Activation of the Contact Pathway in Patients Treated With t-PA or Streptokinase may Attenuate Clot Lysis

Abstract Introduction Current studies on acute burn induced coagulopathy are discordant and often rely on laboratory tests examining fragments of the coagulation cascade. Viscoelastic measures such as thromboelastography (TEG) provide dynamic assessments and are used increasingly at the point-of-care. Clotting activators such as kaolin are used to decrease time to measurement. The aim of this work is to identify the impact of burns on coagulation over time using native (nTEG) or contact pathway activated kaolin TEG (kTEG) Methods A cohort of burn injured patients (n=156) presenting to a regional burn center from 2012 to 2017 were enrolled. Whole blood was assessed at set intervals from admission to 72 hours. Demographic data, injury characteristics, and laboratory measures were obtained from the medical chart. Blood samples underwent viscoelastic assay with both nTEG and kTEG. Patients were stratified into high (>40%, n=33) and low (n=123) total body surface area (TBSA) burn categories. Statistical analyses of viscoelastic parameters (R, α, MA, and LY30) were performed using mixed-effect models. P-values < 0.05 were considered significant. Results Of the 156 thermally injured patients, most were male (71%) with a mean age of 42.5 ±16.5 years, and a mean TBSA burn of 23.3 ±24.6%. Overall mortality was 13.3% (n=21). There were no significant differences in nTEG/kTEG R time or nTEG maximum amplitude (MA) between groups. nTEG showed lower α-angle values in patients in the high TBSA group until hour 24 and this difference was significant at Hour 0 (63.9 ±10.4° vs. 68.3 ±8.3°, p = 0.05). kTEG showed lower α-angles until hour 24 in the high TBSA group, at which point there was a transition to higher α-angle in the high TBSA group (67.7 ±5.9° vs. 71.6 ±4.6° vs., p = 0.03). MA trended lower in the high TBSA group on kTEG and this difference was significant on admission (53.6 ± 11.0 mm vs. 59.6 ±8.1 mm; P=0.02) and hour 2 (51.9 ±14.4 mm vs. 60.3 ±9.2 mm; P=0.006). Clot lysis at 30 minutes (LY30) was variable on admission but significantly lower in the high TBSA group on both kTEG (p=0.004) and nTEG (p=0.001) at Hour 72. Conclusions No difference in time to clot initiation (R) was observed between burn size cohorts. However, rate of clot development (α) and maximal clot strength (MA) were reduced during the first 24 hours in patients with larger burns. After 24 hours, increased MA and reduced fibrinolysis (LY30) in blood from patients with larger burns, suggested a transition from a relatively hypo-coagulable state to a potentially prothrombotic state by 72 hours. Applicability of Research to Practice kTEG may provide better resolution in the detection of burn induced coagulopathy. Further work to assess the applicability of TEG data to direct therapeutic interventions will depend on fully characterizing the extent to which TEG parameters correlate with the clinical coagulopathy.

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Activation of the contact pathway in patients treated with t-PA or streptokinase may attenuate clot lysis

Journal of the American College of Cardiology ◽

10.1016/s0735-1097(98)80314-8 ◽

1998 ◽

Vol 31 ◽

pp. 452

Author(s):

M.P. Latacha ◽

W.T. Schaiff ◽

G.A. Ewald ◽

D.R. Abendschein ◽

P.R. Eisenberg

Keyword(s):

Clot Lysis ◽

Contact Pathway

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Polyphosphate enhances fibrin clot structure

Blood ◽

10.1182/blood-2008-03-145755 ◽

2008 ◽

Vol 112 (7) ◽

pp. 2810-2816 ◽

Cited By ~ 146

Author(s):

Stephanie A. Smith ◽

James H. Morrissey

Keyword(s):

