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Makedonov I, Kahn SR, Abdulrehman J, Schulman S, Delluc A, Gross PL, Galanaud JP. Prevention of the post thrombotic syndrome with anticoagulation: a narrative review. Thromb Haemost 2021; 122:1255-1264. [PMID: 34852380 DOI: 10.1055/a-1711-1263] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The post thrombotic syndrome (PTS) is chronic venous insufficiency secondary to a prior deep vein thrombosis (DVT). It is the most common complication of VTE and, while not fatal, it can lead to chronic, unremitting symptoms as well as societal and economic consequences. The cornerstone of PTS treatment lies in its prevention after DVT. Specific PTS preventative measures include the use of elastic compression stockings (ECS) and pharmacomechanical catheter directed thrombolysis (PCDT). However, the efficacy of these treatments has been questioned by large RCTs. So far, anticoagulation, primarily prescribed to prevent DVT extension and recurrence, appears to be the only unquestionably effective treatment for the prevention of PTS. In this literature review we present pathophysiological, biological, radiological and clinical data supporting the efficacy of anticoagulants to prevent PTS and the possible differential efficacy among available classes of anticoagulants (vitamin K antagonists (VKA), low molecular weight heparins (LMWHs) and direct oral anticoagulants (DOACs)). Data suggest that LMWHs and DOACs are superior to VKAs, but no head-to-head comparison is available between DOACs and LMWHs. Owing to their potentially greater anti-inflammatory properties, LMWHs could be superior to DOACs. This finding may be of interest particularly in patients with extensive DVT at high risk of moderate to severe PTS, but needs to be confirmed by a dedicated RCT.
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Affiliation(s)
- Ilia Makedonov
- Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | | | | | | | | | - Peter L Gross
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Canada
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Tala JA, Polikoff LA, Pinto MG, Li S, Trakas E, Miksa M, Gertz S, Faustino EVS. Protein biomarkers for incident deep venous thrombosis in critically ill adolescents: An exploratory study. Pediatr Blood Cancer 2020; 67:e28159. [PMID: 31904170 DOI: 10.1002/pbc.28159] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/18/2019] [Accepted: 12/11/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND There are no tests to identify critically ill children at high risk of deep venous thrombosis (DVT). In this exploratory study, we aimed to identify proteins that are associated with incident DVT in critically ill adolescents. PROCEDURE Plasma samples were obtained from critically ill adolescents within 24 hours after initiation of cardiopulmonary support. The adolescents were followed with ultrasound to detect the development of DVT of the lower extremity and clinically for bleeding. Thrombin-antithrombin complex and prothrombin fragment 1+2 were measured using immunosorbent assays, whereas procoagulation and anticoagulation factors were measured using multiplex assays. Plasma samples were also analyzed using SOMAscan, an aptamer-based capture assay. The associations between DVT and the log-transformed level of the proteins were assessed using logistic regression adjusting for the presence of femoral venous catheter and severity of illness. Associations were expressed as odds ratio (OR) for every log-fold increase in level of the protein with 95% confidence interval (CI). RESULTS Plasma from 59 critically ill adolescents, of whom 9 developed incident DVT, was analyzed. The median age of the adolescents was 15.1 years (interquartile range, 14.0-16.7 years). Higher levels of thrombin-antithrombin complex (OR: 31.54; 95% CI: 2.09-475.92) and lower levels of factor XIII (OR: 0.03; 95% CI: 0.002-0.44) were associated with DVT. CD36, MIC-1, and EpoR were marginally associated with DVT. Only factor XIII was associated with clinically relevant bleeding (OR: 0.27; 95% CI: 0.08-0.97). CONCLUSIONS We identified candidate protein biomarkers for incident DVT. We plan to validate our findings in adequately powered studies.
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Affiliation(s)
- Joana A Tala
- Yale-New Haven Children's Hospital, New Haven, Connecticut
| | - Lee A Polikoff
- The Warren Alpert School of Medicine at Brown University, Providence, Rhode Island
| | | | - Simon Li
- New York Medical College, Valhalla, New York
| | - Erin Trakas
- University of Rochester Golisano Children's Hospital, Rochester, New York
| | - Michael Miksa
- Children's Hospital at Montefiore, New York City, New York
| | - Shira Gertz
- Saint Barnabas Medical Center, Livingston, New Jersey
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McFarland CP, Lind SE. Thrombin Generation Biomarkers Decline With Parenteral Anticoagulation-An Overlooked Means of Anticoagulation Monitoring? Clin Appl Thromb Hemost 2018; 24:708-717. [PMID: 29439639 PMCID: PMC6714868 DOI: 10.1177/1076029617746506] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Anticoagulation therapy is administered to patients to prevent or stop thrombin generation in vivo. Although plasma tests of in vivo thrombin generation have been available for more than 2 decades, they are not routinely used in clinical trials or practice to monitor anticoagulation therapy. We observed a fall in one such marker, the D-dimer antigen, in patients receiving anticoagulation therapy. We therefore conducted a systematic review of the medical literature to document the change in serum biomarkers of thrombin generation following the initiation of anticoagulation therapy. Using a defined search strategy, we screened PubMed and Embase citations and identified full-length articles published in English. Eighteen articles containing serial changes in 1 of 3 markers of thrombin generation (D-dimer antigen, thrombin–antithrombin complexes, and prothrombin fragment 1+2 antigen levels) in the 14 days following the initiation of anticoagulation were identified. Even though the assays used varied considerably, each of the 3 markers of thrombin generation declined in the initial period of anticoagulation therapy, with changes evident as early as 1 day after beginning therapy. These observations provide a rationale for further exploration of these markers as measures of the adequacy of anticoagulation using classic as well as novel anticoagulants. Particular patient groups that would benefit from additional means of monitoring anticoagulation therapy are discussed.
