Fibrinolytic Parameters Research Articles

Comprehensive coagulation and fibrinolytic potential in the acute phase of pediatric patients with idiopathic nephrotic syndrome evaluated by whole blood-based rotational thromboelastometry.

BackgroundVenous thromboembolism is a rare, serious complication of idiopathic nephrotic syndrome (INS) in childhood. The mechanisms responsible for the hypercoagulable state in the acute phase of INS are poorly understood, however. This study aimed to assess overall coagulation and fibrinolytic function in pediatric patients with INS.MethodsGlobal coagulation and fibrinolysis were examined in whole blood samples from 22 children with initial onset INS (initial-group), 22 children with relapsed INS (relapse-group), and 15 control pediatric patients using rotational thromboelastometry (ROTEM®). In the initial-group, blood samples were obtained before (week 0) and 1–4 weeks after initiation of corticosteroid therapy. EXTEM and FIBTEM were used to assess coagulation and fibrinolysis, respectively. Clot time (CT), clot formation time (CFT), maximum clot firmness (MCF), and α-angle were determined as coagulation parameters, and lysis index at 30 and 60 min (LI30 and LI60, respectively) were assessed as fibrinolytic parameters.ResultsCT was significantly shortened, and MCF and α-angle were significantly greater than controls at week 0 and week 1 both in the initial-group and the relapse-group. MCF correlated with serum albumin (r = 0.70, p < 0.001) and fibrinogen level (r = 0.68, p < 0.001). The fibrinolytic parameters (LI30 and LI60) in the initial-group were stable and higher than those in controls at all time points (p < 0.01).ConclusionsWe have shown that the hypofibrinolytic defect did not improve with effective NS treatment at the early 4-week time-point. Additionally, a likely pre-thrombotic state was evident in the period before initial onset and 1 week after corticosteroid therapy in pediatric INS.

Imbalance of the hemocoagulation and fibrinolysis systems under conditions of diabetes mellitus complicated by acute circulatory disturbance in the pool of carotid arteries of rats

Introduction. Both cerebral ischemia and diabetes mellitus (DM) are evidenced to be associated with hypercoagulation state, though today the facts concerning hemocoagulation condition with diabetes mellitus complicated by cerebral ischemia-reperfusion are lacking. &#x0D; The aim of the study. To examine the dynamics of interrelations between the pro-, anticoagulant and fibrinolytic parameters in rats with diabetes mellitus complicated by acute cerebral circulatory disturbance. &#x0D; Results. At the early ischemic-reperfusion period activation of the pro-coagulant potential (decrease of prothrombin and thrombin time and increase of fibrinogen content) is found to be balanced by a reduced activity of XIII factor and an increase activity of antithrombin III in rats without diabetes mellitus. At the same period in rats with diabetes increase of the pro-coagulant potential is accompanied by the activation of XIII factor and a reduced activity of antithrombin III promoting clot formation. On the 12th day of the observation the parameters of the coagulation chain in the hemostasis system and antithrombin III return to the level of the control animals in rats without diabetes, but in rats with diabetes the factors of intensification of a thrombotic risk remain activated.&#x0D; At the early and late ischemic-reperfusion periods the parameters of blood fibrinolytic activity increase in rats without diabetes; in animals with diabetes mellitus the parameters of fibrinolytic activity remain without changes at the early period of observation (except decrease of a potential plasminogen activity), and they decrease on the 12th day of the post-ischemic period, which deteriorates conditions of thrombolysis. &#x0D; Conclusions. Complication of diabetes mellitus by ischemic-reperfusion lesion of the brain results in imbalance in the hemocoagulation system at the expense of intensification of pro-coagulant mechanisms, and promotes inhibition of fibrinolytic processes with advanced changes in the dynamics of observation.

Fibrin clot properties and fibrinolysis in patients with endocrine hypertension due to aldosterone or catecholamines excess.

The aim of the study was to investigate a new possible background of increased risk of cardiovascular events in two forms of endocrine hypertension: in primary aldosteronism (PA) and pheochromocytoma/paraganglioma (PPGL) in comparison to essential hypertension (EHT). Prothrombotic properties of the fibrin clot structure, impaired fibrinolysis and enhanced thrombin generation have been reported to be associated with increased cardiovascular risk. Patients with PA and PPGL were evaluated at baseline and re-evaluated 3 months after causative treatment. At baseline PA and PPGL patients were compared to matched EHT patients and to healthy controls. The study included 35 patients with PA, 16 patients with PPGL and two reference groups of patients with EHT (32 and 22 patients) and healthy controls (35 and 23 subjects). All subjects underwent evaluation according to the study protocol that included plasma fibrin clot permeability (Ks), clot lysis time, endogenous thrombin potential. There were no differences in clot structure and fibrinolytic activity in PA and PPGL patients as compared to matched patients with EHT, whereas all hypertensive groups were characterized by more compact fibrin clot structure, faster clot formation and enhanced thrombin generation in comparison to healthy controls. Both in PA and PPGL patients, fibrin clot properties and fibrinolytic parameters remained stable after the causative treatment. Patients with PA and PPGL are at a prothrombic state comparable to patients with EHT. The results suggest the higher risk of cardiovascular events observed in hypertensive PA and PPGL as compared to EHT is not mediated through investigated prothrombic mechanisms.

