3p1--STEININGERjjjj COAGULATION PROTEINS: ZYMOGENS AND SERINE

MECHANISM OF COAGULATION AND FIBRINOLYSIS PROTEASES

 Coagulation factors: enzyme precursors (zymogens),
 Blood extravasation non-enzymatic cofactors, and Ca2+ + PL
 Controlled by:  All coag factors normally present in plasma (PL provided
1) Blood vessels by platelets)
2) Platelets  Zymogens: Factors I, VII, IX, X, XI, XII, +
3) Plasma coagulation proteins prekallikrein
4) Physiologic and naturally occurring protease  Cofactors: Factors V, VIII, TF, + HWMK
inhibitors  ZYMOGENS
5) Fibrinolytic system - Substrates with no biologic activity until converted by
 Blood -> prevented from leaving via lining of endothelial enzymes into active enzymes serine proteases
cells in BV - Have exposed, serine-rich, active enzyme sites
 EL -> disrupted by mechanical trauma (surgery), physical -Selectively hydrolyze arginine or lysine
agents (heat), and chemical injury (bact. Endotoxin or containing peptide bonds of other zymogens,
drugs). thus converting them to serine proteases
- Zymogen activation may involve either conformational
HEMOSTASIS OVERVIEW change (twist, turn, bend) in the zymogen molecule or
 Primary hemostasis: platelet and vascular response hydrolytic cleavage of platelet PL surface
 Secondary hemostasis: coagulation factors - Injured, exposed endo surface -> coag rxn -> coag rxn
 + plt, vessels, and coag factors -> stop bleeding and on PL surface of aggregated plt w/c involve hydrolytic
allow vascular repair (fibrin-plt plug) cleavage of the next sequential zymogen to an active
enzyme
PRIMARY HEMOSTASIS - Activation of Factor X and II requires VIII and V (non-
 Initiated by exposure of platelets to the subendo enzymatic cofactors)
connective tissue component of BV (collagen, - These cofactors must be activated (VIIIa and Va) via
microfilaments, basement membrane) small amounts of thrombin
 Acute injury - Thrombin enhances their ability to assists in activation
 Small vessels constrict of factors X and II (high amounts->inhibit VIII and V)
 Platelets immediately adhere to exposed surfaces - Cofactors assists in activation of zymogens
 Releases ADP and ATP + Thromboxane A2 (further > alter zymogen conformation for more efficient
vasoconstriction) cleavage by the serine protease on a platelet PL
 Platelets adhere to one another (reversible primary surface
plt aggregation) >bind to zymogen and appropriate serine protease
 Change shape and organelles become centralized on a platelet PL surface to enhance and accelerate
 Platelets may disaggregate in absence of further the zymogen activation process
stimulation - Transformation of of zymogen -> active serine protease
 In continued stimulation, there will be secondary causes biochem amplification of coag process
irreversible platelet aggregation > prod of serine proteases increases the rate of
 Release of ADP, ATP, and serotonin further transformation of zymogens and the activity
 ADP: secondary plt aggregation and recruits lvl of cofactors
additional platelets to site > Example: traces of thrombin increases the activity
 ATP: not clear of factor VIII 80-fold
 Serotonin: further vasoconstriction  Inhibitors and thrombolytic factors maintain balance in
 Phospholipid (PL) becomes available on platelet the system between clotting and clot lysis
membrane surface for site of fibrin formation and  While the tissue is repaired, the fibrinolytic system
thrombogenesis slowly dissolves the clot with glycoprotein plasmin aka
fibrinolysin. Although plasmin is capable of digesting
SECONDARY HEMOSTASIS (Intrinsic + Extrinsic pathway) many proteins (fibrin, fibrinogen, factors V and VIII) it is
 Intrinsic pathway: activated in vivo by contact of certain also held in check by many inhibitors.
coag proteins w/ subendothelial connective tissue 
 Extrinsic pathway: initiated w/ release of tissue factor
from injured vessel of endothelial cells and
subendothelium into lumen
 Tissue factor
- high molecular weight lipoproteins
- found in most organs (lungs, kidneys, liver, brain,
placenta, spleen, and large blood vessels like vena
cava aorta)
 Both patway lead to secondary hemostasis + stable
fibrin clot
 Clot: fibrin from secondary hemostasis and plt plug from
primary hemostasis
 COAGULATION AND THE KININ SYSTEM  Prekallikrein and HMWK present in adsorbed plasma
 Kinins: peptides of low molecular weight composed of but slightly reduced because they are partially absorbed
amino acids by BasSO4.
 Kinin system: contains factors that are activated by the
coagulation and fibrinolytic systems CHARACTERISTICS OF THE COAGULATION FACTORS
 Kinins are involved in chemotaxis and the sensation of
pain
- mediate inflammatory responses, increase vascular
permeability, vasodilation and hypotension, and
induce contraction of smooth muscle
 Do not have assigned Roman numeral
 Include:
1) Prekallikrein (Fletcher factor)
2) Kallikrein (serine protease/activated form)
3) Kininogen (including LMWK and HMWK or Fitzgerald
factor)
4) Kinins (bradykinin and other subs produced via
conversion of kininogens by kallikrein enzyme)
 Prekallikrein: circulates in plasma as a complez with the
cofactor HMWK and both are part of contact group
 Converted to kallikrein via factor XIIa and HMWK
 Kallikrein: responsible for the conversion of HMWK to
kinins
 Accelerates factor XII activation
 Involved in fibrinolytic system
 Kallikrein + XIIa form complex plasminogen
activator (converts plasminogen -> plasmin)
 Plasmin: necessary of degradation of fibrin clot
 Can also activate Cl in the complement system of
immune rxn

COAGULATION AND THE COMPLEMENT SYSTEM

 Complement system is activated during coagulation &
fibrinolysis
 Complement is important in the mediation of immune
and allergic reactions
 Plasmin activates the first complement component in
the cascade, C1, -> cleavage of C3 to C3a and C3b.
 C3a: anaphyloxin which causes increased vascular
permeability THE COAGULATION GROUP
 C3b: causes immune adherence of red cells to
neutrophils & macrophages, thus enhancing their CONTACT GROUP
phagocytosis  Prekallikrein and HMWK of the kinin group, along with
 Complement activation: held in check by inhibitor factors XII and XI.
known as C’1 inactivator, which also inhibits factors XIIa,  It is adsorbed by contact with a negatively charged
XIIf, XIa, plasmin, + kallikrein/ surface such as collagen or the subendothelium in vivo
 This contact causes slow conversion of factor XII to XIIa,
THE COAGULATION FACTORS which initiates both intrinsic system coagulation and
fibrinolysis
FACTOR NOMENCLATURE  Factor XIIa and HMWK activate Factor XI to XIa and
 Those referred to by roman numerals and two factors in convert prekallikrein to kallikrein
kinin system, prekallikrein, and HMWK (referred to by  Kallikrein and HMWK play a role in: intrinsic coag
name only) activation, fibrinolysis activation, kinin formation, and
 Each factor was assigned a Roman numeral by Int’l activation of complement system.
Committee on Nomenclature Blood Coagulation Fatcors
in the order of its discovery PROTHROMBIN (VIT K-DEPENDENT) GROUP
 The “a” which accompanies the Roman numeral  Contains vit K-dependent coagulation factors II, VII, IX,
denotes the activated serine protease form of the and X.
factor rather than the zymogen (except Factor V and  Synthesized by liver in the presence of vit K (cofactor)
VIII)  Vitamin K: fat soluble; normally ingested in diet and
 Tissue factor (Factor III) and Calcium ions (Ca++) manufactured by gut flora; no substantial storage of vit
 Factor VI -> activates factor V; non-existent k in the body
 Vit K -> necessary to gamma-carboxylate the preformed  Initiates the extrinsic coag pathway by binding its PL
enzyme precursors of factors II, VII, IX, and X. portion to the factor VII, converting it into factor VIIa/
 Gamma-carboxylation of the glutamic acid  Extrinsic: necessity of adding tissue extract (PL) to
residues at the N-terminal or amino-- (NH2) end of plasma samples in vitro to initiate and evaluate this
the factor polypeptide chains, thus allowing factors coagulation pathway in laboratory
to bind Ca++ and form calcium bridges with acidic  Prothrombin time (PT) test: evaluates extrinsic system,
PL surface of the activated platelets performed using a reagent containing rabbit brain or
 Both Ca++ and platelet surface PL are essential for lung tissue thromboplastin and Ca++ to activate factor
enzyme and substrate functions in the coagulation VII and initiate extrinsic pathway
pathways
 Vit k-dependent gamma-carboxylation reactions may be PARTIAL THROMBOPLASTIN AND PLATELET PHOSPHOLIPID
inhibited:  Partial thromboplastin: reagent used as platelet
1) Dietary vit k deficiency substitute in evaluating the intrinsic coag system ->
2) Administration of antibiotics that sterilize the partial thromboplastin time
intestinal tract, where normal flora usually  “Partial” -> reagent consists only of PL portion of tisssue
synthesize vit K thromboplastin
3) Oral anticoagulant therapy (coumarin drug warfarin  Intrinsic system: requires platelet membrane PL for
w/c interferes with gamma-carboxylation) factor X activation in vitro (PPP -> avoid test variation
 Factors released will not bind to the platelet PL surface attributable to patient’s platelets)
and lead to prevention of prothrombin activation ->  Without dependence on px’s platelets, the test may be
deficiency in the coagulation pathway run independently of the number of platelets available,
as PTT provides necessary platelet substitute
FIBRINOGEN GROUP
 Includes: Factor I (fibrinogen), XIII, V, and VIII PHYSIOLOGIC VARIATIONS OF THE COAGULATION FACTORS
 Have the highest molecular weights of all factors and
are the only group that acts as substrates for fibrinolytic NEWBORNS
enzyme plasmin  The concentration of various coaglation factors depends
 Found in platelets specifically in alpha granules with 2 on the px’s age and physical condition
exceptions:  At birth, infants normally are deficient in vitamin K
1) Factor XIII is found in the general platelet cytoplasm,  Moderate deficiency exists in vitamin K-dependent
not in alpha-granules factos
2) Factor VIII:C (coag portion of F VIII) is not found in  Newborn infants are given vitamin K supplements to
platelets correct this deficiency
 Factor VIII (VIII/vWF) is a large multimeric molecule;
has 2 parts: ADULTS
1) Coagulant portion (VIII:C) -> cofactor in intrinsic coag  Physiologic variations of coagulation factors are most
2) von Willebrand portion (VIII:vWF)-> important to commonly associated with increases in the
normal platelet function concentrations of various coagulation factors
 In vitro the molecule can be separated into low  These variations generally do not cause coagulation
molecular weight and high molecular weight parts abnormalities.
 Factor VIII:C - produced in liver, has been called  Few conditions are associated with decreases in
antihemophilic factor because it is defective in patients coagulation factor conc that are not clinically sif (not
with Hemophilia A cause abnormal hemostasis)
 The HMW portion of factor VIII is synthesized by  When factor abnormalities are the primary cause of
endothelial cells and megakaryocytes and is composed clinical disorders, they are considered acquired (e.g.
of 2 parts: liver disease) or inherited (e.g. hemophilia)
1) Antigenic portion (VIIIR:Ag)
2) Von Willbrand portion (VIII:vWF)
-If either is decreased along with factor VIII:C ->
von Willebrand disease results

