From www.bloodjournal.org by guest on June 18, 2017. For personal use only.
THROMBOSIS AND HEMOSTASIS
Factor V Leiden mutation enhances fibrin formation and dissolution in vivo in a
human endotoxemia model
Elif Elmas,1 Nenad Suvajac,1 Bernd Jilma,2 Hartmut Weiler,3 Martin Borggrefe,1 and Carl-Erik Dempfle1
1Department
of Medicine I, University Medical Center Mannheim, Mannheim, Germany; 2Department of Clinical Pharmacology, University of Vienna Medical
School, Vienna, Austria; and 3Blood Research Institute, Blood Center of Wisconsin, Milwaukee
Disseminated intravascular coagulation
in sepsis is associated with microvascular thrombosis and organ dysfunction. It
was expected that prothrombotic disposition such as factor V Leiden (FVL) mutation would worsen clinical outcome. Astonishingly, clinical trial and animal
experimental data indicate that FVL can
be associated with improved survival.
This study investigated the effect of FVL
on the response to endotoxin of the coagulation and fibrinolytic system in hu-
mans. Fourteen healthy male subjects
without FVL and 15 healthy males with
heterozygous FVL received an intravenous bolus dose of endotoxin, 2 ng/kg of
body weight. Blood samples were drawn
before and 1, 2, 4, 6, and 24 hours after
administration of the endotoxin. Injection
of endotoxin led to a more pronounced
increase in soluble fibrin in patients with
FVL than in controls. Patients with FVL
displayed a more sustained increase in
plasmin-plasmin inhibitor complex after
4, 6, and 24 hours. Patients with FVL
mutation also displayed higher levels of
D-dimer and fibrinogen-fibrin degradation products in plasma after 24 hours.
Patients with FVL generate higher levels
of soluble fibrin, which may serve as
cofactor in tissue plasminogen activator–
induced plasminogen activation, leading
to a more sustained activation of fibrinolysis with production of more fibrinogenand fibrin-degradation products. (Blood.
2010;116(5):801-805)
Introduction
Replacement of Arg506 with Gln in coagulation factor V (the factor
V Leiden [FVL] mutation)1 results in the loss of an important
cleavage site for activated protein C (aPC). Factor Va carrying the
FVL mutation is less sensitive to inactivation by aPC. In addition,
FVL may display an impaired cofactor function in the degradation
of factor VIIIa by aPC. FVL predisposes for the development of
venous thrombosis.2 The high prevalence of FVL in the European
population3 indicates some survival advantage, which might be
related to less blood loss on injury or childbirth or to improved
wound healing.4 This may be a consequence of enhanced fibrin
formation due to the impaired inactivation of factor Va.
Presence of disseminated intravascular coagulation (DIC) in
sepsis is associated with an adverse outcome.5 DIC may lead to
microvascular thrombosis, causing multiple organ dysfunctions,
and it is conceivable that a prothrombotic disposition such as FVL
would be associated with an increased rate of fibrin disposition,
causing organ dysfunction and death in sepsis.
Astonishingly, data from the Recombinant Human Activated
Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) and
Extended Evaluation of Recombinant Human Activated Protein C
in Severe Sepsis (ENHANCE) trials indicate that the FVL mutation
might be associated with improved survival in severe sepsis.6,7 In
the PROWESS trial, mortality of patients with severe sepsis with
heterozygous FVL was 15.6%, compared with 31.0% in patients
without FVL in the patient group not treated with recombinant aPC
(Drotrecogin alfa [activated]). In patients treated with Drotrecogin
alfa (activated), the difference was smaller, with a mortality of 20.3% in
heterozygous FVL carriers and 24.9% in patients without FVL.
Kondaveeti et al8 determined FVL status in 259 children with
meningococcal disease. Mortality was similar in patients with and
without heterozygous FVL, but patients with FVL had an increased
rate of surgical skin grafting, referral to plastic surgeon, and/or
amputation.8 In a population-based study, Benfield et al9 did not
find a survival benefit related to the presence of FVL in sepsis, but
the investigators combined patients with heterozygous and with
homozygous FVL and did not account for disease severity.9 Thus,
apart from the PROWESS and ENHANCE study data, there is little
evidence from clinical trials for or against a beneficial effect of the
FVL mutation in severe sepsis.
