1
|
Kenet G, Nolan B, Zulfikar B, Antmen B, Kampmann P, Matsushita T, You CW, Vilchevska K, Bagot CN, Sharif A, Peyvandi F, Young G, Negrier C, Chi J, Kittner B, Sussebach C, Shammas F, Mei B, Andersson S, Kavakli K. Fitusiran prophylaxis in people with hemophilia A or B who switched from prior BPA/CFC prophylaxis: the ATLAS-PPX trial. Blood 2024; 143:2256-2269. [PMID: 38452197 DOI: 10.1182/blood.2023021864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 02/07/2024] [Accepted: 02/12/2024] [Indexed: 03/09/2024] Open
Abstract
ABSTRACT Fitusiran, a subcutaneous investigational small interfering RNA therapeutic, targets antithrombin to rebalance hemostasis in people with hemophilia A or B (PwHA/B), irrespective of inhibitor status. This phase 3, open-label study evaluated the efficacy and safety of fitusiran prophylaxis in males aged ≥12 years with hemophilia A or B, with or without inhibitors, who received prior bypassing agent (BPA)/clotting factor concentrate (CFC) prophylaxis. Participants continued their prior BPA/CFC prophylaxis for 6 months before switching to once-monthly 80 mg fitusiran prophylaxis for 7 months (onset and efficacy periods). Primary end point was annualized bleeding rate (ABR) in the BPA/CFC prophylaxis and fitusiran efficacy period. Secondary end points included spontaneous ABR (AsBR) and joint ABR (AjBR). Safety and tolerability were assessed. Of 80 enrolled participants, 65 (inhibitor, n = 19; noninhibitor, n = 46) were eligible for ABR analyses. Observed median ABRs were 6.5 (interquartile range [IQR], 2.2-19.6)/4.4 (IQR, 2.2-8.7) with BPA/CFC prophylaxis vs 0.0 (IQR, 0.0-0.0)/0.0 (IQR, 0.0-2.7) in the corresponding fitusiran efficacy period. Estimated mean ABRs were substantially reduced with fitusiran by 79.7% (P = .0021) and 46.4% (P = .0598) vs BPA/CFC prophylaxis, respectively. Forty-one participants (63.1%) experienced 0 treated bleeds with fitusiran vs 11 (16.9%) with BPAs/CFCs. Median AsBR and AjBR were both 2.2 with BPA/CFC prophylaxis and 0.0 in the fitusiran efficacy period. Two participants (3.0%) experienced suspected or confirmed thromboembolic events with fitusiran. Once-monthly fitusiran prophylaxis significantly reduced bleeding events vs BPA/CFC prophylaxis in PwHA/B, with or without inhibitors, and reported adverse events were generally consistent with previously identified risks of fitusiran. This trial was registered at www.ClinicalTrials.gov as #NCT03549871.
Collapse
Affiliation(s)
- Gili Kenet
- The National Hemophilia Centre, Amalia Biron Thrombosis Research Institute, Sheba Medical Centre, Tel Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - Beatrice Nolan
- Department of Hematology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Bulent Zulfikar
- Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey
| | - Bulent Antmen
- Department of Pediatric Hematology/Oncology and Bone Marrow Transplantation Unit, Faculty of Medicine, Acibadem University, Adana Hospital, Adana, Turkey
| | - Peter Kampmann
- Department of Hematology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Tadashi Matsushita
- Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Chur-Woo You
- Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea
| | - Kateryna Vilchevska
- Department of Hematology, Ohmatdyt National Children's Specialized Hospital, Kyiv, Ukraine
| | - Catherine N Bagot
- Department of Haematology, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | | | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Guy Young
- Hemostasis and Thrombosis Center, Cancer and Blood Diseases Institute, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Claude Negrier
- UR4609 Hemostasis and Thrombosis, Claude Bernard University Lyon 1, Lyon, France
| | | | | | | | | | | | | | - Kaan Kavakli
- Department of Haematology, Ege University Faculty of Medicine, Children's Hospital, Izmir, Turkey
| |
Collapse
|
2
|
Haisma B, Schols SEM, van Oerle RGM, Verbeek-Knobbe K, Hellenbrand D, Verwoerd EJ, Heubel-Moenen FCJI, Stroobants AK, Meijer D, Rijpma SR, Henskens YMC. Comparative analysis of thrombin generation platforms for patients with coagulation factor deficiencies: A comprehensive assessment. Thromb Res 2024; 240:109045. [PMID: 38834002 DOI: 10.1016/j.thromres.2024.109045] [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: 03/22/2024] [Revised: 05/13/2024] [Accepted: 05/28/2024] [Indexed: 06/06/2024]
Abstract
INTRODUCTION Thrombin generation assays (TGAs) assess the overall functionality of the hemostatic system and thereby provide a reflection of the hemostatic capacity of patients with disorders in this system. Currently, four (semi-)automated TGA platforms are available: the Calibrated Automated Thrombogram, Nijmegen Hemostasis Assay, ST Genesia and Ceveron s100. In this study, we compared their performance for detecting patients with congenital single coagulation factor deficiencies. MATERIALS AND METHODS Pooled patient samples, healthy control samples and normal pooled plasma were tested on all four platforms, using the available reagents that vary in tissue factor and phospholipid concentrations. The TGA parameters selected for analysis were peak height and thrombin potential. Results were normalized by using the calculated mean of healthy controls and a correction for between-run variation. Outcomes were presented as relative values, with the mean of healthy controls standardized to 100 %. RESULTS Across all platforms and reagents used, thrombin potentials and peak heights of samples with coagulation factor deficiencies were lower than those of healthy controls. Reagents designed for bleeding tendencies yielded the lowest values on all platforms (relative median peak height 19-32 %, relative median thrombin potential 19-45 %). Samples representing more severe coagulation factor deficiencies generally exhibited lower relative peak heights and thrombin potentials. CONCLUSIONS Thrombin generation assays prove effective in differentiating single coagulation factor deficient samples from healthy controls, with modest discrepancies observed between the platforms. Reagents designed for assessing bleeding tendencies, featuring the lowest tissue factor and phospholipid concentrations, emerged as the most suitable option for detecting coagulation factor deficiencies.
Collapse
Affiliation(s)
- Bauke Haisma
- Department of Hematology, Radboud university medical center, Geert Grooteplein Zuid 10, 5425 GA Nijmegen, the Netherlands; Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Geert Grooteplein Zuid 10, 5425 GA Nijmegen, the Netherlands.
| | - Saskia E M Schols
- Department of Hematology, Radboud university medical center, Geert Grooteplein Zuid 10, 5425 GA Nijmegen, the Netherlands; Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Geert Grooteplein Zuid 10, 5425 GA Nijmegen, the Netherlands.
| | - René G M van Oerle
- Central Diagnostic Laboratory, Maastricht University Medical Center+, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands; Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER Maastricht, the Netherlands.
| | - Kitty Verbeek-Knobbe
- Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Geert Grooteplein Zuid 10, 5425 GA Nijmegen, the Netherlands; Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 5425 GA Nijmegen, the Netherlands.
| | - Dave Hellenbrand
- Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Geert Grooteplein Zuid 10, 5425 GA Nijmegen, the Netherlands; Central Diagnostic Laboratory, Maastricht University Medical Center+, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands.
| | - Evelien J Verwoerd
- Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Geert Grooteplein Zuid 10, 5425 GA Nijmegen, the Netherlands; Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 5425 GA Nijmegen, the Netherlands.
| | - Floor C J I Heubel-Moenen
- Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Geert Grooteplein Zuid 10, 5425 GA Nijmegen, the Netherlands; Department of Hematology, Internal Medicine, Maastricht University Medical Center+, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands.
| | - An K Stroobants
- Department of Laboratory Medicine, Radboudumc Laboratory of Diagnostics, Radboud university medical center, Geert Grooteplein Zuid 10, 5425 GA Nijmegen, the Netherlands.
| | - Danielle Meijer
- Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Geert Grooteplein Zuid 10, 5425 GA Nijmegen, the Netherlands; Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 5425 GA Nijmegen, the Netherlands.
| | - Sanna R Rijpma
- Department of Hematology, Radboud university medical center, Geert Grooteplein Zuid 10, 5425 GA Nijmegen, the Netherlands; Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 5425 GA Nijmegen, the Netherlands.
| | - Yvonne M C Henskens
- Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Geert Grooteplein Zuid 10, 5425 GA Nijmegen, the Netherlands; Central Diagnostic Laboratory, Maastricht University Medical Center+, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands; Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER Maastricht, the Netherlands.
| |
Collapse
|
3
|
Tardy-Poncet B, Montmartin A, Chambost H, Lienhart A, Frotscher B, Morange PE, Falaise C, Collange F, Dargaud Y, Toussaint-Hacquard M, Ardillon L, Wibaut B, Jeanpierre E, Nguyen P, Volot F, Tardy B. Relationship between plasma tissue Factor Pathway Inhibitor (TFPI) levels, thrombin generation and clinical risk of bleeding in patients with severe haemophilia A or B. Haemophilia 2024; 30:693-701. [PMID: 38650319 DOI: 10.1111/hae.15020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 04/05/2024] [Accepted: 04/07/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION Bleeding severity in severe haemophilic patients, with low thrombin generation (TG) capacity, can vary widely between patients, possibly reflecting differences in tissue factor pathway inhibitor (TFPI) level. AIM To compare free TFPI (fTFPI) levels in patients with severe haemophilia A (sHA) and severe haemophilia B (sHB) and to investigate in these patients as a whole the relationships between bleeding and TG potential, between TG potential and fTFPI level and between fTFPI level and bleeding tendency. METHODS Data on bleeding episodes retrospectively recorded during follow-up visits over 5-10 years were collected and used to calculate the annualised joint bleeding rate (AJBR). fTFPI levels and basal TG parameters were determined in platelet-poor plasma (PPP) and platelet-rich plasma (PRP) using calibrated automated tomography (CAT). RESULTS Mean fTFPI levels did not differ significantly between sHA (n = 34) and sHB (n = 19) patients. Mean values of endogenous thrombin potential (ETP) and thrombin peak (peak) in PPP and PRP were two-fold higher when fTFPI levels < 9.4 versus > 14.3 ng/mL. In patients treated on demand, ETP and peak in PRP were doubled when AJBR was≤ 4.9 $ \le 4.9$ , AJBR being halved in patients with a low fTFPI level (9.4 ng/mL). In patients on factor prophylaxis, no association was found between TG parameters and either fTFPI level or AJBR. CONCLUSION In patients treated on demand, bleeding tendency was influenced by fTFPI levels, which in turn affected basal TG potential. In patients on prophylaxis, bleeding tendency is probably determined primarily by the intensity of this treatment.
Collapse
Affiliation(s)
- Brigitte Tardy-Poncet
- Université Jean Monnet Saint-Étienne, CHUSaint-Étienne, Centre de traitement de l'hémophilie, Mines Saint-Etienne, INSERM, SAINBIOSE U1059, Saint-Etienne, France
- Inserm CIC 1408, CHU Saint-Étienne, Saint-Etienne, France
| | - Aurélie Montmartin
- Université Jean Monnet Saint-Étienne, Mines Saint-Etienne, INSERM, SAINBIOSE U1059, Saint-Etienne, France
| | - Hervé Chambost
- Hôpital Timone, Centre de Traitement de l'Hémophilie, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Anne Lienhart
- Hôpital Cardiologique Louis Pradel, Centre de Référence de l'Hémophilie, Lyon, France
| | - Birgit Frotscher
- Centre de Traitement de l'Hémophilie, CHU de Nancy, Nancy, France
| | - Pierre-Emmanuel Morange
- INSERM, INRAE, C2VN, Laboratoire d'Hématologie, Assistance Publique - Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Céline Falaise
- Hôpital Timone, Centre de Traitement de l'Hémophilie, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Fanny Collange
- Inserm CIC 1408, CHU Saint-Étienne, Saint-Etienne, France
| | - Yesim Dargaud
- Hôpital Cardiologique Louis Pradel, Centre de Référence de l'Hémophilie, Lyon, France
- UR 4609 Hémostase & Thrombose, Université Claude Bernard Lyon 1, Lyon, France
| | | | - Laurent Ardillon
- Centre de Traitement de l'Hémophilie, CHU de Tours, Tours, France
| | - Bénédicte Wibaut
- Centre de Ressources et de Compétences des Maladies Hémorragiques Constitutionnelles Rares, Centre de Référence Maladie de Willebrand, CHU Lille, Lille, France
| | - Emmanuelle Jeanpierre
- Laboratoire d'Hémostase, Pôle de Biologie Pathologie Génétique Médicale, CHU Lille, Lille, France
| | | | - Fabienne Volot
- Centre de Traitement de l'Hémophilie, CHU Dijon, Dijon, France
| | - Bernard Tardy
- Inserm CIC 1408, CHU Saint-Étienne, Saint-Etienne, France
- Université Jean Monnet Saint-Étienne, Mines Saint-Etienne, INSERM, SAINBIOSE U1059, Saint-Etienne, France
| |
Collapse
|
4
|
Sokou R, Parastatidou S, Konstantinidi A, Tsantes AG, Iacovidou N, Piovani D, Bonovas S, Tsantes AE. Contemporary tools for evaluation of hemostasis in neonates. Where are we and where are we headed? Blood Rev 2024; 64:101157. [PMID: 38016836 DOI: 10.1016/j.blre.2023.101157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 11/30/2023]
Abstract
The assessment of hemostatic disorders in neonates is crucial, but remains challenging for clinicians. Although the concept of developmental hemostasis is widely accepted among hemostasis specialists globally, it is probably under-recognized by clinicians and laboratory practitioners. In parallel with age-dependent hemostatic status maturation, comprehension of the differences between normal values is crucial for the accurate diagnosis of potential hemorrhagic and thrombotic disorders of the vulnerable neonatal population. This review outlines the basics of developmental hemostasis and the features of the available coagulation testing methods, with a focus on novel tools for evaluating the neonatal hemostatic profile. Common errors, issues, and pitfalls during the assessment of neonatal hemostasis are discussed, along with their impact on patient management. Current knowledge gaps and research areas are addressed. Further studying to improve our understanding of developmental hemostasis and its reflection on everyday clinical practice is warranted.
