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Apr 28, 2023 1
HEMOSTATIC PHYSIOLOGY
Mansyur ArifDept. of Clinical Pathology
Fac.of Medicine,Hasanuddin University, Makassar
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Regulation of hemostatic mechanism involves complex interaction between vessels walls, blood cell elements and a variety of plasma proteins.
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Blood clotting results from :1. Interaction between endothelial cells and platelets
the primary hemostatic plug.2. The coagulation phase thrombin is generated &
fibrin develops3. Formation of peptide bonds stabilization of the
fibrin network.
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Fibrinolysis is the process of enzymatic degradation of fibrin clots whereby : coagulation activity is limited to the area surrounding vessels wall injury and patency of vessels is maintained or restored
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PLATELET STRUCTURE
Major Structure features:• A typical cell membrane.• Circumferential microtubular system• Dense tubular system• Various granules• Externally communicating open
canalicular system.
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Platelet Membrane
• Bilipid membrane and membrane pro-tein.
• Bilipid membrane around the platelet contains several important glycoproteins that function as surface receptors.
• Bilipid membrane is also the site of complex coagulation activities of the platelet.
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Bilipid membrane (cont.)
1. Glycoprotein Ib (GP Ib). MW of about 140 kD. It serves as the binding site for vWf.
2. Glycoprotein IIb-IIIa (GP IIb-IIIa).A prominent Ca-dependent membrane protein complex that function as a fibrinogen receptor.
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Microtubules and Microfilaments
• Microtubules are composed of tubulin and participate in cytoskeletal support and in contraction of the stimulated cell.
• Microfilaments contain actin and participate in platelet pseudopod forma-tion.
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Dense Tubular System
• Electron dense material.• Selectively binds divalent cations and
serves as the platelet Ca reservoir.• Site of PLT cyclooxygenase and of
prostaglandin synthesis.
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Granules
• Dense granules contain high concentrations of ADP and Ca as well as serotonin. These substances are released upon PLT stimulation, enhance PLT aggregation.
• α Granules store a variety of proteins that are secreted by stimulated PLT. These includes PF4, β-thromboglobulin, PDGF, Fibrinogen, F V, vWf and various glycoproteins important to adhesion (thrombospondin & fibronectin)
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Canaliculi
• Open canalicular system is a complex network of surface membrane invagi-nations that look like vacuoles.
• Increase the PLT surface area.• The contents of PLT granules are
released through this system
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Platelet Physiology
When a blood vessels is injured:• Subendothelial tissue is exposed.• PLT adhere to subendothelial tissue.• Adherence mediated by vWf form a
bridge between subendothelial tissue and GP Ib.
• Thrombin stimulates membrane phospholipids to release arachidonic acid
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Platelet Physiology
• AA is converted to cyclic endoperoxides and TxA2.
• Stimulate granules and dense bodies.• High concentration locally thrombin,
TxA2 and ADP will change GP IIb-IIIa becomes receptor for fibrinogen to forms a bond between adjacent PLT creating a hemostatic plug.
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PhospholipidPhospholipase
Arachidonic acid Cyclo-oxygenase (aspirin inhibits)
PGG2
Peroxidase PGH2
Thromboxane synthetase Prostacyclin synthetase (platelets) (endothelium)
TxA2 PGI2
H2O TxB2 6-keto PGIa
Fig. 1. Arachidonic acid metabolism in platelets endothelium.
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Endothelium Contribution
• Metabolize AA to Prostacyclin (PGI2).• PGI2 has major contribution as
antithrombotic in intact endothelium.• Low dose aspirin completely block TxA2
production.
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Coagulation phase :
1. Conversion of fibrinogen (soluble plasma protein) into insoluble fibrin affected by highly specific enzymatic action of thrombin.
Thrombin must be generated from zymogen, prothrombin, by a series of reactions between serine proteases, co factors & lipid moieties.
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2. Coagulation factors may be group as follows : contact factors, thrombin - sensitive factors, & vit K- dependent factors.Classically, the generation of thrombin is described as occuring through the “extrinsic” or “intrinsic” systems.
Table 1 summarizes the features of the coagulation factors.
