NEPHROLOGY 2009; 14, 462470

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doi:10.1111/j.1440-1797.2009.01128.x

Review Article

Review article: Coagulation cascade and therapeutics update: Relevance to nephrology. Part 1: Overview of coagulation, thrombophilias and history of anticoagulants
REBECCA L C ADAMS and ROBERT J BIRD Pathology Queensland, Princess Alexandra Hospital, Brisbane, Queensland, Australia
SUMMARY: Coagulation involves the regulated sequence of proteolytic activation of a series of zymogens to achieve appropriate and timely haemostasis in an injured vessel, in an environment that overwhelmingly favours an anticoagulant state. In the non-pathological state, the inciting event involves exposure of circulating factor VII/VIIa to extravascularly expressed tissue factor, which brings into motion the series of steps which results in amplication of the initial stimulus, culminating in the conversion of brinogen to brin and clot formation. The precisely synchronized cascade of events is counter-balanced by a system of anticoagulant mechanisms, which serve to ensure that the haemostatic effect is regulated and does not extend inappropriately. Conversely, in pathological states, these events can escape normal control mechanisms, due to either inherited or acquired defects, which lead to thrombosis. Current anticoagulant therapy, although based on medications that have been in existence for upwards of 80 years, is moving towards targeted therapy for specic coagulation factors and events in the coagulation cascade, based on the current knowledge of the main triggers and key events within the series of reactions that culminates in haemostasis. It remains to be seen whether these newer medications will become rst-line therapies for thrombosis in the coming decade. This review aims to elucidate the main events within the coagulation cascade as it is currently understood to operate in vivo, with a brief discussion focusing on hypercoagulable states, and also a short review of the history of anticoagulants as they relate to this model.
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KEY WORDS: thrombosis.

anticoagulants, blood coagulation, haemostasis, thromboplastin (tissue factor),

THE COAGULATION CASCADE The coagulation cascade as it is now understood has undergone a shift in understanding, from the intrinsic and extrinsic pathways, to a more all-encompassing model. This model incorporates an understanding of not only the stepwise pattern of activation of zymogens, but also the intricate interlinking of the pathways, a better understanding of regulatory mechanisms, the concept of the necessity of cellular surfaces upon which these reactions take place, and the potency of several key factors within the pathway, to achieve appropriate and regulated haemostasis.

Correspondence: Dr Robert J Bird, Pathology Queensland, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Qld 4102, Australia. Email: Robert_bird@health.qld.gov.au Accepted for publication 9 March 2009. 2009 The Authors Journal compilation 2009 Asian Pacic Society of Nephrology

The normal state of the circulatory system is that of a series of conduits through which blood ows in a liquid phase, until vascular injury occurs,1 at which time it is appropriate for haemostasis to temporarily seal the defect. In the process of resolution of the vascular injury, dissolution of the haemostatic plug should also concurrently take place. The different mechanisms involved are that of a system which is overwhelmingly tipped in favour of an anticoagulant state, and except in some pathological circumstances, only with appropriate stimulation is haemostasis able to occur.2 The mechanisms in favour of blood owing in a liquid phase include the following: (i) the ow of blood itself diluting any activated or prothrombotic factors; (ii) the normal laminar ow of blood through normal vasculature which prevents platelets from directly contacting the endothelium by way of a thin layer of plasma; (iii) the expression of endothelial antiplatelet and anticoagulant factors in excess of procoagulant factors; (iv) the need for adequate stimulation to produce activated platelets, requiring multiple stimuli for full activation;

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(v) the state of the circulating coagulation factors as a series of inactive zymogens, with some factors also bound to other cells or inactivating complexes, requiring receptor-mediated proteolysis for activation; and (vi) the multiple circulating proteases which serve to degrade any rogue factors that are activated in the presence of a submaximal stimulus. The concept of the coagulation cascade as a series of stepwise enzymatic conversions was rst proposed in 1964.3,4 It highlighted that stepwise activation of inactive precursors, or zymogens, was necessary for the formation of the ultimate product of brin. This was described under the headings of the intrinsic pathway (dependent on contact activation by a negatively-charged surface, and involving coagulation factors XII, XI, IX, VIII and V), and the extrinsic pathway (dependent on tissue-factor being exposed to the circulation, and involving tissue factor and factor VII), converging on a common pathway to activate factor X, leading to conversion of prothrombin (factor II) to thrombin (factor IIa) and culminating in the conversion of brinogen to brin (Fig. 1). Within this cascade model, the contribution of primary haemostasis, with the initial recruitment of platelets, was considered an independent mechanism. Although never intended as a physiological model, this easily conceptualized view of haemostasis has been adopted by many clinicians.

