Coagulation Factor Inhibitors Research Articles

Comprehensive evaluation of anti-emicizumab antibodies in acquired hemophilia A: a detailed case study and methodological evaluation

BackgroundAcquired hemophilia A (AHA) is a rare and severe bleeding disorder characterized by autoantibodies inhibiting coagulation factor (F)VIII. Current treatment of AHA involves bypassing agents or FVIII replacement therapy, yet their efficacy is limited in cases of high inhibitor titers. Emicizumab, a humanized bispecific monoclonal antibody, has shown promising hemostatic effectiveness in persons with congenital hemophilia A (HA) and AHA, but a minority of patients developed anti-drug antibodies (ADAs), compromising its efficacy. MethodsWe present a comprehensive characterization of anti-emicizumab antibodies in a patient with AHA experiencing diminished emicizumab efficacy from week 10 of treatment. We developed a method for analysis of anti-emicizumab antibodies, distinguishing immunoglobulin (Ig) subclasses and IgG subtype profiling. ADAs’ neutralizing activity was evaluated using a modified clotting assay. ResultsThe Luminex-based assay demonstrated the presence of anti-emicizumab antibodies, confirmed through competitive analysis. We detected anti-emicizumab IgG antibodies in the patient’s plasma between week 16 and 29. IgG1 and IgG2 subclasses were identified. Longitudinal analysis showed IgG isotype antibodies against both emicizumab and FVIII. Anti-emicizumab antibodies exhibited noninhibitory activity, confirmed by a modified Bethesda assay. Moreover, no accelerated clearance of emicizumab was observed in plasma samples from the patient. ConclusionThis study presents the first documented case of anti-emicizumab antibodies in AHA. Our study provides insights into ADA development against emicizumab, emphasizing the need for monitoring tools. The developed method enables comprehensive evaluation of ADAs, aiding in personalized treatment strategies. These findings contribute to understanding emicizumab's immunogenicity profile in AHA, facilitating its optimized clinical use.

Preparation and structural characterization of a sulfated octasaccharide with heparin-like anticoagulant activity

Heparins are sulfated polysaccharides with a heterogeneous mixture derived from animal tissues, subject to supply limitations and the risk of animal virus residues. Patients using heparin also face the risks of spontaneous bleeding and thrombocytopenia. Here we reported an efficient riclinoctaose-based approach for rapid chemical synthesis of a structurally defined heparin-like anticoagulant sulfated octasaccharide (SRO). We used sulfur trioxide-pyridine, sulfur trioxide-trimethylamine, and sulfur trioxide-triethylamine complexes as solvents for one-pot O-sulfation and determined the optimal conditions for synthesizing SRO. Sulfur trioxide-trimethylamine provided reasonable control over the degree of substitution between 1.85 and 1.88, revealing a single molecule with a theoretical molecular weight of 2952.96 g/mol. The structural features of the SRO were carried out by Fourier transform infrared spectroscopy and one- and two- dimensional 1H and 13C NMR analysis, revealing sulfation repeatedly present at the fixed positions of C-6/C-2/C-3 and reducing terminals. The anticoagulant activity of SRO was demonstrated by efficiently blocking coagulation in the blood of mice and human. SRO dose-dependently decreased ferric chloride-induced experimental thrombosis in mice. Like heparin, SRO specifically inhibits coagulation factor Xa, but significantly reduces the risk of bleeding compared to heparin. Therefore, we named it octaparin. These results support that octaparin is expected to replace animal-sourced heparin.

Severe acquired hemophilia A associated with COVID-19 vaccination: A case report and literature review.

