Measurement Of Thrombin Generation Research Articles

Protein S contributes to the paradoxical increase in thrombin generation by low-dose dabigatran in the presence of thrombomodulin.

Low dose of dabigatran paradoxically increased thrombin generation through inhibition of protein C activation. Protein S is a co-factor in the activation of protein C. However, the role of protein S in the enhancement of thrombin generation has not been addressed. Firstly, we measured thrombin generation by calibrated automated thrombinography (CAT) and prothrombin fragments 1+2 (F1+2) assays. Secondly, we assessed activated protein C (APC) formation in normal or protein S-deficient plasma spiking with dabigatran. Then, protein C activation was measured. Finally, heavy chain of factor Va (FVa) and its degradation products were detected by western blot. CAT assay showed that 70-141 ng/ml dabigatran paradoxically increased thrombin generation in normal plasma. However, higher concentrations of dabigatran (283 ng/ml) suppressed the level of ETP. F1+2 assay showed the similar results. In protein S-deficient or protein C-deficient plasma, the paradoxical increase in thrombin generation was absent. Level of generated APC was to a similar extent inhibited by dabigatran in normal and protein S-deficient plasma. Low-dose dabigatran inhibited the protein S-dependent inactivation of factor Va. Protein S participated in the paradoxical enhancement of thrombin generation in normal plasma spiking with low concentrations of dabigatran. Increased thrombin generation at low dabigatran can be explained by reduced thrombin-thrombomodulin mediated APC formation and subsequent reduced FVa inactivation that is protein S-dependent.

Mathematical models of coagulation—are we there yet?

BackgroundMathematical models of coagulation have been developed to mirror thrombin generation in plasma, with the aim of investigating how variation in coagulation factor levels regulates hemostasis. However, current models vary in the reactions they capture and the reaction rates used, and their validation is restricted by a lack of large coherent datasets, resulting in questioning of their utility. ObjectivesTo address this debate, we systematically assessed current models against a large dataset, using plasma coagulation factor levels from 348 individuals with normal hemostasis to identify the causes of these variations. MethodsWe compared model predictions with measured thrombin generation, quantifying and comparing the ability of each model to predict thrombin generation, the contributions of the individual reactions, and their dependence on reaction rates. ResultsWe found that no current model predicted the hemostatic response across the whole cohort and all produced thrombin generation curves that did not resemble those obtained experimentally. Our analysis has identified the key reactions that lead to differential model predictions, where experimental uncertainty leads to variability in predictions, and we determined reactions that have a high influence on measured thrombin generation, such as the contribution of factor XI. ConclusionThis systematic assessment of models of coagulation, using large dataset inputs, points to ways in which these models can be improved. A model that accurately reflects the effects of the multiple subtle variations in an individual’s hemostatic profile could be used for assessing antithrombotics or as a tool for precision medicine.

A specific fluorescence resonance energy quenching–based biosensor for measuring thrombin activity in whole blood

BackgroundAt sites of vessel injury, thrombin acts as the central mediator of coagulation by catalyzing fibrin clot formation and platelet activation. Thrombin generation is most frequently measured in plasma samples using small-molecule substrates; however, these have low specificity for thrombin and limited utility in whole blood. Plasma assays are limited because they ignore the hemostatic contributions of blood cells and require anticoagulation and the addition of supraphysiological concentrations of calcium. ObjectivesTo overcome these limitations, we designed and characterized a fluorescence resonance energy quenching–based thrombin sensor (FTS) protein. MethodsThe fluorescence resonance energy quenching pair of mAmetrine and tTomato, separated by a thrombin recognition sequence, was developed. The protein was expressed using Escherichia coli, and purity was assessed using sodium dodecyl sulfate–polyacrylamide gel electrophoresis. The cleavage of FTS was monitored by fluorescence using excitation at 406 nm and emission at 526 nm and 581 nm. ResultsCompared with small-molecule substrates, the FTS demonstrated high specificity for thrombin; it is not cleaved by thrombin or inhibited by α2-macroglobulin and interacts with thrombin’s anion-binding exosite I. The FTS can effectively measure thrombin generation in plasma and in finger-prick whole blood, which allows it to be developed into a point-of-care test of thrombin generation. The FTS does not inhibit standard thrombin-generation assays. Lastly, FTS-based thrombin generation in nonanticoagulated finger-prick blood was delayed but enhanced compared with that in citrated plasma. ConclusionThe FTS will broaden our understanding of thrombin generation in ways that are not attainable with current methods.

