Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state...

55
Introduction to coagulation and laboratory tests Marc Jacquemin Special Haemostasis Laboratory Center for Molecular and Vascular Biology University of Leuven

Transcript of Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state...

Page 1: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Introduction to coagulation and laboratory tests

Marc Jacquemin

Special Haemostasis Laboratory

Center for Molecular and Vascular Biology University of Leuven

Page 2: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Coagulation in a blood vessel: fibrin stabilises the hemostatic clot

Platelet immunostaining Fibrin staining

Page 3: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Polymerisation of fibrin stabilises the hemostatic clot = secondary hemostasis

Page 4: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Norledge BV, et al. Proteins. 2003;53:640-8

Expression of Tissue Factor (TF) and Factor VIIa on phospholipid surfaces in damaged tissues

Page 5: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

VIIa/TF

Initiation of coagulation

Page 6: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

IXa IX

X Xa

VIIa/TF

Initiation of coagulation

Page 7: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

IXa IX

X Xa

VIIa/TF

Initiation of coagulation

Prothrombin Thrombin

Page 8: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Va V

IXa IX

XIa XI

X Xa

VIIIa VIII

VIIa/TF

Initiation of coagulation

Prothrombin Thrombin

Amplification

Page 9: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Va V

IXa IX

XIa XI

X Xa

VIIIa VIII

VIIa/TF

Initiation of coagulation

Prothrombin Thrombin

Amplification

Page 10: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Va V

IXa IX

XIa XI

X Xa

VIIIa VIII

VIIa/TF

Initiation of coagulation

Prothrombin Thrombin

Amplification

Page 11: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Va V

IXa IX

XIa XI

X Xa

VIIIa VIII

VIIa/TF

Initiation of coagulation

Prothrombin Thrombin

Amplification

Page 12: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Va V

IXa IX

XIa XI

X Xa

VIIIa VIII

VIIa/TF

Initiation of coagulation

Prothrombin Thrombin

Amplification Fibrinogen Fibrin

Sustained hemostasis

Page 13: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Va V

IXa IX

XIa XI

X Xa

VIIIa VIII

VIIa/TF

Initiation of coagulation

Prothrombin Thrombin

Amplification Fibrinogen Fibrin

Sustained hemostasis

FXIII

Page 14: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

FVIII is bound to vWF in plasma

A1

FVIII

vWF

Page 15: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Factor VIIIa Factor IXa

Phospholipids

A3

A2

A1

C2

X 100.000 by Factor VIII

Factor X

Factor Xa

Haemostasis

Activated Factor VIII as cofactor of Factor IXa

Page 16: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Hydrophobic residues

Basic residues Phospholipid

binding site

Pratt et al., Nature 2000

FV and FVIII binding to phospholipids

Page 17: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Hydrophobic residues

Basic residues Phospholipid

binding site

Pratt et al., Nature 2000

FV and FVIII binding to phospholipids

Page 18: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Hydrophobic residues

Basic residues Phospholipid

binding site

Pratt et al., Nature 2000

FV and FVIII binding to phospholipids

Page 19: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

hydrophobic

basic

Phospholipids

FVII, FIX, FX, FII binding to phospholipids:

Gla domain

Page 20: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

d Ca ++

Gla Gla Val

Leu Phe

hydrophobic

basic

Phospholipids

Gla:�J�carboxy glutamic acid

FVII, FIX, FX, FII binding to phospholipids:

Gla domain

Page 21: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Glutamic acid

H CJ

CH�

COO-

J-carboxylase

protein CH�

Page 22: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Glutamic acid

-OOC J-carboxy glutamic acid

CJ

CH�

COO-

H CJ

CH�

COO-

J-carboxylase

protein CH�

CH�

Page 23: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Glutamic acid oxidized

vitamin K

reduced vitamin K

vitamin K

-OOC J-carboxy glutamic acid

CJ

CH�

COO-

H CJ

CH�

COO-

J-carboxylase

protein

VKOR

VKR

vitamin K

cycle

CH�

CH�

Page 24: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Glutamic acid oxidized

vitamin K

reduced vitamin K

vitamin K

-OOC J-carboxy glutamic acid

CJ

CH�

COO-

H CJ

CH�

COO-

J-carboxylase

protein

VKOR

VKR

vitamin K

cycle

anti-vit K

CH�

CH�

Page 25: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Coagulation and phospholipids

Page 26: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Coagulation and phospholipids

Modern times, 1936

Page 27: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Anti-phospholipid antibodies

Page 28: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Anti-phospholipid antibodies

Page 29: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Anti-phospholipid antibodies

Thrombosis

but no bleedings

Page 30: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Coagulation assays

Page 31: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Va V

IXa IX

XIa XI

X Xa

VIIIa VIII

VIIa/TF

Initiation of coagulation

Prothrombin Thrombin

Amplification Fibrinogen Fibrin

Sustained hemostasis

FXIII

Page 32: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Prothrombin time (PT) + TF + phospholipids + Ca++

Page 33: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

X Xa

VIIa

Prothrombin Thrombin

Fibrinogen Fibrin

Prothrombin time (PT) + TF + phospholipids + Ca++

Page 34: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

X Xa

VIIa

Prothrombin Thrombin

Fibrinogen Fibrin

Prothrombin time (PT) + TF + phospholipids + Ca++

time between the addition of reagents to citrate plasma and detection of a clot.

