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  • 1
    Online Resource
    Online Resource
    American Society of Hematology ; 2013
    In:  Blood Vol. 122, No. 21 ( 2013-11-15), p. 3600-3600
    In: Blood, American Society of Hematology, Vol. 122, No. 21 ( 2013-11-15), p. 3600-3600
    Abstract: Factor XI (FXI) is a rare bleeding disorder defined as severe deficiency when FXI activity level is less than 20IU/dL. Unlike hemophilia A or B, patients with severe FXI deficiency do not bleed spontaneously and their bleeding tendency is unpredictable and poorly correlated with FXI level. Therefore, almost all patients with severe FXI deficiency are being treated similarly unrelated to their inert bleeding tendency. Lately there is a growing interest in introducing global coagulation tests to assess the risk of bleeding in trauma patients as well as in patients with congenital bleeding disorders. Thrombin generation (TG) test is a global assay that can provide information regarding hemostasis in healthy individuals or in patients with congenital and acquired bleeding disorders. Our group had previously shown that recalcification induced TG is a useful tool to determine the optimal dose of recombinant factor VIIa for patients with severe FXI deficiency and inhibitors going through major surgery (Livnat et al. Thromb Haemost 2009). Aim In the present study we aimed to characterize the capability of TG to serve as an ideal tool to define upfront bleeders and non-bleeders among FXI deficient patients and find the optimal conditions of TG that could distinguish between bleeders and non-bleeders thus eventually leading to efficient personalized treatment. Methods Case control study composed of 16 unrelated patients with FXI levels range 〉 1-8dL-1and 14 healthy controls. For TG assay blood was taken from all participants simultaneously in both buffered citrate and corn trypsin inhibitor (CTI) tubes after obtaining informed consent. TG was performed in platelet poor plasma (PPP) in the presence of 4 µM phospholipids and initiated by recalcification in the presence and absence of 1pM tissue factor (TF). Three TG parameters were analyzed: lag time, thrombin peak and endogenous thrombin potential (ETP). Results Table 1 summarizes FXI activity, FXI genotype, thrombin peak height and bleeding status (i.e, bleeding following challenges when prophylactic treatment was not given) of patients in the study group. As expected, FXI levels poorly correlated with bleeding tendency. Good correlation between FXI levels, bleeding tendency and TG peak height was found when blood was taken in citrated tubes and not in CTI containing tubes. While the normal range of peak height in recalcification-induced TG (without TF) was 421±161 nM, no TG was initiated with recalcification in PPP of FXI patients with less than 1%. FXI levels 2-4% were sufficient to induce TG with recalcification but thrombin peak height was remarkable lower in comparison to controls. In FXI levels above 5%, the thrombin peak height induced by recalcification varied between low to normal range. Interestingly, when TG was initiated by 1pM TF the TG peak of non-bleeders reached normal values (normal peak height in the presence of 1pM TF=411±121), while in the bleeders the peak was reduced unrelated to FXI levels (range 74-205). Conclusions In summary TG induced by recalcification in the presence of low TF but not when performed in CTI tubes may efficiently distinguish between bleeders and non-bleeders in FXI deficient patients going through major trauma unrelated to patients' FXI level. This observation permits to consider less aggressive prophylactic treatment to patients with reduced risk for bleeding thus lowering the risk of thrombosis due to over treatment. Disclosures: No relevant conflicts of interest to declare.
    Type of Medium: Online Resource
    ISSN: 0006-4971 , 1528-0020
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    Language: English
    Publisher: American Society of Hematology
    Publication Date: 2013
    detail.hit.zdb_id: 1468538-3
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  • 2
    In: Blood, American Society of Hematology, Vol. 122, No. 15 ( 2013-10-10), p. 2562-2571
    Abstract: The coagulation cascade via the factor VIII/thrombin/PAR1 axis regulates HSC maintenance. The coagulation cascade via factor VIII/thrombin/PAR1 axis regulates a reciprocal interplay between HSCs and the dynamic bone structure.