Fibrin Clot ◽

Factor Xiiia ◽

Clot Lysis ◽

Factor V ◽

Scanning Electron Micrographs ◽

Dependent Manner ◽

Dense Granules ◽

Contact Pathway ◽

Clot Structure ◽

Fibrin Clots

Abstract Polyphosphate, a linear polymer of inorganic phosphate, is present in platelet dense granules and is secreted on platelet activation. We recently reported that polyphosphate is a potent hemostatic regulator, serving to activate the contact pathway of blood clotting and accelerate factor V activation. Because polyphosphate did not alter thrombin clotting times, it appeared to exert all its procoagulant actions upstream of thrombin. We now report that polyphosphate enhances fibrin clot structure in a calcium-dependent manner. Fibrin clots formed in the presence of polyphosphate had up to 3-fold higher turbidity, had higher mass-length ratios, and exhibited thicker fibers in scanning electron micrographs. The ability of polyphosphate to enhance fibrin clot turbidity was independent of factor XIIIa activity. When plasmin or a combination of plasminogen and tissue plasminogen activators were included in clotting reactions, fibrin clots formed in the presence of polyphosphate exhibited prolonged clot lysis times. Release of polyphosphate from activated platelets or infectious microorganisms may play an important role in modulating fibrin clot structure and increasing its resistance to fibrinolysis. Polyphosphate may also be useful in enhancing the structure of surgical fibrin sealants.

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Differential Role of Components of the Fibrinolytic System in the Formation and Removal of Thrombus Induced by Endothelial Injury

Thrombosis and Haemostasis ◽

10.1055/s-0037-1614532 ◽

1999 ◽

Vol 81 (04) ◽

pp. 601-604 ◽

Cited By ~ 55

Author(s):

Hiroyuki Matsuno ◽

Osamu Kozawa ◽

Masayuki Niwa ◽

Shigeru Ueshima ◽

Osamu Matsuo ◽

...

Keyword(s):

Plasminogen Activator ◽

Thrombus Formation ◽

Endothelial Injury ◽

Fibrinolytic System ◽

Tissue Type ◽

Clot Lysis ◽

Wild Type ◽

Type Plasminogen Activator ◽

Pai 1

SummaryThe role of fibrinolytic system components in thrombus formation and removal in vivo was investigated in groups of six mice deficient in urokinase-type plasminogen activator (u-PA), tissue-type plasminogen activator (t-PA), or plasminogen activator inhibitor-1 (PAI-1) (u-PA-/-, t-PA-/- or PAI-1-/-, respectively) or of their wild type controls (u-PA+/+, t-PA+/+ or PAI-1+/+). Thrombus was induced in the murine carotid artery by endothelial injury using the photochemical reaction between rose bengal and green light (540 nm). Blood flow was continuously monitored for 90 min on day 0 and for 20 min on days 1, 2 and 3. The times to occlusion after the initiation of endothelial injury in u-PA+/+, t-PA+/+ or PAI-1+/+ mice were 9.4 ± 1.3, 9.8 ± 1.1 or 9.7 ± 1.6 min, respectively. u-PA-/- and t-PA-/- mice were indistinguishable from controls, whereas that of PAI-1-/- mice were significantly prolonged (18.4 ± 3.7 min). Occlusion persisted for the initial 90 min observation period in 10 of 18 wild type mice and was followed by cyclic reflow and reocclusion in the remaining 8 mice. At day 1, persistent occlusion was observed in 1 wild type mouse, 8 mice had cyclic reflow and reocclusion and 9 mice had persistent reflow. At day 2, all injured arteries had persistent reflow. Persistent occlusion for 90 min on day 0 was observed in 3 u-PA-/-, in all t-PA-/- mice at day 1 and in 2 of the t-PA-/-mice at day 2 (p <0.01 versus wild type mice). Persistent patency was observed in all PAI-1-/- mice at day 1 and in 5 of the 6 u-PA-/- mice at day 2 (both p <0.05 versus wild type mice). In conclusion, t-PA increases the rate of clot lysis after endothelial injury, PAI-1 reduces the time to occlusion and delays clot lysis, whereas u-PA has little effect on thrombus formation and spontaneous lysis.

