HEMOSTAZ Yard. Doç. Dr. Murat ÖRMEN

Vessels Platelets Fibrinolysis/Inhibitors Coagulation Proteins BleedingClotting Hemostaz

Endothelial Cells Basement Membrane Red Blood CellsPlateletsWhite Cells Vascular System

Platelets Fibrinolysis/Inhibitors Coagulation Proteins Vessels

PRİMER HEMOSTAZ

Platelet Rich Plasma (PRP) Aggregatin g Reagent Aggregat e Clumping Baseline Light Transmission Increased Light Transmission + Platelet Aggregation

Function HEMOSTASİS BLEEDİNG AGREGOMETRİ ANİMASYON

Platelets Coagulation Proteins Fibrinolysis/Inhibitors Vessels

Fibrinogen VII Extrinsic Pathway (PT) Tissue Factor Kinins X X IX XI XII HMWK Prekalli- krein Kalli- krein XIIa XIa IXa VIIIa Xa VIIa Pro- Urokinase Intrinsic Pathway (aPTT) Fibrinolysis VIII Ure- Kinase T-PA Plas- minogen Plasmin Common Pathway IIVa V IIa XIII XIIIa Fibrin Polymer Fibrin Clot + Platelet Plug

Extrinsic Pathway (PT) Common Pathway Fibrinigen VII X Xa VIIa II Va V IIa XIII XIIIa Fibrin Polymer Tissue Factor Fibrin Clot + Platelet Plug

Factor VII Proconvertin, Stable Factor Biosynthesis: Liver, Vitamin K dependent MW: 55,000 daltons Plasma Concentration: 1 mg/L In Vivo Half-Life: 5 hours Pathology: Hypoproconvertinemia, autosomal recessive

Factor VIIIa Tissue Factor Phospholipid (Platelet Factor 3) Factor IXa Factor VIIa Factor X Factor Xa Anti- thrombin III Heparin Anti- thrombin III Ca++ Heparin Activation Procoagulant Anticoagulant Inhibition or Extrinsic X-ase Complex Intrinsic X-ase Complex Tissue Factor Factor III, Thromboplastin Biosynthesis: Brain, lung, subendothelium MW: 45,000 daltons Factor X Stuart-Prower Factor Biosynthesis: Liver, Vitamin K dependent MW: 55,000 daltons Plasma Concentration: 5 mg/L In Vivo Half-Life: 65 hours Pathology: Stuart disease, autosomal recessive

Fibrinogen Kinins X IX XI XII HMWK Prekalli- krein Kalli- krein XIIa XIa IXa VIIIa Xa Intrinsic Pathway (aPTT) VIII Common Pathway IIVa V IIa XIII XIIIa Fibrin Polymer Fibrin Clot + Platelet Plug

High Molecular Weight Kininogen Negatively Charged Activating Surface (e.g., kaolin, ellagic acid silica) Kalli- krein Factor XII Kinins High Blood Pressure and Inflammation Factor XIIa HMWK C1 Esterase Inhibitor C1 Esterase Inhibitor Factor XIIa * FXIIf alter vascular permeability Factor XII Fragments* Activation Procoagulant Anticoagulant Inhibition High Molecular Weight Kininogen (HMWK) Fitzgerald Factor MW: 120,000 daltons Plasma Concentration: 70 mg/L Pathology: Fitzgerald trait, autosomal recessive Factor XII Hageman Factor Biosynthesis: Liver MW: 80,000 daltons Plasma Concentration: 29 mg/L In Vivo Half-Life: 60 hours Pathology: Hageman trait, autosomal recessive

Ca++ High Molecular Weight Kininogen Factor XIIa Kallikrein Prekalli- krein Kalli- krein Activation Procoagulant Anticoagulant Inhibition C1 Esterase Inhibitor C1 Esterase Inhibitor Prekallikrein Fletcher Factor Biosynthesis: Probably Liver MW: 107,000 daltons Plasma Concentration: 50 mg/L Pathology: Fletcher trait, autosomal recessive

Ca++ High Molecular Weight Kininogen Factor XIIa Factor XIa Factor XI Factor XIa Activation Procoagulant Anticoagulant Inhibition  1- Anti- trypsin  1- Anti- trypsin Factor XI Plasma Thromboplastin Antecedent Biosynthesis: Liver MW: 158,000 daltons Plasma Concentration: 4 mg/L In Vivo Half-Life: 65 hours Pathology: Hemophilia C, autosomal recessive

Ca++ Tissue Factor VIIa Factor IXa Factor IX Factor IXa Activation Procoagulant Anticoagulant Inhibition Factor XIa or Anti- thrombin III Heparin Anti- thrombin III Heparin Factor IX Christmas Factor Biosynthesis: Liver, Vitamin K dependent MW: 57,000 daltons Plasma Concentration: 4 mg/L In Vivo Half-Life: 20 hours Pathology: Hemophilia B, (Christmas disease) x-linked recessive

Factor VIII Antihemophilic Factor vWF von Willebrand Factor Biosynthesis: Liver, endothelium; Factor VIII Related Antigen, megakaryocyte MW(FVIII + vWF): million daltons (6-10 subunits – 200,000 daltons each) Plasma Concentration: 7 mg/L (vWF) In vivo Half-Life: 10 hours (Factor VIII) Pathology: Factor VIII-Hemophilia A, x-linked recessive. vWF-von Willebrand’s disease, autosomal dominant Factor IIa Factor VIII Activated Protein C Protein S Phospholipi d (Platelet Factor 3) Inactive Fragments Ca++ Factor VIIIa Protein C Complex Activation Procoagulant Anticoagulant Inhibition Factor Xa or