    Type of Medium: Online Resource
    ISSN: 0006-4971 , 1528-0020
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    Language: English
    Publisher: American Society of Hematology
    Publication Date: 2013
    detail.hit.zdb_id: 1468538-3
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  • 3
    In: Blood, American Society of Hematology, Vol. 120, No. 21 ( 2012-11-16), p. 1121-1121
    Abstract: Abstract 1121 Factor IX (FIX) replacement therapy is the standard of care for patients with haemophilia B. FIX products currently available have a relatively short half-life, requiring 2–3 times a week intravenous prophylactic treatment to achieve a significant bleeding reduction. A recombinant FIX albumin fusion protein (rIX-FP) was generated by genetic fusion of human recombinant albumin to rFIX to extend the half life of FIX. A Phase I/II open-label, multicenter, clinical study of rIX-FP has been completed in previously treated patients with severe hemophilia B (FIX ≤ 2%) as part of the PROLONG - 9FP clinical developmental program. The objectives of the study were to evaluate the prevention of bleeding episodes during once weekly prophylaxis and to assess the hemostatic efficacy of rIX-FP for the treatment of bleeding, in addition to safety and pharmacokinetic (PK) assessments. The study consisted of a 10 to 14 day PK evaluation period, and a 3 to 12 month safety and efficacy evaluation period, during which subjects received either on-demand or prophylaxis treatment. Subjects receiving weekly prophylactic treatment were initially treated with a dose based upon the subject's PK profile, bleeding phenotype, and physical activity level. The dose could be adjusted based on clinical outcome, while maintaining a 7 day treatment interval. Subjects receiving on-demand treatment were treated with a dose based upon the subject's PK profile and WFH recommendations for treatment of bleeding episodes. Seventeen study subjects from hemophilia treatment centers in Israel and Bulgaria participated in the study, 13 of whom received weekly prophylaxis treatment and 4 of whom received on-demand treatment. Following a single infusion of 25 IU/kg rIX-FP (n=13), the PK parameters (t1/2 = 94 hrs, AUC0-inf= 3414 hr*IU/dL) were comparable to those previously reported from the Phase I study (Blood prepublished Aug 2, 2012). In addition, rIX-FP maintained a baseline-corrected mean trough level of 3.8% and 2.7% at Day 7 and Day 14, respectively, after 25 IU/kg rIX-FP administration. There were no AEs considered as possibly related to rIX-FP. There were no allergic reactions, inhibitors to FIX or antibodies to rIX-FP reported. All 10 prophylaxis subjects who were previously receiving routine prophylaxis with FIX were maintained successfully on weekly treatment with rIX-FP for the entire study. Furthermore, three prophylaxis subjects who were previously treated on-demand were maintained successfully on weekly prophylaxis treatment with rIX-FP with at least 85% reduction in the annualized spontaneous and total bleeding rate compared to the annualized bleeding rate prior to study entry. All of the bleeding events were treated successfully, including approximately 90% of the events with a single infusion of rIX-FP. The mean weekly product consumption of rIX-FP (IUs) was reduced compared to the consumption of the previous FIX product (IUs). No subject was withdrawn from the study due to safety concerns or lack of hemostatic efficacy. This Phase I/II study has demonstrated the clinical efficacy of rIX-FP for once weekly routine prophylaxis to prevent spontaneous bleeding episodes and treatment of bleeding episodes, in addition to the excellent safety characteristics and improved PK profile. A detailed analysis of the efficacy of weekly routine prophylaxis and treatment of bleeding episodes, improved PK and safety properties of rIX-FP will be presented. Disclosures: Martinowitz: CSL Behring: Honoraria, Investigator for CSL clinical study of rIX-FP Other. Lubetsky:CSL Behring: Investigator for CSL clinical trial of rIX-FP Other. Santagostino:CSL Behring: Honoraria, Investigator for CSL Behring clinical trial of rIX-FP Other, Research Funding, Speakers Bureau. Jotov:CSL Behring: sub-investigator for CSL clinical trial of rIX-FP Other. Barazani-Brutman:CSL Behring: study coordinator for CSL Behring clinical trial of rIX-FP Other. Voigt:CSL Behring: Employment. Moises:CSL Behring: Employment. Jacobs:CSL Behring: Employment. Lissitchkov:CSL Behring: Investigator for CSL Behgring clinical trial of rIX-FP Other.