Collapse
Affiliation(s)
- Rozeta Sokou
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, Piraeus, Greece.
| | | | | | - Andreas G Tsantes
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
| | - Nicoletta Iacovidou
- Neonatal Department, National and Kapodistrian University of Athens, Aretaieio Hospital, Athens, Greece
| | - Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; IRCCS Humanitas Research Hospital, Milan, Italy
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; IRCCS Humanitas Research Hospital, Milan, Italy
| | - Argirios E Tsantes
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
| |
Collapse
|
5
|
Valke LLFG, Cloesmeijer ME, Mansouritorghabeh H, Barteling W, Blijlevens NMA, Cnossen MH, Mathôt RAA, Schols SEM, van Heerde WL. Pharmacokinetic-Pharmacodynamic Modelling in Hemophilia A: Relating Thrombin and Plasmin Generation to Factor VIII Activity After Administration of a VWF/FVIII Concentrate. Eur J Drug Metab Pharmacokinet 2024; 49:191-205. [PMID: 38367175 PMCID: PMC10904421 DOI: 10.1007/s13318-024-00876-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND Hemophilia A patients are treated with factor (F) VIII prophylactically to prevent bleeding. In general, dosage and frequency are based on pharmacokinetic measurements. Ideally, an alternative dose adjustment can be based on the hemostatic potential, measured with a thrombin generation assay (TGA), like the Nijmegen hemostasis assay. OBJECTIVE The objective of this study was to investigate the predicted performance of a previously developed pharmacokinetic-pharmacodynamic model for FVIII replacement therapy, relating FVIII dose and FVIII activity levels with thrombin and plasmin generation parameters. METHODS Pharmacokinetic and pharmacodynamic measurements were obtained from 29 severe hemophilia A patients treated with pdVWF/FVIII concentrate (Haemate P®). The predictive performance of the previously developed pharmacokinetic-pharmacodynamic model was evaluated using nonlinear mixed-effects modeling (NONMEM). When predictions of FVIII activity or TGA parameters were inadequate [median prediction error (MPE) > 20%], a new model was developed. RESULTS The original pharmacokinetic model underestimated clearance and was refined based on a two-compartment model. The pharmacodynamic model displays no bias in the observed normalized thrombin peak height and normalized thrombin potential (MPE of 6.83% and 7.46%). After re-estimating pharmacodynamic parameters, EC50 and Emax values were relatively comparable between the original model and this group. Prediction of normalized plasmin peak height was inaccurate (MPE 58.9%). CONCLUSION Our predictive performance displayed adequate thrombin pharmacodynamic predictions of the original model, but a new pharmacokinetic model was required. The pharmacodynamic model is not factor specific and applicable to multiple factor concentrates. A prospective study is needed to validate the impact of the FVIII dosing pharmacodynamic model on bleeding reduction in patients.
Collapse
Affiliation(s)
- Lars L F G Valke
- Department of Hematology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
- Hemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, The Netherlands
| | - Michael E Cloesmeijer
- Department of Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Hassan Mansouritorghabeh
- Clinical Research Development Unit, Ghaem Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Wideke Barteling
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Marjon H Cnossen
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ron A A Mathôt
- Department of Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Saskia E M Schols
- Department of Hematology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
- Hemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, The Netherlands
| | - Waander L van Heerde
- Department of Hematology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
- Hemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, The Netherlands.
- Enzyre BV, Novio Tech Campus, Nijmegen, The Netherlands.
| |
Collapse
|
6
|
van de Berg TW, Beckers EAM, Heubel-Moenen FCJI, Henskens YMC, Thomassen MCLGD, Hackeng TM. Sensitive Measurement of Clinically Relevant Factor VIII Levels in Thrombin Generation Assays Requires Presence of Factor XIa. Thromb Haemost 2023; 123:1034-1041. [PMID: 37236229 PMCID: PMC10615588 DOI: 10.1055/a-2101-7961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 05/08/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND Hemophilia A (HA) is characterized by decreased or absent factor VIII (FVIII) activity. Current FVIII assays are based on clotting time and thus only provide information about the initiation of coagulation. In contrast, thrombin generation assays (TGAs) can be used to measure the full coagulation spectrum of initiation, propagation, and termination that provide information on the whole course of thrombin generation and inhibition. However, the commercially available TG kits lack sensitivity for measurements of hemophilia plasma within lower FVIII ranges, which is essential for explaining differences in bleeding phenotypes in hemophiliacs at clinically low levels of FVIII. AIMS Optimization of the TGA for measurements of low FVIII levels in severe HA patients. METHODS TGA measurements were performed in severe HA pooled plasma (n = 10). Investigations of several preanalytical and analytical variables of the assay were performed in a stepwise process and adjusted based on sensitivity toward intrinsic coagulation activation. RESULTS TGA initiated by tissue factor (TF) alone at varying concentrations was unable to significantly differentiate between FVIII levels below 20%. In contrast, TGA activation with low concentrations of TF in presence of FXIa appeared to be highly sensitive for FVIII changes both in high and low ranges. In addition, a representative TGA curve at trough levels could only be produced using the dual TF/FXIa TGA. CONCLUSION We propose a critical optimization for the setup of the TGA for measurements in severe HA plasma. The dual TF/FXIa TGA shows increased sensitivity, especially in lower FVIII ranges, which allows for better individual characterization at baseline, prediction of interventions, and follow-up.
Collapse
Affiliation(s)
- Tom W. van de Berg
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), University Maastricht, Maastricht, The Netherlands
- Department of Hematology, Division of Internal Medicine, Maastricht UMC + , Maastricht, The Netherlands
| | - Erik A. M. Beckers
- Department of Hematology, Division of Internal Medicine, Maastricht UMC + , Maastricht, The Netherlands
| | | | | | - M. Christella L. G. D. Thomassen
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), University Maastricht, Maastricht, The Netherlands
| | - Tilman M. Hackeng
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), University Maastricht, Maastricht, The Netherlands
| |
Collapse
|
7
|
de Moreuil C, Dargaud Y, Nougier C, Dupré PF, Trémouilhac C, Le Joliff D, Rosec S, Lucier S, Pabinger I, Ay C, Couturaud F, Pan-Petesch B. Women with severe postpartum hemorrhage have a decreased endogenous thrombin potential before delivery. J Thromb Haemost 2023; 21:3099-3108. [PMID: 37541589 DOI: 10.1016/j.jtha.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 07/01/2023] [Accepted: 07/19/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND Severe postpartum hemorrhage (PPH), defined as a blood loss ≥1000 mL, is associated with maternal morbidity and mortality. OBJECTIVES We aimed at characterizing coagulation properties of predelivery plasmas from pregnant women with thrombin generation assay and hemostatic biomarkers (plasminogen activator inhibitor-1, tissue factor [TF], and thrombomodulin). METHODS A nested case-control study was conducted within the "Study of Biological Determinants of Bleeding Postpartum," a French prospective cohort study, in order to compare women with severe PPH (cases) and controls matched for age, body mass index, term, and mode of delivery. Plasma was collected at entry in the delivery room, and blood loss was measured objectively. The predelivery endogenous thrombin generation potential (ETP) was measured in plasma using calibrated automated thrombinography and low TF concentration. Hemostatic biomarkers were measured using ELISA kits. RESULTS A total of 142 women (71 cases and 71 controls) were investigated. There was no difference in the median lag phase, thrombin peak, and time to peak between cases and controls. However, median predelivery ETP was lower in cases than in controls (2170 vs 2408 nM.min, P < .0001), independently of mode of delivery and PPH etiology. Median plasminogen activator inhibitor-1 and TF levels were higher in cases compared with controls (107.4 vs 68.1 ng/mL, P = .0003; 34.4 vs 27.4 pg/mL, P = .007), whereas thrombomodulin levels did not differ between the 2 groups. CONCLUSION Among thrombin generation assay parameters, predelivery ETP levels may have a predictive value for severe PPH.
Collapse
Affiliation(s)
- Claire de Moreuil
- UMR 1304, GETBO, Université de Bretagne Occidentale, Brest, France; Internal Medicine, Vascular Medicine and Pneumology Department, Brest University Hospital, Brest, France.
| | - Yesim Dargaud
- Haemostasis Department, Lyon University Hospital, Lyon, France
| | | | | | - Christophe Trémouilhac
- UMR 1304, GETBO, Université de Bretagne Occidentale, Brest, France; Gynecology and Obstetrics Department, Brest University Hospital, Brest, France
| | | | - Sylvain Rosec
- CIC-RB Ressources Biologiques (UF 0827), Brest University Hospital, Brest, France
| | - Sandy Lucier
- CIC 1412, INSERM, Brest University Hospital, Brest, France
| | - Ingrid Pabinger
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | - Francis Couturaud
- UMR 1304, GETBO, Université de Bretagne Occidentale, Brest, France; Internal Medicine, Vascular Medicine and Pneumology Department, Brest University Hospital, Brest, France
| | - Brigitte Pan-Petesch
- UMR 1304, GETBO, Université de Bretagne Occidentale, Brest, France; Haemophilia Treatment Centre, Haematology, Brest University Hospital, Brest, France
| |
Collapse
|
8
|
Ranc A, Bru S, Mendez S, Giansily-Blaizot M, Nicoud F, Méndez Rojano R. Critical evaluation of kinetic schemes for coagulation. PLoS One 2023; 18:e0290531. [PMID: 37639392 PMCID: PMC10461854 DOI: 10.1371/journal.pone.0290531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 08/10/2023] [Indexed: 08/31/2023] Open
Abstract
Two well-established numerical representations of the coagulation cascade either initiated by the intrinsic system (Chatterjee et al., PLOS Computational Biology 2010) or the extrinsic system (Butenas et al., Journal of Biological Chemistry, 2004) were compared with thrombin generation assays under realistic pathological conditions. Biochemical modifications such as the omission of reactions not relevant to the case studied, the modification of reactions related to factor XI activation and auto-activation, the adaptation of initial conditions to the thrombin assay system, and the adjustment of some of the model parameters were necessary to align in vitro and in silico data. The modified models are able to reproduce thrombin generation for a range of factor XII, XI, and VIII deficiencies, with the coagulation cascade initiated either extrinsically or intrinsically. The results emphasize that when existing models are extrapolated to experimental parameters for which they have not been calibrated, careful adjustments are required.
Collapse
Affiliation(s)
- Alexandre Ranc
- Department of Haematology Biology, CHU, Univ Montpellier, Montpellier, France
| | - Salome Bru
- Polytech, Univ Montpellier, Montpellier, France
| | - Simon Mendez
- IMAG, Univ Montpellier, CNRS, Montpellier, France
| | | | | | | |
Collapse
|
9
|
Wolff-Trombini L, Ceripa A, Moreau J, Galinat H, James C, Westbrook N, Allain JM. Microrheology and structural quantification of hypercoagulable clots. BIOMEDICAL OPTICS EXPRESS 2023; 14:4179-4189. [PMID: 37799698 PMCID: PMC10549726 DOI: 10.1364/boe.492669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 10/07/2023]
Abstract
Hypercoagulability is a pathology that remains difficult to explain today in most cases. It is likely due to a modification of the conditions of polymerization of the fibrin, the main clot component. Using passive microrheology, we measured the mechanical properties of clots and correlated them under the same conditions with structural information obtained with confocal microscopy. We tested our approach with known alterations: an excess of fibrinogen and of coagulation Factor VIII. We observed simultaneously a rigidification and densification of the fibrin network, showing the potential of microrheology for hypercoagulability diagnosis.
Collapse
Affiliation(s)
- Laura Wolff-Trombini
- Université de Bordeaux, UMR1034, Inserm, Biology of Cardiovascular Diseases, Pessac, France
| | - Adrien Ceripa
- LMS, CNRS, Ecole Polytechnique, Institut Polytechnique de Paris, Palaiseau, France
- Inria, Palaiseau, France
| | - Julien Moreau
- Université Paris-Saclay, Institut d’Optique Graduate School, CNRS, Laboratoire Charles Fabry, Palaiseau, France
| | - Hubert Galinat
- CHU de Brest, Service d'Hématologie Biologique, Brest, France
| | - Chloe James
- Université de Bordeaux, UMR1034, Inserm, Biology of Cardiovascular Diseases, Pessac, France
- CHU de Bordeaux, Laboratoire d’Hématologie, Pessac, France
| | - Nathalie Westbrook
- Université Paris-Saclay, Institut d’Optique Graduate School, CNRS, Laboratoire Charles Fabry, Palaiseau, France
| | - Jean-Marc Allain
- LMS, CNRS, Ecole Polytechnique, Institut Polytechnique de Paris, Palaiseau, France
- Inria, Palaiseau, France
| |
Collapse
|
10
|
Schutgens RE, Jimenez-Yuste V, Escobar M, Falanga A, Gigante B, Klamroth R, Lassila R, Leebeek FW, Makris M, Owaidah T, Sholzberg M, Tiede A, Werring DJ, van der Worp HB, Windyga J, Castaman G. Antithrombotic Treatment in Patients With Hemophilia: an EHA-ISTH-EAHAD-ESO Clinical Practice Guidance. Hemasphere 2023; 7:e900. [PMID: 37304933 PMCID: PMC10256340 DOI: 10.1097/hs9.0000000000000900] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/24/2023] [Indexed: 06/13/2023] Open
Abstract
Cardiovascular disease is an emerging medical issue in patients with hemophilia (PWH) and its prevalence is increasing up to 15% in PWH in the United States. Atrial fibrillation, acute and chronic coronary syndromes, venous thromboembolism, and cerebral thrombosis are frequent thrombotic or prothrombotic situations, which require a careful approach to fine-tune the delicate balance between thrombosis and hemostasis in PWH when using both procoagulant and anticoagulant treatments. Generally, PWH could be considered as being naturally anticoagulated when clotting factors are <20 IU/dL, but specific recommendations in patients with very low levels according to the different clinical situations are lacking and mainly based on the anecdotal series. For PWH with baseline clotting factor levels >20 IU/dL in need for any form of antithrombotic therapy, usually treatment without additional clotting factor prophylaxis could be used, but careful monitoring for bleeding is recommended. For antiplatelet treatment, this threshold could be lower with single-antiplatelet agent, but again factor level should be at least 20 IU/dL for dual antiplatelet treatment. In this complex growing scenario, the European Hematology Association in collaboration with the International Society on Thrombosis and Haemostasis, the European Association for Hemophilia and Allied Disorders, the European Stroke Organization, and a representative of the European Society of Cardiology Working Group on Thrombosis has produced this current guidance document to provide clinical practice recommendations for health care providers who care for PWH.
