General Review of Hemostasis FibrinolGeneral Review of Hemostasis Fibrinolysis and Thrombosisysis and Thrombosis

高志平高志平

台北榮總台北榮總血液腫瘤科血液腫瘤科

Von Willebrand DiseaseVon Willebrand Disease

vWF: vWF: enhance production of FVIII enhance production of FVIII

protect FVIIIprotect FVIII binding platelet (GPIb/IX) abinding platelet (GPIb/IX) a

nd collagen in subendotheliund collagen in subendotheliumm

vWDvWD FVIII: low, prolonged aPTT FVIII: low, prolonged aPTT BT: prolongedBT: prolonged RIPA, ristocetin cofactorRIPA, ristocetin cofactor Mild bleeding tendencyMild bleeding tendency

Blood, Hadin et al, eds, 2003

Hematology, Hoffman et al, eds,2005

Laboratory Assays for vWDLaboratory Assays for vWD DiagnosisDiagnosis

vWF AgvWF Ag vWF activity: ristocetin cofactorvWF activity: ristocetin cofactor FVIII activity (moderate and severe vWD)FVIII activity (moderate and severe vWD) BT (moderate and severe vWD)BT (moderate and severe vWD) aPTT: too insensitiveaPTT: too insensitive Molecular diagnosis: type II, exon 28Molecular diagnosis: type II, exon 28

ClassificationClassification RIPARIPA vWF multimersvWF multimers

Management of vWDManagement of vWD

ReassuranceReassurance CryoprecipitateCryoprecipitate DDAVPDDAVP FVIIIFVIII vWF productvWF product

Extrinsic pathway Prothrombin time: adding tissue factor, Ca++

aPTT: activated partial thromboplastin time Partial thromboplastin: phospholipid, Ca++, lacking tissue factor

TFPI: tissue factor pathway inhibitorTFPI: tissue factor pathway inhibitorHemostasis and Thrombosis 2005

CoagulationCoagulation Tissue factor initiate blood coagulationTissue factor initiate blood coagulation

TF express in adventitial cells, vascular smooth mTF express in adventitial cells, vascular smooth muscle cells, epidermal cells, neurogliauscle cells, epidermal cells, neuroglia

TF express in monocytes and endothelium after acTF express in monocytes and endothelium after activationtivation

Amplification of the initial stimulus Amplification of the initial stimulus FVIIa activate FIXFVIIa activate FIX FIIa (thrombin) can activate XI, V, VIIIFIIa (thrombin) can activate XI, V, VIII

Feedback inhibition of the procoagulant systFeedback inhibition of the procoagulant systemem TFPI: tissue factor pathway inhibitor TFPI: tissue factor pathway inhibitor AT, PC, PS, EPCRAT, PC, PS, EPCR

Thrombin can Thrombin can activateactivate

FibrinogenFibrinogen FXIFXI FVFV FVIIIFVIII FXIIIFXIII Protein C (after binding thrombomodulin)Protein C (after binding thrombomodulin) TAFI (thrombin-activatable fibrinolysis inhiTAFI (thrombin-activatable fibrinolysis inhi

bitor)bitor)

Factors synthesized in Factors synthesized in endothelial cellsendothelial cells

vWFvWF ThrombomodulinThrombomodulin EPCR (endothelial protein C receptor)EPCR (endothelial protein C receptor) Protein SProtein S TFPITFPI tPAtPA PAI-1PAI-1 PGI2 (prostacyclin), NO (EDRF), CD39, ET-1PGI2 (prostacyclin), NO (EDRF), CD39, ET-1

Common Causes of Prolonged PTCommon Causes of Prolonged PT

Deficiencies of FVII, X, V, II, fibrinogenDeficiencies of FVII, X, V, II, fibrinogen Elevated FDPElevated FDP Heparin of high conc.Heparin of high conc. CoumadinCoumadin Lupus anticoagulant occasionally Lupus anticoagulant occasionally Inhibitors of clotting factorsInhibitors of clotting factors

Vitamin K-dependent Vitamin K-dependent coagulation factors and coagulation factors and anticoagulantsanticoagulants

Factors II, VII, IX, XFactors II, VII, IX, X Protein C, SProtein C, S Protein Z (anti-XaProtein Z (anti-Xa

(Not AT, Not TFPI, Not TAFI)(Not AT, Not TFPI, Not TAFI)

Hematology, Hoffman et al, eds,2005

SuperwarfarinSuperwarfarin

Long-actingLong-acting Need high dose vitamin KNeed high dose vitamin K Potentially lethalPotentially lethal

Common Causes of Prolonged aPTCommon Causes of Prolonged aPTTT

Clotting factor deficiencies other than FVIIClotting factor deficiencies other than FVII Lupus anticoagulant Lupus anticoagulant Inhibitors of clotting factorsInhibitors of clotting factors Elevated FDPElevated FDP Heparin, coumadinHeparin, coumadin