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Table 1. Plasma coagulation factors
Factor Alternative name Path-way
Half-life (hours)
IIIIIIV
VIIVIIIIXXXIXII
XIII HMW kininogen
Prekallikrein
Fibrinogen ProthrombinTissue factorProaccelerinProconvertinAntihemophilic factorChristmas factorStuart - Prower factorPlasma thromboplastin antecedentHageman factorFibrin - stabilizing factorFitzgerald factorFletcher factor
CCICEII
I,E,CIIIII
90-12048-120
Not available12-24
2-610-1218-3024-6045-8040-70
72-200150
48-52
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Coagulation systems : 1. The extrinsic systems : triggered by TF/
tissue factor (complete thromboplastin).- TF + VIIa + Ca activates F X (F Xa) - F Xa + V + Lipid (TF) extrinsic pro- thrombinase (converts prothrombin thrombin). (Fig 1).
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Prothrombin
(Ca 2+) X
(Ca 2+) Test : PT
(Quick)
Thrombin
Fig.1. Generation of thrombin via the extrinsic system. (TF = tissue fct ; PT = prothrombin ; = prothrombin complex ; = F X activating complex).
TFVIIa
XaV
Lipid (TF)
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2. The intrinsic system :a. Contains all the elements necessary for clotting.b. Instead of tissue thromboplastin, the lipid moiety in this system is PF3.c. The contact fcts (F XII, XI, prekallikrein/PK, High Molecular-Weight Kininogen/HMWK) are activated by exposure to negatively charged glass surfaces & other substances (ellagic acid,uric acid crystals,skin,collagen & antibody complexes)
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d. - F XIIa in the presence of PK and HMWK activates F XI.
- F XIa activates IX, which in a complex with VIII, lipid (PF3) and Calcium activates F X.
- F Xa, V and lipid (PF3) comprise “intrinsic prothrombinase”. (fig. 2).
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Contact factors Prothrombin
XIaIX
(Ca 2+)
X
Test : aPTT (Ca 2+)
Thrombin
Fig.2. Generation of thrombin via the intrinsic system. (PK = prekallikrein; HMWK/ high molecular weight kininogen ; PF3 = platelet factor 3 ; aPTT = activated partial thrombplastin time ; = prothrombinase complex ; = F X activa- ting complex.
PKXII XIIa
HMWK
XI
IXaVIIIPF3
XaV
Lipid (PF3)
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e. - Screening test : aPTT screens for all the coagulation factors except F VII. - intrinsic & extrinsic pathways converge at the F X and V level. - A coagulation factor deficiency (or
inhibitor) at this level results in abnormal screening test for both system.
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f. F VIII & V are cofactors for F IXa & Xa. When initial traces of thrombin are genera-ted, F VIII & V are activated (VIIIa & Va). Larger amounts of thrombin results in destruction of these factors. (Fig.3)
g. Interlinkage between the intrinsic & extrinsic systems occurs at several levels. The most important of these is the ability of TF and factor VIIa to activate F IX. (Fig.4)
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Prothrombin Intrinsic system Extrinsic system
Thrombin
Fig.3. Autocatalytic action of thrombin. (TF= tissue fct ; PF3 = platelet fct 3)
IXa VIII VIIIa
PF3
XaV Va
PF3
XaVa V
TF
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Prothrombin Intrinsic system Extrinsic system
XIa
(Ca2+) IX
(Ca2+)
X Xa
ThrombinFig. 4. Linkage between extrinsic and intrinsic systems. Several interaction
occur at various levels of the two systems. Primary among these is the ability of TF and F VIIa and F IX.
TFVIIa
IXaVIIIPF3
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3. Fibrin generation
When thrombin acts on the fibrinogen molecu-
le, two pairs of tiny fibrinopeptides (A & B) are
cleaved off, yielding “activated” fibrin mono-
mer units. The monomers polymerize to form
a loose, unstable fibrin clot, which can be
converted to a stable fibrin clot. (Fig.5)
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ThrombinFibrinogen Fibrin Fibrin Polymer
monomer (hydrogen bonded)
Fig. 5. Fibrin generation
a. Screening test : Thrombin time (TT) TT is prolonged due to : - fibrinogen concentration is very low (<80 mg/dl)- interfere with polymerization of fibrin monomer (fibrin (ogen) degradation product/FDP, parapro-teinemias, uremia)- heparin and abnormal fibrinogen (dysfibrinoge-nemia) are present.
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b. Additional test
In the reptile time test, the snake venom employed selectively cleaves fibrinopeptide A from the fibrinogen molecule. Clotting will proceed even though fibrinopeptide B remains intact.This test can be valuable because it is pro-longed in the same circumstances as the TT except that is not prolonged by the presence of heparin.
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Fibrin stabilization
• Final stage of coagulation• F XIII, a transaminase, is activated by throm-
bin and converts the hydrogen-bonded fibrin strands into more stable, covalent peptide bonds. (Fig.6)
• Screening test : Deficiency of F XIIIa results in clots that dissolve in 5M urea or 1% monochloro-acetic acid.
