Autosomal recessive deficiencies of coagulation factors

Deficiencies of coagulation factors that cause a bleeding disorder, other than factor VIII and factor IX, are inherited as autosomal recessive traits and are generally rare, with prevalence in the general population varying between 1 in 500 000 and 1 in 2 000 000. In the last few years, the number of patients with recessively transmitted coagulation deficiencies has increased in European countries with a high rate of immigration of Islamic populations where consanguineous marriages are frequent. As a consequence of the relative rarity of these deficiencies, the type and severity of bleeding symptoms, the underlying molecular defects and the actual management of bleeding episodes are not as well established as for hemophilia A and B. This article reviews these disorders, in terms of clinical manifestations and characterization of the molecular defects. The general principles of management are also discussed.     

Liver Transplantation in Man—IV,Haemorrhage and Thrombosis

Blood coagulation and fibrinolytic factors have been measured in 13 patients treated by liver transplantation. During operation intravascular coagulation and fibrinolysis were increased, but seldom to a degree which would cause abnormal bleeding. Measurement of the catabolism of radioactive fibrinogen showed that increased intravascular coagulation continued for long periods after the operation. Despite secondarily increased fibrinolysis, there was a high incidence of thrombosis. Treatment with anticoagulants or with fibrinolysis inhibitors may be valuable in these patients.     

Exploring kinase inhibitors as therapies for human arenavirus infections

Arenaviruses are rodent-borne RNA viruses, and some have the capacity to cause hemorrhagic fever and death in infected individuals and thus have been identified as a potential bioterrorism threat. Ribavirin and supportive care are currently the approved therapeutic options for individuals suffering from arenavirus-induced hemorrhagic fever. However, new research has suggested that immune plasma treatment or kinase inhibitors may provide a therapeutic option for treating arenavirus infections in humans. This article puts forth a perspective as to the potential use of kinase inhibitors as an antiviral therapeutic for arenavirus infections.     

DIAGNOSIS OF HEMORRHAGIC DISEASES—Evaluation of Procedures—Part II Preoperative Tests

Routine preoperative tests such as the determination of bleeding time and coagulation time are unnecessary and are not recommended. Rulings which require routine preoperative tests result in the adoption of inferior and unreliable time-saving methods in the laboratory. If the clinical staff insists that laboratory procedures to predict hemorrhage be performed on every patient scheduled for operation, approved methods of performing the tests should be employed.Preoperative procedures should include a personal and a family history, a careful and complete physical examination and screening laboratory tests such as urinalysis, hematocrit, leukocyte count and smear examination, including estimation of the number of thrombocytes.Special hemorrhagic studies are indicated on selected patients. These selected patients include those who have a history of abnormal bleeding, those who consider themselves “easy bleeders” or who have apprehension concerning hemorrhage at the time of operation, and those who have physical signs of hemorrhage. Special hemorrhagic studies should also be performed on patients who have diseases that are known to be associated with vascular and coagulation abnormalities, infants who have not been subjected to tests of trauma and on patients from whom a reliable history cannot be obtained.Extra precaution should be taken if operation is to be performed in hospitals or clinics that do not have adequate blood banking facilities and if the operation to be performed is one in which difficulty in hemostasis is anticipated.The preoperative tests that are indicated on selected patients should include as a minimum: The thrombocyte count, determination of the bleeding time by the Ivy method, determination of the coagulation time by the multiple tube method and the observation of the clot. Where facilities are available, the hemorrhagic study should also include the plasma and serum prothrombin activity tests.     

Hepatocerebral dysfunction

Routine preoperative tests such as the determination of bleeding time and coagulation time are unnecessary and are not recommended. Rulings which require routine preoperative tests result in the adoption of inferior and unreliable time-saving methods in the laboratory. If the clinical staff insists that laboratory procedures to predict hemorrhage be performed on every patient scheduled for operation, approved methods of performing the tests should be employed. Preoperative procedures should include a personal and a family history, a careful and complete physical examination and screening laboratory tests such as urinalysis, hematocrit, leukocyte count and smear examination, including estimation of the number of thrombocytes. Special hemorrhagic studies are indicated on selected patients. These selected patients include those who have a history of abnormal bleeding, those who consider themselves "easy bleeders" or who have apprehension concerning hemorrhage at the time of operation, and those who have physical signs of hemorrhage. Special hemorrhagic studies should also be performed on patients who have diseases that are known to be associated with vascular and coagulation abnormalities, infants who have not been subjected to tests of trauma and on patients from whom a reliable history cannot be obtained. Extra precaution should be taken if operation is to be performed in hospitals or clinics that do not have adequate blood banking facilities and if the operation to be performed is one in which difficulty in hemostasis is anticipated. THE PREOPERATIVE TESTS THAT ARE INDICATED ON SELECTED PATIENTS SHOULD INCLUDE AS A MINIMUM: The thrombocyte count, determination of the bleeding time by the Ivy method, determination of the coagulation time by the multiple tube method and the observation of the clot. Where facilities are available, the hemorrhagic study should also include the plasma and serum prothrombin activity tests.     

