1
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Strilchuk AW, Hur WS, Batty P, Sang Y, Abrahams SR, Yong ASM, Leung J, Silva LM, Schroeder JA, Nesbitt K, de Laat B, Moutsopoulos NM, Bugge TH, Shi Q, Cullis PR, Merricks EP, Wolberg AS, Flick MJ, Lillicrap D, Nichols TC, Kastrup CJ. Lipid nanoparticles and siRNA targeting plasminogen provide lasting inhibition of fibrinolysis in mouse and dog models of hemophilia A. Sci Transl Med 2024; 16:eadh0027. [PMID: 38381848 DOI: 10.1126/scitranslmed.adh0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 01/31/2024] [Indexed: 02/23/2024]
Abstract
Antifibrinolytic drugs are used extensively for on-demand treatment of severe acute bleeding. Controlling fibrinolysis may also be an effective strategy to prevent or lessen chronic recurring bleeding in bleeding disorders such as hemophilia A (HA), but current antifibrinolytics have unfavorable pharmacokinetic profiles. Here, we developed a long-lasting antifibrinolytic using small interfering RNA (siRNA) targeting plasminogen packaged in clinically used lipid nanoparticles (LNPs) and tested it to determine whether reducing plasmin activity in animal models of HA could decrease bleeding frequency and severity. Treatment with the siRNA-carrying LNPs reduced circulating plasminogen and suppressed fibrinolysis in wild-type and HA mice and dogs. In HA mice, hemostatic efficacy depended on the injury model; plasminogen knockdown improved hemostasis after a saphenous vein injury but not tail vein transection injury, suggesting that saphenous vein injury is a murine bleeding model sensitive to the contribution of fibrinolysis. In dogs with HA, LNPs carrying siRNA targeting plasminogen were as effective at stabilizing clots as tranexamic acid, a clinical antifibrinolytic, and in a pilot study of two dogs with HA, the incidence of spontaneous or excess bleeding was reduced during 4 months of prolonged knockdown. Collectively, these data demonstrate that long-acting antifibrinolytic therapy can be achieved and that it provides hemostatic benefit in animal models of HA.
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Affiliation(s)
- Amy W Strilchuk
- Michael Smith Laboratories, University of British Columbia, Vancouver V6T 1Z4, Canada
- Department of Biochemistry and Molecular Biology, University of British Columbia, Vancouver V6T 2A1, Canada
| | - Woosuk S Hur
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Paul Batty
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON K7L 3N6, Canada
| | - Yaqiu Sang
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Sara R Abrahams
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Alyssa S M Yong
- Michael Smith Laboratories, University of British Columbia, Vancouver V6T 1Z4, Canada
| | - Jerry Leung
- Michael Smith Laboratories, University of British Columbia, Vancouver V6T 1Z4, Canada
- Department of Biochemistry and Molecular Biology, University of British Columbia, Vancouver V6T 2A1, Canada
| | - Lakmali M Silva
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892, USA
| | - Jocelyn A Schroeder
- Blood Research Institute, Versiti, Milwaukee, WI 53226, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Kate Nesbitt
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON K7L 3N6, Canada
| | - Bas de Laat
- Synapse Research Institute, Maastricht 6217 KM, Netherlands
| | - Niki M Moutsopoulos
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892, USA
| | - Thomas H Bugge
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892, USA
| | - Qizhen Shi
- Blood Research Institute, Versiti, Milwaukee, WI 53226, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Pieter R Cullis
- Department of Biochemistry and Molecular Biology, University of British Columbia, Vancouver V6T 2A1, Canada
| | - Elizabeth P Merricks
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Matthew J Flick
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - David Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON K7L 3N6, Canada
| | - Timothy C Nichols
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Christian J Kastrup
- Michael Smith Laboratories, University of British Columbia, Vancouver V6T 1Z4, Canada
- Department of Biochemistry and Molecular Biology, University of British Columbia, Vancouver V6T 2A1, Canada
- Blood Research Institute, Versiti, Milwaukee, WI 53226, USA
- Departments of Surgery, Biochemistry, Biomedical Engineering, and Pharmacology and Toxicology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
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2
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Byrnes JR, Lee T, Sharaby S, Campbell RA, Dobson DA, Holle LA, Luo M, Kangro K, Homeister JW, Aleman MM, Luyendyk JP, Kerlin BA, Dumond JB, Wolberg AS. Reciprocal stabilization of coagulation factor XIII-A and -B subunits is a determinant of plasma FXIII concentration. Blood 2024; 143:444-455. [PMID: 37883802 PMCID: PMC10862369 DOI: 10.1182/blood.2023022042] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/28/2023] [Accepted: 10/15/2023] [Indexed: 10/28/2023] Open
Abstract
ABSTRACT Transglutaminase factor XIII (FXIII) is essential for hemostasis, wound healing, and pregnancy maintenance. Plasma FXIII is composed of A and B subunit dimers synthesized in cells of hematopoietic origin and hepatocytes, respectively. The subunits associate tightly in circulation as FXIII-A2B2. FXIII-B2 stabilizes the (pro)active site-containing FXIII-A subunits. Interestingly, people with genetic FXIII-A deficiency have decreased FXIII-B2, and therapeutic infusion of recombinant FXIII-A2 (rFXIII-A2) increases FXIII-B2, suggesting FXIII-A regulates FXIII-B secretion, production, and/or clearance. We analyzed humans and mice with genetic FXIII-A deficiency and developed a mouse model of rFXIII-A2 infusion to define mechanisms mediating plasma FXIII-B levels. Like humans with FXIII-A deficiency, mice with genetic FXIII-A deficiency had reduced circulating FXIII-B2, and infusion of FXIII-A2 increased FXIII-B2. FXIII-A-deficient mice had normal hepatic function and did not store FXIII-B in liver, indicating FXIII-A does not mediate FXIII-B secretion. Transcriptional analysis and polysome profiling indicated similar F13b levels and ribosome occupancy in FXIII-A-sufficient and -deficient mice and in FXIII-A-deficient mice infused with rFXIII-A2, indicating FXIII-A does not induce de novo FXIII-B synthesis. Unexpectedly, pharmacokinetic/pharmacodynamic modeling of FXIII-B antigen after rFXIII-A2 infusion in humans and mice suggested FXIII-A2 slows FXIII-B2 loss from plasma. Accordingly, comparison of free FXIII-B2 vs FXIII-A2-complexed FXIII-B2 (FXIII-A2B2) infused into mice revealed faster clearance of free FXIII-B2. These data show FXIII-A2 prevents FXIII-B2 loss from circulation and establish the mechanism underlying FXIII-B2 behavior in FXIII-A deficiency and during rFXIII-A2 therapy. Our findings reveal a unique, reciprocal relationship between independently synthesized subunits that mediate an essential hemostatic protein in circulation. This trial was registered at www.ClinicalTrials.com as #NCT00978380.
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Affiliation(s)
- James R. Byrnes
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Taek Lee
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sherif Sharaby
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Robert A. Campbell
- Molecular Medicine Program, Department of Internal Medicine, The University of Utah, Salt Lake City, UT
| | - Dre’Von A. Dobson
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Lori A. Holle
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michelle Luo
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kadri Kangro
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jonathon W. Homeister
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Maria M. Aleman
- Department of Pharmacology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - James P. Luyendyk
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, MI
| | - Bryce A. Kerlin
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
- Division of Pediatric Hematology/Oncology/Blood & Marrow Transplantation, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Julie B. Dumond
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC
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3
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Hur WS, Kawano T, Mwiza JMN, Paul DS, Lee RH, Clark EG, Bouck EG, Dutta A, Cai C, Baker SR, Guthold M, Mackman N, Mangin P, Wolberg AS, Bergmeier W, Flick MJ. Mice expressing nonpolymerizable fibrinogen have reduced arterial and venous thrombosis with preserved hemostasis. Blood 2024; 143:105-117. [PMID: 37832029 PMCID: PMC10797557 DOI: 10.1182/blood.2023020805] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 09/06/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023] Open
Abstract
ABSTRACT Elevated circulating fibrinogen levels correlate with increased risk for both cardiovascular and venous thromboembolic diseases. In vitro studies show that formation of a highly dense fibrin matrix is a major determinant of clot structure and stability. Here, we analyzed the impact of nonpolymerizable fibrinogen on arterial and venous thrombosis as well as hemostasis in vivo using FgaEK mice that express normal levels of a fibrinogen that cannot be cleaved by thrombin. In a model of carotid artery thrombosis, FgaWT/EK and FgaEK/EK mice were protected from occlusion with 4% ferric chloride (FeCl3) challenges compared with wild-type (FgaWT/WT) mice, but this protection was lost, with injuries driven by higher concentrations of FeCl3. In contrast, fibrinogen-deficient (Fga-/-) mice showed no evidence of occlusion, even with high-concentration FeCl3 challenge. Fibrinogen-dependent platelet aggregation and intraplatelet fibrinogen content were similar in FgaWT/WT, FgaWT/EK, and FgaEK/EK mice, consistent with preserved fibrinogen-platelet interactions that support arterial thrombosis with severe challenge. In an inferior vena cava stasis model of venous thrombosis, FgaEK/EK mice had near complete protection from thrombus formation. FgaWT/EK mice also displayed reduced thrombus incidence and a significant reduction in thrombus mass relative to FgaWT/WT mice after inferior vena cava stasis, suggesting that partial expression of nonpolymerizable fibrinogen was sufficient for conferring protection. Notably, FgaWT/EK and FgaEK/EK mice had preserved hemostasis in multiple models as well as normal wound healing times after skin incision, unlike Fga-/- mice that displayed significant bleeding and delayed healing. These findings indicate that a nonpolymerizable fibrinogen variant can significantly suppress occlusive thrombosis while preserving hemostatic potential in vivo.
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Affiliation(s)
- Woosuk S. Hur
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Tomohiro Kawano
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jean Marie N. Mwiza
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Biochemistry and Biophysics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - David S. Paul
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Biochemistry and Biophysics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Robert H. Lee
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Biochemistry and Biophysics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Emily G. Clark
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Biochemistry and Biophysics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Emma G. Bouck
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Ananya Dutta
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Can Cai
- Department of Physics, Wake Forest University, Winston-Salem, NC
| | - Stephen R. Baker
- Department of Physics, Wake Forest University, Winston-Salem, NC
| | - Martin Guthold
- Department of Physics, Wake Forest University, Winston-Salem, NC
| | - Nigel Mackman
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Pierre Mangin
- Université de Strasbourg, INSERM, EFS Grand-Est, BPPS UMR-S1255, FMTS, Strasbourg, France
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Wolfgang Bergmeier
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Biochemistry and Biophysics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Matthew J. Flick
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
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4
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Reventun P, Toledano-Sanz P, Alcharani N, Viskadourou M, Morrison AC, Sabater-Lleal M, Wolberg AS, de Vries PS, Smith NL, Osburn WO, Arvanitis M, Lowenstein CJ. CD36 regulates factor VIII secretion from liver endothelial cells. Blood Adv 2024; 8:143-149. [PMID: 38157226 PMCID: PMC10787269 DOI: 10.1182/bloodadvances.2023010023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 11/07/2023] [Indexed: 01/03/2024] Open
Affiliation(s)
- Paula Reventun
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Pablo Toledano-Sanz
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nunzio Alcharani
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
- Departamento de Cardiología, Unidad de Investigación Cardiovascular, Hospital Ramón y Cajal, Universidad Francisco de Vitoria, Madrid, Spain
| | - Maria Viskadourou
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alanna C. Morrison
- Department of Epidemiology, Human Genetics, and Environmental Sciences, Human Genetics Center, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX
| | - Maria Sabater-Lleal
- Unit of Genomics of Complex Disease, Institut d’Investigació Biomèdica Sant Pau, Barcelona, Spain
- Department of Medicine, Cardiovascular Medicine Unit, Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Paul S. de Vries
- Department of Epidemiology, Human Genetics, and Environmental Sciences, Human Genetics Center, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX
| | - Nicholas L. Smith
- Department of Epidemiology, University of Washington, Seattle, WA
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, WA
| | - William O. Osburn
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Marios Arvanitis
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Charles J. Lowenstein
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
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5
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Holle LA, Pantazis JC, Turecek PL, Wolberg AS. Clot formation and fibrinolysis assays reveal functional differences among hemostatic agents in hemophilia A plasma. Res Pract Thromb Haemost 2024; 8:102337. [PMID: 38426025 PMCID: PMC10901841 DOI: 10.1016/j.rpth.2024.102337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 12/21/2023] [Accepted: 01/16/2024] [Indexed: 03/02/2024] Open
Abstract
Background Measuring the activity of hemostatic agents used to treat hemophilia A often requires drug-specific assays. In vitro assays show hemophilic clots have abnormal characteristics, including prolonged clotting time and decreased resistance to fibrinolysis. The ability of certain agents to correct these parameters in vitro is associated with hemostatic efficacy in vivo. Objectives To compare effects of established and emerging hemostatic agents on clot formation and fibrinolysis in hemophilia A plasma. Methods Pooled and individual hemophilia A platelet-poor plasmas were spiked with replacement (recombinant factor VIII [rFVIII], PEGylated rFVIII, polysialylated rFVIII, and porcine rFVIII) or bypassing (emicizumab, rFVIIa, and activated prothrombin complex concentrate) products. Effects on tissue factor-initiated clot formation and fibrinolysis were measured by turbidity. Results Compared to normal pooled plasma, hemophilia-pooled plasma showed reduced clot formation and increased fibrinolysis, and all replacement agents improved these characteristics. rFVIII and PEGylated rFVIII produced similar effects at similar concentrations, whereas polysialylated rFVIII produced slightly higher and porcine rFVIII slightly lower effects at these concentrations. Bypassing agents enhanced clot formation and stability, but patterns differed from replacement agents. The clotting rate showed a concentration-response relationship for all agents. High concentrations of all products produced effects that exceeded the normal range in at least some parameters. Responses of individual donors varied, but all agents improved clot formation and stability in all donors tested. Conclusion Clotting and fibrinolysis assays reveal hemostatic effects of replacement and bypassing therapies at clinically relevant concentrations. These assays may help characterize hemostatic agents and optimize dosing.
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Affiliation(s)
- Lori A. Holle
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jacob C. Pantazis
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Peter L. Turecek
- Plasma-Derived Therapies R&D, Baxalta Innovations GmbH – Takeda, Vienna, Austria
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
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6
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Chowdhury NN, Yang Y, Dutta A, Luo M, Wei Z, Abrahams SR, Revenko AS, Shah F, Miles LA, Parmer RJ, de Laat B, Wolberg AS, Luyendyk JP, Fishel ML, Flick MJ. Plasminogen deficiency suppresses pancreatic ductal adenocarcinoma disease progression. Mol Oncol 2024; 18:113-135. [PMID: 37971174 PMCID: PMC10766200 DOI: 10.1002/1878-0261.13552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 10/06/2023] [Accepted: 11/14/2023] [Indexed: 11/19/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a highly fatal metastatic disease associated with robust activation of the coagulation and fibrinolytic systems. However, the potential contribution of the primary fibrinolytic protease plasminogen to PDAC disease progression has remained largely undefined. Mice bearing C57Bl/6-derived KPC (KRasG12D , TRP53R172H ) tumors displayed evidence of plasmin activity in the form of high plasmin-antiplasmin complexes and high plasmin generation potential relative to mice without tumors. Notably, plasminogen-deficient mice (Plg- ) had significantly diminished KPC tumor growth in subcutaneous and orthotopic implantation models. Moreover, the metastatic potential of KPC cells was significantly diminished in Plg- mice, which was linked to reduced early adhesion and/or survival of KPC tumor cells. The reduction in primary orthotopic KPC tumor growth in Plg- mice was associated with increased apoptosis, reduced accumulation of pro-tumor immune cells, and increased local proinflammatory cytokine production. Elimination of fibrin(ogen), the primary proteolytic target of plasmin, did not alter KPC primary tumor growth and resulted in only a modest reduction in metastatic potential. In contrast, deficiencies in the plasminogen receptors Plg-RKT or S100A10 in tumor cells significantly reduced tumor growth. Plg-RKT reduction in tumor cells, but not reduced S100A10, suppressed metastatic potential in a manner that mimicked plasminogen deficiency. Finally, tumor growth was also reduced in NSG mice subcutaneously or orthotopically implanted with patient-derived PDAC tumor cells in which circulating plasminogen was pharmacologically reduced. Collectively, these studies suggest that plasminogen promotes PDAC tumor growth and metastatic potential, in part through engaging plasminogen receptors on tumor cells.