    Type of Medium: Online Resource
    ISSN: 0006-4971 , 1528-0020
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    Language: English
    Publisher: American Society of Hematology
    Publication Date: 2012
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  • 4
    Online Resource
    Online Resource
    Ovid Technologies (Wolters Kluwer Health) ; 2012
    In:  Blood Coagulation & Fibrinolysis Vol. 23, No. 8 ( 2012-12), p. 729-733
    In: Blood Coagulation & Fibrinolysis, Ovid Technologies (Wolters Kluwer Health), Vol. 23, No. 8 ( 2012-12), p. 729-733
    Type of Medium: Online Resource
    ISSN: 0957-5235
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2012
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  • 5
    Online Resource
    Online Resource
    American Society of Hematology ; 2011
    In:  Blood Vol. 118, No. 21 ( 2011-11-18), p. 2259-2259
    In: Blood, American Society of Hematology, Vol. 118, No. 21 ( 2011-11-18), p. 2259-2259
    Abstract: Abstract 2259 Introduction: In Congenital Bleeding Disorders (CBD), efficacy of Replacement Therapy (RT) can be indirectly measured on the basis of pharmacokinetic (PK) methods. Therapeutic concentrations of clotting factors in the blood-stream at a given time depend on the dose and frequency of RT and the fall off patterns specific for each clotting factor (i.e. PK properties). The issue of the frequency of RT administration is particularly relevant in Factor VII (FVII) deficiency, a CBD characterized by the lack of a rare protein with a very short half-life. Recombinant FVIIa (rFVIIa), plasma-derived FVII (pdFVII) concentrates and Fresh Frozen Plasma (FFP) are used for on-demand or prophylaxis replacement despite reported half-lives in the range of 2–5 hours. Very limited information is available with reference to the pharmacokinetic parameters of infused FVII in FVII deficiency. The same holds for the In Vivo Recovery (IVR). In this study, we evaluated the PK of rFVIIa in 11 severe (FVIIc 〈 2%) FVII deficient patients. Further, evaluation of “incremental” IVR was performed in 116 patients with a FVII deficiency (90 for rFVIIa, 19 for pdFVII concentrates and 7 for FFP). Methods & Results: Eleven severe FVII-deficient individuals in the non-bleeding state were given rFVIIa doses ranging from 16 to 24 μg/Kg/bw (mean 19.7, median 20). Pharmacokinetic parameters of rFVIIa were analyzed with reference to FVIIc post-infusion levels. Analyses of the PK parameters are detailed in Tab. 1. In Tab. 2 results regarding the IVR analyses of rFVIIa, pdFVII and FFP are reported, on the basis of FVIIc 15' after replacement. IVR data were also evaluated with reference to the baseline FVIIc, age and FVII mutation zygosity. Conclusions: PK data are characterized by an optimal correspondence between FVIIc levels and time; data variability is ample considering that all individuals were adults or teen-agers. Terminal half-life appeared longer than the Mean Residence Time (MRT) or T1/2, a data that can be interpreted as a reduction of the factor flow from the plasma pool to the extravascular space at the end of the fall off curve; this is confirmed by the Apparent volume of distribution based on the terminal phase (Vz) that is higher than the Apparent Volume of distribution at equilibrium (Vss). MRT and T1/2 are in keeping with previous studies and appear lower than those already reported for the pdFVII concentrates. Quite variable is also the Clearance (CL) showing that metabolic degradation and/or FVIIa vascular uptake greatly differ among patients. The latter aspect points towards the need for a CL individualized evaluation for patients who are eligible for continuous infusion protocols. Incremental IVRs of rFVIIa and FFP were lower (p 〈 0.001) than those calculated for the pdFVII concentrates. The difference between the recoveries of rFVIIa and pdFVII can either be ascribed to the FVIIc assay (only FVIIa assayed in the case of rFVIIa administration, FVII zymogen and FVIIa assayed in the case of pdFVII concentrates), to a more rapid disappearance rate of FVIIa from the vascular compartment or, finally, to a more rapid uptake by the FVIIa receptors (TF on the pericytes and the PC receptor on the endothelial cells). No difference was found between IVRs in children and adults nor between individuals with baseline FVIIc 〈 2% or ≥ 2%. Also, no differences were found between patients homozygous or compound heterozygous for FVII gene lesions. Disclosures: No relevant conflicts of interest to declare.