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XIII Thrombin
XIIIa Fibrin polymer Fibrin polymer
(hydrogen bonded) (peptide bonded)Fig. 6. Fibrin stabilization. The initially formed clot of polymers of
fibrin monomer is stabilized by thrombin activated F XIII. F XIIIa converts the fibrin strands into covalently bonded, stable fibrin.
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Fibrinolysis• Deposition of fibrin is associated with activati-
on of fibinolysis• Fibrin is a substrate for the proteolytic action
of plasmin.• Plasmin is normally present in its inactive,
zymogen form (plasminogen) in blood, urine and other body fluids.
• Plaminogen may be activated intrinsically by the contact system of coagulation or extrin-sically by TPA/tissue plasminogen activator.
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• Exogenous activation may be induced therapeutically by administration of urokinase or streptokinase. (Fig.7)
• Screening Test :TT may be prolonged due to presence of FDP (may show elevation).
.
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Physiologic inhibitors
• Procoagulant & fibrinolytic activities are homeostatically regulated by counter-balancing natural inhibitors
• In the coagulation system, antithrom-bin III inhibits not only thrombin but other serine protease as well (F IXa, Xa, XIa, XIIa).
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• Protein C along with its cofactor, protein S, degrades F VIIIa and Va.
• Plasmin is neutralized primarily by
2 - antiplasmin.
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Plasminogen
Intrinsic system Extrinsic system
Contact XII XIIa HMWK
Exogenous
Prekallikrein
Plasmin
Fig.7. The fibrinolytic system. Plasmin, the active fibrin(ogen)olytic enzyme, is generated by activation of plasminogen as shown. = plasminogen activator.
Kallikrein TPA UrokinaseStreptokinase
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INTRINSIC SYSTEMHMWK
XII XII aKallikrein
XI XIa EXTRINSIC SYSTEM
VII IX IXa + VIII TF
Ca 2+ Ca 2+ Ca 2+
PL
X Xa + V Ca 2+
PL Prothrombin Thrombin
Fibrinogen Fibrin
XIII XIIIa Stable fibrin clot
Ca 2+
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II. TESTS OF COAGULATION SYSTEM
A. Screening Test 1. Partial thromboplastin time (PTT) and
activated partial thromboplastin time (aPTT)2. Prothrombin time (PT)3. Quantitative fibrinogen4. Thrombin time (TT)5. Screening test for factor XIII
B. Spesific factor assays
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THANK YOU
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III. CONGENITAL HEMORRHAGIC DISORDER
A. Hemophilia A (factor VIII deficiency) and Hemophilia B (factor IX deficiency)
1. Pathophysiology :X chromosome, gene defect.
2. Clinical features :mild, moderate and severe
disease3. Diagnosis :
a. screening testsb. specific factor assay
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4. Therapy : to raise the deficient factor
a. Pharmacologic therapy :
1. Hemophilia A : Desmopressin (dDAVP)
2. Hemophilia B : no effective drugs
b. Replacement therapy :
1. Beware of adverse effects
2. The choice of blood product is critical
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c. Treatment options :
1. Fresh frozen plasma (FFP)
2. Cryoprecipitate
3. Factor concentrates
5. Complication : Arthropathy, Inhibitors, Liver disease, HIV infection.
6. Interdisciplinary care hemophilia center medical care, psychosocial care and
genetic counseling
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B. von Willebrand’s disease
1. Physiology of vWF :- HMW glycoprotein, 250 kD- In plasma and in platelets- as a carrier protein for coag. F VIII- important for primary hemostasis- mediates adhesion of platelets to the s.endot- vWF – F VIII complex : F VIII : C, F VIII : Ag, F VIII : Cag, F VIII : RCof.
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2. Clinical features : >> mucous membrane bleeding, epistaxis, menorrhagia
3. Diagnosis : - Combination of prolonged BT and a decreased F VIII : C level classically- Combination of abnormalities of the functional measures of the vWF – F VIII complex variants of vWF (see table 2)- Ristocetin aggregation - Diff. of type F VIII multimer analysis :type I, IIA, IIB, IIC, III.