Kerlin et al7 compared the survival of wild-type and transgenic
heterozygous and homozygous FVL mice after intraperitoneal
injection of endotoxin and found a significantly improved survival
in heterozygous FVL mice compared with wild-type mice as well
as homozygous FVL mice. However, experiments by Brüggemann
et al,10 using transgenic FVL mice receiving intraperitoneal injections of Escherichia coli bacteria in contrast, did not show any
beneficial effect of the FVL mutation.
The present experimental study does not focus on clinical
outcome but on the mechanisms of action of FVL in the context of
endotoxemia. Although endotoxemia models may differ substantially from actual bacterial sepsis, they may be used to gain
information about the pathophysiology of inflammatory conditions.
We used an established human endotoxemia model in healthy
males with heterozygous FVL and in a control group consisting
of healthy males without FVL. One advantage of this model
compared with a mouse model is that a full array of hemostasis
assays, including various assays for fibrin derivatives, can be used.
Most activation marker assays do not function properly in a mouse
model because the assays are based on murine monoclonal
antibodies directed against human antigens, which show little
Submitted March 26, 2009; accepted February 23, 2010. Prepublished online as
Blood First Edition paper, April 21, 2010; DOI 10.1182/blood-2009-03-213215.
payment. Therefore, and solely to indicate this fact, this article is hereby
marked ‘‘advertisement’’ in accordance with 18 USC section 1734.
The publication costs of this article were defrayed in part by page charge
© 2010 by The American Society of Hematology
BLOOD, 5 AUGUST 2010 䡠 VOLUME 116, NUMBER 5
801
From www.bloodjournal.org by guest on June 18, 2017. For personal use only.
802
BLOOD, 5 AUGUST 2010 䡠 VOLUME 116, NUMBER 5
ELMAS et al
Table 1. Baseline levels of coagulation parameters in FVL patients and controls
Baseline values (mean ⴞ IQR, range)
FVL
Controls
Fibrinogen Clauss, g/L
2.70 ⫾ 0.70 (2.10-4.30)
2.50 ⫾ 0.68 (2.10-3.90)
.430
Sekisui SF, mg/L
5.40 ⫾ 4.18 (0.70-10.60)
5.10 ⫾ 4.50 (2.80-28.20)
.948
Iatron SF, mg/L
5.80 ⫾ 1.38 (5.00-9.40)
7.25 ⫾ 1.20 (4.20-9.00)
.038
TINAquant D-dimer, mg/L
0.31 ⫾ 0.28 (0.04-1.14)
0.10 ⫾ 0.08 (0.02-0.24)
.014
Iatron FDP-P, mg/L
3.20 ⫾ 1.05 (2.40-4.70)
2.20 ⫾ 0.50 (1.60-3.00)
⬍ .001
230.2 ⫾ 99.4 (172.7-476.3)
194.2 ⫾ 79.2 (152.5-336.3)
.064
0.25 ⫾ 0.22 (0.07-0.95)
0.10 ⫾ 0.12 (0.00-0.19)
.001
PPIC, ␮g/L
TINAquant D-dimer (Serum), mg/L
reactivity with the corresponding murine antigens. In addition,
there might be species differences in the response of the coagulation system to endotoxin. The present data might be helpful for the
interpretation of the clinical results for patients with FVL and for
the planning of future clinical trials involving laboratory markers
for coagulation and fibrinolysis activation.
Methods
The local ethical committee of the University Medical Center Mannheim approved all procedures. After written informed consent was
obtained in accordance with the Declaration of Helsinki, 14 healthy
male subjects without FVL or other known thrombophilic disorder, 27 to
51 years of age, and 15 healthy males with heterozygous FVL, 20 to
69 years of age, were included in the trial. The participants had not been
treated with anticoagulant or antiplatelet drugs for at least 2 months
before inclusion in the trial.
The human endotoxemia model described in detail by Pernestorfer et
al11 was used. After overnight fasting, an infusion of 5% glucose was started
and continued for 8.5 hours at 3 mL/kg of body weight per hour. Parallel to
the start of infusion, patients received 500 to 1000 mg of paracetamol to
alleviate symptoms such as headache and fever induced by endotoxin
administration.12 After 30 minutes, venous blood samples were drawn, and
patients received an intravenous bolus dose of endotoxin, 2 ng/kg of body
weight (National Reference Endotoxin, E coli; The United States Pharmacopoial Convention Inc). Further venous blood samples were drawn 1, 2, 4,
6, and 24 hours after administration of the endotoxin.
