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A patient with nephrotic syndrome of unknown aetiology was found to have a grossly prolonged prothrombin time in the absence of any other coagulation abnormality and with no clinical bleeding problem. Subsequent investigations showed his plasma contained an inhibitor-like substance, directed against human but not animal thromboplastin.
Plasma levels of prothrombin fragment 1 + 2 (F 1 + 2), of thrombin-antithrombin III complexes (TAT) and of D-dimers were evaluated at several time intervals in 15 patients affected by acute proximal deep vein thrombosis, complicated or not by pulmonary embolism, and treated by conventional heparin therapy for 9 d. The mean levels of the three markers remained significantly increased throughout the period of observation, except for F 1 + 2 on day 9, when compared to normal values established in a population of normal healthy blood donors. However, whereas heparin significantly decreased the plasma levels of F 1 + 2 and of TAT complexes in less than 3 d. D-dimer levels were not significantly altered. Significant correlations were observed between the plasma levels of the three markers but they were not correlated to the actual intensity of heparin treatment evaluated as the activated partial thromboplastin time prolongation. These results indicate that heparin improves the hypercoagulable state associated with a deep vein thrombosis within the first days of treatment as indicated by TAT and F 1 + 2. They also account for the performances of D-dimer assay for the diagnosis of deep vein thrombosis in patients already receiving heparin, a common situation in routine hospital practice.
The dilute prothrombin time (dPT) is a widely accepted sensitive screening test for the lupus anticoagulant (LA). In general, Simplastin (Organon Teknika), a rabbit brain thromboplastin, diluted 1/500, is used in this test. Recently, human tissue thromboplastin obtained by recombinant DNA technology has become available and we have evaluated the usefulness of one such preparation, Innovin (Dade), for the detection of the LA. dPTs, using several dilutions of Innovin were determined on plasmas from 18 normal individuals and 15 patients with a well-documented LA. The dPT ratios, calculated as the individual result divided by the mean normal, were statistically compared. Innovin in dilutions from 1/100 onwards was found to be significantly more responsive to the LA than Simplastin (P < 0.05). Intra-assay coefficients of variation (CVs) ranged from 1.05% to 14.8% with Innovin, versus 2.7%-24.3% with Simplastin (P < 0.05); inter-assay CVs ranged from 5.6%-11.8% with Innovin, versus 4.2%-33.8% with Simplastin (P < 0.001). Analysis of 316 consecutive plasma samples from non-anticoagulated patients, on which a LA determination was requested, showed a 100% sensitivity and a 96% specificity of the dPT performed with Innovin, as compared to 81% and 93% respectively for the dPT using Simplastin.
Information on performance is invaluable to those who have to decide on the choice of an instrument. More interest is being shown in the use of coagulometers. Accordingly, a tentative protocol for the evaluation of coagulometers is presented for discussion. While it is based on the use of one-stage prothrombin time, principles of evaluation are laid down which should make it generally applicable. It is hoped that the tentative protocol will form the basis of a reference protocol and to this end comments are invited from users of coagulometers and suppliers. Comments for publication may be sent to the Editor of Clinical and Laboratory Haematology or to the Secretary of the Working Party.
This multicentre study compares in parallel nine commercial coagulometers and manual tilt-tube methods for their capacity to distinguish two pairs of lyophilized plasmas with slightly different prothrombin times (PTs). The study was based on the rationale that the more precise a method is, the better it is able to discriminate between plasmas with similar PTs. Good or excellent discrimination, as judged by higher Student t values, were achieved slightly more frequently by coagulometers than by manual methods, particularly when paris of plasmas with smaller PT differences were tested.
In the differential diagnosis of thrombophilic disorders genotyping of prothrombin and factor V are nowadays performed as a routine analysis. In the following we describe the unusual results of the mutation screening using melting point analysis for two patients and the consecutive detection of the mutation C20209T by sequencing the corresponding gene fragments. The molecular result is discussed with special respect to the medical history, ethnic background and clinical findings of both patients.