Comparative analysis of andexanet alfa and prothrombin complex concentrate in reversing anticoagulation by rivaroxaban ex vivo

BackgroundThe comparative effectiveness of the specific antidote andexanet alfa vs the nonspecific therapy four-factor prothrombin complex concentrates (4F-PCCs) as reversal agents for direct factor Xa (FXa) inhibitors in severely bleeding patients is unclear. We hypothesised that specific reversal using andexanet alfa would be more effective than a high dose of PCC (50 IU kg−1) for reversing the FXa inhibitor rivaroxaban. MethodsThe reversal potential of andexanet alfa, various 4F-PCCs, and activated PCC was investigated ex vivo in human blood anticoagulated with rivaroxaban (37.5, 75, 150, and 300 ng ml−1) using a panel of coagulation parameters, including conventional coagulation assays, thrombin generation, and a newly developed viscoelastometric device. We simulated in vivo conditions of coagulation activation and fibrin formation using flow chamber experiments of thrombogenicity potential under arterial flow conditions. ResultsThe 4F-PCCs normalised clotting profiles only at low rivaroxaban concentrations, whereas andexanet alfa and activated PCC significantly shortened clotting time at all rivaroxaban concentrations. Only andexanet alfa restored thrombin generation to baseline. Flow chamber results showed that various 4F-PCCs concentration-dependently restored clot formation. ConclusionsIn contrast to thrombin generation measurements, haemostatic reversal of rivaroxaban using high-dose 4F-PCCs exhibited similar efficacy as andexanet alfa in flow chamber experiments. The haemostatic effects of 4F-PCCs and andexanet alfa in the context of bleeding patients taking FXa inhibitors requires further study.

A Short Thrombin Generation Time-to-Peak/Lag Time Ratio Is an Independent Risk Factor for Mortality in the General Population

Background Thrombin generation (TG) is used to detect small changes in coagulation indicating a bleeding or prothrombotic phenotype. Until now, large prospective studies are missing to study the association of TG parameters with the occurrence of future cardiovascular events and mortality. In this study, we investigated the prospective value of TG measured in baseline plasma samples of a large cohort (n=20,991) with overall mortality (1,098; 5.3%) with a median follow-up of 8.2 years. Methods Thrombin generation was measured by calibrated automated thrombinography (CAT) using PPP Reagent low. The lag time (LT), endogenous thrombin potential (ETP), peak height, time-to-peak (TTP) and velocity index (VI) were quantified. Subjects on anticoagulant therapy were excluded from analysis, because this affects the measurement of TG. Cox regression was used to analyze differences in survival in subjects according to their variations in the TG parameters. The reported results are obtained from a crude model considering only single TG parameters standardized for their standard deviation, and from a final multivariable model further adjusted for sex, age, BMI, smoking, contraceptive use, antiplatelet medication and medical history (hypertension, hypercholesterolemia, diabetes, history of cardiovascular diseases or cancer). Results The TG lag time at 1 pM tissue factor was 4.1 min ± 1.0 on average, and the peak height was 363 nM ± 89. The time-to-peak was 6.6 min ± 1.6 on average, the velocity index was 163 nM/min ± 63 and the endogenous thrombin potential was 1717 nM·min ± 415. The SD-standardized lag time was significantly associated with mortality risk in the crude model (HR LT=1.09; CI:1.03-1.16; p=0.002) and after adjustment for all covariates, including medical history (HR LT=1.09; CI: 1.03-1.15; p=0.002). In contrast, a short time-to-peak was significantly associated with reduced mortality risk (HR TTP=0.92; CI: 0.86-0.98; p=0.012). As the opposite associations of LT and TTP with mortality could have a synergistic effect on the mortality risk, we combined the variables into the novel TTP/LT-ratio. The mean TTP/LT ratio was 1.61 ± 0.14. The hazard ratio for mortality decreased by 40% for each standard deviation increment of the TTP/LT-ratio in the crude model (HR ratio=0.606; CI:0.562-0.654; p<0.001), and by 18% in the fully adjusted model (HR ratio=0.824; CI: 0.766-0.887; p<0.001). The TTP/LT-ratio variable was divided in quintiles for further analysis: Quintile 1 included subjects up to a TTP/LT-ratio of 1.50, quintile 2 ranged from 1.50 to 1.58, quintile 3 ranged from 1.58 to 1.62, quintile 4 ranged from 1.62 to 1.70, and quintile 5 consisted of subjects with a TTP/LT-ratio above 1.70. Subjects in TTP/LT-ratio quintile 1 had an increased mortality risk (HR ratio_Q1vsQ5 =2.96; CI: 2.42-3.63; p<0.001), even after full adjusting (HR ratio_Q1vsQ5 =1.46; CI: 1.18-1.79; p<0.001; Figures 1 and 2). Moreover, subjects in TTP/LT-ratio quintile 2, have a similar statistically significant, although less pronounced increase risk for mortality in the crude model (HR ratio_Q1vsQ5 =2.17; CI: 1.18-2.68; p<0.001) and the fully adjusted model (HR ratio_T2vsT5 =1.29; CI: 1.04-1.60; p=0.019; Figure 1). Conclusion A prolonged TG lag time and a shortened time-to-peak in the general population and within the normal ranges are risk factors for mortality. The combination of a long LT and a short TTP results in a low TTP/LT-ratio, which was identified as an independent risk factor for increased mortality risk in the general population.