These pathways, as described in the cascade model, are reected in the laboratory analysis of coagulation, although as in vitro phenomena, with the intrinsic pathway reected in the measurement of the activated partial thromboplastin time (APTT) and the extrinsic pathway in the prothrombin time (PT). Clinicians should be aware that these are imperfect and sometimes misleading tests of haemostasis as it occurs in vivo, and have limitations as to what information they are able to provide. These screening coagulation tests are abnormal when there is a deciency or dysfunction in one or more of the soluble coagulation factors; however, this alone will not provide information as to bleeding risk. For example, deciency of factor XII, high molecular weight kininogen (HMWK), and prekallikrein, although causing signicant elevation in the APTT, has no associated bleeding tendency,5 whilst a severe deciency in factor VIII or factor IX, with the same APTT, will manifest as a haemophilia phenotype.6 Clinical history in conjunction with skilled interpretation of laboratory parameters is necessary to stratify bleeding risk. Whilst laboratory testing can provide some insight into the aetiology of coagulation abnormalities, there is still no routinely available global test of haemostatic function. A CONTEMPORARY VIEW OF HAEMOSTASIS The currently accepted model of in vivo coagulation highlights the central importance of tissue factor as the main instigator of coagulation, while emphasising the rapid amplication of thrombin as an essential step in the development of a stable clot,7 and the interdependence of coagulation factors and cellular elements.8 It builds on the classical cascade in several ways: (i) activation of both factor X and factor IX by the tissue factor : factor VIIa (TF:FVIIa) complex,9,10 thus linking the extrinsic and intrinsic pathways; (ii) a stepwise and overlapping pattern of activation, with an initial phase, an amplication phase and a propagation phase;1113 and (iii) active and necessary involvement of cellular elements, namely, activated platelets, in the nal two phases, in both providing a negatively-charged phospholipid surface on which reactions can occur, and by providing a localizing surface in direct proximity to the area of damage,14,15 upon which most of the necessary elements for successful coagulation are situated. THE THREE PHASES OF COAGULATION (FIG. 2) Initiation phase: exposure of tissue factor to coagulation factors The initiation phase is heralded by the exposure of tissue factor to blood, either by damage to, or activation of endothelium.16 Tissue factor (TF) is a 47 kDa cell-bound transmembrane glycoprotein and member of the class II cytokine superfamily.17 It functions both as a receptor, with signal transduction resulting in the induction of genes involved in inammation, apoptosis, embryonic development and cell

Fig. 1 The coagulation cascade. The intrinsic pathway and extrinsic pathway are depicted as described in the cascade model of coagulation, reected in the laboratory measurements of APTT and PT.
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Fig. 2 The three stages of coagulation. (1) Initiation: exposure of subendothelial tissue factor leads to the formation of the extrinsic tenase complex, in combination with Factor VIIa. Small amounts of FIXa, FXa and thrombin are formed. (2) Amplication: formation of the intrinsic tenase and prothrombinase complexes on platelet phosphatidylserine (PS) membrane surface, with formation of increased amounts of thrombin. (3) Propagation: the thrombin burst ends in the formation of physiologically relevant amounts of cross-linked brin, resulting in a stable clot.

migration,18 and as a cofactor for factors VII/VIIa. It is constitutively expressed by many extravascular tissues, especially perivascular tissues, and has high levels of expression in the brain, heart, lungs, kidneys, testis and placenta,1921 reecting the importance of these tissues to the organism. Expression can also be induced on endothelium in response to inammatory stimuli, including exposure to bacterial lipopolysaccharide (LPS) in sepsis, adhesion molecules (P-selectin expressed on platelets, CD40 ligand expressed on white blood cells), inammatory cytokines (interleukin6, tumour necrosis factor), and oxidized low-density lipoprotein (LDL).22 TF expression can be induced in monocytes and platelets, and has been detected on circulating microparticles (MP) derived from these and other cell types,23 with some controversy as to whether all haemopoietic tissues, including neutrophils, the primary mediators of inammation, are able to be induced to express TF.24,25 Circulating MP are an area of intense research, as increased levels have been shown to be procoagulant, even in the absence of TF expression.9,11,26,27 MP are tiny (<1 mm) membrane-bound vesicles and express membrane antigens that reect their cellular origin.28 Levels of circulating MP have been shown to be increased in the situations of platelet activation, inammatory stimuli or apoptosis. Elevated levels are encountered in diseases with vascular involvement and hypercoagulability such as disseminated intravascular coagulation, diabetes, immune-mediated thrombosis,

