1
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Mathews N, Tasneem S, Hayward CPM. Rare inherited coagulation and fibrinolytic defects that challenge diagnostic laboratories. Int J Lab Hematol 2023. [PMID: 37211424 DOI: 10.1111/ijlh.14084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 04/12/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Coagulation factors, anticoagulants, and fibrinolytic proteins are important for hemostasis, and mutations affecting these proteins causes some rare inherited bleeding disorders that are particularly challenging to diagnose. AIMS This review provides current information on rare inherited bleeding disorders that are difficult to diagnose. MATERIAL & METHODS A review of the literature was conducted for up to date information on rare and difficult to diagnose bleeding disorders. RESULTS Some rare bleeding disorders cause an inherited deficiency of multiple coagulation factors (F), such as combined FV and FVIII deficiency and familial vitamin K-dependent clotting factor deficiency. Additionally, congenital disorders of glycosylation can affect a variety of procoagulant and anticoagulant proteins and also platelets. Some bleeding disorders reflect mutations with unique impairments in the procoagulant/anticoagulant balance, including those caused by F5 mutations that secondarily increase the plasma levels of tissue factor pathway inhibitor as well as THBD mutations that increase functional thrombomodulin in plasma or cause a consumptive coagulopathy due to thrombomodulin deficiency. Some bleeding disorders accelerate fibrinolysis due to loss-of-function mutations in SERPINE1 and SERPINF2 or in the case of Quebec platelet disorder, a duplication mutation that rewires PLAU and selectively increases expression in megakaryocytes, resulting in a unique platelet-dependent gain-of-function defect in fibrinolysis. DISCUSSION Current information on rare and difficult to diagnose bleeding disorders indicates they have unique clinical and laboratory features, and pathogenic characteristics to consider for diagnostic evaluation. CONCLUSION Laboratories and clinicians should consider rare inherited disorders, and difficult to diagnose conditions, in their strategy for diagnosing bleeding disorders.
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Affiliation(s)
- Natalie Mathews
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada
| | - Subia Tasneem
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Catherine P M Hayward
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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2
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Speybroeck J, Marsee M, Shariff F, Zackariya N, Grisoli A, Lune SV, Larson EE, Hatch J, McCauley R, Shariff F, Aversa JG, Son M, Agostini V, Campello E, Simioni P, Scărlătescu E, Kwaan H, Hartmann J, Fries D, Walsh M. Viscoelastic testing in benign hematologic disorders: Clinical perspectives and future implications of point-of-care testing to assess hemostatic competence. Transfusion 2021; 60 Suppl 6:S101-S121. [PMID: 33089936 DOI: 10.1111/trf.16088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 09/04/2020] [Accepted: 09/05/2020] [Indexed: 01/04/2023]
Abstract
Viscoelastic tests (VETs) have been used routinely for liver transplantation, cardiac surgery, and trauma, but only recently have found clinical utility in benign hematologic disorders. Therefore, guidelines for diagnosis and treatment of these disorders based on viscoelastic variables have been adapted from the existing transplant, cardiothoracic surgery, and trauma resuscitation literature. As a result, diagnostic and therapeutic strategies for benign hematologic disorders utilizing VETs are not uniform. Accordingly, even though there has been a recent increase in the utilization of VET for the diagnosis and treatment of such disorders, the literature is still in its early stages. Analysis of point-of-care viscoelastic tracings from benign hematologic disorders has the potential to allow prompt recognition of disease and to guide patient-specific intervention. Here we present a review describing the application of VETs to benign hematologic disorders.