    Type of Medium: Online Resource
    ISSN: 0006-4971 , 1528-0020
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    Language: English
    Publisher: American Society of Hematology
    Publication Date: 2011
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  • 6
    In: Dermatologic Surgery, Ovid Technologies (Wolters Kluwer Health), Vol. 45, No. 6 ( 2019-06), p. 759-767
    Abstract: Topical application, oral, and IV injection of tranexamic acid (TXA) have been used to reduce surgical bleeding. OBJECTIVE To evaluate the safety and efficacy of TXA injected subcutaneously to reduce bleeding during dermatologic surgery. METHODS In this double-blinded, placebo-controlled, randomized prospective study, 131 patients were randomized to subcutaneous injection of lidocaine 2% diluted 1:1 with either saline (placebo) or TXA 100 mg/1 mL before surgery. Before the second stage or closure, size measurements of bloodstain impregnation on Telfa and surgical wound size were recorded and analyzed using mixed-effects linear regression. Subjective evaluation of hemostasis was performed using 4-point scale grading and analyzed using Fischer's exact test. RESULTS One hundred twenty-seven patients completed the study. The bloodstain to surgical wound size ratio was smaller in the TXA group (1.77) compared with the placebo group (2.49) ( p 〈 .001). An improved effect of TXA on bleeding was observed in the subgroup of patients receiving anticoagulants (mean difference; 95% confidence interval; −0.83; −1.20 to −0.46 p 〈 .001). The subjective hemostasis assessment was significantly better in the TXA group overall ( p = .043) and anticoagulant subgroup ( p = .001) compared with the placebo group. CONCLUSION Subcutaneous injection of TXA was safe, reduced bleeding during dermatologic surgery, and particularly effective for patients receiving anticoagulation treatment.
    Type of Medium: Online Resource
    ISSN: 1076-0512 , 1524-4725
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    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2019
    detail.hit.zdb_id: 2020062-6
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  • 7
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    Online Resource
    Ovid Technologies (Wolters Kluwer Health) ; 2010
    In:  Blood Coagulation & Fibrinolysis Vol. 21, No. 4 ( 2010-06), p. 328-333
    In: Blood Coagulation & Fibrinolysis, Ovid Technologies (Wolters Kluwer Health), Vol. 21, No. 4 ( 2010-06), p. 328-333
    Type of Medium: Online Resource
    ISSN: 0957-5235
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2010
    detail.hit.zdb_id: 2035229-3
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  • 8
    In: European Journal of Anaesthesiology, Ovid Technologies (Wolters Kluwer Health), Vol. 38, No. 4 ( 2021-04), p. 348-357
    Abstract: Trauma-induced coagulopathy (TIC) substantially contributes to mortality in bleeding trauma patients. OBJECTIVE The aim of the study was to administer fibrinogen concentrate in the prehospital setting to improve blood clot stability in trauma patients bleeding or presumed to bleed. DESIGN A prospective, randomised, placebo-controlled, double-blinded, international clinical trial. SETTING This emergency care trial was conducted in 12 Helicopter Emergency Medical Services (HEMS) and Emergency Doctors’ vehicles (NEF or NAW) and four trauma centres in Austria, Germany and Czech Republic between 2011 and 2015. PATIENTS A total of 53 evaluable trauma patients aged at least 18 years with major bleeding and in need of volume therapy were included, of whom 28 received fibrinogen concentrate and 25 received placebo. INTERVENTIONS Patients were allocated to receive either fibrinogen concentrate or placebo prehospital at the scene or during transportation to the study centre. MAIN OUTCOME MEASURES Primary outcome was the assessment of clot stability as reflected by maximum clot firmness in the FIBTEM assay (FIBTEM MCF) before and after administration of the study drug. RESULTS Median FIBTEM MCF decreased in the placebo group between baseline (before administration of study treatment) and admission to the Emergency Department, from a median of 12.5 [IQR 10.5 to 14] mm to 11 [9.5 to 13] mm ( P  = 0.0226), but increased in the FC Group from 13 [11 to 15] mm to 15 [13.5 to 17] mm ( P  = 0.0062). The median between-group difference in the change in FIBTEM MCF was 5 [3 to 7] mm ( P   〈  0.0001). Median fibrinogen plasma concentrations in the fibrinogen concentrate Group were kept above the recommended critical threshold of 2.0 g l −1 throughout the observation period. CONCLUSION Early fibrinogen concentrate administration is feasible in the complex and time-sensitive environment of prehospital trauma care. It protects against early fibrinogen depletion, and promotes rapid blood clot initiation and clot stability. TRIAL REGISTRY NUMBERS EudraCT: 2010-022923-31 and ClinicalTrials.gov: NCT01475344.