Acquired hemophilia A (AHA) is a rare autoimmune disease caused by an antibody that inhibits coagulation factor VIII activity. More than half of patients with AHA cannot identify underlying disorders. The remaining patients are associated with malignancies, autoimmune diseases, skin diseases, infections, and medications. Here, we present a case of 56-year-old Korean man with underlying hypertension, dyslipidemia, and diabetes mellitus who developed AHA following the second dose of BNT162b2 COVID-19 vaccination. He presented with a large 20 × 30 cm-sized hematoma along the psoas muscle and intracranial hemorrhage, necessitating intensive care with mechanical ventilation and continuous renal replacement therapy. Laboratory testing demonstrated that activated partial thromboplastin time and prothrombin times were 74.7 seconds (normal range 29-43 seconds) and 17.2 seconds (normal range 12.5-14.7 seconds), respectively. Laboratory tests confirmed AHA with undetectable factor VIII activity (<1.5%) and a positive factor VIII antibody with a titer of 8.49 Bethesda units/mL. Recombinant factor VIIa (NovoSeven®) was administered every 2 hours to control the bleeding, alongside immunosuppression with methylprednisolone 1 mg/kg daily and cyclophosphamide 2 mg/kg daily to eliminate the autoantibody. Despite the treatments, the patient developed sepsis and succumbed 14 weeks after admission. This rare case underscores the importance of monitoring for AHA following COVID-19 vaccination. Although the benefits outweigh the risks of vaccination, AHA should be considered in the differential diagnosis of unusual bleeding following the vaccinations. Early diagnosis and management before severe bleeding are critical for successfully controlling life-threatening bleeding.

Inhibition of coagulation factor XI/XIa - the next step in increasing the safety of anticoagulant therapy?

Inhibition of coagulation factor XI/XIa - the next step in increasing the safety of anticoagulant therapy?

Structural basis for inhibition of coagulation factor VIII reveals a shared antigenic hotspot on the C1 domain

BackgroundHemophilia A arises from dysfunctional or deficient coagulation factor (F)VIII and leads to inefficient fibrin clot formation and uncontrolled bleeding events. The development of antibody inhibitors is a clinical complication in hemophilia A patients receiving FVIII replacement therapy. LE2E9 is an anti-C1 domain inhibitor previously isolated from a mild/moderate hemophilia A patient and disrupts FVIII interactions with von Willebrand factor and FIXa, though the intermolecular contacts that underpin LE2E9-mediated FVIII neutralization are undefined. ObjectivesTo determine the structure of the complex between FVIII and LE2E9 and characterize its mechanism of inhibition. MethodsFVIII was bound to the antigen binding fragment (Fab) of NB2E9, a recombinant construct of LE2E9, and its structure was determined by cryogenic electron microscopy. ResultsThis report communicates the 3.46 Å structure of FVIII bound to NB2E9, with its epitope comprising FVIII residues S2040 to Y2043, K2065 to W2070, and R2150 to H2155. Structural analysis reveals that the LE2E9 epitope overlaps with portions of the epitope for 2A9, a murine-derived inhibitor, suggesting that these residues represent a shared antigenic region on the C1 domain between FVIII−/− mice and hemophilia A patients. Furthermore, the FVIII:NB2E9 structure elucidates the orientation of the LE2E9 glycan, illustrating how the glycan sterically blocks interactions between the FVIII C1 domain and the von Willebrand factor D′ domain. A putative model of the FVIIIa:FIXa complex suggests potential clashing between the NB2E9 glycan and FIXa light chain. ConclusionThese results describe an antigenic “hotspot” on the FVIII C1 domain and provide a structural basis for engineering FVIII replacement therapeutics with reduced antigenicity.

Atrase A, a P-III class metalloproteinase purified from cobra venom, exhibits potent anticoagulant activity by inhibiting coagulation pathway and activating the fibrinolytic system

Snake venoms, comprising a complex array of protein-rich components, an important part of which are snake venom metalloproteinases (SVMPs). These SVMPs, which are predominantly isolated from viperid venoms, are integral to the pathology of snakebites. However, SVMPs derived from elapid venoms have not been extensively explored, and only a handful of SVMPs have been characterized to date. Atrase A, a nonhemorrhagic P-III class metalloproteinase from Naja atra venom, exhibits weak proteolytic activity against fibrinogen in vitro but has pronounced anticoagulant effects in vivo. This contrast spurred investigations into its anticoagulant mechanisms. Research findings indicate that atrase A notably extends the activated partial thromboplastin time, diminishes fibrinogen levels, and impedes platelet aggregation. The anticoagulant action of atrase A primarily involves inhibiting coagulation factor VIII and activating the endogenous fibrinolytic system, which in turn lowers fibrinogen levels. Additionally, its effect on platelet aggregation further contributes to its anticoagulant profile. This study unveils a novel anticoagulant mechanism of atrase A, significantly enriching the understanding of the roles of cobra venom metalloproteinases in snake venom. Furthermore, these findings underscore the potential of atrase A as a novel anticoagulant drug, offering insights into the functional evolutions of cobra venom metalloproteinases.