Measuring Thrombin Generation in Platelet Rich Plasma with the ST Genesia

Background: Thrombin generation (TG) is nowadays used more and more for diagnosing and monitoring of patients. The ST Genesia is a fully automated device for measuring TG in platelet poor plasma (PPP). As the samples are not being inverted prior to the measurement once loaded in the device, it was not known whether it was possible to measure TG in platelet rich plasma (PRP). Platelets can sediment in time possibly affecting TG results. The goal of this study was to evaluate the use of the ST Genesia for measuring TG in PRP in time and to investigate whether the assay is sensitive to platelet antagonists. Methods: Blood was taken from 6 healthy donors and PRP was immediately prepared by centrifuging the blood once for 15 minutes at 220g. The PRP was divided into 14 tubes: 11 tubes for measuring TG in time; i.e. after 0, 15, 30, 45, 60, 75, 90, 105, 120, 180, 240 minutes after the samples were loaded on board; 1 tube for platelet count measurement, 1 tube for TG with the Calibrated Automated Thrombogram (CAT) assay and 1 tube for freezing the PRP. The PRP reagent of the CAT assay was used for triggering TG that contains a low tissue factor concentration. Tukey's multiple comparisons test was used for statistical analysis. Results: The platelet count remained stable in time even without inverting the vial prior to the measurement up to 3 hours. After 4 hours, platelet count was significantly lower (p<0.01). TG in PRP remained stable in time up to 3 hours, after that lagtime and time-to-peak were extended by an average of 48% and 16%, respectively (p-values <0.0001 and 0.0121, respectively), while ETP and peak height remained stable (with low CV's of <6.0% and <7.3%, respectively). The ST Genesia proved to be sensitive to platelet antagonists aspirin (100µM) and Cangrelor (500nM) as peak height decreased with 22% and 24%, respectively. TG measured with the CAT and the ST Genesia was comparable. Measuring TG in PRP after being frozen at -80°C resulted TG kinetics similar to TG in PPP, with a shorter lagtime (-67%) and time-to-peak (-64%), with an increased peak height (+82%), and velocity index (+383%), and an unaffected ETP. Conclusion: The ST Genesia can be used for the reproducible measurement of TG in PRP up to two hours after loading the samples in the device.

Augmented thrombin formation is related to circulating levels of extracellular vesicles exposing tissue factor and citrullinated histone-3 in anti-neutrophil cytoplasmic antibody-associated vasculitides.

To study circulating myeloperoxidase (MPO)-positive extracellular vesicles (MPO+EVs) exposing citrullinated histone-3 (H3Cit), tissue factor (TF), and plasminogen (Plg) in association to thrombin generation in patients with anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV). We have involved well-characterized patients with AAV together with population-based controls. Flow cytometry was used to assess the levels of MPO+EVs in citrated plasma. MPO+EVs were phenotyped by anti-MPO-antibodies together with anti-CD142 (anti-TF), anti-H3Cit, and anti-Plg antibodies. A modified Calibrated Automated Thrombogram (CAT) assay was utilized to measure thrombin generation in plasma initiated by EVs-enriched pellets. The activity of AAV was evaluated with the Birmingham Vasculitis Activity Score (BVAS). This study comprised 46 AAV patients, 23 in the active stage of the disease and 23 in remission, as well as 23 age- and sex matched population-based controls. Augmented levels of all investigated MPO+ EVs were found in active AAV patients in comparison to the subgroup of patients in remission and controls. Thrombin generation, measured by endogenous thrombin potential (ETP) and peak of thrombin formation, was higher in plasma when triggered by EVs-enriched pellet from AAV patients. ETP and peak were associated with the levels of MPO+TF+ and MPO+H3Cit+ EVs. Additionally, MPO+TF+ EVs correlated with the disease activity evaluated with BVAS. Augmented thrombin generation is found in AAV patients regardless of disease activity and is associated with higher exposure of TF and H3Cit on MPO+EVs. This may contribute to the increased risk of thrombosis seen in AAV patients.

