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Verhagen MJ, van Heerde WL, van der Bom JG, Beckers EA, Blijlevens NM, Coppens M, Gouw SC, Jansen JH, Leebeek FW, van Vulpen LF, Meijer D, Schols SE. In patients with hemophilia, a decreased thrombin generation profile is associated with a severe bleeding phenotype. Res Pract Thromb Haemost 2023; 7:100062. [PMID: 36865907 PMCID: PMC9971314 DOI: 10.1016/j.rpth.2023.100062] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 12/20/2022] [Accepted: 01/02/2023] [Indexed: 02/04/2023] Open
Abstract
Background Heterogeneity in clinical bleeding phenotype has been observed in hemophilia patients with similar FVIII or FIX activity levels. Thrombin generation and plasmin generation, as a global hemostasis assay, may contribute to a better prediction of which patients are at an increased risk of bleeding. Objectives The objective of this study was to describe the association between clinical bleeding phenotype and thrombin generation and plasmin generation profiles in patients with hemophilia. Methods The Nijmegen Hemostasis Assay, which simultaneously measures thrombin and plasmin generation, was performed in plasma samples of patients with hemophilia participating in the sixth Hemophilia in the Netherlands study (HiN6). Patients receiving prophylaxis underwent a washout period. A severe clinical bleeding phenotype was defined as a self-reported annual bleeding rate of ≥5, a self-reported annual joint bleeding rate of ≥3, or the use of secondary/tertiary prophylaxis. Results In total, 446 patients, with a median age of 44 years, were included in this substudy. Thrombin generation and plasmin generation parameters differed between patients with hemophilia and healthy individuals. The median thrombin peak height was 1.0 nM, 25.9 nM, 47.1 nM, and 143.9 nM in patients with severe, moderate, and mild hemophilia and healthy individuals, respectively. A severe bleeding phenotype was observed in patients with a thrombin peak height of <49% and a thrombin potential of <72% compared to healthy individuals, and was independent of the hemophilia severity. The median thrombin peak height was 0.70% in patients with a severe clinical bleeding phenotype and 30.3% in patients with a mild clinical bleeding phenotype. The median thrombin potentials for these patients were 0.06% and 59.3%, respectively. Conclusion A decreased thrombin generation profile is associated with a severe clinical bleeding phenotype in patients with hemophilia. Thrombin generation in combination with bleeding severity may be a better tool to personalize prophylactic replacement therapy irrespective of hemophilia severity.
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Affiliation(s)
- Marieke J.A. Verhagen
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands,Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Nijmegen, The Netherlands,Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Waander L. van Heerde
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands,Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Nijmegen, The Netherlands,Enzyre BV, Novio Tech Campus, Nijmegen, The Netherlands
| | - Johanna G. van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik A.M. Beckers
- Department of Hematology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Michiel Coppens
- Department of Vascular Medicine and Haemophilia Treatment Center, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Samantha C. Gouw
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands,Pediatric Hematology, Emma Children’s Hospital, Amsterdam University Medical Center, University of Amsterdam, The Netherlands
| | - Joop H. Jansen
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frank W.G. Leebeek
- Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Lize F.D. van Vulpen
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Daniëlle Meijer
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Saskia E.M. Schols
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands,Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Nijmegen, The Netherlands,Correspondence Saskia E. M. Schols, Department of Hematology, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands. @radboudumc_weet
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Valke LLFG, Rijpma S, Meijer D, Schols SEM, van Heerde WL. Thrombin generation assays to personalize treatment in bleeding and thrombotic diseases. Front Cardiovasc Med 2022; 9:1033416. [PMID: 36440026 PMCID: PMC9684194 DOI: 10.3389/fcvm.2022.1033416] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/26/2022] [Indexed: 07/30/2023] Open
Abstract
Treatment of bleeding and thrombotic disorders is highly standardized and based on evidence-based medicine guidelines. These evidence-based treatment schemes are well accepted but may lead to either insufficient treatment or over-dosing, because the individuals' hemostatic properties are not taken into account. This can potentially introduce bleeding or thrombotic complications in individual patients. With the incorporation of pharmacokinetic (PK) and pharmacodynamic (PK-PD) parameters, based on global assays such as thrombin generation assays (TGAs), a more personalized approach can be applied to treat either bleeding or thrombotic disorders. In this review, we will discuss the recent literature about the technical aspects of TGAs and the relation to diagnosis and management of bleeding and thrombotic disorders. In patients with bleeding disorders, such as hemophilia A or factor VII deficiency, TGAs can be used to identify patients with a more severe bleeding phenotype and also in the management with non-replacement therapy and/or bypassing therapy. These assays have also a role in patients with venous thrombo-embolism, but the usage of TGAs in patients with arterial thrombosis is less clear. However, there is a potential role for TGAs in the monitoring of (long-term) antithrombotic therapy, for example with the use of direct oral anticoagulants. Finally this review will discuss controversies, limitations and knowledge gaps in relation to the introduction of TGAs to personalize medicine in daily medical practice.
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Affiliation(s)
- Lars L. F. G. Valke
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
- Hemophilia Treatment Center, Nijmegen, Netherlands
| | - Sanna Rijpma
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Danielle Meijer
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Saskia E. M. Schols
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
- Hemophilia Treatment Center, Nijmegen, Netherlands
| | - Waander L. van Heerde
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
- Hemophilia Treatment Center, Nijmegen, Netherlands
- Enzyre BV, Novio Tech Campus, Nijmegen, Netherlands
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3
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Verhagen MJA, Valke LLFG, Schols SEM. Thrombin generation for monitoring hemostatic therapy in hemophilia A: A narrative review. J Thromb Haemost 2022; 20:794-805. [PMID: 35034413 PMCID: PMC9305107 DOI: 10.1111/jth.15640] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/17/2021] [Accepted: 01/10/2022] [Indexed: 11/29/2022]
Abstract
Patients with severe hemophilia A (HA) have an increased risk of spontaneous and trauma-related bleeding because of a congenital absence of factor VIII (FVIII). Most severe HA patients use prophylactic FVIII concentrate, the effect of which can be monitored with FVIII activity level measurement. However, FVIII activity level is less valuable in predicting the potential clinical bleeding risk. Some patients still experience breakthrough bleeds despite adequate FVIII trough levels, whereas others do not bleed with trough levels below threshold. This difference may be caused by inter-individual differences in pro- and anticoagulant factors, the so-called hemostatic balance. Thrombin generation assays (TGAs) measure the hemostatic balance as a whole. Thereby, the TGAs may be a better tool in the guidance and monitoring of treatment in HA patients. In addition, TGAs offer the opportunity to determine the response to bypassing agents and treatment with non-factor replacement therapy, in which FVIII activity assays are not suitable for monitoring. This review summarizes the current knowledge about monitoring different HA treatment modalities by TGA, as a single treatment option and when used in a concomitant fashion.
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Affiliation(s)
- Marieke J. A. Verhagen
- Department of HematologyRadboud University Medical CenterNijmegenThe Netherlands
- Hemophilia Treatment CenterNijmegen‐Eindhoven‐MaastrichtNijmegenThe Netherlands
| | - Lars L. F. G. Valke
- Department of HematologyRadboud University Medical CenterNijmegenThe Netherlands
- Hemophilia Treatment CenterNijmegen‐Eindhoven‐MaastrichtNijmegenThe Netherlands
| | - Saskia E. M. Schols
- Department of HematologyRadboud University Medical CenterNijmegenThe Netherlands
- Hemophilia Treatment CenterNijmegen‐Eindhoven‐MaastrichtNijmegenThe Netherlands
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4
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Bukkems LH, Valke LLFG, Barteling W, Laros-van Gorkom BAP, Blijlevens NMA, Cnossen MH, van Heerde WL, Schols SEM, Mathôt RAA. Combining factor VIII levels and thrombin/plasmin generation: a population pharmacokinetic-pharmacodynamic model for patients with hemophilia A. Br J Clin Pharmacol 2021; 88:2757-2768. [PMID: 34921439 PMCID: PMC9304184 DOI: 10.1111/bcp.15185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 10/07/2021] [Accepted: 12/05/2021] [Indexed: 11/28/2022] Open
Abstract
Aims Prophylactic treatment of haemophilia A patients with factor VIII (FVIII) concentrate focuses on maintaining a minimal trough FVIII activity level to prevent bleeding. However, due to differences in bleeding tendency, the pharmacokinetic (PK)‐guided dosing approach may be suboptimal. An alternative approach could be the addition of haemostatic pharmacodynamic (PD) parameters, reflecting a patient's unique haemostatic balance. Our aim was to develop a population PK/PD model, based on FVIII activity levels and Nijmegen Haemostasis Assay (NHA) patterns, a global haemostatic assay that measures thrombin/plasmin generation simultaneously. Methods PK/PD measurements were collected from 30 patients treated with standard half‐life FVIII concentrate. The relationship between FVIII activity levels and the thrombin/plasmin generation parameters (thrombin potential, thrombin peak height and plasmin peak height), were described by sigmoidal Emax functions. Results The obtained EC50 value was smallest for the normalized thrombin potential (11.6 IU/dL), followed by normalized thrombin peak height (56.6 IU/dL) and normalized plasmin peak height (593 IU/dL), demonstrating that normalized thrombin potential showed 50% of the maximal effect at lower FVIII activity levels. Substantial inter‐individual variability in the PD parameters, such as EC50 of thrombin potential (86.9%) was observed, indicating that, despite similar FVIII activity levels, haemostatic capacity varies significantly between patients. Conclusion These data suggest that dosing based on patients' individual PK/PD parameters may be beneficial over dosing solely on individual PK parameters. This model could be used as proof‐of‐principle to examine the application of PK/PD‐guided dosing. However, the relation between the PD parameters and bleeding has to be better defined.