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Affiliation(s)
- Craig P McFarland
- 1 Department of Medicine, School of Medicine, University of Colorado, Aurora, CO, USA.,2 Division of Hospital Medicine, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Stuart E Lind
- 1 Department of Medicine, School of Medicine, University of Colorado, Aurora, CO, USA.,3 Department of Pathology, School of Medicine, University of Colorado, Aurora, CO, USA
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Cantone L, Angelici L, Bollati V, Bonzini M, Apostoli P, Tripodi A, Bertazzi PA, Baccarelli AA. Extracellular histones mediate the effects of metal-rich air particles on blood coagulation. ENVIRONMENTAL RESEARCH 2014; 132:76-82. [PMID: 24742731 PMCID: PMC4387237 DOI: 10.1016/j.envres.2014.03.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 02/10/2014] [Accepted: 03/10/2014] [Indexed: 05/04/2023]
Abstract
BACKGROUND Epidemiological studies have shown associations of particulate matter (PM) exposure with hypercoagulability and thrombosis. Extracellular circulating histones have recently been identified as novel mediators of inflammatory and procoagulant responses. The potential roles of extracellular histones in PM-related hypercoagulability have yet not been investigated. OBJECTIVES In 63 steel workers, we evaluated the effects of exposure to PM and PM metal components on two extracellular histone modifications (H3K4me3 and H3K9ac); and the association of H3K4me3 and H3K9ac with coagulation markers. METHODS Extracellular H3K4me3 and H3K9ac were determined in plasma through enzyme-linked immunosorbent assays. Coagulation markers included endogenous thrombin potentials (ETPs), tissue-type plasminogen activator antigen (t-PA) and D-dimer. Exposure to PM with aerodynamic diameters <1 μm (PM1) or <10 μm (PM10) and PM10 metal components were estimated for each participant. RESULTS The coagulation marker ETP, measured in the presence of soluble thrombomodulin (ETP TM+), showed significant positive associations with PM1 (β=107.84, p=0.03), PM10 (β=83.06, p=0.02), and zinc (β=75.14, p=0.03); and a marginal association with iron (β=122.58, p=0.07). Additional PM effects were observed on t-PA, D-dimer, and ETP TM+. PM1 exposure was associated with increased plasma H3K4me3 and H3K9ac (β=0.20, p=0.02; β=0.16, p=0.05, respectively). H3K4me3, but not H3K9ac, was associated with zinc (β=0.13, p=0.03) and iron (β=0.32, p=0.01) contained in PM. ETP TM+ was increased in association with higher plasma H3K4me3 (β=0.50, p=0.05) and H3K9ac (β=0.54, p=0.05). CONCLUSIONS This observational study suggests potential roles of extracellular histones in PM-induced hypercoagulability. Experimental studies are warranted to further characterize these findings.
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Affiliation(s)
- L Cantone
- Center of Molecular and Genetic Epidemiology, Department of Clinical Sciences and Community, Università di Milano and Fondazione Cà Granda, IRCCS Ospedale Maggiore Policlinico, Milan, Italy
| | - L Angelici
- Center of Molecular and Genetic Epidemiology, Department of Clinical Sciences and Community, Università di Milano and Fondazione Cà Granda, IRCCS Ospedale Maggiore Policlinico, Milan, Italy
| | - V Bollati
- Center of Molecular and Genetic Epidemiology, Department of Clinical Sciences and Community, Università di Milano and Fondazione Cà Granda, IRCCS Ospedale Maggiore Policlinico, Milan, Italy
| | - M Bonzini
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - P Apostoli
- Occupational Medicine and Industrial Hygiene, University of Brescia, Department of Experimental and Applied Medicine, Brescia, Italy
| | - A Tripodi
- Angelo Bianchi-Bonomi Haemophilia and Thrombosis Centre, Department of Medicine and Medical Specialties, IRCCS Maggiore Hospital, Mangiagalli and Regina Elena Foundation, Milan, Italy
| | - P A Bertazzi
- Center of Molecular and Genetic Epidemiology, Department of Clinical Sciences and Community, Università di Milano and Fondazione Cà Granda, IRCCS Ospedale Maggiore Policlinico, Milan, Italy
| | - A A Baccarelli
- Laboratory of Environmental Epigenetics, Department of Environmental Health, Harvard School of Public Health, Boston, MA, USA.
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Koutroumpi S, Spiezia L, Albiger N, Barbot M, Bon M, Maggiolo S, Gavasso S, Simioni P, Frigo A, Mantero F, Scaroni C. Thrombin generation in Cushing's Syndrome: do the conventional clotting indices tell the whole truth? Pituitary 2014; 17:68-75. [PMID: 23408210 DOI: 10.1007/s11102-013-0467-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Cushing's Syndrome (CS) is associated with an increased mortality, where hypercoagulability seems to have a crucial role in both arterial and venous thrombosis. Parameters of in vitro thrombin generation (TG) such as lag time, peak thrombin and endogenous thrombin potential (ETP), that describe the time until thrombin burst, the peak amount of TG and the total amount of thrombin generated, respectively as well as classical clotting markers were evaluated in 33 CS patients compared to both a group of 28 patients matched for the features of Metabolic Syndrome (MetS) and 31 healthy individuals. CS and MetS patients had shorter lag time (p < 0.0001), higher peak and ETP (p < 0.0001) than healthy controls, though lag time was less shortened in CS (p < 0.0001) respect to MetS group. Prothrombin time (PT) was increased (p < 0.0001) in both CS and MetS patients, while partial thromboplastin time (PTT) was shorter (p < 0.0001) in CS compared to both MetS and healthy group (p < 0.0001). Factor VIII (FVIII), Antithrombin (AT), protein C and S were increased only in CS patients (p < 0.0001). lag time, AT and FVIII correlated to night salivary cortisol (r = + 0.59; p = 0.0005, r = + 0.40; p = 0.003, r = + 0.40; p = 0.04, respectively); PTT correlated inversely to urinary free cortisol (r = -0.45; p = 0.009). BMI correlated negatively to lag time (r = -0.40; p = 0.0001) and positively to peak and ETP (r = + 0.34; p = 0.001, r = + 0.28; p = 0.008, respectively). Obese and diabetic patients had shorter lag time (p = 0.0005; p = 0.0002, respectively), higher ETP (p = 0.0006; p = 0.007, respectively) and peak (p = 0.0003; p = 0.0005, respectively) as well as a more prolonged PT (p = 0.04; p = 0.009, respectively). Hypertensive individuals had higher ETP (p = 0.004), peak (p = 0.0008) and FVIII (p = 0.001). Our findings confirm a prothrombotic state in both CS and MetS patients, though lag time was less shortened in CS. The high levels of endogenous physiological anticoagulants, could possibly represent a protective mechanism against hypercoagulability seen in CS patients.