PHOSPHOLIPIDS CONTRIBUTING TO COAGULATION

TISSUE FACTOR
 Thromboplastin: lipoprotein; complex of 2 parts (PL and
protein); first recognized in 1905 by Paul Morawitz
 Theorized that blood remained fluid because a
thromboplastic factor was not found in plasma
 Believed to remain inside the cells until tissue injury
occurred
 -proposed that thromboplastic factor is known as tissue
factor or tissue thromboplastin
 2) It initiates fibrinolysis. Factor XIIa and kallikrein
together forms the complex required for
THE PROCESS OF FIBRIN CLOT FORMATION conversion of the zymogen plasminogen to serine
protease plasmin (fibrinolytic)
EARLIER THEORIES 3) it initiates kinin and complement systems. The
 Many theories were proposed to explain the formation of kallikrein by XIIf and HMWK causes
mechanisms of blood clotting during the past 3 conversion of HMWK to kinins (e.g. bradykinin).
centuries the plasmin formed as a result of kallikrein also
 1905: Morawitz’s classic coagulation theory (2 stages) initiate complement systems.
 First stage: prothrombin was ought to be
converted to thrombin by a factor knonw as  Kallikrein plays important roles in contact activation
thrombokinase in the presence of Ca++ 1) Perpetuates factor XII activation and its own
 Second stage: thrombin converting fibrinogen to production (rxn 7, 2, and 3)
fibrin 2) Initiates kinin system (rxn 5)
3) Initiates the fibrinolytic and complement system
MODERN THEORY (rxn 2 and 4) together with factor XIIa.
 Two theories: cascade and waterfall 4) Directly activates factor IX. Kallikrein can, on its own,
 Difference in intrinsic and extrinsic coag path -> activate factor IX to IXa (thus completing the
mechanism of initial activation and their mechanism of contact activation system)
activation of factor X
 Both pathways consists of groups of zymogens, which  Plasmin roles (result of contact activation)
are inert when they enter plasma but when activated -> 1) Promotes clot dissolution (rxn 8). plasmin begins the
enzymes fibrinolytic process of gradual blood clot
 These enzymes act as substrates for the next dissolution, which limits the coagulation process.
coagulation factor in the pathway 2) Activates the complement system (rxn 6)
3) Cleaves factor XIIa to XIIf (rxn 9)
INTRINSIC COAGULATION PATHWAY
 Considered to be dominant Factor XI Activation
 Intrinsic -> all components are seen in circulation blood  Factor XIIa, with HMWK, activates factor XI to XIa
 In vitro initiation: exposure of the coagulation factors to  Factor XIa is the enzyme that cleaves the substrate
negatively charged surface (e.g. glass) factor IX to form the serine protease factor IXa
 In vivo initiation: associated with damaged vascular  This reaction requires Ca++ as cofactor
endothelium  Factor XI can be activated directly by contact activation
 Initiation begins at contact phase of coagulation like Factor XII and that factor XIa also activates
 Factors involved: XII, HMWK, prekallikrein, and XI plasminogen
 Both XIa and XIIa involved in initiation of fibrinolytic
Factor XII Activation and complement pathways
 single polypeptide chain zymogen
 Contact phase begins with factor XII absorption to Factor IX Activation
negatively charged surface of vascular collagen exposed  Activation of factor IX to IXa by factor XIa and Ca++
by vessel wall damage completes the contact activation phase of coagulation
 Prekallikrein:single-chain polypeptide, circultaes as  Kallikrein: capable of activation factor IX
complex together with HMWK  Factor IXa + factor VIII cofactor, VIIIa, and Ca++ on
 this complex is absorbed in vivo to the negatively platelet PL surface activates factor X
charged surface of factor XII  Coagulation cascade continues on the platelet surface
 Factor XI also complexes with HMWK on surface
 Once contact group is assembled, factor XII (rxn 1) EXTRINSIC COAGULATION PATHWAY
undergoes conformational change in the presence of  Less complex
kallikrein (accelerates the conversion rate to factor XIIa  Extrinsic: factors other than those normally found in
w/ enhancement of HMWK) (rxn 7) plasma are required here
 This is an extremely slow reaction (rxn 1a) 
Consists of: TF, factor VII, and Ca++
 Enzymes in basophils and endothelial cells also activate  TF: also known as “tissue thromboplastin”
factor XII  Lipoprotein released from cell membranes into
 Factor XIIa is cleaved into XIIf (rxn 2) achieved by plasma on vascular endothelial injury
proteolytic enzymes: plasmin and kallikrein  Factor VII is Vitamin K dependent and circulates as
 HMWK enhances proteolytic effect of kallikrein on single-chain glycoprotein
factor XIIa  The gamma-carboxyglutamic acid residue of
 Both factors XIIa and XIIf activate prekallikrein to factor VII bind the PL portion of TF in the presence
kallikrein of Ca++ (acts as bridge between factor VII and TF)
 Roles of factor XIIa in contact activation:  The VIIa-Ca++-TF complex in the platelet PL surface
1) it initiates the intrinsic pathway of coagulation. In converts factor X to Xa in common pathway
the presence of HMWK, XIIa converts the zymogen
factor XI to the serine protease XIa
 ALTERNATE PATHWAYS LINKING THE EXTRINSIC AND  Common pathway -> completed with thrombin
INTRINSIC PATHWAYS activation of fibrinogen to fibrin via series of steps that
 The factor XIIa (intrinsic system) can activate factor VII stabilize fibrin clot
(extrinsic system)
 The factor VIIa formed in this reaction is a two-chain THROMBIN FEEDBACK SYSTEM
form rather that the single chain formed in the usual  Thrombin (factor IIa) control and balance the
extrinsic pathway hemostatic mechanism by providing feedback
 The two-chain factor VIIa has a greater effect on factor mechanisms to achieve control of the coagulation
X activation than does the single-chain form process (I.e. to prevent excessive bleeding & clotting)
 The factor IXa and Kallikrein have been reported to
activate factor VII in plasma that has been exposed to Thrombin’s Role as Coagulation Activator
glass or other surfaces  Thrombin is a strong serine protease generated throgh
 The activation of intrinsic pathway via extrinsic pathway the action of the prothrombin complex on the platelet
has been shown to occur in vitro and is thought to occur surface
in vivo  It is said to be autocatalytic-> once it is generated,
 The complex Ca++-factor VIIa-TF at the site of injury can thrombin enhances the rate of prothrombinase
slowly activate factor IX to IXa with subsequent production and thus, self-perpetuating.
activation of X to Xa  When present in plasma in small amounts, thrombin
 This alternate pathway allows the coag system to enhances the reactivity of factors V and VIII and
bypass the contact activation phase and could be the stimulates platelet aggregation.
key to the lack of bleeding associated with hereditary  Thrombin is also a trypsin-like enzyme -> acts on
deficiencies of the contact activation factors XII, fibrinogen, causeing conversion to soluble fibrin
prekallikrein, and HMWK monomers
 In another feedback pathway, factor Xa can hydrolyze  Factor XIII (clot-stabilizing) must be activated by
factor VII to produce a two-chain form that is reported thrombin to permit conversion of soluble fibrin to a
to have 85x procoagulant activity of the normal single- stabilized fibrin clot
chain factor VIIa
 A further control mechanism exists in the large Thrombin’s Role as Coagulation Inhibitor
concentrations of factor Xa cleave factor VII into three-  to prevent excessive clottings
chain molecule that is inactive in coagulation  In higher concentrations, thrombin has the opposite
effects on factor V and VIII -> it can destroy them
COMMON COAGULATION PATHWAY  Also activates protein C (potent anticoagulant)
 Activation of factor X  Enhanced by Ca++, a cofactor called
 Common to both intrinsic and extrinsic pathway thrombomodulin on the endothelial surface, and
the cofactor protein S.
Extrinsic Pathway Activation  Enhanced activatio takes plase on endothelial
 Occurs when factor VIIa, TF, and Ca++ form a complex surface
on the platelet PL surface  The protein C-S complex inhibits factors Va and VIIIa,
 This complex acts on the common coagulation pathway thus acting as coagulant inhibitors
to convert factor X to Xa  The protein C-S also stimulates fibrinolysis by increasing
plasminogen activator inhibitor (TPAI)
Intrinsic Pathway Activation  The net effect is prevention of interference with
 Factor VIII, although only a cofactor, must be modified plasmin production (enhanced fibrinolysis)
to its functional form (VIIIa) by thrombin to take part in  Once thrombin has formed a complex with
activation of factor X thrombomodulin, it can no longer stimulate platelet
 The platelet provides a surface for the formation in the aggregation or convert figrinogen to fibrin
intrinsic pathway of the multimolecular complex of
factor IXa-Ca++-factor VIIIa, which binds with platelet PL
and together converts factor X to Xa
 This complex causes the conversion rate of factor X
to Xa to be accelerated several thousand times
beyond the reaction associated with factor IXa
acting alone
 With the gamma-carboxyglutamic acid residue of the
factor Xa in the presence of Ca++, factor Xa also binds to
platelet PL surface and is thus prevented from diffusing
away from the complex
 On the formation of factor Xa, there is formation of
multimolecular complex known as prothrombinase
complex formed in the common pathway: Xa-Va-Ca++-
platelet PL
 The prothrombinase complex converts prothrombin to
thrombin
 FINAL CLOT FORMATION AND STABILIZATION  Activation may occur because of substances
 The action of thrombin on fibrinogen begins the final normally present in plasma (intrinsic activation)
steps of coagulation  Extrinsic activation: substances that enter the
 Fibrinogen is a glycoprotein composed of 3 nonidentical plasma from an outside source
but intricately interwoven paired chains called Aα, Bβ,
and θ which are linked by disulfide bonds near the
terminal ends
 Both α and β chain pairs have small fibrinopeptide at
their terminal ends known as fibrinopeptides A and B
(16 & 14 amino acids, respectively) for a total of 4
fibrinopeptides (2 A and 2 B)

Conversion of Fibrinogen to Fibrin

STEP 1. There is cleavage of the four fibrinopeptides from

the fibrinogen molecule α and β ends by the enzymatic
action of thrombin. The gamma chains remain intact and do
not hydrolize during the fibrin formation. Once the A and B
fibrinopeptides are removed, the structure is referred to as
soluble fibrin monomer / unstable gel (essential for the 2nd
step polymerization of fibrin).

STEP 2. The fibrin monomers aggregate spontaneously end to Intrinsic Plasminogen Activation
end and side to side to form weak (electrostatic bonds only)  Factor XIIa, kallikrein, HMWK and proactivator can
fibrin polymers or strands given the correct environment, activate plasminogen to plasmin intrinsically by one ore
including pH and ionic concentration. However, fibrin more pathways
polymers are soluble and can be dissolved in vitro in 5 M  The plasma proactivator is activated by kallikrein
urea or weak acids like 1% monochloracetic acid. At this during coagulation contact activation
point, the fibrin polymer also is vulnerable to the fibrinolytic
enzyme plasmin. Extrinsic Plasminogen Activation
 Involves plasminogen activators present in organ
STEP 3. the third step provides clot stabilization. It requires tissues
factor XIII, Ca++, and thrombin. Thrombin activates factor XIII,  Tissue plasminogen activators also have been found in
which then functions as a transamidase crossliking adhacent endothelial cells in the form of proteases, particularly in
fibrin monomers through the formation of covalent bonds. the veins.
Both α and θ chains are involved in the formation of
stabilized fibrin clot. The stabilized fibrin clot is insoluble in 5 Plasminogen Activators in Secretory Ducts
M urea and weak acid. Lab tests may be performed with  Keep secretory passages functioning properly
these reagents to screen for factor XIII deficiency.
Exogenous Plasminogen Activation
THE FIBRINOLYTIC SYSTEM  For therapeutic destruction of thrombi, urokinase, a
trypsin-like protease purified from urine, may be
PHYSIOLOGIC FIBRINOLYSIS administered to a patient to actvate plasminogen to
 Defense against occlusion of blood vessels, but is also plasmin and induce fibrinolysis.
important that bleeding does not recur because of  Streptokinase another therapeutic agent to activate
premature lysing of clot. plasminogen to plasmin.
 Tissue plasminogen activator (tPA) is now being used
Activation of Plasminogen to Plasmin for the treatment of thrombosis
 Fibrinolysis is dependent on the enzyme plasmin, which  It is released in vivo on endothelial cell damage
is normally not present in the blood in active form. and can be manufactured in vitro through
 Plasmin, a serine protease like many coag factors, can recombinant DNA techniques
digest or destroy fibrinogen, fibrin, and factors V and
VIII. ROLE OF PLASMINOGEN AND PLASMIN IN NORMAL AND
 Also promotes coagulation and activates kinin and ABNORMAL FIBRINOLYSIS
complement systems  Under normal circumstances, plasminogen is a part of
 Zymogen: known as plaminogen, which is normally any clot because of the tendency of fibrin to absorb
present in plasma, is converted to plasmin by the action plasminogen from plasma.
of plasminogen activators  When plasminogen activators perform their fxn,
 Plasminogen: single-chain glycoprotein that is plasmin is formed within the clot, which gradually
synthesized in the liver and has a molecular wight of dissolves the clot while leaving time for tissue repair.
90,000. Stored & transported in eosinophils. Increased  Free plasmin is also released to plasma; however,
concentration -> inflammation antiplasmins immediately destroy any plasmin released
from the clot.
 When pathologic coagulation processes are involved,
excessive free plasmin released to the plasma
 The available antiplasmin is depleted, and plasmin
begins to destroy components other than fibrin,
including fibrinogen, factors V and VII, and other
factors.
 Plasmin acts more quickly to destroy fibrinogen
because of fibrinogens’s instability
 The covalent bonds of fibrin slow the fibrin degradation
process by plasmin