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Affiliation(s)
- Laura H Bukkems
- Department of Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Lars L F G Valke
- Department of Hematology, Radboud University Medical Centre, Nijmegen, The Netherlands.,Hemophilia Treatment Centre, Nijmegen Eindhoven Maastricht, The Netherlands
| | - Wideke Barteling
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Britta A P Laros-van Gorkom
- Department of Hematology, Radboud University Medical Centre, Nijmegen, The Netherlands.,Hemophilia Treatment Centre, Nijmegen Eindhoven Maastricht, The Netherlands
| | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Marjon H Cnossen
- Department of Pediatric Hematology, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Waander L van Heerde
- Hemophilia Treatment Centre, Nijmegen Eindhoven Maastricht, The Netherlands.,Enzyre BV, Novio Tech Campus, Nijmegen, The Netherlands
| | - Saskia E M Schols
- Department of Hematology, Radboud University Medical Centre, Nijmegen, The Netherlands.,Hemophilia Treatment Centre, Nijmegen Eindhoven Maastricht, The Netherlands
| | - Ron A A Mathôt
- Department of Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
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Måseide RJ, Berntorp E, Nummi V, Lassila R, Tjønnfjord GE, Holme PA. Bleeding phenotype of patients with moderate haemophilia A and B assessed by thromboelastometry and thrombin generation. Haemophilia 2021; 27:793-801. [PMID: 34106506 DOI: 10.1111/hae.14355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 05/04/2021] [Accepted: 05/28/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Predicting the bleeding phenotype is crucial for the management of patients with moderate haemophilia. Global coagulation assays evaluate haemostasis more comprehensively than conventional methods. AIM To explore global coagulation assays and the bleeding phenotype of patients with moderate haemophilia A (MHA) and B (MHB). METHODS The MoHem study is a cross-sectional, multicentre study covering Nordic patients with MHA and MHB. Thromboelastometry in whole blood and thrombin generation (TG) in platelet-poor plasma (1, 2.5 and 5 pM tissue factor (TF)) were compared with joint health (Haemophilia Joint Health Score (HJHS)) and treatment modality. RESULTS We report on 61 patients from Oslo and Helsinki: 24 MHA and 37 MHB. By TG (2.5 pM TF), patients who had been without replacement therapy during the previous 12 months depicted higher endogenous thrombin potential (P = .03). In contrast, those who had low ETP (< median) captured higher HJHS (P = .02). Patients who had undergone orthopaedic surgery generated least thrombin (P = .02). By thromboelastometry, those without the need of factor consumption had short clotting times, and quick times to maximum velocity (< median values) (P = .03). Factor VIII/factor IX activity (FVIII/FIX:C) did not align with the bleeding phenotype, but FIX:C ≤ 3 IU/dL was associated with lower peak thrombin (P = .03). CONCLUSION TG differentiated patients with moderate haemophilia according to HJHS, annual factor consumption, and whether orthopaedic surgery had been performed. Thromboelastometry differentiated according to factor consumption only. Global coagulation assays may assist predicting the bleeding phenotype in moderate haemophilia.
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Affiliation(s)
- Ragnhild J Måseide
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Erik Berntorp
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Vuokko Nummi
- Coagulation Disorders Unit, Haematology, Comprehensive Cancer Centre, Helsinki University Hospital, and Research Program in Systems Oncology, Faculty of Medicine, Helsinki University, Helsinki, Finland
| | - Riitta Lassila
- Coagulation Disorders Unit, Haematology, Comprehensive Cancer Centre, Helsinki University Hospital, and Research Program in Systems Oncology, Faculty of Medicine, Helsinki University, Helsinki, Finland
| | - Geir E Tjønnfjord
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Pål A Holme
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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6
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Crépin R, Morin C, Montmartin A, Tardy-Poncet B, Chelle P. Use of population PK/PD approach to model the thrombin generation assay: assessment in haemophilia A plasma samples spiked by a TFPI antibody. J Pharmacokinet Pharmacodyn 2021; 48:563-580. [PMID: 33846873 DOI: 10.1007/s10928-021-09752-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 03/22/2021] [Indexed: 11/28/2022]
Abstract
The thrombin generation (TG) assay is a well-established tool to capture the clotting potential of any healthy or haemophiliac subject. It measures ex vivo the kinetics of thrombin activation throughout the coagulation. Clinical studies allowed to create two databases gathering the coagulation factor levels and the thrombin generation profile of 40 healthy and 40 haemophiliac A (HA) subjects. Besides, portions of all HA samples were spiked with increasing levels of a TFPI antibody (considered as a possible therapeutic target) and corresponding TG profiles were determined. The non-linear mixed-effect (NLME) modelling aims at describing and explaining the experimentally observed important variability of the TG curves between subjects and the individual effects of spiking with a TFPI antibody. The models consist of an empirical description of the TG kinetics, accounting for an additive residual error and between-subject variability on its parameters. Factor VIII and TFPI were found to significantly explain and reduce the variability of the TG of haemophilia A samples. Besides, the model is shown to correctly reproduce the variability in the response to the ex vivo spiking with the TFPI antibody, by combining the empirical description of TG to a simple Hill equation that accounts for the binding between TFPI and different doses of its antibody. Such models can be useful for clinical practice, with the analysis and comparison of the distributions of TG profiles in healthy and haemophilia populations; and also for research, with the analysis of the effect of TFPI and its neutralization on individual TG profiles.
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Affiliation(s)
- Raphaël Crépin
- Mines Saint-Etienne, Univ Lyon, Univ Jean Monnet, INSERM, U1059 Sainbiose, Centre CIS, 42023, Saint-Étienne, France
| | - Claire Morin
- Mines Saint-Etienne, Univ Lyon, Univ Jean Monnet, INSERM, U1059 Sainbiose, Centre CIS, 42023, Saint-Étienne, France.
| | - Aurélie Montmartin
- INSERM, U1059, SAINBIOSE, Université de Lyon, UJM Saint Etienne, Saint-Étienne, France
| | - Brigitte Tardy-Poncet
- INSERM, U1059, SAINBIOSE, Université de Lyon, UJM Saint Etienne, Saint-Étienne, France
| | - Pierre Chelle
- School of Pharmacy, University of Waterloo, Kitchener, ON, Canada
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Valke LL, Bukkems LH, Barteling W, Laros‐van Gorkom BA, Blijlevens NM, Mathôt RA, van Heerde WL, Schols SE. Pharmacodynamic monitoring of factor VIII replacement therapy in hemophilia A: Combining thrombin and plasmin generation. J Thromb Haemost 2020; 18:3222-3231. [PMID: 32979031 PMCID: PMC7756259 DOI: 10.1111/jth.15106] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/09/2020] [Accepted: 09/14/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Clinical severity of hemophilia A (HA) varies, possibly due to interplay of many factors in the hemostatic pathway. Pharmacokinetic monitoring of factor VIII (FVIII) replacement therapy in HA patients consists of measuring FVIII activity levels and subsequent dose adjustment. The Nijmegen Hemostasis Assay (NHA) measures thrombin generation (TG) and plasmin generation (PG). OBJECTIVE To determine differences in TG and PG between HA patients before and during a pharmacokinetic study and identify best parameters to develop a pharmacodynamic model. METHODS Twenty-five HA patients (baseline FVIII < 1-9 IU/dL) underwent a pharmacokinetic study with a single dose of 25-50 IU/kg standard half-life FVIII concentrate. At baseline and after administration of FVIII TG and PG parameters were measured with the NHA. RESULTS FVIII activity level increased from median 1.0 IU/dL (interquartile range < 1.0-6.0) to 71 IU/dL (62-82) 15 minutes after administration and decreased to 15 IU/dL (10-26) at 24 hours. TG was enhanced simultaneously, with thrombin peak height (TPH) increasing from 22nM (15-35) to 222nM (159-255), and thrombin potential (TP) from 404nM/min (undetectable-876) to 1834nM/min (1546-2353). Twenty-four hours after infusion, TG parameters remained high (TPH 73nM [58.5-126.3]; TP 1394nM/min [1066-1677]) compared to FVIII activity level. PG showed hyperfibrinolysis in severe HA patients compared to mild patients and controls, which normalized after FVIII supplementation. CONCLUSION HA patients showed clear differences in baseline TG and PG despite having comparable FVIII activity levels. These results reveal a discrepancy between FVIII activity level and TG, in which the latter may be a better parameter to monitor individualized treatment in HA patients.