Suppressed Fibrinolytic Activity Demonstrated By Simultaneous Thrombin and Plasmin Generation Assay during Cytokine Release Syndrome after CD19 Chimeric Antigen Receptor-Modified T-Cell Therapy

Introduction: Infusion T cells engineering to express CD19-specific chimeric antigen receptor T cells (CAR-T) following lymphodepleting chemotherapy has shown promising efficacy in patients with relapsed and/or refractory CD19-positive B-cell malignancies including B-cell acute lymphoblastic leukemia (B-ALL), and diffuse large B-cell lymphoma (DLBCL). CAR-T therapy can often be associated with cytokine release syndrome (CRS), which has been reported to present severe coagulopathy. Conventional coagulation and fibrinolysis parameters have been reported to worsen in correlation with CRS grading [Hay KA et al. Blood 2017]. In the present study, we hypothesized that the change of balance between coagulation and fibrinolysis due to coagulopathy is associated with CRS after CAR-T therapy. To clarify our hypothesis, we investigated the global coagulation and fibrinolytic function of patients receiving CD19 CAR-T therapy using simultaneous thrombin and plasmin generation assay (T/P-GA). Patients: We enrolled 13 consecutive patients aged 23-69 years (8 males and 5 females, DLBCL; n = 11, B-ALL; n = 2) receiving CD19 CAR-T therapy from May 2020 to December 2020 at a single center in Japan. Due to a history of internal jugular venous thrombosis, one patient received edoxaban, an anticoagulant. Methods: We evaluated the global functions of coagulation and fibrinolysis using T/P-GA [Matsumoto et al. TH 2013]. This clotting was initiated by the mixture of recombinant human tissue factor (Innovin ®, f.c. 1 pM), phospholipid vesicles (f.c. 4 μM), and tissue-type plasminogen activator (f.c. 3.2 nM). We simultaneously monitored thrombin and plasmin generation using thrombin- and plasmin-specific fluorogenic substrate (Z-Gly-Gly-Arg-AMC and BOC-Glu-Lys-Lys-MAC, respectively) in separate microtiter wells. The first derivatives (velocity) of thrombin and plasmin generation were utilized to derive the parameters, lag time (LT), endogenous potential (EP), peak levels (Peak), and time to peak (ttPeak). In this study, EP of thrombin generation (T-EP) and plasmin-peak (P-Peak) were selected as parameters for evaluation. We calculated the ratio of T-EP and P-Peak of patients' plasmas to those of control normal plasma. A ratio > 1.0 was defined as high coagulation or fibrinolytic potential relative to normal. Using fibrinogen (Fbg), D-dimer, and antithrombin (AT), we also monitored the conventional laboratory markers of hemostasis. Soluble IL-2 receptor (sIL-2R) was also measured as a marker of inflammatory cytokines. Day 0 was defined as the day of CAR-T infusion. Plasmas were collected at T0; pre-lymphodepleting chemotherapy, T1; Days -2-0, T2; Days 1-3, T3; Days 4-6, T4; Days 7-9, T5; Days 10-12, T6; Days 13-18, and T7; Days 19-23. Results: All patients had Grade ≤ 2 CRS. Two cases developed CRS-associated coagulopathy, one of whom required fresh frozen plasma transfusion and cryoprecipitate for low Fbg level, and the other required tranexamic acid for hemorrhagic cystitis. The median values of AT remained within the reference value (RV). The median Fbg values were 229-525 mg/dL, and which were significantly greater at T0-T3 than at T5-T7 (p < 0.05). The median D-dimer values were 0.45-3.9 µg/mL, which were within or above the RV with no significant change between time points. The median values of sIL-2R were 819-3,953 U/mL, and which were significantly increased at T3-T4 than at T0-T1 (p < 0.05). T-EP/P-Peak revealed a median of 1,877/21.9, 1,659/18.6, 1,731/19.8, 1,856/15.0, 1,931/16.3, 1,758/18.5, 1,600/19.1, 1,634/20.3, and 1,594/17.4 nM for T0-T7 and control plasma, respectively, indicating the reduced P-Peak ratios (Fig. 1). T-EP ratios showed consistently maintaining > 1 with no significant difference between time points, while P-Peak ratios were significantly lower at T3 and T4 than at T0 (p < 0.01) (median ratios of T-EP/P-peak; T0; 1.23/1.22, T1; 1.08/1.05, T2; 1.12/1.09, T3; 1.23/0.81, T4; 1.27/0.91, T5; 1.19/1.11, T6; 1.07/1.12, and T7; 1.20/1.15, respectively). Conclusion: The results of T/P-GA showed that hemostatic kinetics in patients with Grade ≤ 2 CRS were likely to shift to hypercoagulable states throughout the entire period and that they were likely to experience hypofibrinolytic activity during the CRS phase. These results suggest that the imbalance of coagulation and fibrinolysis might cause organ disorder due to thrombotic tendency associated with CRS after CAR-T therapy. [Display omitted] DisclosuresTakaori-Kondo: Bristol-Myers K.K.: Honoraria; ONO PHARMACEUTICAL CO., LTD.: Research Funding; Celgene: Research Funding. Nogami: Chugai Pharmaceutical Co., Ltd.: Consultancy, Research Funding.