Interpretation of Mixed aPTTInterpretation of Mixed aPTT

Definition of “correctable”: Definition of “correctable”:

mixed aPTT – C : < 3-5” mixed aPTT – C : < 3-5” Inhibitior with time-dependence after incubInhibitior with time-dependence after incub

ationation

Mixinf aPTTMixinf aPTT

P: 60.5P: 60.5 C: 28.5 C: 28.5 Mixed: 31.0Mixed: 31.0 (o hr)(o hr) P: 64.5P: 64.5 C: 32.5 C: 32.5 Mixed: 34.0Mixed: 34.0 (2 hr)(2 hr)

P: 60.5P: 60.5 C: 28.5 C: 28.5 Mixed: 56.0Mixed: 56.0 (o hr)(o hr) P: 64.5P: 64.5 C: 32.5 C: 32.5 Mixed: 60.0Mixed: 60.0 (2 hr)(2 hr)

P: 60.5P: 60.5 C: 28.5 C: 28.5 Mixed: 31.0Mixed: 31.0 (o hr)(o hr) P: 64.5P: 64.5 C: 32.5 C: 32.5 Mixed: 63.0Mixed: 63.0 (2 hr)(2 hr)

FVIII inhibitorFVIII inhibitor

P: 60.5P: 60.5 C: 28.5 Mixed: 34.0 C: 28.5 Mixed: 34.0 (o hr)(o hr) P: 64.5P: 64.5 C: 32.5 C: 32.5 Mixed: 60.0 Mixed: 60.0 (2 hr)(2 hr) PNT : negative PNT : negative FVIII inhibitor assay: 5 Bethesda unitFVIII inhibitor assay: 5 Bethesda unit FVIIIFVIII 5 %5 % FIXFIX 90 %90 % FVIIFVII 110 %110 %

Lupus anticoagulantLupus anticoagulant

P: 60.5P: 60.5 C: 28.5 Mixed: 54.0 C: 28.5 Mixed: 54.0 (o hr)(o hr) P: 64.5P: 64.5 C: 32.5 C: 32.5 Mixed: 60.0 Mixed: 60.0 (2 hr)(2 hr) PNT : + PNT : + FVIII inhibitor assay: negativeFVIII inhibitor assay: negative FVIIIFVIII 90 %90 % FIXFIX 90 %90 % FVIIFVII 110 %110 %

Antiphospholipid syndromeAntiphospholipid syndrome Anticardiolipin antibodiesAnticardiolipin antibodies Lupus anticoagulantLupus anticoagulant

Antigen specificity: majority Antigen specificity: majority 2-GPI, prothrombin2-GPI, prothrombin Protein cofactorProtein cofactor Syphilis: not dependent on protein cofactor Syphilis: not dependent on protein cofactor

Mechanisms of thrombosisMechanisms of thrombosis Disruption of annexin A5 shieldDisruption of annexin A5 shield Interference protein C pathwayInterference protein C pathway Injury to endotheliumInjury to endothelium ……………………. ?. ?

Blood 1999;93:2153

Blood 1999;93:2153

Hematology Hoffman et al, eds, 2005

Causes of bleeding in Causes of bleeding in APSAPS

HypoprothrombinemiaHypoprothrombinemia Severe thrombocytopeniaSevere thrombocytopenia Acquired platelet dysfunction Acquired platelet dysfunction Acquired inhibitor to specific coagAcquired inhibitor to specific coag

ulation factor, e.g. anti-FVIIIulation factor, e.g. anti-FVIII

Lupus anticoagulant with low levels Lupus anticoagulant with low levels of cogaulation factor activityof cogaulation factor activity

P: 60.5P: 60.5 C: 28.5 Mixed: 56.0 C: 28.5 Mixed: 56.0 (o hr)(o hr) P: 64.5P: 64.5 C: 32.5 C: 32.5 Mixed: 60.0 Mixed: 60.0 (2 hr)(2 hr) PNT: negativePNT: negative FVIII inhibitor : negative FVIII inhibitor : negative FVIIIFVIII 10 %10 % FIXFIX 16 %16 % FVIIFVII 50 %50 %

Lupus anticoagulant with low level oLupus anticoagulant with low level of cogaulation factor activityf cogaulation factor activity

P: 60.5P: 60.5 C: 28.5 Mixed: 56.0 C: 28.5 Mixed: 56.0 (o hr)(o hr) P: 64.5P: 64.5 C: 32.5 C: 32.5 Mixed: 60.0 Mixed: 60.0 (2 hr)(2 hr) PNT: negativePNT: negative FVIII inhibitor : negative FVIII inhibitor : negative FVIIIFVIII 4 %4 % FIXFIX 60%60% FVIIFVII 80 %80 %

FVIII activities in serial dilutionsFVIII activities in serial dilutions

1:101:10 3.5%3.5% 1:401:40 7.6%(1.9% x 4)7.6%(1.9% x 4) 1:80 17.6%(2.2% x 8)1:80 17.6%(2.2% x 8) 1:160 48%% (3.0% x 16)1:160 48%% (3.0% x 16)

TherapyTherapy

No therapy for laboratory No therapy for laboratory abnormality with clinical disorderabnormality with clinical disorder

Anticoagulation for recurrent Anticoagulation for recurrent thrombosisthrombosis

Low dose ASA and heparin for > = Low dose ASA and heparin for > = 3X pregnancy losses3X pregnancy losses