Fibrin(ogen) Degradation by Plasmin

 In the process of fibrinogen or fibrin degradation by
plasmin within a clot, specific molecular fragments are
produced called fibrin(ogen) degradation products (FDP)
or fibrin(ogen) split products (FSP).
 Plasmin cannot distinguish between fibrinogen and
fibrin; therefore, it degrades both.
 This results in the appearance of essentially the same
fragments for fibrinogen and fibrin degradation,
although the Aα and Bβ chains may remain intact in
fibrinogen fragments.
 The degradation products are removed by the
reticuloendothelial system and other organs
 Plasmin acts on specific sites of each fragment to create
smaller fragments throughout the reaction sequence
 Fragments X and Y are referred to as early degradation
products; fragments D and E are late degradation
products
 Fragment X: first and largest fragment (MW = 250,000)
 Result of plasmin cleavage of the terminal portions
of the alpha chains from a fibrin polymer, leaving
isolated fibrin strands
 Fragment is cleaved by plasmin (P) to form 2 Pathologic Effects of Fibrin Degradation Products
fragments called Y (YY) and an intermediate  FDPs are significant because of their hemostatic effects,
complex, DXD. which include antithrombin activity, interference with
 This complex is further cleaved into intermediate polymerization of the fibrin monomer, and
complexes DED and DY/YD until finally, fragments E interference with platelet activity.
and D (D-D dimer) are formed  The early and larger fragments X and Y, along with the
 A single fragment D has a molecular weight of approx intermediate FDPs appear the most impt in exerting
90,000 and that of the D-D dimer is approx 180,000 anticoagulant effects
 The presence of D-D dimer is a specific indicator of in  Fragments Y and D inhibit fibrin polymerization
vivo fibrinolysis, namely, intravascular thrombin  Fragments E is a powerful inhibitor of fibrin
formation leading to fibrin formation and its  In general, most FDPs inhibit coagulation and also form
subsequent degradation incoagulable or slowly coagulable complexes with
 Tests specific for the D-D dimer permit verification of in fibrin monomers or fibrinogen
vivo fibrinolysis, because the presence of the D-D dimer  These complexes in pathological fibrinolytic states are
is indicative only of fibrin (not fibrinogen) degradation detectable by the protamine sulfate and ethanol gel
products. tests
 More accurate: fibrin monomer test
 All four fragments, but particularly low-molecular-
weight FDP have an affinity for coating platelet
membranes and therefore cause a clinically significant
platelet dysfunction by inhibiting aggregation.

NATURALLY OCCURING COAGULATION AND FIBRINOLYTIC

INHIBITORS
 Counterforces of the naturally occuring biochemical
coagulation and fibrinolytic inhibitors are necessary to
achieve balance between activated clotting factors and
fibrinolytic enzymes
 Some inhibitors quickly neutralize activated factors in
the circulation, thus localizing coagulation to the sites
 where it is required, whereas other perform a similar Alpha-1-Antitrypsin
function that limits fibrinolysis  An alpha globulin that is potent inhibitor of factor XIa
 It may also inactivate thrombin at a slow rate
NATURALLY OCCURING INHIBITORS OF COAGULATION  Fibrinolytic system is inhibited by α1-antitrypsin by its
inactivation of plasmin (least significant)
Antithrombin III  Hereditary deficiencies: liver cirrhosis and pulmonary
 AT-III is an important coagulation inhibitor disease (α1-antitrypsin is important to normal
 It is a protein (α2 globulin) synthesized in the liver; pulmonary function) ; not associated with thrombotic
might also in endothelial cells disorders
 Half life: 2.7 days
 Inhibits: thrombin, XIIa, XIa, Xa and IXa by forming C’1 Inactivaor (C’1 Esterase Inhibitor)
enzyme inhibitor complexes with these activated  Glycoprotein that was initially identified by the
factors -> neutralizing them and preventing their action complement system as an inhibitor of C’1 esterase
on other zymogens  Coagulation, fibrinolytic, kinin, and complement
 Also has inhibitory effect on plasmin and kallikrein systems are all affected
 Monitor coagulation, fibrinolytic, kallikrein-kinin, and  In coagulation system: this inhibits factor XIIa and the
complement systems fragments of factor XII (XIIf); also XIa
 Allowed to function without inhibition because of  in fibrinolytic system: inhibits plasmin, kinin system,
decreased levels of AT-III -> severe or lethal results and kallikrein
 Enhanced by cofactor heparin (attaches to AT-III ->
conformational change-> arginine residue of AT-III Proteins C and S
reactive site more accessible to active site of serine  Vitamin K-dependent glycoproteins, but unlike Vit K
proteases) dependent serine proteases, activated protein C and its
 Heparin: increase rate of factor inactivation, not the cofactor protein S are potent inhibitors of coagulation
magnitude  Protein C: activated slowly by thrombin circulating in
 Naturally occurring heparin has been isolated from a plasma and its activation is greatly enhanced when
variety of organs and also present in mast cells and thrombin bind to thrombomodulin on the surface of
basophils endothelial cells and forms 1:1 stoichiometric complex
 Heparan sulfate: naturally occurring chemical relative of with protein S
heparin & likewise an anticoagulant, has been identifies  Thrombin’s specificity is altered when it complexes
on the surface of platelets and the vascular with thrombomodulin on the endothelial surface
endothelium  The structural change -> activates protein C and inhibits
 Together with AT-III -> protect uninjured vessels thrombin’s other functions
against abnormal thrombus formation by  The structurally altered thrombin will not activate
neutralizing serine proteases factors V and VIII or platelets nor will it convert
 Without heparin, AT-III neutralizes thrombin by forming fibrinogen to fibrin
a 1:1 complex with thrombin slowly over a period of  Protein C and S destroy factors Va and VIIIa
minutes  The protein C-S complex enhances fibrinolysis by
 If heparan sulfate is added -> neutralization of thrombin inactivating inhibitors of plasminogen activators
occurs instantaneously and the rate is accelerated from  Enhances plasmin formation-> fibrinolysis
2000 to 10,000x vs when AT-III is alone  Protein C inhibitor: regulates activated protein C
 A small decrease in AT-III concentration may cause  Protein C deficiencies: clinically similar to AT-III
faster clotting reaction because of the lack of control deficiencies in that thromboembolic episodes present
and inhibition by AT-III before 30 years of age
 AT-III can be decreased by therapeutic use of heparin as
an anticoagulant NATURALLY OCCURRING INHIBITORS OF FIBRINOLYSIS
 Heparin -> deplete available plasma AT-III  Controlled by both the affinity of fibrinolytic inhibitors
 Hereditary deficiencies of AT-III both qualitative and for formed plasmin known as antiplasmins
quantitative
Alpha-2-Antiplasmin
Alpha-2-Macroglobulin  An a2-glycoprotein which acts as the principal inhibitor
 Large, naturally occurring plasma glycoprotein of fibrinolysis by binding in a 1:1 stoichiometric
 Binds with various proteolytic enzymes like thrombin, complex with any plasmin free from plasma ->
but does not completely inhibit them neutralizing plasmin
 Rate of thrombin inhibition is slower vs AT-III  This prevents plasmin from binding to fibrin, fibrinogen,
 Protect its bound enzymes against other circulating and factors V and VIII
inhibitors  Also permits slow and orderly dissolution of the clot
 Example: thrombin bound to α2-macroglobulin may still and adequate time for repair of damaged tissues
activate small amounts of factors V and VIII  Complex formed between plasmin and α2-antiplasmin
 May also inhibit fibrinolysis by inhibiting (not totally is similar to thrombin-AT-III complex
eliminating) plasmin’s fxn in fibrinolysis  Both inhibitors bind to active serine site of their
 Inhibits kinin system by inhibiting kallikrein respective enzyme targets -> inactivating the serine
 protease and preventing its enzymatic action on its Hepatic and Other Clearance Mechanisms for Coagulation
usual substrates Components
 Inhibits serine proteases XIIf, and XIa, IIa, and Xa +  The hepatic clearance of soluble components
activities of plasma kallikrein (plasminogen activators, activated serine proteases:
 The conversion of plasminogen to plasmin is also factors IXa, Xa, and VIIa) prevents them from circulating
suppressed by α2-antiplasmin through inhibition of TPA in the venous system
 Most important naturally occurring inhibitor of  Consequently, liver impairment (cirrhosis/hepatitis)
fibrinolysis (first to bind with plasmin in the plasma) may cause systemic fibrinolysis or thrombosis
 When stores are depleted -> inhibitor of α2-  Finely particulate procoagulants such as soluble fibrin
macroglobulin binds plasmin components and early FDPs are removed in the
 When too depleted -> α1-antitrypsin is the last major pulmonary vascular bed
naturally occurring defense against plasmin and  Peripheral blood leukocytes and tissue macrophages
uncontrolled fibrinolysis may also participate in the clearance of coagulation
 In vitro: a2-antiplasmin can decrease the normal binding components
rate of plasminogen to fibrin 30x effectively as a
synthetic fibrinolytic inhibitor called epsilon- CHAPTER SUMMARY (ADDITIONAL NOTES)
aminocaproic acid (EACA) -> treat bleeding disorders  Endothelial cells role; provides:
particularly urinary tract bleeding by inhibiting 1) Vascular plasminogen activator -> initiates
plasminogen activation fibrinolysis
 Heresitary deficiencie: associated with severe 2) Site of protein C activation -> neutralize major
hemorrhagic tendency cofactors in coagulation
 In pathologic conditions involving excessive clotting (e.g. 3) Site of AT-III adherence -> inhibitory effects on
DIC) or excessive fibrinolysis -> a2-antiplasmin levels thrombin and other serine proteases
may be depleted secondary to excessive conversion of 4) Site of thrombomodulin adherence -> binds
plasminogen to plasmin thrombin, preventing thrombin’s coagulant
effects on platelets and factors V, VIII, and
Alpha-2-Macroglobulin fibrinogen
 Large naturally occurring plasma glycoprotein that
inhibits components in both fibrinolytic and coagulation
systems
 Effectively inhibits plasmin after a2-antiplasmin
depletion

Alpha-1-Antitrypsin
 Third most important naturally occurring inhibitor of
the fibrinolytic system
 Inactivates plasmin slowly and does not bind plasmin
until a2-antiplasmin and a2-macroglobulin are saturated
 Plays more important role in the inhibition of
coagulation by its potent effects on factor XIa

Other Fibrinolytic Inhibitors

 AT-III also functions to inhibit fibrinolysis by inhibiting
plasma and kallikrein
 C’1 inactivator also inhibits plasmin

PHYSIOLOGIC COAGULATION CONTROL MECHANISMS

 Inhibits the processes at the site of clot formation and
hepatic and other clearance mechanisms for
coagulation components

Inhibiting Processes at the Site of Clot Formation

 Rapid blood flow thorough the vessels is important to
prevent excessive propagation of thrombus and dilute
any excess procoagulants or profibrinolytic
components at sites of injury
 Fibrin restricts the active coagulants to the interior of
fibrin clot
 The platelets and endothelium also restrict coagulation
to the site of injury
 ROUTINE LABORATORY EVALUATION OF  The time required for this response is a measure of
COAGULATION overall intrinsic and common pathways of
 TESTS FOR INTRINSIC AND COMMON PATHWAYS coagulation.
 Lee and White Whole Blood Coagulation Time  Insensitive to factor deficiencies
 Plasma Recalcification Time  Moderate defects may be present in the face of
 Activated Clotting Time normal results
 Partial Thromboplastin Time  Only 1% to 2% of the normal level of factor VIII ->
 TESTS FOR EXTRINSIC AND COMMON PATHWAYS normal L-W clotting time when mixtures of normal
 Prothrombin Time and hemophiliac plasmas are tested
 Other tests  Technical errors, such as excessive agitation of
tube when checking for clot -> shortened times
 No suitable quality control measure
 No longer considered as an adequate test