Absence of Hyperactivation of Fibrinolysis Explains the Lack of Hemostatic Efficacy of Prophylactic Tranexamic Acid (TXA) in Hypoproliferative Thrombocytopenia

Background: We previously reported the results of the A-TREAT study (American Trial Using Tranexamic Acid in Thrombocytopenia: NCT02578901). This randomized double-blind placebo-controlled trial demonstrated that TXA administration is not superior to placebo in preventing WHO grade 2 or higher bleeding in severely thrombocytopenic patients requiring supportive platelet transfusion following myeloablative therapy for hematologic disorders (Gernsheimer T., ASH 2020 Plenary Session).Here, we present results of the A-TREAT ancillary study - Fibrinolysis Evaluation in A-TREAT (FEAT). Blood samples were collected from a subset (n=115) of A-TREAT participants just prior to initiation of study drug (when the platelet count was <30,000/µl) and at a later time point when TXA was at a steady state trough level (5 ±2 days following study drug initiation). Using global assays of fibrinolysis in plasma, our a priori hypotheses were that: 1] a baseline ‘hyperfibrinolytic’ profile would be associated with a higher proportion of grade 2+ bleeding; and 2] trough TXA levels would be associated with a ‘hypofibrinolytic’ profile and a lower proportion of grade 2+ bleeding.Methods: Fibrinolysis in platelet-free citrated plasma was assessed by 3 global assays: euglobulin clot lysis time (ECLT), plasmin generation (PG), and tPA resistance clot lysis time (tPA-CLT) using previously described methods (Ilich A. RPTH 2020, Miszta A. JTH 2021). Trough plasma TXA concentration was measured using a validated tandem mass spectrometry assay. Individual fibrinolytic analytes (PAI-1, tPA, plasminogen, alpha2-antiplasmin and plasmin-antiplasmin complexes) were quantified by ELISA.Results: Baseline samples did not demonstrate a hyperfibrinolytic profile by ECLT. To the contrary, ECLT values were significantly increased compared to healthy controls (figure 1). Furthermore, none of the measured fibrinolytic parameters (ECLT, tPA-CLT, total PAI-1, tPA, plasminogen, alpha2-antiplasmin or plasmin-antiplasmin complexes) at baseline were associated with a greater risk of grade 2+ bleeding during follow up, regardless of treatment arm. On the follow-up samples, neither pharmacokinetic (trough TXA concentration) nor pharmacodynamic parameters (PG or tPA-CLT) were associated with bleeding severity. A high inter-patient variability of TXA trough concentrations was noted in the treatment arm (min-max: 0.7-10 ug/ml), and drug levels correlated strongly with global fibrinolysis assessment by PG (Spearman r, -0.78, 95% CI -0.88 - -0.62) and tPA-CLT (r, 0.74, 0.56 - 0.85) (figure 2).Conclusions:1] No evidence of fibrinolytic hyperactivation was observed in these thrombocytopenic patients;2] trough TXA concentrations varied significantly between patients receiving the same dosing schedule; and3] tPA-CLT and PG parameters correlated well with TXA plasma concentrations and thus may be used to estimate the extent of fibrinolytic inhibition in patients treated with TXA.Discussion: The absence of hyperactivation of endogenous fibrinolysis in this study is in contrast to our recent findings in trauma. Specifically, we reported that almost half of trauma patients demonstrated evidence of fibrinolytic hyperactivation (by ECLT) on admission (Ilich A. Thromb Res, 2021). Since TXA has been shown to reduce mortality due to bleeding in trauma (CRASH II, Lancet, 2010) and given that baseline hyperfibrinolysis is common in trauma, we hypothesize that the absence of fibrinolytic hyperactivation observed in the A-TREAT study patients likely explains the clinical lack of efficacy of TXA. [Display omitted] DisclosuresGernsheimer: Amgen: Honoraria; Novartis: Honoraria; Principia: Research Funding; Rigel: Research Funding; Cellphire: Consultancy; Dova: Consultancy; Sanofi: Consultancy. Triulzi: Fresenius Kabi: Membership on an entity's Board of Directors or advisory committees; Realta: Membership on an entity's Board of Directors or advisory committees. Wolberg: CSL Behring: Consultancy; Bristol Myers Squibb: Research Funding; Takeda: Research Funding. Key: Takeda: Research Funding; BioMarin: Honoraria, Other: Participation as a clinical trial investigator; Sanofi: Consultancy; Grifols: Research Funding; Uniqure: Consultancy, Other: Participation as a clinical trial investigator.

Time course of coagulation and fibrinolytic parameters in pediatric traumatic brain injury.

Coagulopathy is a well-recognized risk factor for poor outcomes in patients with traumatic brain injury (TBI). Differences in the time courses of coagulation and fibrinolytic parameters between pediatric and adult patients with TBI have not been defined. Patients with TBI and an Abbreviated Injury Scale of the head score ≥ 3, in whom the prothrombin time (PT)-international normalized ratio (INR), activated partial thromboplastin time (APTT), fibrinogen concentration, and plasma D-dimer levels were measured on arrival and at 3, 6, and 12 hours after injury, were retrospectively analyzed. Propensity score-matched analyses were performed to adjust baseline characteristics between pediatric patients (aged < 16 years) and adult patients (aged ≥ 16 years). A total of 468 patients (46 children and 422 adults) were included. Propensity score matching resulted in a matched cohort of 46 pairs. Higher PT-INR and APTT values at 1 to 12 hours after injury and lower fibrinogen concentrations at 1 to 6 hours after injury were observed in the pediatric group compared with the adult group. Plasma levels of D-dimer were elevated in both groups at 1 to 12 hours after injury, but no significant differences were seen between the groups. Multivariate logistic regression analysis of the initial coagulation and fibrinolytic parameters in the pediatric group revealed no prognostic significance of the coagulation parameter values, but elevation of the fibrinolytic parameter D-dimer was an independent negative prognostic factor. In the acute phase of TBI, pediatric patients were characterized by prolongation of PT-INR and APTT and lower fibrinogen concentrations compared with adult patients, but these did not correlate with outcome. D-dimer was an independent prognostic outcome factor in terms of the Glasgow Outcome Scale in pediatric patients with TBI.