Thrombin Generation Is Associated with Venous Thromboembolism Recurrence, but Not with Major Bleeding and Death in the Elderly: A Prospective Multicenter Cohort Study.

It is currently unknown whether thrombin generation is associated with venous thromboembolism (VTE) recurrence, major bleeding, or mortality in the elderly. Therefore, our aim was to prospectively study the association between thrombin generation and VTE recurrence, major bleeding, and mortality in elderly patients with acute VTE. Consecutive patients aged ≥65 years with acute VTE were followed for 2 years, starting from 1 year after the index VTE. Primary outcomes were VTE recurrence, major bleeding, and mortality. Thrombin generation was assessed in 551 patients 1 year after the index VTE. At this time, 59% of the patients were still anticoagulated. Thrombin generation was discriminatory for VTE recurrence, but not for major bleeding and mortality in non-anticoagulated patients. Moreover, peak ratio (adjusted subhazard ratio 4.09, 95% CI, 1.12-14.92) and normalized peak ratio (adjusted subhazard ratio 2.18, 95% CI, 1.28-3.73) in the presence/absence of thrombomodulin were associated with VTE recurrence, but not with major bleeding and mortality after adjustment for potential confounding factors. In elderly patients, thrombin generation was associated with VTE recurrence, but not with major bleeding and/or mortality. Therefore, our study suggests the potential usefulness of thrombin generation measurement after anticoagulation completion for VTE to help identify among elderly patients those at higher risk of VTE recurrence.

Abacavir use is associated with increased prothrombin conversion.

There is ongoing debate as to whether abacavir (ABC) increases the risk for cardiovascular disease(CVD) in people living with HIV (PLHIV) and the mechanisms underlying this possible association. We recently showed that the use of an ABC-containing regimen was independently associated with increased thrombin generation (TG). In the present study, we aim to explore these findings further, by studying the mechanistical processes that underly the global thrombin generation test via thrombin dynamics analysis. Thrombin dynamics analysis can pinpoint the cause of increased thrombin generation associated with ABC-use either to the procoagulant prothrombin conversion pathway or the anticoagulant thrombin inactivation pathway. In this cross-sectional study, 208 virally suppressed PLHIV were included, of whom 94 were on a ABC-containing regimen, 92 on a tenofovir disoproxil fumarate (TDF)-containing regimen, and the remainder on other regimens. We used Calibrated Automated Thrombinography to measure thrombin generation and perform thrombin dynamics analysis. The total amount of prothrombin conversion, as well as the maximum rate of prothrombin conversion were significantly increased in PLHIV on an ABC containing regimen compared to other treatment regimens. The levels of pro- and anticoagulant factors were comparable, indicating that the ABC-induced changes affect the kinetics of prothrombin conversion rather than procoagulant factor levels. Moreover, Von Willebrand Factor (VWF), active VWF and VWF pro-peptide levels were significantly higher in PLHIV than controls without HIV. However, they did not differ between ABC and non-ABC treated participants.

The clinical usefulness of measuring thrombin generation

Not available.

Anticoagulant Activity of Nucleic Acid Nanoparticles (NANPs) Assessed by Thrombin Generation Dynamics on a Fully Automated System.

Rapidly reversible anticoagulant agents have great clinical potential. Oligonucleotide-based anticoagulant agents are uniquely positioned to fill this clinical niche, as they are able to be deactivated through the introduction of the reverse complement oligo. Once the therapeutic and the antidote oligos meet in solution, they are able to undergo isothermal reassociation to form short, inactive, duplexes that are rapidly secreted via filtration by the kidneys. The formation of the duplexes interrupts the structure of the anticoagulant oligo, allowing normal coagulation to be restored. To effectively assess these new anticoagulants, a variety of methods may be employed. The measurement of thrombin generation (TG) reflects the overall capacity of plasma to produce active thrombin and provides a strong contribution to identifying new anticoagulant drugs, including DNA/RNA thrombin binding aptamer carrying fibers which are used through this chapter as an example. Here we describe the TG assessed by Calibrated Automated Thrombogram (CAT) assay in a fully automated system. This method is based on the detection of TG in plasma samples by measuring fluorescent signals released from a quenched fluorogenic thrombin substrate and the subsequent conversion of these signals in TG curves.

Point-of-Care Platform for Diagnosis of Venous Thrombosis by Simultaneous Detection of Thrombin Generation and D-Dimer in Human Plasma.