New method to differentiate between lupus anticoagulants, progressive coagulation inhibitors and coagulation factor deficiencies in the mixing tests.

Mixing tests in activated partial thromboplastin time (APTT) are used for the differentiation between lupus anticoagulants (LA), coagulation inhibitors, and factor deficient samples with APTT prolongation. However, the indexes for the differentiation have not been established. The present study aimed to develop new mixing test indexes for the differentiation. Twenty-six LA-positive, 8 progressive coagulation factor VIII inhibitor, and 35 coagulation deficient samples were employed. APTT were measured for normal plasma, patient plasma, and mixing plasma prepared at a ratio of 1:1 proportion in both without incubation and 2 h-incubation. New two parameters named as ALD50 and mixture plasma-patient plasma after Warming change rate Subtraction (WaS) calculated from the clotting times of normal, 1:1 mixing and patient samples with/without 2 h-incubation were established. In the samples with WaS result of <10.2%, ALD50 of ≥87.8%, and < 87.8% were defined as LA and coagulation factor deficiency, respectively, and WaS of ≥10.2% defined progressive coagulation factor inhibitors. Sensitivity and specificity to LA were 80.8% and 93.0% for ALD50, and sensitivity and specificity to progressive coagulation factor inhibitor were 100.0% and 100.0% for WaS, respectively. The agreement between sample classification and WaS-ALD50 was 88.4% (61/69). ALD50 and WaS showed acceptable sensitivity and specificity to LA and progressive coagulation factor inhibitor, respectively. These indexes would be useful for the differentiation between LA, factor deficiency, and progressive coagulation factor inhibitor in the mixing tests.

Anticoagulant properties and therapeutic potentials of wasp venom

AbstractWasp venom is rich in bioactive substances, such as proteins, peptides, and small molecules. The venom significantly affects the mammalian cardiovascular, nervous, and immune systems, causing mild to severe symptoms following stings. It exhibits both procoagulant and anticoagulant activities, and significant research has identified its ability to modulate the mammalian coagulation system. Active substances that inhibit clotting have been identified and purified through patient case reports and experimental studies. This study reviewed the findings on how wasp venom interacts with platelets and coagulation factors, such as fibrinogen and prothrombin, and demonstrated its dual influence on the coagulation cascade. This highlights the potential of the venom in therapeutic applications, especially as an anticoagulant, as evidenced by the inhibition of coagulation factors and prolonged clotting times after envenomation, suggesting its utility in developing novel anticoagulant therapies. This review focuses on the anticoagulant effects of social wasp venom, which is prevalent in sting incidents, summarizing the research and observations on its therapeutic potential. This emphasizes the significance of further studies to identify and utilize venom components as innovative anticoagulant treatments.

Pharmacokinetics, pharmacodynamics, and safety of fesomersen, a novel antisense inhibitor of factor XI, in healthy Chinese, Japanese, and Caucasian volunteers.

The inhibition of coagulation factor XI (FXI) presents an attractive approach for anticoagulation as it is not expected to increase the risk of clinically relevant bleeding and is anticipated to be at least as effective as currently available anticoagulants. Fesomersen is a conjugated antisense oligonucleotide that selectively inhibits the expression of FXI. The article describes three clinical studies that investigated the safety, pharmacokinetic (PK), and pharmacodynamic (PD) profiles of fesomersen after subcutaneous (s.c.) injection to healthy participants. The studies included participants from diverse ethnic backgrounds (Caucasian, Japanese, and Chinese). Fesomersen demonstrated good safety and tolerability in all three studies. No major bleeding events were observed. After single-dose s.c. injection, fesomersen was rapidly absorbed into the systemic circulation, with maximum fesomersen-equivalent (fesomersen-eq) concentrations (Cmax) in plasma observed within a few hours. After reaching Cmax, plasma fesomersen-eq concentrations declined in a biphasic fashion. The PD analyses showed that the injection of fesomersen led to dose-dependent reductions in FXI activity and increases in activated partial thromboplastin time (aPTT). The maximum observed PD effects were reached between Day 15 and 30, and FXI activity and aPTT returned to near-baseline levels by Day 90 after a single dose. The PK/PD profiles after a single injection were similar among the various ethnic groups. Collectively, the study results suggest that fesomersen has a favorable safety profile and predictable and similar PK and PD profiles across Chinese, Japanese, and Caucasian participants.