The Influence of Zearalenone on Selected Hemostatic Parameters in Sexually Immature Gilts.

Vascular toxicity induced by xenobiotics is associated with dysfunctions or damage to endothelial cells, changes in vascular permeability or dysregulation of the vascular redox state. The aim of this study was to determine whether per os administration of zearalenone (ZEN) influences selected hemostatic parameters in prepubertal gilts. This study was performed on female gilts divided into a control group which received placebo and an experimental group which received ZEN at a dose of 5.0 µg·kg−1 b.w. × day−1. On days 14, 28 and 42, blood samples were collected from the animals for analyses of hematological, coagulation and fibrinolysis parameters, nitric oxide, von Willebrand factor antigen content and catalase activity. The results demonstrated that the treatment of gilts with ZEN at a dose below no observable adverse effect level did not affect the primary hemostasis and the blood coagulation cascade. However, ZEN could have temporarily affected the selected indicators of endothelial cell function (increase of von Willebrand factor, decrease of nitric oxide levels) and the oxidative status plasma (decrease of catalase activity) of the exposed gilts. In summary, these results suggest that the adaptive response to ZEN-exposure can induce a transient imbalance in the vascular system by acting on vascular endothelial cells.

Coagulation and Fibrinolytic Disorder

Traumatic brain injury(TBI)is associated with coagulation and fibrinolytic disorder. It is characterized by consumptive coagulopathy and secondary hyperfibrinolysis associated with hypercoagulability and by hyperfibrinolysis due to the release of tissue plasminogen activator from the injured brain. Thrombin antithrombin III complex, a coagulation parameter, is abnormally high immediately after TBI and declines 6 hours after TBI. Fibrinogen, a coagulation factor, is rapidly consumed and degraded within 3 hours of TBI. D-dimer, a fibrinolytic parameter, is abnormally high on arrival at the hospital and reaches its maximum value 3 hours after TBI; during this time, bleeding tendency increases. Plasminogen activator inhibitor-1, a parameter of fibrinolysis shutdown, peaks at 6 hours after TBI. D-dimer is also known to be a prognostic factor. Patients with a high D-dimer level despite a good level of consciousness on admission are more likely to be "talk and deteriorate." Administration of tranexamic acid, an anti-fibrinolytic agent, early in the acute phase of TBI may reduce mortality. Fresh frozen plasma transfusion should be performed within 3 hours of TBI with monitoring of fibrinogen levels, and the administration dose should be set with a target fibrinogen level of ≧ 150 mg/dL. However, excessive administration should also be avoided. Thus, in the acute phase of TBI, coagulation and fibrinolytic activity changes dynamically and may adversely affect the complicated injury; therefore, monitoring coagulation and fibrinolytic parameters while conducting treatment is recommended.

Disorder of Iron Metabolism as a Universal Pathogenetic Factor in Damage to Organs and Systems in Covid-19