Collapse
Affiliation(s)
- Roger E.G. Schutgens
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Victor Jimenez-Yuste
- Hematology Department, La Paz University Hospital, Autonoma University, Madrid, Spain
| | - Miguel Escobar
- University of Texas Health Science Center at Houston, TX, USA
| | - Anna Falanga
- University of Milano Bicocca, School of Medicine, Monza, Italy
- Department of Transfusion Medicine and Hematology, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Bruna Gigante
- Division of Cardiovascular Medicine, Department of Medicine, Karolinska Institutet, Solna, Sweden
- Department of Clinical Science, Danderyd Hospital, Karolinska institutet, Stockholm, Sweden
| | - Robert Klamroth
- Department of Internal Medicine Angiology and Coagulation Disorders at the Vivantes Klinikum im Friedrichshain, Berlin, Germany
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Germany
| | - Riitta Lassila
- Department of Hematology, Coagulation Disorders Unit, and Research Program Unit in Systems Oncology Oncosys, Medical Faculty, University of Helsinki, Finland
| | - Frank W.G. Leebeek
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Michael Makris
- Haemophilia and Thrombosis Centre, University of Sheffield, United Kingdom
| | - Tarek Owaidah
- King Faisal Specialist Hospital and Research Centre, Alfaisal University, Riyadh, Saudi Arabia
| | - Michelle Sholzberg
- Division of Hematology-Oncology, Departments of Medicine, and Laboratory Medicine and Pathobiology, St. Michael’s Hospital, Li Ka Shing Knowledge Institute, University of Toronto, Canada
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Germany
| | - David J. Werring
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, United Kingdom
| | | | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy
| |
Collapse
|
11
|
Frackiewicz A, Kalaska B, Miklosz J, Mogielnicki A. The methods for removal of direct oral anticoagulants and heparins to improve the monitoring of hemostasis: a narrative literature review. Thromb J 2023; 21:58. [PMID: 37208753 DOI: 10.1186/s12959-023-00501-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 05/10/2023] [Indexed: 05/21/2023] Open
Abstract
The assessment of hemostasis is necessary to make suitable decisions on the management of patients with thrombotic disorders. In some clinical situations, for example, during thrombophilia screening, the presence of anticoagulants in sample makes diagnosis impossible. Various elimination methods may overcome anticoagulant interference. DOAC-Stop, DOAC-Remove and DOAC Filter are available methods to remove direct oral anticoagulants in diagnostic tests, although there are still reports on their incomplete efficacy in several assays. The new antidotes for direct oral anticoagulants - idarucizumab and andexanet alfa - could be potentially useful, but have their drawbacks. The necessity to remove heparins is also arising as heparin contamination from central venous catheter or therapy with heparin disturbs the appropriate hemostasis assessment. Heparinase and polybrene are already present in commercial reagents but a fully-effective neutralizer is still a challenge for researchers, thus promising candidates remain in the research phase.
Collapse
Affiliation(s)
| | - Bartlomiej Kalaska
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland.
| | - Joanna Miklosz
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
| | - Andrzej Mogielnicki
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
| |
Collapse
|
12
|
Kohli R, Platton S, Forbes S, Thuraisingham R, Tan J, Green L, MacCallum P. Renal transplant and hemostasis: early postoperative changes in recipients and donors. Res Pract Thromb Haemost 2023; 7:100168. [PMID: 37274176 PMCID: PMC10238749 DOI: 10.1016/j.rpth.2023.100168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/07/2023] [Accepted: 04/10/2023] [Indexed: 06/06/2023] Open
Abstract
Background The benefit of administering pharmacologic thromboprophylaxis following renal transplantation remains uncertain. Objectives To compare hemostatic parameters before and after renal transplant surgery in both recipients and their donors at predetermined time points. Methods Blood samples were collected at baseline (T1), immediately after surgery (T2), and at 24 hours after surgery (T3) in both recipients and donors and at 72 (T4) and 120 hours (T5) from recipients only. Assays included in vitro thrombin generation, factor VIII (FVIIIc) activity, von Willebrand factor (VWF) antigen, D-dimer, antithrombin activity, prothrombin fragment 1 + 2 (F1 + 2), thrombin-antithrombin complexes, and plasminogen activator inhibitor-1 (PAI-1) antigen. Results Fifty-two patients (28 recipients and 24 donors) were enrolled. Both donors and recipients had increased FVIIIc, VWF, F1 + 2, D-dimer, and PAI immediately after surgery but reduced antithrombin. Mixed-model analysis showed that the magnitude of change over time (between T1 and T3) for FVIIIc (mean estimated difference [MED], 72; 95% CI, 41-102; P < .0001), VWF (MED, 89; 95% CI, 35-142; P = .001), F1 + 2 (MED, 283; 95% CI, 144-422; P < .0001), thrombin-antithrombin complexes (MED, 3.5; 95% CI, 1.9-5.1; P < .0001), D-dimer (MED, 2.2; 95% CI, 1.0-3.3; P < .0001), PAI-1 (MED, 9.2; 95% CI, 3.4-14.9; P = .002), and time to peak thrombin generation (MED, 1.5; 95% CI, 0.35-2.7; P = .01) was more significant in recipients than in donors. Conclusion Persistence of a hypercoagulable state was more prominent in recipients after 24 hours despite recovery in renal function and initiation of thromboprophylaxis.
Collapse
Affiliation(s)
- Ruchika Kohli
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | | | | | | | - Joachim Tan
- St. Georges, University of London, London, United Kingdom
| | - Laura Green
- Barts Health NHS Trust, London, United Kingdom
- Blizard Institute, Queen Mary University of London, London, United Kingdom
- NHS Blood & Transplant, London, United Kingdom
| | - Peter MacCallum
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
- Barts Health NHS Trust, London, United Kingdom
| |
Collapse
|
13
|
de Laat-Kremers R, Zuily S, de Laat B. Editorial: Advances in thrombin generation. Front Cardiovasc Med 2023; 10:1183718. [PMID: 37063969 PMCID: PMC10098350 DOI: 10.3389/fcvm.2023.1183718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/20/2023] [Indexed: 04/03/2023] Open
Affiliation(s)
- Romy de Laat-Kremers
- Department of Data Analysis and Artificial Intelligence, Synapse Research Institute, Maastricht, Netherlands
- Correspondence: Romy de Laat-Kremers
| | | | - Bas de Laat
- Department of Data Analysis and Artificial Intelligence, Synapse Research Institute, Maastricht, Netherlands
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, Netherlands
| |
Collapse
|
14
|
Young G, Srivastava A, Kavakli K, Ross C, Sathar J, You CW, Tran H, Sun J, Wu R, Poloskey S, Qiu Z, Kichou S, Andersson S, Mei B, Rangarajan S. Efficacy and safety of fitusiran prophylaxis in people with haemophilia A or haemophilia B with inhibitors (ATLAS-INH): a multicentre, open-label, randomised phase 3 trial. Lancet 2023; 401:1427-1437. [PMID: 37003287 DOI: 10.1016/s0140-6736(23)00284-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 12/05/2022] [Accepted: 02/01/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Fitusiran, a subcutaneous investigational small interfering RNA therapeutic, targets antithrombin to rebalance haemostasis in people with haemophilia A or haemophilia B, irrespective of inhibitor status. We evaluated the efficacy and safety of fitusiran prophylaxis in people with haemophilia A or haemophilia B with inhibitors. METHODS This multicentre, randomised, open-label phase 3 study was done at 26 sites (primarily secondary or tertiary centres) in 12 countries. Men, boys, and young adults aged 12 years or older with severe haemophilia A or haemophilia B with inhibitors previously treated with on-demand bypassing agents were randomly assigned (2:1) to receive once-a-month 80 mg subcutaneous fitusiran prophylaxis (fitusiran prophylaxis group) or to continue with bypassing agents on-demand (bypassing agents on-demand group) for 9 months. The primary endpoint was mean annualised bleeding rate during the efficacy period in the intention-to-treat population estimated by negative binomial model. Safety was assessed as a secondary endpoint in the safety population. This trial is complete and is registered with ClinicalTrials.gov, NCT03417102. FINDINGS Between Feb 14, 2018, and June 23, 2021, 85 participants were screened for inclusion, of whom 57 (67%; 57 [100%] men; median age 27·0 years [IQR 19·5-33·5]) were randomly assigned: 19 (33%) participants to the bypassing agent on-demand group and 38 (67%) participants to the fitusiran prophylaxis. Negative binomial model-based mean annualised bleeding rate was significantly lower in the fitusiran prophylaxis group (1·7 [95% CI 1·0-2·7]) than in the bypassing agents on-demand group (18·1 [10·6-30·8]), corresponding to a 90·8% (95% CI 80·8-95·6) reduction in annualised bleeding rate in favour of fitusiran prophylaxis (p<0·0001). 25 (66%) participants had zero treated bleeds in the fitusiran prophylaxis group versus one (5%) in the bypassing agents on-demand group. The most frequent treatment-emergent adverse event in the fitusiran prophylaxis group was increased alanine aminotransferase in 13 (32%) of 41 participants in the safety population; there were no increased alanine aminotransferase treatment-emergent adverse events in the bypassing agents on-demand group. Suspected or confirmed thromboembolic events were reported in two (5%) participants in the fitusiran prophylaxis group. No deaths were reported. INTERPRETATION Subcutaneous fitusiran prophylaxis resulted in statistically significant reductions in annualised bleeding rate in participants with haemophilia A or haemophilia B with inhibitors, with two-thirds of participants having zero bleeds. Fitusiran prophylaxis might show haemostatic efficacy in participants with haemophilia A or haemophilia B with inhibitors; therefore, the therapeutic might have the potential to improve the management of people with haemophilia. FUNDING Sanofi.
Collapse
Affiliation(s)
- Guy Young
- Hemostasis and Thrombosis Center, Cancer and Blood Disease Institute, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA.
| | - Alok Srivastava
- Department of Haematology, Christian Medical College & Centre for Stem Cell Research, a unit of inStem, Bengaluru, Christian Medical College Campus, Vellore, India
| | - Kaan Kavakli
- Department of Pediatric Hematology and Oncology, Ege University Faculty of Medicine Children's Hospital, Izmir, Turkey
| | - Cecil Ross
- Department of Hematology, St John's Medical College Hospital, Bangalore, India
| | - Jameela Sathar
- Department of Haematology, Ampang Hospital, Kuala Lumpur, Malaysia
| | - Chur-Woo You
- Department of Pediatrics, Eulji University School of Medicine, Seoul, South Korea
| | - Huyen Tran
- Ronald Sawers Hemophilia Treatment Center, The Alfred, Monash University, Melbourne, Victoria, Australia
| | - Jing Sun
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Runhui Wu
- National Center for Children's Health, Beijing Children's Hospital, Beijing, China
| | - Stacey Poloskey
- Pharmacovigilance, Sanofi, Cambridge, MA, USA; Clinical Development, Sanofi, Cambridge, MA, USA
| | - Zhiying Qiu
- Biostatistics & Programming, Sanofi, Bridgewater, NJ, USA
| | | | | | - Baisong Mei
- Clinical Development, Sanofi, Cambridge, MA, USA
| | - Savita Rangarajan
- Advanced Centre for Oncology, Haematology & Rare Diseases KJ Somaiya Super Specialty, Hospital, Mumbai, India; Faculty of Medicine, University of Southampton, Southampton, UK
| |
Collapse
|
15
|
Srivastava A, Rangarajan S, Kavakli K, Klamroth R, Kenet G, Khoo L, You CW, Xu W, Malan N, Frenzel L, Bagot CN, Stasyshyn O, Chang CY, Poloskey S, Qiu Z, Andersson S, Mei B, Pipe SW. Fitusiran prophylaxis in people with severe haemophilia A or haemophilia B without inhibitors (ATLAS-A/B): a multicentre, open-label, randomised, phase 3 trial. THE LANCET HAEMATOLOGY 2023; 10:e322-e332. [PMID: 37003278 DOI: 10.1016/s2352-3026(23)00037-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/06/2023] [Accepted: 02/01/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Fitusiran, a subcutaneous investigational siRNA therapeutic, targets antithrombin with the goal of rebalancing haemostasis in people with haemophilia A or haemophilia B, regardless of inhibitor status. We aimed to evaluate the efficacy and safety of fitusiran prophylaxis in people with severe haemophilia without inhibitors. METHODS This multicentre, open-label, randomised phase 3 study was conducted at 45 sites in 17 countries. Male participants aged at least 12 years with severe haemophilia A or B without inhibitors, who had previously been treated on-demand with clotting factor concentrates, were randomly assigned in a 2:1 ratio to receive 80 mg subcutaneous fitusiran prophylaxis once per month or to continue on-demand clotting factor concentrates for a total of 9 months. Randomisation was stratified by the number of bleeding events in the 6 months before screening (≤10 bleeds and >10 bleeds) and by haemophilia type (haemophilia A or B). The primary endpoint was annualised bleeding rate, analysed in the intention-to-treat analysis set. Safety and tolerability were assessed in the safety analysis set. This trial is registered with ClinicalTrials.gov, NCT03417245, and is complete. FINDINGS Between March 1, 2018, and July 14, 2021, 177 male participants were screened for eligibility and 120 were randomly assigned to receive fitusiran prophylaxis (n=80) or on-demand clotting factor concentrates (n=40). Median follow-up was 7·8 months (IQR 7·8-7·8) in the fitusiran group and 7·8 months (7·8-7·8) in the on-demand clotting factor concentrates group. The median annualised bleeding rate was 0·0 (0·0-3·4) in the fitusiran group and 21·8 (8·4-41·0) in the on-demand clotting factor concentrates group. The estimated mean annualised bleeding rate was significantly lower in the fitusiran prophylaxis group (3·1 [95% CI 2·3-4·3]) than in the on-demand clotting factor concentrates group (31·0 [21·1-45·5]; rate ratio 0·101 [95% CI 0·064-0·159]; p<0·0001). In the fitusiran group, 40 (51%) of 79 treated participants had no treated bleeds compared with two (5%) of 40 participants in the on-demand clotting factor concentrates group. Increased alanine aminotransferase concentration (18 [23%] of 79 participants in the safety analysis set) was the most common treatment-emergent adverse event in the fitusiran group and hypertension (four (10%) of 40 participants) was the most common in the on-demand clotting factor concentrates group. Treatment-emergent serious adverse events were reported in five (6%) participants in the fitusiran group (cholelithiasis [n=2, 3%], cholecystitis [n=1, 1%], lower respiratory tract infection [n=1, 1%], and asthma [n=1, 1%]) and five (13%) participants in the on-demand clotting factor concentrates group (gastroenteritis, pneumonia, suicidal ideation, diplopia, osteoarthritis, epidural haemorrhage, humerus fracture, subdural haemorrhage, and tibia fracture [all n=1, 3%]). No treatment-related thrombosis or deaths were reported. INTERPRETATION In participants with haemophilia A or B without inhibitors, fitusiran prophylaxis resulted in significant reductions in annualised bleeding rate compared with on-demand clotting factor concentrates and no bleeding events in approximately half of participants. Fitusiran prophylaxis shows haemostatic efficacy in both haemophilia A and haemophilia B, and therefore has the potential to be transformative in the management of all people with haemophilia. FUNDING Sanofi.