Plasma Recalcification Time

 Modification of the L-W which uses citrated
plasma (instead of whole blood), CaCl2,
glass/siliconized tubes, and either PPP/PRP/both.
 Based on the fact that except for calcium, normal
PRP contains all components of the coagulation
mechanism necessary for generating a fibrin clot
 Removal of RBCs makes the clot easier to see
 The time required for blood clot after Ca++ is added
is a general measure of the intrinsic and common
pathways
 By using a parallel test on PPP, screening for
platelet function defect may also be accomplished
 Reference range for PRP and PPP -> 100 to 150
seconds and 130 to 240 seconds
 PRP should clot at least 20 seconds faster vs PPP
 Disadvantage:
 difficulty in standardizing the number of
platelets in the PRP and the length of time
necessary to perform the test, which
moreover is insensitive to moderate factor
deficiencies
 Errors in collection technique -> affect results
by amount of glass contact
Reference Ranges  Same size tube always used to test and
 RR in hemostasis are significantly affected by specimens be tilted uniformly
patient populations, methodology, reagent  Procedure cannot be standardized
systems, instrument systems, and combinations  Sensitivity improved by diluting the plasma:
thereof. 1) it adjusts the PRP closer to the actual in vivo
 Every lab must establish its own reference ranges - platelet count
-> perform 20-40 determinations on plasma from 2) It increases sensitivity of the test system to
healthy volunteers in the same manner as patient factor deficiencies
samples are to be tested 3) It dilutes the natural inhibitors to the
 Calculation of mean and 95% confidence limits coagulation that are present
produces a reference range, which must be  Normal control should be run with each test
reevaluated any time changes are made.
Activated Clotting Time
TESTS FOR THE INTRINSIC AND COMMON PATHWAYS  Developed by Dr. Paul Hattersley
 Uses diatomaceous earth (diatomite) as an
Lee and White Whole Blood Coagulation Time activator of contact factors and requires the blood
 Based on the fact that when venous blood is put to be kept warmed to a constant 37oC -> special
into glass tube (foreign surface), it will form a solid incubator at bedside
clot.
 PRINCIPLE:  Modification: APTT
 Whole blood contains ll components  Choice to screen for factor deficiencies + monitor
necessary to produce a clot when removed heparin therapy
from veins and put into glass tube  also a basis for assays of factors in intrinsic system
 By adding an activator and keeping the blood  Reagent:
at constant 37oC -> more reliable and rapid  Platelet substitute (phospholipid)
screen of the intrinsic and common pathways  Prepared from brain or plant
 REAGENTS: phospholipid
 2 Evacuated tubes containing 12 mg of  Activator
diatomite  Kaolin, Celite, micronized silica, ellagic
 EQUIPMENT: acid
 Portable heat block, thermometer, and 2 stop  PRINCIPLE:
watches  Measures all factors except VII and XIII
 PROCEDURE:  Maximum activation of the contact factor is
 2 tubes with diatomite are brought into 37oC done by adding activator
in a heat block at the patient’s bedside.  Phospholipid is supplied to substitute for
 Using good venipuncture technique, at least 2 platelet factor 3 (PF3)
mL of blood is drawn into a tube and  Essentially the same as recalcification time of
discarded plasma
 The tourniquet is removed and the first tube  SPECIMEN REQUIREMENT:
with diatomite is attached to the needle  Citrated platelet-poor plasma
 When blood starts to flow into the tube, the  REAGENTS:
first stopwatch is started  Phospholipid with activators (APTT reagent)
 The tube is filled, mixed, and placed in the  0.025 M CaCl2
heat block  CONTROLS
 Repeat for second tube for second stopwatch  Commercial lyophilized controls (for normal,
 After 60 seconds, the first tube is observed by midrange, and extended ranges)
tilting it at 5 second interval until clot is  At least 1 normal control and 1 abnormal
formed until clot is formed at which the control
second tube is observed using the same  In house preparations of pooled/frozen
procedure plasma -> controls
 The appropriate stopwatch is stopped at first  EQUIPMENT
appearance of clot in each tube  Manual method
 The duplicated should agree within 10  12 x 75 mm glass tube
seconds  Heat block
 Report average time  Pipets
 REFERENCE RANGE:  Fibrin strand method
 75 to 120 seconds  Epuip for electromechanical fibrin strand
 Heparin therapy: 140 to 185 seconds detection
 INTERPRETATION:  Appropriate cups and pipets
 Prolonged ACT is indicative of one or more  Photo-optical method
factor defects in the intrinsic or common  Specialized instrument
pathways or the presence of a circulating  Appropriate accessories
anticoagulant like heparin  PROCEDURE
 COMMENTS:  PPP of 0.1 mL is added to 0.1 mL of APTT
 Temperature control is critical -> 37oC reagent and incubated at 37oC for the period
 Primary use of ACT is during extracorporeal of time specified (approx 3 to 5 minutes)
circulation where frequent testing and rapid  After incubation, 0.1 mL of warmed CaCl2 is
turnaround time is required added
 No suitable method of quality control, other  Record time of clotting
than duplicate testing  REPORTING
 APTT is reported in seconds, to the nearest
Partial Thromboplastin Time tenth, along with the reference range
 Addition of tissue thromboplastin -> clot  REFERENCE RANGE
 More sensitive to abnormalities in the early stages  Lower limit of 20 seconds to upper limit of 45
 Important: addition of negatively charged seconds
activators to system -> shorter clotting time
 INTERPRETATION  PROCEDURE
 Prolonged (no heparin) -> factor deficiency,  Aliquotes of control and px plasma are
acquired circulating anticoagulant (lupus warmed
inhibitor) antibody specific to factors  PT thromboplastin reagent is warmed at 37oC
 Prolonged (most commercial reagents) -> if for 3 to 5 minutes
factors is less than 40% to 50% vs normal  0.2 mL PT reagent is added -> 0.1 mL plasma
 COMMENT  REFERENCE RANGE
 Sources of Error:  Photo-optical systems: 10-12 seconds
 Sample collection + preparation  Manual methods: 12-14 seconds
 Reagent preparation  REPORTING
 Instrumentation  Different ways:
 Anticoagulant volume should be adjusted for 1) Patient time (sec) with the reference
individuals with hematocrits >0.55 L/L and range
<0.20 L/L 2) Patient time with the control time (sec)
 Hemolysis -> shortened APTT 3) Prothrombin ration (PT divided by mean
 Platelets in plasma -> erratic of reference range and multiplied by 100(
results/shortened APTT 4) Percent activity
 Unexpected heparin contamination ->  The use of international normalized ratio (INR)
lengthen APTT has been proposed as standard method of
 Reagents: improper storage, water impurities, reporting
or incorrect dilution  INTERPRETATION
 Should be tested for sensitivity for factor  Prolonged: abnormality of one or more
deficiencies by performing APTT on serial common extrinsic coag factors
dilutions of plasma  May be hereditary or acquired
 Failing light source, fluctuations in  May also occur with factor inhibitors
temperature, loss of calibration of tubing, or  Sensitive to factor deficiencies less than 40%
contamination will cause instrument error to 50% vs normal
 Good quality control program -> reveal ant  COMMENTS
instrumental/reagent-related error  Reporting via percent activity is no longer
recommended because dilution curve used to
TESTS FOR THE EXTRINSIC AND COMMON PATHWAYS determine percent activity dilutes all factors -
> inaccurate representation of therapy
Prothrombin Time  Sources of error is same with APTT
 Laboratory screens for deficiencies: dactors I, II, V,
VII, and X Other Tests
 No longer considered a measure of prothrombin  for extrinsic and common pathway
 Test of choice for monitoring anticoagulant  Stypven time and prothrombin-proconvertin
therapy by vitamin K antagonists time
 Factors II, VII, and X are sensitive and depressed by  STYPVEN TIME
these anticoagulants  Utilizes powerful coagulant properties of
 Only factor IX is not detected by PT russel’s viper venom obtained for the snake
 PRINCIPLE Vipera russelli
 When tissue extract or thromboplastin is  This venom is capable of bypassing the action
added along with calcium, it reacts with factor of factor VII and directly activating factor X to
VIIa to convert factor X to Xa Xa
 Factor Xa + factor Va + phospholipid + Ca++  When combined with dilute thromboplastin -
 Converts prothrombin to thrombin > fibrin clot through the reaction of factors Xa
 Thrombin subsequently converts fibrinogen to and Va, phospholipid, factor II, and
fibrin fibrinogen
 The time from addition of thromboplastin /  Witts and Hobson believed the venom to be
CaCl2 to clot formation is reported convinient substitute for thromboplastins in
 SPECIMEN REQUIREMENTS PT system
 Citrated platelet-poor plasma  This substitution caused problems in
 REAGENTS AND EQUIPMENT managing patients on anticoagulant therapy
 Thromboplastin/CaCl2 (PT reagent) because Stypven time -> shorter clotting
 Controls times than PT -> serious overdosing ->
resultant bleeding
  Reinstated and until factor assays became
more routin -> used to help differentiate
between factor VII and X deficiencies
 PROTHROMBIN-PROCONVERTIN TEST
 Developed by Drs. Owren and AAs based on
observations that minor deficiencies can be
more pronounced when plasma is diluted
 Plasma is tested at 1:10 dilution and reagent
with dilute thromboplastin extract from
bovine brain, CaCl2, and excess bovine factors
V and I (fibrinogen)
 The addition of labile factor V made the test
more sensitive to factors affected by vit K
antagonists (factors II, VII, and X)
 Freeze dried: sensitivity was adjusted to give
reliable determinations in the therapeutic
range
 Insensitive to factor V and fibrinogen
 Anticoagulant sodium citrate -> instability of
factor V is no longer a great problem
 INHERITED DISORDERS OF COAGULATION