Relevance. The pathogenesis of COVID-19 remains one of the most pressing. The literature discusses the role of iron as a factor supporting inflammatory processes, hypercoagulability and microcirculation crisis in severe COVID-19.The aim of study. was to identify changes in iron metabolism in patients with severe COVID-19 and hyperferritinemia.Material and methods. In this study, we used a content analysis of available scientific publications and our own observations of the peculiarities of the clinical picture and laboratory parameters in patients with a severe course of COVID-19 who had hyperferretinemia at the height of the disease. The main group consisted of 30 patients hospitalized in the Department of Anesthesiology, Resuscitation and Intensive Care of N.A. Semashko City clinical Hospital No. 38 with the diagnosis COVID-19, bilateral polysegmental pneumonia, severe course and hyperferritinemia. The diagnosis of a new coronavirus infection was confirmed by visualization of bilateral viral lung lesions with chest CT-scan, positive PCR test for SARS-CoV-2 and the presence of immunoglobulins to SARS-CoV-2. The control group consisted of 20 healthy volunteers. The study evaluated the biochemical parameters of iron metabolism, fibrinolysis and markers of inflammation. Changes associated with impaired iron metabolism were assessed by the level of serum iron, transferrin, daily and induced iron excretion in the urine. Statistical processing was carried out using nonparametric methods.Results. All patients with severe COVID-19 and hyperferritinemia showed signs of impaired iron metabolism, inflammation and fibrinolysis — a decrease in the level of transferrin (p&lt;0.001), serum iron (p&gt;&lt;0.005), albumin (p&gt;&lt;0.001), lymphocytes (p&gt;&lt;0.001) and an increase in leukocytes (p&gt;&lt;0.001), neutrophils (p&gt;&lt;0.001), CRP (p&gt;&lt;0.005), IL-6 (p&gt;&lt;0.001), D-dimer (p&gt;&lt;0.005), daily urinary iron excretion (p&gt;&lt;0.005) and induced urinary iron excretion (p&gt;&lt;0.001). Conclusions The study showed that in the pathogenesis of the severe course of COVID-19, there is a violation of iron metabolism and the presence of a free iron fraction. The appearance of free iron can be caused by damage to cells with the “release” of iron from cytochromes, myoglobin, hemoglobin, or violation of the binding of iron to transferrin, which may be the result of a change in the protein structure or violation of the oxidation of iron to the trivalent state. When assessing the degree of viral effect on the body, one should take into account the effect of various regulators of iron metabolism, as well as an assessment of the level of free iron not associated with transferrin. Keywords: new coronavirus infection, COVID-19, SARS-CoV-2, iron metabolism, free iron, ferritin, transferrin, NTBI, nontransferrin bound iron&gt;˂0.001), serum iron (p˂0.005), albumin (p˂0.001), lymphocytes (p˂0.001) and an increase in leukocytes (p˂0.001), neutrophils (p˂0.001), CRP (p˂0.005), IL-6 (p˂0.001), D-dimer (p˂0.005), daily urinary iron excretion (p˂0.005) and induced urinary iron excretion (p˂0.001).Conclusions. The study showed that in the pathogenesis of the severe course of COVID-19, there is a violation of iron metabolism and the presence of a free iron fraction. The appearance of free iron can be caused by damage to cells with the “release” of iron from cytochromes, myoglobin, hemoglobin, or violation of the binding of iron to transferrin, which may be the result of a change in the protein structure or violation of the oxidation of iron to the trivalent state. When assessing the degree of viral effect on the body, one should take into account the effect of various regulators of iron metabolism, as well as an assessment of the level of free iron not associated with transferrin.

Tranexamic acid attenuates early post-operative systemic inflammatory response and nutritional loss and avoids reduction of fibrinogen in total hip arthroplasty within an enhanced recovery after surgery pathway

Total hip arthroplasty (THA) is an intervention with significant inflammatory response. The impact of additional doses of tranexamic acid (TXA) on inflammatory response, trauma and nutrition parameters, and coagulation and fibrinolysis changes has rarely been reported. A prospective double-blind randomized trial was performed on elective primary THA. Ninety-nine adult patients were recruited consecutively from 2019 to 2020. They were randomized to receive single-dose of TXA before incision, another dose of TXA at three hours post-operatively, or another two doses of TXA at three and six hours post-operatively. The primary outcomes included changes in white blood cell (WBC) counts, creatine kinase (CK), haemoglobin(Hb), and albumin(Alb); the secondary outcomes included coagulation and fibrinolysis parameters. Compared with single-dose TXA, patients received threedose TXA had significantly reduced WBC counts and fibrinogen/fibrin degradation product (FDP) levels, increased albumin and fibrinogen levels, and prolonged PT on post-operative day (POD) three. Though patients received threedose TXA had a tendency that increased Hb, decreased CK, reduced D-D, and prolonged APTT on POD3, it is not statistically significant. And the other measured outcomes on POD1 and POD2W shared a similar statistical result, except PT. The PT is significantly prolonged on POD2W in threedose group compared with single dose. Three-dose TXA contribute to attenuate early post-operative systemic inflammatory response and nutritional loss, increase fibrinogen, reduce FDP levels, and prolong PT in THA patients within an ERAS pathway, which may associate with reduced early post-operative haemorrhagic tendency, thrombosis risks, and hypercoagulability.

Level of thrombin activated fibrinolysis inhibitor in patients with ischemic stroke

Background and Aims: The purpose of the study to determine the relationship of the thrombin-activated fibrinolysis inhibitor with coagulation and fibrinolysis parameters.

COVID-19-related laboratory coagulation findings.

The alterations in the hemostatic balance in COVID‐19 patients are strongly disturbed and contribute to a high prothrombotic status. The high rate of venous thromboembolism in COVID‐19 patients goes along with derangements in coagulation laboratory parameters. Hemostasis testing has an important role in diagnosed COVID‐19 patients. Elevated D‐dimer levels were found to be a crucial laboratory marker in the risk assessment of thrombosis in COVID‐19 patients. The diagnostic approach also includes prothrombin time and platelet count. Fibrinogen might give an indication for worsening coagulopathy. Other markers (activated partial thromboplastin time (aPTT), fibrinolysis parameters, coagulation factors, natural anticoagulants, antiphospholipid antibodies and parameters obtained by thromboelastography or thrombin generation assays) have been described as being deranged. These may help to understand the pathophysiology of thrombosis in COVID‐19 patients but have currently no place in diagnosis or management in COVID‐19 patients. For monitoring the heparin anticoagulant therapy, the anti‐Xa assay is suggested, because the severe acute‐phase reaction (high fibrinogen and high factor VIII) shortens the aPTT.

