Abstract
Understanding the coagulation process is critical to developing treatments for trauma and coagulopathies. Clinical studies on tranexamic acid (TXA) have resulted in mixed reports on its efficacy in improving outcomes in trauma patients. The largest study, CRASH-2, reported that TXA improved outcomes in patients who received treatment prior to 3 hours after the injury, but worsened outcomes in patients who received treatment after 3 hours. No consensus has been reached about the mechanism behind the duality of these results. In this paper we use a computational model for coagulation and fibrinolysis to propose that deficiencies or depletions of key anti-fibrinolytic proteins, specifically antiplasmin, a1-antitrypsin and a2-macroglobulin, can lead to worsened outcomes through urokinase-mediated hyperfibrinolysis.
Highlights
Severe trauma often induces a coagulopathic state known as Acute Traumatic Coagulopathy (ATC) that manifests in increased bleeding and resultant mortality [1]
We found that additional plasmin inhibitors such as α1-antitrypsin(A1AT) and α2-macroglobulin(A2M), two proteins not often associated with fibrinolysis, play a critical role in preventing tranexamic acid (TXA)-induced hyperfibrinolysis
Computational model of TXA on uPA mediated fibrinolysis shown) as expected since the interactions between TXA and tPA are straightforward and well established. These results show that the bulk of the model, with the exception of the uPA pathway of fibrinolysis, is in agreement with empirical data
Summary
Severe trauma often induces a coagulopathic state known as Acute Traumatic Coagulopathy (ATC) that manifests in increased bleeding and resultant mortality [1]. Tranexamic acid (TXA), has been found to be often effective [3, 4]. There are unknown circumstances in which the treatment has been reported to worsen the condition, with increased bleeding and mortality. The risk of worsening the situation is one of the main reasons why many health care organizations are hesitant to incorporate TXA into their trauma protocol. Developing a mechanistic understanding of how TXA can produce such contrasting results is necessary for widespread adoption of the treatment
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