renal disease, acute coronary syndromes or systemic inammatory disease.29,30 The detection of TF on MP31 has provided a tantalising hypothesis as to a possible mechanism for the continuing activation of TF:FVIIa, surpassing the initial stimulus for coagulation, resulting in potential inappropriate clot propagation. TF expression has been detected in some cancers, with the theory that TF expression may in some cases, mediate tumour-associated thromboses (Trousseau syndrome).22,32 TF is also a prominent component of atheromatous plaques, where it is thought to be the main stimulus of the rapidly formed arterial thrombus on plaque rupture.33 With no known human model of TF deciency, and murine models exhibiting embryonic lethality in homozygous TF knockout mice,34,35 the implication is that lack of this protein is incompatible with life. Tissue factor forms a catalytic complex with factor VIIa (TF:FVIIa), the so-called extrinsic factor tenase complex, on the phospholipid surface of the cell membrane, and activates the zymogens, factor IX (FIX) and factor X (FX).36,37 The activated FX then goes on to generate small amounts of factor IIa (thrombin).15 The duration of the initiation phase is dependent on the concentration of TF:FVIIa and tissue factor pathway inhibitor (TFPI), which acts to neutralize FXa and TF:FVIIa, especially free circulating forms.15 The main, if articial separation of initiation from the subsequent amplication and propagation phases, is the localization of the process on tissue factor
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expressing cells, and the picomolar38 amount of thrombin generated. Amplication phase: conversion from extrinsic to intrinsic thrombin generation In the amplication phase, FIXa with its activated cofactor, FVIIIa, forms the intrinsic factor tenase complex (FIXa:FVIIIa),37 when assembled on a membrane surface (optimally provided by platelets, but also microparticles, activated endothelium and other cells) in the presence of calcium. The formation of the intrinsic tenase complex is essential for the degree of amplication of the clotting process required for sustained haemostasis, by increased FXa production (in the order of 50100 times greater than that produced by the extrinsic tenase TF:FVIIa)15,37 and accelerated thrombin production. The reaction efciency of both the tenase complex (FIXa:FVIIIa), and the prothrombinase complex (FXa:FVa) is enhanced by their co-localization on the phospholipid membrane in the presence of calcium, by many orders of magnitude.39 These activated factors create a positive feedback loop, the result of which is to rapidly generate thrombin in sufcient amounts to form a stable clot. Thrombin acts on platelets through its interaction with platelet receptor GpIb which serves as scaffolding, allowing interactions with other platelet membrane components, such as protease-activated protein-1 (PAR-1),40,41 which causes degranulation of a-granules and FVa membrane expression, and also activation of the GpIIb/IIIa receptor.42 This serves to enhance platelet aggregation, as well as provide a negatively-charged phospholipid surface, by virtue of exposure of phosphatidylserine (PS) from the inner to the outer cell membrane, which occurs as a result of activation of enzymes such as lipid scramblase, involved in the regulation of membrane asymmetry.43 Thrombin also generates increased amounts of FVIIIa, by liberation of FVIII from its complex with von Willebrand factor (FVIII:vWF), as well as activation of factor XI to FXIa,12 which localizes to the platelet surface and causes further activation of the intrinsic pathway enzymes. The platelets involved are likely to be those in the initial haemostatic plug, and are therefore also activated by local collagen at the site of vascular injury. These COAT platelets (collagen and thrombin stimulated) are thought to have enhanced thrombin-generating potential, due to enhanced ability to bind both the tenase and prothrombinase complexes4446 (as detailed in the next section). They are therefore well placed to enable efcient generation of large amounts of thrombin in the amplication and propagation phases. The combination of all of these actions serves to efciently increase the amount of thrombin generated. Propagation phase: thrombin generation with brin deposition The propagation phase relies on recruitment of activated platelets at the site of injury, to provide appropriate localisation of the necessary components for optimum generation
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of thrombin, including the intrinsic tenase complex, the prothrombinase complex, calcium and a phospholipid surface to efciently co-localize all of these components. These reactions are reliant on a population of platelets in sufcient numbers and with the potential to undergo thrombin-mediated activation. The resulting thrombin burst leads to the generation of brin from brinogen to produce a stable brin clot. Soluble brin monomers coalesce into a polymer brin gel, and the action of factor XIIIa, activated by thrombin, covalently cross-links brin strands, to form a stable brin network.1 The thrombin formed also activates thrombin-activatable brinolysis inhibitor (TAFI), which serves to protect the clot from plasminmediated brinolysis. TAFI proteolytically excises lysine residues from the brin clot, thus removing the binding sites of plasminogen to brin, and decreasing the effectiveness of plasmin-mediated clot lysis.47 A concise overview of the sequence of events leading to clot formation is provided in Figure 3. FIBRINOLYSIS: RESOLUTION Fibrinolysis is essential for removing the clot formed by activation of haemostasis mechanisms, both in the situation of appropriate activation in response to vascular trauma, and also in pathological thrombosis (arterial or venous) and atherosclerosis, which are associated with the deposition of intravascular brin.48 The principal mediator of brinolysis is plasmin, which cleaves brin at specic lysine and arginine residues, resulting in the production of brin degradation products.49 Plasmin is produced by proteolytic cleavage of circulating plasminogen by two main effectors, tissue-type plasminogen activator (t-PA), released from endothelial cells in response to thrombin and venous occlusion,50 and urokinase-type plasminogen activator (u-PA), which is secreted as prourokinase, and activated by plasmin and contact factors (kininogen, prekallikrein, FXII).1 These activators of brinolysis are in turn regulated by plasminogen activator inhibitors (PAI), which are present in great excess in owing blood,51 and which form inactivating complexes with t-PA and u-PA to prevent inappropriate plasmin generation. With plasminogen present in the circulation in much higher concentrations than either of the plasminogen activators, the concentrations of t-PA and u-PA become the rate-limiting factors in determining the extent of conversion to plasmin. INHIBITORY PROTEINS: REGULATION OF COAGULATION (TABLE 1) Regulation of the pathway occurs at each level, with each phase associated with inhibitory factors, either by enzymatic inhibition or modulation of cofactor activity. Tissue factor is regulated by a serine protease, tissue factory pathway inhibitor (TFPI), which neutralizes the catalytic activity of FXa and inhibits the TF:FVIIa complex. It is predominantly produced by endothelium, bound to heparin sulfate, as well as other cell types, including plate-