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Platelet-Bound Prekallikrein Promotes Pro-Urokinase-Induced Clot Lysis: A Mechanism for Targeting the Factor XII Dependent Intrinsic Pathway of Fibrinolysis

Thrombosis and Haemostasis ◽

10.1055/s-0038-1642441 ◽

1994 ◽

Vol 71 (03) ◽

pp. 347-352 ◽

Cited By ~ 36

Author(s):

Jean-Pierre Loza ◽

Victor Gurewich ◽

Michael Johnstone ◽

Ralph Pannell

Keyword(s):

Platelet Rich Plasma ◽

Specific Inhibitor ◽

Specific Effect ◽

Clot Lysis ◽

Factor Xii ◽

Intrinsic Pathway ◽

Clot Retraction ◽

Enzymatic Mechanism ◽

Low Concentrations ◽

Factor Xiia

SummaryClots formed from platelet rich plasma were found to be lysed more readily by low concentrations of pro-urokinase (pro-UK) than clots formed from platelet poor plasma. This was not a non-specific effect since the reverse occurred with tissue plasminogen activator. A mechanical explanation due to platelet-mediated clot retraction was excluded by experiments in which retraction was inhibited with cyto-chalasin B. Therefore, a platelet-mediated enzymatic mechanism was postulated to explain the promotion of fibrinolysis. Casein autography of isolated platelets revealed a ≈ 90 kDa band of activity which comigrated with plasma prekallikrein (PK)/kallikrein, a known activator of pro-UK. Furthermore, treatment of platelets with plasma PK activator (PPA), consisting essentially of factor XIIa, induced activation of pro-UK and of chromomgenic substrate for kallikrein (S-2302). This activity corresponded to approximately 40-200 pM kallikrein per 10 8 washed and gel filtered platelets per ml. The activation of pro-UK by PPA-pretreated platelets was dose-dependent and inhibited by soybean trypsin inhibitor but not by bdellin, a specific inhibitor of plasmin, nor by the corn inhibitor of factor XIIa. Kinetic analysis of pro-UK activation by kallikrein showed promotion of the reaction by platelets. The KM of the reaction was reduced by platelets by ≈ 7-fold, while the kcat was essentially unchanged. In conclusion, PK was shown to be tightly associated with platelets where it can be activated by factor XIIa during clotting. The activation of pro-UK by platelet-bound kallikrein provides an explanation for the observed platelet mediated promotion of pro-UK-induced clot lysis. Since pro-UK and plasminogen have also been shown to be associated with platelets, the present findings suggest a mechanism by which the factor Xlla-dependent intrinsic pathway of fibrinolysis can be localized and targeted to a thrombus.

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Expression and Characterization of Clustered Charge-to-Alanine Mutants of Low Mr Single-Chain Urokinase-Type Plasminogen Activator

Thrombosis and Haemostasis ◽

10.1055/s-0038-1642397 ◽

1994 ◽

Vol 71 (01) ◽

pp. 134-140 ◽

Cited By ~ 6

Author(s):

S Ueshima ◽

P Holvoet ◽

H R Lijnen ◽

L Nelles ◽

V Seghers ◽

...

Keyword(s):