    Type of Medium: Online Resource
    ISSN: 0265-0215 , 1365-2346
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2021
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  • 9
    In: Blood, American Society of Hematology, Vol. 118, No. 21 ( 2011-11-18), p. 19-19
    Abstract: Abstract 19 Despite great progress in embryogenesis, the underlying mechanism that controls tissues and organs size remains a mystery. We previously showed that transplanted pig embryonic tissues are markedly enlarged in Factor VIII knockout (F8KO) mice, and identified a regulatory role for thrombin. Here, we describe a novel potential pathway through which coagulation factors might regulate size control of the hematopoietic system. The hematopoietic stem cell (HSC) pool of F8KO mice exhibited instability manifested by three parameters: 1) Reduced proportion of CD34low cells within the Lin−Sca+Kit+ (LSK) progenitors. Median CD34 staining of F8KO LSK cells was 40±4% higher compared to WT controls (n=8 mice, p 〈 0.001). 2) Reduced long term repopulating capacity measured by competitive transplantation. While 6 weeks post transplantation of F8KO or WT BM similar chimerism levels were found, markedly reduced F8KO donor chimerism levels were detected at 22 weeks (22.2±4.4% vs 38.9±9.9%; p=0.008). 3) Hyper responsiveness to G-CSF. We used G-CSF to reveal pre-existing abnormalities in the HSC pool. G-CSF treated F8KO mice exhibited significantly enlarged spleens compared to WTs (256±149mg, n=25 vs 181±61mg, n=32; p=0.01). This difference was corrected upon F8 treatment. We further used splenectomized mice to test the effect of G-CSF on BM alone. The LSK cell number in the peripheral blood (PB) of G-CSF treated splenectomized F8KO mice was 3 fold higher compared to WT splenectomized mice (380±127 cells/ml, n=3 vs 64±6 cells/ml, n=3, P=0.01). Since factor VIII has no known physiological function other than in coagulation, it was tempting to assume that down-stream coagulation factors, in particular thrombin, are responsible for the observed distorted HSC regulation. Indeed, F8KO mice exhibit a 2 fold decrease in peak plasma thrombin concentration compared to WT mice. Furthermore, thrombin receptor 1 knockout mice (PAR1 KO), exhibited enhanced responsiveness to G-CSF, with higher PB LSK cell numbers compared to WT mice (766±180 cells/ml, n=7 vs 489±189 cells/ml, n=5; p 〈 0.005). Likewise, G-CSF induced splenomegaly and LSK mobilization were enhanced in WT mice upon treatment with thrombin inhibitors such as Clexane and Dagibitran, or by the PAR1 antagonist, palmitoylated peptide (pal-RCLSSSAVANRS). To investigate the thrombin site of action, a reciprocal transplantation was performed. Interestingly, chimeras generated by transplantation of WT BM into PAR1KO recipients showed enhanced responsiveness to G-CSF compared to WT recipients. Thus, chimeras lacking PAR1 on their stroma cells only, were more prone to induced splenomegaly than controls (114.4±26.4mg; n=10, vs 162.6±19.34mg; n=5; p 〈 0.003). A less dramatic but significant enhancement was observed in WT recipients of PAR1 KO BM, lacking PAR1 on their hematopoietic cells (141.4±23.5mg, n=10, p=0.026). Our results suggest that thrombin-PAR1 signalling in BM stromal cells has a predominant role in regulating HSC maintenance. Surprisingly, we found that coagulation factors also influence the dynamic bone structure. We evaluated the status of bone formation and remodelling in F8KO, PAR1KO and WT mice at different ages after birth. A decrease in bone density and in trabeculae number was first evident at 2 months of age and was more pronounced at 4 months in both F8KO and PAR1KO mice. In addition, micro CT analysis of distal tibia metaphyses harvested at 4 months revealed reduced bone/tissue volume ratio and trabecular number in F8KO and PAR1KO mice (Fig.1). Thus, reduced thrombin activity is associated