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Affiliation(s)
- Lars L.F.G. Valke
- Department of HematologyRadboud University Medical CentreNijmegenthe Netherlands
- Hemophilia Treatment CentreNijmegen Eindhoven Maastrichtthe Netherlands
| | - Laura H. Bukkems
- Department of Hospital Pharmacy‐Clinical PharmacologyAmsterdam University Medical CentersAmsterdamthe Netherlands
| | - Wideke Barteling
- Department of Laboratory MedicineLaboratory of HematologyRadboud University Medical CentreNijmegenthe Netherlands
| | - Britta A.P. Laros‐van Gorkom
- Department of HematologyRadboud University Medical CentreNijmegenthe Netherlands
- Hemophilia Treatment CentreNijmegen Eindhoven Maastrichtthe Netherlands
| | | | - Ron A.A. Mathôt
- Department of Hospital Pharmacy‐Clinical PharmacologyAmsterdam University Medical CentersAmsterdamthe Netherlands
| | - Waander L. van Heerde
- Hemophilia Treatment CentreNijmegen Eindhoven Maastrichtthe Netherlands
- Enzyre BVNovio Tech CampusNijmegenthe Netherlands
| | - Saskia E.M. Schols
- Department of HematologyRadboud University Medical CentreNijmegenthe Netherlands
- Hemophilia Treatment CentreNijmegen Eindhoven Maastrichtthe Netherlands
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8
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Aghighi S, Riddell A, Lee CA, Brown SA, Tuddenham E, Chowdary P. Global coagulation assays in hemophilia A: A comparison to conventional assays. Res Pract Thromb Haemost 2020; 4:298-308. [PMID: 32110761 PMCID: PMC7040542 DOI: 10.1002/rth2.12295] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 11/18/2019] [Accepted: 11/25/2019] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Global assays measure the interactions of coagulants, anticoagulants, and platelets on thrombin generation and may reflect the comprehensive coagulation potential in patients with hemophilia better than conventional assays. OBJECTIVES The objectives of the current study were to investigate the value of global assays for measuring and monitoring the coagulation potential of patients with hemophilia A (HA). PATIENTS/METHODS Rotational thromboelastometry, thrombin generation assay (TGA), and activated partial thromboplastin time (APTT) clot waveform analysis were investigated in a cohort of patients with severe, moderate, and mild HA and compared with conventional assays. RESULTS The maximum velocity (MaxVel) parameter of modified thromboelastometry analysis, initiated by tissue factor and in the presence of corn trypsin inhibitor (CTI), had 92% sensitivity and 95% specificity for hemophilia diagnosis. The MaxVel also strongly correlated with factor VIII (FVIII) levels of patients with HA (r = .805, P < .0001). CTI improved the sensitivity of TGA, providing more accurate results. In particular, peak height parameter of platelet-rich plasma samples with CTI had a sensitivity and specificity of 100% and 94%, respectively, in all patients with HA. APTT clot waveform analysis minimum value of first derivative (Min1) and minimum value of second derivative (Min2) parameters (representing speed and acceleration of clot formation, respectively) were sensitive and correlated more strongly with FVIII levels than APTT clotting times did (Min1: r = 0.786, P < 0.0001; Min2: r = 0.759, P < 0.0001; APTT: r = -0.513, P = 0.001). CONCLUSIONS The sensitivity and specificity of the global assays was method dependent. Correlation between clinical end points and thrombin generation might also be valuable in the era of non-factor replacement therapy.
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Affiliation(s)
- Saman Aghighi
- KD Haemophilia and Thrombosis CentreRoyal Free HospitalLondonUK
| | - Anne Riddell
- KD Haemophilia and Thrombosis CentreRoyal Free HospitalLondonUK
| | | | - Simon A. Brown
- KD Haemophilia and Thrombosis CentreRoyal Free HospitalLondonUK
- Queensland Children’s HospitalBrisbaneQldAustralia
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Kaolin, used to trigger coagulation in thrombin generation test, increases sensitivity of the method in hemophilia patients. Blood Coagul Fibrinolysis 2020; 31:193-197. [PMID: 31990756 DOI: 10.1097/mbc.0000000000000898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: Thrombin generation test (TGT) is well established tool to research blood coagulation in plasma of hemophilia patients. Traditionally coagulation in this test is triggered by a tissue factor (TF), an extrinsic coagulation pathway activator. However, it is known that disorders of the intrinsic pathway are most important for coagulation in hemophilia. In this study, we hypothesized that triggering coagulation via the intrinsic pathway could increase a sensitivity of the TGT to monitor hemophilia treatment. The aim of this study was to compare thrombin generation in hemophilia A patients with inhibitors to factor VIII before and after infusion of bypassing agent [recombinant-activated factor VIIa (rVIIa)] using standard activation of coagulation by TF or by kaolin, an activator of coagulation by intrinsic pathway. Endogenous thrombin potential (ETP) in nine patients was measured. ETP before (ETP0) and 60 min after rVIIa infusion (ETP60) were compared. It was shown that ETP0 and ETP60 were significantly different when using any coagulation activator (paired Student's t test, P = 0.017 and 3.7 × 10 for clotting activation by TF and kaolin, respectively). The ratios of ETP60/ETP0 were 1.2 ± 0.2 or 30.0 ± 22.4 (mean ± SD, n = 9) for coagulation activated by TF or kaolin, respectively, and were significantly different (paired Student's t test, P < 0.005). The TGT clearly distinguished between ETP0 and ETP60 in the case of any coagulation activator, but ETP increasing after rVIIa infusion was significantly higher when activated with kaolin. This provided increased sensitivity of this method for monitoring hemophilia therapy.
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10
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Panova-Noeva M, van der Meijden PE, ten Cate H. Clinical Applications, Pitfalls, and Uncertainties of Thrombin Generation in the Presence of Platelets. J Clin Med 2019; 9:jcm9010092. [PMID: 31905839 PMCID: PMC7019916 DOI: 10.3390/jcm9010092] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 12/24/2019] [Accepted: 12/24/2019] [Indexed: 12/11/2022] Open
Abstract
Platelet-dependent thrombin generation is a helpful tool to assess ex vivo the interaction between platelets and plasma coagulation factors in the initiation, amplification, and inhibition of thrombin generation (TG). This review article discusses the most relevant available data on the clinical applications of fluorogenic TG, the most widely used TG assay, performed in the presence of platelets, i.e., in platelet-rich plasma. With respect to prothrombotic states, arterial hypertension and obesity were the most prominent cardiovascular conditions linked to increased platelet-dependent TG. In addition, platelet-associated hypercoagulability, assessed by the TG assay, has been shown in individuals with active cancer. In terms of bleeding, platelet-dependent TG has been applied to assess bleeding risk in individuals with hemophilia, von Willebrand disease, and Glanzmann thrombasthenia as well as in subjects with other congenital or acquired coagulation factor deficiencies. In addition to risk prediction, a role of the TG assay has been suggested in monitoring antiplatelet therapy in prothrombotic conditions and replacement therapy in bleeding diathesis. Finally, for the routine clinical use and as a biomarker of disease development and progression, better standardization and clinical validation of platelet-dependent TG are still needed.