Pathogenetic rationale for correction of endothelial dysfunction with quercetin in the complex treatment of non-alcoholic steatohepatitis and diabetic kidney disease in patients with type 2 diabetes mellitus

Objective — to determine effects of therapeutical complex, including metformin, rosuvastatin, essential phospholipids and quercetin, on the state of blood lipid spectrum, endothelial function, fibrinolysis system and platelet hemostasis, which are factors in the progression of nonalcoholic steatohepatitis (NASH) and diabetic kidney disease (DKD).&#x0D; Materials and methods. The investigation was performed in the dynamics of treatment of 60 NASH patients with type 2 diabetes mellitus (DM 2) and DKD of stage I — III. Depending on the prescribed treatment patients were randomized into 2 groups. The comparison group 1 (28 subjects) was administered hypocaloric diet with account of dietary restrictions #9, received essential phospholipids 300 mg 2 caps. 3 times a day) during 30 days for the NASH treatment, and antidiabetic and lipid‑lowering therapy with metformin hydrochloride 1000 mg per day, rosuvastatin (5 mg 1 time per day) for 1 month. Group 2 consisted of 32 patients and in addition to the similar 30 days of dietary recommendations, essential phospholipids, hypoglycemic and hypolipidemic therapy, received quercetin and povidone 500 mg intravenously in 100 ml of isotonic sodium 10 mg for 10 days. The mean age of patients was 53.8 ± 3.52 years. The comparison group consisted of 30 healthy age‑matching subjects.&#x0D; Results. Parameters of endothelial dysfunction, fibrinolysis and platelet hemostasis were determined to check the degree of endothelial‑protective effects of Quercetin against the background of the recommended protocol therapy. As a result of treatment, baseline significantly reduced NO levels (in 1.7 times) in patients of group 1 increased insignificantly (p &gt; 0.05), and significantly raised in 1.5 times (p &lt; 0.05) in group 2. This can be explained by effects of Quercetin as an endothelial protector, as well as by metformin effects, which reduces degree of insulin resistance and promotes body weight reduction, as well as reduction of hyperlipidemia level and probability of deposition of subendothelial proatherogenic fractions.&#x0D; Conclusions. Combined therapy of NASH with DM 2 and diabetic kidney disease with the use of essential phospholipids, statins and metformin with addition of Quercetin was more effective than traditional therapy: it significantly reduced the markers of NASH exacerbation, optimized blood lipid spectrum, restored endothelial functional state, eliminated the phenomena of hypercoagulable syndrome without the additional administration of antiplatelet agents.&#x0D;

Monitoring of Hemostatic Parameters for Early Prediction of First-trimester Miscarriage

: BACKGROUND Hypercoagulation starts as early as the first-trimester pregnancy and is a risk factor for thromboembolic events which are associated with miscarriage. Our study aimed to investigate coagulation, platelets, and fibrinolysis parameters alteration among trimester-specific normal pregnancy and first-trimester miscarriage patients. We also test the accuracy of hemostatic parameters determination for prediction of first-trimester miscarriage. METHODS Retrospective investigation of 50 women whose most recent pregnancy had ended in the first trimester and 54 age-matched consecutive normal pregnancy between 2016-2019. Furthermore, 51 non-pregnant, age-matched women were included in parallel to healthy controls. 12 Screening tests for coagulation and platelet parameters were assessed. RESULTS We found plasma levels of aPTT, FBG, TT were significantly prolonged or decreased in miscarriage subjects than the corresponding first phase in normal pregnancies. PT, INR, aPTT and D-dimer all shift back to normal in miscarriage patients compared with non-pregnant women. Shortened aPTT combined with TT and FBG can predicted the occurrence of first-trimester miscarriage with an AUC of 0.831. CONCLUSIONS Routine assessment of aPTT combined with TT and FBG is a low-cost, widely available marker for prediction of first-trimester miscarriage.

Serial EXTEM, FIBTEM, and tPA Rotational Thromboelastometry Observations in the Maastricht Intensive Care COVID Cohort-Persistence of Hypercoagulability and Hypofibrinolysis Despite Anticoagulation.

Background: Coronavirus Disease 2019 (COVID-19) patients often present with thromboembolic events. In COVID-19 patients, routine hemostatic assays cannot correctly identify patients at risk for thromboembolic events. Viscoelastic testing with rotational thromboelastometry (ROTEM) might improve the characterization of COVID-19-associated coagulopathy.Objective: To unravel underlying coagulopathy and fibrinolysis over time as measured by serial assessment heparin-independent (FIBTEM and EXTEM) and fibrinolysis illustrating (tissue plasminogen activator; tPA) ROTEM assays.Patients/Methods: Between April 23 and June 12, consecutive adult patients enrolled within the Maastricht Intensive Care COVID (MaastrICCht) cohort were included, and a comprehensive set of clinical, physiological, pharmaceutical, and laboratory variables were collected daily. Twice per week, EXTEM, FIBTEM, and tPA ROTEM were performed. Clotting time (CT), clot formation time (CFT), maximum clot firmness (MCF), lysis onset time (LOT), and lysis time (LT) were determined to assess clot development and breakdown and were compared to routine hemostatic assays.Results: In 36 patients, 96 EXTEM/FIBTEM and 87 tPA ROTEM tests were performed during a 6-week follow-up. CT prolongation was present in 54% of EXTEM measurements, which were not matched by prothrombin time (PT) in 37%. Respectively, 81 and 99% of all EXTEM and FIBTEM MCF values were above the reference range, and median MCF remained elevated during follow-up. The ROTEM fibrinolysis parameters remained prolonged with median LOT consequently >49 min and unmeasurable LT in 56% of measurements, suggesting a severe hypofibrinolytic phenotype.Conclusion: ROTEM tests in COVID-19 ICU patients show hypercoagulability and severe hypofibrinolysis persisting over at least 6 weeks.

