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Gupta S, Bravo MC, Heiman M, Nakar C, Brummel-Ziedins K, Miller CH, Shapiro A. Mathematical model of thrombin generation and bleeding phenotype in Amish carriers of Factor IX:C deficiency vs. controls. Thromb Res 2019; 182:43-50. [PMID: 31446339 DOI: 10.1016/j.thromres.2019.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 06/12/2019] [Accepted: 07/21/2019] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Factor IX:C (FIX:C) levels vary in hemophilia B carriers even in pedigrees with a unifying genetic defect. Analyzing the balance between pro-and anticoagulants might increase our understanding of carriers' bleeding potential. AIM In this research study, we evaluated bleeding scores (BS) and a novel mathematical model of thrombin generation (TG) in Amish FIX:C deficient carriers and controls. METHODS Blood samples and BS were obtained from post-menarchal females, including 59 carriers and 57 controls from the same extended pedigree. Factors II, V, VII, VIII, IX, X, antithrombin, tissue factor pathway inhibitor and protein C were assayed to generate mathematical models of TG in response to 5pM tissue factor (TF) and for TF + thrombomodulin. BS was based on a modification of the MCMDM-1VWD scoring system. RESULTS Carriers had a lower mean FIX:C (68% vs. 119%), von Willebrand factor antigen (108 vs.133) and Tissue activatable fibrinolysis inhibitor (103 vs. 111) compared to controls; both groups had a similar mean BS. Carriers demonstrated significantly lower TG parameters on both mathematical models compared to controls. Carriers with FIX:C ≤ 50% had lower TG curves than those >50% but similar BS. CONCLUSION Thrombin generation showed significant differences between carriers and controls, between low (≤50%) and high (>50%) FIX:C carriers, and specifically in the TF + thrombomodulin model, between high FIX:C carriers and controls, although the BS were not different.
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Affiliation(s)
- S Gupta
- Indiana Hemophilia and Thrombosis Center, Indianapolis, IN, United States of America.
| | - M C Bravo
- University of Vermont, Colchester, VT, United States of America.
| | - M Heiman
- Indiana Hemophilia and Thrombosis Center, Indianapolis, IN, United States of America
| | - C Nakar
- Indiana Hemophilia and Thrombosis Center, Indianapolis, IN, United States of America
| | | | - C H Miller
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, United States of America.
| | - A Shapiro
- Indiana Hemophilia and Thrombosis Center, Indianapolis, IN, United States of America
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Abstract
SummaryOur studies involve computational simulations, a reconstructed plasma/platelet proteome, whole blood in vitro and blood exuding from microvascular wounds. All studies indicate that in normal haemostasis, the binding of tissue factor (TF) with plasma factor (F) VIIa (extrinsic FXase complex) results in the initiation phase of the procoagulant response. This phase is negatively regulated by tissue factor pathway inhibitor (TFPI) in combination with antithrombin (AT) and the protein C (PC) pathway. The synergy between these inhibitors provides a threshold-limited reaction in which a stimulus of sufficient magnitude must be provided for continuation of the reaction. With sufficient stimulus, the FXa produced activates some prothrombin. This initial thrombin activates the procofactors and platelets required for presentation of the intrinsic FXase (FVIIIa- FIXa) and prothrombinase (FVa-FXa) complexes which drive the subsequent propagation phase; continuous downregulation of which is provided by AT and the thrombinthrombomodulin- PC complex. FXa generation during the propagation phase is largely (>90%) provided by the intrinsic FXase complex. TF is required for the initiation phase of the reaction but becomes non-essential once the propagation phase has been achieved. The propagation phase catalysts (FVIIIa-FIXa and FVa-FXa) continue to drive the reaction as blood is resupplied to the wound site by flow. Ultimately, the control of the reaction is governed by the pro- and anticoagulant dynamics and the supply of blood reactants to the site of a perforating injury. Our systems have been utilized to examine the qualities of hypothetical and novel antihaemorrhagic and anticoagulation agents and in epidemiologic studies of venous and arterial thrombosis and haemorrhagic pathology.