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Thrombin-binding to constitutively expressed endothelial thrombomodulin activates protein C (PC), which, with protein S as a cofactor, inactivates FV/FVa, FVIII/FVIIa. Protein Z, another vitamin K-dependent protein, inhibits FXa via protein Z-dependent protease inhibitor (ZPI).55 Factor VIIIa is an inherently unstable molecule, and inactivation also occurs spontaneously, through dissociation of the A2 domain. Less specic inhibitors include a1-protease inhibitor, which acts on factor Xa, and a2-macroglobulin, whose primary target is thrombin. THROMBOPHILIC SYNDROMES Thrombosis is a common disorder, with venous thrombosis affecting up to 0.1% of the population each year, with the elderly most affected.56 The thrombophilias can be divided into inherited and acquired disorders which predispose to thrombosis (Table 2). With the advent of genetic testing, it is hypothesized that more genetic causes will continue to be identied, in addition to the well-described Factor V Leiden, and prothrombin gene G20210A mutations. An important concept is that a patient presenting with an apparently unprovoked thrombotic event probably has an underlying inherited or acquired disorder, which predisposes to an increased risk of thrombosis, culminating in clinical thrombosis when exposed to a secondary, situational, risk factor. Although the thrombotic disorders constitute an important group of clinical syndromes, an in-depth discussion of the various disorders is beyond the scope of this overview, and several reviews are available in recent published work.5759 HISTORY OF ANTICOAGULANTS The ideal anticoagulant would be administered p.o., with a predictable dose response and kinetics, and wide therapeutic window, without the need for monitoring of anticoagulant effect, and without haemorrhagic side-effects. This ideal drug, of course, does not yet exist. Until recently, the available anticoagulants (essentially heparin, warfarin and LMWH) have been multi-targeted, that is, acting on multiple coagulation factors. Newer drugs designed for antithrombotic therapy are now becoming available, which are more selective in their action, specically targeting single coagulation factors. The currently available anticoagulants are briey described, with some ideas of future directions for anticoagulants that are currently being investigated also listed. Vitamin K antagonists: warfarin In the 1920s, an outbreak of sweet clover disease, which caused a fatal haemorrhagic disease in cattle after the ingestion of mouldy hay, led to the discovery and subsequent commercial use of vitamin K antagonists (VKA).6062 After an initial foray onto the market as a rodenticide, Warfarin underwent an image makeover and, with a new name
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Fig. 3 Overview of coagulation. The sequence of events leading to the formation of a cross-linked brin clot.

lets, and is found in circulating form bound to LDL.52,53 On administration of i.v. heparin or s.c. low molecular weight heparin (LMWH), the endothelial form is released into circulation. Antithrombin, a serine-protease inhibitor, is the most important inhibitor of coagulation, exerting its actions preferentially on free enzymes, with factors involved with the tenase or prothrombinase complexes less accessible to inactivation. This implies that its main action is to limit the coagulation process to the injured site, without pathological extension of the clot. The action of antithrombin is greatly enhanced by the administration of heparin or heparin-like molecules expressed on endothelium. Heparin cofactor II in the presence of heparin or heparin-like molecules, inactivates thrombin.54

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Table 1 Regulatory proteins of the coagulation cascade, site of expression and substrates upon which they act Regulatory protein Tissue factor pathway inhibitor (TFPI) Expression Endothelium Platelets LDL bound (circulating) Endothelium Liver Endothelium Liver Liver Liver Liver Substrate TF-factor VIIa Factor Xa Free serine proteases Bound serine proteases (less) Thrombin Factor V/Va Factor VIII/VIIIa Factor V/Va Factor VIII/VIIIa Factor Xa Factor Xa Thrombin Thrombin Factor Xa Plasmin Kallikreins

Antithrombin Heparin cofactor II (+ heparin) Thrombomodulin Protein C + cofactor protein S Protein Z-protein Z dependent protease inhibitor (ZPI) a1-protease inhibitor a2-macroglobulin

Table 2 Hypercoagulable states Primary (inherited) Decreased antithrombotic proteins Antithrombin deciency Protein C deciency Protein S deciency Heparin cofactor 2 deciency Thrombomodulin deciency Secondary (acquired) Situational Surgery Sepsis OCP/HRT Pregnancy Immobility Chemotherapy Heparin induced thrombocytopaenia (HIT) Acquired Antiphospholipid syndrome Paroxysmal nocturnal haemoglobinuria (PNH) Malignancy Nephrotic syndrome Inammatory bowel disease Vasculitides Hyperviscosity syndromes Myeloproliferative syndromes

Increased prothrombotic proteins Factor V Leiden (activated protein C resistance) Prothrombin gene mutation G20210A Increased FVII, FVIII, FIX, FXI, vWF Hyperhomocysteinaemia Impaired brinolysis Elevated PAI-1 Decient t-PA release