Citrated blood was centrifuged at 2000g for 20 minutes, and plasma was
harvested and transferred to polypropylene sample tubes. Serum tubes were
stored at room temperature for 60 minutes, then centrifuged at 2000g for
20 minutes, and aliquots of serum were transferred to polypropylene
sample tubes.
The plasma and serum aliquots were frozen in liquid nitrogen and stored
at ⫺70°C until analysis. The laboratory analyses were performed in batches
to minimize analytical bias. For analysis, samples were thawed in a water
bath at 37°C for 10 minutes and then centrifuged at 10 000g for 5 minutes.
Fibrinogen (functional assay according to Clauss13) was measured with
the use of reagents and equipment from DadeBehring Diagnostics.
Photometric immunoassays with the use of antibody-coated latex
particles were also performed on a Hitachi 904 autoanalyzer. The TINAquant D-dimer assay was from Roche Diagnostics. The Iatron SF assay for
soluble fibrin,14 and the assay for fibrinogen and fibrin degradation products
in plasma (FDP-P) was from Iatron Laboratories. The Sekusui SF assay for
measurement of soluble fibrin15 was from Daiichi Pure Chemicals and was
also performed on the Hitachi 904 autoanalyzer, in parallel with the other
assays. Plasmin-plasmin inhibitor complexes (PPICs; plasmin-antiplasmin)
were measured with the use of a 96-well microtiter plate enzyme-linked
immunoabsorbent assay from DRG Instruments GmbH.
Data analysis
To minimize the effect of outliers and distribution effects in view of the
small number of patients, medians and interquartile ranges were used rather
than mean values and standard deviations. All group comparisons were
P
performed with the use of Wilcoxon signed rank sum test. For correlation
graphs, coefficients of correlation R were calculated, using a linear
correlation model.
Results
Effect of FVL on the procoagulant and profibrinolytic response
to endotoxin
Activation of the coagulation system in response to endotoxin, as
well as other stimuli, leads to the formation of fibrin. Depending on
the location, mechanism, and intensity of coagulation activation,
part of the fibrin is not incorporated into clots, but appears in blood
samples as “soluble fibrin.” This soluble fibrin can be detected by
laboratory assays based on monoclonal antibodies against neoepitopes generated directly or indirectly by the action of thrombin
on fibrinogen. For the present study, we used 2 soluble fibrin assays
based on different monoclonal antibodies, but both used similar
immunoassay technologies.
As shown in Table 1, the baseline results of the Sekisui SF assay
were similar in patients with and without FVL. The Iatron SF assay
showed a lower median value in patients with FVL than in controls.
Injection of endotoxin led to considerably more pronounced
increase in soluble fibrin in patients with FVL than in controls
(Figure 1).
Endotoxemia causes enhanced release of tissue plasminogen
activator (tPA) from the endothelium, and soluble fibrin serves as
cofactor in tPA-induced plasminogen activation. Plasmin is inactivated by formation of a covalent complex with ␣2-plasmin
inhibitor. This PPIC may serve as an indicator for in vivo activation
of fibrinolysis. Baseline PPIC levels did not differ significantly
between patients with FVL and controls (Table 1). Endotoxin
injection caused a strong increase in PPIC with a maximum 2 hours
after the injection (Figure 2A). The maximum values were similar
in both groups, but patients with FVL mutation displayed a more
sustained increase in PPIC at 4, 6, and 24 hours after endotoxin
injection.
TINAquant D-dimer is specific for plasmin-modified
crosslinked fibrin derivatives. Baseline values of TINAquant
D-dimer were higher for patients with FVL both in plasma and
in serum, indicating enhanced baseline generation of crosslinked
fibrin degradation products in patients with FVL (Table 1).
Initial serum levels of D-dimer antigen were slightly lower than
plasma levels.