Venous thromboembolism (VTE) refers to a blood clot that starts in a vein. The risk of developing VTE is highest after major surgery or a major injury, or when someone has heart failure, cancer, or infectious disease (e.g., COVID-19). Without prompt treatment to break up clots and prevent more from forming, VTE can restrict or block blood flow and oxygen, which can damage the body tissue or organs. VTE can occur without any obvious signs, and imaging technologies are used. Alternatively rapid measurement of thrombin generation (TG) and D-dimer could be used to make a fast, portable, and easy-to-use diagnostic platform for VTE. Here, we have demonstrated a diagnostic sensing platform with the ability of simultaneous detection of TG and D-dimer in human plasma. Modifications were made to both the assay protocols to eliminate the need for sample dilution and incubation steps. Using a substantially reduced sample volume, the measurement results show comparable performance to the gold standard method. Our platform is able to deliver accurate and cost-effective results for both TG and D-dimer assays when using undiluted plasma in under 15 min. The assays presented are therefore a good candidate technology for use in a point-of-care platform to diagnose VTE.

A Novel Substrate for Assessing Thrombin Activity in Whole Blood

At sites of vessel injury, thrombin acts as the central mediator of coagulation through catalyzing fibrin clot formation and platelet activation. Currently, thrombin generation is measured using small molecule substrates. These substrates are limited in that they detect both active thrombin and thrombin bound to its inhibitor α2-macroglobulin (α2-M) and have limited utility in whole blood (Ninivaggi et al. Clin Chem 2012). In addition, these substrates contain short thrombin recognition sequences ranging from 3-4 amino acids and are unable to form additional exosite interactions with thrombin, which limit their specificity (Gallwitz et al. Plos One 2012). Furthermore, they are unfeasible for in vivo use because their hydrophobicity allows them to enter cells. However, plasma assays are limited because they ignore the hemostatic contributions of red blood cells, platelets and leukocytes and require anticoagulation and the addition of exogenous coagulation activators (Swystun & Liaw. Blood 2016 & do Amaral et al. Stem Cells Int 2016). Thus, we have developed a fluorescence resonance energy transfer (FRET)-based thrombin sensor to overcome these limitations. We cloned and expressed the construct encoding the FRET-based thrombin substrate in Escherichia coli and purified the substrate using affinity chromatography. We confirmed using Sodium dodecyl sulfate−polyacrylamide gel electrophoresis that the substrate was successfully purified and that thrombin cleavage of the purified substrate changes its FRET efficiency by monitoring its spectrum of emission. To determine whether the FRET-based thrombin substrate can form interactions with thrombin's anion binding exosites and assess its potential for in vivo use, we measured the kinetics parameters of the substrate for thrombin in the presence of exosite inhibitors and thrombin's exosite variants as well as mouse thrombin and plasmin. We then compared the resulting kinetics parameters with commercially available thrombin substrates S2238 and technothrombin. We show that unlike S2238 and technothrombin, our FRET-based thrombin sensor forms strong interactions with thrombin's anion binding exosite I and displays preference for free thrombin compared to thrombomodulin (TM) bound thrombin which implied its preference for procoagulant thrombin rather than anticoagulant TM bound thrombin that activates protein C. Furthermore, our FRET-based thrombin substrate has potential to be used in mouse models because it can be efficiently cleaved by mouse thrombin and is relatively plasmin resistant. To assess the specificity of the FRET-based thrombin substrate for thrombin, we compared the rate of hydrolysis of the substrate by thrombin and several other enzymes in circulation and compared the results to S2238 and technothrombin. Our results indicated that when compared to commercially available thrombin substrates, our FRET-based thrombin substrate is highly specific for thrombin. Since the thrombin inhibitor α2-M is present in circulation, we also compared the rate of hydrolysis of the 3 substrates for α2-M bound thrombin and free thrombin. Unlike S2238 and technothrombin, our FRET-based thrombin substrate is uncleaved by α2-M bound thrombin. The key properties of the FRET-based thrombin substrate in comparison to S22238 and technothrombin are summarized in Table 1. We then measured thrombin generation in plasma using our FRET-based thrombin substrate and showed that it is sensitive to direct oral anticoagulants in ways that are consistent with literature findings where thrombin generation was measured using technothrombin (Sivaraja et al. Plos One 2018 & Douxfils et al. Thromb Res 2012). We also confirmed that the FRET-based thrombin substrate itself is not a coagulation inhibitor since its presence did not alter thrombin generation parameters measured using technothrombin. Lastly, we confirmed that the FRET-based thrombin substrate can measure thrombin generation in whole blood since it successfully produced thrombin generation curves. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Serial thrombin generation and exploration of alternative anticoagulants in critically ill COVID-19 patients: Observations from Maastricht Intensive Care COVID Cohort.

