the exception of some abnormal fibrinogens that severely increase the risk of thrombosis. Functional analysis of polymerization and fibrinolysis, structural studies of the fibrin network and the viscoelastic properties of fibrin clot could help to predict the phenotype of congenital dysfibrinogenemia, but have not yet been evaluated in detail. The management is essentially based on personal and family history; however, even individuals who are still asymptomatic and without a family history should be carefully assessed and monitored. Particular situations, such as pregnancy, delivery, and surgery, require a multidisciplinary approach.
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Affiliation(s)
- A Casini
- Angiology and Hemostasis Division, University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - M Neerman-Arbez
- Department of Genetic Medicine and Development, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - R A Ariëns
- Theme Thrombosis, Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine and Multidisciplinary Cardiovascular Research Centre, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - P de Moerloose
- Angiology and Hemostasis Division, University Hospitals and Faculty of Medicine, Geneva, Switzerland
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Chapin JC, Hajjar KA. Fibrinolysis and the control of blood coagulation. Blood Rev 2015; 29:17-24. [PMID: 25294122 PMCID: PMC4314363 DOI: 10.1016/j.blre.2014.09.003] [Citation(s) in RCA: 446] [Impact Index Per Article: 49.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 09/02/2014] [Indexed: 12/11/2022]
Abstract
Fibrin plays an essential role in hemostasis as both the primary product of the coagulation cascade and the ultimate substrate for fibrinolysis. Fibrinolysis efficiency is greatly influenced by clot structure, fibrinogen isoforms and polymorphisms, the rate of thrombin generation, the reactivity of thrombus-associated cells such as platelets, and the overall biochemical environment. Regulation of the fibrinolytic system, like that of the coagulation cascade, is accomplished by a wide array of cofactors, receptors, and inhibitors. Fibrinolytic activity can be generated either on the surface of a fibrin-containing thrombus, or on cells that express profibrinolytic receptors. In a widening spectrum of clinical disorders, acquired and congenital defects in fibrinolysis contribute to disease morbidity, and new assays of global fibrinolysis now have potential predictive value in multiple clinical settings. Here, we summarize the basic elements of the fibrinolytic system, points of interaction with the coagulation pathway, and some recent clinical advances.
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Affiliation(s)
- John C Chapin
- Division of Hematology-Oncology, Department of Medicine, Weill Cornell Medical College, 520 East 70th Street, New York, NY 10065, USA.
| | - Katherine A Hajjar
- Division of Hematology-Oncology, Department of Medicine, Weill Cornell Medical College, 520 East 70th Street, New York, NY 10065, USA; Division of Hematology-Oncology, Department of Pediatrics, Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA; Department of Cell and Developmental Biology, Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA.
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16
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Özdemir Ö, Sarı ME, Kurt A, Şen E, Atalay CR. Recurrent massive haemoperitoneum associated with ruptured corpus luteum in women with congenital afibrinogenemia; case report. Turk J Obstet Gynecol 2014; 11:242-245. [PMID: 28913028 PMCID: PMC5558369 DOI: 10.4274/tjod.04935] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 02/21/2014] [Indexed: 12/01/2022] Open
Abstract
Massive hemoperitoneum secondary to ruptured corpus luteum is a rare but serious and life-threatening complication for women with congenital bleeding disorders and may lead to surgical interventions and even oophorectomy. Congenital afibrinogenemia is a rare inherited coagulation disorder. As it can be asymptomatic, its clinical manifestations vary from minimal tendency of bleeding to life-threatening bleedings. Intraabdominal bleeding due to ovulation is very rare in these patients and only a few cases of corpus luteum rupture and hemoperitoneum in afibrinogenemic patients have been described. We report on a 28-year-old woman with congenital afibrinogenemia with recurrent massive intraabdominal bleeding due to ovulation as the presenting clinical sign. The first episode was managed with fresh frozen plasma, cryoprecipitate and blood transfusions; exploratory laparotomy and excision of the ruptured follicle was performed at the second episode; the third episode was managed with fresh frozen plasma, cryoprecipitate and blood transfusions; exploratory laparotomy and right salphingooopherectomy was performed at the fourth episode; fifth episode was managed with fresh frozen plasma, cryoprecipitate and blood transfusions. Conservative management is crucial for patients with congenital bleeding disorders. These case demonstrate that preservation of ovarian function is possible with a conservative approach and recurrent episodes may be prevented by suppression of ovulation.