Therapeutic options for developing countries have to assure an optimum safety and efficacy and low-cost antihaemophilic concentrates. A single blind randomized crossover study was carried out in 12 previously treated HB patients, comparing the pharmacokinetics (PK), thrombogenicity (TG) and safety of two plasma-derived double-inactivated (solvent/detergent heating at 100 degrees C, 30 min) factor IX (FIX) concentrates, UMAN COMPLEX DI (product A) [plasma-derived prothrombin concentrates (PCC)] and a high purity FIX concentrate AIMAFIX DI (product B, HPFIX). In a non-bleeding state, they received one single intravenous dose 50 IU FIX kg(-1) of PCC or HPFIX, and after a wash-out period of 14 days, the other product. We evaluated acute tolerance and determined PK parameters based on FIX levels measured over a 50 h postinfusion period. We studied fibrinogen, platelets, antithrombin, F1 + 2, TAT, D-dimer, over a 360 min postinfusion period. Ten cases remained in on-demand treatment for 6 months, five with PCC and five with HPFIX. PK and anti-FIX inhibitors were repeated at 3 and 6 months. No inhibitors were detected. PK values (PCC vs. HPFIX): clearence (CL; mL h(-1) kg(-1)) 5.2 +/- 1.4 vs. 6.5 +/- 1.4; the volume of distribution at steady state (mL kg(-1)) 154.9 +/- 54.9 vs. 197.5 +/- 72.5; mean residence time (h) 29.7 +/- 8.1 vs. 30.7 +/- 9.2; T(1/2) (h) 22.3 +/- 7 vs. 23.5 +/- 12.3; incremental recovery (IR; U dL(-1) U(-1) kg(-1)) 0.96 +/- 0.17 vs. 0.76 +/- 0.13. HPFIX showed significant lower IR and higher CL. There were no differences in PK at 3 and 6 months. In TG, significant increments in TAT and F1 + 2 at 30 min and 6 h were found with PCC. Product B PK results agrees with reported results for other HPFIX preparations. Use of PCC product A has to consider its thrombogenic activity.
The N-terminal decapeptide methyl ester, H-Ala-Asn-Lys-Gly-Phe-Leu-Gla-Gla-Val-Arg-OCH3 (16) of bovine prothrombin fragment 1 has been prepared by standard solution techniques, via a fragment coupling strategy. Hexapeptide Boc-Ala-Asn-Lys epsilon (Boc)-Gly-Phe-Leu-OBzl (9) was obtained by coupling Boc-Ala-Asn-Lys epsilon (Boc)Gly-OH (6) to the trifluoroacetate salt of H-Phe-Leu-OBzl (8). Hydrogenolysis of (9) followed by coupling to HCl. H-Gla gamma (OtBu)2-Gla gamma (OtBu)2-Val-Arg(HCl)-OCH3 (14) gave the fully protected decapeptide (15). Treatment of 15 with 90% trifluoroacetic acid followed by ion exchange chromatography of 15 yielded the methyl ester (16). The decapeptide 16 labeled with 125I using the Bolton-Hunter reagent, did not bind to antibodies specific for the calcium ion-induced conformation of bovine fragment 1.
The synthesis of two analogs of sequence 18-23 of bovine prothrombin precursor is described. Hexapeptides Boc-Cys (Acm)-Leu-Glu(OBzl)-Glu(OBzl)-Pro-Cys (Acm)-OBzl and Ac-Cys(Acm-Leu-Glu(OBzl)-Glu(OBzl)-Pro-Cys(Acm)-OMe were synthesized in solution by stepwise addition of Boc-amino acids using dicyclohexylcarbodiimide/N-hydroxybenzotriazole as the coupling reagent. The acetamidomethyl groups were cleaved and oxidized, using iodine in methanol, to the protected cyclic disulfide in 62-69% yield. The O-benzyl groups were removed either by treatment with anhydrous hydrogen fluoride or hydrogen bromide in trifluoroacetic acid to give the cyclic hexapeptide disulfides, R1-Cys-Leu-Glu-Glu-Pro-Cys-OR2 where R1 - H or Ac and R2 = H or CH3. The cyclic hexapeptides were evaluated as substrates for vitamin K-dependent carboxylase. Both peptides are unusually poor substrates for the carboxylase, and each appears to inhibit carboxylation of Phe-Leu-Glu-Glu-Leu, a good substrate for the enzyme.