BackgroundCOVID-19 associated coagulopathy (CAC) is associated with an increase in thromboembolic events. Current guidelines recommend prophylactic heparins in the management of CAC. However, the efficacy of this strategy in the intensive care population remains uncertain.ObjectiveWe aimed to measure thrombin generation (TG) to assess CAC in intensive care unit (ICU) patients receiving thromboprophylaxis with low molecular weight heparin (LMWH) or unfractionated heparin (UFH). In addition, we performed statistical modeling to link TG parameters to patient characteristics and clinical parameters. Lastly, we studied the potency of different anticoagulants as an alternative to LMWH treatment in ex vivo COVID-19 plasma.Patients/MethodsWe included 33 patients with confirmed COVID-19 admitted at the ICU. TG was measured at least twice over the course of 6 weeks after admission. Thrombin generation parameters peak height and endogenous thrombin potential (ETP) were compared to healthy controls. Results were subsequently correlated with a patient characteristics and laboratory measurements. In vitro spiking in TG with rivaroxaban, dabigatran, argatroban and orgaran was performed and compared to LMWH.ResultsAnti-Xa levels of all patients remained within the therapeutic range throughout follow-up. At baseline, the mean (SE) endogenous thrombin potential (ETP) was 1,727 (170) nM min and 1,620 (460) nM min for ellagic acid (EA) and tissue factor (TF), respectively. In line with this we found a mean (SE) peak height of 353 (45) nM and 264 (96) nM for EA and TF. Although fluctuating across the weeks of follow-up, TG parameters remained elevated despite thromboprophylaxis. In vitro comparison of LMWHs and direct thrombin inhibitors (e.g., agratroban, dabigatran) revealed a higher efficacy in reducing coagulation potential for direct thrombin inhibition in both ellagic acid (EA) and tissue factor (TF) triggered TG.ConclusionIn a sub-group of mechanically ventilated, critically ill COVID-19 patients, despite apparent adequate anti-coagulation doses evaluated by anti-Xa levels, thrombin generation potential remained high during ICU admission independent of age, sex, body mass index, APACHE II score, cardiovascular disease, and smoking status. These observations could, only partially, be explained by (anti)coagulation and thrombosis, inflammation, and multi-organ failure. Our in vitro data suggested that direct thrombin inhibition compared with LMWH might offer an alternate, more effective anticoagulant strategy in COVID-19.

THROMBIN PRODUCTION VARIES ACROSS AN IVF CYCLE AND A SIGNIFICANT DIFFERENCE IS NOTED WITH WOMEN WHO CONCEIVE VERSUS THOSE WHO DO NOT

To measure thrombin generation across time points of in vitro fertilization (IVF) and to investigate differences between women who do and do not conceive.

Assessing the individual roles of FII, FV, and FX activity in the thrombin generation process.

Thrombin generation (TG) is known as a physiological approach to assess the hemostatic function. Although it correlates well with thrombosis and bleeding, in the current setup it is not sensitive to the effects of fluctuations in single coagulation factors. We optimized the calibrated automated thrombinography (CAT) method to quantify FII, FV and FX activity within the coagulation system. The CAT assay was fine-tuned for the assessment of FII, FV and FX by diluting the samples in FII-, FV-, or FX-deficient plasma, respectively, and measuring TG. Plasma FII levels correlated linearly with the ETP up to a plasma concentration of 100% FII. FV and FX levels correlated linearly with the peak height up to a plasma level of 2.5% FV and 10% FX, respectively. Sensitized CAT protocols were designed by adding a fixed volume of a pre-diluted patient sample to FII, FV, and FX deficient plasma in TG experiments. This approach makes the TG measurement dependent on the activity of the respective coagulation factor. The ETP or peak height were quantified as readouts for the coagulation factor activity. The intra- and inter-assay variation coefficients varied from 5.0 to 8.6%, and from 3.5 to 5.9%, respectively. Reference values were determined in 120 healthy subjects and the assays were clinically validated in 60 patients undergoing coronary artery bypass grafting (CABG). The sensitized CAT assays revealed that the contribution of FII, FV, and FX to the TG process was reduced after CABG surgery, leading to reduced prothrombin conversion and subsequently, lower TG.

Combined oral contraceptives containing estradiol valerate vs ethinylestradiol on coagulation: A randomized clinical trial.