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Table 2. Laboratory Findings in Hemophilia A and Severe vWF Disease
Labotatory test Finding Hemophilia A vWF disease
Bleeding timeVIII : CVIII : AgVIII : RCof
NormalDecreased
NormalNormal
ProlongedDecreasedDecreasedDecreased
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4. Therapy a. dDVAPb. Cryoprecipitatec. F VIII concentrates
C. Other inherited factor deficiencies 1. F XII, prekallikrein and HMWK2. F I, II, V, VII, X, XI and XIII
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IV. ACQUIRED HEMORRHAGIC DISORDER
A. Vitamin K deficiency1. Etiology
a. dietary deficiencyb. malabsorptionc. antibiotic therapyd. hemorrhagic disease of the new born
2. Clinical features : severe bruising or excessive bleeding or asymptomatic
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3. Diagnosis - severe : prolonged PT and PTT- early or milder def. : prolonged PT 4. Therapy - Parenteral vit. K- FFP
B. Liver disease1. Etiologya. decreased synthesis of coag. factorsb. Vit. K def
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c. Functionally abnormal fibrinogensd. Disseminated Intravasc. Coagulation (DIC) and consumption of coag. factors2. Clinical features - vary with the course of the patient’s liver disease- >> GIT bleeding3. Diagnosis - Lab. findings varies widely
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4. Therapy - trial of parenteral vit K therapy- Replacement therapy FFP
C. Clotting factor inhibitors autoantibodies1. Inhibitors in hemophilia2. Inhibitors in patients without
preexisting bleeding disorders a. Etiology : drugs, autoimmune or
lymphoproliferative disorders, spontaneous a.coagulants
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b. Diagnosis : mixing study, factor assays
c. Therapy : supportive
3. Lupus anticoagulant cardiolipin
a. Prolonged PTT, false + serologic test
b. associated with recurrent
spont.abortions.
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COAGULATION REGULATION AND
HYPERCOAGULABLE STATES
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I. CONTROL MECHANISMS IN COAGULATION
A. Naturally occuring a.coagulants
1. Antithrombin III (AT III) acts as a serine protease inhibitor
2. Protein C, Protein S Vit K – dependent
3. Other plasma protease inhibitor : heparin
cofactor II, 2- macroglobulin.
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B. Fibrinolitic system
1. Activation :
a. Intrinsic activation : a poorly understood mechanism of activation
b. Extrinsic Activation : Tissue plasminogen activator (t-PA), urokinase
c. Exogeneous (therapeutic) activation : streptokinase, urokinase and t-PA
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2. Sites of action a. Fibrinogen b. Fibrin
II. THROMBOTIC DISORDER
A. Congenital thrombotic disorder
1. AT III deficiency
2. Protein C deficiency
3. Protein S deficiency
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B. AQUIRED THROMBOTIC DISORDER THROMBOEMBOLIC DISEASE
1. Risk factors :a. abnormalities of blood flowb. abnormalities of the vasculaturec. abnormalities of the coagulation system
2. Clinical manifestations :a. Venous thrombosis
- superficial thrombosis - deep vein thrombosis
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b. Pulmonary embolismc. Arterial thrombosisd. Other
4. Therapya. Agents treatment and prevention 1. Anticoagulants :- Heparin- Warfarin 2. Thrombolytic agents :- Streptokinase- Urokinase- t-PA
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b. Treatment approaches
1. Deep vein thrombosis : >> heparin, thrombolytic agent
2. Pulmonary embolus : heparin, thrombolytic agent
3. Myocardial infarction : thrombolytic agent
4. Peripheral artery and catheter thrombosis :
thrombolytic agent.
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III. THROMBOHEMORRHAGIC DISORDER
A. Disseminated intravascular coagulation(DIC)1. Pathophysiology (see table 3)
a. Initiation : pathologic activation of the coag. cascade
b. Thrombosis c. Consumption d. Fibrinolysis
e. Hemolysis
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Infectious condition Gram negative septicemiaOther endotoxin-related condition
Obstetric conditionsAbruptio placentaeAmniotic fluid embolismRetained dead fetus
Vascular conditionsAneurysmGiant cavernous hemangioma
Hematologic conditions Massive hemolysisPromyelocytic leukemiaSnake venom
Trauma
Table 3. Conditions that commonly precipitate DIC
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2. Clinical features varies widely a. diffuse bleeding from multiple sites b. thrombotic lessions
3. Diagnosis lab. findings vary with time & circumstances Severe DIC :
a. Thrombocytopenia b. Prolonged PT, PTT, TTc. Decreased fibrinogend. FSPse. Microangiopathic hemolytic anemia
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4. Therapy :
a. Low grade DIC treatment may not be necessary
b. Clinically significant bleeding replacement of depleted coagulation factors and cells
c. Thrombosis : heparin
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B. Thrombotic thrombocytopenic purpura
(TTP) and hemolytic-uremic syndrome
(HUS)
C. Heparin thrombocytopenia
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THANK YOU