In a search for a probe which would report its proteolysis to thrombin, the human blood coagulation zymogen prothrombin was covalently labeled with fluorescein. Fluorescein isothiocyanate (FITC) and dichlorotriazinylaminofluorescein (DCTAF) both introduced approximately 1 molecule of dye, but labeling occurred at different locations, as FITC had no effect on clotting activity whereas DCTAF caused 95% inactivation. At pH 9.0 DCTAF, but not FITC, could induce labeling up to 4 mol/mol. All derivatives were activated normally by prothrombinase (the activating complex of Factor Xa, Factor V(a), Ca2+ and phospholipids), as indicated by the pattern of bands on SDS gel electrophoresis and an unaltered yield of activity toward a chromogenic substrate for thrombin. Upon undergoing this limited proteolysis, the most heavily labeled derivative showed a 40% increase in fluorescence of the fluorescein at 520 nm (lambda ex 480 nm). In contrast, the fluorescence of lightly labeled forms was more intense but increased by only 0-5% upon activation. The data suggest that the lower fluorescence of the most labeled form is due to an intramolecular quenching effect between the dye molecules on individual polypeptide chains that is partly relieved when activation occurs.
The vitamin K-dependent proteins involved in blood coagulation processes each contain a small cystine loop with the sequence -Gla-Cys-X-Gla-Gla-X-Cys-. A method for the synthesis of the heptapeptide derivative representing the 17-23 sequence of bovine prothrombin, Z-Gla-Cys-Leu-Gla-Gla-Pro-Cys-OBzl, has been developed. The 25Mg2+ n.m.r. spectrum of the heptapeptide derivative has been obtained and is compared to the n.m.r. spectra obtained from the interaction of 25Mg2+ with Z-Gla-OMe and Z-Gla-Gla-OMe.
The effect of calcium (II) and magnesium (II) ions on the conformation of the 18-23 cyclic peptide loop of bovine prothrombin are investigated by the molecular mechanics program AMBER (Assisted Model Building with Energy Refinement). The work is an extension of an earlier paper (Eastman et al., Int. J. Peptide Protein Res. 27, 1986, 530-553) that employed the program ECEPP (Empirical Conformational Energy Program for Peptides). In the absence of either metal ion, or in the presence of either one Ca(II) or one Mg(II) ion, the lowest-energy forms found by AMBER have the Gla21-Pro22 peptide bond in a trans conformation. In the presence of two Ca(II) or Mg(II) ions, the loop form of lowest energy is decidedly cis. The coordination about the Ca(II) and Mg(II) ions is different in both the single and double metal cases. In addition, the peptide chains that emerge from the loop are oriented parallel to each other in the lowest-energy complex with two Ca(II) ions, but are not parallel in the lowest-energy complex with two Mg(II) ions.
A 28-residue peptide corresponding to the 35-62 region of bovine prothrombin fragment 1 (BF1) was synthesized by solid-phase methods. In BF1 this region consists of three conserved aromatic residues within an alpha-helical region followed by a disulfide loop. This synthetic peptide was used to produce murine monoclonal antibodies (MAbs) that would recognize and bind native BF1. Antibody AH.Ab.E3, an IgG1 antibody that was isolated and cloned, recognized and bound to both the synthetic peptide and the BF1 molecule. Residues 55-59 (REKLN) were shown to be critical for antibody binding. This MAb was subsequently used to study the 48-62 disulfide loop region of BF1. MAb AH.Ab.E3, which has been shown to bind the BF1 calcium-dependent conformation (BF1:Ca), does not appear to perturb the binding interaction between BF1:Ca and phospholipid (PL) vesicles as studied by light scattering methods.