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Affiliation(s)
- Özhan Özdemir
- Ankara Numune Education and Research Hospital, Clinic of Gynecology and Obstetrics, Ankara, Turkey
| | - Mustafa Erkan Sarı
- Ankara Numune Education and Research Hospital, Clinic of Gynecology and Obstetrics, Ankara, Turkey
| | - Aslıhan Kurt
- Ankara Numune Education and Research Hospital, Clinic of Gynecology and Obstetrics, Ankara, Turkey
| | - Ertuğrul Şen
- Ankara Numune Education and Research Hospital, Clinic of Gynecology and Obstetrics, Ankara, Turkey
| | - Cemal Reşat Atalay
- Ankara Numune Education and Research Hospital, Clinic of Gynecology and Obstetrics, Ankara, Turkey
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17
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Stroka D, Keogh A, Vu D, Fort A, Stoffel MH, Kühni-Boghenbor K, Furer C, Banz V, Demarmels Biasiutti F, Lämmle B, Candinas D, Neerman-Arbez M. In vitro rescue of FGA deletion by lentiviral transduction of an afibrinogenemic patient's hepatocytes. J Thromb Haemost 2014; 12:1874-9. [PMID: 25163824 DOI: 10.1111/jth.12714] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 08/06/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Congenital afibrinogenemia is a rare inherited autosomal recessive disorder in which a mutation in one of three genes coding for the fibrinogen polypeptide chains Aα, Bβ and γ results in the absence of a functional coagulation protein. A patient with congenital afibrinogenemia, resulting from an FGA homozygous gene deletion, underwent an orthotopic liver transplant that resulted in complete restoration of normal hemostasis. The patient's explanted liver provided a unique opportunity to further investigate a potential novel treatment modality. OBJECTIVE To explore a targeted gene therapy approach for patients with congenital afibrinogenemia. METHODS AND RESULTS At the time of transplant, the patient's FGA-deficient hepatocytes were isolated and transduced with lentiviral vectors encoding the human fibrinogen Aα-chain. FGA-transduced hepatocytes produced fully functional fibrinogen in vitro. CONCLUSIONS Orthotopic liver transplantation is a possible rescue treatment for failure of on-demand fibrinogen replacement therapy. In addition, we provide evidence that hepatocytes homozygous for a large FGA deletion can be genetically modified to restore Aα-chain protein expression and secrete a functional fibrinogen hexamer.