Nutrition and Cardiovascular Disease: The Potential Role of Marine Bioactive Proteins and Peptides in Thrombosis Prevention.

Thrombus and cardiovascular diseases pose a significant health threat, and dietary interventions have shown promising potential in reducing the incidence of these diseases. Marine bioactive proteins and peptides have been extensively studied for their antithrombotic properties. They can inhibit platelet activation and aggregation by binding to key receptors on the platelet surface. Additionally, they can competitively anchor to critical enzyme sites, leading to the inhibition of coagulation factors. Marine microorganisms also offer alternative sources for the development of novel fibrinolytic proteins, which can help dissolve blood clots. The advancements in technologies, such as targeted hydrolysis, specific purification, and encapsulation, have provided a solid foundation for the industrialization of bioactive peptides. These techniques enable precise control over the production and delivery of bioactive peptides, enhancing their efficacy and safety. However, it is important to note that further research and clinical studies are needed to fully understand the mechanisms of action and therapeutic potential of marine bioactive proteins and peptides in mitigating thrombotic events. The challenges and future application perspectives of these bioactive peptides also need to be explored.

Inhibitory potential of recombinant and native peanut Bowman-Birk inhibitor against proteases of human blood coagulation pathway

Plant proteinase/protease inhibitors (PIs) have therapeutic potential besides their role in regulating endogenous protease activity in several physiological processes. They exert their function by inhibiting the catalytic activity of specific proteases. The use of PIs for inhibiting coagulation factors and slowing down the blood coagulation process has emerged as a critical intervention point for developing antithrombotic agents. The present study has demonstrated the characterization of bacterially expressed recombinant peanut Bowman-Birk inhibitor (rPnBBI) and evaluation of its anticoagulant potential compared to native PnBBI (isoinhibitors pool) purified from peanuts. The full-length BBI gene was cloned, and rPnBBI (7.53 kDa) expressed in the soluble fraction of Escherichia coli BL21 (DE3) strain was isolated by passing through the trypsin affinity column. The purified rPnBBI with β-sheets as major secondary structural elements exhibited inhibitory activity towards bovine trypsin and chymotrypsin at diverse pH and temperatures. Both, rPnBBI and PnBBI showed anticoagulant effects by prolonging the activated partial thromboplastin time (aPTT) and inhibiting the activity of proteases/factors (plasma kallikrein, FXIIa, FXIa, FIXa, and FXa) involved in the blood coagulation pathway. Besides, rPnBBI and PnBBI showed a similar inhibitory tendency towards FXIIa, FXIa, and FIXa, while rPnBBI exhibited a higher inhibition potential than PnBBI towards FXa. Contrarily, PnBBI showed higher inhibitory potential than rPnBBI on plasma kallikrein. Altogether, the bioactive BBI molecules from the natural food source peanuts showed significant anticoagulant potential, which could be exploited in the prophylaxis of thromboembolic disorders associated with various human diseases.

A Compound Heterozygosis of Two Novel Mutations in vWF Exacerbates vWD in a Chinese Pedigree.

von Willebrand disease (vWD), caused by mutations in the von Willebrand factor (vWF) coding gene, is a disease characterized by abnormal coagulation activity and a severe tendency for hemorrhage. Therefore, identifying mutations in vWF is important for diagnosing congenital vWD. We studied a 23-year-old male vWD patient and his parents. Clotting methods were used to determine activated partial thromboplastin time (aPTT), prothrombin time (PT), fibrinogen (FIB) levels, FVIII activity. Chromogenic substrate method was used to determine vWF antigen and activity. The platelet count was determined. Mutations were searched using whole-exome sequencing and certified by Sanger sequencing. Clinical data, including activated partial thromboplastin time (APTT), prothrombin time (PT), thrombin time (TT), fibrinogen levels, FX activity, FX antigen levels, and the platelet count were collected. A mixing study was performed to eliminate the presence of coagulation factor inhibitors and lupus anticoagulants. Mutations were screened by using whole-exome sequencing (WES) and were verified by using Sanger sequencing. The proband showed severely decreased vWF antigen, vWF activity, and FVIII activity. RIPA (RISTO-CETIN-induced platelet aggregation) was 0%. Data from WES showed that the proband carried compound heterozygous variants vWF: NM_000552.5 (c.3213C>A p.Cys1071Ter) and vWF: NM_000552.5 (c.6598+2T>C). The proband's mother carried variant vWF: NM_000552.5 (c.3213C>A p.Cys1071Ter) while the proband's father carried variant vWF: NM_000552.5 (c.6598+2T>C). All laboratory test indexes of the proband's parents, including vWF antigen, vWF activity, and FVIII activity, were within the normal ranges. We identified a compound heterozygosis with two novel mutations in vWF (c.3213C>A, c.6598+2T >C) in a family pedigree, and our results demonstrate that the compound heterozygous mutations probably exacerbate vWD.