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Affiliation(s)
- S Koutroumpi
- Endocrinology Unit, Department of Medicine-DIMED, University of Padua, Via Ospedale, 105, 35128, Padua, Italy
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Bhutia S, Wong PF. Once versus twice daily low molecular weight heparin for the initial treatment of venous thromboembolism. Cochrane Database Syst Rev 2013; 2013:CD003074. [PMID: 23857562 PMCID: PMC10964127 DOI: 10.1002/14651858.cd003074.pub3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND In the initial treatment of venous thromboembolism (VTE) low molecular weight heparin (LMWH) is administered once or twice daily. A once daily treatment regimen is more convenient for the patient and may optimise home treatment. However, it is not clear whether a once daily treatment regimen is as safe and effective as a twice daily treatment regimen. This is the second update of a review first published in 2003. OBJECTIVES To compare the efficacy and safety of once daily versus twice daily administration of LMWH. SEARCH METHODS For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched May 2013) and CENTRAL (2013, Issue 4). SELECTION CRITERIA Randomised clinical trials in which LMWH given once daily is compared with LMWH given twice daily for the initial treatment of VTE. DATA COLLECTION AND ANALYSIS Two review authors assessed trials for inclusion and extracted data independently. MAIN RESULTS Five studies were included with a total of 1508 participants. The pooled data showed no statistically significant difference in recurrent VTE between the two treatment regimens (OR 0.82, 0.49 to 1.39; P = 0.47). A comparison of major haemorrhagic events (OR 0.77, 0.40 to 1.45; P = 0.41), improvement of thrombus size (OR 1.41, 0.66 to 3.01; P = 0.38) and mortality (OR 1.14, 0.62 to 2.08; P = 0.68) also showed no statistically significant differences between the two treatment regimens. None of the five included studies reported data on post-thrombotic syndrome. AUTHORS' CONCLUSIONS Once daily treatment with LMWH is as effective and safe as twice daily treatment with LMWH.
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Affiliation(s)
- Sherab Bhutia
- Department of Vascular Surgery, The Townsville Hospital, Townsville, Australia.
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Abstract
The most frequent and feared complication of paroxysmal nocturnal hemoglobinuria (PNH) is thrombosis. Recent research has demonstrated that the complement and coagulation systems are closely integrated with each influencing the activity of the other to the extent that thrombin itself has recently been shown to activate the alternative pathway of complement. This may explain some of the complexity of the thrombosis in PNH. In this review, the recent changes in our understanding of the pathophysiology of thrombosis in PNH, as well as the treatment of thrombosis, will be discussed. Mechanisms explored include platelet activation, toxicity of free hemoglobin, nitric oxide depletion, absence of other glycosylphosphatidylinositol-linked proteins such as urokinase-type plasminogen activator receptor and endothelial dysfunction. Complement inhibition with eculizumab has a dramatic effect in PNH and has a major impact in the prevention of thrombosis as well as its management in this disease.
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Tarantini L, Bonzini M, Tripodi A, Angelici L, Nordio F, Cantone L, Apostoli P, Bertazzi PA, Baccarelli AA. Blood hypomethylation of inflammatory genes mediates the effects of metal-rich airborne pollutants on blood coagulation. Occup Environ Med 2013; 70:418-25. [PMID: 23476046 DOI: 10.1136/oemed-2012-101079] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVES Recent investigations have associated airborne particulate matter (PM) with increased coagulation and thrombosis, but underlying biological mechanisms are still incompletely characterised. DNA methylation is an environmentally sensitive mechanism of gene regulation that could potentially contribute to PM-induced hypercoagulability. We aimed to test whether altered methylation mediates environmental effects on coagulation. METHODS We investigated 63 steel workers exposed to a wide range of PM levels, as a work-related condition with well-characterised prothrombotic exposure. We measured personal PM10 (PM≤10 µm in aerodynamic diameter), PM1 (≤1 µm) and air metal components. We determined leukocyte DNA methylation of NOS3 (nitric-oxide-synthase-3) and EDN1 (endothelin-1) through bisulfite-pyrosequencing and we measured ETP as a global coagulation-activation test after standardised triggers. RESULTS ETP increased in association with PM10 (β=20.0, 95% CI 3.0 to 37.0), PM1 (β=80.8 95% CI 14.9 to 146.7) and zinc (β=51.3, 95% CI 0.01 to 111.1) exposures. NOS3 methylation was negatively associated with PM10 (β=-0.2, 95% CI -0.4 to -0.03), PM1 (β=-0.8, 95% CI -1.4 to -0.1), zinc (β=-0.9, 95% CI -1.4 to -0.3) and iron (β=-0.7, 95% CI -1.4 to -0.01) exposures. Zinc exposure was negatively associated with EDN1 (β=-0.3, 95% CI -0.8 to -0.1) methylation. Lower NOS3 (β=-42.3; p<0.001) and EDN1 (β=-14.5; p=0.05) were associated with higher ETP. Statistical mediation analysis formally confirmed NOS3 and EDN1 hypomethylation as intermediate mechanisms for PM-related coagulation effects. CONCLUSIONS Our study showed for the first time, that gene hypomethylation contributes to environmentally induced hypercoagulability.
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Affiliation(s)
- Letizia Tarantini
- Department of Clinical and Community Sciences, Università degli Studi di Milano and IRCCS Maggiore Hospital, Mangiagalli and Regina Elena Foundation, Milan, Italy
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Gouya G, Palkovits S, Kapiotis S, Madl C, Locker G, Stella A, Wolzt M, Heinz G. Bioactivity of enoxaparin in critically ill patients with normal renal function. Br J Clin Pharmacol 2013; 74:806-14. [PMID: 23227470 DOI: 10.1111/j.1365-2125.2012.04285.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT Venous thromboembolism is a frequent complication in critically ill patients that has a negative impact on patient outcomes. Critically ill patients have significantly lower plasma anti-factor-Xa activity levels compared with control patients after administration of subcutaneous heparin. The clinical relevance of the different anti-factor-Xa levels after prophylactic doses of low molecular weight heparin (LMWH) in critically ill patients is not completely understood. WHAT THIS STUDY ADDS The standard dose of 40 mg enoxaparin led to a significant increase in anti-FXa levels in this selected cohort of ICU patients with normal renal function. This study found only subtle pharmacokinetic differences, but a comparable pharmacodynamic action, after enoxaparin administration in critically ill and normal medical ward patients. Thrombin generation with TGA RC-low and TGARC-high reagents was significantly reduced in ICU and normal ward patients after receiving LMWH. Both readouts appear equally useful for estimating the pharmacodynamics of enoxaparin. The ex vivo model of thrombosis was used for the first time in patients to evaluate the anti-thrombotic activity of LMWH. This method did not show any difference in thrombus formation after administration of enoxaparin in the individual group of patients. AIM In critically ill patients, reduced anti-FXa plasma activity following subcutaneous administration of enoxaparin or nadroparin has been described. In this study, we aimed to investigate the bioactivity of enoxaparin in critically ill patients and controls. METHODS A prospective, controlled, open label study was performed on a medical intensive care unit (ICU) and a general medical ward. Fifteen ICU patients (male = 12, median age 52 years [IQR 40-65], with a median Simplified Acute Physiology Score of 30 [IQR 18-52]) and sex- and age-matched medical ward patients were included. The anti-FXa plasma activity was measured after a single subcutaneous dose of40 mg enoxaparin. The thrombus size of a clot formed in an ex vivo perfusion chamber and endogenous thrombin potential (ETP) were measured. RESULTS The anti-FXa plasma activity increased significantly after enoxaparin administration, with peak levels at 3 h after treatment, but was comparable between the ICU and medical ward groups (median 0.16 IU ml-1 [IQR 0-0.22 IU ml-1] vs. 0.2 IU ml-1 [IQR 0.15-0.27 IU ml-1],respectively, P = 0.13). The area under the anti-FXa activity curve from 0–12 h was similar between the groups (median 0.97 IU ml-1 h [IQR0.59-2.1] and 1.48 IU ml-1 h1 [IQR 0.83-1.62], P = 0.42 for the ICU group compared with the control group, respectively). The ETP was lower in the ICU group (P < 0.05) at baseline, but it was comparable at 3 h between the groups. Thrombus size decreased at 3 h compared with pre-dose (P = 0.029) and was not different between the groups. CONCLUSION Similar bioactivity was achieved with a standard dose of subcutaneous enoxaparin in this selected cohort of ICU and general ward patients with normal renal function.