Intrinsic Pathway Disorders

The purpose of the intrinsic pathway is to bring about the
activation of factor X (Xa). Three separate proteins in the
plasma begin the intrinsic pathway. The interrelated roles of
these three proteins are collectively termed the "contact
phase" of coagulation. In this context, "contact" denotes a
point in time when plasma hemostatic components and
tissue or artificial surfaces meet, after which a chain of
reactions ensues. The product of the contact phase is the
activation of factor XI (Xla) that carries the intrinsic pathway
forward.
Factor XII (Hageman), prekallikrein (Fletcher), high-molecular-
weight kininogen (HMWK; Fitzgerald), and factor XI (plasma
thromboplastin antecedent or PTA) are the four plasma
contact factors and are synthesized by the liver. Patients
LABORATORY FINDINGS. The laboratory findings are similar
deficient in any one of the first three proteins generally are
to those in factor XII deficiency. However, the patients' APTT
hemostatically competent and asymptomatic.
results will shorten if the plasma is incubated with a surface-
activating substance such as kaolin.
They appear to bypass these contact activation schemes and
generate fibrin by other means. The intrinsic system is
High-Molecular-Weight Kininogen (Fitzgerald Factor)
markedly slowed by a defective contact phase only when
Deficiency
tested in vitro.
High-molecular-weight kininogen normally facilitates contact
The roles of these four proteins are interdependent, and the
activation of factors XII and prekallikrein. Its absence results
proteins are structurally related (Fig. 55-1). Prekallikrein and
in poor contact-phase reactions, a deficiency of kinin
factor Xl (considered substrates for factor XIIa) circulate
formation (active forms derived from kininogen), and
complexed to HMWK. The role Of the catalytic cofactor
defective fibrinolysis reactions.
HMWK is to configure these substrates so that their reactive
The autosomal recessive Fitzgerald defect does not produce
sites are available for factor XIIa.
clinical bleeding. The APTT results typically are mildly
The first three Contact factors also have roles in the
prolonged, other tests reference limits.
fibrinolytic system, in the activation of factor V II, and in the
body's response to systemic infectious agents.
Factor XI Deficiency (Hemophilia C)
Once factor XII is activated during contact-phase reactions,
Factor XII (Hageman Factor) Deficiency
the active form (Xlla)ein the presence of HMWK,
Factor XII deficiency is an autosomal recessive trait that can
enzymatically cleaves factorXI (PTA) to Xla. This reaction
be expressed in homozygous or heterozygous forms. The
takes place on a phospholipid—rich surface, such as platelets.
homozygote, possessing two abnormal alleles, has no factor
Factor Xla behaves as a serine protease and can cleave more
XII; heterozygotes demonstrate variance in their factor XII
factor XII tp XIIa to amplify the contact reactions. The other
plasma concentrations.
substrate for factor Xla in the intrinsic system is factor IX.
Originally described in 1953, factor XI deficiency represents
CLINICAL FINDINGS. Patients homozygous for factor XII
the first inherited disorder in the intrinsic cascade to which a
deficiency do not suffer from a bleeding disorder. In fact,
clinical bleeding syndrome is attributed. The defect thought
they may be vulnerable to excessive clotting (thromboses). It
to be a result Of decreased synthesis of the protein rather
is noteworthy that the index patient, Hageman, succumbed
than production of an abnormal molecule3 and is controlled
to pulmonary embolism.
by an incompletely recessive autosome found largely in
Jewish populations.
LABORATORYFINDINGS. Laboratory findings are normal
except for determinations Of the intrinsic System such as a
CLINICAL FINDINGS. The disorder produces a mild bleeding
prolonged activated partial thromboplastin time. (APTT). The
syndrome that responds well to therapy. Most factor Xl—
APTT is corrected with both adsorbed plasma and aged
deficient patients are symptomatically "silent" until stressed
serum (Chap. 53). Factor XII assays will confirm the deficiency.
by trauma or surgery. The clinical syndrome may include
episodes of epistaxis (nosebleeds), hematuria, and
THERAPY. Generally, no therapy is necessary for this disorder,
menorrhagia. Surgery or trauma produces exaggerated
as the abnormality is an in vitro phenomenon.
bleeding. The same patient may differ in the degree of
bleeding response from one event to another.
Prekallikrein (Fletcher Factor)
CLINICAL FINDINGS. Fletcher factor deficiency is believed to
LABORATORY FINDINGS. Deficiencies of factor Xl produce
be transmitted as an autosomal recessive trait. As in
prolonged APT T values that are corrected by both adsorbed
Hageman factor deficiency, prekallikrein-deficient patients
plasma and aged serum. Factor assay reveals the specific
generally do not demonstrate clinical bleeding and may be
factor deficiency and activity levels. Factor Xl increases in
vulnerable to thrombotic events.
concentration on storage. This fact can interfere with
laboratory testing for the factor if the test sample is not CLINICAL FINDINGS. A bleeding diathesis arises from
handled properly. One-stage prothrombin time (PT) values decreased or defective factor VIII:C. The severity of the
and bleeding time results are not affected. A disorder is tied to the degree of deficiency. Most severely
radioimmunoassay procedure has been developed that affected patients possess less than 1% activity of factor VIII:C;
correlates positively with assay levels. A two—stage test moderately affected patients have 2% to 5% activity; and
utilizing a fluorogenic substrate to detect the presence of mildly affected patients generally have more than 5% activity.
factor Xla has been described. Clinical bleeding necessitating medical intervention occurs
most frequently In severely afflicted hemophiliacs. Patients
THERAPY. No single specific blood component exists to treat who maintain factor activity levels above 6% may remain
factor XI deficiency. Fresh whole blood, fresh plasma, or fresh clinically silent until traumatized or submitted to surgical
frozen plasma have all been used. Plasma concentrations procedures without prophylactic preparation. A patient's
should be raised to 20% to 30% of normal activity to protect factor activity level remains fairly constant throughout life.
the patient.
Typical bleeding episodes result from trauma but may be
Factor X Activation Phase Disorders spontaneous in the most severe cases; Bleeding into soft
The activation of factor X is considered the final reaction tissues (hematomas) or joints (hemarthroses), epistaxis,
occurring in both intrinsic and extrinsic pathways. Once hematuria, gastrointestinal or intracranial hemorrhages, and
activated, factor Xa begins another series of reactions termed postoperative bleeding constitute the majority of
the "common" pathway leading to formation of fibrin. hemorrhagic events in the hemophiliac. Repeated
Factors VIII:C and IXa in the intrinsic pathway and factor VIIa hemarthroses can cripple and deform over time. The joints of
in the extrinsic pathway, in conjunction with lipid and Ca++, the knee, hip, elbow, ankle, and shoulder are most
are required for the activation of factor X. Deficiencies of the vulnerable. Taking analgesics such as aspirin during these
factors necessary for the activation of factor X by way of the events is contraindicated, the drug inhibits platelet function.
intrinsic pathway (VIII:C and IXa) cause serious bleeding
disorders and occur frequently. LABORATORY FINDINGS. The screening test to detect factor
VIII:c deficiency IS the APTT. Prolonged APTT results that are
Factor VIII:C Deficiency (Hemophilia A i Classic Hemophilia) corrected by fresh adsorbed plasma but not by serum and
Classic hemophilia is recorded in antiquity It is sometimes results of factor VIII:C assays identify the efficiency and
referred to as the "royal disease, " as Queen Victoria of characterize the activity levels. Obligatory carriers have been
England was a carrier, and the condition eventually spread detected by combined factor VIII:C and VII C:Ag assays.
through Europe's royal families. It was first described Carrier detection is not without error because of procedure
scientifically in 1803. Much of the current knowledge about variation and unpredictable X chromosome inactivation (Lyon
hemophilia A has evolved in the last 30 years. hypothesis). Levels of factor VIII:C differ in the daughters of
carrier females (maternal carriers) and the daughters of
Today, 85% of diagnosed congenital bleeding disorders are hemophiliacs (paternal carriers).
hemophilia A or factor VIII:C deficiency. Exact incidence
figures are difficult to find, but best estimates in the Western THERAPY. The therapy for hemophilia A involves many Issues.
world cite 5 cases per 100,000 population. Replacement of factor VIII:C by infusion of cryoprecipitate
products IS done when the goal is to arrest bleeding. The
Hemophilia A is a sex-linked disorder transmitted on an X decision to administer prophylactic (preventive) infusions
chromosome by carrier women to their sons. Carrier women depends on less well-defined criteria: cost, availability, home
produce clinically normal daughters who may carry the or hospital setting, age, status of joints, frequency of
chromosomal defect. Sons of affected men are unaffected, bleeding episodes, risk of hepatitis or AIDS, and the
but the daughters are obligatory carriers. One-third of new psychological adjustment of the patient, as well as of family
cases occur spontaneously through mutations or variability in members. In milder cases, pharmacologic agents such as I-
the expression of the X chromosome, causing skipped desamino-8-D-arginine-vasopressin (DDA VP) may be
generations. substituted for donor components. This synthetic analogue of
the antidiuretic hormone 8-arginine vasopressin increases
Factor VIII/vWF (or factor VIII complex) is a macromolecular plasma factor VIII:C by causing its release from endogenous
complex circulating In plasma that consists of two distinct but stores.
related components (VIII:C and VIII:vWF). These two
components have been characterized experimentally by their The incorporation of a siphon technique during plasma
genetic, functional, and immunologic properties. Table 55-1 thawing has markedly improved factor VIII:C recovery from
presents the terms applied to this complex molecule. Figure single-donor plasma.% Compared with single—donor
55-2 depicts the formation of the factor VIII/vWF cryoprecipitate, commercially prepared and purified
complewand the pattern of inheritance of the two concentrates have a lower yield, higher cost, and higher risk
components. of transmitting hepatitis and AIDS.

