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Newall F, Johnston L, Ignjatovic V, Monagle P. Unfractionated heparin therapy in infants and children. Pediatrics 2009; 123:e510-8. [PMID: 19221154 DOI: 10.1542/peds.2008-2052] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Unfractionated heparin is frequently used in tertiary pediatric centers for the prophylaxis and treatment of thromboembolic disease. Recent evidence suggests that the clinical outcomes of unfractionated heparin therapy in children are poor, as determined by target-range achievement and adverse-event rates. These reports of poor outcomes may be related to an age-dependent mechanism of action of unfractionated heparin. Furthermore, several published studies have indicated that unfractionated heparin-monitoring assays currently in clinical use have significant limitations that likely affect the safety and efficacy of anticoagulant management. This review summarizes the growing body of evidence suggesting that pediatric-specific recommendations for unfractionated heparin therapy management are required to improve clinical outcomes related to this commonly prescribed medication.
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Affiliation(s)
- Fiona Newall
- MN, BSci, Royal Children's Hospital, Clinical Haematology Department, 9th Floor, Main Building, Flemington Road, Parkville, Victoria 3052, Australia.
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Erez O, Espinoza J, Chaiworapongsa T, Gotsch F, Kusanovic JP, Than NG, Mazaki-Tovi S, Vaisbuch E, Papp Z, Yoon BH, Han YM, Hoppensteadt D, Fareed J, Hassan SS, Romero R. A link between a hemostatic disorder and preterm PROM: a role for tissue factor and tissue factor pathway inhibitor. J Matern Fetal Neonatal Med 2009; 21:732-44. [PMID: 19012190 DOI: 10.1080/14767050802361807] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Vaginal bleeding is a risk factor for preterm PROM (PPROM). A disorder of decidual hemostasis has been implicated in the genesis of PROM. Indeed, excessive thrombin generation has been demonstrated in PPROM both before and at the time of diagnosis. Decidua is a potent source of tissue factor (TF), the most powerful natural pro-coagulant. A decidual hemostatic disorder may link vaginal bleeding, PPROM and placental abruption. This study was conducted to determine the behaviour of maternal TF and its natural inhibitor, the tissue factor pathway inhibitor (TFPI) in PPROM. METHODS This cross-sectional study included women with PPROM (n = 123) and women with normal pregnancies (n = 86). Plasma concentrations of TF and TFPI were measured by a sensitive immunoassay. Non-parametric statistics were used for analysis. RESULTS (1) The median maternal plasma TF concentration was significantly higher in patients with PPROM than in women with normal pregnancies (median: 369.5 pg/mL; range: 3.27-2551 pg/mL vs. median: 291.5 pg/mL; range: 6.3-2662.2 pg/mL respectively, p = 0.001); (2) the median maternal TFPI plasma concentration was significantly lower in patients with PPROM than in women with normal pregnancies (median: 58.7 ng/mL; range: 26.3-116 ng/mL vs. median: 66.1 ng/mL; range: 14.3-86.5 ng/mL respectively, p = 0.019); (3) there was no correlation between the plasma concentration of TF and TFPI and the gestational age at sample collection; and (4) among patients with PPROM there was no association between the presence of intra-amniotic infection or inflammation and median plasma concentrations of TF and TFPI. CONCLUSIONS (1) Patients with PPROM have a higher median plasma concentration of TF and a lower median plasma concentration of TFPI than women with normal pregnancies. (2) These findings suggest that PPROM is associated with specific changes in the hemostatic/coagulation system.
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Affiliation(s)
- Offer Erez
- Perinatology Research Branch, NICHD, NIH, DHHS, Detroit, Michigan, USA.
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Erez O, Romero R, Hoppensteadt D, Than NG, Fareed J, Mazaki-Tovi S, Espinoza J, Chaiworapongsa T, Kim SS, Yoon BH, Hassan SS, Gotsch F, Friel L, Vaisbuch E, Kusanovic JP. Tissue factor and its natural inhibitor in pre-eclampsia and SGA. J Matern Fetal Neonatal Med 2008; 21:855-69. [PMID: 19065458 PMCID: PMC3171292 DOI: 10.1080/14767050802361872] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Tissue factor (TF), the major activator of the extrinsic pathway of coagulation, is abundant in the placenta and decidua. The aim of this study was to determine the maternal plasma concentrations of TF and its primary inhibitor, tissue factor pathway inhibitor (TFPI), in women who delivered small for gestational age (SGA) neonates, and in pre-eclampsia. STUDY DESIGN A cross-sectional study included the following groups: 1) women with normal pregnancies (n = 86); 2) patients who delivered SGA neonates (n = 61) and 3) women with pre-eclampsia (n = 133). Maternal plasma concentrations of TF and TFPI were measured by a sensitive immunoassay. Non-parametric statistics were used for analysis. RESULTS 1) Women with pre-eclampsia had a significantly higher median plasma concentration of TF than patients with a normal pregnancy (median: 1187 pg/mL; range: 69-11675 vs. median: 291.5 pg/mL; range: 6.3-2662.2; p < 0.0001, respectively); 2) Similarly, TFPI concentrations were higher in pre-eclampsia than in normal pregnancy (median: 87.5 ng/mL; range 25.4-165.1 vs. median: 66.1 ng/mL; range: 14.3-86.5; p < 0.0001, respectively); 3) Surprisingly, mothers with SGA neonates had a lower median maternal plasma concentration of TF (median: 112.2 pg/mL; range: 25.6-1225.3) than women with a normal pregnancy (p < 0.0001). CONCLUSION 1) Maternal plasma concentrations of TF in patients with pre-eclampsia, but not in those who delivered an SGA neonate, were higher than in women with normal pregnancies; 2) Although the role of immunoreactive plasma TF in coagulation remains controversial, our observations suggest that changes are present in the context of complications of pregnancy.