Vascular complications remain the most common cause of early renal allograft loss in patients with end-stage renal failure. Underlying thrombophilic disorders increase the risk of early graft thrombosis. A male adolescent with high-risk thrombophilia because of combined heterozygous factor V Leiden (G1691A) and prothrombin gene (G20210A) mutation developed HIT II. Hemodialysis and subsequent renal transplantation were undertaken using recombinant hirudin, a direct and selective thrombin inhibitor, as an anticoagulant. Primary function in the transplanted kidney was excellent. No thrombotic or hemorrhagic events have occurred and follow-up showed excellent long-term graft survival. Patients on HD have an increased risk for the development of HIT, and therefore, they need repetitive screening for the development of acquired thrombotic risk factors (e.g. HIT II or lupus anticoagulant). R-hirudin is efficacious and safe on both HD and following renal transplantation.
A prospective study was conducted to evaluate a new compact portable coagulation monitor (Ciba-Corning Biotrack 512 Monitor), which enables the clinician to perform instantaneous activated partial thromboplastin time (APTT) and prothrombin time (PT). 126 patients scheduled for heparinized and nonheparinized vascular surgery, and gynaecological surgery, were included. A drop of capillary or venous whole blood was applied in disposable cartridges to successively perform APTT and PT, and the results of the tests were compared with conventional laboratory methods, performed in two different laboratories (Lab. A and B). Comparisons between Lab. A. and Lab. B. enables determination of the bias, precision, and percent of outliers (patients whose values differed more than 20%) in conventional methods. The reference value was defined as the mean of Lab. A. and Lab. B. values. For PT, there were no statistical differences between the capillary and venous samples performed with the portable monitor, and the reference value, for the bias, the precision and the proportion of outliers. For APTT, there were no statistical differences between the capillary and venous samples performed with the portable monitor, and the reference value, for the bias and the precision. The percent of outliers, however, was significantly greater with the venous sample of the compact monitor than with the reference (48 versus 22%), and even if it did not reach the statistical significance (P = 0.07) it was also higher with the capillary sample performed with the Ciba Monitor than with the reference (33%).(ABSTRACT TRUNCATED AT 250 WORDS)
Prothrombin complex concentrates prepared for clinical use are reviewed with emphasis on frequently observed adverse reactions such as viral hepatitis and thromboembolic complications. Preparation procedures and quality control are described briefly, and the use of these concentrates in the treatment of hemophilia A patients who develop factor VIII inhibitors is also described. The causes of and methods for the detection of potential thrombogenicity are discussed and suggestions which may result in a safer product are made.
The prothrombin time (PT) is measured in feline plasma usually by means of a method that has been optimized for measurements in human plasma (standard test). In the present study the sensitivity of this test was investigated in comparison to a modified PT using a human placental thromboplastin. In the modified test, 100 microliter sample predilution (1:5, 1:10, and 1:20) were incubated with 100 microliter of a human fibrinogen solution (2 g/l) until 100 microliter Ca-thromboplastin was added. When measured in 31 samples with a reduced, and 22 samples with an increased activity of the coagulation factors II, V, VII and/or X the modified test showed an increased sensitivity as well as a correlation between PT and the changes in single factor activity which was distinctly closer compared to the standard test. The highest sensitivity was produced by a 1:10 or 1:20 sample dilution. A test procedure modified in this way, is thus, a more reliable screening test for the extrinsic system in cats and should be used for routine diagnostics.
We evaluated the clinical usefulness of a protein induced by vitamin K absence, antagonist-prothrombin (PIVKA-II), in detecting hepatocellular carcinoma (HCC) specifically in patients with liver cirrhosis, and the possible correlation between levels of PIVKA-II and pathological features of HCC. Plasma levels of PIVKA-II and alpha-fetoprotein (AFP) were measured in 628 patients with various diseases, including 253 with liver cirrhosis and 116 with HCC. PIVKA-II was detected (greater than or equal to 0.1 arbitrary unit/mL) in 54.3% of HCC and the concentration showed a positive correlation with the tumour size. As a screening test for the detection of HCC, PIVKA-II produced values comparable with those of AFP with a sensitivity, specificity and validity of 52.8, 98.8 and 51.6% respectively. Sixteen of 45 patients (37%) with HCC who had low AFP (less than 100 ng/mL) levels were positive for PIVKA-II. No apparent relationship, however, could be found between the levels of PIVKA-II and the aetiology or pathological findings of HCC. These results suggest that PIVKA-II can be a reliable marker for detecting HCC in patients with liver cirrhosis.