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Affiliation(s)
- Marina Panova-Noeva
- Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany;
| | - Paola E.J. van der Meijden
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, 6200 Maastricht, The Netherlands;
| | - Hugo ten Cate
- Department of Internal Medicine, Laboratory of Clinical Thrombosis and Haemostasis, and Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, 6200 Maastricht, The Netherlands
- Correspondence:
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11
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Chelle P, Montmartin A, Damien P, Piot M, Cournil M, Lienhart A, Genre‐Volot F, Chambost H, Morin C, Tardy‐Poncet B. Tissue factor pathway inhibitor is the main determinant of thrombin generation in haemophilic patients. Haemophilia 2019; 25:343-348. [DOI: 10.1111/hae.13679] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 12/14/2018] [Accepted: 12/14/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Pierre Chelle
- CIS‐EMSE, SAINBIOSE Ecole Nationale Supérieure des Mines de Saint‐Etienne Saint Etienne France
- INSERM, U1059, SAINBIOSE Université de Lyon, UJM‐Saint‐Etienne Saint‐Etienne France
| | - Aurélie Montmartin
- INSERM, U1059, SAINBIOSE Université de Lyon, UJM‐Saint‐Etienne Saint‐Etienne France
| | - Pauline Damien
- INSERM, CIC 1408, FCRIN‐INNOVTE CHU Saint‐Etienne Saint‐Etienne France
| | - Michèle Piot
- INSERM, U1059, SAINBIOSE Université de Lyon, UJM‐Saint‐Etienne Saint‐Etienne France
| | - Michel Cournil
- CIS‐EMSE, SAINBIOSE Ecole Nationale Supérieure des Mines de Saint‐Etienne Saint Etienne France
- INSERM, U1059, SAINBIOSE Université de Lyon, UJM‐Saint‐Etienne Saint‐Etienne France
| | - Anne Lienhart
- Centre de référence et de traitement de l’hémophilie Hopital Cardiologique Louis Pradel Lyon France
| | | | - Hervé Chambost
- Centre de traitement de l’hémophilie Hôpital d’enfants La Timone Marseille France
| | - Claire Morin
- CIS‐EMSE, SAINBIOSE Ecole Nationale Supérieure des Mines de Saint‐Etienne Saint Etienne France
| | - Brigitte Tardy‐Poncet
- INSERM, U1059, SAINBIOSE Université de Lyon, UJM‐Saint‐Etienne Saint‐Etienne France
- INSERM, CIC 1408, FCRIN‐INNOVTE CHU Saint‐Etienne Saint‐Etienne France
- Centre de traitement de l’hémophilie CHU Saint‐Etienne Saint‐Etienne France
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12
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Chelle P, Montmartin A, Piot M, Ardillon L, Wibaut B, Frotscher B, Cournil M, Morin C, Tardy-Poncet B. Prediction of individual factor VIII or IX level for the correction of thrombin generation in haemophilic patients. Haemophilia 2018; 24:995-1001. [DOI: 10.1111/hae.13539] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2018] [Indexed: 11/26/2022]
Affiliation(s)
- P. Chelle
- Mines saint-Etienne; Univ Lyon; Univ Jean Monnet; INSERM; Centre CIS; Saint Etienne France
- INSERM; U1059; SAINBIOSE; Univ Lyon; Saint Etienne France
| | - A. Montmartin
- INSERM; U1059; SAINBIOSE; Univ Lyon; Saint Etienne France
| | - M. Piot
- INSERM; U1059; SAINBIOSE; Univ Lyon; Saint Etienne France
| | - L. Ardillon
- Service d'Hématologie-Hémostase; CHU Trousseau; Tours Cedex France
| | - B. Wibaut
- Unité d'Hémostase Clinique; Institut Cœur Poumon; Haemophilia Treatment Centre; CHRU Lille; Lille France
| | - B. Frotscher
- Haemophilia Treatment Centre; CHU Nancy; Vandoeuvre-lès-Nancy France
| | - M. Cournil
- Mines saint-Etienne; Univ Lyon; Univ Jean Monnet; INSERM; Centre CIS; Saint Etienne France
- INSERM; U1059; SAINBIOSE; Univ Lyon; Saint Etienne France
| | - C. Morin
- Mines saint-Etienne; Univ Lyon; Univ Jean Monnet; INSERM; Centre CIS; Saint Etienne France
- INSERM; U1059; SAINBIOSE; Univ Lyon; Saint Etienne France
| | - B. Tardy-Poncet
- INSERM; U1059; SAINBIOSE; Univ Lyon; Saint Etienne France
- INSERM; CIC 1408; FCRIN-INNOVTE; Saint-Etienne France
- CHU Saint-Etienne; Haemophilia Treatment Centre; UMI, Hôpital Nord; Saint-Etienne France
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13
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Evaluation of recombinant factor VIII Fc (Eloctate) activity by thromboelastometry in a multicenter phase 3 clinical trial and correlation with bleeding phenotype. Blood Coagul Fibrinolysis 2018; 28:540-550. [PMID: 28486277 PMCID: PMC5642334 DOI: 10.1097/mbc.0000000000000638] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
The aim of this study was to compare the hemostatic efficacy of recombinant factor VIII Fc (rFVIIIFc) (Eloctate) and Advate by ex-vivo rotation thromboelastometry (ROTEM) of whole blood and to explore potential ROTEM parameters that may be more predictive of a patient's bleeding tendency than plasma FVIII activity. Thirteen clinical sites were selected to perform ROTEM on freshly collected blood samples from 44 patients in the phase 3 study for rFVIIIFc, including 16 patients undergoing sequential pharmacokinetic assessment of Advate and rFVIIIFc. Equivalent hemostatic activity was observed for rFVIIIFc and Advate in postinfusion samples, followed by improvements for rFVIIIFc in clotting time, clot formation time and alpha angle (α) for a longer duration than Advate, consistent with the pharmacokinetic improvements reported previously for rFVIIIFc. Our study did not demonstrate a statistical correlation between a patient's ROTEM activity at baseline or at trough and the occurrence of spontaneous bleeds while on prophylactic therapy. However, an association was observed between postinfusion clotting time and the occurrence of one or more spontaneous bleeds vs. no bleeds over a follow-up period of 1 year (P = 0.003). How well a patient's whole blood clotting deficiency is corrected after a dose of FVIII may be an indicator of subsequent bleeding tendency in patients with otherwise equivalent FVIII peak and trough levels. The technical challenges of standardizing the ROTEM, largely overcome in the current study, may however preclude the use of this method for widespread assessment of global hemostasis unless additional assay controls or normalization procedures prove to be effective.
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14
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Slatter DA, Percy CL, Allen-Redpath K, Gajsiewicz JM, Brooks NJ, Clayton A, Tyrrell VJ, Rosas M, Lauder SN, Watson A, Dul M, Garcia-Diaz Y, Aldrovandi M, Heurich M, Hall J, Morrissey JH, Lacroix-Desmazes S, Delignat S, Jenkins PV, Collins PW, O'Donnell VB. Enzymatically oxidized phospholipids restore thrombin generation in coagulation factor deficiencies. JCI Insight 2018; 3:98459. [PMID: 29563336 PMCID: PMC5926910 DOI: 10.1172/jci.insight.98459] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 02/16/2018] [Indexed: 12/11/2022] Open
Abstract
Hemostatic defects are treated using coagulation factors; however, clot formation also requires a procoagulant phospholipid (PL) surface. Here, we show that innate immune cell–derived enzymatically oxidized phospholipids (eoxPL) termed hydroxyeicosatetraenoic acid–phospholipids (HETE-PLs) restore hemostasis in human and murine conditions of pathological bleeding. HETE-PLs abolished blood loss in murine hemophilia A and enhanced coagulation in factor VIII- (FVIII-), FIX-, and FX-deficient human plasma . HETE-PLs were decreased in platelets from patients after cardiopulmonary bypass (CPB). To explore molecular mechanisms, the ability of eoxPL to stimulate individual isolated coagulation factor/cofactor complexes was tested in vitro. Extrinsic tenase (FVIIa/tissue factor [TF]), intrinsic tenase (FVIIIa/FIXa), and prothrombinase (FVa/FXa) all were enhanced by both HETE-PEs and HETE-PCs, suggesting a common mechanism involving the fatty acid moiety. In plasma, 9-, 15-, and 12-HETE-PLs were more effective than 5-, 11-, or 8-HETE-PLs, indicating positional isomer specificity. Coagulation was enhanced at lower lipid/factor ratios, consistent with a more concentrated area for protein binding. Surface plasmon resonance confirmed binding of FII and FX to HETE-PEs. HETE-PEs increased membrane curvature and thickness, but not surface charge or homogeneity, possibly suggesting increased accessibility to cations/factors. In summary, innate immune-derived eoxPL enhance calcium-dependent coagulation factor function, and their potential utility in bleeding disorders is proposed. Innate immune-derived enzymatically oxidized phospholipids enhance calcium-dependent coagulation factor function.