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Affiliation(s)
- Nayela N. Chowdhury
- Department of Pediatrics and Herman B Wells Center for Pediatric ResearchIndianapolisINUSA
- Indiana University Simon Comprehensive Cancer CenterIndianapolisINUSA
- Department of Pharmacology and ToxicologyIndiana University School of MedicineIndianapolisINUSA
| | - Yi Yang
- Department of Pathology and Laboratory MedicineUniversity of North Carolina at Chapel HillNCUSA
- Lineberger Comprehensive Cancer CenterUniversity of North Carolina at Chapel HillNCUSA
- UNC Blood Research CenterUniversity of North Carolina at Chapel HillNCUSA
| | - Ananya Dutta
- Department of Pathology and Laboratory MedicineUniversity of North Carolina at Chapel HillNCUSA
- Lineberger Comprehensive Cancer CenterUniversity of North Carolina at Chapel HillNCUSA
- UNC Blood Research CenterUniversity of North Carolina at Chapel HillNCUSA
| | - Michelle Luo
- Department of Pathology and Laboratory MedicineUniversity of North Carolina at Chapel HillNCUSA
- Lineberger Comprehensive Cancer CenterUniversity of North Carolina at Chapel HillNCUSA
- UNC Blood Research CenterUniversity of North Carolina at Chapel HillNCUSA
| | - Zimu Wei
- Department of Pathobiology & Diagnostic InvestigationMichigan State UniversityEast LansingMIUSA
- Institute for Integrative ToxicologyMichigan State UniversityEast LansingMIUSA
- Department of Pharmacology and ToxicologyMichigan State UniversityEast LansingMIUSA
| | - Sara R. Abrahams
- Department of Pathology and Laboratory MedicineUniversity of North Carolina at Chapel HillNCUSA
- Lineberger Comprehensive Cancer CenterUniversity of North Carolina at Chapel HillNCUSA
- UNC Blood Research CenterUniversity of North Carolina at Chapel HillNCUSA
| | | | - Fenil Shah
- Department of Pediatrics and Herman B Wells Center for Pediatric ResearchIndianapolisINUSA
- Indiana University Simon Comprehensive Cancer CenterIndianapolisINUSA
| | - Lindsey A. Miles
- Department of Molecular MedicineScripps Research InstituteLa JollaCAUSA
| | - Robert J. Parmer
- Department of Medicine, Veterans Administration San Diego Healthcare SystemUniversity of California, San DiegoCAUSA
| | - Bas de Laat
- Synapse Research InstituteMaastrichtThe Netherlands
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory MedicineUniversity of North Carolina at Chapel HillNCUSA
- Lineberger Comprehensive Cancer CenterUniversity of North Carolina at Chapel HillNCUSA
- UNC Blood Research CenterUniversity of North Carolina at Chapel HillNCUSA
| | - James P. Luyendyk
- Department of Pathobiology & Diagnostic InvestigationMichigan State UniversityEast LansingMIUSA
- Institute for Integrative ToxicologyMichigan State UniversityEast LansingMIUSA
- Department of Pharmacology and ToxicologyMichigan State UniversityEast LansingMIUSA
| | - Melissa L. Fishel
- Department of Pediatrics and Herman B Wells Center for Pediatric ResearchIndianapolisINUSA
- Indiana University Simon Comprehensive Cancer CenterIndianapolisINUSA
- Department of Pharmacology and ToxicologyIndiana University School of MedicineIndianapolisINUSA
| | - Matthew J. Flick
- Department of Pathology and Laboratory MedicineUniversity of North Carolina at Chapel HillNCUSA
- Lineberger Comprehensive Cancer CenterUniversity of North Carolina at Chapel HillNCUSA
- UNC Blood Research CenterUniversity of North Carolina at Chapel HillNCUSA
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7
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Wolberg AS. Fibrinogen and fibrin: synthesis, structure, and function in health and disease. J Thromb Haemost 2023; 21:3005-3015. [PMID: 37625698 PMCID: PMC10592048 DOI: 10.1016/j.jtha.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 08/15/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023]
Abstract
Fibrinogen is an extraordinary molecule by any estimation. It is large, structurally intricate, and circulates at high concentrations. Its biological end product, insoluble fibrin(ogen) or fibrin, can assume a diverse array of conformations with the ability to interact with numerous plasma proteins and cells and withstand biochemical and biomechanical disruption to facilitate wound healing. Quantitative and qualitative defects in fibrinogen or fibrin are associated with bleeding, thrombosis, inflammation, and diseases affected by these processes. Numerous studies investigating mechanisms by which fibrin(ogen) and fibrin contribute to health and disease have been published. This review for the 20th-anniversary series in the Journal of Thrombosis and Haemostasis summarizes interesting aspects of fibrin(ogen) biology, biochemistry, biophysics, and physiology and highlights exciting findings published in the past 2 decades.
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Affiliation(s)
- Alisa S Wolberg
- Department of Pathology and Laboratory Medicine, UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA.
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8
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Desage S, Leuci A, Enjolras N, Holle LA, Singh S, Delavenne X, Wolberg AS, Biswas A, Dargaud Y. Characterization of a recombinant factor IX molecule fused to coagulation factor XIII-B subunit. Haemophilia 2023; 29:1483-1489. [PMID: 37707428 DOI: 10.1111/hae.14855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/19/2023] [Accepted: 08/29/2023] [Indexed: 09/15/2023]
Abstract
INTRODUCTION AND AIM Severe haemophilia B (HB) is characterized by spontaneous bleeding episodes, mostly into joints. Recurrent bleeds lead to progressive joint destruction called haemophilic arthropathy. The current concept of prophylaxis aims at maintaining the FIX level >3-5 IU/dL, which is effective at reducing the incidence of haemophilic arthropathy. Extended half-life FIX molecules make it easier to achieve these target trough levels compared to standard FIX concentrates. We previously reported that the fusion of a recombinant FIX (rFIX) to factor XIII-B (FXIIIB) subunit prolonged the half-life of the rFIX-LXa-FXIIIB fusion molecule in mice and rats 3.9- and 2.2-fold, respectively, compared with rFIX-WT. However, the mechanism behind the extended half-life was not known. MATERIALS AND METHODS Mass spectrometry and ITC were used to study interactions of rFIX-LXa-FXIIIB with albumin. Pharmacokinetic analyses in fibrinogen-KO and FcRn-KO mice were performed to evaluate the effect of albumin and fibrinogen on in-vivo half-life of rFIX-LXa-FXIIIB. Finally saphenous vein bleeding model was used to assess in-vivo haemostatic activity of rFIX-LXa-FXIIIB. RESULTS AND CONCLUSION We report here the key interactions that rFIX-LXa-FXIIIB may have in plasma are with fibrinogen and albumin which may mediate its prolonged half-life. In addition, using the saphenous vein bleeding model, we demonstrate that rFIX-FXIIIB elicits functional clot formation that is indistinguishable from that of rFIX-WT.
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Affiliation(s)
- Stephanie Desage
- UR4609 - Hemostase et Thrombose, Universite Claude Bernard Lyon I, Lyon, France
- Unite d'Hemostase Clinique, Hopital Cardiologique, Hospices Civils de Lyon, Lyon, France
| | - Alexandre Leuci
- UR4609 - Hemostase et Thrombose, Universite Claude Bernard Lyon I, Lyon, France
| | - Nathalie Enjolras
- UR4609 - Hemostase et Thrombose, Universite Claude Bernard Lyon I, Lyon, France
| | - Lori A Holle
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Sneha Singh
- Arijit Biswas Lab, arijitbiswaslab.com, Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Xavier Delavenne
- Laboratory of Pharmacology and Toxicology, University Hospital, Saint-Etienne, France
| | - 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
| | - Arijit Biswas
- Arijit Biswas Lab, arijitbiswaslab.com, Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Yesim Dargaud
- UR4609 - Hemostase et Thrombose, Universite Claude Bernard Lyon I, Lyon, France
- Unite d'Hemostase Clinique, Hopital Cardiologique, Hospices Civils de Lyon, Lyon, France
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9
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Groeneveld DJ, Poole LG, Bouck EG, Schulte A, Wei Z, Williams KJ, Watson VE, Lisman T, Wolberg AS, Luyendyk JP. Robust coagulation activation and coagulopathy in mice with experimental acetaminophen-induced liver failure. J Thromb Haemost 2023; 21:2430-2440. [PMID: 37054919 PMCID: PMC10524846 DOI: 10.1016/j.jtha.2023.03.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/07/2023] [Accepted: 03/30/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Patients with acetaminophen (APAP)-induced acute liver failure (ALF) display both hyper- and hypocoagulable changes not necessarily recapitulated by standard hepatotoxic doses of APAP used in mice (eg, 300 mg/kg). OBJECTIVES We sought to examine coagulation activation in vivo and plasma coagulation potential ex vivo in experimental settings of APAP-induced hepatotoxicity and repair (300-450 mg/kg) and APAP-induced ALF (600 mg/kg) in mice. RESULTS APAP-induced ALF was associated with increased plasma thrombin-antithrombin complexes, decreased plasma prothrombin, and a dramatic reduction in plasma fibrinogen compared with lower APAP doses. Hepatic fibrin(ogen) deposits increased independent of APAP dose, whereas plasma fibrin(ogen) degradation products markedly increased in mice with experimental ALF. Early pharmacologic anticoagulation (+2 hours after 600 mg/kg APAP) limited coagulation activation and reduced hepatic necrosis. The marked coagulation activation evident in mice with APAP-induced ALF was associated with a coagulopathy detectable ex vivo in plasma. Specifically, prolongation of the prothrombin time and inhibition of tissue factor-initiated clot formation were evident even after restoration of physiological fibrinogen concentrations. Plasma endogenous thrombin potential was similarly reduced at all APAP doses. Interestingly, in the presence of ample fibrinogen, ∼10 times more thrombin was required to clot plasma from mice with APAP-induced ALF compared with plasma from mice with simple hepatotoxicity. CONCLUSION The results indicate that robust pathologic coagulation cascade activation in vivo and suppressed coagulation ex vivo are evident in mice with APAP-induced ALF. This unique experimental setting may fill an unmet need as a model to uncover mechanistic aspects of the complex coagulopathy of ALF.
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Affiliation(s)
- Dafna J Groeneveld
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA
| | - Lauren G Poole
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA
| | - Emma G Bouck
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Anthony Schulte
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA
| | - Zimu Wei
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA
| | - Kurt J Williams
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA
| | - Victoria E Watson
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA
| | - Ton Lisman
- Section of Hepatobiliary Surgery and Liver Transplantation and Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - James P Luyendyk
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA; Department of Pharmacology & Toxicology, Michigan State University, East Lansing, Michigan, USA.
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10
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Bouck EG, Grinsztejn E, Mcnamara M, Stavrou EX, Wolberg AS. Thromboembolic risk with gender-affirming hormone therapy: potential role of global coagulation and fibrinolysis assays. Res Pract Thromb Haemost 2023; 7:102197. [PMID: 37822706 PMCID: PMC10562871 DOI: 10.1016/j.rpth.2023.102197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 07/14/2023] [Accepted: 07/18/2023] [Indexed: 10/13/2023] Open
Abstract
Gender-affirming hormonal therapies are a critical component of the care of transgender individuals. Transgender people are commonly prescribed estrogen or testosterone to promote male-to-female or female-to-male transitions and to preserve gender-specific characteristics long-term. However, some exogenous hormones, especially certain estrogen preparations, are an established risk factor of thrombosis. As the number of individuals seeking gender-based care is rising, there is an urgent need to identify and characterize the mechanisms underlying hormone-associated thrombosis and incorporate this information into clinical algorithms for diagnosis and management. Herein, we discuss historical evidence on the incidence of thrombosis and changes in plasma composition in transgender and cisgender cohorts. We present 3 case studies to demonstrate knowledge gaps in thrombosis risk stratification and prediction tools. We also present data from in vitro coagulation and fibrinolysis assays and discuss how information from these kinds of assays may be used to help guide the clinical management of transgender individuals.
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Affiliation(s)
- Emma G. Bouck
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, NC, USA
| | - Eduarda Grinsztejn
- Department of Medicine, Hematology and Oncology Division, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Megan Mcnamara
- Medicine Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Evi X. Stavrou
- Medicine Service, Section of Hematology-Oncology, Louise Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA
- Department of Medicine, Hematology and Oncology Division, CWRU School of Medicine, Cleveland, OH, USA
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, NC, USA
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11
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Poole LG, Schmitt LR, Schulte A, Groeneveld DJ, Cline HM, Sang Y, Hur WS, Wolberg AS, Flick MJ, Hansen KC, Luyendyk JP. Altered fibrinogen γ-chain cross-linking in mutant fibrinogen-γ Δ5 mice drives acute liver injury. J Thromb Haemost 2023; 21:2175-2188. [PMID: 37062522 PMCID: PMC10524487 DOI: 10.1016/j.jtha.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 03/09/2023] [Accepted: 04/03/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Hepatic deposition of cross-linked fibrin(ogen) occurs alongside platelet accumulation as a hallmark of acetaminophen (APAP)-induced liver injury. OBJECTIVES We sought to define the precise role of the fibrinogen γ-chain C-terminal integrin αIIbβ3 binding domain in APAP-induced liver injury. METHODS Mice expressing mutant fibrinogen incapable of engaging integrin αIIbβ3 due to a C-terminal fibrinogen γ-chain truncation (mutant fibrinogen-γΔ5 [FibγΔ5] mice) and wild-type mice were challenged with APAP (300 mg/kg, intraperitoneally). RESULTS We observed an altered pattern of fibrin(ogen) deposition in the livers of APAP-challenged FibγΔ5 mice. This led to the unexpected discovery that fibrinogen γ-chain cross-linking was altered in the livers of APAP-challenged FibγΔ5 mice compared with that in wild-type mice, including absence of γ-γ dimer and accumulation of larger molecular weight cross-linked γ-chain complexes. This finding was not unique to the injured liver because activation of coagulation did not produce γ-γ dimer in plasma from FibγΔ5 mice or purified FibγΔ5 fibrinogen. Sanger sequencing predicted that the fibrinogen-γΔ5 γ-polypeptide would terminate at lysine residue 406, but liquid chromatography tandem mass spectrometry analysis revealed that this critical lysine residue was absent in purified fibrinogen-γΔ5 protein. Interestingly, hepatic deposition of this uniquely aberrantly cross-linked fibrin(ogen) in FibγΔ5 mice was associated with exacerbated hepatic injury, an effect not recapitulated by pharmacologic inhibition of integrin αIIbβ3. CONCLUSION The results indicate that fibrinogen-γΔ5 lacks critical residues essential to form γ-γ dimer in response to thrombin and suggest that hepatic accumulation of abnormally cross-linked fibrin(ogen) can exacerbate hepatic injury.
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Affiliation(s)
- Lauren G Poole
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA; Institute for Integrative Toxicology, Michigan State University, East Lansing, Michigan, USA. https://twitter.com/PoolePAR_ty
| | - Lauren R Schmitt
- Department of Biochemistry and Molecular Genetics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Anthony Schulte
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA
| | - Dafna J Groeneveld
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA
| | - Holly M Cline
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA
| | - Yaqiu Sang
- Department of Pathology and Laboratory Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Woosuk S Hur
- Department of Pathology and Laboratory Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Matthew J Flick
- Department of Pathology and Laboratory Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kirk C Hansen
- Department of Biochemistry and Molecular Genetics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - James P Luyendyk
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA; Institute for Integrative Toxicology, Michigan State University, East Lansing, Michigan, USA; Department of Pharmacology and Toxicology, Michigan State University, East Lansing, Michigan, USA.
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12
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Kangro K, Campbell RA, Tilvawala R, Flick MJ, Wolberg AS. Citrullination of α2-antiplasmin is unlikely to contribute to enhanced plasmin generation in COVID-19 pathophysiology. Res Pract Thromb Haemost 2023; 7:102195. [PMID: 37736033 PMCID: PMC10510058 DOI: 10.1016/j.rpth.2023.102195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 07/16/2023] [Accepted: 08/07/2023] [Indexed: 09/23/2023] Open
Affiliation(s)
- Kadri Kangro
- Department of Pathology and Laboratory Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Robert A. Campbell
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Ronak Tilvawala
- Department of Molecular Biosciences, University of Kansas, Lawrence, Kansas, USA
| | - Matthew J. Flick
- Department of Pathology and Laboratory Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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13
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Rudran T, Antoniak S, Flick MJ, Ginsberg MH, Wolberg AS, Bergmeier W, Lee RH. Protease-activated receptors and glycoprotein VI cooperatively drive the platelet component in thromboelastography. J Thromb Haemost 2023; 21:2236-2247. [PMID: 37068592 PMCID: PMC10824270 DOI: 10.1016/j.jtha.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/27/2023] [Accepted: 04/09/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Thromboelastography (TEG) is used for real-time determination of hemostatic status in patients with acute risk of bleeding. Thrombin is thought to drive clotting in TEG through generation of polymerized fibrin and activation of platelets through protease-activated receptors (PARs). However, the specific role of platelet agonist receptors and signaling in TEG has not been reported. OBJECTIVES Here, we investigated the specific receptors and signaling pathways required for platelet function in TEG using genetic and pharmacologic inhibition of platelet proteins in mouse and human blood samples. METHODS Clotting parameters (R time, α-angle [α], and maximum amplitude [MA]), were determined in recalcified, kaolin-triggered citrated blood samples using a TEG 5000 analyzer. RESULTS We confirmed the requirement of platelets, platelet contraction, and αIIbβ3 integrin function for normal α and MA. Loss of the integrin adaptor Talin1 in megakaryocytes/platelets (Talin1mKO) also reduced α and MA, but only minimal defects were observed in samples from mice lacking Rap1 GTPase signaling. PAR4mKO samples showed impaired α but normal MA. However, impaired TEG traces similar to those in platelet-depleted samples were observed with samples from PAR4mKO mice depleted of glycoprotein VI on platelets or with addition of a Syk inhibitor. We reproduced these results in human blood with combined inhibition of PAR1, PAR4, and Syk. CONCLUSION Our results demonstrate that standard TEG is not sensitive to platelet signaling pathways critical for integrin inside-out activation and platelet hemostatic function. Furthermore, we provide the first evidence that PARs and glycoprotein VI play redundant roles in platelet-mediated clot contraction in TEG.