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Ragni MV, Yabes JG, Fogarty PF, Josephson NC, Kessler CM, Neff AT, Raffini L, Brummel-Ziedins K, Moore CG. Pilot randomized, non-inferiority, cross-over trial of once-weekly vs. three times-weekly recombinant factor VIII prophylaxis in adults with severe haemophilia A. Haemophilia 2016; 23:e43-e46. [PMID: 27943502 DOI: 10.1111/hae.13131] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2016] [Indexed: 11/29/2022]
Affiliation(s)
- M V Ragni
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, USA
| | - J G Yabes
- Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - P F Fogarty
- University of Pennsylvania, Philadelphia, PA, USA
| | | | - C M Kessler
- Georgetown University Medical Center, Washington, DC, USA
| | - A T Neff
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - L Raffini
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - K Brummel-Ziedins
- Department of Biochemistry, University of Vermont, Colchester, VT, USA
| | - C G Moore
- Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA, USA
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Ragni MV, DiMichele DM, Hay CM, Malec LM, Seaman CD, Li J, Yabes JG, Butenas S, Brummel-Ziedins K. Thrombin generation and bleeding in haemophilia inhibitor patients during immune tolerance induction. Haemophilia 2015; 22:240-247. [PMID: 26517283 DOI: 10.1111/hae.12830] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 09/09/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Inhibitor formation complicates haemophilia treatment and requires immune tolerance induction to rid inhibitors over 5 BU. In the prospective, randomized International Immune Tolerance Study, immune tolerance induction was equally effective with high-dose (HD) (200 IU kg-1 day-1 ) and low-dose (LD) (50 IU kg-1 3× per week) factor VIII, but haemorrhages were twofold higher in the LD arm. This finding was unexpected as inhibitors neutralize FVIII activity. We hypothesized that the thrombin generation assay (TGA), a global measure of clot formation, might predict bleeding better than FVIII levels. METHODS We evaluated TGA using relipidated tissue factor (TF) on 83 thawed, recalcified corn trypsin inhibitor/citrate plasma samples from 31 subjects (17 HD, 14 LD) who participated on the ITI study, and who had sufficient sample available and appropriate informed consent. RESULTS There were no significant differences in peak thrombin, estimated thrombin potential, maximum rate or lag time between HD and LD arms; between pre-, during and post-ITI time points, or after FVIII spiking. In 19 subjects (12 HD, 7 LD) with anti-FVIII<1.0 BU, the prevalence of non-neutralizing antibody (NNA) and neutralizing antibody (NA) was 89.5% (17/19), and the latter strongly correlated with anti-VIII titer, r = 0.73 [95% CI: 0.55, 0.88]. CONCLUSION In haemophilia inhibitor patients, thrombin generation is present, but does not predict bleeding risk. Following tolerance induction, NNA remains detectable in the majority.
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Affiliation(s)
- M V Ragni
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, USA
| | - D M DiMichele
- Division of Blood Diseases and Resources, National Heart Blood Lung Institute, Bethesda, MD, USA
| | - C M Hay
- Department of Hematology, Manchester University Royal Infirmary, Manchester, UK
| | - L M Malec
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - C D Seaman
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, USA
| | - J Li
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - J G Yabes
- Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - S Butenas
- Department of Biochemistry, University of Vermont, Colchester, VT, USA
| | - K Brummel-Ziedins
- Department of Biochemistry, University of Vermont, Colchester, VT, USA
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Undas A, Brummel-Ziedins K, Mann KG. Why does aspirin decrease the risk of venous thromboembolism? On old and novel antithrombotic effects of acetyl salicylic acid. J Thromb Haemost 2014; 12:1776-87. [PMID: 25213262 DOI: 10.1111/jth.12728] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 09/05/2014] [Indexed: 01/15/2023]
Abstract
It is well established that aspirin, an irreversible inhibitor of platelet cyclooxygenase activity, is effective in secondary prevention of arterial thromboembolic events. The pooled results of the recent randomized, multicenter WARFASA and ASPIRE aspirin trials showed a 32% reduction in the rate of recurrence of venous thromboembolism (VTE) in patients receiving aspirin following VTE. These clinical data support evidence that platelets contribute to the initiation and progression of venous thrombosis and aspirin inhibits thrombin formation and thrombin-mediated coagulant reactions. In addition to the known acetylation of serine 529 residue in platelet cyclooxygenase-1, the postulated mechanisms of aspirin-induced antithrombotic actions also involve the acetylation of other proteins in blood coagulation, including fibrinogen, resulting in more efficient fibrinolysis. This review summarizes current knowledge on the aspirin-induced antithrombotic effects that potentially explain clinical studies showing reduced rates of VTE events in aspirin-treated subjects.
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Affiliation(s)
- A Undas
- Institute of Cardiology, Jagiellonian University, Krakow, Poland
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Abstract
Computational models can offer an integrated view of blood clotting dynamics and may ultimately be instructive regarding an individual's risk of bleeding or clotting. Appropriately, developed and validated models could allow clinicians to simulate the outcomes of therapeutics and estimate risk of disease. Computational models that describe the dynamics of thrombin generation have been developed and have been used in combination with empirical studies to understand thrombin dynamics on a mechanistic basis. The translation of an individual's specific coagulation factor composition data using these models into an integrated assessment of hemostatic status may provide a route for advancing the long-term goal of individualized medicine. This review details the integrated approaches to understanding: (i) What is normal thrombin generation in individuals? (ii) What is the effect of normal range plasma composition variation on thrombin generation in pathologic states? (iii) Can disease progression or anticoagulation be followed by understanding the boundaries of normal thrombin generation defined by plasma composition? (iv) What are the controversies and limitations of current computational approaches? Progress in these areas can bring us closer to developing models that can be used to aid in identifying hemostatic risk.
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Affiliation(s)
- K Brummel-Ziedins
- Colchester Research Facility, University of Vermont, Colchester, VT 05446, USA.