Collapse
|
16
|
Lee SH, Cha B, Ko J, Afzal M, Park J. Acoustofluidic separation of proteins from platelets in human blood plasma using aptamer-functionalized microparticles. BIOMICROFLUIDICS 2023; 17:024105. [PMID: 37153865 PMCID: PMC10162022 DOI: 10.1063/5.0140096] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 02/20/2023] [Indexed: 05/10/2023]
Abstract
Microfluidic liquid biopsy has emerged as a promising clinical assay for early diagnosis. Herein, we propose acoustofluidic separation of biomarker proteins from platelets in plasma using aptamer-functionalized microparticles. As model proteins, C-reactive protein and thrombin were spiked in human platelet-rich plasma. The target proteins were selectively conjugated with their corresponding aptamer-functionalized microparticles of different sizes, and the particle complexes served as a mobile carrier for the conjugated proteins. The proposed acoustofluidic device was composed of an interdigital transducer (IDT) patterned on a piezoelectric substrate and a disposable polydimethylsiloxane (PDMS) microfluidic chip. The PDMS chip was placed in a tilted arrangement with the IDT to utilize both vertical and horizontal components of surface acoustic wave-induced acoustic radiation force (ARF) for multiplexed assay at high-throughput. The two different-sized particles experienced the ARF at different magnitudes and were separated from platelets in plasma. The IDT on the piezoelectric substrate could be reusable, while the microfluidic chip can be replaceable for repeated assays. The sample processing throughput with the separation efficiency >95% has been improved such that the volumetric flow rate and flow velocity were 1.6 ml/h and 37 mm/s, respectively. For the prevention of platelet activation and protein adsorption to the microchannel, polyethylene oxide solution was introduced as sheath flows and coating on to the walls. We conducted scanning electron microscopy, x-ray photoemission spectroscopy , and sodium dodecyl sulfate- analysis before and after the separation to confirm the protein capture and separation. We expect that the proposed approach will provide new prospects for particle-based liquid biopsy using blood.
Collapse
Affiliation(s)
- Song Ha Lee
- Department of Mechanical Engineering, Chonnam National University, 77 Yongbong-ro, Buk-gu, Gwangju 61186, Republic of Korea
| | - Beomseok Cha
- Department of Mechanical Engineering, Chonnam National University, 77 Yongbong-ro, Buk-gu, Gwangju 61186, Republic of Korea
| | - Jeongu Ko
- Department of Mechanical Engineering, Chonnam National University, 77 Yongbong-ro, Buk-gu, Gwangju 61186, Republic of Korea
| | - Muhammad Afzal
- Center of Immunology Marseille-Luminy, Aix-Marseille University, 171 Av, De Luminy, 13009 Marseille, France
| | - Jinsoo Park
- Department of Mechanical Engineering, Chonnam National University, 77 Yongbong-ro, Buk-gu, Gwangju 61186, Republic of Korea
| |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
Boyce S, Rangarajan S. RNAi for the Treatment of People with Hemophilia: Current Evidence and Patient Selection. J Blood Med 2023; 14:317-327. [PMID: 37123985 PMCID: PMC10132380 DOI: 10.2147/jbm.s390521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 03/31/2023] [Indexed: 05/02/2023] Open
Abstract
Severe hemophilia is associated with spontaneous, prolonged and recurrent bleeding. Inadequate prevention and treatment of bleeding can lead to serious morbidity and mortality. Due to the limitations of intravenous clotting factor replacement, including the risk of inhibitory antibodies, innovative novel therapies have been developed that have dramatically changed the landscape of hemophilia therapy. Ribonucleic acid interference (RNAi) has brought the opportunity for multiple strategies to manipulate the hemostatic system and ameliorate the bleeding phenotype in severe bleeding disorders. Fitusiran is a RNAi therapeutic that inhibits the expression of the natural anticoagulant serpin antithrombin. Reduction in antithrombin is known to cause thrombosis if coagulation parameters are otherwise normal and can rebalance hemostasis in severe hemophilia. Reports from late stage clinical trials of fitusiran in hemophilia A and B participants, with and without inhibitory antibodies to exogenous clotting factor, have demonstrated efficacy in preventing bleeding events showing promise for a future "universal" prophylactic treatment of individuals with moderate-severe hemophilia.
Collapse
Affiliation(s)
- Sara Boyce
- Haemophilia Comprehensive Care Centre, University Hospital Southampton, Southampton, UK
- Correspondence: Sara Boyce, Email
| | | |
Collapse
|
19
|
Sidonio RF, Hoffman M, Kenet G, Dargaud Y. Thrombin generation and implications for hemophilia therapies: A narrative review. Res Pract Thromb Haemost 2022; 7:100018. [PMID: 36798897 PMCID: PMC9926221 DOI: 10.1016/j.rpth.2022.100018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 10/24/2022] [Accepted: 11/09/2022] [Indexed: 01/07/2023] Open
Abstract
Thrombin plays an essential role in achieving and maintaining effective hemostasis and stable clot formation. In people with hemophilia, deficiency of procoagulant factor (F)VIII or FIX results in insufficient thrombin generation, leading to reduced clot stability and various bleeding manifestations. A correlation has been found between the bleeding phenotype of people with hemophilia and the extent of thrombin generation, with individuals with increased thrombin generation being protected from bleeding and those with lower thrombin generation having increased bleeding tendency. The amount, location, and timing of thrombin generation have been found to affect the formation and stability of the resulting clot. The goal of all therapies for hemophilia is to enhance the generation of thrombin with the aim of restoring effective hemostasis and preventing or controlling bleeding; current treatment approaches rely on either replacing or mimicking the missing procoagulant (ie, FVIII or FIX) or rebalancing hemostasis through lowering natural anticoagulants, such as antithrombin. Global coagulation assays, such as the thrombin generation assay, may help guide the overall management of hemostasis by measuring and monitoring the hemostatic potential of patients and, thus, assessing the efficacy of treatment in people with hemophilia. Nevertheless, standardization of the thrombin generation assay is needed before it can be adopted in routine clinical practice.
Collapse
Affiliation(s)
- Robert F. Sidonio
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia, USA,Department of Pediatrics, Emory University, Atlanta, Georgia, USA,Correspondence Robert F Sidonio, Aflac Cancer and Blood Disorders Center Children’s Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA 30322, USA. @nashgreenie
| | - Maureane Hoffman
- Department of Pathology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Gili Kenet
- The Israeli National Hemophilia Center and Thrombosis Unit, Sheba Medical Center, Tel Hashomer, Israel,The Amalia Biron Thrombosis Research Institute, Tel Aviv University, Tel Aviv, Israel
| | - Yesim Dargaud
- Unité d’Hémostase Clinique, Centre National de Reference de l'Hemophilie, Hôpital Cardiologique Louis Pradel, Université Lyon, Lyon, France
| |
Collapse
|
20
|
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.
Collapse
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
| |
Collapse
|
21
|
Sun W, Han D, Awad MA, Leibowitz JL, Griffith BP, Wu ZJ. Role of thrombin to non-physiological shear stress induced platelet activation and function alternation. Thromb Res 2022; 219:141-149. [PMID: 36179652 DOI: 10.1016/j.thromres.2022.09.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/08/2022] [Accepted: 09/20/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE Non-physiological shear stress (NPSS) and thrombin have two distinct mechanisms for activating platelets. NPSS in mechanically assisted circulation (MAC) devices can cause platelet dysfunction, e.g., by shedding its key receptors. In addition, patients with heart failure have increased levels of thrombin generation, which may further affect the NPSS-induced platelet dysfunction, resulting in device-associated complications. This study aimed to assess the combined effect of NPSS and thrombin in platelet activation, expression of adhesion receptors on the platelet surface, and alterations of platelet aggregation. METHODS Fresh human blood from healthy donors was divided into two groups; one group was treated by adding 0.01 U/mL thrombin, and another group not treated with thrombin served as a control comparison. They were then pumped through a novel blood shearing device which produces similar shear stress conditions to those in the MAC devices. Three levels of NPSS (i.e., 75, 125, and 175 Pa) with a 1.0 s exposure time were selected for the shearing conditions. Expression of platelet activation markers (PAC-1, activated GPIIb/IIIa and CD62P, platelet surface P-selectin) were investigated along with the shedding of platelet receptors (GPIb, GPIIb/IIIa, and GPVI), generation of platelet microparticles, and Phosphatidylserine (PS)-positive platelets detected by flow cytometry. Platelet aggregation (induced by collagen/ristocetin) was measured by Lumi-aggregometry. RESULTS Platelet receptors were shed after exposure to NPSS showing a positive correlation with the level of shear stress. The generation of platelet microparticles and PS-positive platelets also increased with greater NPSS. Elevated NPSS decreased the platelet aggregation capacity. Platelet activation level increased with greater NPSS. Being treated by thrombin can further exacerbate these characteristics under same level of NPSS, except that platelet activation level drastically dropped after the exposure to 175 Pa NPSS in the thrombin-treated blood. CONCLUSION After being treated by thrombin, platelets became more susceptible to NPSS, resulting in more receptor shedding, platelet microparticles, and PS-positive platelets, thus limiting platelet aggregation capacity after exposure to NPSS. Platelet activation, in terms of PAC-1 and P-selectin, is an interim status competing between the expression and shedding of these makers/receptors. When platelets have reached a saturation level of activation, exposure to excessive NPSS can potentially impair activation.
Collapse
Affiliation(s)
- Wenji Sun
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Dong Han
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Morcos A Awad
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Joshua L Leibowitz
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bartley P Griffith
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Zhongjun J Wu
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, MD, USA.
| |
Collapse
|
22
|
Mathews N, Pluthero FG, Rand ML, Stain AM, Carcao M, Blanchette VS, Kahr WHA. Thromboelastography and thrombin generation assessments for pediatric severe hemophilia A patients are highly variable and not predictive of clinical phenotypes. Res Pract Thromb Haemost 2022; 6:e12800. [PMID: 36186102 PMCID: PMC9511091 DOI: 10.1002/rth2.12800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 07/02/2022] [Accepted: 07/23/2022] [Indexed: 11/24/2022] Open
Abstract
Background Severe hemophilia A (SHA) patients vary in severity of bleeding, arthropathy, and requirements for replacement factor VIII (FVIII). Baseline hemostatic activity assays using calibrated automated thrombography (CAT) and thromboelastography (TEG) may offer insights into the physiological basis of clinical heterogeneity. Objectives Use CAT and TEG to measure baseline hemostatic activity in a cohort of 30 pediatric SHA patients with available clinical data. Determine effect of contact activation inhibition with corn trypsin inhibitor (CTI). Assess heterogeneity among patients for baseline hemostatic activity and examine correlations between assay results and clinical parameters including FVIII dosing regimen, von Willebrand factor level, and Pettersson arthropathy score. Methods SHA blood after FVIII washout was subjected to TEG, and platelet‐rich (PRP) and platelet‐poor plasma was used for CAT assays. Varying concentrations of tissue factor (TF) were used. Statistical analysis examined relationships between assay results, and clinical parameters. Results CTI treatment was required to obtain TEG and CAT results representative of baseline hemostatic activity. Weak activity was observed in assays with low TF concentrations (0.5–2 pM), and most but not all samples approached normal activity levels at high TF concentrations (10–20 pM). A significant positive correlation was observed between results of TEG and CAT‐PRP assays. Correlations were not detected between hemostatic assay results and clinical parameters. Conclusions In vitro hemostatic assay results of samples containing platelets showed concordance. Assay results were not predictive of FVIII requirements or correlated with other clinical parameters. SHA patient heterogeneity is influenced by factors other than baseline hemostatic activity.