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Affiliation(s)
- Tanvi Rudran
- Department of Biochemistry and Biophysics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Silvio Antoniak
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Matthew J Flick
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Mark H Ginsberg
- Department of Medicine, University of California, San Diego, La Jolla, California, USA
| | - Alisa S Wolberg
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Wolfgang Bergmeier
- Department of Biochemistry and Biophysics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Robert H Lee
- Department of Biochemistry and Biophysics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
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14
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Grover SP, Snir O, Hindberg K, Englebert TM, Braekkan SK, Morelli VM, Jensen SB, Wolberg AS, Mollnes TE, Ueland T, Mackman N, Hansen JB. High plasma levels of C1-inhibitor are associated with lower risk of future venous thromboembolism. J Thromb Haemost 2023; 21:1849-1860. [PMID: 37003465 DOI: 10.1016/j.jtha.2023.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/02/2023] [Accepted: 03/20/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND C1-inhibitor (C1INH) is a broad-acting serine protease inhibitor with anticoagulant activity. The impact of C1INH plasma levels within the normal physiological range on risk of venous thromboembolism (VTE) is unknown. We assessed the association of plasma C1INH levels and VTE risk and evaluated the impact of C1INH on thrombin and plasmin generation in ex vivo assays. METHODS A nested case-control study with 405 patients with VTE and 829 age- and sex-matched controls was derived from the Tromsø Study. Odds ratios (ORs) with 95% confidence intervals (95% CI) for VTE were estimated across plasma C1INH quartiles. Genetic regulation of C1INH was explored using quantitative trait loci analysis of whole exome sequencing data. The effect of plasma C1INH levels on coagulation was evaluated ex vivo by calibrated automated thrombography. RESULTS Individuals with C1INH levels in the highest quartile had a lower risk of VTE (OR 0.68, 95% CI: 0.49-0.96) compared with those with C1INH in the lowest quartile. In subgroup analysis, the corresponding ORs were 0.60 (95% CI: 0.39-0.89) for deep vein thrombosis and 0.85 (95% CI: 0.52-1.38) for pulmonary embolism, respectively. No significant genetic determinants of plasma C1INH levels were identified. Addition of exogenous C1INH to normal human plasma reduced thrombin generation triggered by an activator of the intrinsic coagulation pathway, but not when triggered by an activator of the extrinsic coagulation pathway. CONCLUSIONS High plasma levels of C1INH were associated with lower risk of VTE, and C1INH inhibited thrombin generation initiated by the intrinsic coagulation pathway ex vivo.
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Affiliation(s)
- Steven P Grover
- Division of Hematology, Department of Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, North Carolina, USA. https://twitter.com/StevenPGrover
| | - Omri Snir
- Thrombosis Research Center, Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway; Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Kristian Hindberg
- Thrombosis Research Center, Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway. https://twitter.com/KristianHindbe1
| | - Tatianna M Englebert
- Division of Hematology, Department of Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, North Carolina, USA. https://twitter.com/OlsonTatianna
| | - Sigrid K Braekkan
- Thrombosis Research Center, Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway; Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway.
| | - Vânia M Morelli
- Thrombosis Research Center, Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway; Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Søren B Jensen
- Thrombosis Research Center, Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway; Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, North Carolina, USA. https://twitter.com/aswolberg
| | - Tom Eirik Mollnes
- Research Laboratory, Nordland Hospital, Bodø, Norway; Department of Immunology, Oslo University Hospital and University of Oslo, Norway; Centre of Molecular Inflammation Research, Norwegian University of Science and Technology, Trondheim, Norway
| | - Thor Ueland
- Thrombosis Research Center, Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway; Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway. https://twitter.com/ThorUeland
| | - Nigel Mackman
- Division of Hematology, Department of Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, North Carolina, USA. https://twitter.com/NMackman
| | - John-Bjarne Hansen
- Thrombosis Research Center, Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway; Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
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15
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Ji Y, Temprano-Sagrera G, Holle LA, Bebo A, Brody JA, Le NQ, Kangro K, Brown MR, Martinez-Perez A, Sitlani CM, Suchon P, Kleber ME, Emmert DB, Ozel AB, Dobson DA, Tang W, Llobet D, Tracy RP, Deleuze JF, Delgado GE, Gögele M, Wiggins KL, Souto JC, Pankow JS, Taylor KD, Trégouët DA, Moissl AP, Fuchsberger C, Rosendaal FR, Morrison AC, Soria JM, Cushman M, Morange PE, März W, Hicks AA, Desch KC, Johnson AD, de Vries PS, Wolberg AS, Smith NL, Sabater-Lleal M. Antithrombin, Protein C, and Protein S: Genome and Transcriptome-Wide Association Studies Identify 7 Novel Loci Regulating Plasma Levels. Arterioscler Thromb Vasc Biol 2023; 43:e254-e269. [PMID: 37128921 PMCID: PMC10330350 DOI: 10.1161/atvbaha.122.318213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 04/13/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Antithrombin, PC (protein C), and PS (protein S) are circulating natural anticoagulant proteins that regulate hemostasis and of which partial deficiencies are causes of venous thromboembolism. Previous genetic association studies involving antithrombin, PC, and PS were limited by modest sample sizes or by being restricted to candidate genes. In the setting of the Cohorts for Heart and Aging Research in Genomic Epidemiology consortium, we meta-analyzed across ancestries the results from 10 genome-wide association studies of plasma levels of antithrombin, PC, PS free, and PS total. METHODS Study participants were of European and African ancestries, and genotype data were imputed to TOPMed, a dense multiancestry reference panel. Each of the 10 studies conducted a genome-wide association studies for each phenotype and summary results were meta-analyzed, stratified by ancestry. Analysis of antithrombin included 25 243 European ancestry and 2688 African ancestry participants, PC analysis included 16 597 European ancestry and 2688 African ancestry participants, PSF and PST analysis included 4113 and 6409 European ancestry participants. We also conducted transcriptome-wide association analyses and multiphenotype analysis to discover additional associations. Novel genome-wide association studies and transcriptome-wide association analyses findings were validated by in vitro functional experiments. Mendelian randomization was performed to assess the causal relationship between these proteins and cardiovascular outcomes. RESULTS Genome-wide association studies meta-analyses identified 4 newly associated loci: 3 with antithrombin levels (GCKR, BAZ1B, and HP-TXNL4B) and 1 with PS levels (ORM1-ORM2). transcriptome-wide association analyses identified 3 newly associated genes: 1 with antithrombin level (FCGRT), 1 with PC (GOLM2), and 1 with PS (MYL7). In addition, we replicated 7 independent loci reported in previous studies. Functional experiments provided evidence for the involvement of GCKR, SNX17, and HP genes in antithrombin regulation. CONCLUSIONS The use of larger sample sizes, diverse populations, and a denser imputation reference panel allowed the detection of 7 novel genomic loci associated with plasma antithrombin, PC, and PS levels.
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Affiliation(s)
- Yuekai Ji
- Cardiovascular Division, Department of Medicine, University of Minnesota, MN, USA
| | - Gerard Temprano-Sagrera
- Unit of genomics of Complex Disease, Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), Barcelona, Spain
| | - Lori A Holle
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, NC, USA
| | - Allison Bebo
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, TX, USA
| | | | - Ngoc-Quynh Le
- Unit of genomics of Complex Disease, Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), Barcelona, Spain
| | - Kadri Kangro
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, NC, USA
| | - Michael R Brown
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, TX, USA
| | - Angel Martinez-Perez
- Unit of genomics of Complex Disease, Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), Barcelona, Spain
| | - Colleen M Sitlani
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, WA, USA
| | - Pierre Suchon
- C2VN, INSERM, INRAE, Aix Marseille Univ, France
- Laboratory of Haematology, La Timone Hospital, France
| | - Marcus E Kleber
- SYNLAB MVZ für Humangenetik Mannheim, Germany
- Vth Department of Medicine, Medical Faculty Mannheim, Heidelberg University, Germany
| | - David B Emmert
- Institute for Biomedicine (affiliated to the University of Lübeck), Eurac Research, Italy
| | - Ayse Bilge Ozel
- Department of Human Genetics, University of Michigan, C.S. Mott Children’s Hospital, MI, USA
| | - Dre’Von A Dobson
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, NC, USA
| | - Weihong Tang
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, MN, USA
| | - Dolors Llobet
- Unit of Thrombosis and Hemostasis, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Russell P Tracy
- Department of Pathology and Laboratory Medicine, University of Vermont College of Medicine, VT, USA
| | - Jean-François Deleuze
- Centre National de Recherche en Génomique Humaine, CEA, France
- Centre d’Etude du Polymorphisme Humain, Fondation Jean Dausset, France
- Laboratory of Excellence on Medical Genomics (GenMed), France
| | - Graciela E Delgado
- Vth Department of Medicine, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Martin Gögele
- Institute for Biomedicine (affiliated to the University of Lübeck), Eurac Research, Italy
| | | | - Juan Carlos Souto
- Unit of genomics of Complex Disease, Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), Barcelona, Spain
- Unit of Thrombosis and Hemostasis, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - James S Pankow
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, MN, USA
| | - Kent D Taylor
- The Institute for Translational Genomics and Population Sciences, Department of Pediatrics, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, CA, USA
| | - David-Alexandre Trégouët
- Laboratory of Excellence on Medical Genomics (GenMed), France
- INSERM UMR 1219, Bordeaux Population Health Research Center, France
| | - Angela P Moissl
- Vth Department of Medicine, Medical Faculty Mannheim, Heidelberg University, Germany
- Institute of Nutritional Sciences, Friedrich Schiller University Jena, Germany
- Competence Cluster for Nutrition and Cardiovascular Health(nutriCARD) Halle-Jena-Leipzig, Germany
| | - Christian Fuchsberger
- Institute for Biomedicine (affiliated to the University of Lübeck), Eurac Research, Italy
| | - Frits R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, the Netherlands
| | - Alanna C Morrison
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, TX, USA
| | - Jose Manuel Soria
- Unit of genomics of Complex Disease, Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), Barcelona, Spain
| | - Mary Cushman
- Larner College of Medicine, University of Vermont, VT, USA
| | - Pierre-Emmanuel Morange
- C2VN, INSERM, INRAE, Aix Marseille Univ, France
- Laboratory of Haematology, La Timone Hospital, France
| | - Winfried März
- Vth Department of Medicine, Medical Faculty Mannheim, Heidelberg University, Germany
- Synlab Academy, Synlab Holding Deutschland GmbH, Germany
| | - Andrew A Hicks
- Institute for Biomedicine (affiliated to the University of Lübeck), Eurac Research, Italy
| | - Karl C Desch
- Department of Pediatrics, University of Michigan, C.S. Mott Children’s Hospital, MI, USA
| | - Andrew D Johnson
- National Heart Lung and Blood Institute, Division of Intramural Research, Population Sciences Branch, The Framingham Heart Study, MA, USA
| | - Paul S de Vries
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, TX, USA
| | | | | | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, NC, USA
| | - Nicholas L Smith
- Department of Epidemiology, University of Washington, WA, USA
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente, WA, USA
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, WA, USA
| | - Maria Sabater-Lleal
- Unit of genomics of Complex Disease, Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), Barcelona, Spain
- Cardiovascular Medicine Unit, Department of Medicine, Karolinska Institutet, Center for Molecular Medicine, Stockholm, Sweden
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16
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Huffman JE, Nicolas J, Hahn J, Heath AS, Raffield LM, Yanek LR, Brody JA, Thibord F, Almasy L, Bartz TM, Bielak LF, Bowler RP, Carrasquilla GD, Chasman DI, Chen MH, Emmert DB, Ghanbari M, Haessle J, Hottenga JJ, Kleber ME, Le NQ, Lee J, Lewis JP, Li-Gao R, Luan J, Malmberg A, Mangino M, Marioni RE, Martinez-Perez A, Pankratz N, Polasek O, Richmond A, Rodriguez BA, Rotter JI, Steri M, Suchon P, Trompet S, Weiss S, Zare M, Auer P, Cho MH, Christofidou P, Davies G, de Geus E, Deleuze JF, Delgado GE, Ekunwe L, Faraday N, Gögele M, Greinacher A, He G, Howard T, Joshi PK, Kilpeläinen TO, Lahti J, Linneberg A, Naitza S, Noordam R, Paüls-Vergés F, Rich SS, Rosendaal FR, Rudan I, Ryan KA, Souto JC, van Rooij FJ, Wang H, Zhao W, Becker LC, Beswick A, Brown MR, Cade BE, Campbell H, Cho K, Crapo JD, Curran JE, de Maat MP, Doyle M, Elliott P, Floyd JS, Fuchsberger C, Grarup N, Guo X, Harris SE, Hou L, Kolcic I, Kooperberg C, Menni C, Nauck M, O'Connell JR, Orrù V, Psaty BM, Räikkönen K, Smith JA, Soria JM, Stott DJ, van Hylckama Vlieg A, Watkins H, Willemsen G, Wilson P, Ben-Shlomo Y, Blangero J, Boomsma D, Cox SR, Dehghan A, Eriksson JG, Fiorillo E, Fornage M, Hansen T, Hayward C, Ikram MA, Jukema JW, Kardia SL, Lange LA, März W, Mathias RA, Mitchell BD, Mook-Kanamori DO, Morange PE, Pedersen O, Pramstaller PP, Redline S, Reiner A, Ridker PM, Silverman EK, Spector TD, Völker U, Wareham N, Wilson JF, Yao J, Trégouët DA, Johnson AD, Wolberg AS, de Vries PS, Sabater-Lleal M, Morrison AC, Smith NL. Whole genome analysis of plasma fibrinogen reveals population-differentiated genetic regulators with putative liver roles. medRxiv 2023:2023.06.07.23291095. [PMID: 37398003 PMCID: PMC10312878 DOI: 10.1101/2023.06.07.23291095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Genetic studies have identified numerous regions associated with plasma fibrinogen levels in Europeans, yet missing heritability and limited inclusion of non-Europeans necessitates further studies with improved power and sensitivity. Compared with array-based genotyping, whole genome sequencing (WGS) data provides better coverage of the genome and better representation of non-European variants. To better understand the genetic landscape regulating plasma fibrinogen levels, we meta-analyzed WGS data from the NHLBI's Trans-Omics for Precision Medicine (TOPMed) program (n=32,572), with array-based genotype data from the Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE) Consortium (n=131,340) imputed to the TOPMed or Haplotype Reference Consortium panel. We identified 18 loci that have not been identified in prior genetic studies of fibrinogen. Of these, four are driven by common variants of small effect with reported MAF at least 10% higher in African populations. Three ( SERPINA1, ZFP36L2 , and TLR10) signals contain predicted deleterious missense variants. Two loci, SOCS3 and HPN , each harbor two conditionally distinct, non-coding variants. The gene region encoding the protein chain subunits ( FGG;FGB;FGA ), contains 7 distinct signals, including one novel signal driven by rs28577061, a variant common (MAF=0.180) in African reference panels but extremely rare (MAF=0.008) in Europeans. Through phenome-wide association studies in the VA Million Veteran Program, we found associations between fibrinogen polygenic risk scores and thrombotic and inflammatory disease phenotypes, including an association with gout. Our findings demonstrate the utility of WGS to augment genetic discovery in diverse populations and offer new insights for putative mechanisms of fibrinogen regulation. Key Points Largest and most diverse genetic study of plasma fibrinogen identifies 54 regions (18 novel), housing 69 conditionally distinct variants (20 novel).Sufficient power achieved to identify signal driven by African population variant.Links to (1) liver enzyme, blood cell and lipid genetic signals, (2) liver regulatory elements, and (3) thrombotic and inflammatory disease.
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17
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Hahn J, Bressler J, Domingo-Relloso A, Chen MH, McCartney DL, Teumer A, van Dongen J, Kleber ME, Aïssi D, Swenson BR, Yao J, Zhao W, Huang J, Xia Y, Brown MR, Costeira R, de Geus EJC, Delgado GE, Dobson DA, Elliott P, Grabe HJ, Guo X, Harris SE, Huffman JE, Kardia SLR, Liu Y, Lorkowski S, Marioni RE, Nauck M, Ratliff SM, Sabater-Lleal M, Spector TD, Suchon P, Taylor KD, Thibord F, Trégouët DA, Wiggins KL, Willemsen G, Bell JT, Boomsma DI, Cole SA, Cox SR, Dehghan A, Greinacher A, Haack K, März W, Morange PE, Rotter JI, Sotoodehnia N, Tellez-Plaza M, Navas-Acien A, Smith JA, Johnson AD, Fornage M, Smith NL, Wolberg AS, Morrison AC, de Vries PS. DNA methylation analysis is used to identify novel genetic loci associated with circulating fibrinogen levels in blood. J Thromb Haemost 2023; 21:1135-1147. [PMID: 36716967 DOI: 10.1016/j.jtha.2023.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 11/04/2022] [Accepted: 01/17/2023] [Indexed: 01/30/2023]
Abstract
BACKGROUND Fibrinogen plays an essential role in blood coagulation and inflammation. Circulating fibrinogen levels may be determined based on interindividual differences in DNA methylation at cytosine-phosphate-guanine (CpG) sites and vice versa. OBJECTIVES To perform an EWAS to examine an association between blood DNA methylation levels and circulating fibrinogen levels to better understand its biological and pathophysiological actions. METHODS We performed an epigenome-wide association study of circulating fibrinogen levels in 18 037 White, Black, American Indian, and Hispanic participants, representing 14 studies from the Cohorts for Heart and Aging Research in Genomic Epidemiology consortium. Circulating leukocyte DNA methylation was measured using the Illumina 450K array in 12 904 participants and using the EPIC array in 5133 participants. In each study, an epigenome-wide association study of fibrinogen was performed using linear mixed models adjusted for potential confounders. Study-specific results were combined using array-specific meta-analysis, followed by cross-replication of epigenome-wide significant associations. We compared models with and without CRP adjustment to examine the role of inflammation. RESULTS We identified 208 and 87 significant CpG sites associated with fibrinogen levels from the 450K (p < 1.03 × 10-7) and EPIC arrays (p < 5.78 × 10-8), respectively. There were 78 associations from the 450K array that replicated in the EPIC array and 26 vice versa. After accounting for overlapping sites, there were 83 replicated CpG sites located in 61 loci, of which only 4 have been previously reported for fibrinogen. The examples of genes located near these CpG sites were SOCS3 and AIM2, which are involved in inflammatory pathways. The associations of all 83 replicated CpG sites were attenuated after CRP adjustment, although many remained significant. CONCLUSION We identified 83 CpG sites associated with circulating fibrinogen levels. These associations are partially driven by inflammatory pathways shared by both fibrinogen and CRP.