Coumadin, was launched as an anticoagulant for clinical use in the 1950s.10 Vitamin K antagonists exert their anticoagulant effect by inhibiting the g-carboxylation of the vitamin K-dependent coagulation factors (II, VII, IX, X, PC, PS, PZ) by inhibition of two hepatic enzymes, vitamin K reductase and vitamin K epoxide reductase,49,63 with mutations in the latter having recently been linked to the uncommonly seen phenomenon of warfarin resistance.64,65 Although also causing inhibition of the anticoagulant PC and PS, the net effect is that of overall anticoagulation. It should be noted that following initiation of warfarin therapy, the depletion of PC and PS is more rapid than that of factors II, VII, IX and X. This results in an early transient procoagulant period, which mandates the concurrent use of rapidly acting anticoagulants (usually
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heparins) in the treatment of thrombosis until a therapeutic anticoagulant effect is demonstrated by international normalized ratio monitoring.66

Heparin The rst anticoagulant drug to be identied and manufactured was heparin, commercially available in the 1920s.59 Initially derived from hepatic tissue (heparin; from the Greek hepar or liver), it is now mainly manufactured from porcine intestinal tissue.67 It requires the presence of a plasma cofactor, antithrombin, to exert its activity. Unfractionated heparin (UFH) consists of a family of highly sulfated polysaccharides, with chains ranging in molecular

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weight from 300030 000, with a mean of approximately 15 000. Only one-third of the chain possesses the polysaccharide sequence that exhibits high afnity for antithrombin and inactivates serine proteases66 (factors II, VII, IX, X). At prophylactic or therapeutic doses, this is the only mechanism of action. In higher doses, heparin cofactor II is activated,68 and exerts its negative actions on thrombin. The non-linear kinetics of heparin clearance are due to initial non-specic binding to endothelium, platelets and macrophages, and then renal clearance.66 Reversal for overanticoagulation is available in the form of protamine sulfate. Low molecular weight heparins Developed in the 1980s, LMWH are derived from UFH by chemical or enzymatic depolymerisation. Molecular weights of the molecules range 20009000, with a mean of 4000 5000. Approximately 5075% of LMWH are too short to catalyse thrombin inhibition, but retain FXa inhibition, with the result that they have greater capacity to preferentially inhibit FXa than UFH.69 The shorter polysaccharide chains exhibit less non-specic plasma and endothelial binding, so dosing is more predictable, except in the cases of obesity, renal impairment and pregnancy, when monitoring is recommended. Anti-FXa levels can be used to monitor anticoagulation; however, with an inverse relationship between creatinine clearance and anti-Xa levels,70 and an increased risk of bleeding complications, in severe renal impairment, UFH may be a better choice than LMWH. Pentasaccharides: fondaparinux and idraparinux A heparin derivative, fondaparinux, is a synthetic analogue of the pentasaccharide sequence in heparin that mediates the AT interaction,71 inhibiting anti-Xa activity, but exhibiting no anti-IIa (thrombin) activity. Idraparinux is a highly sulfated analogue of fondaparinux with a longer half-life. With no binding to other plasma proteins, the pharmacokinetics are linear, and with a predictable dose response, monitoring is not usually required, although anti-Xa assays can be used if required. Fondaparinux is excreted unchanged in the urine, and should not be used in severe renal impairment. Parenteral direct thrombin inhibitors: desirudin, lepirudin, bivalirudin, argatroban Hirudins are polypeptides rst isolated from the salivary glands of the medicinal leech. They bind thrombin at the active site and brin binding site, and form an irreversible hirudin : thrombin complex.72 There are two recombinant hirudin preparations, desirudin and lepirudin.66 They are renally excreted. Bivalirudin is a synthetic version of hirudin that reversibly binds thrombin.73 It is only minimally renally excreted, with the majority undergoing proteolytic cleavage or hepatic metabolism. Argatroban is a small synthetic molecule that selectively and reversibly binds thrombin.74 It is metabolized by the liver. None of these drugs have a selective reversal agent.