Docking-based computational analysis of guava (Psidium guajava) leaves derived bioactive compounds as a coagulation factor IXa inhibitor.

Thrombotic disorders pose a global health threat, emphasizing the urgent need for effective management strategies. This study explores the potential of bioactive compounds derived from guava leaves in inhibiting coagulation factor IXa (CFIXa) using in silico methods. Using GC-MS, bioactive compounds extracted from guava leaf through ethanol maceration were identified. Pharmacokinetic properties were elucidated using SwissADME. Molecular docking with AutoDock Vina was used to investigate the interactions with CFIXa. CFIXa was modeled with pysimm/LAMMPS and analyzed with CastP for active site identification. The setup with a higher solvent concentration and lower surface area yielded the highest percent yield (78.541 g, 39.27%). Among the 28 identified bioactive compounds, predominantly terpenoids, only seven exhibited suitable pharmacokinetic properties for oral ingestion and drug development. Docking analysis revealed favorable binding of these compounds to CFIXa (-7.6:-5.3). This study shows inhibition of coagulation factor IXa, thus bridging the ambiguity surrounding the effect of guava leaves on hemostasis. These findings also reveal that guava leaf extract harbors bioactive compounds with potential as coagulation pathway inhibitors, promising novel avenues for thrombotic disorder management.

First-in-Human Study to Assess the Safety, Tolerability, Pharmacokinetics and Pharmacodynamics of Factor XI Monoclonal Antibody SHR-2004 in Healthy Subjects

Introduction: Thromboembolic disease is a major global health problem. Inhibition of coagulation factor XI (FXI) is a novel strategy for the prevention and treatment of thrombotic diseases without affecting exogenous coagulation pathways. SHR-2004 is ahumanized monoclonal antibody that selectively binds to FXI and FXIa, hindering the activation of FXI by FXIIa and thereby blocking the cascade amplification process of endogenous coagulation pathways and exerting anticoagulant effects. This first-in-human, phase I study aimed to assess the safety, tolerability, pharmacokinetics (PK), pharmacodynamics (PD) and immunogenicity of SHR-2004 in healthy Chinese subjects. Methods: This single-center, randomized, double-blind, dose-escalation, placebo-controlled study (NCT05369767; Figure 1) evaluated SHR-2004 adminstered intravenously (i.v., part A) or subcutaneously (s.c., part B). In part A, 24 healthy subjects (8 for each dose level) received single i.v. dose of SHR-2004 (0.1, 0.3 or 1.0 mg/kg) or placebo in a randomization ratio of 3:1. In part B, 40 subjects (10 for each dose level) received single s.c. dose of SHR-2004 (0.5, 1.0, 3.0 or 4.5 mg/kg) or placebo (4:1). The safety, tolerability, PK, PD and immunogenicity of SHR-2004 were assessed. Results: SHR-2004 was well tolerated at all tested doses, and all adverse events were mild. A total of 88 treatment-related adverse events (TRAEs) were reported in 35 of 50 subjects assigned to SHR-2004 (70.0% of subjects), and 20 TRAEs were reported in 8 of 14 subjects receiving placebo (57.1%). Two subjects in the SHR-2004 cohorts and one in the placebo cohort showed mild ecchymosis. There was no evidence of other clinically relevant bleeding events. The plasma exposure of SHR-2004 (maximum concentration, C max and area under the plasma concentration-time curve, AUC) increased in a dose-dependent manner for both i.v. and s.c. dose cohorts (Figure 2). The median time-to-peak concentration (T max) was 1.76 -2.79 hours after the start of i.v. infusion, and 4.0-6.5 days after s.c. injection, respectively. The mean elimination half-life (t 1/2) ranged from 12.4 to 13.2 days following i.v. infusion, and 11.7 to 12 days after s.c. injection. It was observed that FXI activity decreased and activated partial thromboplastin time (APTT) was prolonged after i.v. and s.c. administration in a dose- and time-dependent manner. In the 1.0 mg/kg i.v. cohort, FXI activity was almost completely inhibited immediately after completion of the infusion, with average APTT prolonged to nearly three times that of baseline, and these effects persisted until day 9. Following s.c. administration, more than 80% inhibition was achieved within 12h after injection in the 3 mg/kg and 4.5 mg/kg cohort, and the maximum inhibition was maintained to day 22 and day 29, respectively. Similarly, the APTT was prolonged more than 1.7-fold in a gentle and sustained manner from 12h post-dose to day 29 in the 3 mg/kg and 4.5 mg/kg dose levels. Conclusion: Single intravenous infusion (0.1-1.0 mg/kg) and subcutaneous injection (0.5-4.5 mg/kg) of SHR-2004 are safe and well tolerated. SHR-2004 showed predictable PK with a relatively slowly elimination, which supports administration once a month in the future clinical and market. The encouraging PD data demonstrated a fast and sustained anticoagulant effect. These data indicate that SHR-2004 is a promising candidate for further development as a potential anticoagulant drug, which is expected to minimize the risk of bleeding while maintaining effective anticoagulation.