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Affiliation(s)
- Julie Hahn
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas, USA.
| | - Jan Bressler
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Arce Domingo-Relloso
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, New York, USA; Department of Chronic Diseases Epidemiology, National Center for Epidemiology, Carlos III Health Institutes, Madrid, Spain; Department of Statistics and Operations Research, University of Valencia, Burjassot, Spain
| | - Ming-Huei Chen
- Population Sciences Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, Framingham, Massachusetts, USA
| | - Daniel L McCartney
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, United Kingdom
| | - Alexander Teumer
- Department SHIP/Clinical-Epidemiological Research, Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Greifswald, Greifswald, Germany; Department of Population Medicine and Lifestyle Diseases Prevention, Medical University of Bialystok, Bialystok, Poland
| | - Jenny van Dongen
- Department of Biological Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Marcus E Kleber
- Vth Department of Medicine, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany; SYNLAB MVZ Humangenetik Mannheim, Mannheim, Germany
| | - Dylan Aïssi
- Univ. Bordeaux, INSERM, Bordeaux Population Health Research Center, UMR 1219, Molecular Epidemiology of Vascular and Brain Disorders, Bordeaux, France
| | - Brenton R Swenson
- Cardiovascular Health Research Unit, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Jie Yao
- Pediatrics, Genomic Outcomes, The Institute for Translational Genomics and Population Sciences, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, USA
| | - Wei Zhao
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA; Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | - Jian Huang
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, United Kingdom
| | - Yujing Xia
- Department of Twin Research and Genetic Epidemiology, St Thomas Hospital Campus, King's College London, London, United Kingdom
| | - Michael R Brown
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Ricardo Costeira
- Department of Twin Research and Genetic Epidemiology, St Thomas Hospital Campus, King's College London, London, United Kingdom
| | - Eco J C de Geus
- Department of Biological Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Graciela E Delgado
- Vth Department of Medicine, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Dre'Von A Dobson
- Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Paul Elliott
- Department of Epidemiology and Biostatistics, MRC Centre for Environment and Health, School of Public Health, Imperial College London, London, United Kingdom; UK Dementia Research Institute, Imperial College London, London, United Kingdom; British Heart Foundation Centre for Research Excellence, Imperial College London, London, United Kingdom
| | - Hans J Grabe
- Department of Psychiatry and Psychotherapy, University Medicine Greifswald, Greifswald, Germany; German Center for Neurodegenerative Diseases (DZNE), Site Rostock/Greifswald, Greifswald, Germany
| | - Xiuqing Guo
- Pediatrics, Genomic Outcomes, The Institute for Translational Genomics and Population Sciences, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, USA
| | - Sarah E Harris
- Lothian Birth Cohorts, Department of Psychology, University of Edinburgh, Edinburgh, United Kingdom
| | - Jennifer E Huffman
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Sharon L R Kardia
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Yongmei Liu
- Medicine, Cardiology, Duke Molecular Physiology Institute, Durham, North Carolina, USA
| | - Stefan Lorkowski
- Institute of Nutritional Sciences, Friedrich Schiller University Jena, Jena, Germany; Competence Cluster for Nutrition and Cardiovascular Health (nutriCARD) Halle-Jena-Leipzig, Jena, Germany
| | - Riccardo E Marioni
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, United Kingdom
| | - Matthias Nauck
- DZHK (German Centre for Cardiovascular Research), Partner Site Greifswald, Greifswald, Germany; Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Scott M Ratliff
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Maria Sabater-Lleal
- Genomics of Complex Disease Unit, Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain; Department of Medicine, Cardiovascular Medicine Unit, Karolinska Institutet, Stockholm, Sweden
| | - Tim D Spector
- Department of Twin Research and Genetic Epidemiology, St Thomas Hospital Campus, King's College London, London, United Kingdom
| | - Pierre Suchon
- Center for CardioVascular and Nutrition research (C2VN), INSERM 1263, INRAE 1260, Hematology Laboratory, La Timone University Hospital of Marseille, Aix-Marseille University, Marseille, France
| | - Kent D Taylor
- Pediatrics, Genomic Outcomes, The Institute for Translational Genomics and Population Sciences, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, USA
| | - Florian Thibord
- Population Sciences Branch, National Heart, Lung, and Blood Institute, Framingham, Massachusetts, USA
| | - David-Alexandre Trégouët
- Univ. Bordeaux, INSERM, Bordeaux Population Health Research Center, UMR 1219, Molecular Epidemiology of Vascular and Brain Disorders, Bordeaux, France
| | - Kerri L Wiggins
- Department of Medicine, Division of General Internal Medicine, University of Washington, Seattle, Washington, USA
| | - Gonneke Willemsen
- Department of Biological Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Jordana T Bell
- Department of Twin Research and Genetic Epidemiology, St Thomas Hospital Campus, King's College London, London, United Kingdom
| | - Dorret I Boomsma
- Department of Biological Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Shelley A Cole
- Population Health Program, Texas Biomedical Research Institute, San Antonio, Texas, USA
| | - Simon R Cox
- Lothian Birth Cohorts, Department of Psychology, University of Edinburgh, Edinburgh, United Kingdom
| | - Abbas Dehghan
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, United Kingdom
| | - Andreas Greinacher
- Institute for Immunology and Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Karin Haack
- Population Health Program, Texas Biomedical Research Institute, San Antonio, Texas, USA
| | - Winfried März
- Vth Department of Medicine, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany; SYNLAB Academy, SYNLAB Holding Deutschland GmbH, Mannheim, Germany; Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Pierre-Emmanuel Morange
- Cardiovascular and Nutrition Reserach Center (C2VN), INSERM, INRAE, Aix-Marseille University, Marseille, France
| | - Jerome I Rotter
- Pediatrics, Genomic Outcomes, The Institute for Translational Genomics and Population Sciences, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, USA
| | - Nona Sotoodehnia
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Maria Tellez-Plaza
- Department of Chronic Diseases Epidemiology, National Center for Epidemiology, Carlos III Health Institutes, Madrid, Spain
| | - Ana Navas-Acien
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Jennifer A Smith
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA; Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | - Andrew D Johnson
- Population Sciences Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, Framingham, Massachusetts, USA
| | - Myriam Fornage
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas, USA; Institute of Molecular Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Nicholas L Smith
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, USA; Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA; Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, Washington, USA
| | - Alisa S Wolberg
- Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Alanna C Morrison
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Paul S de Vries
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas, USA.
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18
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Ilich A, Gernsheimer TB, Triulzi DJ, Herren H, Brown SP, Holle LA, Lucas AT, de Laat B, El Kassar N, Wolberg AS, May S, Key NS. Absence of hyperfibrinolysis may explain lack of efficacy of tranexamic acid in hypoproliferative thrombocytopenia. Blood Adv 2023; 7:900-908. [PMID: 36044391 PMCID: PMC10025092 DOI: 10.1182/bloodadvances.2022008255] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/29/2022] [Accepted: 08/21/2022] [Indexed: 11/20/2022] Open
Abstract
The American Trial Using Tranexamic Acid (TXA) in Thrombocytopenia (A-TREAT, NCT02578901) demonstrated no superiority of TXA over placebo in preventing World Health Organization (WHO) grade 2 or higher bleeding in patients with severe thrombocytopenia requiring supportive platelet transfusion following myeloablative therapy for hematologic disorders. In this ancillary study, we sought to determine whether this clinical outcome could be explained on the basis of correlative assays of fibrinolysis. Plasma was collected from A-TREAT participants (n = 115) before the initiation of study drug (baseline) and when TXA was at steady-state trough concentration (follow-up). Global fibrinolysis was measured by 3 assays: euglobulin clot lysis time (ECLT), plasmin generation (PG), and tissue-type plasminogen activator (tPA)-challenged clot lysis time (tPA-CLT). TXA was quantified in follow-up samples by tandem mass spectrometry. Baseline samples did not demonstrate fibrinolytic activation by ECLT or tPA-CLT. Furthermore, neither ECLT nor levels of plasminogen activator inhibitor-1, tPA, plasminogen, alpha2-antiplasmin, or plasmin-antiplasmin complexes were associated with a greater risk of WHO grade 2+ bleeding. TXA trough concentrations were highly variable (range, 0.7-10 μg/mL) and did not correlate with bleeding severity, despite the fact that plasma TXA levels correlated strongly with pharmacodynamic assessments by PG (Spearman r, -0.78) and tPA-CLT (r, 0.74). We conclude that (1) no evidence of fibrinolytic activation was observed in these patients with thrombocytopenia, (2) trough TXA concentrations varied significantly between patients receiving the same dosing schedule, and (3) tPA-CLT and PG correlated well with TXA drug levels.
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Affiliation(s)
- Anton Ilich
- Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
- UNC Blood Research Center, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Terry B. Gernsheimer
- Department of Medicine/Hematology and Seattle Cancer Care Alliance, University of Washington, Seattle, WA
| | | | - Heather Herren
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Siobhan P. Brown
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Lori A. Holle
- UNC Blood Research Center, University of North Carolina School of Medicine, Chapel Hill, NC
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Andrew T. Lucas
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC
| | - Bas de Laat
- Synapse Research Institute, Maastricht, The Netherlands
| | - Nahed El Kassar
- Division of Blood Diseases and Resources, National Heart Lung and Blood Institute, Washington, DC
| | - Alisa S. Wolberg
- UNC Blood Research Center, University of North Carolina School of Medicine, Chapel Hill, NC
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Susanne May
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Nigel S. Key
- Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
- UNC Blood Research Center, University of North Carolina School of Medicine, Chapel Hill, NC
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
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19
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Nugent D, Acharya SS, Baumann KJ, Bedrosian C, Bialas R, Brown K, Corzo D, Haidar A, Hayward CPM, Marks P, Menegatti M, Miller ME, Nammacher K, Palla R, Peltier S, Pruthi RK, Recht M, Sørensen B, Tarantino M, Wolberg AS, Shapiro AD. Building the foundation for a community-generated national research blueprint for inherited bleeding disorders: research priorities for ultra-rare inherited bleeding disorders. Expert Rev Hematol 2023; 16:55-70. [PMID: 36920862 PMCID: PMC10020868 DOI: 10.1080/17474086.2023.2175661] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/30/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Ultra-rare inherited bleeding disorders (BDs) present important challenges for generating a strong evidence foundation for optimal diagnosis and management. Without disorder-appropriate treatment, affected individuals potentially face life-threatening bleeding, delayed diagnosis, suboptimal management of invasive procedures, psychosocial distress, pain, and decreased quality-of-life. RESEARCH DESIGN AND METHODS The National Hemophilia Foundation (NHF) and the American Thrombosis and Hemostasis Network identified the priorities of people with inherited BDs and their caregivers, through extensive inclusive community consultations, to inform a blueprint for future decades of research. Multidisciplinary expert Working Group (WG) 3 distilled highly feasible transformative ultra-rare inherited BD research opportunities from the community-identified priorities. RESULTS WG3 identified three focus areas with the potential to advance the needs of all people with ultra-rare inherited BDs and scored the feasibility, impact, and risk of priority initiatives, including 13 in systems biology and mechanistic science; 2 in clinical research, data collection, and research infrastructure; and 5 in the regulatory process for novel therapeutics and required data collection. CONCLUSIONS Centralization and expansion of expertise and resources, flexible innovative research and regulatory approaches, and inclusion of all people with ultra-rare inherited BDs and their health care professionals will be essential to capitalize on the opportunities outlined herein.
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Affiliation(s)
- Diane Nugent
- Center for Inherited Blood Disorders, Orange, California, USA
- Children’s Hospital of Orange County, University of California at Irvine, Irvine, California, USA
| | - Suchitra S. Acharya
- Hemostasis and Thrombosis Center, Northwell Health, New Hyde Park, New York, New York, USA
| | - Kimberly J. Baumann
- Center for Bleeding and Clotting Disorders, M Health Fairview, Minneapolis, Minnesota, USA
| | | | - Rebeca Bialas
- Plasminogen Deficiency Foundation, Durham, North Carolina, USA
| | - Kai Brown
- National Hemophilia Foundation, New York, New York, USA
| | - Deya Corzo
- Sigilon Therapeutics, Cambridge, Massachusetts, USA
| | - Amar Haidar
- Patient author, Lived Experience Expert, Dearborn, Michigan, USA
| | - Catherine P. M. Hayward
- Hamilton Regional Laboratory Medicine Program, Hamilton Health Sciences, Hamilton, Ontario, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Peter Marks
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Marzia Menegatti
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | | | - Roberta Palla
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Skye Peltier
- Center for Bleeding and Clotting Disorders, M Health Fairview, Minneapolis, Minnesota, USA
| | - Rajiv K. Pruthi
- Comprehensive Hemophilia Center, Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael Recht
- American Thrombosis and Hemostasis Network, Rochester, New York, USA
- The Hemophilia Center, Oregon Health & Science University, Portland, Oregon, USA
| | | | | | - Alisa S. Wolberg
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Amy D. Shapiro
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana, USA
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Dobson DA, Holle LA, Lin FC, Huffman JE, Luyendyk JP, Flick MJ, Smith NL, de Vries PS, Morrison AC, Wolberg AS. Novel genetic regulators of fibrinogen synthesis identified by an in vitro experimental platform. J Thromb Haemost 2023; 21:522-533. [PMID: 36696182 PMCID: PMC10111212 DOI: 10.1016/j.jtha.2022.10.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/06/2022] [Accepted: 10/26/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Fibrinogen has an established, essential role in both coagulation and inflammatory pathways, and these processes are deeply intertwined in the development of thrombotic and atherosclerotic diseases. Previous studies aimed to better understand the (patho) physiological actions of fibrinogen by characterizing the genomic contribution to circulating fibrinogen levels. OBJECTIVES Establish an in vitro approach to define functional roles between genes within these loci and fibrinogen synthesis. METHODS Candidate genes were selected on the basis of their proximity to genetic variants associated with fibrinogen levels and expression in hepatocytes and HepG2 cells. HepG2 cells were transfected with small interfering RNAs targeting candidate genes and cultured in the absence or presence of the proinflammatory cytokine interleukin-6. Effects on fibrinogen protein production, gene expression, and cell growth were assessed by immunoblotting, real-time polymerase chain reaction, and cell counts, respectively. RESULTS HepG2 cells secreted fibrinogen, and stimulation with interleukin-6 increased fibrinogen production by 3.4 ± 1.2 fold. In the absence of interleukin-6, small interfering RNA knockdown of FGA, IL6R, or EEPD1 decreased fibrinogen production, and knockdown of LEPR, PDIA5, PLEC, SHANK3, or CPS1 increased production. In the presence of interleukin-6, knockdown of FGA, IL6R, or ATXN2L decreased fibrinogen production. Knockdown of FGA, IL6R, EEPD1, LEPR, PDIA5, PLEC, or CPS1 altered transcription of one or more fibrinogen genes. Knocking down ATXN2L suppressed inducible but not basal fibrinogen production via a post-transcriptional mechanism. CONCLUSIONS We established an in vitro platform to define the impact of select gene products on fibrinogen production. Genes identified in our screen may reveal cellular mechanisms that drive fibrinogen production as well as fibrin(ogen)-mediated (patho)physiological mechanisms.
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Affiliation(s)
- Dre'Von A Dobson
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, NC, USA
| | - Lori A Holle
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, NC, USA
| | - Feng-Chang Lin
- Department of Biostatistics and North Carolina Translational and Clinical Sciences Institute, University of North Carolina at Chapel Hill, NC, USA
| | | | - James P Luyendyk
- Department of Pathobiology and Diagnostic Investigation, Michigan State University, East Lansing, MI, USA
| | - Matthew J Flick
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, NC, USA
| | - Nicholas L Smith
- Department of Epidemiology, University of Washington, Seattle WA, USA; Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle WA, USA; Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle WA, USA; Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Paul S de Vries
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle WA, USA
| | - Alanna C Morrison
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle WA, USA
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, NC, USA.