急危重症眼镜蛇伤大鼠多项凝血指标动态变化

目的动态观察蛇伤后大鼠多项凝血指标、病理及皮下出血情况的改变,为蛇毒毒理及抗蛇毒制剂的研究提供实验数据。方法将SD大鼠注入2～4 LD50眼镜蛇毒造模,于注毒后不同时段(20～140 min)分别进行凝血功能、肝脏和肾脏病理等检测,处死大鼠后观察注毒部位皮下出血情况。结果大鼠注入4 LD50蛇毒20 min,凝血酶原时间(PT)、部分凝血酶原时间(APTT)延长;40 min时,纤维蛋白原(Fbg)明显下降;40 min后凝血功能逐渐回复至0 min水平。肾脏、肝脏组织见血管扩张、充血明显。注毒部位皮下出血范围于20～80min时最明显。2 LD50剂量组凝血功能的变化与4 LD50组相似,但其Fbg下降程度小于4 LD50组,皮下出血面积较4 LD50组小。结论眼镜蛇毒引起凝血功能改变,且其变化程度与剂量及注入时间密切相关。     

Sucrose Synthetase of Rice Grains and Potato Tubers

ABSTRACT

Human coagulation factor XII, the initiating factor in the intrinsic coagulation pathway, is critical for pathological thrombosis but not for hemostasis. Pharmacologic inhibition of factor XII is an attractive alternative in providing protection from pathologic thrombus formation while minimizing hemorrhagic risk. Large quantity of recombinant active factor XII is required for screening inhibitors and further research. In the present study, we designed and expressed the recombinant serine protease domain of factor XII in Pichia pastoris strain X-33, which is a eukaryotic expression model organism with low cost. The purification protocol was simplified and the protein yield was high (~20 mg/L medium). The purified serine protease domain of factor XII behaved homogeneously as a monomer, exhibited comparable activity with the human βFXIIa, and accelerated clot formation in human plasma. This study provides the groundwork for factor XII inhibitors screening and further research.     

Laboratory evaluation of a bleeding patient.

Most causes of abnormal bleeding can be determined from a complete blood count including platelet count and bleeding, prothrombin, activated partial thromboplastin, and thrombin times. Occasionally, further evaluation is necessary, such as tests of factor XIII function, fibrinolysis, and vascular integrity. Possible diagnoses include disseminated intravascular coagulation, thrombotic thrombocytopenic purpura, vitamin K deficiency, von Willebrand''s disease, heparin-induced thrombocytopenia, acquired inhibitors of factor VIII, lupus anticoagulants, and coagulation disorders related to the acquired immunodeficiency syndrome.     

Clinical disorders of fibrinolysis: a critical review

Much progress has recently been made in understanding the biochemistry and physiology of endogenous fibrinolysis. As a result, a better understanding of the mechanisms and clinical consequences of disordered fibrinolysis has emerged. Increased fibrinolytic activity is an uncommon but important cause of hemorrhagic disease. Congenital disorders of fibrinolysis which cause bleeding include increased plasma plasminogen activator activity and deficiency of alpha-2 antiplasmin. Acquired disorders associated with increased fibrinolytic activity and bleeding include liver cirrhosis, amyloidosis, acute promyelocytic leukemia, some solid tumors, and certain snake envenomation syndromes. Increased fibrinolysis is important to recognize because epsilon-aminocaproic acid (EACA) may be required to prevent or control bleeding. Diminished fibrinolytic activity has been associated with a variety of thrombotic disorders, but a direct cause-and-effect relationship has yet to be established. Congenital abnormalities of fibrinolysis associated with thrombosis include plasminogen deficiency, decreased endothelial generation of plasminogen activator activity, and certain abnormal fibrinogens. Thrombosis in these disorders is effectively managed with warfarin. Diminished fibrinolysis has also been reported in "idiopathic" venous thrombosis, oral contraceptive-induced and post-operative venous thrombosis, coronary artery disease, cerebrovascular disease, systemic lupus erythematosus, and thrombotic thrombocytopenic purpura, but the significance of abnormal fibrinolysis in these disorders is uncertain. Large, prospective studies of fibrinolytic variables as risk factors for vascular and thrombotic disease are needed to determine whether pharmacologic augmentation of impaired fibrinolysis could be useful in the prevention or treatment of these disorders.     