Contraceptives containing ethinylestradiol (EE) induce changes in the coagulation system and are associated with a risk of venous thromboembolism. However, studies comparing the effects of combined oral contraceptives containing EE and low-potency estrogens (ie, estradiol [E2 ] and estradiol valerate [EV]) on coagulation biomarkers are limited. This study represents secondary outcomes of a randomized trial comparing combined oral contraceptives containing EV + dienogest (DNG), EE + DNG, and DNG alone on selected coagulation biomarkers. We could compare the specific effects of the different estrogen components owing to the inclusion of preparations containing the same progestin. We enrolled 59 healthy, 18- to 35-year-old, non-smoking women, of whom three discontinued. The participants were randomly allocated to 9 weeks of continuous treatment with EV 2mg + DNG 2-3mg (n= 20), EE 0.03 mg + DNG 2mg (n= 20), or DNG 2mg (n= 19). Blood samples were collected at baseline and after 9 weeks. We assessed coagulation in vitro by thrombin generation using the Calibrated Automated Thrombogram. Thrombin generation was evaluated by lag time, time to thrombin peak, thrombin peak, and endogenous thrombin potential in response to tissue factor (1pm). In vivo coagulation assessment was based on levels of prothrombin fragment 1+2 (F1 +2) (thrombin generation) and D-dimer (fibrin turnover). NCT02352090. Lag time and time to thrombin peak remained unaltered after exposure to EV + DNG, whereas EE + DNG shortened both lag time (mean percentage change -24%, 95% confidence interval [CI] -32% to -15%; p< 0.01) and time to thrombin peak (-26%, 95% CI -37% to -16%; p< 0.01). EV + DNG induced lower thrombin peak and endogenous thrombin potential than EE + DNG (peak; +45%, 95% CI 22%-67% vs +147%,95% CI 96%-198%; p< 0.01, and endogenous thrombin potential; +26%, 95% CI 15%-38% vs +64%, 95% CI 51%-76%; p< 0.01). Median F1 +2 levels remained unchanged with EV + DNG (p= 0.22) but increased within normal ranges with EE + DNG (from 152 pmol/L, 95% CI 127-206]pmol/L to 194 pmol/L, 95% CI 149-250 pmol/L, p= 0.04). The within-group change in D-dimer levels was not significant in any of the groups. DNG alone did not affect these biomarkers. Both in vitro and in vivo thrombin generation was lower after exposure to EV + DNG compared with EE + DNG. The lower thrombin generation measures after treatment with EV + DNG indicate less enhancement of coagulation potential and suggest that EV may be favorable to EE as a component of combined oral contraceptives.

Semi-automated thrombin dynamics applying the ST Genesia thrombin generation assay.

BackgroundThe haemostatic balance is an equilibrium of pro- and anticoagulant factors that work synergistically to prevent bleeding and thrombosis. As thrombin is the central enzyme in the coagulation pathway, it is desirable to measure thrombin generation (TG) in order to detect possible bleeding or thrombotic phenotypes, as well as to investigate the capacity of drugs affecting the formation of thrombin. By investigating the underlying processes of TG (i.e., prothrombin conversion and inactivation), additional information is collected about the dynamics of thrombin formation.ObjectivesTo obtain reference values for thrombin dynamics (TD) analysis in 112 healthy donors using an automated system for TG.MethodsTG was measured on the ST Genesia, fibrinogen on the Start, anti-thrombin (AT) on the STA R Max and α2Macroglobulin (α2M) with an in-house chromogenic assay.ResultsTG was measured using STG-BleedScreen, STG-ThromboScreen and STG-DrugScreen. The TG data was used as an input for TD analysis, in combination with plasma levels of AT, α2M and fibrinogen that were 113% (108–118%), 2.6 μM (2.2 μM−3.1 μM) and 2.9 g/L (2.6–3.2 g/L), respectively. The maximum rate of the prothrombinase complex (PCmax) and the total amount of prothrombin converted (PCtot) increased with increasing tissue factor (TF) concentration. PCtot increased from 902 to 988 nM, whereas PCmax increased from 172 to 508 nM/min. Thrombin (T)-AT and T-α2M complexes also increased with increasing TF concentration (i.e., from 860 to 955 nM and from 28 to 33 nm, respectively). PCtot, T-AT and T-α2M complex formation were strongly inhibited by addition of thrombomodulin (−44%, −43%, and −48%, respectively), whereas PCmax was affected less (−24%). PCtot, PCmax, T-AT, and T-α2M were higher in women using oral contraceptives (OC) compared to men/women without OC, and inhibition by thrombomodulin was also significantly less in women on OC (p < 0.05).ConclusionsTG measured on the ST Genesia can be used as an input for TD analysis. The data obtained can be used as reference values for future clinical studies as the balance between prothrombin conversion and thrombin inactivation has shown to be useful in several clinical settings.

Patients With Multiple Myeloma Have a Disbalanced Whole Blood Thrombin Generation Profile.