The functional role of factor VIII:C is as a cofactor in the On the other hand, these products are highly purified, they
activation of factor X to X. Thrombin is required to modify the state concentrations on the label, they are stable and lower
structure of factor VIII:C in order for it to fulfill its proteolytic volumes are required. The use of single-donor
action of factor IXa on role in accelerating factor X. cryoprecipitate pools is common in hospital settings, whereas
commercial concentrates generally are used in clinic or home Three variants of the disease are known on the basis of the
care settings, but practices differ. antigenic reactivity of factor IX. If the antigen reacts with
specific antibody, the patient is termed cross-reactive
Factor assays are used to monitor therapeutic progress. material positive (CRM+); if the antigen is undetectable, the
Activity levels of10% 20% will stop most bleeding into joints patient is termed CRM-; if the antigen reactivity is reduced
or muscles. Deeper joint bleeding and hematomas mandate but detectable, the patient is termed CRMR (reduced).
20% to 30% activity levels. Gastrointestinal bleeding, dental Patients who are CRM+ have been the most extensively
extractions, and surgery necessitate 50% to 80% activity studied. No correlation exists between antigen presence and
levels. Intravenous administration of DDAVP to mild clotting activity of the factor IX molecule.
hemophiliac patients may raise plasma levels of factor VIII:C
threefold to sixfold. Baseline plasma levels of factor VIII:C Some CRM+ variants of factor IX deficiency apparently entail
must be sufficient so that an increase invoked by DDAVP will a gene that codes for a defective primary sequence (structure)
protect the patient. of the factor IX molecule. Six varieties of CRM+ factor IX
deficiency have been described, each presenting different
An estimated 10% of severely affected patients develop molecular and behavioral properties. Differentiation of these
antibodies against factor VIII:C. These antibodies appear variants is not clinically useful at this time.
without regard to the number of transfused products
received or the type of product used. No linkage has been LABORATORY FINDINGS. Moderate to severe factor IX
established between the major histocompatibility complex deficiency is revealed by a prolonged APTT that is corrected
and the response to factor VIII:C There is no method to with aged serum but not with adsorbed plasma. Mild cases
determine who will develop antibodies and who will not. can produce an APTT value within normal limits, yet the
patient may exhibit severe bleeding with trauma or surgery.
The antibodies are IgG with kappa light chains and heavy
chains. These antibodies are characteristically found in The one-stage PT test using rabbit brain or lung
patients who fail to respond to infusions of factor VIII:C thromboplastin will be within reference limits, but ox brain
products but who previously had responded well. A single thromboplastin testing may reveal an abnormal result in a
patient may respond differently from infusion to infusion. subgroup of these patients. Specific factor IX assay
procedures are used for diagnosis and to assess activity levels
Patients have been plasmapheresed in an attempt to purge during therapy. Severely affected patients may have activity
the antibody from plasma, but the procedure has not been levels below 1%. Moderately affected patients possess 1% to
strikingly successful. Porcine factor VIII:C concentrates have 5% of normal activity, and mild affliction is manifest as 6% to
been used because of the low cross reactivity between 49% activity.
human factor VIII:C antibodies and porcine factor VIll.
Prothrombin complex concentrates present another option THERAPY. Therapy involve either commercial concentrate
for patients with high titers of antibody. These concentrates products or human single-donor plasma units. Because of
bypass the need for factor VIII:C by providing factors II, V II, IX, volume considerations, single plasma unit infusions may be
and X, some of which may be activated. Use of these unable to increase the activity to a level needed for
concentrates usually is reserved for life-threatening hemostasis. One unit of factor IX activity is equal to the
situations. activity Of factor IX in 1.0 mL of normal plasma. Calculations
of dosage reveal that infusion of unrealistically large
Factor IX Deficiency (Hemophilia B; Christmas Disease) quantities of plasma would be necessary to bring factor IX
In 1947, Pavlovsky demonstrated that in vitro mixing of activity levels to more than 20% of normal in most deficient
plasmas from two "hemophilia" patients resulted in patients. Commercial concentrates can achieve higher levels
correction of the recalcification time of both plasmas. At that of activity in smaller infusion volumes but have the same
time, all male patients exhibiting hemophilia symptoms were infection risks discussed for factor VIII concentrates. Heparin
thought to have classic hemophilia; in which case, these is administered with these products to minimize the
results would not have been obtained. In 1952, other thrombotic risk, and the timing of the infusion is controlled
investigators found hemophilia patients who possessed over a short period. Concentrates are reserved for use in life
factor VIII in their plasma but whose serum did not contain threatening situations. Plasma exchanges with normal donor
another substance that required vitamin K for synthesis and plasma have been performed to achieve 50% to 100% activity
could be adsorbed to barium salts. The factor was named levels and prevent cardiac overload.
plasma thromboplastin component (PTC) or Christmas factor
for the surname of one index patient. Laboratory monitoring of the patient is achieved by factor IX
assays before and after therapy. Factor IX activity levels of
CLINICAL FINDINGS. Factor IX deficiency (hemophilia B) is a 20% to 30% will initially correct minor soft-tissue
sex-linked recessive trait and is expressed in mild, moderate, hemorrhages. Correction of hematuria, body cavity
and severe forms. It generally is considered to be a milder hemorrhage, central nervous system hemorrhage, or
form of hemophilia than factor VIII:C deficiency because gastrointestinal bleeding requires activity levels of 50% to
clinically, these patients are not as prone to hemorrhages in 100%.
the gastrointestinal tract, abdomen, central nervous system,
or genitourinary tract. However, the severely factor IX Computer tomography scanning has proved valuable in
deficiency patient is clinically indistinguishable from the identifying the location and extent of these hemorrhages.
factor VIII:C-deficient patient. Dental extractions may require prophylactic infusions.
Von Willebrand's Disease Cryoprecipitate contains the high—molecular-weight
In 1926, Eric von Willebrand described the disorder that multimers Of v WF that affect the bleeding time. Commercial
bears his name as an autosomal dominant trait that produces factor VIII:C concentrates contain increased levels of factor
a prolonged bleeding time and evidence of vascular fragility. VIII:C but lack other components of the factor VIII complex
These patients are vulnerable to bruising, epistaxis, (VIII:vWF) necessary to correct the bleeding time. After
menorrhagia, and hemorrhage from tooth extraction. cryoprecipitate infusion, factor VIII:C levels increase in
plasma within 12 to 24 hours and remain elevated for several
Von Willebrand's disease is now known to be an autosomal days. Intravenous DDAVP also has been successful in
trait with either dominant or recessive inheritance. It is controlling the hemorrhagic sequelae of surgery, bypassing
caused by defects in both the factorVIII:C and the von the patient's dependence on human blood products.
Willebrand factor the factor VIII complex described earlier.
An important contribution by Zimmerman and associates in
1971 demonstrated that the vWF portion of the VIII is
reduced or absent in von Willebrand's disease. In this same
year, it was demonstrated that platelets in von Willebrand
plasma, in contrast to platelets in normal plasma, do not
aggregate in the presence of an antibiotic, ristocetin. The
ristocetin effect is secondary to a lack of v WF (or factor
VIIIR•RCo) in the plasma, as von Willebrand platelets react
normally when placed in normal plasma. It is not clear what EXTRINSIC AND COMMON PATHWAY DISORDERS
relation this in vitro effect bears to in vivo bleeding defects in In order for the extrinsic system Co become operative, tissue
the patient. damage and the release of tissue lipoproteins must occur. In
the presence Of Ca+2 and tissue lipoprotein (thromboplastin),
Structural defects in the factor VIII complex in this disorder plasma factor VII is activated and, in turn, activates factor X
result in a variety of v WF multimer combinations plasma to Xa.
(see Fig. 55-2). Although decreased, the factor VIII:C The intrinsic an extrinsic systems possess interrelated
component is nearly always present, as is VIIIR:Ag. Variation feedback loops, whichare not entirely understood. Examples
in the large multimers of vWF in plasma is the basis for include the ability of active factor XII (Xlla) fragments to
identifying variant types of this disease. amplify the activity of factor V II, the ability of factor IXa to
activate factor V II, and the ability of factor V Ila to activate
Von Willebrand's disease is the most frequently inherited both factors IX and X.
coagulopathy. True incidence figures are difficult to locate as Factor Xa begins the common pathway. In combination with
many cases are clinically silent and thus undiscovered. No phospholipid, Ca++, and cofactor V, factor Xa will convert
racial or ethnic prevalence is observed. Sometimes, the prothrombin (II) to thrombin (Ila), which in turn converts
disorder is not manifested until adulthood and the patient is fibrinogen (l) to fibrin.
surgically or traumatically stressed. Cases of acquired von
Willebrand's disease have been reported and generally are Factor VII Deficiency
associated with autoimmune or lymphoproliferative Factor VII deficiency is an autosomal recessive genetic
disorders, where abnormal antibodies are generated against abnormality with intermediate expression. It is rare,
the v W F. Treatment of the primary disease ameliorates the occurring in approximately 1 in 500,000 individuals. Variants
symptoms of acquired von Willebrand disease. exist, labeled CRM+ and CRMR according to their antigenic
reactivity. The behavior Of this factor can vary in testing
CLINICAL FINDINGS. Bleeding appears to be more severe in procedures depending on the tissue source of the
the child and decreases in severity with age. Muscular thromboplastin used. Correlation between clinical bleeding
hematomas and hernarthroses are rare unless the patient tenden and activity levels in assays are poor.
inherits the autosomal recessive form of the disease. There is
no real clinical difference in presentation between Type I and CLINICAL FINDINGS. Hemorrhage from mucous membranes
Type II disease (see Table 55-2) except in liver disease or and into soft tissues occurs most frequently in children. Adult
pregnancy, in which levels of vWF are increased. Under these heterozygotes usually tolerate surgery well but may be
circumstances, patients with Type I disease may have vulnerable to thrombotic events.
correction of the hemostatic defect; patients with Type II
disease will not. LABORATORY FINDINGS. Diagnosis of factor VII deficiency is
based on a family history and demonstrated prolongation Of
LABORATORY FINDINGS. Typical laboratory data include the one-stage p T, while the APTT and thrombin clotting time
prolonged bleeding time, equivocal APT T results (depending (TCT) results are within reference ranges. This is the only
on plasma levels of factor VIII:C), decreased activity of factor deficiency in which the PT is the only observed abnormality.
VIII:C, abnormal ristocetin platelet factor VIII related activity Substitution testing procedures exhibit correction of the PT
(VIIIR:RCo) and decreased levels of large vWF multimers. with normal aged serum but no correction with adsorbed
plasma. Specific factor VII assay confirms the diagnosis;
THERAPY. Therapy measures are targeted at increasing levels affected patients demonstrate 10% to 20% of normal activity.
of factor VIII:C in plasma and shortening the bleeding time. Chromogenic substrate procedures exist to measure factor
Infusion of cryoprecipitate, the only component that contains VII's ability to cleave factor X. It should be noted that factor
all elements of the factor VIII complex, is commonly used. VII levels increase during pregnancy.
 THERAPY. Therapy requires infusion of fresh frozen plasma,
THERAPY. Donor plasma and serum components and as factor V is labile in storage. Plasma activity levels of 25% to
commercial concentrates containing the prothrombin 30% of normal are sufficient in most cases to ensure
complex factors are used. Factor X (Stuart—Prower Factor) hemostasis. Because of the apparent platelet involvement in
Deficiency Factor X was recognized as unique and given its this disorder, aspirin products should be avoided. The plasma
numeral in 1959. The index patients' surnames (Stuart and P supernatant fluid removed after cryoprecipitates have
rower) are synonymous with factor X. Deficiency of this formed m component preparations (cryofree plasma)
factor is inherited as an autosomal trait that is incompletely contains adequate levels of factor V when fresh and is used in
recessive but shows high penetrance. 'Immune variants some locations.
(CRM+ CRM- and CRMR) exist. This disorder is uncommon in
the general population. Factor II (Prothrombin) Deficiency
Factor II deficiency may be inherited as either a deficiency
CLINICAL FINDINGS. The symptoms of factor X deficiency or a dysfunction and is rare in the general population.
arehighly variable. Patients may exhibit lifelong histories of Hypoprothrombinemia is an autosomal recessive trait.
bruising, soft-tissue bleeding, or postsurgical or post-trauma Homozygotes have assayed levels of 2% to 25% of normal,
hemorrhages. All possible acquired causes, as well as the whereas heterozygotes maintain levels of 50% or greater.
possibility of multiple factor deficiencies, must be eliminated Eleven variants of dysfunctional prothrombin molecules have
in making the diagnosis. been reported.

LABORATORY FINDINGS. The deficiency produces prolonged CLINICAL FINDINGS. Patients with less than 50% activity
P T, APT T, and Stypven time values and a prothrombin exhibit mild bleeding tendencies similar to those seen in mild
utilization abnormality. Specific factor X assay procedures are hemophilia. Hemarthroses are rare. Medications containing
diagnostic. The PT is corrected by aged serum but not by aspirin may cause bleeding tendencies.
adsorbed plasma.
LABORATORY FINDINGS. Laboratory values differ with activity
THERAPY. Frozen plasma components or prothrombin levels of factor II. Both APT T and one-stage PT will be
complex concentrates are used for therapy. Activity levels of prolonged. The TCT procedures produce normal results.
10% to 40% of normal are considered adequate for Diagnostic procedures include a two-stage assay for
hemostasis. prothrombin activity and immune-based factor assays using
antiprothrombin Dysprothrombinemic patients will produce
Factor V Deficiency (Owren's Disease; Labile Factor abnormal results in the two-stage assay but normal immune
Deficiency) reactions. Care should be taken to rule out vitamin K
Factor V deficiency was discovered in 1944 in Norway by deficiency, liver disease, and multifactor defects.
Professor Owren. He demonstrated that adsorbed normal
plasma, when added to his patient's plasma, corrected the THERAPY— Therapy depends on which type of disorder is
prolonged PT. Other investigators subsequently described present and on its severity of expression. Fresh frozen plasma
similar findings. is the usual choice. Vitamin K-dependent protein
concentrates are also available but carry a risk of thrombosis.
An autosomal recessive trait, factor V deficiency is
demonstrated by homozygotes and is mild to silent in Factor I (Fibrinogen) Deficiency
heterozygotes. Factor V also has been described as being A defect in fibrin formation may be the result of an inherited
deficient in conjunction with factor VIII:C (V —VIII deficiency) lack of fibrinogen (afibrinogenemia), an inherited deficiency
in an other group of patients. A variety of autoimmune of fibrinogen (hypofibrinogenemia), or an inherited
disorders is known to produce mixtures of IgG and IgM production of a dysfunctional fibrinogen molecule
antibodies to factor V, resulting in an acquired form of (dysfibrinogenemia). The condition is rare. Afibrinogenernic
disease. patients have nearly undetectable amounts of fibrinogen;
hypofibrinogenemic patients possess less than 100 mg/dL
CLINICAL FINDINGS. Factor V activity less than 10% of normal (reference range: 200—400 mg/dL), and in both cases, the
results in hemorrhagic diatheses. Clinical episodes are similar molecular structure of fibrinogen is normal. Substitution of
to those in the mild to moderate hemophilias. Deficiencies amino acids in fibrinogen's polypeptide chains produces a
ofplatelet-borne factor V (platelet factor 1) may cause an structural change that may result in:
abnormal bleeding time and seem to precipitate more clinical (1) the inability to submit to proteolysis by thrombin,
problems than do decreases in plasma factor V levels. It is because the cleavage sites are inappropriate;
suggested that activated platelet-borne factor V is the (2) peculiar behavior during polymerization stages secondary
binding site for activated plasma factor X (Xa) and factor II to aberrant charge distribution across the molecule; (3) the
(prothrombin). Platelet aggregation studies are normal. addition of "dangling" (Inappropriate) side groups that affect
reactivity; or
LABORATORY FINDINGS. Bot the PT and the APTT are (3) (4) the persistence of fetal fibrinogen into adulthood.
prolonged. If the PT is corrected with adsorbed normal
plasma, evidence points to factor V deficiency. The possibility All four possibilities are categorized under the term
of combined (multiple) factor deficiencies must be eliminated. dysfibrinogenemia, and many variants have been described.
These specific factor V assay is considered diagnostic. These patients demonstrate abnormal function but have
normal levels in antigenic assays. All three forms of
fibrinogen disorder are inherited as autosomal traits. of factor XIII exist.
Afibrinogenemia is recessive in expression and clinically
severe. Hypofibrinogenemia and dysfibrinogenemia are THERAPY. Therapy is accomplished with infusion of donor
phenotypically dominant, and bleeding episodes are less plasma or commercial purified, lyophilized placental factor
severe. XIII.