Steroid for refractory casesSteroid for refractory cases

Thrombosis Thrombosis and and

Antithrombotic TherapyAntithrombotic Therapy

Blood, Handin et al, eds, 2003

TTPTTP

Thrombotic Thrombocytopenic Thrombotic Thrombocytopenic PurpuraPurpura

Mealloprotease (ADAMTS 13) Mealloprotease (ADAMTS 13) ultralarge multimers of vWF ultralarge multimers of vWF platelet thrombi platelet thrombi

TTPTTP

Pentad:Pentad: thrombocytopeniathrombocytopenia microangiopathic hemolytic microangiopathic hemolytic

anemiaanemia feverfever renal failurerenal failure fluctuating neurological symptfluctuating neurological sympt

omsoms ManagementManagement

Plasma exchangePlasma exchange ImmunomodulationImmunomodulation

NEJM 2002;347:596

Postgraduate Hematology 2005

Blood, Handin et al, eds, 2003

Serine proteaseSerine protease

Canonical catalytic triadCanonical catalytic triad His 57, Asp 102, Ser 195 by chymotrypsin His 57, Asp 102, Ser 195 by chymotrypsin

numbernumber FII, VII, IX, X, XI FII, VII, IX, X, XI

(NOT FV, FVIII, FXIII, fibrinogen, vWF)(NOT FV, FVIII, FXIII, fibrinogen, vWF) Protein C (NOT protein S, AT)Protein C (NOT protein S, AT) Plaminogen, tPA (NOT PAI-I, TAFI)Plaminogen, tPA (NOT PAI-I, TAFI)

SerpinsSerpins

Serine protease inhibitorSerine protease inhibitor AntithrombinAntithrombin PAI-1, PAI-2PAI-1, PAI-2 PCIPCI Heparin cofactor IIHeparin cofactor II 2-antiplasmin2-antiplasmin

FV Leiden and FV HongKongFV Leiden and FV HongKong

FV Leiden: Arg506GlnFV Leiden: Arg506GlnAPC resistance: APC resistance: APC sensitivity ratioAPC sensitivity ratio

FV HongKong: Arg306GlaFV HongKong: Arg306Glano increased risk of venous thrombosisno increased risk of venous thrombosis

FV Cambridge: Arg306ThrFV Cambridge: Arg306Thr

Hemostasis and Thrombosis, 5th ed, 2006

Postgraduate Hematology 2005

Diagnosis of DVT/PEDiagnosis of DVT/PE

D-dimerD-dimer Venogram: less usedVenogram: less used Doppler, compression ultrasonographyDoppler, compression ultrasonography Spiral CT scan Spiral CT scan Radionucleotide lung scanRadionucleotide lung scan MRIMRI

Management of DVTManagement of DVT

Underlying etiologies (provoked or unprovoked)Underlying etiologies (provoked or unprovoked) Screening for thrombophilia geneticsScreening for thrombophilia genetics Heparin/LMWHHeparin/LMWH CoumadinCoumadin

Contraindication in pregnancyContraindication in pregnancy Delayed effectDelayed effect Variation in dosage Variation in dosage

Thrombolytic agents?Thrombolytic agents?

Hemostasis and Thrombosis, 5th ed, 2006

Postgraduate Hematology 2005

Hematology Hoffman et al, eds, 2005

Hematology Hoffman et al, eds, 2005

Postgraduate Hematology 2005

Management of Coumarin OverdoseManagement of Coumarin Overdose

Risk of bleeding vs risk of thrombosisRisk of bleeding vs risk of thrombosis INR < 6 INR < 6 lower doselower dose INR 6-10INR 6-10 vit K 1-2 mg, PO or SQvit K 1-2 mg, PO or SQ INR > 10INR > 10 vit K 2-4 mg, PO or SQvit K 2-4 mg, PO or SQ Serious bleedingSerious bleeding vit K 5-10 mg IVvit K 5-10 mg IV

FFPFFP

PCCPCC

Williams Hematology 7th ed, 2006

FibrinolysisFibrinolysis

Lysine binding sites in tPA and PLG (plasmiLysine binding sites in tPA and PLG (plasminogen)nogen) Cofactor activity of fibrinCofactor activity of fibrin

tPA vs uPA: need of fibrintPA vs uPA: need of fibrin uPARuPAR Glu-PLG Glu-PLG Lys-PLG Lys-PLG Antifibrinolytic agents: blocking LBS in PLGAntifibrinolytic agents: blocking LBS in PLG Antiplasmin synthesized in liverAntiplasmin synthesized in liver

Blood, Handin et al, eds, 2003

TAFITAFI

Thrombin-activatable fibrinolysis inhibiThrombin-activatable fibrinolysis inhibitor Procarboxypeptidase Btor Procarboxypeptidase B

Removing the carboxy-terminal lysine rRemoving the carboxy-terminal lysine residue of fibrin, which are the binding siesidue of fibrin, which are the binding sites for PLG and tPAtes for PLG and tPA

Reducing cofactor activity of fibrin in PLReducing cofactor activity of fibrin in PLG activationG activation

Blood, Handin et al, eds, 2003