with decreased bone mass and compromises bone architecture. This in turn can affect the long-term maintenance of repopulating HSC.Fig. 1Representative micro-CT analyses of tibial metaphyses revealing reduced bone/tissue volume ratio and trabeculae numbers by 57.13±6.53%, and 73.1±4.7% in F8KO and by 44.83±15.2% and 37.11±8.07% in PAR1KO mice, respectively.Fig. 1. Representative micro-CT analyses of tibial metaphyses revealing reduced bone/tissue volume ratio and trabeculae numbers by 57.13±6.53%, and 73.1±4.7% in F8KO and by 44.83±15.2% and 37.11±8.07% in PAR1KO mice, respectively. Taken together, these results show a critical and novel role for the coagulation cascade, in part via the Thrombin/PAR1 axis, in regulating the reciprocal interplay between the dynamic bone structure and HSC maintenance and mobilization. While further studies in Hemophilia are warranted, our new insights also suggest that thrombin inhibitors such as Clexane and Dabigatran could potentially enhance HSC mobilization in G-CSF treated donors and increase the number of cells harvested. Disclosures: No relevant conflicts of interest to declare.
    Type of Medium: Online Resource
    ISSN: 0006-4971 , 1528-0020
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    Language: English
    Publisher: American Society of Hematology
    Publication Date: 2011
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  • 10
    In: Blood, American Society of Hematology, Vol. 112, No. 11 ( 2008-11-16), p. 1215-1215
    Abstract: Inhibitors to factor XI (FXI) can develop following exposure to plasma products in 33% of patients with severe FXI deficiency who are homozygous for the type II nonsense mutation prevalent in Jews (Salomon et al. Blood2003;101:4783). Hemostasis in five such patients was previously achieved during surgery by infusion of recombinant factor VIIa (rFVIIa) and tranexamic acid, but two patients experienced arterial thrombosis following surgery (Schulman et al. Hemophilia2006; 12:223). Conceivably, the rather high dose of rFVIIa used was responsible for the thrombotic events in these patients. In a previous in vitro study, we showed that low concentrations of rFVIIa can correct thrombin generation in plasma of patients with severe FXI deficiency and an inhibitor to FXI (Livnat et al. J Thromb Hemost2006; 4:192). In the present study we addressed the question whether low doses of rFVIIa and use of tranexamic would be hemostatically effective and less thrombogenic during and after major surgery in patients with severe FXI deficiency in whom plasma derivatives could not be used. Three patients (two with FXI inhibitor and one with severe IgA deficiency) underwent major surgery managed by a single low dose infusion of rFVIIa and administration of tranexamic acid 1 G q.i.d for 7 days (Table). In patient 1 the infusion was given immediately prior to surgery and in patients 2 and 3 at the end of surgery. Hemostasis was achieved in all patients and no thrombosis occurred. No. Sex/age FXI (U/dL) FXI inhibitor (B.U) Operation Single dose rVIIa (uG/Kg) Adverse events * IgA deficiency 1 M/62 & lt; 0.01 5.0 Laparoscopic cholecystectomy 30 None 2 M/61 & lt; 0.01 5.0 Transuretheral prostatectomy 16 None 3 M/63 0.02 0* Parathyroidectomy 15 None These observations suggest that a single infusion of low dose rFVIIa and use of tranexamic acid can be a safe modality of treatment in patients with severe FXI deficiency who cannot receive blood products. Furthermore, the protocol outlined here may be used to avoid inhibitor formation in patients with extremely severe FXI deficiency who undergo surgery.
    Type of Medium: Online Resource
    ISSN: 0006-4971 , 1528-0020
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    Language: English
    Publisher: American Society of Hematology
    Publication Date: 2008
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