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Reitsma SE, Holle LA, Bouck EG, Monroe DM, Mast AE, Burthem J, Bolton-Maggs PHB, Gidley GN, Wolberg AS. Tissue factor pathway inhibitor is a potential modifier of bleeding risk in factor XI deficiency. J Thromb Haemost 2023; 21:467-479. [PMID: 36696199 PMCID: PMC10111213 DOI: 10.1016/j.jtha.2022.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/26/2022] [Accepted: 10/06/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Factor (F) XI deficiency is associated with increased bleeding risk in some individuals. Neither FXI levels nor clinical clotting assays predict the bleeding risk. Compared with controls, FXI-deficient bleeders have reduced clot formation, decreased fibrin network density, and increased susceptibility to fibrinolysis. Tissue factor pathway inhibitor (TFPI) was recently implicated as a modifying factor in individuals with bleeding of unknown cause. OBJECTIVES To determine the potential of TFPI in modifying the bleeding risk in FXI-deficient individuals. METHODS The effects of TFPI on thrombin generation and clot formation, structure, and fibrinolysis in FXI-deficient plasma were measured in vitro in the absence or presence of inhibitory anti-TFPI antibody or exogenous recombinant TFPIα. Total plasma TFPI concentration was measured in 2 independent cohorts of controls and FXI-deficient individuals classified as bleeders or nonbleeders (cohort 1: 10 controls and 16 FXI-deficient individuals; cohort 2: 48 controls and 57 FXI-deficient individuals) and correlated with ex vivo plasma clot formation and fibrinolysis parameters associated with bleeding risk. RESULTS In an in vitro FXI deficiency model, inhibition of TFPI enhanced thrombin generation and clot formation, increased the network density, and decreased fibrinolysis, whereas an increase in TFPI had the opposite effects. Compared with controls, plasma from FXI-deficient bleeders had higher TFPI concentration. Total plasma TFPI concentrations correlated with parameters from ex vivo clotting and fibrinolysis assays that differentiate FXI-deficient bleeders and nonbleeders. CONCLUSION Coagulation and fibrinolysis parameters that differentiate FXI-deficient nonbleeders and bleeders were altered by plasma TFPIα. Total plasma TFPI was increased in FXI-deficient bleeders. TFPI may modify the bleeding risk in FXI-deficient individuals.
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Affiliation(s)
- Stéphanie E Reitsma
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Lori A Holle
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Emma G Bouck
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Dougald M Monroe
- Department of Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, North Carolina, USA
| | - Alan E Mast
- Versiti Blood Research Institute, Milwaukee, Wisconsin, USA
| | - John Burthem
- Department of Haematology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK; Institute of Cancer Sciences, The University of Manchester, Manchester, UK
| | | | - Gillian N Gidley
- Institute of Cancer Sciences, The University of Manchester, Manchester, UK; Department of Haematology, St James' Hospital, Leeds Teaching Hospitals Trust, UK
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA.
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22
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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23
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Bouck EG, Arvanitis M, Osburn WO, Sang Y, Reventun P, Ahmadzia HK, Smith NL, Lowenstein CJ, Wolberg AS. High risk oral contraceptive hormones do not directly enhance endothelial cell procoagulant activity in vitro. PLoS One 2023; 18:e0284333. [PMID: 37075041 PMCID: PMC10115293 DOI: 10.1371/journal.pone.0284333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/28/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Oral contraceptive (OC) use increases venous thromboembolism risk 2-5-fold. Procoagulant changes can be detected in plasma from OC users even without thrombosis, but cellular mechanisms that provoke thrombosis have not been identified. Endothelial cell (EC) dysfunction is thought to initiate venous thromboembolism. It is unknown whether OC hormones provoke aberrant procoagulant activity in ECs. OBJECTIVE Characterize the effect of high-risk OC hormones (ethinyl estradiol [EE] and drospirenone) on EC procoagulant activity and the potential interplay with nuclear estrogen receptors ERα and ERβ and inflammatory processes. METHODS Human umbilical vein and dermal microvascular ECs (HUVEC and HDMVEC, respectively) were treated with EE and/or drospirenone. Genes encoding the estrogen receptors ERα and ERβ (ESR1 and ESR2, respectively) were overexpressed in HUVEC and HDMVEC via lentiviral vectors. EC gene expression was assessed by RT-qPCR. The ability of ECs to support thrombin generation and fibrin formation was measured by calibrated automated thrombography and spectrophotometry, respectively. RESULTS Neither EE nor drospirenone, alone or together, changed expression of genes encoding anti- or procoagulant proteins (TFPI, THBD, F3), integrins (ITGAV, ITGB3), or fibrinolytic mediators (SERPINE1, PLAT). EE and/or drospirenone did not increase EC-supported thrombin generation or fibrin formation, either. Our analyses indicated a subset of individuals express ESR1 and ESR2 transcripts in human aortic ECs. However, overexpression of ESR1 and/or ESR2 in HUVEC and HDMVEC did not facilitate the ability of OC-treated ECs to support procoagulant activity, even in the presence of a pro-inflammatory stimulus. CONCLUSIONS The OC hormones EE and drospirenone do not directly enhance thrombin generation potential of primary ECs in vitro.
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Affiliation(s)
- Emma G Bouck
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Marios Arvanitis
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - William O Osburn
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Yaqiu Sang
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Paula Reventun
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Homa K Ahmadzia
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, George Washington University, Washington, DC, United States of America
| | - Nicholas L Smith
- Department of Epidemiology, University of Washington, Seattle, WA, United States of America
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA, United States of America
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, WA, United States of America
| | - Charles J Lowenstein
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
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Kamin Mukaz D, Guo B, Long DL, Judd SE, Plante TB, McClure LA, Wolberg AS, Zakai NA, Howard G, Cushman M. D-dimer and the risk of hypertension: The REasons for Geographic And Racial Differences in Stroke Cohort Study. Res Pract Thromb Haemost 2023; 7:100016. [PMID: 36760775 PMCID: PMC9903654 DOI: 10.1016/j.rpth.2022.100016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 11/17/2022] [Indexed: 01/21/2023] Open
Abstract
Background Reasons for increased risk of hypertension in Black compared with White people are only partly understood. D-dimer, a thrombo-inflammatory marker higher in Black individuals, is also higher in people with hypertension. However, the impact of D-dimer on racial disparities in risk of incident hypertension has not been studied. Objectives To assess whether D-dimer is associated with the risk of incident hypertension, whether the association between D-dimer and the risk of incident hypertension differs by race, and whether the biology reflected by D-dimer explains racial disparities in the risk of incident hypertension. Methods This study included 1867 participants in the REasons for Geographic And Racial Differences in Stroke cohort study without baseline hypertension and with a second visit 9.4 years after baseline. Risk ratios of incident hypertension by baseline D-dimer level were estimated, a D-dimer-by-race interaction was tested, and the mediating effect of D-dimer (which represents underlying biological processes) on the association of race and hypertension risk was assessed. Results The risk of incident hypertension was 47% higher in persons in the top quartile than in those in the bottom quartile of D-dimer (risk ratio [RR]: 1.47; 95% CI: 1.23-1.76). The association was partly attenuated after adjusting for sociodemographic and adiposity-related risk factors (RR: 1.22; 95% CI: 1.02-1.47). The association of D-dimer and hypertension did not differ by race, and D-dimer did not attenuate the racial difference in the risk of incident hypertension. Conclusion D-dimer concentration reflects pathophysiology related to the development of hypertension. Specific mechanisms require further study and may involve adiposity.
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Affiliation(s)
- Debora Kamin Mukaz
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Boyi Guo
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - D. Leann Long
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Suzanne E. Judd
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Timothy B. Plante
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Leslie A. McClure
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania, USA
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Neil A. Zakai
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
- Department of Pathology and Laboratory Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - George Howard
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
- Department of Pathology and Laboratory Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
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25
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Hur WS, King KC, Patel YN, Nguyen YV, Wei Z, Yang Y, Juang LJ, Leung J, Kastrup CJ, Wolberg AS, Luyendyk JP, Flick MJ. Elimination of fibrin polymer formation or crosslinking, but not fibrinogen deficiency, is protective against diet-induced obesity and associated pathologies. J Thromb Haemost 2022; 20:2873-2886. [PMID: 36111375 PMCID: PMC9669152 DOI: 10.1111/jth.15877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/09/2022] [Accepted: 09/12/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Obesity predisposes individuals to metabolic syndrome, which increases the risk of cardiovascular diseases, non-alcoholic fatty liver disease (NAFLD), and type 2 diabetes. A pathological manifestation of obesity is the activation of the coagulation system. In turn, extravascular fibrin(ogen) deposits accumulate in adipose tissues and liver. These deposits promote adiposity and downstream sequelae by driving pro-inflammatory macrophage function through binding the leukocyte integrin receptor αM β2 . OBJECTIVES An unresolved question is whether conversion of soluble fibrinogen to a crosslinked fibrin matrix is required to exacerbate obesity-driven diseases. METHODS Here, fibrinogen-deficient/depleted mice (Fib- or treated with siRNA against fibrinogen [siFga]), mice expressing fibrinogen that cannot polymerize to fibrin (FibAEK ), and mice deficient in the fibrin crosslinking transglutaminase factor XIII (FXIII-) were challenged with a high-fat diet (HFD) and compared to mice expressing a mutant form of fibrinogen lacking the αM β2 -binding domain (Fib𝛾390-396A ). RESULTS AND CONCLUSIONS Consistent with prior studies, Fib𝛾390-396A mice were significantly protected from increased adiposity, NAFLD, hypercholesterolemia, and diabetes while Fib- and siFga-treated mice gained as much weight and developed obesity-associated pathologies identical to wildtype mice. FibAEK and FXIII- mice displayed an intermediate phenotype with partial protection from some obesity-associated pathologies. Results here indicate that fibrin(ogen) lacking αM β2 binding function offers substantial protection from obesity and associated disease that is partially recapitulated by preventing fibrin polymer formation or crosslinking of the wildtype molecule, but not by reduction or complete elimination of fibrinogen. Finally, these findings support the concept that fibrin polymerization and crosslinking are required for the full implementation of fibrin-driven inflammation in obesity.
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Affiliation(s)
- Woosuk S. Hur
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Katharine C. King
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Yesha N. Patel
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Y-Van Nguyen
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Zimu Wei
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, MI, USA
| | - Yi Yang
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lih Jiin Juang
- Michael Smith Laboratories, and Department of Biochemistry and Molecular Biology, The University of British Columbia, Vancouver, BC, Canada
| | - Jerry Leung
- Michael Smith Laboratories, and Department of Biochemistry and Molecular Biology, The University of British Columbia, Vancouver, BC, Canada
| | - Christian J. Kastrup
- Michael Smith Laboratories, and Department of Biochemistry and Molecular Biology, The University of British Columbia, Vancouver, BC, Canada
- Blood Research institute, Versiti, Milwaukee, WI, USA
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - James P Luyendyk
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, MI, USA
| | - Matthew J. Flick
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Kangro K, Wolberg AS, Flick MJ. Fibrinogen, Fibrin, and Fibrin Degradation Products in COVID-19. Curr Drug Targets 2022; 23:1593-1602. [PMID: 36029073 DOI: 10.2174/1389450123666220826162900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/31/2022] [Accepted: 06/15/2022] [Indexed: 01/25/2023]
Abstract
Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) is the highly pathogenic and highly transmissible human coronavirus that is the causative agent for the worldwide COVID-19 pandemic. COVID-19 manifests predominantly as a respiratory illness with symptoms consistent with viral pneumonia, but other organ systems (e.g., kidney, heart, brain) can also become perturbed in COVID-19 patients. Accumulating data suggest that significant activation of the hemostatic system is a common pathological manifestation of SARS-CoV-2 infection. The clotting protein fibrinogen is one of the most abundant plasma proteins. Following activation of coagulation, the central coagulation protease thrombin converts fibrinogen to fibrin monomers, which selfassemble to form a matrix, the primary structural component of the blood clot. Severe COVID-19 is associated with a profound perturbation of circulating fibrinogen, intra- and extravascular fibrin deposition and persistence, and fibrin degradation. Current findings suggest high levels of fibrinogen and the fibrin degradation product D-dimer are biomarkers of poor prognosis in COVID-19. Moreover, emerging studies with in vitro and animal models indicate fibrin(ogen) as an active player in COVID-19 pathogenesis. Here, we review the current literature regarding fibrin(ogen) and COVID-19, including possible pathogenic mechanisms and treatment strategies centered on clotting and fibrin(ogen) function.
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Affiliation(s)
- Kadri Kangro
- Department of Pathology and Laboratory Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Matthew J Flick
- Department of Pathology and Laboratory Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
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27
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Lawson MA, Holle LA, Dow NE, Hennig G, de Laat B, Moore HB, Moore EE, Cohen MJ, Bouchard BA, Freeman K, Wolberg AS. Plasma-based assays distinguish hyperfibrinolysis and shutdown subgroups in trauma-induced coagulopathy. J Trauma Acute Care Surg 2022; 93:579-587. [PMID: 35687811 PMCID: PMC9613511 DOI: 10.1097/ta.0000000000003723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trauma patients with abnormal fibrinolysis have increased morbidity and mortality. Knowledge of mechanisms differentiating fibrinolytic phenotypes is important to optimize treatment. We hypothesized that subjects with abnormal fibrinolysis identified by whole blood viscoelastometry can also be distinguished by plasma thrombin generation, clot structure, fibrin formation, and plasmin generation measurements. METHODS Platelet-poor plasma (PPP) from an observational cross-sectional trauma cohort with fibrinolysis shutdown (% lysis at 30 minutes [LY30] < 0.9, n = 11) or hyperfibrinolysis (LY30 > 3%, n = 9) defined by whole blood thromboelastography were studied. Noninjured control subjects provided comparative samples. Thrombin generation, fibrin structure and formation, and plasmin generation were measured by fluorescence, confocal microscopy, turbidity, and a fluorescence-calibrated plasmin assay, respectively, in the absence/presence of tissue factor or tissue plasminogen activator (tPA). RESULTS Whereas spontaneous thrombin generation was not detected in PPP from control subjects, PPP from hyperfibrinolysis or shutdown patients demonstrated spontaneous thrombin generation, and the lag time was shorter in hyperfibrinolysis versus shutdown. Addition of tissue factor masked this difference but revealed increased thrombin generation in hyperfibrinolysis samples. Compared with shutdown, hyperfibrinolysis PPP formed denser fibrin networks. In the absence of tPA, the fibrin formation rate was faster in shutdown than hyperfibrinolysis, but hyperfibrinolysis clots lysed spontaneously; these differences were masked by addition of tPA. Tissue plasminogen activator-stimulated plasmin generation was similar in hyperfibrinolysis and shutdown samples. Differences in LY30, fibrin structure, and lysis correlated with pH. CONCLUSION This exploratory study using PPP-based assays identified differences in thrombin generation, fibrin formation and structure, and lysis in hyperfibrinolysis and shutdown subgroups. These groups did not differ in their ability to promote tPA-triggered plasmin generation. The ability to characterize these activities in PPP facilitates studies to identify mechanisms that promote adverse outcomes in trauma. LEVEL OF EVIDENCE Prognostic/Epidemiological; Level III.
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Affiliation(s)
| | - Lori A. Holle
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nathan E. Dow
- Department of Surgery, University of Vermont, Burlington, VT, USA
| | - Grant Hennig
- Department of Pharmacology, University of Vermont, Burlington, VT, USA
| | - Bas de Laat
- Synapse Research Institute, Maastricht, the Netherlands
| | - Hunter B. Moore
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ernest E. Moore
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO, USA
| | - Mitchell J. Cohen
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Beth A. Bouchard
- Department of Biochemistry and Laboratory for Clinical Biochemistry Research, University of Vermont, Burlington, VT, USA
| | - Kalev Freeman
- Department of Surgery, University of Vermont, Burlington, VT, USA
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Conway EM, Mackman N, Warren RQ, Wolberg AS, Mosnier LO, Campbell RA, Gralinski LE, Rondina MT, van de Veerdonk FL, Hoffmeister KM, Griffin JH, Nugent D, Moon K, Morrissey JH. Understanding COVID-19-associated coagulopathy. Nat Rev Immunol 2022; 22:639-649. [PMID: 35931818 PMCID: PMC9362465 DOI: 10.1038/s41577-022-00762-9] [Citation(s) in RCA: 107] [Impact Index Per Article: 53.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2022] [Indexed: 02/06/2023]
Abstract
COVID-19-associated coagulopathy (CAC) is a life-threatening complication of SARS-CoV-2 infection. However, the underlying cellular and molecular mechanisms driving this condition are unclear. Evidence supports the concept that CAC involves complex interactions between the innate immune response, the coagulation and fibrinolytic pathways, and the vascular endothelium, resulting in a procoagulant condition. Understanding of the pathogenesis of this condition at the genomic, molecular and cellular levels is needed in order to mitigate thrombosis formation in at-risk patients. In this Perspective, we categorize our current understanding of CAC into three main pathological mechanisms: first, vascular endothelial cell dysfunction; second, a hyper-inflammatory immune response; and last, hypercoagulability. Furthermore, we pose key questions and identify research gaps that need to be addressed to better understand CAC, facilitate improved diagnostics and aid in therapeutic development. Finally, we consider the suitability of different animal models to study CAC.
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Affiliation(s)
- Edward M Conway
- Centre for Blood Research, Life Sciences Institute, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nigel Mackman
- Department of Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ronald Q Warren
- Molecular Cellular and Systems Blood Science Branch, Division of Blood Diseases and Resources, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Laurent O Mosnier
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA, USA
| | - Robert A Campbell
- Department of Internal Medicine, Division of General Medicine, University of Utah, Salt Lake City, UT, USA
| | - Lisa E Gralinski
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Matthew T Rondina
- Department of Internal Medicine, Division of General Medicine, University of Utah, Salt Lake City, UT, USA
| | - Frank L van de Veerdonk
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Karin M Hoffmeister
- Versiti Translational Glycomics Center, Blood Research Institute and Medical College of Wisconsin, Milwaukee, WI, USA
| | - John H Griffin
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA, USA
| | - Diane Nugent
- Department of Paediatrics, School of Medicine, University of California at Irvine, Irvine, CA, USA
| | - Kyung Moon
- Molecular Cellular and Systems Blood Science Branch, Division of Blood Diseases and Resources, National Heart, Lung, and Blood Institute, Bethesda, MD, USA.
- Bacteriology and Mycology Branch, Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA.
| | - James H Morrissey
- Department of Biological Chemistry, University of Michigan Medical School, Ann Arbor, MI, USA.