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Affiliation(s)
- Jacob Speybroeck
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Mathew Marsee
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Faadil Shariff
- Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Nuha Zackariya
- Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Anne Grisoli
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Stefani Vande Lune
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Emilee E Larson
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Jordan Hatch
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Ross McCauley
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Faisal Shariff
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - John G Aversa
- Department of General Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Michael Son
- Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Vanessa Agostini
- Department of Transfusion Medicine, IRCC Polyclinic Hospital San Marino, Genoa, Italy
| | - Elena Campello
- Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padua University Hospital, Padua, Italy
| | - Paolo Simioni
- Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padua University Hospital, Padua, Italy
| | - Escaterina Scărlătescu
- Department of Anaesthesia and Intensive Care, Fundeni Clinical Institute, Bucharest, Romania
| | - Hau Kwaan
- Department of Hematology Oncology, Northwestern University School of Medicine, Chicago, Illinois
| | - Jan Hartmann
- Department of Medical Affairs, Haemonetics Corporation, Boston, Massachusetts
| | - Dietmar Fries
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Mark Walsh
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana.,Saint Joseph Regional Medical Center, Mishawaka, Indiana
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Prabhudesai A, Sharma R, Shetty S, Phadnis A, Kulkarni B. Congenital PAI-1 deficiency results in psoas hematoma in an Indian patient. Thromb Res 2020; 190:35-38. [PMID: 32278876 DOI: 10.1016/j.thromres.2020.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/07/2020] [Accepted: 04/02/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Aniket Prabhudesai
- ICMR-National Institute of Immunohaematology, Department of Thrombosis and Haemostasis, KEM Hospital, Parel, Mumbai 400012, India
| | - Ratna Sharma
- Jupiter Hospital, Eastern Express Highway, Service Rd, Thane 400601, India
| | - Shrimati Shetty
- ICMR-National Institute of Immunohaematology, Department of Thrombosis and Haemostasis, KEM Hospital, Parel, Mumbai 400012, India
| | - Ashish Phadnis
- Jupiter Hospital, Eastern Express Highway, Service Rd, Thane 400601, India
| | - Bipin Kulkarni
- ICMR-National Institute of Immunohaematology, Department of Thrombosis and Haemostasis, KEM Hospital, Parel, Mumbai 400012, India.
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The utility of thromboelastography and tranexamic acid in plasminogen activator inhibitor deficiency during pregnancy: a rare case report. Blood Coagul Fibrinolysis 2020; 31:87-91. [DOI: 10.1097/mbc.0000000000000869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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5
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Wyganowska-Świątkowska M, Tarnowski M, Murtagh D, Skrzypczak-Jankun E, Jankun J. Proteolysis is the most fundamental property of malignancy and its inhibition may be used therapeutically (Review). Int J Mol Med 2018; 43:15-25. [PMID: 30431071 PMCID: PMC6257838 DOI: 10.3892/ijmm.2018.3983] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 09/06/2018] [Indexed: 12/22/2022] Open
Abstract
The mortality rates of cancer patients decreased by ~1.5% per year between 2001 and 2015, although the decrease depends on patient sex, ethnic group and type of malignancy. Cancer remains a significant global health problem, requiring a search for novel treatments. The most common property of malignant tumors is their capacity to invade adjacent tissue and to metastasize, and this cancer aggressiveness is contingent on overexpression of proteolytic enzymes. The components of the plasminogen activation system (PAS) and the metal-loproteinase family [mainly matrix metalloproteinases (MMPs)] are overexpressed in malignant tumors, driving the local invasion, metastasis and angiogenesis. This is the case for numerous types of cancer, such as breast, colon, prostate and oral carcinoma, among others. Present chemotherapeutics agents typically attack all dividing cells; however, for future therapeutic agents to be clinically successful, they need to be highly selective for a specific protein(s) and act on the cancerous tissues without adverse systemic effects. Inhibition of proteolysis in cancerous tissue has the ability to attenuate tumor invasion, angiogenesis and migration. For that purpose, inhibiting both PAS and MMPs may be another approach, since the two groups of enzymes are overexpressed in cancer. In the present review, the roles and new findings on PAS and MMP families in cancer formation, growth and possible treatments are discussed.