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Affiliation(s)
- Offer Erez
- Perinatology Research Branch, NICHD, NIH, DHHS, Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan, USA
| | - Roberto Romero
- Perinatology Research Branch, NICHD, NIH, DHHS, Detroit, Michigan, USA
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan, USA
| | - Debra Hoppensteadt
- Loyola University Medical Center, Department of Pathology, Maywood, Illinois, USA
| | - Nandor Gabor Than
- Perinatology Research Branch, NICHD, NIH, DHHS, Detroit, Michigan, USA
| | - Jawed Fareed
- Loyola University Medical Center, Department of Pathology, Maywood, Illinois, USA
| | - Shali Mazaki-Tovi
- Perinatology Research Branch, NICHD, NIH, DHHS, Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan, USA
| | - Jimmy Espinoza
- Perinatology Research Branch, NICHD, NIH, DHHS, Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan, USA
| | - Tinnakorn Chaiworapongsa
- Perinatology Research Branch, NICHD, NIH, DHHS, Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan, USA
| | - Sung-Su Kim
- Perinatology Research Branch, NICHD, NIH, DHHS, Detroit, Michigan, USA
| | - Bo Hyun Yoon
- Seoul National University College of Medicine, Department of Obstetrics and Gynecology, Seoul, South Korea
| | - Sonia S. Hassan
- Perinatology Research Branch, NICHD, NIH, DHHS, Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan, USA
| | - Francesca Gotsch
- Perinatology Research Branch, NICHD, NIH, DHHS, Detroit, Michigan, USA
| | - Lara Friel
- Perinatology Research Branch, NICHD, NIH, DHHS, Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan, USA
| | - Edi Vaisbuch
- Perinatology Research Branch, NICHD, NIH, DHHS, Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan, USA
| | - Juan Pedro Kusanovic
- Perinatology Research Branch, NICHD, NIH, DHHS, Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan, USA
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Ma Q, Tobu M, Schultz C, Jeske W, Hoppensteadt D, Walenga J, Cornelli U, Lee J, Linhardt R, Hanin I, Fareed J. Molecular weight dependent tissue factor pathway inhibitor release by heparin and heparin oligosaccharides. Thromb Res 2006; 119:653-61. [PMID: 16824584 PMCID: PMC4142645 DOI: 10.1016/j.thromres.2006.05.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2005] [Revised: 05/01/2006] [Accepted: 05/09/2006] [Indexed: 11/28/2022]
Abstract
Heparin and low molecular weight heparins exert their vascular effects by mobilizing tissue factor pathway inhibitor (TFPI) from the vascular endothelium into the blood circulation. We compared the influence of molecular weight on the TFPI release by heparin and its fractions in a non-human primate model. Primates were treated with unfractionated heparin, a low molecular weight heparin (gammaparin), or a heparin-derived oligosaccharide mixture (C3). Endothelial TFPI release was determined using both immunologic and functional assays. After intravenous administration, all agents significantly increased TFPI levels (p<0.05) in a dose dependent manner. The increase produced by unfractionated heparin and gammaparin was greater than that by C3 at an equal dosage (p<0.05). With subcutaneous injection, all agents produced less TFPI release. Repeated administration of heparin-derived oligosaccharides gradually increased TFPI release. A 1.89 fold increase in TFPI levels was observed 4 days after C3 treatment (2.5 mg/kg). Our findings indicated that TFPI release is dependent on the molecular weight of heparin and its derivatives. Heparin oligosaccharides exert their vascular effects through increased TFPI release after long-term repeated administration.