Oral direct thrombin inhibitors: ximelagatran, dabigatran etexilate Although ximelagatran was voluntarily withdrawn from the market due to concerns over hepatic enzyme elevations, dabigatran etexilate is in advanced stages of development, with large, multicentre stage III trials both recently completed and nearing completion.75 It is metabolized rapidly by non-specic esterases, and then undergoes primarily renal excretion. Oral FXa inhibitors: rivaroxaban, razaxaban, apixaban Phase III trials are currently nearing completion, or have been newly published, with initial results comparing favourably with LMWH. These selective, oral, direct Xa inhibitors which are being evaluated for anticoagulant effectiveness, as well as favourable dosing regimens, need monitoring for bleeding complications.76 Future targets for drug therapy There are several avenues for new anticoagulant drugs currently being explored, based on the three phases of coagulation, including the initiation phase, for which there are no selective drugs yet available. NAPc2 is a form of a compound isolated from the canine hookworm, which inhibits the TF:FVIIa complex by way of a binding site on FX, and is under study in phase II trials.77 This and other drugs are currently in the process of undergoing clinical and preclinical trials. SUMMARY OF THEMES The process of haemostasis is tightly regulated, with the balance between anticoagulant and procoagulant mechanisms favouring an anticoagulant state with procoagulant processes only coming into effect in the appropriate circumstances. This process is dependent on a number of interlinking factors, including the appropriate assembly of platelets, with the activation of circulating and tissue-bound coagulation factors in order to allow the enzymatic conversions to proceed at an efcient rate. A deciency in any of the components may result in inadequate amounts of thrombin being generated to allow timely formation of a brin clot, and thus the inability to respond appropriately to vascular injury. However, equally important is the potential for inappropriate activation of the processes, with the resultant haemorrhagic or thrombotic (arterial or venous) diatheses presenting as common clinical conundrums. REFERENCES
1. Hoffman R, Benz E, Shattil SJ, Furie Bruce, Cohen H (eds). Hematology: Basic Principles and Practice, 4th edn. Philadelphia, PA: Elsevier, 2005. 2. Dahlbck B. Blood coagulation. Lancet 2000; 355: 162732. 2009 The Authors Journal compilation 2009 Asian Pacic Society of Nephrology

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3. MacFarlane RG. An enzyme cascade in the blood clotting mechanism and its function as a biochemical amplier. Nature 1994; 202: 989. 4. Davie EW, Ratnoff SI. Waterfall sequence for intrinsic blood clotting. Science 1964; 145: 131012. 5. Spronk HMH, Govers-Riemslag JWP, ten Cate H. The blood coagulation system as a molecular machine. Bioessays 2003; 25: 122028. 6. Chavin SI. Factor VIII: Structure and function in blood clotting. Am. J. Hematol. 1984; 16: 297306. 7. Bungay S. Modelling the effect of amplication pathway factors on thrombin generation: A comparison of hemophilias. Transfus. Apher. Sci. 2008; 38: 417. 8. Prez-Gmez F, Bover R. The new coagulation cascade and its possible inuence on the delicate balance between thrombosis and hemorrhage. Rev. Esp. Cardiol. 2007; 60: 121719. 9. Marlar RA, Kleiss AJ, Grifn JH. An alternative extrinsic pathway of human blood coagulation. Blood 1982; 60: 135358. 10. Kalafatis M, Swords NA, Rand MD, Mann KG. Membranedependent reaction in blood coagulation: Role of the vitamin K dependent complexes. Biochem. Biophys. Acta. 1994; 1227: 113 29. 11. Mackman N, Tilley RE, Key NS. Role of the extrinsic pathway of blood coagulation in hemostasis and thrombosis. Arterioscler. Thromb. Vasc. Biol. 2007; 27: 168793. 12. Monroe DM, Hoffman M. What does it take to make the perfect clot? Arterioscler. Thromb. Vasc. Biol. 2006; 26: 418. 13. Hoffman M, Monroe DM. Coagulation 2006: A modern view of hemostasis. Hematol. Oncol. Clin. North Am. 2007; 21: 111. 14. Furie B, Furie C. In vivo thrombus formation. J. Thromb. Haemost. 2007; 5: S1217. 15. Butenas S, Mann KG. Blood coagulation. Biochemistry 2002; 67: 312. 16. Greer P, Foerster J, Lukens JN, Rodgers GM, Paraskevas F, Glader B (eds). Wintrobes Clinical Hematology, 11th, edn. Philadelphia, PA: Lippincott, Williams and Wilkins, 2004. 17. Key NS, Geng J, Bach RR. Tissue factor; From Morawitz to microparticles. Trans. Am. Clin. Climatol. Assoc. 2007; 118: 16573. 18. Rao LV, Pendurthi UR. Tissue factor-factor VIIa signalling. Arterioscler. Thromb. Vasc. Biol. 2005; 25: 4756. 19. Semeraro N, Colucci M. Tissue factor in health and disease. Thromb. Hemost. 1997; 78: 75964. 20. Mackman N, Sawley MS, Keeton MR, Loskutoff DJ. Murine tissue factor gene espression in vivo: Tissue and cell specicity and regulation by lipopolysaccharide. Am. J. Pathol. 1993; 143: 7684. 21. Drake TA, Morrissey JH, Edgington TS. Selective cellular expression of tissue factor in human tissues. Implications for disorders of hemostasis and thrombosis. Am. J. Pathol. 1989; 134: 108797. 22. Grignani G, Maiolo A. Cytokines and hemostasis. Haematologica 2000; 85: 96772. 23. Panes O, Matus V, Sez CG, Quiroga T, Pereira J, Mezzano D. Human platelets synthesize and express functional tissue factor. Blood 2007; 109: 524250. 24. Egorina EM, Sovershaev MA, Olsen JO, sterud B. Granulocytes do not express but acquire monocyte-derived tissue factor in whole blood: Evidence for a direct transfer. Blood 2008; 111: 120816. 25. Redecha P, Tilley R, Tencati M et al. Tissue factor: A link between C5a and neutrophil activation in antiphospholipid antibody induced fetal injury. Blood 2007; 110: 242331. 26. Sturk-Maquelin KN, Nieuwland R, Romjin FP, Eijsman L, Hack CE, Sturk A. Pro- and non-coagulant forms of non-cell bound tissue factor in vivo. J Thromb Haemost. 2003; 1: 192026. 27. Piccin A, Murphy WG, Smith OP. Circulating microparticles: Pathophysiology and clinical implications. Blood 2007; 21: 15771.