Differentiation of Acquired Hemophilia a from Lupus Anticoagulant Using Global Coagulation Assays and Magnesium-Dependent Activated Partial Thromboplastin Time Assay

CONCLUSION Rapid and reliable differentiation between bleeding and thrombotic tendency in cases with prolonged activated partial thromboplastin time (APTT) remains challenging in clinical practice, in particular, distinguishing cases positive for coagulation factor inhibitor or lupus anticoagulant (LA). To differentiate acquired hemophilia A (AHA) from LA using three global coagulation assays: rotational thromboelastometry (ROTEM), thrombin generation assay (TGA), and clot waveform analysis (CWA); also to validate the effectiveness of magnesium-dependent APTT (APTT-Mg) assay. This method uses APTT-Mg and normal APTT using Ca to screen for LA, and APTT-Mg/APTT ratio is smaller in LA. We included patients with prolonged APTT without congenital coagulation factor deficiency who were referred to our department between November 2019 and September 2021. APTT prolongation was defined as &amp;gt;35 s (normal range: 25-35 s) measured routinely with Coagpia APTT-N (Sekisui Medical). The AHA group had a confirmed diagnosis and underwent treatment of AHA. The LA group was divided into LA1 (possible LA) and LA2 (definite LA). LA1 was defined by any of the following conditions: (1) index of circulation anticoagulant ≥15 in the cross-mixing test performed with Coagpia APTT-N; (2) positive dilute Russell's viper venom time (DRVVT) phospholipid neutralization method using Gladipore LA (Medical &amp; Biological Laboratories); (3) positive APTT phospholipid neutralization test using Hemosil SCT (Instrumentation Laboratory); (4) positive for anti-CL antibody; (5) positive for anti-CLβ2GPI antibody; or (6) positive for phosphatidylserine-dependent anti-PT antibody. LA2 was defined by index of circulation anticoagulant &amp;gt;12.4 in the cross-mixing test performed by Thrombocheck APTT-SLA (Sysmex Corporation), or item (2) or (3) above, in accordance with criteria of LA in the International Society of Thrombosis and Haemostasis. LA1 and LA2 did not overlap, because cases that did not meet the conditions of LA2 were treated as LA1, and global coagulation assays were performed in all LA cases. In the global coagulation assays, 12 healthy volunteer samples were tested and regarded as the normal goroup. For the APTT-Mg assay, equal volumes of 25 mmol MgCl 2 and 25 mmol CaCl 2 were used instead of the normally used CaCl 2, and Thrombocheck APTT-SLA was used to measure APTT-Mg, which was then divided by the normal APTT concentration measured with the same APTT reagent. Ten patients in the AHA, 12 in the LA1, and 32 in the LA2 groups were eligible. ROTEM showed that clotting time in the non-activated rotational thromboelastometry assay (NATEM) mode was &amp;gt;3600 s (minimum 1363 s) for AHA, 501 s (IQR: 430-632 s) for LA1, 533 s (IQR: 443-641 s) for LA2, and 500 s (IQR: 429-645 s) for the normal group. TGA showed that peak thrombin concentration was 16 nM (IQR: 13-29 nM) in the AHA group, 242 nM (IQR: 175-273 nM) in the LA1 group, 174 nM (IQR: 129-259 nM) in the LA2 group, and 190 nM (IQR: 125-288 nM) in the normal group. In the CWA, Ad|min1| was 2.1 (IQR: 1.7-3.2) in the AHA group, 8.7 (IQR: 8.0-9.5) in the LA1 group, 6.7 (IQR: 5.8-8.4) in the LA2 group, and 10.3 (IQR: 9.8-10.6) in the normal group. APTT-Mg/APTT was 1.23 (IQR: 1.18-1.29), 1.26 (IQR: 1.23-1.38), and 1.05 (IQR: 0.95-1.20) in the AHA, LA1, and LA2 groups, respectively. ROTEM, TGA, and CWA effectively differentiated between the LA1/2 and AHA groups. Clotting time in non-activated rotational thromboelastometry assay mode (ROTEM) and peak height (TGA) were better at distinguishing high-titer LA cases from LA-positive AHA cases. APTT-Mg/APTT could be suitable for distinguishing AHA from high-titer LA; however, it may not be useful for differentiating AHA from low-titer or suspected LA.