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Affiliation(s)
- Ghazaleh Gouya
- Department of Clinical Pharmacology, Medical University Vienna, Währinger Gürtel 18-20, Vienna, Austria.
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Rydzewska-Rosołowska A, Borawski J, Myśliwiec M. Hepatocyte growth factor/activin A/follistatin system activation during hemodialysis with different low molecular weight heparins. Ren Fail 2010; 31:791-7. [PMID: 19925286 DOI: 10.3109/08860220903180608] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Hepatocyte growth factor (HGF), activin A (Act A), and follistatin (FS) compose an organotrophic system; interestingly it is modified by heparin. To understand if LMWHs (considered distinct drugs) have different clinical profiles regarding the above growth factors, we studied the effects of enoxaparin, nadroparin, and dalteparin on their plasma levels. Seventeen chronic HD patients completed this prospective, crossover trial. They were randomized into six groups: each patient was administered enoxaparin (effective dose of 0.75 mg/kg), nadroparin (70.4 IU/kg) and dalteparin (78.6 IU/kg) in three time periods of two months each. At the end of this period, the cytokine's plasma levels were measured by immunoassays at the start and at 10 min and 180 min of the HD procedure. At 10 min, we observed a striking increase in plasma HGF (32-fold), Act A (4-fold), and FS (53%), all p = 0.0003. The levels of HGF and Act A remained markedly elevated after 180 min (by 295% and 87%, respectively; both p < 0.002), while those of FS returned to baseline. There were no differences in cytokine profile comparing both their peak concentrations and the areas under the curve. Enoxaparin, dalteparin, and nadroparin are seemingly not different considering the release of HGF/Act A/FS during HD procedures; this may reflect their similar profile in other aspects. Moreover, the concentrations of HGF/Act A/FS are close to therapeutic ones, which may partly explain the mechanisms underlying some of the emerging extra-anticoagulant effects of LMWHs.
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Bonzini M, Tripodi A, Artoni A, Tarantini L, Marinelli B, Bertazzi PA, Apostoli P, Baccarelli A. Effects of inhalable particulate matter on blood coagulation. J Thromb Haemost 2010; 8:662-8. [PMID: 19922434 PMCID: PMC3093960 DOI: 10.1111/j.1538-7836.2009.03694.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Particulate matter (PM) exposure has been linked to increased risk of cardiovascular disease, possibly resulting from hypercoagulability and thrombosis. Lung and systemic inflammation resulting from PM inhalation may activate blood coagulation, but mechanisms for PM-related hypercoagulability are still largely unknown. OBJECTIVES To identify coagulation mechanisms activated by PM in a population with well-characterized exposure. METHODS We measured prothrombin time (PT), activated partial thromboplastin time, endogenous thrombin potentials (ETPs) with/without exogenous triggers and with/without soluble thrombomodulin, tissue-type plasminogen activator (t-PA) antigen, D-dimer and C-reactive protein (CRP) in 37 workers in a steel production plant with well-characterized exposure to PM with aerodynamic diameter of < 1 mum (PM(1)) and coarse PM (PM(10) - PM(1)). Blood samples were collected from each subject on the first (baseline) and last (postexposure) day of a 4-day work week. We analyzed differences between baseline and postexposure levels using a paired Student's t-test. We fitted multivariate mixed-regression models to estimate the associations of interquartile range PM(1) and coarse PM exposure with parameter levels. RESULTS None of the parameters showed any significant changes from baseline in postexposure samples. However, exposure levels were associated with shorter PT (beta[PM(1)] = -0.33 s, P = 0.08; beta[PM(coarse)] = - 0.33 s, P = 0.01), and higher ETP without exogenous triggers and with thrombomodulin (beta[PM(1)] = + 99 nm min, P = 0.02; beta[PM(coarse)] = + 66 nm min, P = 0.05), t-PA (beta[PM(1)] = + 0.72 ng mL(-1), P = 0.01; beta[PM(coarse)] = + 0.88 ng mL(-1), P = 0.04), and CRP (beta[PM(1)] = + 0.59 mg L(-1), P = 0.03; beta[PM(coarse)] = + 0.48 mg L(-1), P = 0.01). CONCLUSIONS PM exposure did not show any short-term effect within the week of the study. The association of PM exposure with PT, ETP and CRP provides some evidence of long-term effects on inflammation and coagulation.
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Affiliation(s)
- M Bonzini
- Department of Clinical and Biological Sciences, University of Insubria, Varese, Italy.
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Helley D, de Latour RP, Porcher R, Rodrigues CA, Galy-Fauroux I, Matheron J, Duval A, Schved JF, Fischer AM, Socié G. Evaluation of hemostasis and endothelial function in patients with paroxysmal nocturnal hemoglobinuria receiving eculizumab. Haematologica 2010; 95:574-81. [PMID: 20081060 DOI: 10.3324/haematol.2009.016121] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Paroxysmal nocturnal hemoglobinuria (PNH) is associated with an increased risk of thrombosis through unknown mechanisms. DESIGN AND METHODS We studied 23 patients with PNH, before and after five and 11 weeks of treatment with eculizumab. We examined markers of thrombin generation and reactional fibrinolysis (prothrombin fragment 1+2 (F1+2), D-dimers, and plasmin antiplasmin complexes (P-AP), and endothelial dysfunction tissue plasminogen activator (t-PA), plasminogen activator inhibitor (PAI-1), soluble thrombomodulin (sTM), intercellular adhesion molecule 1 (sICAM-1), vascular cell adhesion molecule (sVCAM-1), endothelial microparticles (EMPs), and tissue factor pathway inhibitor (TFPI). RESULTS At baseline, vWF, sVCAM-1, the EMP count, and F1+2 and D-dimer levels were significantly elevated in the patients, including those with no history of clinical thrombosis. Treatment with eculizumab was associated with significant decreases in plasma markers of coagulation activation (F1+2, P=0.012, and D-dimers, P=0.01), and reactional fibrinolysis (P-AP, P=0.0002). Eculizumab treatment also significantly reduced plasma markers of endothelial cell activation (t-PA, P=0.0005, sVCAM-1, P<0.0001, and vWF, P=0.0047) and total (P=0.0008) and free (P=0.0013) TFPI plasma levels. CONCLUSIONS Our results suggest a new understanding of the contribution of endothelial cell activation to the pathogenesis of thrombosis in PNH. The terminal complement inhibitor, eculizumab, induced a significant and sustained decrease in the activation of both the plasma hemostatic system and the vascular endothelium, likely contributing to the protective effect of eculizumab on thrombosis in this setting.