A small group of sulfated benzofurans induces steady-state submaximal inhibition of thrombin

Despite the development of promising direct oral anticoagulants, which are all orthosteric inhibitors, a sizable number of patients suffer from bleeding complications. We have hypothesized that allosterism based on the heparin-binding exosites presents a major opportunity to induce sub-maximal inhibition of coagulation proteases, thereby avoiding/reducing bleeding risk. We present the design of a group of sulfated benzofuran dimers that display heparin-binding site-dependent partial allosteric inhibition of thrombin against fibrinogen (ΔY?=?55–75%), the first time that a small molecule (MW??<?800) has been found to thwart macromolecular cleavage by a monomeric protease in a controlled manner. The work leads to the promising concept that it should be possible to develop allosteric inhibitors that reduce clotting, but do not completely eliminate it, thereby avoiding major bleeding complications that beset anticoagulants today.     

凝血因子Ⅶ及其重组表达新进展

凝血因子Ⅶ是一种维生素K依赖型的单链糖蛋白,在凝血过程中发挥着极其重要的作用,在临床上有广泛的应用,可用于伴有抑制物的血友病、先天性FⅦ缺乏症、血小板无力症及外科手术或严重外伤导致的创伤出血等止血用途.基因重组技术提供了能够大规模制备人凝血因子Ⅶ的有效途径,近年来已尝试并建立了多种人凝血因子Ⅶ的重组表达系统.对重组人凝...     

Thrombin Generation in Zebrafish Blood

To better understand hypercoagulability as an underlying cause for thrombosis, the leading cause of death in the Western world, new assays to study ex vivo coagulation are essential. The zebrafish is generally accepted as a good model for human hemostasis and thrombosis, as the hemostatic system proved to be similar to that in man. Their small size however, has been a hurdle for more widespread use in hemostasis related research. In this study we developed a method that enables the measurement of thrombin generation in a single drop of non-anticoagulated zebrafish blood. Pre-treatment of the fish with inhibitors of FXa and thrombin, resulted in a dose dependent diminishing of thrombin generation, demonstrating the validity of the assay. In order to establish the relationship between whole blood thrombin generation and fibrin formation, we visualized the resulting fibrin network by scanning electron microscopy. Taken together, in this study we developed a fast and reliable method to measure thrombin generation in whole blood collected from a single zebrafish. Given the similarities between coagulation pathways of zebrafish and mammals, zebrafish may be an ideal animal model to determine the effect of novel therapeutics on thrombin generation. Additionally, because of the ease with which gene functions can be silenced, zebrafish may serve as a model organism for mechanistical research in thrombosis and hemostasis.     

Snake venom proteases affecting hemostasis and thrombosis

The structure and function of snake venom proteases are briefly reviewed by putting the focus on their effects on hemostasis and thrombosis and comparing with their mammalian counterparts. Up to date, more than 150 different proteases have been isolated and about one third of them structurally characterized. Those proteases are classified into serine proteases and metalloproteinases. A number of the serine proteases show fibrin(ogen)olytic (thrombin-like) activities, which are not susceptible to hirudin or heparin and perhaps to most endogenous serine protease inhibitors, and form abnormal fibrin clots. Some of them have kininogenase (kallikrein-like) activity releasing hypotensive bradykinin. A few venom serine proteases specifically activate coagulation factor V, protein C, plasminogen or platelets. The venom metalloproteinases, belonging to the metzincin family, generally show fibrin(ogen)olytic and extracellular matrix-degrading (hemorrhagic) activities. A few venom metalloproteinases show a unique substrate specificity toward coagulation factor X, platelet membrane receptors or von Willebrand factor. A number of the metalloproteinases have chimeric structures composed of several domains such as proteinase, disintegrin-like, Cys-rich and lectin-like domains. The disintegrin-like domain seems to facilitate the action of those metalloproteinases by interacting with platelet receptors. A more detailed analysis of snake venom proteases should find their usefulness for the medical and pharmacological applications in the field of thrombosis and hemostasis.     