Collapse
Affiliation(s)
- Natalie Mathews
- Division of Haematology/Oncology Hospital for Sick Children Toronto Ontario Canada
| | - Fred G Pluthero
- Cell Biology Program Research Institute, Hospital for Sick Children Toronto Ontario Canada
| | - Margaret L Rand
- Division of Haematology/Oncology Hospital for Sick Children Toronto Ontario Canada.,Translational Medicine Program Hospital for Sick Children Toronto Ontario Canada.,Departments of Laboratory Medicine & Pathobiology Biochemistry, and Pediatrics, University of Toronto Toronto Ontario Canada
| | - Ann Marie Stain
- Division of Haematology/Oncology Hospital for Sick Children Toronto Ontario Canada
| | - Manuel Carcao
- Division of Haematology/Oncology Hospital for Sick Children Toronto Ontario Canada.,Department of Pediatrics University of Toronto Toronto Ontario Canada
| | - Victor S Blanchette
- Division of Haematology/Oncology Hospital for Sick Children Toronto Ontario Canada.,Department of Pediatrics University of Toronto Toronto Ontario Canada
| | - Walter H A Kahr
- Division of Haematology/Oncology Hospital for Sick Children Toronto Ontario Canada.,Cell Biology Program Research Institute, Hospital for Sick Children Toronto Ontario Canada.,Departments of Pediatrics and Biochemistry University of Toronto Toronto Ontario Canada
| |
Collapse
|
23
|
Bernardo Á, Caro A, Martínez-Carballeira D, Corte JR, Vázquez S, Palomo-Antequera C, Andreu A, Fernández-Pardo Á, Oto J, Gutiérrez L, Soto I, Medina P. Applicability of the Thrombin Generation Test to Evaluate the Hemostatic Status of Hemophilia A Patients in Daily Clinical Practice. J Clin Med 2022; 11:jcm11123345. [PMID: 35743412 PMCID: PMC9224793 DOI: 10.3390/jcm11123345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 05/25/2022] [Accepted: 06/07/2022] [Indexed: 02/01/2023] Open
Abstract
Hemophilia A (HA) is a rare bleeding disorder caused by factor VIII (FVIII) deficiency due to various genetic mutations in the F8 gene. The disease severity inversely correlates with the plasma levels of functional FVIII. The treatment of HA patients is based on FVIII replacement therapy, either following a prophylactic or on-demand regime, depending on the severity of the disease at diagnosis and the patient’s clinical manifestations. The hemorrhagic manifestations are widely variable amongst HA patients, who may require monitoring and treatment re-adjustment to minimize bleeding symptoms. Notably, laboratory monitoring of the FVIII activity is difficult due to a lack of sensitivity to various FVIII-related molecules, including non-factor replacement therapies. Hence, patient management is determined mainly based on clinical manifestations and patient–clinician history. Our goal was to validate the ST Genesia® automated thrombin generation analyzer to quantify the relative hemostatic status in HA patients. We recruited a cohort of HA patients from the Principality of Asturias (Spain), following treatment and at a stable non-bleeding phase. The entire cohort (57 patients) had been comprehensively studied at diagnosis, including FVIII and VWF activity assays and F8 genetic screening, and then clinically monitored until the Thrombin Generation Test (TGT) was performed. All patients were recruited prior to treatment administration, at the maximum time-window following the previous dose. Interestingly, the severe/moderate patients had a similar TGT compared to the mild patients, reflecting the non-bleeding phase of our patient cohort, regardless of the initial diagnosis (i.e., the severity of the disease), treatment regime, and FVIII activity measured at the time of the TGT. Thus, TGT parameters, especially the peak height (Peak), may reflect the actual hemostatic status of a patient more accurately compared to FVIII activity assays, which may be compromised by non-factor replacement therapies. Furthermore, our data supports the utilization of combined TGT variables, together with the severity of patient symptoms, along with the F8 mutation type to augment the prognostic capacity of TGT. The results from this observational study suggest that TGT parameters measured with ST Genesia® may represent a suitable tool to monitor the hemostatic status of patients requiring a closer follow-up and a tailored therapeutic adjustment, including other hemophilia subtypes or bleeding disorders.
Collapse
Affiliation(s)
- Ángel Bernardo
- Department of Hematology, Central University Hospital of Asturias (HUCA), 33011 Oviedo, Spain; (A.C.); (D.M.-C.); (J.R.C.); (S.V.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
- Correspondence:
| | - Alberto Caro
- Department of Hematology, Central University Hospital of Asturias (HUCA), 33011 Oviedo, Spain; (A.C.); (D.M.-C.); (J.R.C.); (S.V.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Daniel Martínez-Carballeira
- Department of Hematology, Central University Hospital of Asturias (HUCA), 33011 Oviedo, Spain; (A.C.); (D.M.-C.); (J.R.C.); (S.V.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - José Ramón Corte
- Department of Hematology, Central University Hospital of Asturias (HUCA), 33011 Oviedo, Spain; (A.C.); (D.M.-C.); (J.R.C.); (S.V.); (I.S.)
| | - Sonia Vázquez
- Department of Hematology, Central University Hospital of Asturias (HUCA), 33011 Oviedo, Spain; (A.C.); (D.M.-C.); (J.R.C.); (S.V.); (I.S.)
| | - Carmen Palomo-Antequera
- Department of Internal Medicine, Central University Hospital of Asturias (HUCA), 33011 Oviedo, Spain;
- Bone Metabolism, Vascular Metabolism and Chronic Inflammatory Diseases Group, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain
| | - Alfredo Andreu
- Department of Pharmacology, University of Navarra, 31008 Pamplona, Spain;
| | - Álvaro Fernández-Pardo
- Hemostasis, Thrombosis, Arteriosclerosis and Vascular Biology Research Group, Medical Research Institute Hospital La Fe (IIS La Fe), 46026 Valencia, Spain; (Á.F.-P.); (J.O.); (P.M.)
| | - Julia Oto
- Hemostasis, Thrombosis, Arteriosclerosis and Vascular Biology Research Group, Medical Research Institute Hospital La Fe (IIS La Fe), 46026 Valencia, Spain; (Á.F.-P.); (J.O.); (P.M.)
| | - Laura Gutiérrez
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
- Department of Medicine, University of Oviedo, 33006 Oviedo, Spain
| | - Inmaculada Soto
- Department of Hematology, Central University Hospital of Asturias (HUCA), 33011 Oviedo, Spain; (A.C.); (D.M.-C.); (J.R.C.); (S.V.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Pilar Medina
- Hemostasis, Thrombosis, Arteriosclerosis and Vascular Biology Research Group, Medical Research Institute Hospital La Fe (IIS La Fe), 46026 Valencia, Spain; (Á.F.-P.); (J.O.); (P.M.)
| |
Collapse
|
24
|
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.
Collapse
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
| |
Collapse
|
25
|
Abdelmaguid A, Roberts LN, Tugores L, Joslin JR, Hunt BJ, Parmar K, Nebres D, Naga SS, Khalil E, Bramham K. Evaluation of novel coagulation and platelet function assays in patients with chronic kidney disease. J Thromb Haemost 2022; 20:845-856. [PMID: 35068080 PMCID: PMC9306477 DOI: 10.1111/jth.15653] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 12/24/2021] [Accepted: 01/18/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hemostasis evaluation in chronic kidney disease (CKD) is critical for optimal management of thrombotic and bleeding events. Standard coagulation screens are inadequate for predicting coagulopathy in CKD. OBJECTIVE To evaluate hemostasis parameters in patients with different stages of CKD using novel coagulation assays. PATIENTS/METHODS Cross-sectional study of 30 healthy controls (HC) and 120 CKD patients (10 Stage 2, 20 Stage 3, 20 Stage 4, 20 Stage 5 not requiring renal replacement therapy, 20 transplant, 10 newly started on hemodialysis [HD], 20 established on HD). Standard laboratory tests were performed in addition to rotational thromboelastometry (ROTEM), multiple electrode aggregometry (MEA), thrombin generation assays, D-dimer, and markers of thrombogenesis (thrombin-antithrombin [TAT]), fibrinolysis, and endothelial activation (intercellular adhesion molecule-1 [ICAM-1]). RESULTS D-dimer, TAT, and ICAM-1 concentrations were significantly higher in patients with CKD than HC (P < .01). ROTEM maximum clot firmness was significantly higher in patients than in HC (P < .01). In CKD Stage 5 patients (pre-HD and started HD) adenosine diphosphate and thrombin receptor activating peptide MEA tests were significantly lower than HC indicating platelet aggregation defect (P < .05). Multivariate analysis confirmed the direct effect of estimated glomerular filtration rate (eGFR) in the variance of ROTEM and MEA tests. Endogenous thrombin potential and peak thrombin were not statistically different between groups, but Stage 5 CKD patients had prolonged lag time (7.91 vs. 6.33, P < .001) and time to thrombin peak (10.8 vs. 9.5, P < .05) compared to HC. CONCLUSIONS Patients with CKD exhibit features of concomitant hypercoagulability measured by ROTEM and platelet dysfunction measured with MEA. eGFR was an independent determinant of platelet dysfunction and hypercoagulability.
Collapse
Affiliation(s)
- Alyaa Abdelmaguid
- Department of Women and Children’s HealthKing’s College LondonLondonUK
- King’s Kidney CareKing’s College Hospital NHS Foundation TrustLondonUK
- Department of Experimental and Clinical Internal MedicineMedical Research InstituteAlexandria UniversityAlexandriaEgypt
| | - Lara N. Roberts
- King’s Thrombosis CentreDepartment of Haematological MedicineKing’s College Hospital NHS Foundation TrustLondonUK
| | - Laura Tugores
- Department of ObstetricsKing’s College HospitalLondonUK
| | - Jennifer R. Joslin
- King’s Kidney CareKing’s College Hospital NHS Foundation TrustLondonUK
- Renal SciencesFaculty of Life Sciences and MedicineKing’s College LondonLondonUK
| | - Beverley J. Hunt
- Thrombosis and Haemostasis CentreGuy’s and St Thomas’ NHS Foundation TrustLondonUK
| | - Kiran Parmar
- Thrombosis and Haemostasis CentreGuy’s and St Thomas’ NHS Foundation TrustLondonUK
| | - Danilo Nebres
- King’s Kidney CareKing’s College Hospital NHS Foundation TrustLondonUK
| | - Salah S. Naga
- Department of Internal MedicineFaculty of MedicineAlexandria UniversityAlexandriaEgypt
| | - Eman S. Khalil
- Department of Experimental and Clinical Internal MedicineMedical Research InstituteAlexandria UniversityAlexandriaEgypt
| | - Kate Bramham
- Department of Women and Children’s HealthKing’s College LondonLondonUK
- King’s Kidney CareKing’s College Hospital NHS Foundation TrustLondonUK
| |
Collapse
|
26
|
Pittman DD, Rakhe S, Bowley SR, Jasuja R, Barakat A, Murphy JE. Hemostatic efficacy of marstacimab alone or in combination with bypassing agents in hemophilia plasmas and a mouse bleeding model. Res Pract Thromb Haemost 2022; 6:e12679. [PMID: 35316941 PMCID: PMC8925002 DOI: 10.1002/rth2.12679] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/07/2022] [Indexed: 11/06/2022] Open
Abstract
Background Patients with hemophilia have deficiencies in intrinsic coagulation factors and can develop inhibitors that limit the effectiveness of replacement coagulation factors. Marstacimab, a human monoclonal antibody, binds and inhibits the human tissue factor pathway inhibitor. Marstacimab is currently under development as a potential prophylactic treatment to prevent bleeding episodes in patients with hemophilia A and B. Objective To assess the effects of marstacimab alone or in combination with the bypassing agent recombinant factor FVIIa (rFVIIa) or activated prothrombin complex concentrate (aPCC) on thrombin generation and bleeding. Methods Marstacimab and/or rFVIIa or aPCC were added to hemophilic A or B plasma or nonhemophilic plasma in vitro. Hemostatic activity was measured using the thrombin generation assay. In vivo effects were assessed using a mouse acute bleeding model. Male hemophilia A mice were dosed with marstacimab plus aPCC before tail clip; blood loss was quantified by measuring hemoglobin. Results Marstacimab plus rFVIIa or aPCC slightly increased peak thrombin levels compared with either agent alone. This increase was within the reported range for nonhemophilic plasma and did not exceed levels observed in nonhemophilic plasma treated with marstacimab alone. Hemophilia A mice that received 200 U/kg aPCC had significantly reduced bleeding (62%) compared with vehicle‐treated mice (p < 0.05), and marstacimab plus aPCC reduced bleeding by 83.3% compared with vehicle (p= 0.0009). Conclusions Marstacimab alone or with bypassing agents increased hemostasis in hemophilia plasma without generating excessive thrombin. The hemostatic activity of marstacimab plus aPCC was confirmed in hemophilia A mice.
Collapse
Affiliation(s)
- Debra D. Pittman
- Rare Disease Research Unit Pfizer Inc. Cambridge Massachusetts USA
| | - Swapnil Rakhe
- Rare Disease Research Unit Pfizer Inc. Cambridge Massachusetts USA
| | - Sheryl R. Bowley
- Rare Disease Research Unit Pfizer Inc. Cambridge Massachusetts USA
| | - Reema Jasuja
- Rare Disease Research Unit Pfizer Inc. Cambridge Massachusetts USA
| | - Amey Barakat
- Rare Disease Research Unit Pfizer Inc. Cambridge Massachusetts USA
| | - John E. Murphy
- Rare Disease Research Unit Pfizer Inc. Cambridge Massachusetts USA
| |
Collapse
|
27
|
Petkovic MJ, Tran HA, Ebeling PR, Zengin A. Osteoporosis management and falls prevention in patients with haemophilia: Review of haemophilia guidelines. Haemophilia 2022; 28:388-396. [PMID: 35290707 PMCID: PMC9310867 DOI: 10.1111/hae.14540] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 02/21/2022] [Accepted: 02/25/2022] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Patients with haemophilia (PWH) have a high prevalence of osteoporosis, falls and fractures at all ages. The role of haemophilia itself may contribute to low bone mineral density (BMD) due to coagulation factor deficiency. Guidelines for the management of osteoporosis, fracture and fall risk may help to reduce fracture and fall risk, and delay osteoporosis onset. AIM We aim to review current haemophilia guidelines regarding osteoporosis prevention, screening, diagnosis and management, and fall prevention. METHOD A database search (Ovid MEDLINE) revealed two haemophilia guidelines (World and British) published within the last ten years. Local Australian haemophilia guidelines were identified through a manual search. RESULTS All haemophilia guidelines were found to contain inadequate recommendations for osteoporosis management and fall prevention due to a lack of evidence in the literature. CONCLUSION Further studies are required to assess the trajectory of bone health in PWH, the mechanism of bone loss in PWH, and the effectiveness of weight-bearing exercises, interventions for fall prevention, screening programmes, and use of anti-osteoporosis medications in PWH across the lifecourse.