D-dimer antigen measured with the TINAquant D-dimer assay
in plasma and serum differed in kinetics. Endotoxin injection led to
an increase in D-dimer antigen levels both in serum (Figure 2B)
and plasma (Figure 3A), but the highest levels in serum were found
after 2 hours, whereas in plasma, the maximum levels were found
after 24 hours. The course of D-dimer antigen in serum resembles
From www.bloodjournal.org by guest on June 18, 2017. For personal use only.
BLOOD, 5 AUGUST 2010 䡠 VOLUME 116, NUMBER 5
A
400
30
20
10
0
400
FVL
N
FVL
N
200
300
35
Iatron SF [mg/L]
P = .0325
P = .0402
[% initial value]
600
24h
40
803
Iatron SF
500
50
Sekisui SF [mg/L]
800
B
Sekisui SF
1000
[% initial value]
Figure 1. Soluble fibrin levels before and 1, 2, 4, 6,
and 24 hours after administration of the endotoxin.
Results are shown as medians and interquartile ranges
for patients with FVL (F) and controls (䡺). Patients with
FVL display a higher level of soluble fibrin after endotoxin
infusion. Inserts show the distribution of the 24-hour
values for patients with FVL and controls (N).
FVL MUTATION ENHANCES FIBRIN FORMATION
24h
30
P = .0030
25
20
P = .0030
15
P = .0026
10
5
0
200
FVL
N
100
FVL
N
0
0
A
0h
B
1h
C
2h
D
4h
E
6h
F
24h
Sample
the course of PPIC. No significant differences were observed between
patients with FVL and controls in serum D-dimer antigen levels.
Baseline levels of FDP-P were significantly higher in patients
with FVL than in controls (Table 1). This indicates that persons
with FVL have an increased activation of fibrinolysis. FDP-P levels
increased in response to endotoxin injection, and the kinetics were
similar to TINAquant D-dimer measured in plasma, with the
highest values present after 24 hours (Figure 3B). Patients with
FVL displayed higher levels of FDP-P and D-dimer 24 hours after
endotoxin injection, and the difference was statistically significant
for FDP-P (P ⬍ .009).
Discussion
Endotoxin injection caused a higher level of soluble fibrin and a
more sustained activation of fibrinolysis in patients with FVL than
in controls without FVL.
Soluble fibrin supports tPA-induced plasminogen activation.16,17 A good example for this effect is the injection of
thrombin-like snake venom enzymes such as ancrod, which induce
massive intravascular fibrin formation.18 The plasminogen activation in response to ancrod injection occurs without changes in tPA
or plasminogen activator inhibitor 1 (PAI-1) levels and is caused
primarily by the cofactor effect of fibrin on tPA-induced plasminogen activation.19
Injection of endotoxin similarly causes formation of large
amounts of plasmin, with a maximum PPIC concentration after
2 hours.20 In contrast to ancrod, endotoxin also stimulates tPA
2000
PPIC (PAP) [µg/L]
1200
[% initial value]
B
PPIC
FVL
N
1400
1000
500
P = .0495
FVL
N
P = .0260
600
400
P = .0100
0
C
2h
D
4h
E
6h
F
24h
release from the endothelium.20,21 The profibrinolytic response is
subsequently terminated by increasing levels of PAI-1,20,21 resulting in a rapid drop in PPIC concentration.
The present results indicate that this drop in PPIC is less
pronounced in patients with FVL. This may be a consequence of
the increased amount of soluble fibrin acting as cofactor in
tPA-induced plasminogen activation and possibly shielding tPA
from inactivation by PAI-1. Pernerstorfer at al20 showed that
maximal thrombin generation occurs 4 to 6 hours after endotoxin
infusion. Levels of prothrombin fragment F1.2 and thrombinantithrombin complexes, as well as soluble fibrin, return to baseline
within 24 hours.20 In patients with FVL, thrombin formation and
formation of soluble fibrin follow different kinetics, with elevated
levels also after 24 hours.
Enhanced fibrinolysis is a central defense mechanism against
organ dysfunction in sepsis-induced DIC.22 Inhibition of fibrinolysis by treatment with antifibrinolytic agents in this condition
promotes microvascular thrombosis, resulting in organ failure.23 In
survivors of severe sepsis, markers of coagulation and fibrinolytic
activation correlate, whereas in nonsurvivors coagulation activation is not balanced by activation of fibrinolysis.22 In animal
experiments, homozygous FVL provides no survival benefit in
endotoxemia.7 A possible explanation is that homozygous FVL
exaggerates fibrin formation to a level that is above the threshold
for effective clearance.