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Affiliation(s)
- David A Slatter
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Charles L Percy
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Keith Allen-Redpath
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Joshua M Gajsiewicz
- Departments of Biological Chemistry and Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Nick J Brooks
- Faculty of Natural Science, Department of Chemistry, Imperial College London, London, United Kingdom
| | - Aled Clayton
- Institute of Cancer and Genetics, Velindre Cancer Centre, School of Medicine, and
| | - Victoria J Tyrrell
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Marcela Rosas
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Sarah N Lauder
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Andrew Watson
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Maria Dul
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, United Kingdom
| | - Yoel Garcia-Diaz
- School of Chemistry, Vanderbilt University, Nashville, Tennessee, USA
| | - Maceler Aldrovandi
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Meike Heurich
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Judith Hall
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - James H Morrissey
- Departments of Biological Chemistry and Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | | | - P Vincent Jenkins
- Haematology Department, University Hospital of Wales, Cardiff, United Kingdom
| | - Peter W Collins
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Valerie B O'Donnell
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
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15
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Dargaud Y, Wolberg AS, Gray E, Negrier C, Hemker HC. Proposal for standardized preanalytical and analytical conditions for measuring thrombin generation in hemophilia: communication from the SSC of the ISTH. J Thromb Haemost 2017; 15:1704-1707. [PMID: 28656617 PMCID: PMC5680042 DOI: 10.1111/jth.13743] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Y Dargaud
- Hospices Civils de Lyon, Clinical Haemostasis Unit, Hopital Cardiologique Louis Pradel - Universite Lyon 1, Lyon, France
| | - A S Wolberg
- Department of Pathology and Laboratory Medicine, UNC, Chapel Hill, NC, USA
| | - E Gray
- Haemostasis Section, Biotherapeutics, National Institute for Biological Standards and Control, Potters Bar, Hertfordshire, UK
| | - C Negrier
- Hospices Civils de Lyon, Clinical Haemostasis Unit, Hopital Cardiologique Louis Pradel - Universite Lyon 1, Lyon, France
| | - H C Hemker
- Cardiovascular Research Institute Maastricht (CARIM), University of Maastricht, Maastricht, the Netherlands
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16
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Duarte RCF, Ferreira CN, Rios DRA, Reis HJD, Carvalho MDG. Thrombin generation assays for global evaluation of the hemostatic system: perspectives and limitations. Rev Bras Hematol Hemoter 2017; 39:259-265. [PMID: 28830606 PMCID: PMC5568585 DOI: 10.1016/j.bjhh.2017.03.009] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 01/28/2017] [Accepted: 03/30/2017] [Indexed: 12/22/2022] Open
Abstract
The existing techniques to evaluate hemostasis in clinical laboratories are not sensitive enough to detect hypercoagulable and mild hypocoagulable states. Under different experimental conditions, the thrombin generation test may meet these requirements. This technique evaluates the overall balance between procoagulant and anticoagulant forces and has provided new insights in our understanding of the coagulation cascade, as well as of the diagnosis of hypocoagulability and hypercoagulability conditions. Thrombin generated in the thrombin generation test can be quantified as platelet-rich or platelet-poor plasma using the calibrated automated thrombogram method, which monitors the cleavage of a fluorogenic substrate that is simultaneously compared to the known thrombin activity in a non-clotting plasma sample. The calibrated automated thrombogram method is an open system, in which different antibodies, proteins, enzymes and peptides can be introduced to answer specific questions regarding hemostatic processes. The thrombin generation test has great clinical potential, such as in monitoring patients taking anticoagulants and antiplatelet drugs, screening for genetic or acquired thrombotic disorders, and evaluating bleeding risk control in patients with hemophilia using bypass agents or replacement therapy. Different to conventional coagulation tests, the thrombin generation test can be used for an overall evaluation of hemostasis, the results of which can then be used to evaluate specific characteristics of hemostasis, such as prothrombin time, activated partial thromboplastin time, and levels of fibrinogen and other coagulation factors. The introduction of this method will contribute to a better understanding and evaluation of overall hemostatic processes; however, this method still requires standardization and clinical validation.
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17
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Baumgartner CK, Zhang G, Kuether EL, Weiler H, Shi Q, Montgomery RR. Comparison of platelet-derived and plasma factor VIII efficacy using a novel native whole blood thrombin generation assay. J Thromb Haemost 2015; 13:2210-9. [PMID: 26453193 PMCID: PMC4715732 DOI: 10.1111/jth.13169] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 09/30/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND We have recently developed a successful gene therapy approach for hemophilia A in which factor VIII (FVIII) expression is targeted to platelets by the αIIb promoter. Levels of platelet-expressed FVIII (2bF8) achieved by gene therapy may vary between individuals due to differences in ex vivo transduction and gene expression efficiency. Accurate assays to evaluate 2bF8 efficacy are desirable. OBJECTIVE To compare the hemostatic efficacy of 2bF8 with replacement therapy over a wide therapeutic dose range. METHODS Efficacy of 2bF8 was assessed using a new transgenic mouse model expressing high 2bF8 levels (LV18(tg) ). Blood from LV18(tg) mice or FVIII(null) mice infused with recombinant FVIII was mixed with FVIII(null) blood at different ratios ex vivo to achieve several concentrations of 2bF8 or plasma FVIII. Samples were evaluated with a novel native whole blood thrombin generation assay that uses recalcified whole blood without the addition of tissue factor to initiate coagulation. RESULTS FVIII dose dependency was observed in all five thrombin generation parameters. While the total amount of thrombin generated was similar, 2bF8 significantly accelerated thrombin generation compared with plasma FVIII. Remarkably, a 10-fold lower dose of 2bF8 than plasma FVIII (0.2% vs. 2%) significantly shortened the onset and peak of thrombin generation compared with FVIII(null) blood. CONCLUSION Using a new transgenic mouse model, we showed that the novel native whole blood thrombin generation assay established here can be used to monitor platelet targeted FVIII gene therapy. The higher therapeutic efficacy of 2bF8 compared with factor replacement therapy seemed to be due to acceleration of thrombin generation.
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Affiliation(s)
- C K Baumgartner
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
| | - G Zhang
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
| | - E L Kuether
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - H Weiler
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
| | - Q Shi
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
- Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - R R Montgomery
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
- Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA
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18
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Mohammed BM, Martin EJ, Salinas V, Carmona R, Young G, Brophy DF. Failure of corn trypsin inhibitor to affect the thrombin generation assay in plasma from severe hemophiliacs. J Thromb Haemost 2014; 12:1558-61. [PMID: 25041427 DOI: 10.1111/jth.12659] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Indexed: 08/31/2023]
Abstract
BACKGROUND The thrombin generation assay (TGA) is an important global coagulation assay; however, it suffers from the lack of preanalytical standardization. The addition of corn trypsin inhibitor (CTI) to blood collection tubes before TGA has been previously advocated to block the contact activation pathway. Emerging data, however, suggest that CTI may only be necessary when minimal tissue factor (TF) concentrations < 1 pmol are used. OBJECTIVES To determine whether blood collection tubes containing CTI influenced TGA parameters. METHODS This cross-sectional, observational study performed the TGA using TF 1 pmol L(-1) in 15 healthy volunteers, 14 severely factor VIII (FVIII)-deficient patients, and 15 severely FVIII-deficient patients with documented FVIII inhibitors. TGA was conducted using blood tubes that contained CTI 33 μg mL(-1) and no CTI. RESULTS CTI markedly reduced peak thrombin (P = 0.002) and endogenous thrombin potential (P < 0.001) in the healthy volunteers but had no significant effect on TGA parameters in severely FVIII-deficient patients or those with inhibitors. CONCLUSIONS This lack of effect raises additional questions regarding the need for CTI as a preanalytical addition to blood collection tubes during TGA in severe hemophiliacs, particularly when activating samples with TF 1 pmol L(-1) .
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Affiliation(s)
- B M Mohammed
- Coagulation Advancement Laboratory, Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA; Department of Clinical Pharmacy, Faculty of Pharmacy, Cairo University, Cairo, Egypt
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19
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Khanum F, Collins PW, Harris RL, Bowen DJ. Characterization ofF8defects in haemophilia A in Pakistan: investigation of correlation between mutation type and thein vitrothrombin generation assay. Haemophilia 2013; 20:287-93. [DOI: 10.1111/hae.12272] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2013] [Indexed: 11/28/2022]
Affiliation(s)
- F. Khanum
- Department of Haematology; School of Medicine; Cardiff University; Cardiff UK
| | - P. W. Collins
- Department of Haematology; School of Medicine; Cardiff University; Cardiff UK
| | - R. L. Harris
- Department of Haematology; School of Medicine; Cardiff University; Cardiff UK
| | - D. J. Bowen
- Department of Haematology; School of Medicine; Cardiff University; Cardiff UK
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20
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Al Hawaj MA, Martin EJ, Venitz J, Barrett JC, Kuhn JG, Nolte ME, Brophy DF. Monitoring rFVIII prophylaxis dosing using global haemostasis assays. Haemophilia 2013; 19:409-14. [PMID: 23510278 DOI: 10.1111/hae.12110] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2013] [Indexed: 11/28/2022]
Abstract
Secondary factor VIII (FVIII) prophylaxis converts severe haemophiliacs (FVIII:C < 1 IU dL(-1)) to a moderate phenotype (FVIII:C ≥ 1 IU dL(-1)), however, plasma FVIII:C is a poor predictor of bleeding risk. This study used thromboelastography (TEG) and thrombin generation assay (TGA) to quantify coagulation across a 48 h rFVIII prophylaxis period. 10 severe haemophiliacs with varying clinical bleeding phenotypes received their standard rFVIII prophylaxis dose and blood samples were obtained over 48 h. Measured parameters included FVIII:C, TEG and TGA at each time point. FVIII:C pharmacokinetics (PK) and correlation between global assay parameters was performed. The FVIII:C PK parameters were consistent with previous literature. There was significant correlation between FVIII:C and TEG R-time and aPTT (both P < 0.001). Significant correlations existed between FVIII:C and TGA peak, ETP and velocity parameters (all P < 0.001). At 24 h the TEG parameters were sub-therapeutic despite median FVIII:C of 13.0 IU dL(-1). TGA was sensitive to FVIII:C below 1 IU dL(-1). Those with the severest bleeding phenotype had the lowest TGA parameters. There was significant correlation between FVIII:C and TEG and TGA. TEG lost sensitivity at 48 h, but not TGA. Prospective studies are needed to determine whether these data can be used to design individualized rFVIII prophylaxis regimens.