Afibrinogenemic patients' platelets appear affected in that a ACQUIRED DISORDERS OF COAGULATION

prolonged bleeding time may be measured. Platelets have a AND FIBRINOLYSIS
surface receptor for fibrinogen, and fibrinogen apparently is Hepatic Disease
necessary for platelet function in vivo. The liver is the principal site of synthesis of procoagulant,
fibrinolytic, and coagulation inhibitory' proteins. Liver
A host of acquired disorders may reduce the fibrinogen disorders present two challenges: decreased synthesis of
concentration in the plasma. Examples include renal disease, coagulation, lysis, and inhibitory proteins, and impaired
hepatic disease, and "consumptive" disorders such as clearance of activated hemostatic components.
disseminated intravascular coagulation. The history and
clinical features aid in the differentiation between inherited The type of disorder differs in neonates and adults. Neonates
and acquired forms. display decreased levels of plasma contact factors secondary
to hepatic immaturity. They also lack sufficient levels of
CLINICAL FINDINGS. Hemorrhages in afibrinogenemia and plasminogen and antithrombin Ill. In addition, neonates
hypofibrinogenemia differ in severity. With a complete lack express a unique fetal fibrinogen that does not behave in the
of fibrinogen, spontaneous bleeding has occurred. Mucosal, same manner as adult fibrinogen, and they have decreased
intestinal, and intracranial sites are most commonly affected. levels of fibrinogen (hypodysfibrinogenemia). Decreases of
Surgery and trauma present risks commensurate with the vitamin K—dependent factors in the neonate will be
concentration of functional fibrinogen available, and poor discussed later in this chapter.
wound healing has been observed.
In adults, parenchymal liver diseases, such as cirrhosis and
LABORATORY FINDINGS. All laboratory test times that hepatitis, and diseases that infiltrate liver tissue, such as
depend on fibrin formation will be prolonged in neoplasm, affect the synthetic capacity of theorgan.
afibrinogenemia, whereas these tests may or may not be Hemostatic changes often are subtle. Prolongation of the PT
prolonged in hypofibrinogenemia. Thrombin clotting times is considered a sign of worsening disease because of
are sensitive to fibrinogen levels and function. Routine depression of vitamin K-dependent factor synthesis, poor
screening procedures such as the APT T and PT return dietary intake, or malabsorption of vitamin K. Fibrinolytic
variable results. Addition of reagent fibrinogen will correct events and thrombocytopenia may accompany liver disease.
these endpoints. Platelet counts in hypofibrinogenemia are
within the reference range, as are the concentrations of LABORATORY FINDINGS. Screening tests such s the PT, APTT,
other procoagulant factors. Prolonged ReptilaseR (venom) TCT, bleeding time, platelet cotint, fibrinogen levels, and
Clotting times occur in dysfibrinogenemia. Tests measuring fibrin split products determinations are used to monitor
the activity of fibrinogen are relatively insensitive to hemostatic status in liver ease.
structural changes and vary unpredictably with the defect.
THERAPY. Infusion of fresh plasma may bolster the circulating
POSTCOAGULATION STABILIZATION DEFECTS levels procoagulants and minimize the hemorrhagic risk.
Commercial prothrombin complex concentrates generally are
Factor XIII (Fibrin-Stabilizing Factor) Deficiency not used in liver disease because of the depressed levels of
inhibitory antithrombin Ill available.
CLINICAL FINDINGS. A rare disorder, factor XIII deficiency is
an autosomal recessive trait in which only homozygotes Factor X (Stuart—Prower Factor) Deficiency
express the syndrome. The homozygous patient exhibits Factor X was recognized as unique and given its numeral in
spontaneous bleeding and poor wound healing with unusual 1959. The index patients' surnames (Stuart and Prower) are
scar formation. General symptoms are similar to those of synonymous with factor X. Deficiency of this factor is
mild hemophilia. The syndrome is incompatible with inherited as an autosomal trait that is incompletely recessive
pregnancy unless replacement therapy is provided but shows high penetrance. 'Immune variants (CRM CRM-
throughout gestation. All patients should avoid aspirin and CRMR) exist. This disorder is uncommon in the general
products. population.

LABORATORY FINDINGS. Inadequate crosslinking of fibrin CLINICAL FINDINGS. The symptoms of factor X deficiency are
results in an unstable and friable clot with excessive red cell highly variable. Patients may exhibit lifelong histories of
“fall out.” Fibrin clots incubated with 5 M urea or 1% bruising, soft-tissue bleeding, or postsurgical or post-trauma
monochloracetic acid dissolve rapidly, and if adequate hemorrhages. All possible acquired causes, as well as the
controls for excessive fibrinolysis are included, this test is possibility of multiple factor deficiencies, must be eliminated
relatively specific. The condition cannot be evaluated in the in making the diagnosis.
presence of heparin. Elaborate specific factor XIII assay
procedures are available but are not suitable for routine LABORATORY FINDINGS. The deficiency produces prolonged
clinical use. Immunologic procedures to measure quantities PT, APT T, and Stypven time values and a prothrombin
utilization abnormality. Specific factor X assay procedures are hemophilia. Hemarthrosis are rare. Medications containing
diagnostic. The PT is corrected by aged serum but not by aspirin may cause bleeding tendencies.
adsorbed plasma.
LABORATORY FINDINGS. Laboratory values differ with activity
THERAPY. Frozen plasma components or prothrombin levels of factor II. Both APTT and one-stage PT will be
complex concentrates are used for therapy. Activity levels prolonged. The TCT procedures produce normal results.
of 10% to 40% of normal are considered adequate for Diagnostic procedures include a two-stage assay for
hemostasis. prothrombin activity and immune-based factor assays using
antiprothrombin antisera. Dysprothrombinemic patients will
Factor V Deficiency (Owren's Disease; Factor Deficiency) produce abnormal results in the twostage assay but normal
Factor V deficiency was discovered in 1944 in Norway by immune reactions. Care should be taken to rule out vitamin K
Professor Owren. Hc demonstrated that adsorbed normal deficiency, liver disease, and multifactor defects.
plasma, when added to his patient's plasma, corrected the
prolonged PT. Other investigators subsequently described THERAPY. Therapy depends on which type of disorder is
similar findings. present and on its severity of expression. Fresh frozen plasma
is the usual choice. Vitamin K-dependent protein
An autosomal recessive trait, factor V deficiency is concentrates are also available but carry a risk of thrombosis.
demonstrated by homozygotes and is mild to silent in
heterozygotes. Factor V also has been described as being Factor I (Fibrinogen) Deficiency
deficient in conjunction with factor VIII:C (V—VIII deficiency) A defect in fibrin formation may be the result of an inherited
in another group of patients. A variety of autoimmune lack of fibrinogen (afibrinogenemia), an inherited deficiency
disorders is known to produce mixtures of IgG and IgM of fibrinogen (hypofibrinogenemia), or an inherited
antibodies to factor V, resulting in an acquired form of the production of a dysfunctional fibrinogen molecule
disease. (dysfibrinogenemia). The condition is rare. Afibrinogenemic
patients have nearly undetectable amounts of fibrinogen;
CLINICAL FINDINGS. Factor V activity less than 10% of normal hypofibrinogenemic patients possess less than 100 mg/dL
results in hemorrhagic diatheses. Clinical episodes are similar (reference range: 200-400 mg/dL), and in both cases, the
to those in the mild to moderate hemophilias. Deficiencies of molecular structure of fibrinogen is normal. Substitution of
platelet-borne factor V (platelet factor 1) may cause an amino acids in fibrinogen's polypeptide chains produces a
abnormal bleeding time and seem to precipitate more clinical structural change that may result in: (1) the inability to
problems than do decreases in plasma factor V levels. It is submit to proteolysis by thrombin, because the cleavage sites
suggested that activated platelet-borne factor V is the are inappropriate; (2) peculiar behavior during
binding Site for activated plasma factor X (Xa) and factor II polymerization stages secondary to aberrant charge
(prothrombin). Platelet aggregation studies are normal. distribution across the molecule; (3) the addition of
"dangling” (inappropriate) side groups that affect reactivity;
LABORATORY FINDING. Both the PT and the APTT are or (4) the persistence of fetal fibrinogen into adulthood. All
prolonged. If the PT is corrected with adsorbed normal four possibilities are categorized under the term
plasma, evidence points to factor V deficiency. The possibility dysfibrinogenemia, and many variants have been described."
of combined (multiple) factor deficiencies must b eliminated. These patients demonstrate abnormal function but have
The specific factor V assay is considered diagnostic. normal levels in antigenic assays.

THERAPY. Therapy requires infusion of fresh frozen plasma, All three forms of fibrinogen disorder are inherited as
as factor V is labile in storage. Plasma activity levels of 25% to autosomal traits. Afibrinogenemia is recessive in expression
30% of normal are sufficient in most cases to ensure and clinically severe. Hypofibrinogenemia and
hemostasis. Because of the apparent platelet involvement in dysfibrinogenemia are phenotypically dominant, and
this disorder, aspirin products should be avoided. The plasma bleeding episodes are less severe.
supernatant fluid removed after cryoprecipitates have
formed in component preparations (cryofree plasma) Afibrinogenemic patients' platelets appear affected in that a
contains adequate levels of factor V when fresh and is used in prolonged bleeding time may be measured. Platelets have a
some locations. surface receptor for fibrinogen, and fibrinogen apparently is
necessary for platelet function in vivo.
Factor II (prothrombin) Deficiency
Factor II deficiency may be inherited as either a deficiency or A host of acquired disorders may reduce the fibrinogen
a dysfunction and is rare in the general population. concentration in the plasma. Examples include renal disease,
Hypoprothrombinemia is an autosomal recessive trait. hepatic disease, and "consumptive" disorders such as
Homozygotes have assayed levels of 2% to 25% of normal, disseminated intravascular coagulation. The history and
where heterozygotes maintain levels of 50% or greater. clinical features aid in the differentiation between inherited
Eleven variants of dysfunctional prothrombin molecules have and acquired forms.
been reported.
CLINICAL FINDINGS. Hemorrhages in afibrinogenemia and
CLINICAL FINDINGS. Patient’s with less than 50% activity hypofibrinogenemia differ in severity. With a complete lack
exhibit mild bleeding tendencies similar to those in mild of fibrinogen, spontaneous bleeding has occurred. Mucosal,
intestinal, and intracranial sites are most commonly affected.
Surgery and trauma present risks commensurate with the levels of fibrinogen (hypodysfibrinogenemia). Decreases of
concentration of functional fibrinogen available, and poor vitamin K-dependent factors in the neonate will be discussed
wound healing has been observed. later in this chapter.

LABORATORY FINDINGS. All laboratory test times that In adults, parenchymal liver diseases, such as cirrhosis and
depend on fibrin formation will be prolonged in hepatitis, and diseases that infiltrate liver tissue, such as
afibrinogenemia, whereas these tests may or may not be neoplasm, affect the synthetic capacity of the organ.
prolonged in hypofibrinogenemia. Thrombin clotting times Hemostatic changes often are subtle. Prolongation of the PT
are sensitive to fibrinogen levels and function. Routine is considered a sign of worsening disease because of
screening procedures such as the APTT and PT return variable depression of vitamin K-dependent factor synthesis, poor
results. Addition of reagent fibrinogen will correct these dietary intake, or malabsorption of vitamin K. Fibrinolytic
endpoints. Platelet counts in hypofibrinogenemia are within events and thrombocytopenia may accompany liver disease.
the reference range, as are the concentrations of other Laboratory Findings Screening tests such as the PT, APTT, TCT,
procoagulant factors. Prolonged Reptilase (venom) clotting bleeding time, platelet count, fibrinogen levels, and fibrin
times occur in dysfibrinogenemia. Tests measuring the split products determinations are used to monitor hemostatic
activity of fibrinogen are relatively insensitive to structural status in liver disease. Therapy Infusion of fresh plasma may
changes and vary unpredictably with the defect. bolster the circulating levels of procoagulants and minimize
the hemorrhagic risk. Commercial prothrombin complex
POSTCOAGULATION STABILIZATION DEFECTS concentrates generally are not used in liver disease because
of the depressed levels of inhibitory antithrombin III available.
Factor XIII (Fibrin-Stabilizing Factor) Deficiency
Vitamin K Deficiency
CLINICAL FINDINGS. A rare disorder, factor XIII deficiency is Vitamin K is a necessary cofactor for the conversion of
an autosomal recessive trait in which only homozygotes terminal glutamic acid residues to gamma-carboxyglutamic
express the syndrome. The homozygous patient exhibits acid on factors II, VII, IX, and X as well as on protein C. This
spontaneous bleeding and poor wound healing with unusual conversion takes place in the hepatocyte and is necessary for
scar formation. General symptoms are similar to those of proper function. Vitamin K is produced by the normal flora of
mild hemophilia. The syndrome is incompatible with the gastrointestinal tract and absorbed. Deficiencies can
pregnancy unless replacement therapy is provided occur if the normal flora is not present (because of broad-
throughout gestation. All patients should avoid aspirin spectrum oral antibiotics), if absorption is decreased
products. (obstructive jaundice), or if antagonistic drugs (coumarin
family) are taken. Vitamin K may be a required dietary
LABORATORY FINDINGS. Inadequate crosslinking of fibrin supplement for the neonate, because the supply through the
results in an unstable and friable clot with excessive red cell placenta is minimal during gestation, and the gut is sterile for
"fall out." Fibrin clots incubated with 5 M urea or 1% several days after birth. The less than 10% activity levels of
monochloracetic acid dissolve rapidly, and if adequate prothrombin (II) in newborn plasma may result in
controls for excessive fibrinolysis are included, this test is hemorrhage, and premature infants are even more
relatively specific. The condition cannot be evaluated in the susceptible. Breastfed babies are more prone to vitamin K
presence of heparin. Elaborate specific factor XIII assay deficiency than are babies on prepared formulas, because
procedures are available but are not suitable for routine maternal milk provides less of the vitamin than babies
clinical use. Immunologic procedures to measure quantities require. Breast milk also is sterile; therefore, seeding of the
of factor XIII exist. newborn gut with bacteria is further retarded. Injections of
vitamin K administered to neonates help overcome this
THERAPY. Therapy is accomplished with infusion of donor temporary deficiency. Maternal drugs should be screened to
plasma or commercial purified, lyophilized placental factor ascertain that no antagonists to vitamin K are being ingested
XIII. and transferred by way of milk to the baby.