Elevated levels of PAI-1,24 as well as activated thrombinactivated fibrinolysis inhibitor (TAFIa),25 are frequent findings in
patients with severe meningococcal sepsis. Meningococcal sepsis
TINAquant D-dimer (Serum)
FVL
N
4000
3000
2000
1000
0
B
1h
C
2h
Sample
200
A
0h
B
1h
1000
0
800
6h
1500
[% initial value]
A
A
0h
D
4h
Sample
E
6h
F
24h
A
0h
B
1h
C
2h
D
4h
Sample
E
6h
F
24h
Figure 2. PPIC and serum D-dimer levels before and
1, 2, 4, 6, and 24 hours after administration of the
endotoxin. Results are shown as medians and interquartile ranges for patients with FVL (F) and controls (䡺).
Patients with FVL display a more sustained generation of
PPIC after endotoxin infusion. Highest levels of D-dimer
in serum are observed 2 hours after endotoxin infusion.
Inserts in panel A show the distribution of the 6-hour
values for patients with FVL and controls (N).
From www.bloodjournal.org by guest on June 18, 2017. For personal use only.
A
B
TINAquant D-dimer
2000
1500
TINAquant D-Dimer [mg/L]]
2500
24h
8
400
7
6
5
4
3
2
1
0
FVL
N
1000
FVL
N
500
Iatron FDP-P
450
9
[% initial value]
3000
[% initial value]
BLOOD, 5 AUGUST 2010 䡠 VOLUME 116, NUMBER 5
ELMAS et al
350
300
24h
20
Iatron FDP-P [mg/L]
804
P = .0088
15
10
5
250
0
200
FVL
N
FVL
N
150
100
0
50
A
0h
1hB
C
2h
D
4h
E
6h
F
24h
A
0h
B
1h
Sample
C
2h
D
4h
E
6h
F
24h
Sample
can be associated with tissue necrosis caused by widespread
microvascular occlusion, a condition termed sepsis-induced purpura
fulminans.26 As mentioned earlier, children with meningococcal
infection and FVL had an increased rate of surgical skin grafting,
referral to plastic surgeon, and/or amputation,8 indicating that the
enhanced fibrin formation caused by FVL in conjunction with high
PAI-1 and TAFIa promotes microvascular occlusion rather than
preventing it.
A possible beneficial effect of FVL in sepsis would probably
disappear if fibrinolysis is suppressed by massively elevated PAI-1
levels, if strongly elevated levels of the TAFIa prevent binding of
plasminogen and tPA to the fibrin, or if massive coagulation
activation leads to formation of more fibrin than can be cleared by
the fibrinolytic system.
In conclusion, FVL induces an enhanced fibrinolytic response
to endotoxin injection, presumably caused by higher levels of
soluble fibrin acting as cofactor in tPA-induced plasminogen
activation. “Latent coagulation”27 with presence of soluble fibrin
complexes in the circulation might serve as a defense mechanism,
leading to increased plasminogen activation, clearance of fibrin
deposits, reduction of fibrinogen levels, and generation of fibrinogen degradation products acting as “endogenous anticoagulants.”
Figure 3. TINAquant D-dimer and Iatron FDP-P levels
before and 1, 2, 4, 6, and 24 hours after administration of the endotoxin. Results are shown as medians
and interquartile ranges for patients with FVL (F) and
controls (䡺). Patients with FVL display higher levels of
D-dimer and FDP-P 24 hours after endotoxin injection.
Inserts show the distribution of the 24-hour values for
patients with FVL and controls (N).
Acknowledgments
We thank the medical technicians of the laboratory, Anja Kirchner,
Natascha Heim, and Cornelia Kehl, for excellent laboratory work.
This work was supported by Heinrich Vetter Stiftung, Mannheim.
Authorship
Contribution: E.E. and N.S. were responsible for the human
endotoxemia model experiments; B.J. contributed the experimental
details for the endotoxemia model; the experimental approach and
results were thoroughly discussed with H.W., who had performed
similar experiments in mice; M.B. reviewed the manuscript; and
C.-E.D. developed the experimental design for the study, supervised the endotoxemia model experiments, performed the laboratory analyses, and wrote the manuscript.