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Affiliation(s)
- M A Al Hawaj
- Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA 23298-0533, USA
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21
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Coagulation proteins influencing global coagulation assays in cirrhosis: hypercoagulability in cirrhosis assessed by thrombomodulin-induced thrombin generation assay. BIOMED RESEARCH INTERNATIONAL 2013; 2013:856754. [PMID: 23555099 PMCID: PMC3595107 DOI: 10.1155/2013/856754] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 01/03/2013] [Accepted: 01/24/2013] [Indexed: 01/14/2023]
Abstract
Background. Liver disease is accompanied by profound hemostatic disturbances. We investigated the influences of pro- and anticoagulation factors on global coagulation tests including prothrombin time (PT), activated partial thromboplastin time (aPTT), and thrombin generation assay (TGA) in cirrhosis. We also investigated whether cirrhotic patients exhibit hypo- or hypercoagulability using the TGA. Methods. The TGA was performed on a calibrated automated thrombogram, given lag time, endogenous thrombin potential (ETP), and peak thrombin in 156 cirrhotic patients and 73 controls. Results. PT was determined according to the factor (F) II, FV, FVII, FIX, and protein C levels. We observed that aPTT was dependent on FII, FIX, and FX levels. The ETP was dependent on FII, antithrombin, and protein C with 5 pM tissue factor (TF) stimulation, and FIX and protein C at 1 pM TF. The ETP ratio with 1 pM TF increased significantly in cirrhosis, indicating hypercoagulability, whereas that with 5 pM TF did not increase in cirrhosis. Conclusion. PT and the TGA are sensitive to protein C levels. Even with prolonged PT, the TGA can detect hypercoagulability in cirrhosis. Further studies should evaluate global coagulation status in cirrhosis patients using the newly devised TGA system.
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22
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Evaluation of a standardized protocol for thrombin generation measurement using the calibrated automated thrombogram: An international multicentre study. Thromb Res 2012; 130:929-34. [DOI: 10.1016/j.thromres.2012.07.017] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 07/19/2012] [Accepted: 07/19/2012] [Indexed: 11/16/2022]
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23
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Collins PW, Chalmers E, Hart DP, Liesner R, Rangarajan S, Talks K, Williams M, Hay CR. Diagnosis and treatment of factor VIII and IX inhibitors in congenital haemophilia: (4th edition). Br J Haematol 2012; 160:153-70. [DOI: 10.1111/bjh.12091] [Citation(s) in RCA: 159] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Peter W. Collins
- School of Medicine; Cardiff University; University Hospital of Wales; Wales; UK
| | | | - Daniel P. Hart
- The London School of Medicine and Dentistry; Royal London Hospital; Barts, Queen Mary University; London; UK
| | - Ri Liesner
- Great Ormond Street NHS Trust; London; UK
| | - Savita Rangarajan
- Hampshire Hospital NHS Foundation Trust; Basingstoke & North Hampshire Hospital; Basingstoke; UK
| | - Kate Talks
- Royal Victoria Infirmary; Newcastle upon Tyne; UK
| | - Mike Williams
- Birmingham Childrens' Hospital NHS Foundation Trust; Birmingham; UK
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24
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Abstract
Prophylaxis is the recommended treatment for people with severe haemophilia. It is unlikely that a single prophylactic regimen, for example based on weight, would be optimal for all patients and therefore each individual should have a personalized regimen, agreed between themselves and their haemophilia centre. This regimen should take into account the individual's bleeding pattern, the condition of their musculoskeletal system, level and timing of physical activity and measurement of coagulation factor in their blood. It is important to recognize that prophylactic regimens are likely to need to change with time as the circumstances of an individual change. For example, activity may change with age or with the season and an individual's factor VIII pharmacokinetics vary with age. Knowledge of a patient's pharmacokinetics is likely to help personalize prophylaxis when combined with other information. Factor VIII pharmacokinetics are simple to measure in routine clinical practice and can be adequately calculated from 2 to 3 blood samples combined with a simple to use computer program. Prophylaxis is expensive and, in countries with a limited health care budget, ways to improve its cost effectiveness need to be considered to allow increased access to this treatment. For example, increasing the frequency of prophylaxis can dramatically reduce the amount of treatment required to sustain measureable factor levels and hence reduce cost. The introduction of longer-acting coagulation factors may necessitate a change in concepts about prophylaxis because whilst these agents may sustain an apparently adequate trough level with fewer infusions, the length of time a person spends at a low level will be increased and this could increase the risk of bleeding, especially at the time of increased physical activity. There is convincing evidence that prophylaxis is the optimal therapy for severe haemophilia, optimizing treatment for each individual and increasing access to this treatment modality are important goals for the future.
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Affiliation(s)
- P W Collins
- Arthur Bloom Haemophilia Centre, School of Medicine, Cardiff University, Heath Park, Cardiff, UK. peter.collins@.wales.nhs.uk
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25
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Dargaud Y, Sorensen B, Shima M, Hayward C, Srivastava A, Negrier C. Global haemostasis and point of care testing. Haemophilia 2012; 18 Suppl 4:81-8. [PMID: 22726088 DOI: 10.1111/j.1365-2516.2012.02855.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The evaluation of the coagulation profile has used so far either clotting-based or chromogenic assays with different endpoints. Clotting-based techniques are the most used worldwide, and they certainly are useful for diagnosis of clotting factor deficiencies. However, the information provided is relatively limited, and therefore the individual profile of coagulation is poorly assessed. This is reflected by the weak correlation between the results of these assays and the clinical phenotype. Among the assays that benefited from technological advances, thrombin generation and thromboelastography are probably the most actively investigated, but they require specific instruments and are not fully automated. Their standardisation level is rapidly progressing, and they are progressively entering the clinical scene, with the attempt to provide additional information on the coagulation process and a meaningful clinical correlation. These inherited bleeding disorders frequently require replacement therapy using clotting factor concentrates that increase the plasma level of the missing clotting factor. The classical adjustment of the therapy is mainly based on the measurement of the plasma clotting activity of the protein administered. If one considers that a certain level of thrombin generated would predict clinical efficacy, monitoring of thrombin formation might offer new possibilities to individually predict the bleeding phenotype, select the most adapted therapeutic product and tailor the dose. The same holds true for thromboelastography/thromboelastometry which evaluate fibrin formation as well as clot resistance to fibrinolytic challenge, one step further down in the coagulation process. In this regard, these 2 assays could be seen as complementary in terms of information provided on the coagulation profile at the individual level.
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Affiliation(s)
- Y Dargaud
- Unite d'Hemostase Clinique, Hopital Edouard Herriot, EAM4174, Universite Lyon 1, Lyon, France
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Ay Y, Balkan C, Karapinar DY, Akin M, Bilenoğlu B, Kavakli K. Feasibility of using thrombin generation assay (TGA) for monitoring of haemostasis during supplementation therapy in haemophilic patients without inhibitors. Haemophilia 2012; 18:911-6. [PMID: 22639879 DOI: 10.1111/j.1365-2516.2012.02849.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2012] [Indexed: 11/27/2022]
Abstract
Monitoring factor replacement treatment and observing concordance with clinical haemostasis is crucial in vital haemorrhages and major surgeries in haemophilic patients. We aimed to investigate the value of the thrombin generation assay (TGA) and thromboelastography (TEG) for monitoring haemostasis in haemophilic patients during factor replacement treatment. The study group consisted of 29 patients (21 haemophilia A, 8 haemophilia B). All the patients FVIII-inhibitor were negative. A total of 35 bleeding episodes and/or surgical interventions were evaluated. aPTT, FVIII/FIX activity, TEG and TGA tests were conducted before and after factor therapy during the bleeding episode or surgical prophylaxis of haemophilic patients. Correlations among these tests were evaluated and compared with clinical responses. No correlation was found among aPTT, factor activities and clinical outcome. There were also no correlation found between TEG parameters and clinical outcome. The only significant correlation found between TGA parameters and clinical outcome was the correlation between peak thrombin. In conclusion, we found superiority of TGA-peak thrombin over other traditional tests for monitoring haemostasis in haemophilic patients in this study.
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Affiliation(s)
- Y Ay
- Deparment of Hematology, Ege University Medical School, Children's Hospital, Ege Hemophilia Center, Bornova, Izmir, Turkey
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van Geffen M, van Heerde WL. Global haemostasis assays, from bench to bedside. Thromb Res 2012; 129:681-7. [PMID: 22221936 DOI: 10.1016/j.thromres.2011.12.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 12/02/2011] [Accepted: 12/04/2011] [Indexed: 10/14/2022]
Abstract
Bleeding and thrombosis are the ultimate clinical outcomes of aberrations in the haemostatic process. Haemostasis prevents excessive blood loss due to the effort of various compartments like the vasculature, blood cells, coagulation and fibrinolysis. The complexity of all processes involved makes the diagnosis of aberrations difficult, cumbersome and expensive. A single assay to detect any factor disturbing this haemostatic balance with high sensitivity and specificity would be of great value, especially if the outcome of this assay correlates well with clinical outcome. Despite years of research, such an assay is not yet available; however, some interesting candidates are under development and combine the effects of various compartments. This review describes the development of global haemostasis assays and summarizes the current state of the art of these haemostasis assays covering thrombin and plasmin generation, turbidity and thromboelastography/thromboelastometry. Finally, we discuss the applicability of global assays in clinical practice and we provide a future perspective on the ongoing development of automation and miniaturisation as it is our belief that these developments will benefit the standardization of global haemostasis assays.