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Affiliation(s)
- Dominique Helley
- Service d'Hématologie Biologique, Hôpital Européen Georges Pompidou, 20-40 Rue Leblanc, 75908 Paris cedex 15, France.
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Martinez Trabal JL, Comerota AJ, LaPorte FB, Kazanjian S, DiSalle R, Sepanski DM. The quantitative benefit of isolated, segmental, pharmacomechanical thrombolysis (ISPMT) for iliofemoral venous thrombosis. J Vasc Surg 2008; 48:1532-7. [DOI: 10.1016/j.jvs.2008.07.013] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Revised: 06/27/2008] [Accepted: 07/02/2008] [Indexed: 11/17/2022]
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Pottier P, Fouassier M, Hardouin JB, Volteau C, Planchon B. D-dimers, thrombin-antithrombin complexes, and risk factors for thromboembolism in hospitalized patient. Clin Appl Thromb Hemost 2008; 15:666-75. [PMID: 18796458 DOI: 10.1177/1076029608321436] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION There is lack of data about the correlation between hemostatic markers and the clinical and biological risk factors (RFs) for venous thromboembolism (VTE) in medical inpatients without suspicion of acute VTE. MATERIAL AND METHODS To evaluate the coagulation activation status in patients with current known RFs for VTE, the authors measured 2 markers of hypercoagulability, thrombin antithrombin (TAT) complexes and D-dimers, at day 1 in 165 patients hospitalized in internal medicine wards without suspected acute VTE. All known RFs for VTE were systematically assessed at admission and classified in a chronological way as permanent or transient. RESULTS Surprisingly, TAT values followed a multimodal distribution. D-dimers showed a normal distribution after a logarithmic transformation (P = .34, Shapiro-Wilk test). Interestingly, a significant progression in D-dimer levels was found according to the chronological classification of RFs. D-dimer variations on multivariate analysis (not applicable for TAT because of the multimodal distribution) correlated independently with a recent inability to walk and an increase in C reactive protein level more than 10 mg/L. CONCLUSIONS (a) this study is the first to describe the variations of hypercoagulability markers according to a systematic screening of RFs for VTE in inpatients without suspicion of acute VTE, (b) TAT appeared as a less relevant marker of hypercoagulability than D-dimers in internal medicine inpatients, (d) the chronological classification of RFs identified clearly groups at risk for the prethrombotic state, and (d) an increased hypercoagulability state was demonstrated in patients with an association between a recent immobility and increased inflammatory markers.
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Affiliation(s)
- Pierre Pottier
- Department of Internal Medicine, Nantes University-Hospital Centre, Nantes, France.
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Thanou M, Henderson S, Kydonieus A, Elson C. N-sulfonato-N,O-carboxymethylchitosan: A novel polymeric absorption enhancer for the oral delivery of macromolecules. J Control Release 2007; 117:171-8. [PMID: 17184870 DOI: 10.1016/j.jconrel.2006.11.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2006] [Revised: 10/26/2006] [Accepted: 11/07/2006] [Indexed: 10/23/2022]
Abstract
Chitosan has been shown to act on the mucosal epithelial barriers mainly when protonated at acidic pH values in which it is soluble. Soluble chitosan is able to improve the permeation and absorption of neutral to cationic macromolecules only, as it forms polyelectrolyte complexes with anionic macromolecules. LMWH (Low Molecular Weight Heparin) is an anionic polysaccharide finding clinical application as an improved antithrombotic agent compared to Unfractionated Heparin (UFH). In this study we have employed N-sulfonato-N,O-carboxymethylchitosan (SNOCC) as a potential intestinal absorption enhancer of LMWH, Reviparin. SNOCC was prepared at 3 different viscosity grades 20, 40 and 60 cps and identified as SNOCC-20, SNOCC-40 and SNOCC-60, respectively. SNOCC materials were tested in vitro for their ability to decrease the Trans Epithelial Electrical Resistance (TEER) of Caco-2 cell monolayers. They were further tested as transport enhancers of hydrophilic compounds such as (14)C-mannitol, FITC-Dextran (MW 4400 Da) and Reviparin (LMWH). Solutions of Reviparin, with or without SNOCC, were administered intraduodenally in vivo in rats and the absorption of the drug was assessed by measuring the Anti-Xa levels in rat plasma. In vitro studies showed that SNOCC materials were able to induce a concentration dependent decrease in the TEER of the Caco-2 monolayers. SNOCC-40 and -60 were shown to decrease resistance more readily compared to the low viscosity SNOCC-20. (14)C-mannitol permeation data across intestinal epithelia were in agreement with the observed decrease in TEER; the higher viscosity SNOCC-60 was the most effective demonstrating a 51-fold enhancement of the permeation of the radiolabeled marker. Studies with both FITC-Dextran and Reviparin demonstrated significantly increased permeation across Caco-2 cell monolayers when they were co-incubated at the apical side of the monolayer. Intestinal absorption of Reviparin in rats was increased when it was co-administered with SNOCC-40 and -60, in agreement with in vitro data. Anti-Xa levels were elevated to and above the antithrombotic levels and were sustained for at least 6 h, giving an 18.5-fold increase in the AUC of LMWH in rats. In conclusion, SNOCC-40 and -60 have been shown to enhance both permeation and absorption of Reviparin across intestinal epithelia proving their potential as polymeric absorption enhancers.
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Affiliation(s)
- M Thanou
- Genetic Therapies Centre, Chemistry, Imperial College London, SW72AZ, London, UK.