Conflict-of-interest disclosure: The authors declare no competing financial interests.
Correspondence: Carl-Erik Dempfle, University Hospital of
Mannheim, I Department of Medicine, Theodor Kutzer Ufer 1-3,
D-68167 Mannheim, Germany; e-mail: [email protected].
References
1. Bertina RM, Koeleman BP, Koster T, et al. Mutation in blood coagulation factor V associated with
resistance to activated protein C. Nature. 1994;
369(6475):64-67.
2. Dahlback B. New molecular insights into the genetics of thrombophilia. Resistance to activated
protein C caused by Arg506 to Gln mutation in
factor V as a pathogenic risk factor for venous
thrombosis. Thromb Haemost. 1995;74(1):139148.
3. Dahlback B. Resistance to activated protein C
caused by the R506Q mutation in the gene for
factor V is a common risk factor for venous thrombosis. J Intern Med Suppl. 1997;740:1-8.
4. Lindqvist PG, Dahlback B. Carriership of Factor V
Leiden and evolutionary selection advantage.
Curr Med Chem. 2008;15(15):1541-1544.
5. Dhainaut JF, Yan SB, Joyce DE, et al. Treatment
effects of drotrecogin alfa (activated) in patients
with severe sepsis with or without overt disseminated intravascular coagulation. J Thromb Haemost. 2004;2(11):1924-1933.
6. Yan SB, Nelson DR. Effect of factor V Leiden
polymorphism in severe sepsis and on treatment
with recombinant human activated protein C. Crit
Care Med. 2004;32(5 Suppl):S239-S246.
7. Kerlin BA, Yan SB, Isermann BH, et al. Survival
advantage associated with heterozygous factor V
Leiden mutation in patients with severe sepsis
and in mouse endotoxemia. Blood. 2003;102(9):
3085-3092.
8. Kondaveeti S, Hibberd ML, Booy R, Nadel S,
Levin M. Effect of the factor V Leiden mutation on
the severity of meningococcal disease. Pediatr
Infect Dis J. 1999;18(10):893-896.
9. Benfield TL, Dahl M, Nordestgaard BG, TybjaergHansen A. Influence of the factor V Leiden mutation on infectious disease susceptibility and outcome: a population-based study. J Infect Dis.
2005;192(10):1851-1857.
10. Bruggemann LW, Schoenmakers SH, Groot AP,
Reitsma PH, Spek CA. Role of the factor V Leiden mutation in septic peritonitis assessed in factor V Leiden transgenic mice. Crit Care Med.
2006;34(8):2201-2206.
11. Pernerstorfer T, Hollenstein U, Hansen J, et al.
Heparin blunts endotoxin-induced coagulation
activation. Circulation. 1999;100(25):2485-2490.
12. Pernerstorfer T, Schmid R, Bieglmayer C,
Eichler HG, Kapiotis S, Jilma B. Acetaminophen
has greater antipyretic efficacy than aspirin in endotoxemia: a randomized, double-blind, placebocontrolled trial. Clin Pharmacol Ther. 1999;66(1):
51-57.
13. Clauss A. Rapid physiological coagulation
method in determination of fibrinogen [in German]. Acta Haematol. 1957;17(4):237-246.
14. Nakahara K, Kazahaya Y, Shintani Y, et al. Measurement of soluble fibrin monomer-fibrinogen
complex in plasmas derived from patients with
various underlying clinical situations. Thromb
Haemost. 2003;89(5):832-836.
15. Suzuki A, Ebinuma H, Matsuo M, Miyazaki O,
Yago H. The monoclonal antibody that recognizes
an epitope in the C-terminal region of the fibrinogen alpha-chain reacts with soluble fibrin and fibrin monomer generated by thrombin but not with
those formed as plasmin degradation products.
Thromb Res. 2007;121(3):377-385.
16. Halvorsen S, Skjonsberg OH, Godal HC. The
stimulatory effect of soluble fibrin on plasminogen
activation by tissue plasminogen activator as
studied by the Coa-set Fibrin Monomer test.
Thromb Res. 1991;61(4):453-461.