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Affiliation(s)
- Mark van Geffen
- Laboratory of Haematology, department of Laboratory Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
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Ninivaggi M, Dargaud Y, van Oerle R, de Laat B, Hemker HC, Lindhout T. Thrombin generation assay using factor IXa as a trigger to quantify accurately factor VIII levels in haemophilia A. J Thromb Haemost 2011; 9:1549-55. [PMID: 21605333 DOI: 10.1111/j.1538-7836.2011.04358.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The available methods for measuring factor VIII (FVIII) activity suffer reportedly from lack of sensitivity and precision in the < 1 IU dL(-1) range. This precludes correlation of clinical phenotype with FVIII levels. OBJECTIVES To study a possible association between clinical phenotype in patients with FVIII levels < 1 IU dL(-1). METHODS/RESULTS The FIXa-driven FVIII assay (FVIII-CAT) has a detection limit of 0.05 IU dL(-1). For the range of 0-2 IU dL(-1) FVIII, the intra-assay coefficient of variation (CV) is around 2% and the inter-assay CV is about 8%. We tested 30 hemophiliacs with FVIII:C between < 1 and 6 IU dL(-1) as measured in the one-stage clotting assay using the FVIII-CAT assay. For genetic defects related to moderate hemophilia, the FVIII-CAT test finds FVIII levels that are in good agreement with those determined with the one-stage assay. Of the 21 hemophilic patients with FVIII < 1 IU dL(-1), four patients exhibited a mild bleeding phenotype. When we applied TF-initiated thrombin generation, patients with a mild clinical phenotype showed significantly higher endogenous thrombin potentials. CONCLUSION The novel developed FVIII assay measures accurately FVIII levels below 1 IU dL(-1). Its application demonstrated that the clinical heterogeneity in individuals with < 1 IU dL(-1) FVIII is not associated with their FVIII level.
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MIKOVIC D, WOODHAMS BJ, HOLMSTRÖM M, ELEZOVIC I, ANTOVIC A, MOBARREZ F, ELFVINGE P, ANTOVIC JP. On-demand but not prophylactic treatment with FVIII concentrate increase thrombin activatable fibrinolysis inhibitor activation in severe haemophilia A patients. Int J Lab Hematol 2011; 34:35-40. [DOI: 10.1111/j.1751-553x.2011.01349.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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WARTIOVAARA-KAUTTO U, JOUTSI-KORHONEN L, ILVESKERO S, ARMSTRONG E, LASSILA R. Platelets significantly modify procoagulant activities in haemophilia A. Haemophilia 2011; 17:743-51. [DOI: 10.1111/j.1365-2516.2011.02601.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Gringeri A, Muça-Perja M, Mangiafico L, von Mackensen S. Pharmacotherapy of haemophilia A. Expert Opin Biol Ther 2011; 11:1039-53. [PMID: 21682657 DOI: 10.1517/14712598.2011.570006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Haemophilia A is due to factor VIII (FVIII) deficiency. The main treatment is replacement therapy with FVIII concentrates. However, these concentrates carried a high risk of blood-borne viral infections and still have a high risk of inducing anti-FVIII inhibitors. AREAS COVERED An overview of products available and therapeutic options for haemophilia A management in order to help in decision making. A literature search using Medline with the keywords: 'haemophilia', 'factor VIII', 'therapy', 'inhibitor', 'concentrate', 'bleeding', 'prophylaxis', 'on demand', 'plasma-derived', 'recombinant', 'coagulation factors', 'immunotolerance' was performed. The years 1960 - 2010 are included. EXPERT OPINION Progress in management of patients with haemophilia A has allowed increased life expectancy and quality of life. There is evidence that prophylaxis prevents or, at least, slows down arthropathy development when started early in childhood. FVIII concentrates have achieved high levels of blood-borne pathogen safety. However, treatment is frequently complicated by development of FVIII-neutralizing inhibitors, which prevent control of bleeding and predispose to a high morbidity and mortality risk. Bypassing agents are effective in bleeding treatment in a high percentage of cases. Prophylaxis with bypassing agents and their use in combination are offering opportunities in management of inhibitor patients. More evidence is necessary to understand how to prevent and manage this complication.
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Standardisation of thrombin generation test - which reference plasma for TGT?: An international multicentre study. Thromb Res 2010; 125:353-6. [DOI: 10.1016/j.thromres.2009.11.012] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2009] [Revised: 10/09/2009] [Accepted: 11/10/2009] [Indexed: 11/22/2022]
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A modified thrombin generation test for investigating very low levels of factor VIII activity in hemophilia A. Int J Hematol 2009; 90:576-582. [PMID: 19937483 DOI: 10.1007/s12185-009-0450-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2009] [Revised: 10/19/2009] [Accepted: 11/03/2009] [Indexed: 10/20/2022]
Abstract
Discrepancies between low levels of FVIII:C and clinical symptoms in severe hemophilia A are well-known. We have recently demonstrated that levels of FVIII:C < 0.2 IU/dl were consistent with clinical phenotype by clot waveform analysis, suggesting that precise measurement of very low levels of FVIII:C was clinically important. Thrombin generation tests (TGTs) triggered by tissue factor (TF) have been recently utilized to monitor coagulation function in hemophilia A. We examined whether TGT was useful for evaluating hemophilia A patients with very low levels of FVIII:C. TGTs in 40 hemophilia A plasmas with FVIII:C < 0.2-17 IU/dl (measured by clot waveform analysis using MDA-II) were performed using TF and/or ellagic acid (ELG). The lagtime in ELG-TGT at very low levels of FVIII:C was shortened dose-dependently, whilst this parameter in TF-TGT was not significantly affected. Other parameters (endogenous thrombin potential, peak thrombin, time to peak) correlated with FVIII:C levels to some extent in both assays (r = 0.4-0.7). Using a TF/ELG mixture in TGT, however, the correlation coefficients increased to ~0.85. TGT parameters correlated well with levels of FVIII:C > 0.2 IU/dl, although the lagtime was not especially informative. We conclude that modified TGT, using a TF/ELG mixture as the trigger, is useful for monitoring coagulation function at very low levels of FVIII:C in hemophilia A.
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Percy CL, Macartney N, Pollard B, Rayment R, Collins PW. Laboratory monitoring of Scott Syndrome. Br J Haematol 2009; 149:803. [DOI: 10.1111/j.1365-2141.2009.07935.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
SUMMARY Haemophilia comprehensive care centres (HCCC) were first created more than 50 years ago. Their first objective was educating the patient and healthcare professionals in the management of bleeding. Today HCCCs are centres of excellence with multidisciplinary specialists, which continue to provide essential services that are continually reassessed in light of new scientific information. In addition, HCCCs make significant research contributions by studying new methods to improve the well-being of patients with haemophilia. Laboratory expertise is one of the central pillars of HCCCs with a direct impact on diagnosis and management of the haemophilia disease. Vast efforts have been made for the standardization of factor VIII (FVIII) and FIX measurements and inhibitor detection. Molecular biology has improved diagnostics and made it possible to develop new, more secure FVIII and FIX concentrates for replacement therapy. However, phenotyping of each haemophilia patient with an accurate prediction of the individual bleeding risk and also the individual response of patients to antihaemophilic treatment still remains a challenge. In the last 5 years, an expanding interest of haematologists for thrombin generation testing (TGT) reflects the need for new laboratory tools able to evaluate the overall coagulating capacity of patients. This study will review unmet laboratory needs in haemophilia and the potential applications of TGT in the management of haemophiliacs. Furthermore, technical and standardization issues of the method will be discussed.
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Affiliation(s)
- Y Dargaud
- Unité d'Hémostase Clinique, Hôpital Edouard Herriot, Lyon, France.