Plasminogen Activator ◽

Solvent Accessibility ◽

Site Directed Mutagenesis ◽

Clot Lysis ◽

Wild Type ◽

Single Chain ◽

Charged Amino Acids ◽

Type Plasminogen Activator ◽

Urokinase Type Plasminogen Activator ◽

Pharmacokinetic Properties

SummaryIn an effort to modify the fibrinolytic and/or pharmacokinetic properties of recombinant low M r single-chain urokinase-type plasminogen activator (rscu-PA-32k), mutants were prepared by site-directed mutagenesis of clusters of charged amino acids with the highest solvent accessibility. The following mutants of rscu-PA-32k were prepared: LUK-2 (Lys 212, Glu 213 and Asp 214 to Ala), LUK-3 (Lys 243 and Asp 244 to Ala), LUK-4 (Arg 262, Lys 264, Glu 265 and Arg 267 to Ala), LUK-5 (Lys 300, Glu 301 and Asp 305 to Ala) and LUK-6 (Arg 400, Lys 404, Glu 405 and Glu 406 to Ala).The rscu-PA 32k moictic3 were expressed in High Five Ttichoplasiani cells, and purified to humugciicily from the conditioned cell culture medium, with recoveries of 0.8 to 3.7 mg/1. The specific fibrinolytic activities (220,000 to 300,000 IU/mg), the rates of plasminogen activation by the single-chain moieties and the rates of conversion In lwo chain moieties by plasmin were comparable for mutant and wild-type rscu PA 32k moieties, with the exception of LUK-5 which was virtually inactive. Equi-effective lysis (50% in 2 h) of 60 pi 125I-fibrin labeled plasma clots submerged in 0.5 ml normal human plasma was obtained with 0.7 to 0.8 μg/ml of wild-type or mutant rscu-PA-3?.k, except with LUK-5 (no significant lysis with 16 pg/ml). Following bolus injection in hamsters, all rscu-PA-32k moieties had a comparably rapid plasma clearance (1.3 to 2.7 ml/min), as a result of a short initial half-life (1.4 to 2.5 min). In hamsters with pulmonary embolism, continuous intravenous infusion over 60 min at a dose of 1 mg/kg, resulted in 53 to 72% clot lysis with the mutants, but only 23% with LUK-5, as compared to 36% for wild-type rscu-PA-32k.These data indicate that clustered charge-to-alanine mutants of rscu-PA-32k, designed to eliminate charged regions with the highest solvent accessibility, do not have significantly improved functional, fibrinolytic or pharmacokinetic properties.

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Activated Protein C Increases Fibrin Clot Lysis by Neutralization of Plasminogen Activator Inhibitor No Evidence for a Cofactor Role of Protein S

Thrombosis and Haemostasis ◽

10.1055/s-0038-1647055 ◽

1988 ◽

Vol 60 (02) ◽

pp. 328-333 ◽

Cited By ~ 44

Author(s):

N J de Fouw ◽

Y F de Jong ◽

F Haverkate ◽

R M Bertina

Keyword(s):

Plasminogen Activator ◽

Protein C ◽

Blood Platelets ◽

Plasminogen Activator Inhibitor ◽

Protein S ◽

Tissue Type ◽

Clot Lysis ◽

Activator Inhibitor ◽

Pai 1

summaryThe effect of purified human activated protein G (APC) on fibrinolysis was studied using a clot iysis system consisting of purified glu-plasminogen, tissue-type plasminogen activator, plasminogen activator inhibitor (released from endothelial cells or blood platelets), fibrinogen, 125T-fibrinogen and thrombin. All proteins were of human origin.In this system APC could increase fibrinolysis in a dose dependent way, without affecting fibrin formation or fibrin crosslinking. However, this profibrinolytic effect of APC could only be observed when plasminogen activator inhibitor (PAI-l) was present. The effect of APC was completely quenched by pretreatment of APC with anti-protein C IgG or di-isopropylfluorophosphate. Addition of the cofactors of APC:protein S, Ca2+-ions and phospholipid-alone or in combination did not enhance the profibrinolytic effect of APC. These observations indicate that human APC can accelerate in vitro clot lysis by the inactivation of PAI-1 activity. However, the neutralization of PAI-1 by APC is independent of the presence or absence of protein S, phospholipid and Ca2+-ions.

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Recombinant Variants of Tissue-Type Plasminogen Activator Containing Amino Acid Substitutions in the Finger Domain

Thrombosis and Haemostasis ◽

10.1055/s-0038-1646342 ◽

1992 ◽

Vol 68 (06) ◽

pp. 672-677 ◽

Cited By ~ 4

Author(s):

Hitoshi Yahara ◽

Keiji Matsumoto ◽

Hiroyuki Maruyama ◽

Tetsuya Nagaoka ◽

Yasuhiro Ikenaka ◽

...

Keyword(s):