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Mann KG, Orfeo T, Butenas S, Undas A, Brummel-Ziedins K. Blood coagulation dynamics in haemostasis. Hamostaseologie 2009; 29:7-16. [PMID: 19151839 PMCID: PMC3152749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
Our studies involve computational simulations, a reconstructed plasma/platelet proteome, whole blood in vitro and blood exuding from microvascular wounds. All studies indicate that in normal haemostasis, the binding of tissue factor (TF) with plasma factor (F) VIIa (extrinsic FXase complex) results in the initiation phase of the procoagulant response. This phase is negatively regulated by tissue factor pathway inhibitor (TFPI) in combination with antithrombin (AT) and the protein C (PC) pathway. The synergy between these inhibitors provides a threshold-limited reaction in which a stimulus of sufficient magnitude must be provided for continuation of the reaction. With sufficient stimulus, the FXa produced activates some prothrombin. This initial thrombin activates the procofactors and platelets required for presentation of the intrinsic FXase (FVIIIa-FIXa) and prothrombinase (FVa-FXa) complexes which drive the subsequent propagation phase; continuous downregulation of which is provided by AT and the thrombin-thrombomodulin-PC complex. FXa generation during the propagation phase is largely (>90%) provided by the intrinsic FXase complex. TF is required for the initiation phase of the reaction but becomes non-essential once the propagation phase has been achieved. The propagation phase catalysts (FVIIIa-FIXa and FVa-FXa) continue to drive the reaction as blood is resupplied to the wound site by flow. Ultimately, the control of the reaction is governed by the pro- and anticoagulant dynamics and the supply of blood reactants to the site of a perforating injury. Our systems have been utilized to examine the qualities of hypothetical and novel antihaemorrhagic and anticoagulation agents and in epidemiologic studies of venous and arterial thrombosis and haemorrhagic pathology.
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Affiliation(s)
- K G Mann
- University of Vermont, Department of Biochemistry, Burlington, VT, USA.
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Brummel-Ziedins K, Undas A, Orfeo T, Gissel M, Butenas S, Zmudka K, Mann KG. Thrombin generation in acute coronary syndrome and stable coronary artery disease: dependence on plasma factor composition. J Thromb Haemost 2008; 6:104-10. [PMID: 17944993 DOI: 10.1111/j.1538-7836.2007.02799.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Acute coronary syndrome (ACS) is associated with thrombin formation, triggered by ruptured or eroded coronary atheroma. We investigated whether thrombin generation based on circulating coagulation protein levels, could distinguish between acute and stable coronary artery disease (CAD). METHODS AND RESULTS Plasma coagulation factor (F) compositions from 28 patients with ACS were obtained after onset of chest pain. Similar data were obtained from 25 age- and sex-matched patients with stable CAD. All individuals took aspirin. Patients on anticoagulant therapy were excluded. The groups were similar in demographic characteristics, comorbidities and concomitant treatment. Using each individual's coagulation protein composition, tissue factor (TF) initiated thrombin generation was assessed both computationally and empirically. TF pathway inhibitor (TFPI), antithrombin (AT), factor II (FII) and FVIII differed significantly (P < 0.01) between the groups, with levels of FII, FVIII and TFPI higher and AT lower in ACS patients. When thrombin generation profiles from individuals in each group were compared, simulated maximum thrombin levels (P < 0.01) and rates (P < 0.01) were 50% higher with ACS while the initiation phases of thrombin generation were shorter. Empirical reconstructions of the populations reproduced the thrombin generation profiles generated by the computational model. The differences between the thrombin generation profiles for each population were primarily dependent upon the collective contribution of AT, FII and FVIII. CONCLUSION Simulations of thrombin formation based on plasma composition can discriminate between acute and stable CAD.
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Brummel-Ziedins K, Undas A, Orfeo T, Gissel M, Butenas S, Zmudka K, Mann K. THROMBIN GENERATION PROFILES IN PATIENTS WITH ACUTE CORONARY SYNDROME AND STABLE CORONARY ARTERY DISEASE: A COMPUTATIONAL ANALYSIS. J Thromb Haemost 2007. [DOI: 10.1111/j.1538-7836.2007.tb03233.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
In this review, the complexity arising from the heterogeneity of the human hemostatic proteome is introduced and discussed with respect to impact on the diagnosis, prophylaxis and therapeutic interventions in thrombotic and hemorrhagic diseases. In the 'healthy' population, coagulation factor levels extend over a 2-4-fold range in concentration. In addition, the qualitative performance of these proteins is governed by many molecular events which are influenced both by genetic instructions which influence post-translational modification and by environmental processes that alter coagulation proteins during circulation. As a consequence, the stimulus-response coupling which follows tissue factor presentation to blood and the subsequent expression of thrombin activity is highly variable even in the 'normal' population. The consequences of this molecular heterogeneity and its potential influence on the diagnosis, prophylaxis and ultimate therapy of coagulation diseases are illustrated. It is the intention of the authors to be provocative; encouraging further investigations to understand the clinical significance of the heterogeneity of the human hemostatic proteome.
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Affiliation(s)
- K G Mann
- Department of Biochemistry, University of Vermont, College of Medicine, Burlington, VT 05405, USA.
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