Factor II Factor IIa (Thrombi n) Anticoagulant Inhibition Phospholipid (Platelet Factor 3) Activation Procoagulant Factor Va Factor Xa Ca++ * or Heparin Cofactor II Prothrombinase Complex Factor IIa Anti- thrombin III Heparin Anti- thrombin III Heparin * Activation Fragments Factor II Prothrombin Biosynthesis: Liver, Vitamin K dependent MW: 70,000 daltons Plasma Concentration: 100 mg/L In Vivo Half-Life: 100 hours Pathology: Hypoprothrombinemia, autosomal recessive

Factor V Proaccelerin, Labile Factor Biosynthesis: Liver, megakaryocytes MW: 330,000 daltons Plasma Concentration: 5-12 mg/L In Vivo Half-Life: 25 hours Pathology: Parahemophilia, autosomal recessive

Fibrinogen Factor I Biosynthesis: Liver MW: 340,000 daltons Plasma Concentration: 2500 mg/L In Vivo Half-Life: 20 hours Pathology: Afibrinogenemia, autosomal recessive. Dysfibrinogenemia, autosomal dominant Factor IIa Factor IIa Fibrinopeptid e A Fibrinopeptid e B Fibrinogen Factor II Fibrin Monomer Procoagulant Activation Factor IIa Activation Procoagulant Fibrin Polymer CA+ Factor XIII Factor XIIIa Soluble Fibrin Polyme r Plasmin Anticoagulant Inhibition Procoagulant Activation Fibrin (Factor Ia) Stable Thrombus (Clot) Activate d Platelet s FDPs Fibrinogen Degradatio n Products FDPs & XDPs (Cross-linked DPs) (e.g. D-dimers) Factor XIII Fibrin Stabilizing Factor (FSF) Biosynthesis: Megakaryocytes, liver MW: 320,000 daltons Plasma Concentration: 10mg/L In Vivo Half-Life: 12 days Pathology: FSF deficiency, autosomal recessive

Thromboplastin and Calcium Patient’s Plasma Factors I II V VII X Prothrombin Time

Ca++ Patient’s Plasma Factors I II V VIII IX X XI XII Phospholipid and Activator Activated Partial Thromboplastin Time

Quantitative Fibrinogen High concentration of thrombin 1:10 dilution patient’s plasma Time (in seconds) Fibrinogen in mg/dL :4 0 1:3 0 1:2 0 1:1 0 1:5

Heparin/AT-III Complex

Minimum Plasma Levels MinorMajor FactorSpontaneousTrauma Hemorrhageor Surgery I Fibrinogen mg/dL II % V5-1525% VII % VIII % Hemophilia A % von Willebrand2525% IX % X % XI % XII1010% XIII15% Williams, W. J., Hematology, 1972

Platelets Fibrinolysis/Inhibitors Coagulation Proteins Vessels

Fibrinolysis Activators: t-PA,u-PA, STK, XII, HMWK, PK Plasminogen Plasmin Fibrinogen Fibrin Degradation Products R.E.S.

Plasminogen Biosynthesis: Liver MW: 90,000 daltons Plasma Concentration: 120 mg/L In Vivo Half-Life: 48 hours Pathology: Plasminogen deficiency, autosomal dominant. Dysplasminogenemia, autosomal recessive Urokinase Kallikrein tPA (tissue Plasminogen Activator) Plasminogen  2 - Anti- plasmin  2 - Anti- plasmin Activation Procoagulant Anticoagulant Inhibition Plasmin or

Fibrinogen VII Extrinsic Pathway (PT) Tissue Factor Kinins X X IX XI XII HMWK Prekalli- krein Kalli- krein XIIa XIa IXa VIIIa Xa VIIa Pro- Urokinase Intrinsic Pathway (aPTT) Fibrinolysis VIII Ure- Kinase T-PA Plas- minogen Plasmin Common Pathway IIVa V IIa XIII XIIIa Fibrin Polymer Fibrin Clot + Platelet Plug

Antithrombin-III Inhibition of Thrombin Thrombin, Antithrombin-III and Heparin Heparin Lysine Site Acidic Site Arginine Site Serine Site Thrombin (Active) Antithrombin-III (Nonactivated) Inactivation of Thrombin Thrombin (Inhibited) Heparin Antithrombin-III Heparin Thrombin Complex Antithrombin-III (Complexed)

Antithrombin-III Decreased Levels 1. Congenital 2. Acquired – decreased synthesis 3. Acquired – increased utilization 4. Drug-induced

Protein C Vitamin K-dependent plasma protein Inactivates Factors V and VIII Stimulates fibrinolysis

Protein C Biosynthesis: Liver, Vitamin K dependent MW: 56,000 daltons Plasma Concentration: 3-5 mg/L In Vivo Half-Life: 6-7 hours Pathology: Protein C deficiency, autosomal recessive (?) * Requires Protein S for functional activity Thrombo- modulin Factor IIa Protein C Activated Protein C Inhibitor Protein C Inhibitor Activated Protein C* Protein C Activation Peptide Activation Procoagulant Anticoagulant Inhibition

Deficiencies of Protein C I. Congenital Hereditary autosomal dominant II. Acquired A. DIC B. Liver disease C. During post-operative period D. Anticoagulant therapy

Clinical Manifestations Superficial thrombophlebitis Venous thromboses in adolescents or young adults Arterial thromboses rarely observed Skin necrosis during onset of oral anticoagulant therapy

Protein S Cofactor for Protein C Vitamin K-dependent protein Enhances binding of Protein C to phospholipid surfaces