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Yoneda M, Brosnan JF, Norris LA, Bonnar J. The effect of LMWH (tinzaparin) on coagulation and fibrinolytic activation in pregnant women at risk of thrombosis. Thromb Res 2006; 117:283-90. [PMID: 15869785 DOI: 10.1016/j.thromres.2005.03.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2005] [Revised: 03/30/2005] [Accepted: 03/31/2005] [Indexed: 11/29/2022]
Affiliation(s)
- Misaho Yoneda
- Department of Obstetrics and Gynaecology, Trinity Centre for Health Sciences, St. James's Hospital, Dublin 8, Ireland
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Hinterhuber G, Böhler K, Kittler H, Quehenberger P. Extended monitoring of hemostatic activation after varicose vein surgery under general anesthesia. Dermatol Surg 2006; 32:632-9. [PMID: 16706757 DOI: 10.1111/j.1524-4725.2006.32134.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Postoperative heparin prophylaxis after stripping of the long saphenous vein is a matter of controversial discussion, and practices vary by surgeon and country. OBJECTIVE The aim of this study was to assess the extent of hypercoagulability by continued monitoring of activation markers of coagulation and fibrinolysis for a period of 3 weeks after stripping of the long saphenous vein and concomitant phlebectomy. METHODS Including 21 patients, the following markers were measured preoperatively and on postoperative day 1, 2, 3, 7, 14, and 21: Activation products of coagulation: thrombin-antithrombin complex (TAT), thrombus precursor protein (TPP), and prothrombin-fragment F1+2 (F1+2), and markers of fibrinolysis: plasmin-alpha(2)-antiplasmin complexes (PAP), D-Dimer, tissue plasminogen activator (t-PA) antigen, and plasminogen activator inhibitor 1 (PAI-1) antigen. RESULTS TAT levels increased significantly until day 3 (p=.008) and normalized within 14 days. TPP levels increased significantly until day 7 (p=.02), decreasing to initial values within 21 days. PAP complexes increased significantly until day 2 (p=.02) reducing to baseline within the observation period. D-Dimer levels increased immediately after surgery (p<.001) until day 14 (p<.001) and returned to baseline until day 21. CONCLUSIONS Significant hemostatic activation after varicose vein surgery was observed and persisted until 3 weeks postoperatively, indicating that heparin prophylaxis for 2 to 3 weeks is advisable for at-risk patients.
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Affiliation(s)
- Gabriele Hinterhuber
- Department of Dermatology, Division of General Dermatology, Medical University of Vienna, Vienna, Austria.
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Extended Monitoring of Hemostatic Activation After Varicose Vein Surgery Under General Anesthesia. Dermatol Surg 2006. [DOI: 10.1097/00042728-200605000-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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van Dongen CJ, MacGillavry MR, Prins MH. Once versus twice daily LMWH for the initial treatment of venous thromboembolism. Cochrane Database Syst Rev 2005:CD003074. [PMID: 16034885 DOI: 10.1002/14651858.cd003074.pub2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND In the initial treatment of venous thromboembolism (VTE) low molecular weight heparin (LMWH) is administered once or twice daily. A once daily treatment regimen is more convenient for the patient and may optimise home treatment. However, it is not clear whether a once daily treatment regimen is as safe and effective as a twice daily treatment regimen. OBJECTIVES To compare the efficacy and safety of once daily versus twice daily administration of LMWH. SEARCH STRATEGY We identified trials through searching the Specialised Register of the Cochrane Peripheral Vascular Diseases Group (last searched April 2005), the Cochrane Central Controlled Trials Register (CENTRAL) (last searched Issue 2, 2005), handsearches of relevant journals, checking cross-references and through personal communication with experts. SELECTION CRITERIA Randomised clinical trials in which LMWH given once daily is compared to LMWH given twice daily for the initial treatment of venous thromboembolism. DATA COLLECTION AND ANALYSIS Two authors assessed trials for inclusion and extracted data independently. MAIN RESULTS Five studies were included with a total of 1508 participants. The pooled data showed a statistically non-significant difference in recurrent venous thromboembolism between the two treatment regimens (OR 0.82, 0.49 to 1.39). A comparison of major haemorrhagic events (OR 0.77, 0.40 to 1.45) and mortality (OR 1.14, 0.62 to 2.08) also showed a statistically non-significant difference between the two treatment regimens. AUTHORS' CONCLUSIONS Once daily treatment with LMWH is as effective and safe as twice daily treatment with LMWH. However, the 95% confidence interval implies that there is a possibility that the risk of recurrent VTE might be higher when people are treated once daily. Hence, the decision to treat a person with a once daily regimen will depend on the evaluated balance between increased convenience and the potential for a lower efficacy.
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Affiliation(s)
- C J van Dongen
- Department of Clinical Epidemiology and Biostatistics, Room J2-204, Academic Medical Center, University of Amsterdam, PO Box 22700, 1100 DE Amsterdam, Netherlands.
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Hull RD, Marder VJ, Mah AF, Biel RK, Brant RF. Quantitative assessment of thrombus burden predicts the outcome of treatment for venous thrombosis: a systematic review. Am J Med 2005; 118:456-64. [PMID: 15866245 DOI: 10.1016/j.amjmed.2005.01.025] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2004] [Indexed: 10/25/2022]
Abstract
PURPOSE Clot-burden change in patients receiving anticoagulant therapy, by predicting subsequent recurrent venous thromboembolism, may provide a clinically relevant surrogate endpoint of prognostic importance. The validity of this objective measure is yet to be established. METHODS A PubMed search was performed to retrieve articles published up to December 2003. We identified 11 randomized trials reported from 1990 to 2003 that met our study identification and selection criteria. Anticoagulant therapy subsequently approved by regulatory affairs was assessed by clot-burden change and the validated outcome measure, long-term venous thromboembolism. Two additional randomized trials, partly meeting the inclusion criteria, were included in the sensitivity analysis. RESULTS Individual studies suggested a predictive relationship between clot-burden change and likelihood of recurrent venous thromboembolism irrespective of the particular anticoagulant. The summary treatment effects strongly favored the therapy under evaluation and were in harmony for improved clot-burden (relative risk 0.82; 95% CI, 0.76-0.88; P <0.001) and for recurrent venous thromboembolism (relative risk 0.56; 95% CI, 0.42-0.76; P <0.001). The aggregate data show a striking predictive correlation for clot-burden change and subsequent recurrent venous thromboembolism using meta-regression analysis; (correlation = 0.81, P = 0.005) validating quantitative clot-burden assessment. CONCLUSION Clot-burden change predicts long-term outcome, providing clinically relevant, patient-specific prognostic findings that may guide duration of anticoagulant therapy as well as provide a valid surrogate endpoint for clinical trials of innovative antithrombotic therapy, allowing more efficient trials exposing far fewer patients to the hazards of ineffective therapy than is required for outcome studies. Noninvasive assessment (duplex ultrasonography) of clot-burden change is currently being deployed for use in clinical trials.
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Affiliation(s)
- Russell D Hull
- Thrombosis Research Unit, 601 South Tower, Foothills Hospital, 1403 29th Street NW, Calgary, Alberta, Canada T2N 2T9.
