Coagulation

Key Points
Physiologic hemostasis consists of the plasma coagulation, fibrinolysis, and the anticoagulation protein systems. Physiologic hemostasis is initiated by factor VIIa and tissue factor Physiologic hemostasis is not fully represented by current assays to detect coagulation abnormalities such as aptt and pt

Key points
Current assays to assess coagulation protein abnormalities have good diagnostic power to recognize specific defects in coagulation proteins Acquired coagulation protein defects more commmonly reflect general medical disorders than specific protein defects

Physiologic hemostasis
Coagulation = Fibrinolysis Anticoagulation Cellular: platelets, endothelium, granulocytes, monocytes Protein: clotting factors, fibrinolytic factors, and natural anticoagulants

Endothelium: natural anticoagulant properties

Glycosaminoglycans binds anti-thrombin III Thrombomodulin=protein C activated by low levels of thrombin Secretes ectonucleotidase which degrades ADP Secretes prostacyclin and N.O.=prevents plt activation Binds fibrinolytic agents: plasminogen, tissue plasminogen activator, single chain urokinase

Role of platelets
Vessel injury platelets adhere to collagen vWF sticks plt to collagen adhesion activates plts plt granules released to generate thrombin on surface plts aggregate and form plug

Role of coagulation proteins

Tissue factor upregulated at site of injury TF+factor 7(a) activates factor 9 activates factor 10 in the presence of factor 5(a) converts prothrombin to thrombin

Proteins of the Plasma Coagulation System

Surface-Bound Zymogens Factor XII Prekallikrein Factor XI Vitamin K-Dependent Zymogens Factor VII Factor IX Factor X Factor II Protein C Cofactors/Substrates High M, kininogen Factor VIII Factor V Fibrinogen Protein S

Coagulation Protein System

Vit K dependent factors exist as phospholipid bound zymogens on the surface of cells and cell membranes. Among the surface bound factors, only deficiency of factor 11 is clinically associated with bleeding. Co-factors act as receptors for zymogens: factors 8(a) and 5(a) for 9(a) and 10(a). Factors 5 and 8 are substrates of thrombin.

Physiologic Protein Assemblies

Tenase complex=activates factor 10 assembly: factor 9(a) + thrombin activated factor 8(a) on phospholipid/cell membrane Prothrombinase complex=accelerates prothrombin conversion to thrombin assembly: factor 10(a) + thrombin activated factor 5(a) on phospholipid/cell membrane

Prothrombinase complex

FX(a) + FV(a) Prothrombin------- Thrombin

Tenase Compex
Extrinsic Tenase Tissue Factor + FVII(a) Factor X----------------------Factor X(a) Intrinsic Tenase F IX(a) + VIII(a) Factor X-----------------------Factor X(a)

 Physiologic protein assemblies: 1. critical regulatory points 2. targets of anticoagulant agents being developed

Formation of Fibrin
Thrombin cleaves fibrinopeptide A and B from fibrinogen soluble fibrin monomers acted upon by factor 13 insoluble clot

Fibrinolytic system
Plasminogen converted to plasmin by: 1. tPA tissue plasminogen activator 2. ScuPA single chain urokinase plasminogen activator 3. TcuPA two chain urokinase plasminogen activator All found in endothelium, granulocytes and monocytes

Substrates of plasmin
1. fibrinogen X fragment from D and E then Y fragment to form soluble D and E(fibrinogen degradation products) or fibrin degaration products if acted on fibrin 2. Fibrin liberates soluble D-D dimer 3. Soluble D-D dimer insoluble D-D dimer(indicative of D.I.C.)

Anticoagulant protein system

1. Protein C/S system: activated system reduces thrombin formation and stimulate fibrinolysis 2. Plasma serine protease inhibitor(antithrombin III): inhibits factors 2(a), 10(a), 7(a), 9(a), 11(a), kallikrein and 12(a). Note: heparin potentiates anti-thrombin III

Current Hypothesis for the initiation of the Hemostatic System

Tissue Factor Pathway

Usual causes of bleeding

1. defect/deficiency of coag proteins 2. Defect of platelet number and function 3. Defect in adhesive interactions between platelets and vessel wall

Coagulation protein Defect

1. True protein deficiency 2. Inhibitor to protein usually Ig. Acquired inhibitors are seen in hypergammaglobulinemia, abnormal endogenous production of heparin, fibronectin, cryoglobulin 3. Enhanced clearance due to Ag-Ab complex 4. Abnormal protein due to mutation

Hereditary Coagulation Protein Defects

Hemophilia A Hemophilia B

Acquired Coagulation Protein Deficiencies

1. 2. 3. 4. 5. D.I.C. Liver Disease Vit K deficiency Massive Transfusion Acquired Coagulation Protein inhibitors

Blood Platelets and von Willebrands Disease

Key Points
Platelets are highly complex cells that participate in critical reactions central to hemostasis and thrombosis, including adhesion to subendothelium, secretion of granule contents, aggregation, and provision of membrane surface for activation of coagulation factors.