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.
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Chowdhury NN, Yang Y, Shen Y, Gampala S, Babb O, Han B, Wolberg AS, Flick MJ, Fishel ML. Abstract 2447: Unraveling the role of the fibrinolytic system in pancreatic cancer progression. Cancer Res 2022. [DOI: 10.1158/1538-7445.am2022-2447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Pancreatic ductal adenocarcinoma (PDAC) exhibits one of the poorest prognoses of all solid cancers and is associated with very low overall and progression-free survival rate. Clinically, PDAC patient tumors show high expression levels of multiple components of the coagulation system (e.g., tissue factor, etc.) and fibrinolytic system, including urokinase plasminogen activator (uPA) and receptor (uPAR). In addition, pancreatic cancer patients show elevated levels of circulating fibrinogen (Fib) and the fibrin degradation product D-dimer in plasma, with increased correlation in patients with distant metastasis. We hypothesized that targeting the plasminogen activation system components would disrupt PDAC tumor progression. Using pancreatic cancer cell lines from the KPC mouse model (K-rasLSL.G12D/+; p53LSL.R172H/+; Elas-CreER), individual components of the fibrinolytic system (uPA and uPAR) were eliminated using CRISPR-Cas9 technology. Knocking out uPA and uPAR in KPC cells resulted in significantly smaller tumors relative to Cas9 control tumors. Compared to WT mice, KPC murine pancreatic cancer cells injected orthotopically in Plg-/- mice had significantly attenuated tumor growth, suggesting the pro-tumor effect of tumor cell-derived uPA/uPAR expression was linked at least in part to plasmin(ogen) activation to enhance PDAC tumor progression. To further investigate the contribution of Plg or Fib in the microenvironment in PDAC progression, we used Plg or Fib specific antisense oligonucleotide (ASO) treatment to specifically deplete plasminogen or fibrinogen levels in mice bearing human PDAC tumors. Treatment with Plg-ASO or Fib-ASO significantly decreased tumor burden in both orthotopic and subcutaneous models bearing human tumors. Bioluminescent imaging revealed that Plg-ASO and Fib-ASO treatment also decreased the spontaneous metastatic burden. Histological analysis of lung and liver tissue from Plg-ASO-treated mice confirmed reduced metastatic burden of the primary tumor, especially to the lungs. Similarly, Fib-ASO-treated mice had significantly lower metastatic burden in both liver and lung tissues. Our data demonstrate that depleting Plg or Fib in circulation reduces tumor growth and metastasis. Collectively, our data suggests the PA system is important to both tumor growth and metastasis. Based on our findings with Plg depletion, the unexpected finding that depletion of the plasmin target fibrin(ogen) in the microenvironment also significantly reduces primary tumor growth and metastasis suggests plasmin(ogen) may function through fibrin(ogen)-independent mechanisms to promote PDAC progression.
Citation Format: Nayela N. Chowdhury, Yi Yang, Yingnan Shen, Silpa Gampala, Olivia Babb, Bumsoo Han, Alisa S. Wolberg, Matthew J. Flick, Melissa L. Fishel. Unraveling the role of the fibrinolytic system in pancreatic cancer progression [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 2447.
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Affiliation(s)
| | - Yi Yang
- 2University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | | | - Silpa Gampala
- 4Indiana University Wells Center for Pediatric Research, Indianapolis, IN
| | - Olivia Babb
- 4Indiana University Wells Center for Pediatric Research, Indianapolis, IN
| | | | - Alisa S. Wolberg
- 5University of North Carolina at Chapel Hill School of Medicine, Indianapolis, IN
| | - Matthew J. Flick
- 2University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
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Abstract
As the third most common vascular disease, venous thromboembolism is associated with significant mortality and morbidity. Pathogenesis underlying venous thrombosis is still not fully understood. Accumulating data suggest fibrin network structure and factor XIII-mediated crosslinking are major determinants of venous thrombus mass, composition, and stability. Understanding the cellular and molecular mechanisms mediating fibrin(ogen) and factor XIII production and function and their ability to influence venous thrombogenesis and resolution may inspire new anticoagulant strategies that target these proteins to reduce or prevent venous thrombosis in certain at-risk patients. This article summarizes fibrinogen and factor XIII biology and current knowledge of their function during venous thromboembolism.
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Affiliation(s)
- Alisa S Wolberg
- Department of Pathology and UNC Blood Research Center, University of North Carolina, Chapel Hill
| | - Yaqiu Sang
- Department of Pathology and UNC Blood Research Center, University of North Carolina, Chapel Hill
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Nersesian S, Sholzberg M, Cushman M, Wolberg AS. The Journey to a Successful Illustrated Review. Res Pract Thromb Haemost 2022; 6:e12721. [PMID: 35599704 PMCID: PMC9115973 DOI: 10.1002/rth2.12721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/19/2022] [Accepted: 04/22/2022] [Indexed: 12/05/2022] Open
Abstract
Illustrated review articles, rooted in scientific rigor, are made up of “capsules” or panels of visuals that together provide an up‐to‐date overview of a topic. Illustrated reviews aim to provide a more accessible format than traditional written reviews to facilitate more effective knowledge translation and dissemination. However, the novelty of this format can dissuade prospective authors due to uncertainty and lack of comfort. To remedy this uncertainty, we have summarized the journey of developing an illustrated review, from identifying an appropriate topic to submitting the final manuscript for peer review. We highlight the importance of approaching an illustrated review from a storytelling perspective, and encouraging authors to keep their audience in mind when picking a theme or characters. We provide storyboard considerations and simplify graphic design principles to develop an outline and line draft for the illustrated review. We list programs available to authors to demystify creating attractive and engaging scientific visuals. Finally, we provide information on choosing colors or fonts and where to find copyright‐free icons, graphics, illustrations, and pictures. This review provides prospective authors with the knowledge, tools, and resources to create an effective illustrated review article. If there is difficulty with the links embedded within the document please download the full PDF.
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Affiliation(s)
- Sarah Nersesian
- Microbiology and Immunology Dalhousie University Halifax Nova Scotia Canada
| | - Michelle Sholzberg
- St Michael's Hospital, Departments of Medicine and Laboratory Medicine & Pathobiology, Li Ka Shing Knowledge Institute, University of Toronto Toronto Ontario Canada
| | - Mary Cushman
- Department Medicine Robert Larner MD College of Medicine Burlington Vermont USA
| | - Alisa S. Wolberg
- Pathology and Laboratory Medicine and UNC Blood Research Center University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
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Mast AE, Wolberg AS, Gailani D, Garvin MR, Alvarez C, Miller JI, Jones P, Aronow B, Jacobson D. Response to comment on 'SARS-CoV-2 suppresses anticoagulant and fibrinolytic gene expression in the lung'. eLife 2022; 11:e74951. [PMID: 35014952 PMCID: PMC8752086 DOI: 10.7554/elife.74951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 11/24/2021] [Indexed: 11/16/2022] Open
Abstract
Early in the SARS-CoV-2 pandemic, we compared transcriptome data from hospitalized COVID-19 patients and control patients without COVID-19. We found changes in procoagulant and fibrinolytic gene expression in the lungs of COVID-19 patients (Mast et al., 2021). These findings have been challenged based on issues with the samples (Fitzgerald and Jamieson, 2022). We have revisited our previous analyses in the light of this challenge and find that these new analyses support our original conclusions.
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Affiliation(s)
- Alan E Mast
- Versiti Blood Research Institute, Department of Cell Biology Neurobiology and Anatomy Medical College of WisconsinMilwaukeeUnited States
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research CenterChapel HillUnited States
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical CenterNashvilleUnited States
| | - Michael R Garvin
- Oak Ridge National Laboratory, Biosciences DivisionOak RidgeUnited States
| | - Christiane Alvarez
- Oak Ridge National Laboratory, Biosciences DivisionOak RidgeUnited States
| | - J Izaak Miller
- Oak Ridge National Laboratory, Biosciences DivisionOak RidgeUnited States
| | - Piet Jones
- University of Tennessee Knoxville, The Bredesen Center for Interdisciplinary Research and Graduate EducationKnoxvilleUnited States
| | - Bruce Aronow
- Biomedical Informatics, Cincinnati Children’s Hospital Research Foundation, University of CincinnatiCincinnatiUnited States
| | - Daniel Jacobson
- Oak Ridge National Laboratory, Biosciences DivisionOak RidgeUnited States
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Kattula S, Sang Y, de Ridder G, Silver AC, Bouck EG, Cooley BC, Wolberg AS. Novel venous thromboembolism mouse model to evaluate the role of complete and partial factor XIII deficiency in pulmonary embolism risk. J Thromb Haemost 2021; 19:2997-3007. [PMID: 34431201 PMCID: PMC8605765 DOI: 10.1111/jth.15510] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/19/2021] [Accepted: 08/23/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Venous thrombosis (VT) and pulmonary embolism (PE), collectively venous thromboembolism (VTE), cause high mortality and morbidity. Factor XIII (FXIII) crosslinks fibrin to enhance thrombus stability and consequently may influence PE risk. Elucidating mechanisms contributing to PE is limited by a lack of models that recapitulate human PE characteristics. OBJECTIVE We aimed to develop a mouse model that permits embolization of red blood cell (RBC)- and fibrin-rich VT and determine the contribution of FXIII to PE risk. METHODS AND RESULTS In a thrombin-infusion PE model, F13a+/+ , F13a+/- , and F13a-/- mice had similar incidence of microthrombi in the lungs; however, thrombi were small, with low RBC content (≤7%), unlike human PEs (~70%). To identify a model producing PE consistent with histological characteristics of human PE, we compared mouse femoral vein electrolytic injury, femoral vein FeCl3 injury, and infrarenal vena cava (IVC) stasis models of VT. Electrolytic and FeCl3 models produced small thrombi with few RBCs (5% and 4%, respectively), whereas IVC stasis produced large thrombi with higher RBC content (68%) that was similar to human PEs. After IVC stasis and ligature removal (de-ligation) to permit thrombus embolization, compared to F13a+/+ mice, F13a+/- and F13a-/- mice had similar and increased PE incidence, respectively. CONCLUSIONS Compared to thrombin infusion-, electrolytic injury-, and FeCl3 -based models, IVC stasis produces thrombi that are more histologically similar to human thrombi. IVC stasis followed by de-ligation permits embolization of existing RBC- and fibrin-rich thrombi. Complete FXIII deficiency increases PE incidence, but partial deficiency does not.
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Affiliation(s)
- Sravya Kattula
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, USA
| | - Yaqiu Sang
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, USA
| | - Gustaaf de Ridder
- Department of Pathology and Laboratory Medicine, Transfusion Medicine, University of North Carolina at Chapel Hill, USA
| | - Anna C. Silver
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, USA
| | - Emma G. Bouck
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, USA
| | - Brian C. Cooley
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, USA
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, USA
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Abstract
Fibrinogen plays a fundamental role in coagulation through its support for platelet aggregation and its conversion to fibrin. Fibrin stabilizes clots and serves as a scaffold and immune effector before being broken down by the fibrinolytic system. Given its importance, abnormalities in fibrin(ogen) and fibrinolysis result in a variety of disorders with hemorrhagic and thrombotic manifestations. This review summarizes (i) the basic elements of fibrin(ogen) and its role in coagulation and the fibrinolytic system; (ii) the laboratory evaluation for fibrin(ogen) disorders, including the use of global fibrinolysis assays; and (iii) the management of congenital and acquired disorders of fibrinogen and fibrinolysis.
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Affiliation(s)
- Jori E May
- Division of Hematology/Oncology, University of Alabama at Birmingham, 1720 2nd Avenue South, NP 2503, Birmingham, AL 35294, USA
| | - Alisa S Wolberg
- UNC Department of Pathology and Laboratory Medicine, UNC Blood Research Center, 8018A Mary Ellen Jones Building, CB7035, Chapel Hill, NC 27599-7035, USA
| | - Ming Yeong Lim
- Department of Internal Medicine, Division of Hematology and Hematologic Malignancies, University of Utah, 2000 Circle Hope Drive, Room 4126, Salt Lake City, UT 84112, USA.
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Yang Y, Abrahams SR, Kothari A, Matada H, Davey K, Wolberg AS, Flick MJ. Abstract PO-127: A uPA/uPAR axis in both the tumor cell and stromal compartment drives PDAC disease progression. Cancer Res 2021. [DOI: 10.1158/1538-7445.panca21-po-127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a lethal solid tumor malignancy with a 5-year survival rate of 9%. In both patients and animal models of disease, PDAC is associated with robust coagulation system activity. Intriguingly, in addition to being a rich source of procoagulant factors, PDAC tumors highly express fibrinolytic system components. Supporting this concept, urokinase plasminogen activator (uPA) and uPA receptor (uPAR) expression positively correlates with reduced overall patient survival. Here, we tested the hypothesis that the expression and activity of plasminogen activation (PA) system components are functionally linked to PDAC tumor growth and disease progression. We generated C57Bl/6-derived KPC (i.e., KRasG12D, TRP53R172H) PDAC cell lines in which uPA and uPAR were knocked out using CRISPR-Cas9. We then analyzed orthotopic tumor growth and experimental metastasis in mice carrying null or functional mutations in uPA, uPAR, or plasminogen to evaluate the interplay of PA components derived from tumor cells and/or stromal cells in mediating PDAC progression. Although both KPC cell CRISPR variants retained procoagulant function, elimination of tumor cell uPA or uPAR yielded significantly smaller tumors when compared to Cas9 control tumor cells in wildtype mice. Similarly, the growth of WT KPC tumor cells in C57Bl/6 background uPA-KO or uPAR-KO mice also resulted in reduced tumor growth. To our surprise, the metastasis potential of WT KPC tumor cells in uPA-KO or uPAR-KO mice did not change when compared to wildtype mice. Regarding to the uPA/uPAR axis downstream effector plasminogen, the growth of WT KPC tumors in plasminogen-KO mice was also significantly reduced, but not to the same extent as when eliminating uPA or uPAR. In addition, eliminating plasminogen drastically reduced WT KPC tumor cells metastasis potential. In conclusion, our data suggest a mechanism whereby uPA functions through uPAR in both the tumor cell and stromal cell compartments to promote PDAC progression through plasminogen-dependent and -independent mechanisms.
Citation Format: Yi Yang, Sara R. Abrahams, Aditi Kothari, Harshi Matada, Keely Davey, Alisa S. Wolberg, Matthew J. Flick. A uPA/uPAR axis in both the tumor cell and stromal compartment drives PDAC disease progression [abstract]. In: Proceedings of the AACR Virtual Special Conference on Pancreatic Cancer; 2021 Sep 29-30. Philadelphia (PA): AACR; Cancer Res 2021;81(22 Suppl):Abstract nr PO-127.
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Affiliation(s)
- Yi Yang
- University of North Carolina, Chapel Hill, Chapel Hill, NC
| | | | - Aditi Kothari
- University of North Carolina, Chapel Hill, Chapel Hill, NC
| | - Harshi Matada
- University of North Carolina, Chapel Hill, Chapel Hill, NC
| | - Keely Davey
- University of North Carolina, Chapel Hill, Chapel Hill, NC
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Ilich A, Sparkenbaugh EM, Wolberg AS, Key NS, Pawlinski R. Pathologically stiff erythrocytes impede contraction of blood clots: Comment. J Thromb Haemost 2021; 19:2893-2894. [PMID: 34668297 DOI: 10.1111/jth.15512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Anton Ilich
- Department of Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, NC, USA
| | - Erica M Sparkenbaugh
- Department of Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, NC, USA
| | - Alisa S Wolberg
- Department of Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, NC, USA
| | - Nigel S Key
- Department of Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, NC, USA
| | - Rafal Pawlinski
- Department of Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, NC, USA
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Grover SP, Hindberg K, Wolberg AS, Braekkan S, Mackman N, Hansen JB. Abstract 110: C1 Esterase Inhibitor Functions As An Anticoagulant In Human And Murine Venous Thrombosis. Arterioscler Thromb Vasc Biol 2021. [DOI: 10.1161/atvb.41.suppl_1.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Factor (F) XII and FXI play a central role in venous thrombus formation in preclinical disease models and contributes to venous thromboembolism (VTE) in humans. Agents targeting FXIa have been developed and effectively prevent VTE in humans. C1 esterase inhibitor (C1INH) is a serine protease inhibitor that inhibits several proteases, including FXII and FXI. In this study, we investigated the anticoagulant activity of C1INH in humans and mice. First, plasma C1INH levels were determined in a population-based nested case-control study consisting of 405 VTE patients and 829 age- and sex-matched controls derived from the Tromsø Study. Participants with plasma C1INH levels in the highest quartile had a significantly lower risk of VTE (odds ratio [OR] of 0.68, confidence interval 0.49-0.96, P<0.05), unprovoked VTE (OR 0.59, confidence interval 0.39-0.89) and pulmonary embolism (OR 0.57, confidence interval 0.34-0.92) compared to participants with C1INH levels in the lowest quartile after adjustment for age and sex. Secondly, plasma-based thrombin generation studies were conducted to assess the anticoagulant function of C1INH. Supplementation of normal human pooled plasma with exogenous human purified C1INH (0.2 and 0.4mg/ml) significantly inhibited thrombin generation initiated with silica (P<0.05) and significantly prolonged the activated partial thromboplastin assay clotting time (P<0.001). Thirdly, administration of a clinically approved human purified C1INH product to mice significantly reduced thrombus weight (P<0.05) in the murine inferior vena cava stenosis model of venous thrombosis. Studies with C1 inhibitor deficient mice and substrate selective C1INH variants are currently ongoing. Our results indicate that C1INH serves as an endogenous anticoagulant with higher plasma levels of C1INH associated with a decreased future risk of VTE. Further, exogenous C1INH effectively inhibits thrombin generation in vitro and venous thrombus formation in a mouse model. Our findings suggest that C1INH may prevent thrombosis caused by activation of the intrinsic coagulation pathway.