Amino Acid ◽

Plasminogen Activator ◽

Half Life ◽

Tissue Type ◽

Clot Lysis ◽

Amino Acid Substitutions ◽

Wild Type ◽

Plasma Clot ◽

Tissue Type Plasminogen Activator ◽

Type Plasminogen Activator

SummaryTissue-type plasminogen activator (t-PA) is a fibrin-specific agent which has been used to treat acute myocardial infarction. In an attempt to clarify the determinants for its rapid clearance in vivo and high affinity for fibrin clots, we produced five variants containing amino acid substitutions in the finger domain, at amino acid residues 7–9, 10–14, 15–19, 28–33, and 37–42. All the variants had a prolonged half-life and a decreased affinity for fibrin of various degrees. The 37–42 variant demonstrated about a 6-fold longer half-life with a lower affinity for fibrin. Human plasma clot lysis assay estimated the fibrinolytic activity of the 37–42 variant to be 1.4-fold less effective than that of the wild-type rt-PA. In a rabbit jugular vein clot lysis model, doses of 1.0 and 0.15 mg/kg were required for about 70% lysis in the wild-type and 37–42 variant, respectively. Fibrinogen was degraded only when the wild-type rt-PA was administered at a dose of 1.0 mg/kg. These findings suggest that the 37–42 variant can be employed at a lower dosage and that it is a more fibrin-specific thrombolytic agent than the wild-type rt-PA.

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A Collaborative Study to Establish the 2nd International Standard for Tissue Plasminogen Activator (t-PA)

Thrombosis and Haemostasis ◽

10.1055/s-0038-1646067 ◽

1987 ◽

Vol 58 (04) ◽

pp. 1085-1087 ◽

Cited By ~ 23

Author(s):

P J Gaffney ◽

A D Curtis

Keyword(s):

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Collaborative Study ◽

Chinese Hamster ◽

World Health ◽

Clot Lysis ◽

Expert Committee ◽

Single Chain ◽

International Standard ◽

Tissue Plasminogen

SummaryAn international collaborative study involving ten laboratories located in eight different countries was undertaken in order to replace the current International Standard (I.S.) for tissue plasminogen activator (t-PA). Two lyophilised candidate preparations of high purity were assessed in comparison with the current I.S. for t-PA using only a clot lysis assay. One preparation (coded 861670) was purified from a cultured melanoma cell supernatant and was about 98% single chain t-PA while the other preparation (coded 861624) was derived from Chinese hamster ovary (CHO) cells following DNA recombinant procedures and was 75% single chain t-PA.Both candidate preparations of t-PA compared in quite a satisfactory manner with the current I.S. from the viewpoint of the biometrics of parallel line bioassays and both preparations were quite stable for long periods at low temperatures and stable from up to 1 month at temperatures of 20° and 38° C. Both fultil the criteria to serve as a satisfactory Znd International Standard for t-PA. The Fibrinolysis Subcommittee of the International Committee for Thrombosis and Haemostasis recommended the melanoma source t-PA (861670) as the next I.S. in order to maintain continuity with the 1st I.S. which was also a melanomatype preparation. The data from the ten laboratories indicated that each ampoule of the new proposed standard contains 850 international units of t-PA activity by the clot lysis assay. It is planned to present the results of this study to the Expert Committee on Biological Standardization of the World Health Organization at its next meeting and to request that the preparation of t-PA, coded 861670, be established as the 2ndlnternational Standard for t-PA.

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A Collaborative Study to Establish the Second International Standard for Streptokinase

Thrombosis and Haemostasis ◽

10.1055/s-0038-1647298 ◽

1990 ◽

Vol 64 (02) ◽

pp. 267-269 ◽

Cited By ~ 7

Author(s):

A B Heath ◽

P J Gaffney

Keyword(s):

High Purity ◽

Collaborative Study ◽

World Health Organisation ◽

World Health ◽

Clot Lysis ◽

Current Standard ◽

International Standard ◽

Accelerated Degradation ◽

The World ◽

International Collaborative Study

SummaryAn International Standard for Streptokinase - Streptodomase (62/7) has been used to calibrate high purity clinical batches of SK since 1965. An international collaborative study, involving six laboratories, was undertaken to replace this standard with a high purity standard for SK. Two candidate preparations (88/826 and 88/824) were compared by a clot lysis assay with the current standard (62/7). Potencies of 671 i.u. and 461 i.u. were established for preparations A (88/826) and B (88/824), respectively.Either preparation appeared suitable to serve as a standard for SK. However, each ampoule of preparation A (88/826) contains a more appropriate amount of SK activity for potency testing, and is therefore preferred. Accelerated degradation tests indicate that preparation A (88/826) is very stable.The high purity streptokinase preparation, coded 88/826, has been established by the World Health Organisation as the 2nd International Standard for Streptokinase, with an assigned potency of 700 i.u. per ampoule.

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