ACQUIRED DISORDERS OF COAGULATION AND The one-stage PT is used to assess levels of vitamin K-
FIBRINOLYSIS dependent coagulation factors in the newborn when clinically
indicated.
Hepatic Disease
The liver is the principal site of synthesis of procoagulant, THERAPEUTIC ANTICOAGULATION
fibrinolytic, and coagulation inhibitory proteins. Liver Heparin
disorders present two challenges: decreased synthesis of Heparin is the intravenous anticoagulant most frequently
coagulation, lysis, and inhibitory proteins, and impaired used in clinical medicine. It is used extensively in specimen
clearance of activated hemostatic components. collection for laboratory studies and in preventing fibrin
deposition on intravenous tubing devices residing in vessels.
The type of disorder differs in neonates and adults. Neonates Heparin is an acid mucopolysaccharide that acts in
display decreased levels of plasma contact factors secondary conjunction with antithrombin Ill to inhibit most of the serine
to hepatic immaturity. They also lack sufficient levels of proteases in the coagulation pathways. It is metabolized by
plasminogen and antithrombin III. In addition, neonates the liver and has a half-life of approximately 3 hours.
express a unique fetal fibrinogen that does not behave in the
same manner as adult fibrinogen, and they have decreased Coumarin Drugs (Oral Anticoagulants)
The oral anticoagulants were discovered in Wisconsin during secondary to citrate excess. The decrease in ionized calcium
an investigation of hemorrhagic disease in cattle. The herds levels in the plasma is directly related to the rate of infusion
were consuming contaminated fodder containing spoiled of blood product and may affect cardiac rhythm adversely.
sweet clover, which contains bishydroxycoumarin that Citrate is cleared eventually from the body through the liver
caused the bleeding. Warfarin is the most frequently used and kidneys. Hypotension, hepatic disease, hypothermia, and
coumarin. It is water soluble and is administered orally. It is hypovolemia all limit citrate clearance.
absorbed in the small bowel and circulates loosely bound to
albumin in plasma. It can cross the placenta and appear in The physiologic results of incompatibility between the donor
breast milk. Warfarin interferes with the carboxylation of the red cells and recipient plasma or serum are well documented
vitamin K-dependent plasma factors in the liver by in texts of immunohematology. Screening coagulation studies
interrupting the enzymatic phase of this reaction. This results should be obtained postreaction to ascertain hemostatic
in nonfunctional proteins circulating in plasma that are competence and document recovery.
referred to as proteins induced by vitamin K antagonist
(PIVKA). Infusion of enormous quantities of blood implies tissue
trauma or disease of extraordinary proportions. Platelets and
CIRCULATING ANTICOAGULANT (INHIBITORY) SUBSTANCES factors V and VIII:C are especially vulnerable to storage. The
Substances produced by the body that inhibit coagulation are in vivo effect of infusing decreased levels of all the
termed circulating anticoagulants. Such products are procoagulants is cumulative. Alternating infusions of red cells,
considered pathologic and are produced in response to a fresh plasma, and platelet components may be required to
variety of stimuli. The majority of these substances are maintain adequate levels of procoagulants.
antibodies, and the existence of an antibody to each of the
protein procoagulants has been demonstrated. Stimuli The bleeding time is considered a sensitive indicator of
include infusion of blood or blood products, release of tumor depressed platelet function in extensively transfused patients.
substances into the circulation, and autoimmune disorders. The APTT and PT values are less sensitive but useful in
deciding whether to supplement therapy with cryoprecipitate
Inhibitory activity directed against factor VIII/WF and factor or fresh plasma.
IX have been discussed with the deficiency states. The
laboratory results in the presence of such activity will mimic Artificial Surface Effects
those seen in the hemophiliac states. The demonstrated consequences of exposing blood to an
artificial surface include the formation of thrombi and emboli,
An inhibitor has been described in 5% to 10% of patients with consumption of procoagulant proteins and platelets.
systemic lupus erythematosus (SLE). Affected patients exhibit alteration of the function of these proteins, and incitement of
prolonged whole-blood clotting times and PT.2 This same systemic syndromes (fever, vasoconstriction, and bronchial
circulating anticoagulant activity has since been documented constriction) as a sequela of interactive reactions with
in patients who have drug-induced lupus, other immune surfaces. When blood and artificial surface meet, plasma
disorders or malignant tumors, as well as in persons proteins, especially fibrinogen, coat the exposed area (Fig.
exhibiting no primary disease. Patients treated with 55-3). Platelets may or may not attach, spread, and de
phenothiazines appear especially likely to produce this granulate. Antifibrinogen antibodies do not react with
inhibitor. layered fibrinogen, giving support to the theory that the
deposited protein has changed its antigenic properties. The
Increased levels of fibrin(ogen) split (degradation) products protein coat may change its composition over time,
(FSP or FDP). as seen in disseminated intravascular becoming less thrombogenic as it ages.
coagulation and lytic disorders, exert an anticoagulant effect.
The FSPs interfere with the polymerization of fibrin strands In the presence of complement, neutrophils and
and combine with procoagulant molecules in plasma to form macrophages are attracted to protein-coated artificial
complexes incapable of normal coagulant reactivity. Control surfaces and may assist in debriding the surface of both
of fibrin formation to limit the quantities of FSP produced platelets and protein. Aggregates of leukocytes may form and
with component replacement therapy. if necessary, are used be displaced into the circulation, forming microemboli as a
to manage this problem. Laboratory procedures utilized to result of complement activation.
evaluate this process include latex FSP agglutination tests,
measurement of fibrin monomers, platelet counts, fibrinogen The APTT, PT, platelet count, fibrinogen level, plasminogen
levels, APTT, and PT. level, antithrombin III assay. FSP determinations, and fibrin
monomer titer may all be used to evaluate and monitor the
Massive Transfusion Effects effects of an artificial surface within a patient's vascular
Transfusion of large quantities of blood can jcopardize system.
hemostatic competency for one or more of the following
reasons: (1) excessive quantities of infused citrate: (2) a
donor product incompatible with the recipient's system: and
(3) deficient labile clotting factors or platelets in the stored
blood.

As a powerful chelator, citrate can bind plasma Ca+2 needed

for hemostasis, however, clinical bleeding does not occur
 Replacement therapy with blood components may be
necessary following acute DIC to control hemorrhaging. Fresh
frozen plasma, platelet concentrates, and cryoprecipitates
may be used. A complete profile of coagulation and lysis
should be performed at clinically determined intervals to
assess this syndrome during management.

Disseminated Intravascular Coagulation Fibrinolysis

Disseminated intravascular coagulation (DIC) is a Often referred to as primary fibrinolysis (pathologic
complication of other primary disorders. It results in fibrinogenolysis or PF), the fibrinolysis syndrome in a pure
consumption of coagulation proteins and platelets into form is unusual. The disease is a result of the release of
thrombi, which are deposited locally or widely in the excessive amounts of plasminogen activators into the
circulation. Coagulation and fibrinolytic processes occur circulation either from damaged cells or from malignant cells,
simultaneously, and either one may dominate at a given time. as in prostatic carcinoma. These activators convert
plasminogen into plasmin in the absence of fibrin formation.
There is no age group or gender preference for DIC, and Plasmin is nonspecific in its action and will cleave fibrinogen,
much variation occurs in its clinical presentation. The single as well as factors V and VIII. As fibrinogen is broken down,
common thread connecting all versions of DIC is the FSP accumulate, which have an anticoagulant effect. The net
liberation of a thromboplastic substance that subsequently result is the inability of the blood to clot and thus bleeding.
results in coagulation. Plasmin is activated by the contact
phase reactions or by tissue activators released by damaged It is important to distinguish primary fibrinolysis from
cells (see Fig. 50-4). The progress of DIC may be controlled by secondary fibrinolysis, such as occurs in DIC. The laboratory
plasmin or thrombin at any given moment which results in a evidence for fibrinolysis is similar to that demonstrated in DIC.
dominant clinical exhibition of either hemorrhage or Nearly all tests are abnormal in both syndromes. Four tools
thrombosis. may be applied to distinguish the two syndromes: (1) the
euglobulin clot lysis time will be markedly shortened in
Damage to tissue, with the resulting release of tissue fluid primary fibrinolysis (PF) but normal to only slightly shortened
and the exposure of foreign surfaces to blood, brings about in DIC; (2) the platelet count remains greater than 100 X 10'/L
activation of coagulation. Endothelial cells may be damaged in PF, whereas it frequently drops below this level in DIC; (3)
by bacterial toxins, hypoxic shock, acidosis, antigenantibody antithrombin III assays will demonstrate decreased levels in
reactions, overwhelming infections, and malignancies. DIC and normal levels in PF; and (4) the D-dimer test, which is
Thromboplastic substances also can be injected directly into specific for the degradation of fibrin, will be positive in DIC
the circulation through insect or snake bites or released and negative in PF.
along with plasminogen activators in complicated
pregnancies and deliveries, malignant diseases, and In the absence of any evidence of thrombosis (DIC),
syndromes involving severe tissue trauma (burns, heat antifibrinolytic drugs may be used to treat the condition.
strokes, surgery, or crush injuries).
These drugs include natural antiplasmins, bovinc parotid
Acute DIC develops in a matter of hours, hemorrhage nearly extract (aprotinin), and synthetic lysine analogues
always occurs, and skin signs of purpura, gangrene, and epsilonaminocaproic acid (EACA) or trans-p-
bullae may appear. The mortality rate is estimated at 60% to aminomethylcyclohexanecarboxylic acid (AMCA). Often,
80% in these cases. Chronic DIC occurs in patients who have however, DIC is assumed to be present and the patient
already exhibited a thrombotic tendency or event, and managed accordingly. Prolonged cardiopulmonary bypass
hemorrhage is much less frequent. pump time in surgery and acute trauma to and hypoxia of
tissues have precipitated the primary fibrinolytic state. Such
Laboratory evidence that DIC is in progress includes cases are brief and self-limited. Prostatic carcinoma has
prolonged TCT, PT, and APTT; decreased platelets, fibrinogen, produced a long-term lytic syndrome that necessitates
and AT-Il levels; and elevated FSP and fibrin monomers. The therapy.
D-dimer test is positive in DIC as soon as 4 hours after onset.
Fibrinogen levels may decrease in 4 to 24 hours; platelets Drug Interactions with Coagulation Systems
decrease up to 48 hours post onset (CS Greenberg; Table 55-3 presents an abbreviated list of drugs with their
unpublished data). Peripheral blood films may reveal known effects on hemostasis mechanisms. Drugs may
erythrocyte fragments, as well as decreased numbers of directly enhance, retard, or inhibit reactions or indirectly
platelets. Hemoglobin and hematocrit values reflect the stimulate the formation of inhibitory substances that
severity of hemorrhage. neutralize reactants. Many of these drugs are in common use,
and it therefore behooves the coagulation laboratory to be
Use of heparin in the treatment of DIC is controversial. aware of their potential influence on testing systems and the
Heparin may be of benefit of thrombosis is damaging organ possibility of within-patient variation during therapy with
function, reversal of the damage is possible, and there are no these agents.
contraindications to the use of heparin. It is most important
to correct the disorder that invoked the DIC in the first place.
 CHAPTER SUMMARY
Coagulation disorders are categorized by mode of acquisition
into inherited or acquired types. Inherited disorders may be
further divided by site of biochemical disturbance within the
intrinsic, extrinsic, common, or stabilization pathways. Most
inherited disorders involve only one procoagulant defect.
Multiple factor deficiencies and inhibitory substances may
coexist in the acquired syndromes. The roles and effects of
exogenous substances such as vitamins, drugs, transfusions,
and introduction of artificial surfaces or prothrombotic or
proteolytic substances into the circulation are considered.
The patient's history, demographic category, and clinical
status are codeterminants in the interpretation and value of
laboratory data in hemostatic disorders.