Enzyme-linked coagulation assay: a clot-based, solid-phase assay for thrombin

A new, solid-phase microtiter plate assay for thrombin has been developed, using fibrinogen bound to wells of a microtiter plate and peroxidase-fibrinogen in solution as an indicator system. When small amounts of thrombin are added to the mixture, peroxidase-fibrin and plate-bound fibrin are formed, and the peroxidase-fibrin binds to the plate-bound fibrin. The amount of peroxidase-fibrin binding is proportional to the thrombin concentration and time of incubation. Using this assay, thrombin was measured at concentrations as low as 0.25 ng/ml (0.006 nM) in 150 microliter of sample. In the presence of the specific inhibitors benzamidine and D-phenylalanyl-L-prolyl-L-arginine chloromethyl ketone, the thrombin activity is reduced, at relative concentrations of inhibitors consistent with their affinities and mechanisms of action. The enzyme-linked coagulation assay is generally useful as a highly sensitive and convenient alternative to conventional "clot-based" tests of coagulation.     

Identification and quantification of prosthetic mitral regurgitation by flow convergence method using transthoracic approach

Ultrasound is the preferred imaging modality in diagnosis of vascular complications following cardiac catheterization and intervention. In some cases, however, bleeding surrounding the femoral vessels, may severely distort the color Doppler images, making detection of venous complications especially difficult. This report refers to such a case where post-catheterization haematoma was suspected to cause an obstruction of the femoral vein. Spectral Doppler recordings of blood flow in the common femoral vein, up-stream, distal to the hemorrhagic area, confirmed the diagnosis of obstruction by demonstrating changes in the venous flow pattern in the common femoral vein, consistent with venous hypertension. Due to the poor quality of the ultrasound images, the exact cause of the obstruction had to be established by another imaging modality, not affected by haemorrhages. CT showed that the common femoral vein was compressed at the puncture site by surrounding haemorrhages. Thus, when bleeding due to cardiac catheterization is associated with possible venous obstruction and findings by color Doppler are equivocal due to degradation of the color-Doppler image, detection of venous hypertension by spectral Doppler, performed distal to the bleeding area, strongly supports the presence of venous obstruction where the exact cause may be established by CT.     

Coagulopathy after snake bite by Bothrops neuwiedi: case report and results of in vitro experiments

Coagulation studies were performed in a patient who had been bitten by a snake of the species Bothrops neuwiedi. The patient presented with hemorrhagic necrosis at the envenomization site and considerable bleeding from venous puncture sites. He developed a severe defibrination syndrome with a clottable fibrinogen level of approximately 0.1 g/l. Fibrinogen was not measurable by clotting time assay. Fibrin degradation products were greatly elevated. Treatment with antivenom caused an anaphylactic reaction within ten minutes and serum sickness after three days. In vitro experiments revealed that B. neuwiedi venom directly activates Factors II and X, but does not activate Factor XIII. In vivo consumption of Factor XIII after B. neuwiedi envenomization is ascribed to the action of Factor IIa. At low venom concentrations clotting is initiated by activation of prothrombin by the venom either directly or via Factor X activation. Treatment with heparin might be beneficial in coagulopathy secondary to snake bite by reducing circulating active thrombin. The venom contains thrombin-like proteases which cause slow clotting of fibrinogen, and plasmin-like components causing further proteolysis of fibrinogen and fibrin. Antivenom has no effect on the proteolytic action of the snake venom. The in vivo effects of antivenom are presumably caused by acceleration of the elimination of venom components from the circulation. Intravenous administration of antivenom caused normalization of blood coagulation parameters within 48 h.     

Effects of compounds from Passiflora edulis Sims f. flavicarpa juice on blood coagulation and on proteolytic enzymes

Passion fruit (Passiflora edulis Sims f. flavicarpa) is popularly known for its sedative and calming properties and is consumed as a fresh fruit or as a juice. The clinical observation of blood incoagulability associated with excessive consumption of passion fruit juice, in a patient treated with warfarin, prompted the current study to investigate in vitro the presence of blood clotting inhibitors in Passiflora edulis Sims f. flavicarpa extract. After purification process, two compounds of distinct molecular weight and inhibitory action were better characterized. One is a trypsin inhibitor similar to inhibitors from Bowman-Birk family, named PeTI-I12, and other is a compound active in coagulation that prolongs aPTT and PT, but does not change TT. The aim of this study is to provide evidence that passion fruit extract's components play a role on hemostasis and therefore may be relevant in the handling of patients treated with anticoagulants or suffering hemorrhagic diseases.     