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Affiliation(s)
| | | | - Daniel Murtagh
- Urology Research Center, Department of Urology, Health Science Campus, The University of Toledo, Toledo, OH 43614‑2598, USA
| | - Ewa Skrzypczak-Jankun
- Urology Research Center, Department of Urology, Health Science Campus, The University of Toledo, Toledo, OH 43614‑2598, USA
| | - Jerzy Jankun
- Urology Research Center, Department of Urology, Health Science Campus, The University of Toledo, Toledo, OH 43614‑2598, USA
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6
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Saes JL, Schols SEM, van Heerde WL, Nijziel MR. Hemorrhagic disorders of fibrinolysis: a clinical review. J Thromb Haemost 2018; 16:S1538-7836(22)02207-3. [PMID: 29847021 DOI: 10.1111/jth.14160] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Indexed: 12/28/2022]
Abstract
Hyperfibrinolytic bleeding can be caused by a deficiency of one of the inhibitors of fibrinolysis (plasminogen activator inhibitor type 1 [PAI-1] or α2-antiplasmin [α2-AP]), or an excess of one of the activators of fibrinolysis: tissue-type plasminogen activator or urokinase-type plasminogen activator. This review focuses on the clinical implications of these disorders. The bleeding phenotype of fibrinolytic disorders is characterized by delayed bleeding after trauma, surgery and dental procedures. Bleeding in areas of high fibrinolytic activity is also common, such as menorrhagia and epistaxis. Patients with α2-AP deficiency present with the most severe bleeding episodes. Recently, it was discovered that hyperfibrinolytic disorders are associated with a high rate of obstetric complications such as miscarriage and preterm birth, especially in PAI-1 deficient patients. Hyperfibrinolytic disorders are probably underdiagnosed because of lack of knowledge and lack of accurate diagnostic tests. A substantial part of the large group of patients diagnosed as 'bleeding of unknown origin' could actually have a hyperfibrinolytic disorder. In the case of a high index of suspicion (i.e. because of a positive family history, recurrent bleeding or uncommon type of bleeding such as an intramedullary hematoma), further testing should not be withheld because of normal results of standard hemostatic screening assays. Timely diagnosis is important because these disorders can generally be treated well with antifibrinolytic agents.
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Affiliation(s)
- J L Saes
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
- Haemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, the Netherlands
| | - S E M Schols
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
- Haemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, the Netherlands
| | - W L van Heerde
- Haemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, the Netherlands
| | - M R Nijziel
- Department of Hematology, Catharina Hospital, Eindhoven, the Netherlands
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7
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Kindell DG, Keck RW, Jankun J. Comparison between the clot-protecting activity of a mutant plasminogen activator inhibitor-1 with a very long half-life and 6-aminocaproic acid. Exp Ther Med 2015; 9:2339-2343. [PMID: 26136983 DOI: 10.3892/etm.2015.2399] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 11/17/2014] [Indexed: 01/10/2023] Open
Abstract
Plasminogen activator inhibitor (PAI)-1 is a serpin glycoprotein that can stabilize blood clots by inhibiting fibrinolysis. However, wild-type PAI-1 has the disadvantage of a short half-life of ∼2 h. A very long half-life (VLHL) PAI-1 mutant was developed previously with an active-form half-life of >700 h, making it a possible candidate for use in hemorrhagic therapy. Current treatments for mitigating hemorrhage, other than inducers of blood clotting, are limited to lysine analog antifibrinolytics, including 6-aminocaproic acid and tranexamic acid. VLHL PAI-1 has been previously demonstrated to limit bleeding; however, the efficacy of this protein compared with lysine analog antifibrinolytics has not been investigated. The aim of the current study was to compare the clot stabilizing properties of the novel antifibrinolytic VLHL PAI-1 with those of 6-aminocaproic acid in reference plasma. Using thromboelastographic analysis, VLHL PAI-1 exhibited an IC50 (half maximal inhibitory concentration) of 8.8×10-8 mol/l, while 6-aminocaproic acid showed an IC50 of 1.6×10-4 mol/l. However, at doses of >9.0×10-7 mol/l, VLHL PAI-1 exhibited a delay in the onset of clot formation, which may be attributed to thrombin inhibition by excess PAI-1. The inhibition of tissue plasminogen activator by VLHL PAI-1 demonstrated improved efficacy over 6-aminocaproic acid in mitigating hemorrhage. In addition, patients with a PAI-1 deficiency, which causes blood clots to lyse rapidly resulting in profuse bleeding, may benefit from the application of VLHL PAI-1 as an antihemorrhagic therapy.