Collapse
Affiliation(s)
- Madison J Petkovic
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Huyen A Tran
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia.,Clinical Haematology Department, Alfred Hospital, Thrombosis & Haemostasis Unit, Melbourne, Australia
| | - Peter R Ebeling
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Ayse Zengin
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| |
Collapse
|
28
|
Gebetsberger J, Schirmer M, Wurzer WJ, Streif W. Low Bone Mineral Density in Hemophiliacs. Front Med (Lausanne) 2022; 9:794456. [PMID: 35186990 PMCID: PMC8849249 DOI: 10.3389/fmed.2022.794456] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 01/10/2022] [Indexed: 12/14/2022] Open
Abstract
Objective To review the current knowledge on bone health in patients with hemophilia A and the underlying pathogenetic mechanisms. Data Sources Original research articles, meta-analyses, and scientific reviews. Data Synthesis Already in childhood, patients with hemophilia A are prone to low bone mineral density, leading to osteopenia and/or osteoporosis. Initially associated with the life style of hemophilia, today we are faced with accumulating evidence that coagulation factor VIII is involved directly or indirectly in bone physiology. Conclusion Understanding the role of factor VIII and the mechanisms of decreased bone mineral density in hemophilia A is critically important, especially as non-factor replacement therapies are available, and treatment decisions potentially impact bone health.
Collapse
Affiliation(s)
| | - Michael Schirmer
- Department of Internal Medicine, Clinic II, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Werner Streif
- Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| |
Collapse
|
29
|
The role of the calibrated automated thrombogram in neonates: describing mechanisms of neonatal haemostasis and evaluating haemostatic drugs. Eur J Pediatr 2022; 181:23-33. [PMID: 34283272 PMCID: PMC8760221 DOI: 10.1007/s00431-021-04196-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/11/2021] [Accepted: 07/01/2021] [Indexed: 12/04/2022]
Abstract
Premature infants are at high risk of haemorrhage and thrombosis. Our understanding of the differences between the neonatal and adult haemostatic system is evolving. There are several limitations to the standard coagulation tests used in clinical practice, and there is currently a lack of evidence to support many of the transfusion practices in neonatal medicine. The evaluation of haemostasis is particularly challenging in neonates due to their limited blood volume. The calibrated automated thrombogram (CAT) is a global coagulation assay, first described in 2002, which evaluates both pro- and anti-coagulant pathways in platelet-rich or platelet-poor plasma. In this review, the current applications and limitations of CAT in the neonatal population are discussed.Conclusion: CAT has successfully elucidated several differences between haemostatic mechanisms in premature and term neonates compared with adults. Moreover, it has been used to evaluate the effect of a number of haemostatic drugs in a pre-clinical model. However, the lack of evidence of CAT as an accurate predictor of neonatal bleeding, blood volume required and the absence of an evidence-based treatment algorithm for abnormal CAT results limit its current application as a bedside clinical tool for the evaluation of sick neonates. What is Known: • The Calibrated automated thrombogram (CAT) is a global coagulation assay which evaluates pro- and anti-coagulant pathways. • CAT provides greater information than standard clotting tests and has been used in adults to evaluate bleeding risk. What is New: • This review summarises the physiological differences in haemostasis between neonates and adults described using CAT. • The haemostatic effect of several drugs has been evaluated in neonatal plasma using CAT.
Collapse
|
30
|
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.
Collapse
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
| |
Collapse
|
31
|
Inaba H, Nishikawa S, Shinozawa K, Shinohara S, Nakazawa F, Amano K, Kinai E. Coagulation assay discrepancies in Japanese patients with non-severe hemophilia A. Int J Hematol 2021; 115:173-187. [PMID: 34751920 DOI: 10.1007/s12185-021-03256-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/29/2021] [Accepted: 10/29/2021] [Indexed: 11/29/2022]
Abstract
Patients with non-severe hemophilia A often show discrepancies in factor VIII (FVIII) activity. However, information on variant-specific coagulation assay characteristics in Japanese patients is limited. Pathogenic variants were classified into three groups, thrombin-cleavage site (TC), A1-A2-A3 interface (IF), and non-discrepant, with reference to previous studies. Cutoff values for the one-stage assay (OSA)/chromogenic substrate assay (CSA) ratio, which is suitable for distinguishing discrepancies, were determined for all five aPTT reagents. TGA and CWA parameters and bleeding scores were compared between groups. Two of the 39 patients with non-severe hemophilia A (5%) were classified as TC, 10 (26%) as IF, and 27 (69%) as non-discrepant. The OSA/CSA cutoff values between the groups varied widely by aPTT reagent and tended to be relatively low compared to previous studies. As an indicator of bleeding tendency, TGA had a low correlation coefficient for the IF variant, but this was not significant and was comparable to FVIII activity and CWA. Moreover, various parameters and bleeding tendency differed among patients with the same variants. Thus, our findings suggest that it is difficult to adequately assess the bleeding tendency of individual patients, even with the various assessments currently available.
Collapse
Affiliation(s)
- Hiroshi Inaba
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
| | - Satomi Nishikawa
- Scientific Research, Scientific Affairs, Sysmex Corporation, Kobe, Japan
| | - Keiko Shinozawa
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Sho Shinohara
- Reagent Engineering, Sysmex Corporation, Kobe, Japan
| | - Fumie Nakazawa
- Scientific Research, Scientific Affairs, Sysmex Corporation, Kobe, Japan
| | - Kagehiro Amano
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Ei Kinai
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| |
Collapse
|
32
|
Murphy CA, O'Reilly DP, Edebiri O, Weiss L, Cullivan S, El-Khuffash A, Doyle E, Donnelly JC, Malone FD, Ferguson W, Drew RJ, O'Loughlin J, Neary E, Maguire PB, Kevane B, NíAinle F, McCallion N. Haematological parameters and coagulation in umbilical cord blood following COVID-19 infection in pregnancy. Eur J Obstet Gynecol Reprod Biol 2021; 266:99-105. [PMID: 34601263 PMCID: PMC8454187 DOI: 10.1016/j.ejogrb.2021.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/01/2021] [Accepted: 09/17/2021] [Indexed: 11/15/2022]
Abstract
Objective The aim of this study was to evaluate infants, born to women with SARS-CoV-2 detected during pregnancy, for evidence of haematological abnormalities or hypercoagulability in umbilical cord blood. Study design This was a prospective observational case-control study of infants born to women who had SARS-CoV-2 RNA detected by PCR at any time during their pregnancy (n = 15). The study was carried out in a Tertiary University Maternity Hospital (8,500 deliveries/year) in Ireland. This study was approved by the Hospital Research Ethics Committee and written consent was obtained. Umbilical cord blood samples were collected at delivery, full blood count and Calibrated Automated Thrombography were performed. Demographics and clinical outcomes were recorded. Healthy term infants, previously recruited as controls to a larger study prior to the outbreak of COVID-19, were the historical control population (n = 10). Results Infants born to women with SARS-CoV-2 had similar growth parameters (birth weight 3600 g v 3680 g, p = 0.83) and clinical outcomes to healthy controls, such as need for resuscitation at birth (2 (13.3%) v 1 (10%), p = 1.0) and NICU admission (1 (6.7%) v 2 (20%), p = 0.54). Haematological parameters (Haemoglobin, platelet, white cell and lymphocyte counts) in the COVID-19 group were all within normal neonatal reference ranges. Calibrated Automated Thrombography revealed no differences in any thrombin generation parameters (lag time (p = 0.92), endogenous thrombin potential (p = 0.24), peak thrombin (p = 0.44), time to peak thrombin (p = 0.94)) between the two groups. Conclusion In this prospective study including eligible cases in a very large population of approximately 1500 women, there was no evidence of derangement of the haematological parameters or hypercoagulability in umbilical cord blood due to COVID-19. Further research is required to investigate the pathological placental changes, particularly COVID-19 placentitis and the impact of different strains of SARS-CoV-2 (particularly the B.1.1.7 and the emerging Delta variant) and the severity and timing of infection on the developing fetus.
Collapse
Affiliation(s)
- Claire A Murphy
- Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Neonatology, Rotunda Hospital, Dublin, Ireland; Conway-SPHERE Research Group, Conway Institute, University College Dublin, Ireland.
| | - Daniel P O'Reilly
- Department of Neonatology, Rotunda Hospital, Dublin, Ireland; Conway-SPHERE Research Group, Conway Institute, University College Dublin, Ireland
| | - Osasere Edebiri
- Conway-SPHERE Research Group, Conway Institute, University College Dublin, Ireland; School of Medicine, University College Dublin, Ireland
| | - Luisa Weiss
- Conway-SPHERE Research Group, Conway Institute, University College Dublin, Ireland
| | - Sarah Cullivan
- Conway-SPHERE Research Group, Conway Institute, University College Dublin, Ireland; Department of Hematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Afif El-Khuffash
- Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Neonatology, Rotunda Hospital, Dublin, Ireland
| | - Emma Doyle
- Department of Pathology, Rotunda Hospital, Dublin, Ireland
| | - Jennifer C Donnelly
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin, Ireland; Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fergal D Malone
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin, Ireland; Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Wendy Ferguson
- Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Neonatology, Rotunda Hospital, Dublin, Ireland; Department of Paediatric Infectious Diseases, Children's Health Ireland at Temple Street, Dublin, Ireland
| | - Richard J Drew
- Irish Meningitis and Sepsis Reference Laboratory, Children's Health Ireland at Temple Street, Dublin, Ireland; Clinical Innovation Unit, Rotunda Hospital, Dublin, Ireland; Department of Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - John O'Loughlin
- Department of Laboratory Medicine, Rotunda Hospital, Dublin, Ireland
| | - Elaine Neary
- Department of Neonatology, Liverpool Women's Hospital, Liverpool, United Kingdom; Department of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Patricia B Maguire
- Conway-SPHERE Research Group, Conway Institute, University College Dublin, Ireland
| | - Barry Kevane
- Conway-SPHERE Research Group, Conway Institute, University College Dublin, Ireland; Department of Hematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Fionnuala NíAinle
- Conway-SPHERE Research Group, Conway Institute, University College Dublin, Ireland; School of Medicine, University College Dublin, Ireland; Department of Hematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Naomi McCallion
- Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Neonatology, Rotunda Hospital, Dublin, Ireland
| |
Collapse
|
33
|
Daniel Y, Conort S, Foricher R, Hejl C, Travers S, Foissaud V, Martinaud C. Evaluation of hemostatic capacities among commando candidates: Would their blood suit a hemorrhagic war-injured patient in case of blood donation on the battlefield? J Trauma Acute Care Surg 2021; 91:672-680. [PMID: 34225350 DOI: 10.1097/ta.0000000000003335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In case of a warm fresh whole blood transfusion on the battlefield, the blood donation usually occurs just after a combat phase and often after several days on the fields. To explore the hemostatic capacity of such blood, we analyzed the blood of volunteers attending the commando course of the French Navy, considering this course as an experimental model, placing them into the same physiological conditions as those faced by deployed fighters. METHODS Venous blood was collected at the beginning of the course, mimicking their baseline status, and a second time 6 weeks later, from the remaining candidates, during the actual commando training, mimicking the stress conditions. For each candidate, we observed the differences between the two blood samples. RESULTS Of the 112 men that attended the first day of the course, only 17 remained 6 weeks later. In the second blood samples, we noted significant increased leucocytes and platelets counts and significant decreased hematocrit and hemoglobin levels. Thrombin generation assays showed significantly lower normalized peak heights (-31%), lower normalized endogenous thrombin potential values (-29%), and lower velocity index (-35%). Normalized lag time and time to peak did not differ. Viscoelastometric testing revealed a significant increasing in clot firmness as assessed by maximum amplitude and amplitude at 6 minutes. The clot speed was significantly increased. CONCLUSION This work brings new data on coagulation during prolonged and considerable physical exercise. No obvious deleterious modification of hemostatic properties was observed. The decrease of the endogenous thrombin potentials may reflect a better ability to control the thrombin generation once started. Altogether, these results suggest that this blood could suit well a hemorrhagic war-injured patient. LEVEL OF EVIDENCE Prospective observational cohort study, Level III.
Collapse
Affiliation(s)
- Yann Daniel
- From the Riflemen and Commandos Naval Force (Y.D., S.C.), French Navy, Lorient; Department of Clinical Operations (R.F., C.M.), French Military Blood Institute; Department of Laboratory Medicine, Percy Military Medical Center (C.H., V.F.), Clamart; and 1ère Chefferie du Service de Santé (S.T.), French Military Health Service, Villacoublay, France
| | | | | | | | | | | | | |
Collapse
|
34
|
de Laat-Kremers RMW, Ninivaggi M, van Moort I, de Maat M, de Laat B. Tailoring the effect of antithrombin-targeting therapy in haemophilia A using in silico thrombin generation. Sci Rep 2021; 11:15572. [PMID: 34330995 PMCID: PMC8324778 DOI: 10.1038/s41598-021-95066-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 07/14/2021] [Indexed: 11/09/2022] Open
Abstract
Factor (F) VIII deficiency causes bleeding in haemophilia A patients because of the reduced formation of procoagulant enzyme thrombin, which is needed to make the blood clot. We measured the dynamics of coagulation in haemophilia A patients by measuring thrombin generation (TG). Additionally, we quantified the procoagulant process of prothrombin conversion and anticoagulant process of thrombin inhibitor complex formation. In haemophilia A, prothrombin conversion is severely reduced, causing TG to be low. Nevertheless, the thrombin inactivation capacity of these patients is comparable to that in healthy subjects, leading to a severe imbalance between procoagulant and anticoagulant processes and a subsequent increased bleeding risk. A novel therapy in haemophilia A is the targeting of anticoagulant pathway, e.g. thrombin inhibitor antithrombin (AT), to restore the haemostatic balance. We simulated the effect of AT reduction on TG in silico. Lowering AT levels restored TG dose-dependently and an AT reduction of 90-95% led to almost normal TG in most patients . However, the variation in response to AT reduction was large between patients, indicating that this approach should be tailored to each individual patients. Ideally, TG and thrombin dynamics simulation could in the future contribute to the management of patients undergoing AT targeting therapy.