Page 35: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

PT results

• time (seconds)

Page 36: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

PT results

• time (seconds) • percent (%) by comparison to PT with dilutions of plasma 13 sec = 100% 40 sec = 10%

Page 37: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

PT results

• time (seconds) • percent (%) by comparison to PT with dilutions of plasma 13 sec = 100% 40 sec = 10% Follow up of

Anti-vit K treatment

Page 38: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

PT results

• time (seconds) • percent (%) by comparison to PT with dilutions of plasma 13 sec = 100% 40 sec = 10% • International Normalized Ratio (INR) 13 sec = 1 40 sec = 3.5

Follow up of Anti-vit K treatment

Page 39: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

APTT (Activated Partial Thromboplastin Time)

+ phospholipids + Ca++

+ non physiological surface (glass, silica, kaolin)

Page 40: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

APTT (Activated Partial Thromboplastin Time)

XIIa XII

HK / PK Contact Activation

pathway

+ phospholipids + Ca++

+ non physiological surface (glass, silica, kaolin)

Page 41: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Va V

IXa IX

XIa XI

X Xa

VIIIa VIII

Prothrombin Thrombin

Fibrinogen Fibrin

APTT (Activated Partial Thromboplastin Time)

XIIa XII

HK / PK Contact Activation

pathway

+ phospholipids + Ca++

+ non physiological surface (glass, silica, kaolin)

Page 42: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Interpretation of coagulations assays

Page 43: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

X Xa

VIIa

Prothrombin Thrombin (IIa)

Fibrinogen Fibrin

PT

Prolonged isolated PT

Page 44: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Va V

IXa IX

XIa XI

X Xa

VIIIa VIII

Prothrombin Thrombin (IIa)

Fibrinogen Fibrin

APTT nl XIIa XII

HMWK / PK

X Xa

VIIa

Prothrombin Thrombin (IIa)

Fibrinogen Fibrin

PT >

Prolonged isolated PT

Page 45: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Isolated prolonged PT (lower % value, increased INR)

acquired decreased FVII

• early liver disease • early anti-vit K treatment

« anti-phospholipid » antibody *

constitutive FVII defect

not bleeding disorders *

Page 46: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Va V

IXa IX

XIa XI

X Xa

VIIIa VIII

Prothrombin Thrombin (IIa)

Fibrinogen Fibrin

APTT > XIIa XII

HMWK / PK

X Xa

VIIa

Prothrombin Thrombin (IIa)

Fibrinogen Fibrin

PT nl

Prolonged isolated APTT

Page 47: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Isolated prolonged APTT

acquired • inhibitor antibody (FVIII) • « anti-phospholipid » antibody

constitutive • Von Willebrand disease • hemophilia A and B (FVIII, FIX) • FXI • FXII (contact activation pathway)

not bleeding disorders *

*

*

FVIII vWF

Page 48: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Differential diagnosis of isolated prolonged APTT

mix of patient’s plasma with normal plasma

Page 49: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Differential diagnosis of isolated prolonged APTT

mix of patient’s plasma with normal plasma

Correction of the APTT:

DECREASED FACTOR low titer or slow acting antibody

Factors XII, FXI, FIX, FVIII?

Page 50: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Differential diagnosis of isolated prolonged APTT

mix of patient’s plasma with normal plasma

NO correction of the APTT:

ANTIBODY

inhibitor antibody? anti-phospholipid antibody?

Correction of the APTT:

DECREASED FACTOR low titer or slow acting antibody

Factors?

Page 51: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Prolonged PT and APTT

Page 52: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Va V

IXa IX

XIa XI

X Xa

VIIIa VIII

Prothrombin Thrombin (IIa)

Fibrinogen Fibrin

APTT

XIIa XII

HMWK / K

X Xa

VIIa

Prothrombin Thrombin (IIa)

Fibrinogen Fibrin

PT

Page 53: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Va V

IXa IX

XIa XI

X Xa

VIIIa VIII

Prothrombin Thrombin (IIa)

Fibrinogen Fibrin

APTT

XIIa XII

HMWK / K

X Xa

VIIa

Prothrombin Thrombin (IIa)

Fibrinogen Fibrin

PT

Page 54: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

Acquired prolonged aPTT and PT

Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII, IX, X, II

• acute DIC V • massive blood transfusion V

• lupus inhibitor none after dilution • antibody to FV V

• rare systemic diseases Gaucher’s disease V, X

Nieman Pick disease Amyloid

• heparin • oral anticoag treatment VII, IX, X, II

Page 55: Introduction to coagulation and laboratory tests · Acquired prolonged aPTT and PT Clinical state Deficiency • advanced liver disease VII, V, IX, X , II • vit K deficiency VII,

APTT: Intentional and Strategic Family Engagementiel.org/sites/default/files/APTT Chicago June 2015.pdf · Build awareness of school readiness criteria for APTT implementation. 4.