The influences of selected clotting and fibrinolysis factors on survival of patients with kidney tumors - a prospective study.

Multiple studies suggest that cancer leads to activation of clotting and fibrinolysis pathways, elevating the risk of thromboembolic events. Kidney cancer is often complicated by clotting disorders. In this study, we hypothesized that preoperative clotting and fibrinolysis parameters are altered in healthy volunteers and kidney tumor patients. We also hypothesized that these differences may be associated with survival in patients who have undergone operations due to kidney tumors. In this study, 96 patients with kidney tumors and 30 healthy volunteers were recruited at a single university center. All patients were assessed for pre-operative serum concentrations of tissue factor (TF), tissue factor pathway inhibitor (TFPI, total TFPI, full-length TFPI, truncated TFPI), plasmin-antiplasmin complex (PAP), thrombin-antithrombin complex (TAT), von Willebrand factor (vWF), clotting factor XIII A1 (FXIIIA1), D-dimers, and fibrinogen. Additionally, standard peripheral blood morphology was evaluated. Malignant kidney tumors were diagnosed in 85 of 96 tumor patients. In patients with kidney tumors, there were statistically significantly higher concentrations of fibrinogen, D-dimers, TAT, PAF, TF, TFPI, vWF, FXIIIA1, and leukocyte counts compared to the control group. Statistically significant correlations were found between multiple parameters. This points to significant clotting system alterations. Cox stepwise hazard analysis showed that pre-operative fibrinogen and D-Dimer concentrations were significantly associated with survival. In patients with kidney tumors, multiple clotting and fibrinolysis parameters are significantly altered. Routine pre-operative measures should include determination of fibrinogen and D-dimer concentrations as these markers aid in prediction of survival probability.

Comparison of the in-vivo effect of two tranexamic acid doses on fibrinolysis parameters in adults undergoing valvular cardiac surgery with cardiopulmonary bypass - a pilot investigation

BackgroundThe blood saving efficacy of TXA in cardiac surgery has been proved in several studies, but TXA dosing regimens were varied in those studies. Therefore, we performed this study to investigate if there is a dose dependent in-vivo effect of TXA on fibrinolysis parameters by measurement of fibrinolysis markers in adults undergoing cardiac surgery with CPB.MethodsA double-blind, randomized, controlled prospective trial was conducted from February 11, 2017 to May 05, 2017. Thirty patients undergoing cardiac valve surgery were identified and randomly divided into a placebo group, low-dose group and high-dose group by 1: 1: 1. Fibrinolysis parameters were measured by plasma levels of D-Dimers, plasminogen activator inhibitor-1 (PAI-1), thrombin activatable fibrinolysis inhibitor (TAFI), plasmin-antiplasmin complex (PAP), tissue plasminogen activator (tPA) and thrombomodulin (TM). Those proteins were measured at five different sample times: preoperatively before the TXA injection (T1), 5 min after the TXA bolus (T2), 5 min after the initiation of CPB (T3), 5 min before the end of CPB (T4) and 5 min after the protamine administration (T5). A Thrombelastography (TEG) and standard coagulation test were also performed.ResultsCompared with the control group, the level of the D-Dimers decreased in the low-dose and high-dose groups when the patients arrived at the ICU and on the first postoperative morning. Over time, the concentrations of PAI-1, TAFI, and TM, but not PAP and tPA, showed significant differences between the three groups (P < 0.05). Compared with the placebo group, the plasma concentrations of PAI-1 and TAFI decreased significantly at the T3 and T4 (P < 0.05); TAFI concentrations also decreased at the T5 in low-dose group (P < 0.05). Compared with the low-dose group, the concentration of TM increased significantly at the T4 in high-dose group.ConclusionsThe in-vivo effect of low dose TXA is equivalent to high dose TXA on fibrinolysis parameters in adults with a low bleeding risk undergoing valvular cardiac surgery with cardiopulmonary bypass, and a low dose TXA regimen might be equivalent to high dose TXA for those patients.Trial registrationChiCTR-IPR-17010303, Principal investigator: Zhen-feng ZHOU, Date of registration: January 1, 2017.

Combinations of fibrinolytic gene polymorphisms (plasminogen activator inhibitor type 1 4G/5G, factor XIII Val34Leu and angiotensin-converting enzyme I/D) in women with idiopathic infertility.

During normal pregnancy depressed fibrinolytic system is caused by changes in many factors, which could be influenced by different gene polymorphisms. The aim of this study was to investigate the combination of fibrinolysis-related gene polymorphisms in women with idiopathic infertility. We genotype polymorphisms 4G/5G in plasminogen activator inhibitor type 1 (PAI-1), Val34Leu in factor XIII (FXIII) and I/D in angiotensin-converting enzyme (ACE) gene. The patients group consisted of 83 females with idiopathic infertility, while the control group included 121 females with at least one born child. The alleles and genotypes distributions showed no significant differences between analyzed groups. Although higher frequency of PAI-1 5G5G genotype in patients did not reach statistical significance, 5G5G genotype of PAI-1 in combination with ValVal genotype of FXIII leads to higher risk for infertility (P < 0.05). In addition, when we added ACE I/D polymorphism in analysis, the 4G in PAI-1 and D allele in ACE, showed protective effect in combination with FXIII polymorphism (P < 0.05). The finding that combined homozygosity of 5G of PAI-1, commonly associated with greater fibrinolytic activity and bleeding tendency, in combination with Val genotype of FXIII impose a risk for female idiopathic infertility. The protective effect of alleles 4G (PAI-1) and D (ACE) suggest that different combinations of polymorphisms influencing fibrinolysis could lead to better established hemostatic balance and reproductive success. Further analyses, with larger number of samples, as well as assessment of additional biochemical parameters of fibrinolysis, should be performed to clarify the role of gene polymorphisms on fibrinolysis and consequently their influence on reproductive success.