Collapse
Affiliation(s)
- Romy M W de Laat-Kremers
- Department of Data Analysis and Artificial Intelligence, Synapse Research Institute, Pastoor Habetsstraat 50, 6217 KM, Maastricht, The Netherlands. .,Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands.
| | - Marisa Ninivaggi
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands
| | - Iris van Moort
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Moniek de Maat
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Bas de Laat
- Department of Data Analysis and Artificial Intelligence, Synapse Research Institute, Pastoor Habetsstraat 50, 6217 KM, Maastricht, The Netherlands.,Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands
| |
Collapse
|
35
|
de Breet CPDM, Zwaveling S, Vries MJA, van Oerle RG, Henskens YMC, Van't Hof AWJ, van der Meijden PEJ, Veenstra L, Ten Cate H, Olie RH. Thrombin Generation as a Method to Identify the Risk of Bleeding in High Clinical-Risk Patients Using Dual Antiplatelet Therapy. Front Cardiovasc Med 2021; 8:679934. [PMID: 34179143 PMCID: PMC8224526 DOI: 10.3389/fcvm.2021.679934] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 05/04/2021] [Indexed: 01/29/2023] Open
Abstract
Background: Patients using dual antiplatelet therapy after percutaneous coronary intervention are at risk for bleeding. It is currently unknown whether thrombin generation can be used to identify patients receiving dual antiplatelet therapy with increased bleeding risk. Objectives: To investigate whether thrombin generation measurement in plasma provides additional insight into the assessment of bleeding risk for high clinical-risk patients using dual antiplatelet therapy. Methods: Coagulation factors and thrombin generation in platelet-poor plasma were measured in 93 high clinical-risk frail patients using dual antiplatelet therapy after percutaneous coronary intervention. During 12-month follow-up, clinically relevant bleedings were reported. Thrombin generation at 1 and 6 months after percutaneous coronary intervention was compared between patients with and without bleeding events. Results: One month after percutaneous coronary intervention, the parameters of thrombin generation, endogenous thrombin potential, peak height, and velocity index were significantly lower in patients with bleeding in the following months compared to patients without bleeding. At 6 months follow-up, endogenous thrombin potential, peak height, and velocity index were still (significantly) decreased in the bleeding group as compared to non-bleeders. Thrombin generation in the patients' plasma was strongly dependent on factor II, V, and VIII activity and fibrinogen. Conclusion: High clinical-risk patients using dual antiplatelet therapy with clinically relevant bleeding during follow-up show reduced and delayed thrombin generation in platelet-poor plasma, possibly due to variation in coagulation factors. Thus, impaired thrombin-generating potential may be a "second hit" on top of dual antiplatelet therapy, increasing the bleeding risk in high clinical-risk patients. Thrombin generation has the potential to improve the identification of patients using dual antiplatelet therapy at increased risk of bleeding.
Collapse
Affiliation(s)
- C P D M de Breet
- Department of Internal Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands.,Department of Internal Medicine, Zuyderland Medisch Centrum, Heerlen, Netherlands
| | - S Zwaveling
- Department of Biochemistry-CARIM, Maastricht University, Maastricht, Netherlands.,Groene Hart Ziekenhuis, Gouda, Netherlands
| | - M J A Vries
- Department of Internal Medicine, Jeroen Bosch Ziekenhuis, 's-Hertogenbosch, Netherlands
| | - R G van Oerle
- Department of Biochemistry-CARIM, Maastricht University, Maastricht, Netherlands
| | - Y M C Henskens
- Department of Biochemistry-CARIM, Maastricht University, Maastricht, Netherlands
| | - A W J Van't Hof
- Department of Cardiology, Zuyderland Medisch Centrum, Heerlen, Netherlands.,Department of Cardiology, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands
| | | | - L Veenstra
- Department of Cardiology, Zuyderland Medisch Centrum, Heerlen, Netherlands
| | - H Ten Cate
- Department of Internal Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands.,Department of Biochemistry-CARIM, Maastricht University, Maastricht, Netherlands
| | - R H Olie
- Department of Internal Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands.,Department of Biochemistry-CARIM, Maastricht University, Maastricht, Netherlands
| |
Collapse
|
36
|
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.
Collapse
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
| |
Collapse
|
37
|
Differential roles of factors IX and XI in murine placenta and hemostasis under conditions of low tissue factor. Blood Adv 2021; 4:207-216. [PMID: 31935292 DOI: 10.1182/bloodadvances.2019000921] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 10/28/2019] [Indexed: 01/31/2023] Open
Abstract
The intrinsic tenase complex (FIXa-FVIIIa) of the intrinsic coagulation pathway and, to a lesser extent, thrombin-mediated activation of FXI, are necessary to amplify tissue factor (TF)-FVIIa-initiated thrombin generation. In this study, we determined the contribution of murine FIX and FXI to TF-dependent thrombin generation in vitro. We further investigated TF-dependent FIX activation in mice and the contribution of this pathway to hemostasis. Thrombin generation was decreased in FIX- but not in FXI-deficient mouse plasma. Furthermore, injection of TF increased levels of FIXa-antithrombin complexes in both wild-type and FXI-/- mice. Genetic studies were used to determine the effect of complete deficiencies of either FIX or FXI on the survival of mice expressing low levels of TF. Low-TF;FIX-/y male mice were born at the expected frequency, but none survived to wean. In contrast, low-TF;FXI-/- mice were generated at the expected frequency at wean and had a 6-month survival equivalent to that of low-TF mice. Surprisingly, a deficiency of FXI, but not FIX, exacerbated the size of blood pools in low-TF placentas and led to acute hemorrhage and death of some pregnant dams. Our data indicate that FIX, but not FXI, is essential for survival of low-TF mice after birth. This finding suggests that TF-FVIIa-mediated activation of FIX plays a critical role in murine hemostasis. In contrast, FXI deficiency, but not FIX deficiency, exacerbated blood pooling in low-TF placentas, indicating a tissue-specific requirement for FXI in the murine placenta under conditions of low TF.
Collapse
|
38
|
Laboratory monitoring of hemophilia A treatments: new challenges. Blood Adv 2021; 4:2111-2118. [PMID: 32396619 DOI: 10.1182/bloodadvances.2019000849] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/04/2020] [Indexed: 12/12/2022] Open
Abstract
Monitoring factor VIII (FVIII) activity has traditionally been complicated by discrepancies between assays for the various sorts of FVIII molecules. The advent of novel nonfactor therapies (emicizumab, fitusiran, and anti-tissue factor pathway inhibitor antibodies) in hemophilia A poses a new level of difficulty on the laboratory monitoring of these patients. To use the correct assays and for a proper interpretation of their results, it is pertinent to understand the mode of action of these nonfactor agents. Furthermore, the biochemical consequences for the different types of activity assays (whether it be specific FVIII activity assays or global coagulation assays) should be taken into account as well. In this review, these aspects will be discussed. In addition, the use of various animal models to estimate FVIII-equivalence of the nonfactor therapies will be presented.
Collapse
|
39
|
Lefèvre CR, Jaffré A, Pontis A, Nedelec-Gac F, Guéret P, Gouin-Thibault I, Fraisse B, Bayart S, Guillet B. Management of a High-Risk Surgery with Emicizumab and Factor VIII in a Child with a Severe Hemophilia A and Inhibitor. TH OPEN 2021; 5:e163-e165. [PMID: 34007955 PMCID: PMC8116169 DOI: 10.1055/s-0041-1728667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 01/25/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Charles R Lefèvre
- Laboratoire d'Hémostase Bioclinique, CHU de Rennes, Bretagne, France.,Centre Régional de Traitement de l'Hémophilie, CHU de Rennes, Bretagne, France.,Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France
| | - Anaïs Jaffré
- Service de Réanimation Pédiatrique, CHU de Rennes, Bretagne, France
| | - Adeline Pontis
- Laboratoire d'Hémostase Bioclinique, CHU de Rennes, Bretagne, France
| | - Fabienne Nedelec-Gac
- Laboratoire d'Hémostase Bioclinique, CHU de Rennes, Bretagne, France.,Centre Régional de Traitement de l'Hémophilie, CHU de Rennes, Bretagne, France
| | - Pierre Guéret
- Laboratoire d'Hémostase Bioclinique, CHU de Rennes, Bretagne, France.,Centre Régional de Traitement de l'Hémophilie, CHU de Rennes, Bretagne, France
| | | | - Bernard Fraisse
- Service de Chirurgie Pédiatrique, CHU de Rennes, Bretagne, France
| | - Sophie Bayart
- Centre Régional de Traitement de l'Hémophilie, CHU de Rennes, Bretagne, France
| | - Benoit Guillet
- Centre Régional de Traitement de l'Hémophilie, CHU de Rennes, Bretagne, France.,Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France
| |
Collapse
|
40
|
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.
Collapse
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
| |
Collapse
|
41
|
Lin WY, Zhu R, Zhang Z, Lu X, Wang H, He W, Hu Y, Tang L. RNAi targeting heparin cofactor II promotes hemostasis in hemophilia A. MOLECULAR THERAPY-NUCLEIC ACIDS 2021; 24:658-668. [PMID: 33996250 PMCID: PMC8093307 DOI: 10.1016/j.omtn.2021.03.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 03/31/2021] [Indexed: 01/15/2023]
Abstract
Hemophilia A is a hemorrhagic disease due to congenital deficiencies of coagulation factor VIII (FVIII). Studies show that hemophilia patients with anticoagulant deficiency present less severe hemorrhagic phenotypes. We aimed to find a new therapeutic option for hemophilia patients by RNA interference (RNAi) targeting heparin cofactor II (HCII), a critical anticoagulant protein inactivating the thrombin. The optimal small interfering RNA (siRNA) was conjugated to an asialoglycoprotein receptor ligand (N-acetylgalactosamine [GalNAc]-HCII), promoting targeted delivery to the liver. After administration, GalNAc-HCII demonstrated effective, dose-dependent, and persistent HCII inhibition. After 7 days, in normal mice, GalNAc-HCII reduced HCII levels to 25.04% ± 2.56%, 11.65% ± 2.41%, and 6.50% ± 1.73% with 2, 5, and 10 mg/kg GalNAc-HCII, respectively. The hemostatic ability of hemophilia mice in the GalNAc-HCII-treated group significantly improved, with low thrombus formation time in the carotid artery thrombosis models and short bleeding time in the tail-clipping assays. After repeated administration, the prolonged activated partial thromboplastin time (APTT) was reduced. A 30 mg/kg dose did not cause pathological thrombosis. Our study confirmed that GalNAc-HCII therapy is effective for treating hemophilia mice and can be considered a new option for treating hemophilia patients.
Collapse
Affiliation(s)
- Wen-Yi Lin
- Institute of Hematology, Union Hospital Affiliated Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ruiqi Zhu
- Institute of Hematology, Union Hospital Affiliated Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhen Zhang
- Institute of Hematology, Union Hospital Affiliated Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xuan Lu
- Institute of Hematology, Union Hospital Affiliated Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huafang Wang
- Institute of Hematology, Union Hospital Affiliated Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wenjuan He
- Institute of Hematology, Union Hospital Affiliated Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yu Hu
- Institute of Hematology, Union Hospital Affiliated Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liang Tang
- Institute of Hematology, Union Hospital Affiliated Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
42
|
Mori F, Genuardo C, Nannizzi S, Farina C. Intra- and interassay variations of two thrombin generation methods. Int J Lab Hematol 2021; 43:O218-O220. [PMID: 33759358 DOI: 10.1111/ijlh.13524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 02/24/2021] [Accepted: 03/07/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Filippo Mori
- Research Department, Kedrion S.p.A, Lucca, Italy
| | | | | | | |
Collapse
|
43
|
Pontara E, Cattini MG, Cheng C, Bison E, Denas G, Pengo V. Insight into the hypercoagulable state of high-risk thrombotic APS patients: Contribution of aβ2GPI and aPS/PT antibodies. J Thromb Haemost 2021; 19:805-813. [PMID: 33249717 DOI: 10.1111/jth.15199] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/24/2020] [Accepted: 11/24/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Most high-risk thrombotic antiphospholipid syndrome (APS) patients test positive for anti-β2-glycoprotein I (aβ2GPI) and anti-phosphatidylserine/prothrombin (aPS/PT) antibodies. Information on the influence of these antibodies on thrombin generation and activated protein C resistance (aPCr) is still sparse and contradictory. METHODS Plasma of 16 patients poured into a β2GPI affinity column allowed the perfect separation of aβ2GPI and aPS/PT antibodies. aPS/PT antibodies were further purified through a prothrombin affinity column. Obtained material was spiked into normal pooled plasma (NPP) and tested in the thrombin generation assay in the absence or presence of aPC. RESULTS aPS/PT antibodies showed a marked anticoagulant effect. Affinity purified aPS/PT and aβ2GPI antibodies from five patients were compared. aPS/PT antibodies showed significantly prolonged lag time and time to peak (5.0 minutes [interquartile range (IQR)3.5-6.1] versus 2.7 minutes [IQR2.2-3.5], P = .03 and 8.7 minutes [IQR6.7-10.3] versus 5.7 minutes [IQR4.5-6.2], P = .05, respectively) and significantly lower peak and velocity index (143 nmol/L [IQR131-163] versus 171 nmol/L [IQR157-182], P = .03 and 35 nmol/L/min [IQR32-59] versus 72 nmol/L/min [IQR54-77], P = .03, respectively). When aPC was added to the system, aPCr was significantly increased compared to controls for both aβ2GPI and aPS/PT antibodies. However, it was significantly stronger using aPS/PT antibodies. Median inhibition of endogenous thrombin potential was 22% (IQR16-33) with aPS/PT compared to 52% (IQR46-56) with aβ2GPI antibodies (P = .002). CONCLUSIONS Aβ2GPI antibodies show a mild anticoagulant and moderate procoagulant effect in thrombin generation and moderate aPC resistance. Conversely, aPS/PT antibodies show a strong anticoagulant effect and a strong aPCr.