28. Greenwalt TJ. The how and why of exocytic vesicles. Transfusion 2006; 46: 14352. 29. George FD. Microparticles in vascular diseases. Thromb. Res. 2008; 122: S559. 30. Daniel L, Dou L, Berland Y, Lesavre P, Mecarelli-Halbwachs L, Dignat-George F. Circulating microparticles in renal diseases. Nephrol. Dial. Transplant. 2008; 23: 212932. 31. Del Conde I, Shrimpton CN, Thiagarajan P, Lopez JA. Tissuefactor-bearing microparticles arise from lipid rafts and fuse with activated platelets to initiate coagulation. Blood 2005; 206: 1604 11. 32. Rak J, Milsom C, Yu J. Tissue factor in cancer. Curr. Opin. Hematol. 2008; 15: 5228. 33. Viles-Gonzalez JF, Annand SX, Zafar MU, Fuster V, Badimon JJ. Tissue factor coagulation pathway: A new therapeutic target in atherothrombosis. J. Cardiovasc. Pharmacol. 2004; 43: 66976. 34. Carmeliet P, Mackman N, Moons L et al. Role of tissue factor in embryonic blood vessel development. Nature 1996; 383: 735. 35. Mackmann N, Sawdey MS, Keeton MR, Loskutoff DJ. Murine tissue factor gene expression in vivo: Tissue and cell specicity and regulation by lipopolysaccharide. Am. J. Pathol. 1993; 143: 76 84. 36. Osterud B, Rappaport SI. Activation of factor IX by the reaction product of tissue factor and factor VII: Additional pathway for initiating blood coagulation. Proc Natl Acad. Sci. U.S.A. 1977; 74: 526064. 37. Mann KG, Brummel-Ziedins K, Orfeo T, Butenas S. Models of blood coagulation. Blood Cells Mol. Dis. 2006; 36: 10817. 38. Orfeo T, Brufatto N, Nesheim ME et al. The factor V activation paradox. J. Biol. Chem. 2004; 279: 1958091. 39. Mann KG, Butenas S, Brummel K. The dynamics of thrombin formation. Arterioscler. Thromb. Vasc. Biol. 2003; 12: 1725. 40. Ramakrishnan V, DeGuzman F, Bao M, Hall SW, Leung LL, Phillips DR. A thrombin receptor function for platelet glycoprotein Ib-IX unmasked by cleavage of glycoprotein V. Proc Natl Acad. Sci. U.S.A. 2001; 98: 18238. 41. De Candia E, Hall SW, Rutella S, Landol R, Andrews RK, De Cristofaro R. Binding of thrombin to glycoprotein Ib accelerates the hydrolysis of PAR-1 on intact platelets. J. Biol. Chem. 2001; 276: 46928. 42. Biloduae ML, Hamm HE. Regulation of protease-activated reveptor (PAR)1 and PAR4 signaling in human platelets by compartmentalized cyclic nucleotide actions. J. Pharmacol. Exp. Ther. 2007; 322: 77888. 43. Piccin A, Murphy WG, Smith OP. Circulating microparticles: Pathophysiology and clinical implications. Blood Rev. 2007; 21: 15771. 44. Alberio L, Safa O, Clemetson KJ et al. Surface expression and functional characterization of alpha-granule factor V in human platelets: Effects of ionophore A123187, thrombin, collagen, and convulxin. Blood 2003; 95: 1694702. 45. Dale GL, Friese P, Batar P et al. Stimulated platelets use serotonin to enhance their retention of procoagulant proteins on the cell surface. Nature 2002; 415: 1759. 46. Kempton CL, Hoffman M, Roberts HR et al. Platelet heterogeneity: Variation in coagulation complexes on platelet subpopulations. Arterioscler. Thromb. Vasc. Biol. 205: 8616. 47. Bouma BN, Mosnier LO. Thrombin activatable brinolysis inhibitor (TAFI) at the interface between coagulation and brinolysis. Pathophysiol. Haemost. Thromb. 2004; 33: 37581. 48. Romanic AM, Arleth AJ, Willette RN, Ohlstein EH. Factor XIIIa cross-links lipoprotein(a) with brinogen and is present in human atherlsclerotic lesions. Circ. Res. 1998; 83: 2649.