蜱源抗凝血因子研究进展

蜱是一种人畜共患体表寄生虫,通过叮咬宿主和吸血,将病原体传播给宿主,引发多种疾病。凝血反应是人和动物的重要生理过程,是生理性止血的重要环节。蜱叮咬和吸食宿主血液周期长,在吸血过程中分泌多种抗凝物质,抑制凝血反应,可帮助蜱长时间保持吸血状态。目前,已知的蜱源抗凝物质依据其功能主要包括蛋白酶抑制剂、纤维蛋白(原)溶解剂、血小板聚集抑制剂和血管活性蛋白4大类。这些抗凝血物质可分别作用于凝血级联反应中内源性通路、外源性通路、共同通路中的关键步骤,以及促进纤蛋白溶解和抑制血小板激活,从而抑制宿主血管中的凝血反应。蛋白酶抑制剂主要通过抑制凝血级联反应共同通路中凝血酶和Xa因子活性;纤维蛋白(原)溶解剂引起纤维蛋白原的水解并延迟纤维蛋白凝块的形成;血小板聚集抑制剂通过降解血小板聚集激动剂,并结合血栓素A2(thromboxane A2, TXA2)和血小板上的αIIbβ3整合素抑制血小板聚集;血管活性蛋白抑制宿主血管收缩以及伤口愈合和血管生成。此外,还有一些蜱分泌的其他蛋白分子可通过不同的通路来实现抗凝血作用。本文对迄今为止各类蜱中发现的具有抗凝血活性的蛋白和小分子及其抗凝血作用机制进行总结阐述,将...     

Crimean-Congo hemorrhagic fever virus

Crimean-Congo hemorrhagic fever virus (CCHFV) is an important human pathogen, which is the cause of a tick-borne illness occurring in many areas of Africa, Asia, and Europe. CCHF is characterized by a sudden onset of high fever, chills, and severe headache. Other symptoms can include gastrointestinal disorders, such as nausea, vomiting, and diarrhea. In severe cases, hemorrhagic manifestations can occur and often present as large areas of ecchymosis, rather than frank bleeding. Exposure to ticks, particularly those in the genus Hyalomma, or direct contact with virus-infected animals or people are considered the major risk factors. Studies on CCHFV are impeded by the biocontainment needed for their manipulation. However, the increasing worldwide medical awareness, the enormous interest of the media in hemorrhagic fever diseases, and their potential to be used as a bioweapon, have greatly spurred on research on this important virus, as evidenced by many new developments including the development of a reverse genetics system which should greatly enhance future research with this virus.     

Thrombin-like serine protease,antiquorin from Euphorbia antiquorum latex induces platelet aggregation via PAR1-Akt/p38 signaling axis

Plant latex proteases (PLPs) are pharmacologically essential and are integral components of traditional medicine in the management of bleeding wounds. PLPs are known to promote blood coagulation and stop bleeding by interfering at various stages of hemostasis. There are a handful of scientific reports on thrombin-like enzymes characterized from plant latices. However, the role of plant latex thrombin-like enzymes in platelet aggregation is not well known. In the present study, we attempted to purify and characterize thrombin-like protease responsible for platelet aggregation. Among tested plant latices, Euphorbia genus latex protease fractions (LPFs) induced platelet aggregation. In Euphorbia genus, E. antiquorum LPF (EaLPF) strongly induced platelet aggregation and attenuated bleeding in mice. The purified thrombin-like serine protease, antiquorin (Aqn) is a glycoprotein with platelet aggregating activities that interfere in intrinsic and common pathways of blood coagulation cascade and alleviates bleeding and enhanced excision wound healing in mice. In continuation, the pharmacological inhibitor of PAR1 inhibited Aqn-induced phosphorylation of cPLA₂, Akt, and P38 in human platelets. Moreover, Aqn-induced platelet aggregation was inhibited by pharmacological inhibitors of PAR1, PI3K, and P38. These data indicate that PAR1-Akt/P38 signaling pathways are involved in Aqn-induced platelet aggregation. The findings of the present study may open up a new avenue for exploiting Aqn in the treatment of bleeding wounds.