Effects of long-term high-altitude exposure on fibrinolytic system

ABSTRACT Objective High altitude (HA), with the main feature of hypobaric hypoxia, is an independent risk factor for thrombosis. However, little is known on the alterations of fibrinolytic system in adaptation to HA. In this study, we investigated changes of fibrinolytic system parameters between individuals permanently living at HA and low altitude (LA) regions, and provided data for further studies on HA-induced thrombotic disease. Material and methods A total of 226 eligible participants, including 103 LA participants, 100 healthy HA subjects and 23 high altitude polycythemia (HAPC) patients, were recruited in this study. Six fibrinolytic parameters, i.e. fibrinogen (Fbg), D-dimer (DDi), antithrombin III (AT-III), plasminogen activator inhibitor-1 (PAI-1), tissue plasminogen activator (tPA) and plasminogen (PLG) were analyzed respectively. PAI-1 and tPA were performed by using bio-immuno-assays and an automated coagulation analyzer was used to conduct Fbg, DDi, AT-III and PLG tests. Results Plasma levels of Fbg, DDi, PAI-1 and PLG were significantly higher in healthy HA group than in LA group (all p < 0.05), whereas tPA was significantly lower in healthy HA group. No significant difference in AT-III was observed between healthy HA and LA groups (p > 0.05). All these fibrinolytic parameters showed no significant distinctions between healthy HA subjects and HAPC patients (all p > 0.05). HGB showed no relationship with fibrinolytic parameters in HA cohort. Conclusion This study demonstrates that HA environment has a significant effect on fibrinolytic system and provides a foundation for further studies on HA hypobaric hypoxia-induced thrombotic disease.

Some fibrinolytic parameters in coronary artery disease patients: focus on unstable angina subgroups

Unstable angina is classified into new-onset, progressive, and angina at rest. Though hemostasis plays a crucial role in the pathogenesis of coronary artery disease, including unstable angina, limited data exist regarding peculiarities of fibrinolytic parameters in the above-mentioned types of unstable angina. Our study aims to investigate if there is a difference in the fibrinolytic state between the groups of patients with new-onset, progressive unstable angina in comparison with stable angina patients depending on medical history data, electrocardiographic and hemodynamic features. In our cross-sectional study, we recruited 93 coronary artery disease patients (mean age 62.32 (6.94) years, 41 males (44.1%)). They were divided into 3 groups: stable angina patients (n=22) (control), new-onset unstable angina patients (n=21), and progressive unstable angina patients (n=50). The groups were comparable by baseline characteristics. Blood samples were obtained before treatment onset. The concentrations of tissue plasminogen activator and inhibitor of plasminogen activator (type 1) were measured by the ELISA method. We registered 14 points at the admission department, particularly age, sex, body mass index, smoking, presence of the family history of cardiovascular disorders, ST-segment depression, T-wave variability, arrhythmias, left bundle branch blockage, heart rate, systolic and diastolic blood pressure, Sokolov-Lyon voltage criteria, and unstable angina type (new-onset or progressive). After comparison of fibrinolytic parameters’ concentrations among groups under investigation, we defined the main independent predictors among observed 14 parameters to create optimal regression models for assessment of fibrinolytic parameters concentrations. The groups under investigation differ significantly in concentration of tissue plasminogen activator (P&lt;0.001) and inhibitor of plasminogen activator (type 1) (P&lt;0.001). The tissue plasminogen activator concentration correlated significantly with ST depression (r=0.344, P=0.001), T wave variability (r=-0.233, P=0.02), systolic blood pressure (r=-0.675, P&lt;0.001), diastolic blood pressure (r=-0.655, P&lt;0.001), heart rate (r=-0.568, P&lt;0.001) and clinical unstable angina subgroups (r=-0.706, P&lt;0.001) as well as plasminogen activator inhibitor (type 1) concentration associated with age (r=-0.560, P&lt;0.001), body mass index (r=-0.249, P=0.049), ST-segment depression (r=0.542, P&lt;0.001), arrhythmia (r=0.210, P=0.03), systolic blood pressure (r=0.310, P=0.04), and clinical unstable angina subgroups (r=-0.406, P&lt;0.001). An optimal regression models for tissue plasminogen activator and its inhibitor assessment included systolic blood pressure, heart rate, unstable angina subgroup (R2adj. = 65.0%, P&lt;0.001) and systolic blood pressure, unstable angina subgroup (R2adj. = 42.7%, P&lt;0.001), respectively. Thus, fibrinolytic state among unstable angina clinical types differs significantly independently on observed baseline clinical, electrocardiographic and hemodynamic parameters. This finding confirms the utility of Braunwald unstable angina classification.