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Salvagno GL, Astermark J, Lippi G, Ekman M, Franchini M, Guidi GC, Berntorp E. Thrombin generation assay: a useful routine check-up tool in the management of patients with haemophilia? Haemophilia 2009; 15:290-6. [PMID: 19149855 DOI: 10.1111/j.1365-2516.2008.01877.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Severity assessment of patients with haemophilia A (HA) is traditionally based on FVIII activity (FVIII:C). Clinical phenotype of HA patients often differs between individuals with the same FVIII:C determined with clotting and chromogenic assays. The aim of this study was to assess the influence of the FVIII:C on thrombin generation (TG) assay parameters both in vitro and ex-vivo postinfusion plasma. For in-vitro approach, influence of FVIII:C was evaluated on TG parameters in several dilutions of a normal plasma pool with commercial FVIII-depleted-plasma (FVIIIDP) and in others experiments, adding increasing amounts of different commercial FVIII concentrates (Fanhdi, Haemate-P, Hemofil-M and Kogenate Bayer) to FVIIIDP. In a series of 50 postinfusion samples, from HA patients of different severity, we assayed TG and FVIII:C (chromogenic and clotting). In vitro experiments, the 50% of maximum TG peak (TGMP) was achieved using only 5% FVIII:C and the TGMP was obtained with 40% of normal VIII:C. Impaired response compared with normal plasma was found in FVIIIDP using addition of increasing amounts of different commercial FVIII concentrates. An overall good correlation between the two FVIII assays was observed (y = 0.9115x - 0.273, r = 0.975, P < 0.001); TGMP and the Lag-Phase-Time (LPT) provided some discrepant results when compared with the total range of FVIII:C measurements. In contrast, correlations for TGMP, LPT and endogenous thrombin potential were improved in samples restricted to FVIII:C <5%. We conclude that TG parameters tentatively could be a tool to tailor the global haemostatic capacity in haemophilic patients.
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Affiliation(s)
- G L Salvagno
- Department of Clinical Chemistry, Verona University Hospital, Verona, Italy.
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Eichinger S, Lubsczyk B, Kollars M, Traby L, Zwiauer K, Gleiss A, Quehenberger P, Kyrle PA. Thrombin generation in haemophilia A patients with factor VIII inhibitors after infusion of recombinant factor VIIa. Eur J Clin Invest 2009; 39:707-13. [PMID: 19490067 DOI: 10.1111/j.1365-2362.2009.02168.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Development of factor VIII inhibitors is a serious complication in haemophilia A patients. Recombinant factor VIIa (rVIIa) is clinically effective, but its effects on haemostatic system need still to be fully elucidated. MATERIAL AND METHODS In an open controlled study, we measured thrombin generation (peak thrombin) in venous blood and prothrombin fragment F1 + 2 (F1 + 2) and D-dimer in venous and in shed blood in five haemophilia A patients with inhibitors before and after rVIIa infusion. A total of five healthy individuals who did not receive rVIIa served as controls. RESULTS At baseline, patients had lower mean (min-max) peak thrombin levels than controls [0.12 (0.0-0.6) vs. 186.9 (116.0-254.4) nM, P = 0.001]. After infusion, peak thrombin levels increased in average to 40.7 (28.3-51.6) nM, which translates into 80.2% (95% CI 65.4-88.6%) lower levels compared to that of controls. Mean (min-max) F1 + 2 levels in venous blood did not differ significantly between patients and controls [160.7 (89.8-331.3) vs. 160.8 (104.4-242.3) pmol L(-1)], but increased in average (min-max) by 39.4% (14.1-58.5%) after infusion. In blood emerging from incisions made to determine the bleeding (shed blood), F1 + 2 levels were lower in patients than controls [1383.3 (906.4-2044.6) vs. 2981.7 (1610.0-4539.6) pmol L(-1); P = 0.04], but were not affected by rVIIa; D-dimer levels were significantly higher in haemophiliacs than in controls and remained unchanged after infusion. CONCLUSIONS Haemophilia A patients with factor VIII inhibitors have low thrombin generation. After rVIIa, the extent of coagulation activation as measured by levels of F1 + 2 is increased, but thrombin generation is restored to only 20%. Peak thrombin levels could reflect the effects of rVIIa on coagulation mechanisms, and their relevance with regard to the clinical coagulation defect of haemophilia A patients with factor VIII inhibitors might be evaluated.
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Affiliation(s)
- S Eichinger
- Department of Internal Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria.
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Powell JS. Recombinant factor VIII in the management of hemophilia A: current use and future promise. Ther Clin Risk Manag 2009; 5:391-402. [PMID: 19536318 PMCID: PMC2697540 DOI: 10.2147/tcrm.s4412] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Hemophilia A is a rare inherited bleeding disorder due to mutation of the gene that encodes the coagulation protein factor VIII. Historically, prior to the availability of treatment with factor VIII preparations, most boys died from uncontrolled bleeding, either spontaneous bleeding or after injury, before reaching 20 years of age. One of the most impressive triumphs of modern medicine is that with current recombinant factor VIII replacement therapy, a boy born in the 21st century with severe hemophilia A can anticipate a normal life expectancy with essentially no permanent complications from bleeding. For severe hemophilia A, current optimal treatment should have two goals: first, to provide sufficient factor VIII to prevent spontaneous bleeding, and second, to provide sufficient factor VIII to have normal coagulation function after any trauma. However, the replacement therapy requires tremendous resources for effective use, and remains extraordinarily expensive. Thus there are opportunities for further advances in therapy for hemophilia A. Two major concerns continue to trouble current optimal treatment approaches: some patients will develop neutralizing antibodies during the first 50 infusions of therapeutic factor VIII, and second, to administer therapeutic factor VIII every other day in young boys often requires placement of a central venous access device, and such use carries the life-threatening risks of infection and thrombosis. Because of the effectiveness of current therapy, any new developments in treatment will require significant concerns for safety, both immediate and in the long term. A number of research groups seek to prolong the biological efficacy of infused recombinant factor VIII. Currently, one such promising development is in the advanced stages of clinical trial. The goals will be to improve further the quality of life of an individual with severe hemophilia A, and to reduce the burden of current treatment strategies on families and medical resources. Hopefully, the hemophilia community will continue to participate actively in the clinical trials needed to address these new challenges.
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Affiliation(s)
- Jerry S Powell
- Division of Hematology and Oncology, University of California Davis Cancer Center, Sacramento, CA, USA
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Calibrated automated thrombin generation and modified thromboelastometry in haemophilia A. Thromb Res 2009; 123:895-901. [DOI: 10.1016/j.thromres.2008.09.011] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2008] [Revised: 09/01/2008] [Accepted: 09/15/2008] [Indexed: 11/22/2022]
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Abstract
BACKGROUND The goal of the coagulation pathway is the conversion of fibrinogen to fibrin and formation of an insoluble clot. Although relatively rare, congenital fibrinogen disorders are interesting and pose several challenges that can serve as paradigms for many diseases. An impressive body of knowledge has accumulated recently, particularly thanks to international collaborative clinical and genetic studies allowing the molecular characterization of these disorders. However, apart from the possibility of developing safer fibrinogen concentrates and the availability of prenatal diagnosis, the basic therapeutic approach has changed little. OBJECTIVE We need to better understand the clinical phenotype of patients in order to administer fibrinogen preparations or other treatments more appropriately. METHODS We discuss current therapeutic options and others that could be available in the near future. RESULTS/CONCLUSION Patients with congenital fibrinogen deficiencies require better predictive tests for clinical complications and more efficient and available fibrinogen concentrates. Global hemostasis tests in combination with routine assays could help to individually tailor therapeutic protocols.
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Affiliation(s)
- Philippe de Moerloose
- University Hospital, Division of Angiology and Haemostasis, 1211 Geneva 14, Switzerland.
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VERBRUGGEN B, MEIJER P, NOVáKOVA I, VAN HEERDE W. Diagnosis of factor VIII deficiency. Haemophilia 2008; 14 Suppl 3:76-82. [DOI: 10.1111/j.1365-2516.2008.01715.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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van Veen JJ, Gatt A, Makris M. Thrombin generation testing in routine clinical practice: are we there yet? Br J Haematol 2008; 142:889-903. [PMID: 18564356 DOI: 10.1111/j.1365-2141.2008.07267.x] [Citation(s) in RCA: 160] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Thrombin is the central enzyme in the coagulation cascade. Estimation of an individual's potential to generate thrombin may correlate more closely with a hyper- or hypo-coagulable phenotype, compared to traditional coagulation tests. The possible correlation and recent technical advances in thrombin generation measurement has caused a significant interest in the method and the development of commercial assays. Several variations of the assay exist depending on the defect to be investigated. Fluorogenic thrombin generation assays have acceptable intra-laboratory variation but a higher inter-laboratory variation. Variation in preanalytical variables makes comparisons between studies difficult. Thrombin generation is highly variable between individuals and there are suggestions that this may allow individualized treatment based on global haemostatic response in patients with bleeding disorders or on anticoagulant therapy. In patients with thrombotic disorders it may be possible to identify those at higher risk of recurrent thrombosis. For both scenarios, however, data from large prospective studies are lacking or inconclusive and a good relationship between thrombin generation and phenotype remains to be established. Further standardization of the assay is needed before large multicentre studies can be conducted and until then thrombin generation in routine clinical practice is not yet a reality.
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Affiliation(s)
- J J van Veen
- Leicester Haemophilia Comprehensive Care Centre & Haemostasis and Thrombosis Unit, Leicester, UK.
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