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22
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Abstract
PURPOSE OF REVIEW After decades of near oblivion, thrombin generation is being revived as an overall function test of the plasmatic coagulation system in platelet-poor plasma (PPP). In platelet-rich plasma (PRP) it assesses platelet procoagulant functions as well. RECENT FINDINGS The recently developed use of special fluorogenic thrombin substrates allows monitoring of thrombin concentration in clotting PPP and PRP on line in up to 24 parallel samples. Studies in model systems stress the importance of cell-bound thrombin generation such as measured in PRP. SUMMARY The method can be profitably applied to various hitherto unyielding problems such as the control of (low-molecular-weight) heparin therapy, the detection of lupus anticoagulant, and various forms of thrombomodulin and activated protein C resistance (including the use of oral contraceptives) as well as monitoring the treatment of hemophiliacs by factor VIII bypassing therapy. In PRP it reflects the abnormalities encountered in von Willebrand disease and Glanzmann and Bernard-Soulier thrombopathy as well as the action of antiplatelet drugs.
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Affiliation(s)
- H Coenraad Hemker
- Synapse BV, Cardiovascular Research Institute, 6200 MD Maastricht, The Netherlands.
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Małyszko J, Małyszko JS, Hryszko T, Pawlak K, Myśliwiec M. Comparison of effects of different heparins on thrombin activatable fibrinolysis inhibitor in hemodialyzed patients. Am J Nephrol 2004; 24:624-9. [PMID: 15627717 DOI: 10.1159/000082862] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2004] [Accepted: 11/15/2004] [Indexed: 11/19/2022]
Abstract
BACKGROUND Thrombin activatable fibrinolysis inhibitor (TAFI) is a regulator of endogenous fibrinolysis. Heparin is used routinely during dialysis sessions to prevent clot formation in the extracorporeal circuit; therefore the aim of the study was to assess whether unfractionated heparin or low-molecular-weight heparins affect TAFI concentration and activity in hemodialyzed patients. METHODS Dalteparin (n = 16) or enoxaparin (n = 25) were administered before the second hemodialysis session in the week in a single dose, whereas unfractionated heparin (n = 18) was given first as a bolus, then in a pump. We also evaluated thrombin activity (thrombin-antithrombin complexes, prothrombin fragments 1 + 2), TAFI activator, thrombomodulin, a catalyzer of TAFI activation and a marker of endothelial cell injury, and the degree of plasmin generation (plasmin-antiplasmin complexes). RESULTS TAFI concentration, activity and markers of ongoing coagulation, i.e. prothrombin fragments 1 + 2 and thrombin-antithrombin complexes, were significantly higher in patients anticoagulated with unfractionated heparin when compared to both enoxaparin and dalteparin groups. Thrombin-antithrombin complexes, plasmin-antiplasmin complexes, prothrombin fragments 1 + 2, and thrombomodulin did not differ between patients anticoagulated with dalteparin and enoxaparin. CONCLUSIONS Our results suggest that low-molecular-weight heparins influence TAFI and other hemostatic parameters in hemodialyzed patients to a lesser degree than unfractionated heparin. Increased TAFI is possibly due to thrombin appearance during hemodialysis with unfractionated heparin.
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Affiliation(s)
- Jolanta Małyszko
- Department of Nephrology and Transplantology, Medical University, Białystok, Poland.
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Schutgens REG, Esseboom EU, Snijder RJ, Haas FJLM, Verzijlbergen F, Nieuwenhuis HK, Lisman T, Biesma DH. Low molecular weight heparin (dalteparin) is equally effective as unfractionated heparin in reducing coagulation activity and perfusion abnormalities during the early treatment of pulmonary embolism. ACTA ACUST UNITED AC 2004; 144:100-7. [PMID: 15322504 DOI: 10.1016/j.lab.2004.04.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Little is known about the differences between unfractionated heparin (UFH) and low molecular weight heparin (LMWH) with regard to their effects on coagulation activity during treatment for pulmonary embolism. The objective of this study was to compare UFH and LMWH (dalteparin) in the early treatment of pulmonary embolism in terms of control of coagulation markers and perfusion abnormalities. Thirty-seven patients with acute pulmonary embolism were randomized to receive intravenous UFH or subcutaneous dalteparin, each accompanied by acenocoumarol. Daily blood samples were obtained for the measurement of thrombin generation (fragments 1 and 2 [F1+2], thrombin-antithrombin (TAT) complexes and fibrin monomers [FMs]) and fibrinolysis (d-dimer concentrations and clot-lysis times). Ventilation-perfusion scintigraphies were performed, and with the data they yielded, percentage of vascular obstruction scores (PVOs) were calculated on days 0 and 5. The international normalized ratio was within the therapeutic range in both groups on day 3. F1+2 and TAT complexes rapidly normalized, without differences between the groups (P =.5 and.4, respectively). FM levels did not decrease and, in fact, showed an increase in the UFH group from day 3 on (P <.05 between groups). d-Dimer levels decreased over time, with no differences between groups (P =.6). Clot-lysis times were shorter in the UFH group (P <.05). PVOs on days 0 and 5 were not different (P =.5 and.8, respectively), but the decrease in PVOs over time was greater in the dalteparin group (P =.04). These results show that dalteparin is at least as effective as UFH in reducing coagulation activity and perfusion abnormalities in the early treatment of pulmonary embolism.
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Affiliation(s)
- Roger E G Schutgens
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, the Netherlands.
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Siegemund A, Petros S, Siegemund T, Scholz U, Seyfarth HJ, Engelmann L. The endogenous thrombin potential and high levels of coagulation factor VIII, factor IX and factor XI. Blood Coagul Fibrinolysis 2004; 15:241-4. [PMID: 15060420 DOI: 10.1097/00001721-200404000-00007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
High plasma concentrations of factor VIII, factor IX and factor XI have been reported as thrombosis risk factors. Using the thrombin generation test in platelet-poor plasma, it was aimed to describe the mechanism for this increased thrombosis risk. Endogenous thrombin potential was measured in platelet-poor plasma in 180 patients with a history of thromboembolism, and results were compared with those of 180 age-matched and sex-matched controls. Subjects with major hereditary and acquired thrombophilia were excluded. Plasma concentrations of the clotting factor VIII, factor IX and factor XI were significantly elevated in patients compared with controls. The mean endogenous thrombin potential was significantly higher in patients than in controls: 191.3 +/- 3.1 (95% confidence interval, 185.3-197.4) arbitrary units versus 180.8 +/- 2.6 (95% confidence interval, 175.7-185.9) arbitrary units (P = 0.009). The endogenous thrombin potential was significantly higher in patients with elevated factor IX and factor XI, but elevated factor VIII was not associated with a significant increase in endogenous thrombin potential. In conclusion, the increased thrombosis risk associated with high plasma concentrations of factor IX and factor XI may be explained by the increase in endogenous thrombin potential. However, this did not help explain the association between elevated factor VIII and thrombosis risk.