Structural properties of newly 4,7-dihydroxycoumarin derivatives as potential inhibitors of XIIa, Xa, IIa factors of coagulation

Some coumarin derivatives show notable anticoagulant properties through their ability to interrupt the enzymatic function of vitamin K epoxide reductase. The current challenge lies in the development of novel derivatives that are more efficient and less harmful, specifically targeting the direct inhibition of coagulation factors. This study examined the direct inhibitory potential of two recently synthesized coumarin derivatives, 3-(1-(3-hydroxy-4-methoxyphenyl)-amino)-ethyldiene)-2,4-dioxochroman-7-yl acetate (A-3OH) and 3-(1-(4-hydroxy-3-methoxyphenyl)-amino)-ethyldiene)-2,4-dioxochroman-7-yl acetate (A-4OH), according to coagulation factors IIa, Xa, and XIIa. Accurately defining the structural properties of compounds is of great importance for a comprehensive understanding of the biological activity of pharmaceutical agents. In regard, this study aimed to analyze the structural (Potential Energy Surface (PES)), spectroscopic (FT-IR, NMR, and UV–Vis), and electronic properties (Quantum Theory of Atoms in Molecules (QTAIM)) of two newly synthesized compounds. These properties are determined using a combination of experimental and theoretical methods (B3LYP-D3BJ/6–311++G(d,p) level of theory). The investigated compounds deviate from planarity based on the results of structural properties. The results of QTAIM analysis show the presence of partially covalent hydrogen bonds and closed-shell van der Waals interactions that stabilize the examined compounds. Based on the large correlation coefficient (R) and low mean absolute error (MAE) of the spectroscopic data showed that the applied level of theory effectively replicated the experimental finding. The results from the molecular docking study suggest that both compounds demonstrate similar inhibitory effects on IIa when compared to the standard inhibitor dabigatran (DAB). The efficacy of A-3OH in inhibiting Xa is similar to that of conventional inhibitors apixaban (API), and rivaroxaban (RIV). The observed inhibitory effect of both compounds on coagulation factor XIIa was more potent than that of the conventional co-crystallized inhibitor. The results of this study add to the understanding of the structure-activity relationship of coumarin derivatives and provide possibilities for enhancing anticoagulant therapy and clinical outcomes for coagulation-related illnesses. The findings lay a foundation for further in vitro and in vivo investigations into the anticoagulant activities of the compounds, contributing to their potential pharmaceutical application.