APTT: Intentional and Strategic Family Engagementiel.org/sites/default/files/APTT Chicago June 2015.pdf · Build awareness of school readiness criteria for APTT implementation. 4.

Evaluation of Unexplained Prolonged APTT &/or PT · ©2015 MFMER | slide-1 Evaluation of Unexplained Prolonged APTT &/or PT Review & Update 12-2015 William L. Nichols, M.D. Special

Evaluation of Unexplained Prolonged APTT &/or PT · ©2015 MFMER | slide-1 Evaluation of Unexplained Prolonged APTT &/or PT Review & Update 12-2015 William L. Nichols, M.D. Special

WELCOME TO OUR APTT TEAM MEETING!

WELCOME TO OUR APTT TEAM MEETING!

VOLUME 16, ISSUE 2 • JULY 2010 aPTT VERSES HEPARIN ANTI-XA · In This Issue aPTT VERSES HEPARIN ANTI-XA for Monitoring Heparin ... (ASCP), Hemostasis Application Consultant ...

VOLUME 16, ISSUE 2 • JULY 2010 aPTT VERSES HEPARIN ANTI-XA · In This Issue aPTT VERSES HEPARIN ANTI-XA for Monitoring Heparin ... (ASCP), Hemostasis Application Consultant ...

Case Report Coexistence of Factor VII Deficiency and ...

Case Report Coexistence of Factor VII Deficiency and ...

Testosterone deficiency: myth, facts, and controversy · testosterone deficiency. men. Testosterone deficiency.

Testosterone deficiency: myth, facts, and controversy · testosterone deficiency. men. Testosterone deficiency.

PT APTT Technical Information

PT APTT Technical Information

Nano Mrs. Homemaker 2012Shipra Suncity Aptt. HT/Samachar Aptt. Forms Distributed : 2300 Foot Fall: 213 Participation: 147 Forms Distributed :2200 Foot Fall: 188 Participation: 124

Nano Mrs. Homemaker 2012Shipra Suncity Aptt. HT/Samachar Aptt. Forms Distributed : 2300 Foot Fall: 213 Participation: 147 Forms Distributed :2200 Foot Fall: 188 Participation: 124

Congenital Deficiency of Blood Clotting Factors II, VII ......factors VII, IX, and X. Studies on parents ofthe patient showed normal levels offactors II, VII, IX, and x. Plasma Normal

Congenital Deficiency of Blood Clotting Factors II, VII ......factors VII, IX, and X. Studies on parents ofthe patient showed normal levels offactors II, VII, IX, and x. Plasma Normal

Academic Parent-Teacher Teams (APTT)

Academic Parent-Teacher Teams (APTT)

PT and aPTT - HUMAN Diagnostics Worldwide · > Intrinsic Pathway: triggered by thrombin, collagen and negatively charged surfaces. The corresponding assay is aPTT. > Extrinsic Pathway:

PT and aPTT - HUMAN Diagnostics Worldwide · > Intrinsic Pathway: triggered by thrombin, collagen and negatively charged surfaces. The corresponding assay is aPTT. > Extrinsic Pathway:

Coagulation Disorders Corrina Mc Mahon. Laboratory investigations PT: VII, X, V PT: VII, X, V APTT; XII, XI, IX, VIII APTT; XII, XI, IX, VIII TT; Fibrinogen.

Coagulation Disorders Corrina Mc Mahon. Laboratory investigations PT: VII, X, V PT: VII, X, V APTT; XII, XI, IX, VIII APTT; XII, XI, IX, VIII TT; Fibrinogen.

Boron deficiency combined with magnesium deficiency

Boron deficiency combined with magnesium deficiency

29 Comparison aPTT Values

29 Comparison aPTT Values

Perdarahan, Ct, Bt,Ptt,Aptt

Perdarahan, Ct, Bt,Ptt,Aptt

Effects of Responsive Reagents on PT & APTT Testing · Effects of Responsive Reagents on PT & APTT Testing Laura Worfolk Title: Effects of responsive reagents on PT & APTT testing

Effects of Responsive Reagents on PT & APTT Testing · Effects of Responsive Reagents on PT & APTT Testing Laura Worfolk Title: Effects of responsive reagents on PT & APTT testing

Academic Parent Teacher Team APTT Meeting November 17, 2014 6-7pm.

Academic Parent Teacher Team APTT Meeting November 17, 2014 6-7pm.

Factor VII Deficiency Diagnosis and Management Hamid Hoorfar MD Inherited Blood Disorders Clinic Esfahan Medical Sciences University 2014.

Factor VII Deficiency Diagnosis and Management Hamid Hoorfar MD Inherited Blood Disorders Clinic Esfahan Medical Sciences University 2014.

Factor VII Deficiency Diagnosis and Management

Factor VII Deficiency Diagnosis and Management

APTT vs Anti-Xa for Unfractionated Heparin Anticoagulation ...

APTT vs Anti-Xa for Unfractionated Heparin Anticoagulation ...