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Ahmadzia HK, Luban NL, Li S, Guo D, Miszta A, Gobburu JV, Berger JS, James AH, Wolberg AS, van den Anker J. Optimal use of intravenous tranexamic acid for hemorrhage prevention in pregnant women. Am J Obstet Gynecol 2021; 225:85.e1-85.e11. [PMID: 33248975 DOI: 10.1016/j.ajog.2020.11.035] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 11/05/2020] [Accepted: 11/19/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Every 2 minutes, there is a pregnancy-related death worldwide, with one-third caused by severe postpartum hemorrhage. Although international trials demonstrated the efficacy of 1000 mg tranexamic acid in treating postpartum hemorrhage, to the best of our knowledge, there are no dose-finding studies of tranexamic acid on pregnant women for postpartum hemorrhage prevention. OBJECTIVE This study aimed to determine the optimal tranexamic acid dose needed to prevent postpartum hemorrhage. STUDY DESIGN We enrolled 30 pregnant women undergoing scheduled cesarean delivery in an open-label, dose ranging study. Subjects were divided into 3 cohorts receiving 5, 10, or 15 mg/kg (maximum, 1000 mg) of intravenous tranexamic acid at umbilical cord clamping. The inclusion criteria were ≥34 week's gestation and normal renal function. The primary endpoints were pharmacokinetic and pharmacodynamic profiles. Tranexamic acid plasma concentration of >10 μg/mL and maximum lysis of <17% were defined as therapeutic targets independent to the current study. Rotational thromboelastometry of tissue plasminogen activator-spiked samples was used to evaluate pharmacodynamic profiles at time points up to 24 hours after tranexamic acid administration. Safety was assessed by plasma thrombin generation, D-dimer, and tranexamic acid concentrations in breast milk. RESULTS There were no serious adverse events including venous thromboembolism. Plasma concentrations of tranexamic acid increased in a dose-proportional manner. The lowest dose cohort received an average of 448±87 mg tranexamic acid. Plasma tranexamic acid exceeded 10 μg/mL and maximum lysis was <17% at >1 hour after administration for all tranexamic acid doses tested. Median estimated blood loss for cohorts receiving 5, 10, or 15 mg/kg tranexamic acid was 750, 750, and 700 mL, respectively. Plasma thrombin generation did not increase with higher tranexamic acid concentrations. D-dimer changes from baseline were not different among the cohorts. Breast milk tranexamic acid concentrations were 1% or less than maternal plasma concentrations. CONCLUSION Although large randomized trials are necessary to support the clinical efficacy of tranexamic acid for prophylaxis, we propose an optimal dose of 600 mg in future tranexamic acid efficacy studies to prevent postpartum hemorrhage.
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Campbell RA, Hisada Y, Denorme F, Grover SP, Bouck EG, Middleton EA, Wolberg AS, Rondina MT, Mackman N. Comparison of the coagulopathies associated with COVID-19 and sepsis. Res Pract Thromb Haemost 2021; 5:e12525. [PMID: 34027292 PMCID: PMC8131194 DOI: 10.1002/rth2.12525] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/26/2021] [Accepted: 03/30/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is associated with activation of coagulation that mainly presents as thrombosis. Sepsis is also associated with activation of coagulation that mainly presents as disseminated intravascular coagulation. Many studies have reported increased levels of plasma d-dimer in patients with COVID-19 that is associated with severity, thrombosis, and mortality. OBJECTIVES The aim of this study was to compare levels of circulating extracellular vesicle tissue factor (EVTF) activity and active plasminogen activator inhibitor 1 (PAI-1) in plasma from patients with COVID-19 or sepsis. METHODS We measured levels of d-dimer, EVTF activity, and active PAI-1 in plasma samples from patients with COVID-19 (intensive care unit [ICU], N = 15; and non-ICU, N = 20) and patients with sepsis (N = 35). RESULTS Patients with COVID-19 had significantly higher levels of d-dimer, EVTF activity, and active PAI-1 compared with healthy controls. Patients with sepsis had significantly higher levels of d-dimer and EVTF activity compared with healthy controls. Levels of d-dimer were significantly lower in patients with COVID-19 compared with patients with sepsis. Levels of EVTF activity were significantly higher in ICU patients with COVID-19 compared with patients with sepsis. Levels of active PAI-1 were significantly higher in patients with COVID-19 compared with patients with sepsis. CONCLUSIONS High levels of both EVTF activity and active PAI-1 may promote thrombosis in patients with COVID-19 due to simultaneous activation of coagulation and inhibition of fibrinolysis. The high levels of active PAI-1 in patients with COVID-19 may limit plasmin degradation of crosslinked fibrin and the release of d-dimer. This may explain the lower levels of D-dimer in patients with COVID-19 compared with patients with sepsis.
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Affiliation(s)
- Robert A. Campbell
- University of Utah Molecular Medicine ProgramSalt Lake CityUTUSA,Department of Internal MedicineUniversity of UtahSalt Lake CityUTUSA
| | - Yohei Hisada
- UNC Blood Research CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA,Division of HematologyDepartment of MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Frederik Denorme
- University of Utah Molecular Medicine ProgramSalt Lake CityUTUSA
| | - Steven P. Grover
- UNC Blood Research CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA,Division of HematologyDepartment of MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Emma G. Bouck
- UNC Blood Research CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA,Department of Pathology and Laboratory MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | | | - Alisa S. Wolberg
- UNC Blood Research CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA,Department of Pathology and Laboratory MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Matthew T. Rondina
- University of Utah Molecular Medicine ProgramSalt Lake CityUTUSA,George E. Wahlen VAMC Department of Internal Medicine and GRECCSalt Lake CityUTUSA,Department of PathologyUniversity of UtahSalt Lake CityUTUSA
| | - Nigel Mackman
- UNC Blood Research CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA,Division of HematologyDepartment of MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
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40
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Chang WC, Jackson JW, Machlus KR, Wolberg AS, Ovanesov MV. Fluorescence artifact correction in the thrombin generation assay: Necessity for correction algorithms in procoagulant samples. Res Pract Thromb Haemost 2021; 5:447-455. [PMID: 33870030 PMCID: PMC8035796 DOI: 10.1002/rth2.12499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 02/01/2021] [Accepted: 02/07/2021] [Indexed: 11/10/2022] Open
Abstract
Introduction The thrombin generation (TG) test is a global hemostasis assay sensitive to procoagulant conditions. However, some TG assays may underestimate elevated TG when the thrombin fluorogenic substrate is depleted or fluorescence is attenuated by the inner filter effect (IFE). Objectives We sought to elucidate the extent to which procoagulant conditions require correcting for fluorogenic substrate depletion and/or IFE. Methods We analyzed corrections for substrate depletion and IFE and their effect on TG parameters in plasma samples with elevated blood coagulation factors in the presence or absence of thrombomodulin via commercial calibrated automated thrombogram (CAT) platform and in‐house software capable of internal thrombin calibration with or without CAT‐like artifact correction. Results Elevated thrombin peak height (TPH) and endogenous thrombin potential (ETP) were detected with 2× and 4× increases in blood coagulation factors I, V, VIII, IX, X, and XI, or prothrombin in the presence or absence of artifact correction. The effect of the CAT algorithm was evident in TG curves from both low procoagulant (thrombomodulin‐supplemented) and procoagulant (factor‐supplemented) plasma samples. However, in all samples, with the exception of elevated prothrombin, CAT’s correction was small (<10%) and did not affect detection of procoagulant samples versus normal plasma. For elevated prothrombin samples, uncorrected TPH or ETP values were underestimated, and CAT correction produced drastically elevated TG curves. Conclusions Our data suggest that correction for substrate consumption and IFE, as offered by the CAT algorithm, is critical for detecting a subset of extremely procoagulant samples, such as elevated prothrombin, but is not necessary for all other conditions, including elevated factors XI and VIII.
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Affiliation(s)
- William C Chang
- Office of Tissues and Advanced Therapies Center for Biologics Evaluation and Research US Food and Drug Administration Silver Spring MD USA
| | - Joseph W Jackson
- Office of Tissues and Advanced Therapies Center for Biologics Evaluation and Research US Food and Drug Administration Silver Spring MD USA
| | - Kellie R Machlus
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center University of North Carolina at Chapel Hill Chapel Hill North Carolina USA.,Vascular Biology Program, Department of Surgery Boston Children's Hospital and Harvard Medical School Boston MA USA.,Present address: Brigham and Women's Hospital Harvard Medical School Boston MA 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
| | - Mikhail V Ovanesov
- Office of Tissues and Advanced Therapies Center for Biologics Evaluation and Research US Food and Drug Administration Silver Spring MD USA
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41
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Li S, Ahmadzia HK, Guo D, Dahmane E, Miszta A, Luban NLC, Berger JS, James AH, Wolberg AS, van den Anker JN, Gobburu JVS. Population pharmacokinetics and pharmacodynamics of Tranexamic acid in women undergoing caesarean delivery. Br J Clin Pharmacol 2021; 87:3531-3541. [PMID: 33576009 DOI: 10.1111/bcp.14767] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/21/2021] [Accepted: 02/03/2021] [Indexed: 12/23/2022] Open
Abstract
AIMS The population pharmacokinetics (PK) and pharmacodynamics (PD) of tranexamic acid (TXA) have not been studied to prevent postpartum haemorrhage (PPH) in pregnant women. It is unclear which TXA dose assures sufficient PPH prevention. This study investigated population PK/PD of TXA in pregnant women who underwent caesarean delivery to determine the optimal prophylactic doses of TXA for future studies. METHODS We analysed concentration (PK) and maximum lysis (PD) data from 30 pregnant women scheduled for caesarean delivery who received 5, 10 or 15 mg/kg of TXA intravenously using population approach. RESULTS TXA PK was best described by a two-compartment model with first-order elimination and the following parameters: clearance (between-subject variability) of 9.4 L/h (27.7%), central volume of 10.1 L (47.4%), intercompartmental clearance of 22.4 L/h (66.7%), peripheral volume of 14.0 L (13.1%) and additive error of 1.4 mg/L. The relationship between TXA concentration and maximum lysis was characterized by a sigmoid Emax model with baseline lysis of 97%, maximum inhibition of 89%, IC50 of 6.0 mg/L (65.3%), hill factor of 8.5 (86.3%) and additive error of 7.3%. Simulations demonstrated that 500 and 650 mg of TXA maintained therapeutic targets for 30 minutes and 1 hour, respectively, in 90% of patients. CONCLUSION This is the first population PK and PD study of TXA in pregnant women undergoing caesarean delivery. Our analysis suggests that a 650 mg dose provides adequate PPH prophylaxis up to 1 hour, which is less than the currently used 1000 mg of TXA in pregnant women.
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Affiliation(s)
- Shuhui Li
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, M.D., USA
| | - Homa K Ahmadzia
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, D.C., USA
| | - Dong Guo
- School of Pharmacy, University of Maryland, Baltimore, M.D., USA
| | - Elyes Dahmane
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, M.D., USA
| | - Adam Miszta
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, N.C., USA.,Synapse Research Institute, Maastricht, the Netherlands
| | - Naomi L C Luban
- Division of Hematology, Children's National Hospital, Washington, D.C., USA.,Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Jeffrey S Berger
- Department of Anesthesiology and Critical Care Medicine, The George Washington University School of Medicine and Health Sciences, Washington, D.C., USA
| | - Andra H James
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University, Durham, N.C., USA
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, N.C., USA
| | - John N van den Anker
- Division of Clinical Pharmacology, Children's National Hospital, Washington, D.C., USA.,Division of Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Switzerland
| | - Jogarao V S Gobburu
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, M.D., USA
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42
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Mast AE, Wolberg AS, Gailani D, Garvin MR, Alvarez C, Miller JI, Aronow B, Jacobson D. SARS-CoV-2 suppresses anticoagulant and fibrinolytic gene expression in the lung. eLife 2021; 10:64330. [PMID: 33683204 PMCID: PMC8049742 DOI: 10.7554/elife.64330] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 03/06/2021] [Indexed: 12/13/2022] Open
Abstract
Extensive fibrin deposition in the lungs and altered levels of circulating blood coagulation proteins in COVID-19 patients imply local derangement of pathways that limit fibrin formation and/or promote its clearance. We examined transcriptional profiles of bronchoalveolar lavage fluid (BALF) samples to identify molecular mechanisms underlying these coagulopathies. mRNA levels for regulators of the kallikrein–kinin (C1-inhibitor), coagulation (thrombomodulin, endothelial protein C receptor), and fibrinolytic (urokinase and urokinase receptor) pathways were significantly reduced in COVID-19 patients. While transcripts for several coagulation proteins were increased, those encoding tissue factor, the protein that initiates coagulation and whose expression is frequently increased in inflammatory disorders, were not increased in BALF from COVID-19 patients. Our analysis implicates enhanced propagation of coagulation and decreased fibrinolysis as drivers of the coagulopathy in the lungs of COVID-19 patients.
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Affiliation(s)
- Alan E Mast
- Versiti Blood Research Institute, Department of Cell Biology Neurobiology and Anatomy Medical College of Wisconsin, Milwaukee, United States
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, Chapel Hill, United States
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, United States
| | - Michael R Garvin
- Oak Ridge National Laboratory, Biosciences Division, Oak Ridge, United States
| | - Christiane Alvarez
- Oak Ridge National Laboratory, Biosciences Division, Oak Ridge, United States
| | - J Izaak Miller
- Oak Ridge National Laboratory, Biosciences Division, Oak Ridge, United States
| | - Bruce Aronow
- University of Tennessee Knoxville, The Bredesen Center for Interdisciplinary Research and Graduate Education, Knoxville, United States.,Biomedical Informatics, Cincinnati Children's Hospital Research Foundation, Cincinnati, United States.,University of Cincinnati, Cincinnati, United States
| | - Daniel Jacobson
- Oak Ridge National Laboratory, Biosciences Division, Oak Ridge, United States.,University of Tennessee Knoxville, The Bredesen Center for Interdisciplinary Research and Graduate Education, Knoxville, United States.,University of Tennessee Knoxville, Department of Psychology, Knoxville, United States
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43
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Bouck EG, Denorme F, Holle LA, Middelton EA, Blair A, de Laat B, Schiffman JD, Yost CC, Rondina MT, Wolberg AS, Campbell RA. COVID-19 and Sepsis Are Associated With Different Abnormalities in Plasma Procoagulant and Fibrinolytic Activity. Arterioscler Thromb Vasc Biol 2021; 41:401-414. [PMID: 33196292 PMCID: PMC7942774 DOI: 10.1161/atvbaha.120.315338] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Coronavirus disease 2019 (COVID-19) is associated with derangement in biomarkers of coagulation and endothelial function and has been likened to the coagulopathy of sepsis. However, clinical laboratory metrics suggest key differences in these pathologies. We sought to determine whether plasma coagulation and fibrinolytic potential in patients with COVID-19 differ compared with healthy donors and critically ill patients with sepsis. Approach and Results: We performed comparative studies on plasmas from a single-center, cross-sectional observational study of 99 hospitalized patients (46 with COVID-19 and 53 with sepsis) and 18 healthy donors. We measured biomarkers of endogenous coagulation and fibrinolytic activity by immunoassays, thrombin, and plasmin generation potential by fluorescence and fibrin formation and lysis by turbidity. Compared with healthy donors, patients with COVID-19 or sepsis both had elevated fibrinogen, d-dimer, soluble TM (thrombomodulin), and plasmin-antiplasmin complexes. Patients with COVID-19 had increased thrombin generation potential despite prophylactic anticoagulation, whereas patients with sepsis did not. Plasma from patients with COVID-19 also had increased endogenous plasmin potential, whereas patients with sepsis showed delayed plasmin generation. The collective perturbations in plasma thrombin and plasmin generation permitted enhanced fibrin formation in both COVID-19 and sepsis. Unexpectedly, the lag times to thrombin, plasmin, and fibrin formation were prolonged with increased disease severity in COVID-19, suggesting a loss of coagulation-initiating mechanisms accompanies severe COVID-19. CONCLUSIONS Both COVID-19 and sepsis are associated with endogenous activation of coagulation and fibrinolysis, but these diseases differently impact plasma procoagulant and fibrinolytic potential. Dysregulation of procoagulant and fibrinolytic pathways may uniquely contribute to the pathophysiology of COVID-19 and sepsis.