17. Verheijen JH, Nieuwenhuizen W, Wijngaards G.
Activation of plasminogen by tissue activator is
increased specifically in the presence of certain
soluble fibrin(ogen) fragments. Thromb Res.
1982;27(4):377-385.
18. Dempfle CE, Argiriou S, Kucher K, Muller-Peltzer H,
Rubsamen K, Heene DL. Analysis of fibrin formation
From www.bloodjournal.org by guest on June 18, 2017. For personal use only.
BLOOD, 5 AUGUST 2010 䡠 VOLUME 116, NUMBER 5
and proteolysis during intravenous administration of
ancrod. Blood. 2000;96(8):2793-2802.
19. Dempfle CE, Alesci S, Kucher K, Muller-Peltzer H,
Rubsamen K, Borggrefe M. Plasminogen activation
without changes in tPA and PAI-1 in response to subcutaneous administration of ancrod. Thromb Res.
2001;104(6):433-438.
20. Pernerstorfer T, Hollenstein U, Hansen JB, et al.
Lepirudin blunts endotoxin-induced coagulation
activation. Blood. 2000;95(5):1729-1734.
21. Spiel AO, Mayr FB, Firbas C, Quehenberger P,
Jilma B. Validation of rotation thrombelastography
in a model of systemic activation of fibrinolysis
and coagulation in humans. J Thromb Haemost.
2006;4(2):411-416.
FVL MUTATION ENHANCES FIBRIN FORMATION
22. Asakura H, Ontachi Y, Mizutani T, et al. An enhanced fibrinolysis prevents the development of
multiple organ failure in disseminated intravascular coagulation in spite of much activation of
blood coagulation. Crit Care Med. 2001;29(6):
1164-1168.
23. Asakura H, Sano Y, Yamazaki M, Morishita E,
Miyamoto K, Nakao S. Role of fibrinolysis in tissue-factor-induced disseminated intravascular
coagulation in rats–an effect of tranexamic acid.
Haematologica. 2004;89(6):757-758.
24. Binder A, Endler G, Muller M, Mannhalter C,
Zenz W. 4G4G genotype of the plasminogen activator inhibitor-1 promoter polymorphism associates with disseminated intravascular coagulation
805
in children with systemic meningococcemia.
J Thromb Haemost. 2007;5(10):2049-2054.
25. Emonts M, de Bruijne EL, Guimaraes AH, et al.
Thrombin-activatable fibrinolysis inhibitor is associated with severity and outcome of severe meningococcal infection in children. J Thromb Haemost. 2008;6(2):268-276.
26. Gamper G, Oschatz E, Herkner H, et al. Sepsisassociated purpura fulminans in adults. Wien Klin
Wochenschr. 2001;113(3-4):107-112.
27. Lasch HG, Heene DL, Huth K, Sandritter W.
Pathophysiology, clinical manifestations and
therapy of consumption-coagulopathy (“Verbrauchskoagulopathie”). Am J Cardiol. 1967;
20(3):381-391.
From www.bloodjournal.org by guest on June 18, 2017. For personal use only.
2010 116: 801-805
doi:10.1182/blood-2009-03-213215 originally published
online April 21, 2010
Factor V Leiden mutation enhances fibrin formation and dissolution in
vivo in a human endotoxemia model
Elif Elmas, Nenad Suvajac, Bernd Jilma, Hartmut Weiler, Martin Borggrefe and Carl-Erik Dempfle
Updated information and services can be found at:
http://www.bloodjournal.org/content/116/5/801.full.html
Articles on similar topics can be found in the following Blood collections
Thrombosis and Hemostasis (1075 articles)
Information about reproducing this article in parts or in its entirety may be found online at:
http://www.bloodjournal.org/site/misc/rights.xhtml#repub_requests
Information about ordering reprints may be found online at:
http://www.bloodjournal.org/site/misc/rights.xhtml#reprints
Information about subscriptions and ASH membership may be found online at:
http://www.bloodjournal.org/site/subscriptions/index.xhtml
Blood (print ISSN 0006-4971, online ISSN 1528-0020), is published weekly by the American Society
of Hematology, 2021 L St, NW, Suite 900, Washington DC 20036.
Copyright 2011 by The American Society of Hematology; all rights reserved.