Key points
Abnormalities of either platelet number or platelet function can play an important role in the balance of hemostasis and thrombosis Almost unique to laboratory medicine and pathology, assessment of platelet pathology may be determined in real time upon living cells obtained from the patient

Key Points
Von Willebrand factor is a multimeric protein synthesized by endothelial cells and megakaryocytes that plays a central role in platelet adhesive interactions Platelet counts and platelet function are affected by auto-immune processes, a wide variety of drugs, and a number of acquired disorders

Platelet biology
Glycocalyx rich in glycoproteins: source of adhesive glycoproteins(congenital bleeding or increased thrombotic risk) Phospholipid: procoagulant effect Granules: alpha= ADP and Calcium dense=fibrinogen, vWF, P-selectin

Platelet activation
Thrombin change platelet shape release of granules, conformational change of glycoprotein IIb/IIIa complex receptors to coagulation proteins, fibrinogen and P-selectin occur at the surface

Laboratory Exams for Platelets

Platelet count and mean platelet volume Bleeding time= no predictive value; can not be relied upon Platelet aggregation studies for Glanzmann thrombasthenia Clot retraction time for thrombocytopenia and Glanzmann thrombasthenia

Quantitative Platelet Disorders

Congenital thrombocytopenia= usually due to mutations; accompanies a lot of syndromes like May-Hegglin anomaly. Fletcher, Bernard Soulier ITP Drug induced thrombocytopenia Heparin induced thrombocytopenia

 Thrombotic thrombocytopenic purpura= deficient activity of plasma vWF cleaving metalloproteinase(ADAMTS-13); this binds platelets and produce platelet thrombi in the microcirculation; also seen in connective tissue disease and D.I.C.

thrombocytosis
Transient: acute blood loss, rebound from thrombocytopenia, acute infection/inflammation, response to exercise Sustained: iron deficiency, hemolytic anemia, asplenia, CA, chronic inflammation/infection

Disorders of platelet adhesion

Bernard Soulier Syndrome: abnormal platelet GP Ib-IX complex which mediates binding of vWF to platelet Abnormal GP Ia/IIa and GP VI= no response to collagen

Von Willebrand s Disease

3 types are known Type 1= partial quantitative defect Type 2 has 4 subtypes= qualitative deficiency Type 3= complete deficiency

Glanzmann thrombasthenia
Quantitative or qualitative defect in the GP IIb and IIIa Autosomal recessive Markedly impaired platelet aggregation Prolonged bleeding time Severe mucocutaneous bleeding

Acquired disorders of Platelet Function

Myeloproliferative Disorders Acute leukemias and Myelodysplastic syndromes Dysproteinemias Uremia Acquired storage pool disease: antiplatelet antibodies, SLE, chronic ITP, D.I.C., leukemias

Drugs that affect platelet function

Pls refer to table 39-9 page 764 of 21st edition of Henry

Table 39-9 -- Drugs That Affect Platelet Function Cyclooxygenase inhibitors Aspirin Nonsteroidal anti-inflammatory agents Indomethacin, phenylbutazone, ibuprofen, sulfinpyrazone, sulindac, meclofenamic acid ADP receptor antagonists Ticlopidine, clopidogrel GP IIb/IIIa receptor antagonists c7E3 (abciximab), tirofiban, eptifibatride Drugs that increase platelet cyclic AMP or cyclic GMP Adenylate cyclase activators Prostaglandins I2, D2, E1 and analogs Phosphodiesterase inhibitors Dipyridamole Cilostazol Anagrelide Milrinone Methyl xanthines Caffeine, theophylline, aminophylline Nitric oxide and nitric oxide donors Antimicrobials Penicillins Cephalosporins Nitrofurantoin Hydroxychloroquine Miconazole Cardiovascular drugs -Adrenergic blockers (propranolol) Vasodilators (nitroprusside, nitroglycerin) Diuretics (furosemide)

Calcium channel blockers Quinidine Angiotensin converting enzyme inhibitors Anticoagulants Heparin Thrombolytic agents Streptokinase, tissue plasminogen activator, urokinase Psychotropics and anesthetics Tricyclic antidepressants Imipramine, amitriptyline, nortriptyline Phenothiazines Chlorpromazine, promethazine, trifluoperazine Local anesthetics General anesthesia (halothane) Chemotherapeutic agents Mithramycin Carmustine Daunorubicin Miscellaneous agents Dextrans and hydroxyethyl starch Lipid lowering agents (clofibrate, halofenate) -Aminocaproic acid Antihistaminics Ethanol Vitamin E Radiographic contrast agents Food items (omega-3 fatty acids, vitamin E, onions, garlic, ginger, cumin, turmeric, cloves, black tree fungus, Ginko) Source: with permission from Rao AK: Acquired disorders of platelet function. In Colman RW (ed.): Hemostasis and Thrombosis: Basic Principles and Clinical Practice. Philadelphia, Lippincott Williams & Wilkins, 2006

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