Collapse
Affiliation(s)
- Elena Pontara
- Thrombosis Research Laboratory, University of Padova, Padova, Italy
| | | | - Chunyan Cheng
- Thrombosis Research Laboratory, University of Padova, Padova, Italy
| | - Elisa Bison
- Thrombosis Research Laboratory, University of Padova, Padova, Italy
| | - Gentian Denas
- Thrombosis Research Laboratory, University of Padova, Padova, Italy
| | - Vittorio Pengo
- Thrombosis Research Laboratory, University of Padova, Padova, Italy
- Arianna Foundation on Anticoagulation, Bologna, Italy
| |
Collapse
|
44
|
Rehill AM, McCluskey S, O'Donnell JS, Dockal M, Preston RJS. Heterogeneity in Bleeding Tendency and Arthropathy Development in Individuals with Hemophilia. Semin Thromb Hemost 2021; 47:183-191. [PMID: 33636749 DOI: 10.1055/s-0041-1723769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
People with hemophilia (PWH) have an increased tendency to bleed, often into their joints, causing debilitating joint disease if left untreated. To reduce the incidence of bleeding events, PWH receive prophylactic replacement therapy with recombinant factor VIII (FVIII) or FIX. Bleeding events in PWH are typically proportional to their plasma FVIII or IX levels; however, in many PWH, bleeding tendency and the likelihood of developing arthropathy often varies independently of endogenous factor levels. Consequently, many PWH suffer repeated bleeding events before correct dosing of replacement factor can be established. Diagnostic approaches to define an individual's bleeding tendency remain limited. Multiple modulators of bleeding phenotype in PWH have been proposed, including the type of disease-causing variant, age of onset of bleeding episodes, plasma modifiers of blood coagulation or clot fibrinolysis pathway activity, interindividual differences in platelet reactivity, and endothelial anticoagulant activity. In this review, we summarize current knowledge of established factors modulating bleeding tendency and discuss emerging concepts of additional biological elements that may contribute to variable bleeding tendency in PWH. Finally, we consider how variance in responses to new gene therapies may also necessitate consideration of patient-specific tailoring of treatment. Cumulatively, these studies highlight the need to reconsider the current "one size fits all" approach to treatment regimens for PWH and consider therapies guided by the bleeding phenotype of each individual PWH at the onset of therapy. Further characterization of the biological bases of bleeding heterogeneity in PWH, combined with the development of novel diagnostic assays to identify those factors that modulate bleeding risk in PWH, will be required to meet these aspirations.
Collapse
Affiliation(s)
- Aisling M Rehill
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Seán McCluskey
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland.,National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - James S O'Donnell
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland.,National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland.,St James' Hospital, Dublin, Ireland
| | - Michael Dockal
- Baxalta Innovations GmbH, A Member of the Takeda Group of Companies, Vienna, Austria
| | - Roger J S Preston
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland.,National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | | |
Collapse
|
45
|
Ninivaggi M, de Laat‐Kremers RMW, Carlo A, de Laat B. ST Genesia reference values of 117 healthy donors measured with STG-BleedScreen, STG-DrugScreen and STG-ThromboScreen reagents. Res Pract Thromb Haemost 2021; 5:187-196. [PMID: 33537543 PMCID: PMC7845068 DOI: 10.1002/rth2.12455] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/06/2020] [Accepted: 10/10/2020] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION The ST Genesia is a benchtop, fully automated thrombin generation (TG) device. It is completely standardized and ensures a uniform heat distribution throughout the measurement. We aimed to determine reference values and to compare TG in men and women with and without the use of oral contraceptives (OCs). MATERIALS AND METHODS Plasma from 117 healthy donors was measured on the ST Genesia with the available reagent kits: STG-BleedScreen, STG-DrugScreen, and STG-ThromboScreen. All kits include at least two quality controls and a reference plasma to normalize data. STG-ThromboScreen has a second trigger containing thrombomodulin (TM) to include the effect on the protein C pathway. Means were compared with one-way analysis of variance and reference ranges were established with 2.5th to 97.5th percentiles on absolute TG parameters. RESULTS Mean age of the donors was 35 years (SD ± 12); 49.6% were men, 37.6% women without OCs, and 12.8% women with OCs. Men and women without OCs had, respectively, a mean peak height of 167 nM and 164 nM with STG-BleedScreen, 335 nM and 351 nM with STG-DrugScreen, and 192 nM and 198 nM with STG-ThromboScreen. Women taking OCs had a mean peak height of 263 nM, 473 nM, and 312nM, respectively (P < .05 compared to men/women without OCs). TM decreased endogenous thrombin potential by 54% in men, 47% in women without OCs, and only 25% in women with OCs (P < .05 compared to men/women without OCs). CONCLUSIONS TG in men and women without OCs was similar; however, women taking OCs had significantly higher TG values, and the effect of TM was also less pronounced in these women.
Collapse
Affiliation(s)
| | | | | | - Bas de Laat
- Synapse Research InstituteMaastrichtThe Netherlands
| |
Collapse
|
46
|
Abstract
Hemophilia is caused by a lack of antihemophilic factor(s), for example, factor VIII (FVIII; hemophilia A) and factor IX (FIX; hemophilia B). Low bone mass is widely reported in epidemiological studies of hemophilia, and patients with hemophilia are at an increased risk of fracture. The detailed etiology of bone homeostasis imbalance in hemophilia is unclear. Clinical and experimental studies show that FVIII and FIX are involved in bone remodeling. However, it is likely that antihemophilic factors affect bone biology through thrombin pathways rather than via their own intrinsic properties. In addition, among patients with hemophilia, there are pathophysiological processes in several systems that might contribute to bone loss. This review summarizes studies on the association between hemophilia and bone remodeling, and might shed light on the challenges facing the care and prevention of osteoporosis and fracture in patients with hemophilia.
Collapse
Affiliation(s)
- Hanshi Wang
- Department of Sports Medicine and Joint Surgery, The People's Hospital of China Medical University, Shenyang, People's Republic of China
| | - Xizhuang Bai
- Department of Sports Medicine and Joint Surgery, The People's Hospital of China Medical University, Shenyang, People's Republic of China
| |
Collapse
|
47
|
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.
Collapse
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
| |
Collapse
|
48
|
Mairesse A, Bayart JL, Desmet S, Lopes Dos Santos H, Saussoy P, Defour JP, Eeckhoudt S, van Dievoet MA. Biological variation data and analytical specification goal estimates of the thrombin generation assay with and without thrombomodulin in healthy individuals. Int J Lab Hematol 2020; 43:450-457. [PMID: 33185328 DOI: 10.1111/ijlh.13388] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 10/15/2020] [Accepted: 10/19/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Evaluation of an individual's thrombin-generating capacity enables a global assessment of the coagulation cascade and is therefore thought to better reflect the clotting function of blood. However, the lack of standardization still hampers the use in routine clinical practice. METHODS Nineteen healthy subjects were sampled once a week for 5 consecutive weeks. Thrombin generation assay (TGA) was performed in duplicate by calibrated automated thrombogram (CAT) on platelet poor plasma with and without thrombomodulin. After exclusion of outliers, a nested analysis of variance (ANOVA) was performed to evaluate the biological variability (BV) results. Analytical variation (CVA ), within-individual variation (CVI ), between-individual variation (CVG ), index of individuality (II), and reference change value (RCV) were calculated. RESULTS All parameters taken together, the CVA, CVI , and CVG without TM, ranged from 2.8% to 6.5%, from 4.1% to 13.3% and from 10.4% to 28.4%, respectively. For TG with TM, CVI and CVG were higher and ranged from 5.0% to 18.1% and from 14.9% to 35.3%, respectively. For endogenous thrombin potential (ETP), a CVI of 4.1% and CVG of 10.4% were obtained without addition of thrombomodulin (TM). With addition of TM, both CVI and CVG were higher: 14.0% and 34.8%, respectively. The II was low and the RCV ranged from 17.2% to 50.4%. CONCLUSION CAT parameters are highly individualized and population-based reference values could be called into question. The assessment of BV and RCV for thrombin generation assays could optimize interpretation of serial patient results and guide setting of analytical specification goals.
Collapse
Affiliation(s)
- Antoine Mairesse
- Département des Laboratoires Cliniques, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Jean-Louis Bayart
- Département des Laboratoires Cliniques, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Sandrine Desmet
- Département des Laboratoires Cliniques, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Helder Lopes Dos Santos
- Département des Laboratoires Cliniques, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Pascale Saussoy
- Département des Laboratoires Cliniques, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Jean-Philippe Defour
- Département des Laboratoires Cliniques, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Stéphane Eeckhoudt
- Département des Laboratoires Cliniques, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | | |
Collapse
|
49
|
van Paridon PCS, Panova-Noeva M, van Oerle R, Schultz A, Hermanns IM, Prochaska JH, Arnold N, Binder H, Schmidtmann I, Beutel ME, Pfeiffer N, Münzel T, Lackner KJ, Ten Cate H, Wild PS, Spronk HMH. Thrombin generation in cardiovascular disease and mortality - results from the Gutenberg Health Study. Haematologica 2020; 105:2327-2334. [PMID: 33054057 PMCID: PMC7556497 DOI: 10.3324/haematol.2019.221655] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 12/03/2019] [Indexed: 11/09/2022] Open
Abstract
Thrombin generation may be a potential tool to improve risk stratification for cardiovascular diseases. This study aims to explore the relation between thrombin generation and cardiovascular risk factors, cardiovascular diseases, and total mortality. For this study, N=5000 subjects from the population-based Gutenberg Health Study were analysed in a highly standardized setting. Thrombin generation was assessed by the Calibrated Automated Thrombogram method at 1 and 5 pM tissue factors trigger in platelet poor plasma. Lag time, endogenous thrombin potential, and peak height were derived from the thrombin generation curve. Sex-specific multivariable linear regression analysis adjusted for age, cardiovascular risk factors, cardiovascular diseases and therapy, was used to assess clinical determinants of thrombin generation. Cox regression models adjusted for age, sex, cardiovascular risk factors and vitamin K antagonists investigated the association between thrombin generation parameters and total mortality. Lag time was positively associated with obesity and dyslipidaemia for both sexes (p<0.0001). Obesity was also positively associated with endogenous thrombin potential in both sexes (p<0.0001) and peak height in males (1 pM tissue factor, p=0.0048) and females (p<0.0001). Cox regression models showed an increased mortality in individuals with lag time (1 pM tissue factor, hazard ratio=1.46, [95% CI: 1.07; 2.00], p=0.018) and endogenous thrombin potential (5 pM tissue factor, hazard ratio = 1.50, [1.06; 2.13], p=0.023) above the 95th percentile of the reference group, independent of the cardiovascular risk profile. This large-scale study demonstrates traditional cardiovascular risk factors, particularly obesity, as relevant determinants of thrombin generation. Lag time and endogenous thrombin potential were found as potentially relevant predictors of increased total mortality, which deserves further investigation.
Collapse
Affiliation(s)
- Pauline C S van Paridon
- Department of Internal Medicine, (CARIM), Maastricht University Medical Center, The Netherlands
| | - Marina Panova-Noeva
- CTH, University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Rene van Oerle
- Department of Internal Medicine, (CARIM), Maastricht University Medical Center, The Netherlands
| | - Andreas Schultz
- Center for Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Iris M Hermanns
- Center for Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Jürgen H Prochaska
- CTH, University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Nathalie Arnold
- Center for Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Harald Binder
- Institute of Medical Biometry and Statistics, University of Freiburg, Germany
| | - Irene Schmidtmann
- Institute of Medical Biostatistics, Epidemiology, Informatics, University Medical Center Mainz
| | - Manfred E Beutel
- Dept of Psychosomatic Medicine and Psychotherapy, University Medical Center, Mainz, Germany
| | - Norbert Pfeiffer
- Dept of Ophthalmology, University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Thomas Münzel
- Center for Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Karl J Lackner
- Institute for Clinical Chemistry and Laboratory Medicine, University Medical Center, Mainz, Germany
| | - Hugo Ten Cate
- Department of Internal Medicine, (CARIM), Maastricht University Medical Center, The Netherlands
| | - Philipp S Wild
- CTH, University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Henri M H Spronk
- Department of Internal Medicine, (CARIM), Maastricht University Medical Center, The Netherlands
| |
Collapse
|
50
|
Deciphering the coagulation profile through the dynamics of thrombin activity. Sci Rep 2020; 10:12544. [PMID: 32719370 PMCID: PMC7385119 DOI: 10.1038/s41598-020-69415-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 07/09/2020] [Indexed: 12/18/2022] Open
Abstract
Thrombosis has proven to be extremely difficult to predict. Measuring the generation of thrombin is a very sensitive method to detect changes in the hemostatic system. We developed a method based on the generation of thrombin to further fingerprint hemostasis, which we have named thrombin dynamics. Via this method we are able to exactly measure the prothrombin conversion and thrombin inactivation, and any change in the coagulation cascade will be reflected in these two processes. In the current study we analyzed the importance of the members of the prothrombin complex on the dynamics of thrombin activation and inactivation. We show that prothrombin conversion is predominantly influenced by factor X and antithrombin, which will provide essential insights in complex thrombosis-related diseases, such as liver cirrhosis and kidney failure.
Collapse
|