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Affiliation(s)
- D Stroka
- Clinic for Visceral Surgery and Medicine, Department of Clinical Research, Bern University Hospital, University of Bern, Bern, Germany
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Liao Z, Tang H, Xie Y, Duan X, Xu S, Liu C, Cheng Y, Chen Y, Tan Y, Wang D, Luo M, Tao Z. Fibrinogen Hangzhou: Congenital dysfibrinogenemia caused by the novel missense mutation in FGG (γ308Asn→Thr). Clin Chim Acta 2014. [DOI: 10.1016/j.cca.2013.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Solomon C, Hagl C, Rahe-Meyer N. Time course of haemostatic effects of fibrinogen concentrate administration in aortic surgery. Br J Anaesth 2013; 110:947-56. [PMID: 23388508 PMCID: PMC3657602 DOI: 10.1093/bja/aes576] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background There is currently a contrast between the demonstrated benefits of fibrinogen concentrate in correcting bleeding and reducing transfusion, and its perceived thrombogenic potential. This analysis evaluates the effects of fibrinogen concentrate on coagulation up to 12 days after administration during aortic surgery. Methods We performed a post hoc analysis of a prospective, randomized, double-blind, controlled trial of fibrinogen concentrate as first-line haemostatic therapy in aortic surgery. After cardiopulmonary bypass (CPB) and protamine administration, subjects with coagulopathic bleeding received fibrinogen concentrate or placebo. The placebo group received allogeneic blood products, including fresh-frozen plasma (FFP; n=32); the fibrinogen concentrate group received fibrinogen concentrate alone (FC; n=14), or fibrinogen concentrate followed by allogeneic blood products (FC+FFP; n=15). Plasma fibrinogen, fibrin-based clotting (ROTEM®-based FIBTEM assay), and peri- and postoperative haematological and coagulation parameters were compared. Results Plasma fibrinogen and FIBTEM maximum clot firmness (MCF) decreased ∼50% during CPB but were corrected by FC or FC+FFP. At last suture, the highest values for plasma fibrinogen (360 mg dl−1) and FIBTEM MCF (22 mm) were within normal ranges—below the acute phase increases observed after surgery. In patients receiving only FFP as a source of fibrinogen, these parameters recovered marginally by last suture (P<0.001 vs FC and FC+FFP). All groups displayed comparable haemostasis at 24 h post-surgery. Fibrinogen concentrate did not cause alterations of other haemostasis parameters. Conclusions Fibrinogen concentrate provided specific, significant, short-lived increases in plasma fibrinogen and fibrin-based clot firmness after aortic surgery.
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Affiliation(s)
- C Solomon
- Department of Anaesthesiology and Intensive Care Medicine, SALK University Hospital, Salzburg, Austria.
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Ueda Y, Nojima M, Yamamoto S. Successful ABO-incompatible kidney transplantation in patient with congenital afibrinogenemia. Transpl Int 2012; 25:e98-e100. [PMID: 22624802 DOI: 10.1111/j.1432-2277.2012.01504.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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21
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Reidy K, Brand B, Jost B. Severe elbow arthropathy in a patient with congenital afibrinogenemia: a case report. J Bone Joint Surg Am 2010; 92:456-8. [PMID: 20124074 DOI: 10.2106/jbjs.i.00149] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Kerstin Reidy
- Department of Orthopedics, Balgrist, University of Zurich, Forchstrasse 340, CH-8008 Zurich, Switzerland
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22
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Tziomalos K, Vakalopoulou S, Perifanis V, Garipidou V. Treatment of congenital fibrinogen deficiency: overview and recent findings. Vasc Health Risk Manag 2009; 5:843-8. [PMID: 19851522 PMCID: PMC2762433 DOI: 10.2147/vhrm.s5305] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Afibrinogenemia is a rare bleeding disorder with an estimated prevalence of 1:1,000,000. It is an autosomal recessive disease resulting from mutations in any of the 3 genes that encode the 3 polypeptide chains of fibrinogen and are located on the long arm of chromosome 4. Spontaneous bleeding, bleeding after minor trauma and excessive bleeding during interventional procedures are the principal manifestations. We review the management of afibrinogenemia. Replacement therapy is the mainstay of treatment of bleeding episodes in these patients and plasma-derived fibrinogen concentrate is the agent of choice. Cryoprecipitate and fresh frozen plasma are alternative treatments that should be used only when fibrinogen concentrate is not available. Secondary prophylactic treatment may be considered after life-threatening bleeding whereas primary prophylactic treatment is not currently recommended. We also discuss alternative treatment options and the management of surgery, pregnancy and thrombosis in these patients. The development of new tests to identify higher risk patients and of safer replacement therapy will improve the management of afibrinogenemia in the future.
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Affiliation(s)
- Konstantinos Tziomalos
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece.
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