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Affiliation(s)
- Emma G. Bouck
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Frederik Denorme
- University of Utah Molecular Medicine Program, Salt Lake City, Utah
| | - Lori A. Holle
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Antoinette Blair
- University of Utah Molecular Medicine Program, Salt Lake City, Utah
| | - Bas de Laat
- Synapse Research Institute, Maastricht, the Netherlands
| | - Joshua D. Schiffman
- Department of Pediatrics, University of Utah, Salt Lake City, UT 84112,PEEL Therapeutics, Inc., Salt Lake City, UT 84112
| | | | - Matthew T. Rondina
- University of Utah Molecular Medicine Program, Salt Lake City, Utah,Department of Internal Medicine & Pathology, University of Utah, Salt Lake City, Utah,George E. Wahlen VAMC Department of Internal Medicine and GRECC, Salt Lake City, Utah, 84148
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Robert A. Campbell
- University of Utah Molecular Medicine Program, Salt Lake City, Utah,Department of Internal Medicine & Pathology, University of Utah, Salt Lake City, Utah
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44
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Miszta A, Ahmadzia HK, Luban NLC, Li S, Guo D, Holle LA, Berger JS, James AH, Gobburu JVS, van den Anker J, de Laat B, Wolberg AS. Application of a plasmin generation assay to define pharmacodynamic effects of tranexamic acid in women undergoing cesarean delivery. J Thromb Haemost 2021; 19:221-232. [PMID: 33001565 PMCID: PMC7875467 DOI: 10.1111/jth.15114] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 12/27/2022]
Abstract
Essentials Tranexamic acid (TXA) is an antifibrinolytic drug used to reduce bleeding. Assaying plasmin generation (PG) in plasma detects clinically relevant TXA levels in vitro and ex vivo. 3.1-16.2 µg/mL TXA half-maximally inhibits PG in plasma from women undergoing cesarean delivery. PG velocity shows the strongest dose-relationship at low TXA concentrations (≤10 µg/mL). ABSTRACT: Background Tranexamic acid (TXA) is used to reduce bleeding. TXA inhibits plasmin(ogen) binding to fibrin and reduces fibrinolysis. TXA antifibrinolytic activity is typically measured by clot lysis assays; however, effects on plasmin generation (PG) are unclear due to a lack of tools to measure PG in plasma. Aims Develop an assay to measure PG kinetics in human plasma. Determine effects of TXA on PG and compare with fibrinolysis measured by rotational thromboelastometry (ROTEM). Methods We characterized effects of plasminogen, tissue plasminogen activator, fibrinogen, and α2 -antiplasmin on PG in vitro. We also studied effects of TXA on PG in plasma from 30 pregnant women administered intravenous TXA (5, 10, or 15 mg/kg) during cesarean delivery. PG was measured by calibrated fluorescence. PG parameters were compared with TXA measured by mass spectrometry and ROTEM of whole blood. Results The PG assay is specific for plasmin and sensitive to tissue plasminogen activator, fibrin(ogen), and α2 -antiplasmin. Addition of TXA to plasma in vitro dose dependently prolonged the clot lysis time and delayed and reduced PG. For all doses of TXA administered intravenously, the PG assay detected delayed time-to-peak (≤3 hours) and reduced the velocity, peak, and endogenous plasmin potential (≤24 hours) in plasma samples obtained after infusion. The PG time-to-peak, velocity, and peak correlated significantly with TXA concentration and showed less variability than the ROTEM lysis index at 30 minutes or maximum lysis. Conclusions The PG assay detects pharmacologically relevant concentrations of TXA administered in vitro and in vivo, and demonstrates TXA-mediated inhibition of PG in women undergoing cesarean delivery.
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Affiliation(s)
- Adam Miszta
- Department of Pathology and UNC Blood Research Center, University of North Carolina, Chapel Hill, NC, USA
- Synapse Research Institute, Maastricht, The Netherlands
| | - Homa K. Ahmadzia
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, The George Washington University, Washington, DC, USA
| | - Naomi L. C. Luban
- Division of Hematology/Oncology, Department of Pediatrics and Pathology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Shuhui Li
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, MD, USA
| | - Dong Guo
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, MD, USA
| | - Lori A. Holle
- Department of Pathology and UNC Blood Research Center, University of North Carolina, Chapel Hill, NC, USA
| | - Jeffrey S. Berger
- Department of Anesthesiology, The George Washington University, Washington, DC, USA
| | - Andra H. James
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University, Durham, NC, USA
| | - Jogarao V. S. Gobburu
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, MD, USA
| | - John van den Anker
- Division of Clinical Pharmacology, Department of Pediatrics, Children’s National Hospital, George Washington University of School of Medicine and Health Sciences, Washington, DC, USA
| | - Bas de Laat
- Synapse Research Institute, Maastricht, The Netherlands
| | - Alisa S. Wolberg
- Department of Pathology and UNC Blood Research Center, University of North Carolina, Chapel Hill, NC, USA
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45
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Maners J, Gill D, Pankratz N, Laffan MA, Wolberg AS, de Maat MPM, Ligthart S, Tang W, Ward-Caviness CK, Fornage M, Debette S, Dichgans M, McKnight B, Boerwinkle E, Smith NL, Morrison AC, Dehghan A, de Vries PS. A Mendelian randomization of γ' and total fibrinogen levels in relation to venous thromboembolism and ischemic stroke. Blood 2020; 136:3062-3069. [PMID: 33367543 PMCID: PMC7770565 DOI: 10.1182/blood.2019004781] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 07/12/2020] [Indexed: 12/23/2022] Open
Abstract
Fibrinogen is a key component of the coagulation cascade, and variation in its circulating levels may contribute to thrombotic diseases, such as venous thromboembolism (VTE) and ischemic stroke. Gamma prime (γ') fibrinogen is an isoform of fibrinogen that has anticoagulant properties. We applied 2-sample Mendelian randomization (MR) to estimate the causal effect of total circulating fibrinogen and its isoform, γ' fibrinogen, on risk of VTE and ischemic stroke subtypes using summary statistics from genome-wide association studies. Genetic instruments for γ' fibrinogen and total fibrinogen were selected, and the inverse-variance weighted MR approach was used to estimate causal effects in the main analysis, complemented by sensitivity analyses that are more robust to the inclusion of pleiotropic variants, including MR-Egger, weighted median MR, and weighted mode MR. The main inverse-variance weighted MR estimates based on a combination of 16 genetic instruments for γ' fibrinogen and 75 genetic instruments for total fibrinogen indicated a protective effect of higher γ' fibrinogen and higher total fibrinogen on VTE risk. There was also a protective effect of higher γ' fibrinogen levels on cardioembolic and large artery stroke risk. Effect estimates were consistent across sensitivity analyses. Our results provide evidence to support effects of genetically determined γ' fibrinogen on VTE and ischemic stroke risk. Further research is needed to explore mechanisms underlying these effects and their clinical applications.
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Affiliation(s)
- Jillian Maners
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX
| | - Dipender Gill
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, United Kingdom
| | - Nathan Pankratz
- Department of Laboratory Medicine and Pathology, School of Medicine, University of Minnesota, Minneapolis, MN
| | - Michael A Laffan
- Centre for Haematology, Imperial College London, London, United Kingdom
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC
| | | | - Symen Ligthart
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Weihong Tang
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN
| | - Cavin K Ward-Caviness
- National Health and Environmental Effects Laboratory, US Environmental Protection Agency, Chapel Hill, NC
| | - Myriam Fornage
- The Brown Foundation Institute of Molecular Medicine, The University of Texas Health Science Center at Houston, Houston, TX
| | - Stephanie Debette
- Stroke Research Group, Division of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- Department of Neurology, Institute for Neurodegenerative Disease, Bordeaux University Hospital, Bordeaux, France
| | - Martin Dichgans
- Institute for Stroke and Dementia Research, University Hospital, Ludwig-Maximilians-Universität, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Barbara McKnight
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX
| | - Eric Boerwinkle
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Nicholas L Smith
- Kaiser Permanente Washington Research Institute, Kaiser Permanente Washington, Seattle, WA
- Department of Epidemiology, University of Washington, Seattle, WA
- Seattle Epidemiologic Research and Information Center, Office of Research and Development, Department of Veteran Affairs, Seattle, WA
| | - Alanna C Morrison
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX
| | - Abbas Dehghan
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, United Kingdom
- Medical Research Council-Public Health England (MRC-PHE) Centre for Environment and Health, School of Public Health, Imperial College London, London, United Kingdom; and
- UK Dementia Research Institute, Imperial College London, London, United Kingdom
| | - Paul S de Vries
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX
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Merkulova AA, Mitchell SC, Merkulov S, Wolberg AS, Neerman-Arbez M, Schmaier AH. Case Report: Unmasked Inherited Dysfibrinogenemia After Everolimus Therapy. Front Med (Lausanne) 2020; 7:591546. [PMID: 33330551 PMCID: PMC7729062 DOI: 10.3389/fmed.2020.591546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 11/05/2020] [Indexed: 11/13/2022] Open
Abstract
A previously hemostatically asymptomatic patient with common variable hypogammaglobulinemia was given everolimus to prevent growth of her liver. Within several months, the patient developed a severe bleeding disorder. The bleeding was due to fibrin polymerization defect that upon sequencing was shown to be dysfibrinogenemia Krakow III. Elimination of the mTor inhibitor ameliorated the clinical bleeding state.
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Affiliation(s)
- Alona A Merkulova
- Department of Medicine, Hematology and Oncology, Case Western Reserve University, Cleveland, OH, United States
| | - Steven C Mitchell
- Department of Medicine, Hematology and Oncology, Case Western Reserve University, Cleveland, OH, United States
| | - Sergei Merkulov
- Department of Medicine, Cardiovascular Medicine, Case Western Reserve University, Cleveland, OH, United States
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, United States
| | - Marguerite Neerman-Arbez
- Department of Genetic Medicine and Development, University Medical Center Geneva, Geneva, Switzerland.,Division of Angiology and Haemostasis, University Hospital, Geneva, Switzerland
| | - Alvin H Schmaier
- Department of Medicine, Hematology and Oncology, Case Western Reserve University, Cleveland, OH, United States.,Department of Medicine, Hematology and Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
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47
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Dobson DA, Wolberg AS. COVID-19 pandemic perspectives: A scientific silver lining? Res Pract Thromb Haemost 2020; 4:1083-1086. [PMID: 33134774 PMCID: PMC7590274 DOI: 10.1002/rth2.12432] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 08/26/2020] [Accepted: 08/29/2020] [Indexed: 01/19/2023] Open
Abstract
Accounts of the numerous negative effects caused by COVID‐19 are pervasive, but few perspectives have identified any positive impacts of this massive societal shift. This forum examines potentially positive changes that have occurred within the scientific community amid the chaotic pandemic. Among these positives are the formation of virtual supergroups and an interdisciplinary brain trust. In forcing scientists away from their lab benches, COVID‐19 has created time and space for more conversations about science and experimental design. Being away from the lab in this time of social unrest has also given scientists time to directly address institutional racism and its suppression of diversity in science. Although COVID‐19 has been an unforeseen disaster of epic proportions, some of the resulting changes in our scientific community should remain in place after the pandemic is over. By leveraging these small wins, we will undoubtedly return to our laboratories stronger, smarter, and more efficient.
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Affiliation(s)
- Dre'Von A Dobson
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center University of North Carolina Chapel Hill NC USA
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center University of North Carolina Chapel Hill NC USA
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48
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Mackman N, Antoniak S, Wolberg AS, Kasthuri R, Key NS. Coagulation Abnormalities and Thrombosis in Patients Infected With SARS-CoV-2 and Other Pandemic Viruses. Arterioscler Thromb Vasc Biol 2020; 40:2033-2044. [PMID: 32657623 PMCID: PMC7447001 DOI: 10.1161/atvbaha.120.314514] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/29/2020] [Indexed: 02/07/2023]
Abstract
The world is amid a pandemic caused by severe acute respiratory syndrome-coronavirus 2. Severe acute respiratory syndrome-coronavirus causes serious respiratory tract infections that can lead to viral pneumonia, acute respiratory distress syndrome, and death. Some patients with coronavirus disease 2019 (COVID-19) have an activated coagulation system characterized by elevated plasma levels of d-dimer-a biomarker of fibrin degradation. Importantly, high levels of D-dimer on hospital admission are associated with increased risk of mortality. Venous thromboembolism is more common than arterial thromboembolism in hospitalized COVID-19 patients. Pulmonary thrombosis and microvascular thrombosis are observed in autopsy studies, and this may contribute to the severe hypoxia observed in COVID-19 patients. It is likely that multiple systems contribute to thrombosis in COVID-19 patients, such as activation of coagulation, platelet activation, hypofibrinolysis, endothelial cell dysfunction, inflammation, neutrophil extracellular traps, and complement. Targeting these different pathways may reduce thrombosis and improve lung function in COVID-19 patients.
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Affiliation(s)
- Nigel Mackman
- From the Department of Medicine, UNC Blood Research Center (N.M., S.A., A.S.W., R.K., N.S.K.), University of North Carolina at Chapel Hill
- Division of Hematology, Department of Medicine (N.M., R.K., N.S.K.), University of North Carolina at Chapel Hill
| | - Silvio Antoniak
- From the Department of Medicine, UNC Blood Research Center (N.M., S.A., A.S.W., R.K., N.S.K.), University of North Carolina at Chapel Hill
- Department of Pathology and Laboratory Medicine (S.A., A.S.W.), University of North Carolina at Chapel Hill
| | - Alisa S. Wolberg
- From the Department of Medicine, UNC Blood Research Center (N.M., S.A., A.S.W., R.K., N.S.K.), University of North Carolina at Chapel Hill
- Department of Pathology and Laboratory Medicine (S.A., A.S.W.), University of North Carolina at Chapel Hill
| | - Raj Kasthuri
- From the Department of Medicine, UNC Blood Research Center (N.M., S.A., A.S.W., R.K., N.S.K.), University of North Carolina at Chapel Hill
- Division of Hematology, Department of Medicine (N.M., R.K., N.S.K.), University of North Carolina at Chapel Hill
| | - Nigel S. Key
- From the Department of Medicine, UNC Blood Research Center (N.M., S.A., A.S.W., R.K., N.S.K.), University of North Carolina at Chapel Hill
- Division of Hematology, Department of Medicine (N.M., R.K., N.S.K.), University of North Carolina at Chapel Hill
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Cushman M, Barnes GD, Creager MA, Diaz JA, Henke PK, Machlus KR, Nieman MT, Wolberg AS. Venous Thromboembolism Research Priorities: A Scientific Statement From the American Heart Association and the International Society on Thrombosis and Haemostasis. Circulation 2020; 142:e85-e94. [PMID: 32776842 DOI: 10.1161/cir.0000000000000818] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Venous thromboembolism is a major cause of morbidity and mortality. The impact of the US Surgeon General's The Surgeon General's Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism in 2008 has been lower than expected given the public health impact of this disease. This scientific statement highlights future research priorities in venous thromboembolism, developed by experts and a crowdsourcing survey across 16 scientific organizations. At the fundamental research level (T0), researchers need to identify pathobiological causative mechanisms for the 50% of patients with unprovoked venous thromboembolism and to better understand mechanisms that differentiate hemostasis from thrombosis. At the human level (T1), new methods for diagnosing, treating, and preventing venous thromboembolism will allow tailoring of diagnostic and therapeutic approaches to individuals. At the patient level (T2), research efforts are required to understand how foundational evidence impacts care of patients (eg, biomarkers). New treatments, such as catheter-based therapies, require further testing to identify which patients are most likely to experience benefit. At the practice level (T3), translating evidence into practice remains challenging. Areas of overuse and underuse will require evidence-based tools to improve care delivery. At the community and population level (T4), public awareness campaigns need thorough impact assessment. Large population-based cohort studies can elucidate the biological and environmental underpinnings of venous thromboembolism and its complications. To achieve these goals, funding agencies and training programs must support a new generation of scientists and clinicians who work in multidisciplinary teams to solve the pressing public health problem of venous thromboembolism.
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Cushman M, Barnes GD, Creager MA, Diaz JA, Henke PK, Machlus KR, Nieman MT, Wolberg AS. Venous thromboembolism research priorities: A scientific statement from the American Heart Association and the International Society on Thrombosis and Haemostasis. Res Pract Thromb Haemost 2020; 4:714-721. [PMID: 32685877 PMCID: PMC7354403 DOI: 10.1002/rth2.12373] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/04/2020] [Indexed: 12/27/2022] Open
Abstract
Venous thromboembolism (VTE) is a major cause of morbidity and mortality. The impact of the Surgeon General’s Call to Action in 2008 has been lower than expected given the public health impact of this disease. This scientific statement highlights future research priorities in VTE, developed by experts and a crowdsourcing survey across 16 scientific organizations. At the fundamental research level (T0), researchers need to identify pathobiologic causative mechanisms for the 50% of patients with unprovoked VTE and better understand mechanisms that differentiate hemostasis from thrombosis. At the human level (T1), new methods for diagnosing, treating, and preventing VTE will allow tailoring of diagnostic and therapeutic approaches to individuals. At the patient level (T2), research efforts are required to understand how foundational evidence impacts care of patients (eg, biomarkers). New treatments, such as catheter‐based therapies, require further testing to identify which patients are most likely to experience benefit. At the practice level (T3), translating evidence into practice remains challenging. Areas of overuse and underuse will require evidence‐based tools to improve care delivery. At the community and population level (T4), public awareness campaigns need thorough impact assessment. Large population‐based cohort studies can elucidate the biologic and environmental underpinings of VTE and its complications. To achieve these goals, funding agencies and training programs must support a new generation of scientists and clinicians who work in multidisciplinary teams to solve the pressing public health problem of VTE.
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Affiliation(s)
- Mary Cushman
- Department of Medicine Department of Pathology and Laboratory Medicine Larner College of Medicine at the University of Vermont Burlington VT USA
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center University of Michigan Ann Arbor MI USA
| | - Mark A Creager
- Heart and Vascular Center Dartmouth-Hitchcock Medical Center Geisel School of Medicine at Dartmouth Lebanon NH USA
| | - Jose A Diaz
- Division of Surgical Research Vanderbilt University Medical Center Nashville TN USA
| | - Peter K Henke
- Department of Surgery University of Michigan Ann Arbor MI USA
| | | | - Marvin T Nieman
- Department of Pharmacology Case Western Reserve University Cleveland OH USA
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine UNC Blood Research Center University of North Carolina at Chapel Hill Chapel Hill NC USA
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