BackgroundMultiple myeloma (MM) is associated with a high prevalence of bleeding and an increased risk of thrombo-embolism. MM patients have reduced platelet- and red blood cell (RBC) numbers in blood, which may indicate that the paradoxical hemostasis profile is a consequence of a disturbed platelet and RBC homeostasis.ObjectivesTo get better insight in the disbalanced hemostasis of MM patients.MethodsWe conducted a case-control study on the whole blood (WB) coagulation profiles of 21 MM patients and 21 controls. We measured thrombin generation (TG) in WB and platelet poor plasma (PPP) of MM patients and controls.ResultsIn WB-TG, we observed that the median time to the thrombin Peak was 52% longer in MM patients than in controls, while the median endogenous thrombin potential until the Peak (ETPp) was 39% higher in MM-patients than in controls. In line with these findings, the levels of platelets, RBCs, white blood cells and agonist induced platelet activation were decreased in MM patients compared to controls. The plasma TG experiments showed no differences between MM-patients and controls.ConclusionPatients with MM have a disturbed blood cell metabolism and a disbalanced WB-TG profile. This disbalance may explain the paradoxically high prevalence of bleeding symptoms in MM patients vs. an increased thrombosis risk. There was no disturbance observed in plasma TG, indicating that blood cells are the major determinants for the disbalanced hemostasis in MM patients.

P1693: THROMBOMODULIN RESISTANCE: A NEW PROTHROMBOTIC PATHWAY IN COVID-19

Background: Hypercoagulability and endothelial dysfunction have been shown to be closely related and both are considered as one of the main factors influencing the severity of COVID-19 patients. Thrombomodulin, among other factors, plays a key role as an anticoagulant factor through activation of protein C and subsequent limitation of thrombin generation. The endothelium also exerts anticoagulant activity under normal conditions. However, in COVID-19 patients, especially the most severe ones, the inflammatory process has been shown to trigger the release of the cytokine ANGPT2 through the endothelium, leading to the arrest of thrombomodulin and thus contributing to the prothrombotic state. Indeed, recent studies suggest that ANGPT2 inhibition may be explored as a therapeutic target for COVID-19 patients and other hypercoagulable diseases. However, to date there are no studies evaluating the role of thrombomodulin in COVID-19 hypercoagulability. Aims: To analyze thrombomodulin resistance in hospitalized COVID-19 patients by thrombin generation test and correlation with disease severity. Methods: Forty-two hospitalized COVID-19 patients on admission were included in the study. Blood samples were anticoagulated by trisodium citrate, and immediately centrifugated for platelet poor plasma, and frozen at -80ºC until analysis. The hemostatic profile of patients was determined by routine laboratory techniques and the Quantra® Hemostasis Analyzer. Thrombomodulin resistance was assessed by comparing Endogenous Thrombin Potential (ETP) with/without thrombomodulin using GENESIA® analyzer. Student’s t-test or Mann-Whitney U-test were used for comparison of means. Correlation was evaluated by Spearman correlation coefficient. Need for mechanical ventilation, ICU admission, encephalitis, thrombosis or death were considered as adverse events. Results: 23.8% of patients (n=10) had an adverse event during hospitalization. Patients with and without adverse events showed similar ETP (1615 vs 1486; P=0.257). However, the thrombin generation study with thrombomodulin revealed a higher ETP in patients with adverse event (1237.8 vs 786.9 mA; P=0.002). Consistent with this result, these patients showed a higher resistance to thrombomodulin with a lower % inhibition of ETP compared to patients without adverse event (24.3 vs 47.6; P=0.003). In fact, 100% of patients with adverse events showed <40% inhibition of ETP with thrombomodulin (P<0.001). Patients with a poor prognosis also showed a higher thrombin-peak (352.9 vs 310.6 nM; P=0.038), with an even more notable difference in the presence of thrombomodulin (308.6 vs 197.9 nM; P=0.006). In addition, these patients had a significantly higher thrombin generation velocity (247.8 vs. 144.3 nM/min; P=0.004) and consequently a shorter time to peak (4.4 vs 5.4 min; P=0.042). Notably, lower % inhibition by thrombomodulin and higher thrombin peak correlated significantly with higher clot stiffness measured by Quantra® (R=0.372, P=0.017 and R=0.320, P=0.042, respectively). ETP in the presence of thrombomodulin proved to be a good predictor of an adverse event during admission with an AUC of 0.791 (P<0.001). Summary/Conclusion: Measurement of thrombin generation can be a powerful tool for the analysis of patients with COVID-19 on admission and thus for risk stratification. Increased thrombomodulin resistance is associated with the presence of an adverse event in patients and may be considered as new independent prognostic marker.