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Affiliation(s)
- Daniel Glenn Kindell
- Urology Research Center, Department of Urology, University of Toledo, Health Science Campus, Toledo, OH 43614, USA
| | - Rick Wayne Keck
- Urology Research Center, Department of Urology, University of Toledo, Health Science Campus, Toledo, OH 43614, USA
| | - Jerzy Jankun
- Urology Research Center, Department of Urology, University of Toledo, Health Science Campus, Toledo, OH 43614, USA ; Protein Research Chair, Department of Biochemistry, College of Sciences, King Saud University, Riyadh 11451, Kingdom of Saudi Arabia ; Department of Clinical Nutrition, Medical University of Gdańsk, Gdańsk, Pomerania 80-211, Poland
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8
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Hochleitner G, Sutor K, Levett C, Leyser H, Schlimp CJ, Solomon C. Revisiting Hartert's 1962 Calculation of the Physical Constants of Thrombelastography. Clin Appl Thromb Hemost 2015; 23:201-210. [PMID: 26400661 PMCID: PMC5349316 DOI: 10.1177/1076029615606531] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Thrombelastography (TEG)/thromboelastometry (ROTEM) devices measure viscoelastic clot strength as clot amplitude (A). Transformation of clot amplitude into clot elasticity (E with TEG; CE with ROTEM) is sometimes necessary (eg, when calculating platelet component of the clot). With TEG, clot amplitude is commonly transformed into shear modulus (G; expressed in Pa or dyn/cm2) as follows: G = (5000 × A)/(100 – A). Use of the constant “5000” stems from Hartert's 50-year-old calculation of G for a normal blood clot. We question the value of calculating G as follows: (1) It may be questioned whether TEG/ROTEM analysis enable measurement of elasticity because viscosity may also contribute to clot amplitude. (2) It has been suggested that absolute properties of a blood clot cannot be measured with TEG/ROTEM analysis because the strain amplitude applied by the device is uncontrolled and changes during the course of coagulation. (3) A review of the calculation of G using Hartert's methods and some updated assumptions suggests that the value of 5000 is unreliable. (4) Recalculation of G for the ROTEM device yields a different value from that with Hartert TEG, indicating a degree of inaccuracy with the calculations. (5) Shear modulus is simply a multiple of E/CE and, because of the unreliability of G in absolute terms, it provides no additional value versus E/CE. The TEG and ROTEM are valuable coagulation assessment tools that provide an evaluation of the viscoelastic properties of a clot, not through measuring absolute viscoelastic forces but through continuous reading of the clot amplitude relative to an arbitrary, preset scale.
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Affiliation(s)
| | - Ken Sutor
- 2 Meridian HealthComms, Cheshire, United Kingdom
| | | | | | - Christoph J Schlimp
- 4 Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre, Vienna, Austria.,5 Department of Anesthesiology and Intensive Care, AUVA Trauma Hospital of Klagenfurt, Austria
| | - Cristina Solomon
- 4 Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre, Vienna, Austria.,6 CSL Behring, Marburg, Germany.,7 Department of Anesthesiology, Perioperative Care and General Intensive Care, Paracelsus Medical University, Salzburg University Hospital, Salzburg, Austria
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Wyganowska-Świątkowska M, Surdacka A, Skrzypczak-Jankun E, Jankun J. The plasminogen activation system in periodontal tissue (Review). Int J Mol Med 2014; 33:763-8. [PMID: 24535478 DOI: 10.3892/ijmm.2014.1653] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 01/28/2014] [Indexed: 11/05/2022] Open
Abstract
The plasminogen activation system (PAS) plays an essential role in tissue proteolysis in physiological and pathological processes. Periodontitis is a chronic infection associated with increased proteolysis driven by plasminogen activation. In this comprehensive review, we summarise the effects of PAS in wound healing, tissue remodelling, inflammation, bacterial infection, and in the initiation and progression of periodontal disease. Specifically, we discuss the role of plasminogen activators (PAs), including urokinase PA (uPA), tissue-type PA (tPA), PA inhibitor type 1 (PAI-1) and 2 (PAI-2) and activated plasminogen in periodontal tissue, where their concentrations can reach much higher values than those found in other parts of the body. We also discuss whether PA deficiencies can have effects on periodontal tissue. We conclude that in periodontal disease, PAS is unbalanced and equalizing its function can improve the clinical periodontal tissue condition.
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Affiliation(s)
| | - Anna Surdacka
- Department of Conservative Dentistry and Periodontology, Poznań University of Medical Sciences, Poznań 60-820, Poland
| | - Ewa Skrzypczak-Jankun
- Urology Research Center, Department of Urology, College of Medicine, University of Toledo, Toledo, OH 43614, USA
| | - Jerzy Jankun
- Protein Research Chair, Department of Biochemistry, College of Sciences, King Saud University, Riyadh 11451, Kingdom of Saudi Arabia
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