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Affiliation(s)
- Annelie Siegemund
- Clinical Hemostaseology, Medical ICU and Department of Pneumology, University of Leipzig, Germany
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Sjøland JA, Smith Pedersen R, Jespersen J, Gram J. Intraperitoneal heparin reduces peritoneal permeability and increases ultrafiltration in peritoneal dialysis patients. Nephrol Dial Transplant 2004; 19:1264-8. [PMID: 14993509 DOI: 10.1093/ndt/gfh065] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Patients on long-term treatment with peritoneal dialysis (PD) suffer from increasing peritoneal permeability and loss of ultrafiltration as a result of persistent inflammation, which may be triggered by bioincompatible dialysis fluids. Heparins have anti-inflammatory and anticoagulant properties. We have examined the effect of intraperitoneal (IP) low-molecular weight heparin (tinzaparin) on peritoneal permeability and ultrafiltration in PD patients. METHODS By means of a double-blinded cross-over design, 21 PD patients were randomized to receive either placebo or tinzaparin intraperitoneally once a day for two treatment periods of 3 months, separated by a wash-out period. The effect of heparin on peritoneal permeability and ultrafiltration was assessed using the 4 h standard peritoneal equilibration test. RESULTS IP tinzaparin reduced significantly the dialysate-to-plasma ratios (D/P) of creatinine (P < 0.01), urea (P < 0.01) and albumin (P<0.05). In addition, the ratio of glucose concentration in dialysate at 4 h dwell to that of 0 h dwell (D(4)/D(0)) was increased (P<0.05) along with an increase in ultrafiltration volume (P<0.05). CONCLUSIONS IP tinzaparin reduces peritoneal permeability to small solutes and increases ultrafiltration in PD patients.
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Affiliation(s)
- Jonas Angel Sjøland
- Department of Clinical Biochemistry, Ribe County Hospital in Esbjerg/Varde, and Department for Thrombosis Research, University of Southern Denmark, Denmark.
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Planès A. Review of bemiparin sodium--a new second-generation low molecular weight heparin and its applications in venous thromboembolism. Expert Opin Pharmacother 2003; 4:1551-61. [PMID: 12943485 DOI: 10.1517/14656566.4.9.1551] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Bemiparin sodium (Hibor, Ivor, Zivor, Badyket, Laboratorios Farmaceuticos Rovi SA) is a new second-generation low molecular weight heparin (LMWH). Bemiparin has the lowest mean molecular weight (3600 Da), the longest half-life (5.3 h) and the largest antifactor Xa:antifactor IIa ratio (8:1) of all LMWHs. Bemiparin promotes a greater release of tissue factor pathway inhibitor than unfractionated heparin (UFH) or dalteparin. These properties could result in a more favourable efficacy:safety ratio than the currently marketed LMWHs. Bemiparin 2500 IU/day was as effective as UFH for preventing venous thromboembolism (VTE) in moderate risk abdominal surgery. Bemiparin 3500 IU/day significantly reduced VTE compared to UFH in high-risk hip replacement surgery. Bemiparin 3500 IU/day started postoperatively was as effective as enoxaparin 4000 IU/day started preoperatively in total knee arthroplasty, with a trend towards a lower rate of proximal deep vein thrombosis (DVT), pulmonary embolism and symptomatic VTE. In patients with acute DVT, bemiparin was more effective than UFH in thrombus mass reduction and at least as effective as UFH for the prevention of clinical recurrence. Bemiparin was as effective as UFH for clot prevention during haemodialysis. The use of bemiparin was associated with a lower incidence of major and minor bleeding as compared to UFH in abdominal surgery. When compared with enoxaparin in orthopaedic surgery, a lower rate of complications at injection site was observed.
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Affiliation(s)
- Andre Planès
- Orthopedic Department, Clinique Radio-Chirurgicale du Mail, La Rochelle, France.
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Ahmad S, Bacher HP, Lassen MR, Hoppensteadt DA, Leitz H, Misselwitz F, Walenga JM, Fareed J. Investigations of the immunoglobulin subtype transformation of anti-heparin-platelet factor 4 antibodies during treatment with a low-molecular-weight heparin (clivarin) in orthopedic patients. Arch Pathol Lab Med 2003; 127:584-8. [PMID: 12708902 DOI: 10.5858/2003-127-0584-iotist] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT It is now widely accepted that the pathophysiology of heparin-induced thrombocytopenia (HIT) syndrome is mediated by the generation of a wide array of functional and molecularly heterogeneous anti-heparin-platelet factor 4 (AHPF4) antibodies that may mediate platelet and/or endothelial cell activation/destruction. OBJECTIVE We investigated the differential prevalence and functionality of AHPF4 immunoglobulin subtypes (IgA, IgG, and IgM) in plasmas obtained from orthopedic patients immobilized with Plaster-Cast and treated with clivarin (a low-molecular-weight heparin) in comparison to a placebo for the prophylaxis of deep-vein thrombosis. DESIGN AND METHODS Clivarin was administered subcutaneously at a fixed daily dosage of 1750 U without any adjustment or loading dosage. Citrated plasmas were obtained at baseline, at 10 to 14 days, and at postbrace procedure (5-12 weeks). An enzyme-linked immunosorbent assay (ELISA) was used to quantitate the AHPF4 antibody titers. The functionality of the ELISA-positive samples was determined by a 14C-serotonin release assay (SRA). RESULTS In the ELISA test, 16 of 1073 samples (1.5%; 6 in clivarin and 10 in placebo groups) were positive for AHPF4 antibodies (mean optical density [OD] = 0.46 +/- 0.02). None of the ELISA-positive samples for AHPF4 antibodies could mediate platelet activation responses as determined by the SRA (0%-3% serotonin release, P >.10, n = 16). Through differential immunoglobulin subtype analysis of the samples positive for (cumulative) AHPF4 antibodies, we determined that their relative prevalence in plasma were as follows: IgM (mean OD = 0.71 +/- 0.13) > IgG (0.31 +/- 0.08) > IgA (0.14 +/- 0.02). Although there was no significant difference in the total antibody titers between clivarin and placebo groups, the antibody subtyping data showed conversion trends (ie, IgA [clivarin to placebo], IgG [placebo to clivarin], and IgM [clivarin to placebo]). CONCLUSION These observations indicate that even at reduced dosages, clivarin can shift the immunogenic up-regulation toward the IgG subpopulation; however, the IgG subtype is of a nonfunctional type of AHPF4 antibody and thus may not cause any HIT-related pathogenic responses.
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Affiliation(s)
- Sarfraz Ahmad
- Loyola University of Chicago, Stritch School of Medicine, Maywood, Ill, USA
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