PB0705 Pharmacological Inhibition of Coagulation Factor XI Reduces Thromboinflammation in a Nonhuman Primate Model of Early Atherosclerosis

PB0705 Pharmacological Inhibition of Coagulation Factor XI Reduces Thromboinflammation in a Nonhuman Primate Model of Early Atherosclerosis

The Hemostatic System in Newborns and the Risk of Neonatal Thrombosis.

Newborns are the most vulnerable patients for thrombosis development among all children, with critically ill and premature infants being in the highest risk group. The upward trend in the rate of neonatal thrombosis could be attributed to progress in the treatment of severe neonatal conditions and the increased survival in premature babies. There are physiological differences in the hemostatic system between neonates and adults. Neonates differ in concentrations and rate of synthesis of most coagulation factors, turnover rates, the ability to regulate thrombin and plasmin, and in greater variability compared to adults. Natural inhibitors of coagulation (protein C, protein S, antithrombin, heparin cofactor II) and vitamin K-dependent coagulation factors (factors II, VII, IX, X) are low, but factor VIII and von Willebrand factor are elevated. Newborns have decreased fibrinolytic activity. In the healthy neonate, the balance is maintained but appears more easily converted into thrombosis. Neonatal hemostasis has less buffer capacity, and almost 95% of thrombosis is provoked. Different triggering risk factors are responsible for thrombosis in neonates, but the most important risk factors for thrombosis are central catheters, fluid fluctuations, liver dysfunction, and septic and inflammatory conditions. Low-molecular-weight heparins are the agents of choice for anticoagulation.

Considerations for simultaneous detection of autoantibodies to coagulation factor and lupus anticoagulant

In patients with autoimmune coagulation factor deficiency (AiCFD), the production of autoantibodies that inhibit coagulation factors in the blood reduces the activity of those relevant coagulation factors, resulting in severe bleeding symptoms. Recently, reports of patients with AiCFD have noted the concomitant detection of lupus anticoagulant (LA), a risk factor for thrombosis. LA-positive patients may show bleeding symptoms due to decreased activity of coagulation factor II (FII) caused by autoantibodies against FII, in addition to thrombotic symptoms, a condition termed LA-hypoprothrombinemia syndrome (LAHPS). Anti-FII antibodies in LAHPS cases are frequently cleared antibodies that can be detected using immunological techniques, such as enzyme-linked immunosorbent assay (ELISA). Recently, several cases of coagulation FV inhibitors, known as autoimmune FV deficiency, have been reported. Some of these cases may be complicated by LA, which can cause thrombosis. False-positive results for anticoagulant inhibitors are known to occur in LA cases; therefore, immunological confirmation of antibodies against coagulation factors is recommended. Additionally, acquired hemophilia A (AHA), caused by autoantibodies against FVIII, is a typical acquired hemorrhagic diathesis, although affected patients may present with thrombosis associated with LA. Thus, it is important to remember that hemorrhagic diathesis due to autoantibodies against clotting factors can also result in thrombosis, as demonstrated by the co-detection of LA. When clotting factor inhibitors are detected in LA-positive individuals, it is important to confirm the presence of autoantibodies against coagulation factors using immunological methods, such as ELISA, to avoid false-positive results.

BLEEDING DISORDERS A scare or properly reassured

In an attempt to distinguish between ALL, CML, CLL,AML, ITP, DIC, hemophilia A, hemophilia B, vonWillebrand disease, Microangiopathic Hemolytic Anemia,Bernard-Soulier syndrome, Glanzmann thrombasthenia,Vitamin K deficiency, Heparin-inducedthrombocytopenia, Coagulation Factor Inhibitor, andFactor 5 Leiden, might influence the decision to work asa consultant clinical pathologist. Since most patientswith bleeding disorders are at risk for post-surgicalbleeding, CNS bleeding, post-trauma bleeding,nosebleeds (epistaxis), death from liver illness(hemorrhage), etc., it might become challenging formed school students or junior doctors to diagnose.When performing any type of invasive or non-invasiveprocedure, including emergency or elective surgery,hospitals, clinics, and the relevant junior doctors andmedical students must treat these illnesses as theprimary focus of care and conduct routine blood tests,platelet count, PT, PTT, hemoglobin, bleeding time, and,if necessary, a bone marrow biopsy. An abnormalristocetin test (for Von Willebrand disease) and a Ddimer test (for DIC) can be considered. It needs properinterpretation with a strong command of concepts,evaluation, and then diagnosis.