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Affiliation(s)
- Qing Ma
- Department of Pharmacology and Experimental Therapeutics, Stritch School of Medicine, Loyola University Chicago, Maywood, IL 60153, United States
- Corresponding authors. Ma is to be contacted at Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14260, United States. Tel.: +1 716 645 2828x243. Fareed, Department of Pathology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL 60153, United States. Tel.: +1 708 216 3262. (Q. Ma), (J. Fareed)
| | - Mahmut Tobu
- Department of Pathology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL 60153, United States
| | - Christopher Schultz
- Department of Pathology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL 60153, United States
| | - Walter Jeske
- Department of Pathology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL 60153, United States
| | - Debra Hoppensteadt
- Department of Pathology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL 60153, United States
| | - Jeanine Walenga
- Department of Pathology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL 60153, United States
| | - Umberto Cornelli
- Department of Pharmacology and Experimental Therapeutics, Stritch School of Medicine, Loyola University Chicago, Maywood, IL 60153, United States
| | - John Lee
- Department of Pharmacology and Experimental Therapeutics, Stritch School of Medicine, Loyola University Chicago, Maywood, IL 60153, United States
- Department of Pathology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL 60153, United States
| | - Robert Linhardt
- Department of Chemistry and Chemical Biology, Rensselaer Polytechnic Institute, Troy, NY 12180, United States
| | - Israel Hanin
- Department of Pharmacology and Experimental Therapeutics, Stritch School of Medicine, Loyola University Chicago, Maywood, IL 60153, United States
| | - Jawed Fareed
- Department of Pharmacology and Experimental Therapeutics, Stritch School of Medicine, Loyola University Chicago, Maywood, IL 60153, United States
- Department of Pathology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL 60153, United States
- Corresponding authors. Ma is to be contacted at Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14260, United States. Tel.: +1 716 645 2828x243. Fareed, Department of Pathology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL 60153, United States. Tel.: +1 708 216 3262. (Q. Ma), (J. Fareed)
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Lwaleed BA, Bass PS. Tissue factor pathway inhibitor: structure, biology and involvement in disease. J Pathol 2006; 208:327-39. [PMID: 16261634 DOI: 10.1002/path.1871] [Citation(s) in RCA: 145] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Tissue factor (TF)-initiated coagulation plays a significant role in the pathophysiology of many diseases, including cancer and inflammation. Tissue factor pathway inhibitor (TFPI) is a plasma Kunitz-type serine protease inhibitor, which modulates initiations of coagulation induced by TF. In a factor (F) Xa-dependent feedback system, TFPI binds directly and inhibits the TF-FVII/FVIIa complex. Normally, TFPI exists in plasma both as a full-length molecule and as variably carboxy-terminal truncated forms. TFPI also circulates in complex with plasma lipoproteins. The levels and the dual inhibitor effect of TFPI on FXa and TF-FVII/FVIIa complex offers insight into the mechanisms of various pathological conditions triggered by TF. The use of selective pharmacological inhibitors has become an indispensable tool in experimental haemostasis and thrombosis research. In vivo administration of recombinant TFPI (rTFPI) in an experimental animal model prevents thrombosis (and re-thrombosis after thrombolysis), reduces mortality from E. coli-induced-septic shock, prevents fibrin deposition on subendothelial human matrix and protects against disseminated intravascular coagulation (DIC). Thus, TFPI may play an important role in modulating TF-induced thrombogenesis and it may also provide a unique therapeutic approach for prophylaxis and/or treatment of various diseases. In this review, we consider structural and biochemical aspects of the TFPI molecule and detail its inhibitory mechanisms and therapeutic implications in various disease conditions.
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Affiliation(s)
- Bashir A Lwaleed
- Department of Urology, Southampton University Hospitals NHS Trust, Tremona Road, Southampton SO16 6YD, UK.
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Hansen JB, Huseby KR, Huseby NE, Sandset PM, Hanssen TA, Nordøy A. Effect of cholesterol lowering on intravascular pools of TFPI and its anticoagulant potential in type II hyperlipoproteinemia. Arterioscler Thromb Vasc Biol 1995; 15:879-85. [PMID: 7600119 DOI: 10.1161/01.atv.15.7.879] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Tissue factor pathway inhibitor (TFPI) inhibits the extrinsic coagulation system. A major pool of TFPI is associated with the vascular endothelium and can be mobilized into the circulation by heparin. In circulating blood, TFPI is mainly associated with LDL (80%), whereas 10% to 20% is carrier free. In this study, heparin administration caused a 2.2-fold and a 7.5-fold increase in TFPI activity and TFPI antigen, respectively, in 25 patients with phenotypes IIa and IIb hyperbetalipoproteinemia. Because the antigen determination of TFPI almost exclusively measures carrier-free TFPI, more than 90% of the heparin-induced increase in TFPI activity was caused by mobilization of carrier-free TFPI from the vascular endothelium. Therapeutic lowering of total cholesterol (a decrease of 31.1 +/- 11.6%, P < .001) by 40 mg/d lovastatin in 17 patients with hyperbetalipoproteinemia was accompanied by a parallel decrease in TFPI activity (of 27.7 +/- 24.2%, P < .001) because of a reduction in LDL-TFPI complexes. However, drug intervention did not affect carrier-free TFPI or the magnitude of the vascular pool of TFPI that could be mobilized into the circulation by heparin. Moreover, this reduction of LDL-TFPI complexes did not reduce the anticoagulant potency of TFPI in plasma or of the vascular endothelial pool. The results of this study may imply that the anticoagulant potency of TFPI is associated with its carrier-free form in plasma or on the endothelium and that downregulation of LDL affects neither the size nor the anticoagulant potency of the endothelial pool of TFPI.
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Affiliation(s)
- J B Hansen
- Department of Medicine, University of Tromsø, Norway
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