2009 The Authors Journal compilation 2009 Asian Pacic Society of Nephrology

470

RLC Adams and RJ Bird

49. Greer P, Foerster J, Lukens JN, Rodgers GM, Paraskevas F, Glader B (eds). Wintrobes Clinical Hematology, 11th, edn. Philadelphia, PA: Lippincott, Williams and Wilkins, 2004. 50. Syzmanski LM, Pate RR, Durstie JL. Effects of maximal exercise and venous occlusion on brinolytic activity in physically active and inactive men. J. Appl. Physiol. 1994; 77: 230510. 51. Sprengers ED, Kluft C. Plasminogen activator inhibitors. Blood 1987; 69: 3817. 52. Bronze GJ. Tissue factor pathway inhibitor. Thromb. Haemost. 1995; 74: 9093. 53. Dahlback B. Blood coagulation. Lancet 2000; 355: 162732. 54. Pike RN, Buckle AM, le Bonnie BF, Church FC. Control of the coagulation system by serpins; Getting by with a little help from glycosaminoglycans. FEBS J. 2005; 272: 484251. 55. Corrl J, Gonzlez-Conejero R, Hernandez-Espinosa D, Vicente V. Protein Z/Z-dependent protease inhibitor (PZ/ZPI) anticoagulant system and thrombosis. Br. J. Haematol. 2007; 137: 99108. 56. Coiteux I, Mazzolai L Deep vein thrombosis: Epidemiology, risk factors and natural history. Praxis 2006; 95: 4559. 57. Dahlbck B. Advances in understanding pathogenic mechanisms of thrombophilic disorders. Blood 2008; 112: 1927. 58. Cohn DM, Roshani S, Middeldorp S. Thrombophilia and venous thromboembolism: Implications for testing. Semin. Thromb. Hemost. 2007; 33: 57381. 59. Middeldorp S, van Hyckama Vleig A. Does thrombophilia testing help in the clinical management of patients? BJH 2008; 143: 32135. 60. Wardrop D, Keeling D. The story of the discovery of heparin and warfarin. BJH 2008; 141: 75763. 61. Campbell HA, Link KP. Studies on the hemorrhagic sweet clover disease. IV. The isolation and crysallization of the hemorrhagic agent. J. Biol. Chem. 1941; 138: 2133. 62. Carlquist JF, Horne BD, Muhlestein JB et al. Genotypes of the cytochrome p450 isoform, CYP2C9, and the vitamin K epoxide reductase complex subunit 1 conjointly determine stable warfarin dose: A prospective study. 2006; 22: 1917. 63. Suttie JW. Mechanism of action of vitamin K: Synthesis of gamma-carboxyglutamic acid. CRC Crit. Rev. Biochem. 1980; 8: 191223. 64. Kamali F. Genetic inuences on the response to warfarin. Curr. Opin. Hematol. 2006; 13: 35761.

65. Limdi NA, Veenstra DL. Warfarin pharmacogenetics. Pharmacotherapy 2008; 28: 108497. 66. Kovacs MJ, Rodger M, Anderson DR et al. Comparison of 10-mg and 5-mg warfarin initiation nomograms together with lowmolecular-weight heparin for outpatient treatment of acute venous thromboembolism. A randomized, double-blind, controlled trial. Ann. Intern. Med. 2003; 138: 71419. 67. De Caterina R, Husted S, Wallentin L et al. Anticoagulants in heart disease: Current status and perspectives. Eur. Heart J. 2007; 28: 880913. 68. Colman RW, Marder VJ, Clowes AW, George JN, Goldhaber SZ (eds). Hemostasis and Thrombosis: Basic Principles and Clinical Practice, 5th edn. Philadelphia, PA: Lippincott, Williams and Wilkins, 2006. 69. Weitz JI. Low molecular weight heparins. N. Engl. J. Med. 1997; 337: 68898. 70. Hirsh J, Raschke R. Heparin and low-molecular weight heparin: The Seventh ACP Conference on Antothrombotic and Thrombolytic Therapy. Chest 2004; 126: 18852035. 71. Bauer KA. Fondaparinux: A new synthetic and selective inhibitor or Factor Xa. Best Pract. Res. Clin. Haematol. 2004; 17: 89104. 72. Chang J. The hirudin binding site of human a-thrombin. J. Biol. Chem. 1989; 264: 714146. 73. Robson R, White H, Aylward P, Frampton C. Bivalirudin pharmacokinetics and pharmacodynamics: Effect of renal function, dose and gender. Clin. Pharmacol. Ther. 2002; 71: 4339. 74. Swan SK, Hursting MJ. The pharmacokinetics and pharmacodynamics of argatroban: Effects of age, gender, and hepatic or renal dysfunction. Pharmacotherapy 2000; 20: 31829. 75. Eriksson BI, Dahl OE, Rosencher N et al. Dabigatran etexilate versus enoxaparin for prevention of venous thromboembolism after total hip replacement: A randomised, double-blind, noninferiority trial. Lancet 2007; 370: 94956. 76. Lassen MR, Ageno W, Borris LC et al. RECORD3 Investigators. Rivaroxaban versus enoxaparin for thromboprophylaxis after total knee arthroplasty. N. Engl. J. Med. 2008; 358: 277686. 77. Giuliano RP, Wiviott SD, Stone PH et al. Recombinant nematode anticoagulant protein c2 in patients with non-ST-segment elevation acute coronary syndrome: The ANTHEM-TIMI-32 trial. J. Am. Coll. Cardiol. 2007; 49: 2398407.

2009 The Authors Journal compilation 2009 Asian Pacic Society of Nephrology