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2017 | OriginalPaper | Buchkapitel

2. Blood Coagulation

verfasst von : Antonio Fasano, Adélia Sequeira

Erschienen in: Hemomath

Verlag: Springer International Publishing

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Abstract

This chapter is devoted to the description and modeling of the process of blood coagulation which is crucial for life and is the result of an intricate sequence of chemical reactions, involving an active role of platelets and of a surprisingly large number of blood born massive molecules performing a sequence of operations aimed at the formation of the clot and at its subsequent dissolution. Due to such a complexity there is an enormous variety of conditions leading to insufficient or excessive coagulation. We will discuss also the biological and mathematical aspects regarding these pathologies.

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Fußnoten
1
A widespread belief, still alive in the nineteenth century, was that limb swelling accompanying pregnancy was due to the accumulation of excess milk which found its way to reach the legs. The name “phlegmatia lactea” was coined for this condition by the French physician and botanist François Boissier de Sauvages de Lacroix (1706–1767) (known as Sauvage) in his Nosologia Methodica (1768). Pregnancy may increase the risk of thrombosis in various ways. The swollen uterus can compress pelvic vessels, reducing blood circulation in the legs. Hormonal changes can also produce hypercoagulability by increasing the concentration in blood of pro-coagulant factors and reducing the concentration of anticoagulant factors. A more serious condition sometimes related to pregnancy is the Antiphospholipid Antibody (or Hughes, or sticky blood) Syndrome, due to the autoimmune production of antibodies against a cell membrane substance called phospholipid, eventually producing clots.
 
2
Nevertheless, we must consider that in this context “heat” was not meant just as a physical quantity, but as a vital entity carried by blood.
 
3
Such a fibrous component was isolated much later by Marcello Malpighi (1628–1694).
 
4
Despite his fame (testified by the great success of his book Several Chirurgical Treatises—London, Flesher 1676) as member of the Company of Barber-Surgeons his social rank was inferior to the one of physicians.
 
5
Though he was one of the founders of pathology, it is reductive to call him just a pathologist, since this great man was also a biologist, the editor of the Archiv für pathologische Anatomie und Physiologie und für klinische Medizin (known as the Virchow’s journal), the founder of the Gesellschaft für Anthropologie, Ethnologie und Urgeschichte (very influential in German archaeology), and the leader of a democratic party. He wrote about many different subjects. He was such a strong opponent of Bismarck, that he was challenged by him to a duel in 1865. The legend says that, having to choose the weapons, he selected two pork sausages, one of them charged with trichinosis larvae, thus discouraging his adversary. Not everything he did was perfect: he was skeptic about Darwin’s evolution theory.
 
6
Virchow described the mechanism of thromboembolism [253], a phenomenon that was by no means clear at his time (inflammation was considered by many physicians the real cause of thrombosis: this was the subject of a famous dispute with the French pathologist Jean Cruveilhier). Curiously, he did not formulate the famous “triad”, which for some reason found a firm place in the literature much after his death (apparently not before 1950!). See the interesting review [22].
 
7
Circumcision is a very old practice, already found in ancient Egypt and that was widely adopted also in the Islamic world. Its origin in Egypt was probably as an initiation practice to religious offices. The Book of the Dead describes self-circumcision by the sun-god Ra: Blood fell from the phallas of Ra after he had finished cutting himself.
 
8
The fact that hemophilia is gender related was suggested by the American physician John Conrad Otto (1774–1844) as early as 1803.
 
9
In numbers, 1 over 10,000 men is hemophilic. The probability that a woman is hemophilic is the square of that number. Cases of hemophilic women have been reported (see e.g. [90]).
 
10
The only male child of Tsar Nicholas II (Aleksej Nikolaevič Romanov) got hemophilia through his mother Alice (third row in Fig. 2.5), who as a Tsarina took the name Aleksandra Fëdorovna Romanova. The Tsarina believed that Grigory Rasputin (a controversial character) was able to heal the tsarevich with his prayers (he actually recommended not to credit the physicians) and in this way he acquired great power at court.
 
11
A distinguished French Medicine Professor, Trousseau related a state of hypercoagulability to the presence of some malignancies. He diagnosed his fatal illness having got a thromboflebitis in his left upper arm. The presence of cancer induced thromboflebitis has become known as Trousseau Syndrome.
 
12
We will refer his contributions in the field of leukemia in the last chapter. The list of people who contributed to the early studies on platelets is actually longer (see the review paper [55]).
 
13
In this connection the name of the eminent French hematologist Georges Hayem (1841–1933) has to be remembered as one of the founders of modern hematology. He performed the first count of platelets. In 1882 he illustrated the effects of thrombocytopenia (low platelets count)
 
14
The eminent Canadian Physician William Osler (1849–1919) called them third corpuscles. The name platelets was introduced in 1910 by the American pathologist James Wright (1869–1928).
 
15
Large molecules like proteins have specific sites which are engaged in specific reactions.
 
16
The volume unit femtoliter is often used for small particles. It corresponds to 1 μm3 = 10−15 l.
 
17
All data concerning human blood are subjected to large variations, according to sex, body weight, and health conditions. A parameter which instead is bound to stay in a narrow range is blood pH whose value must be between 7.35 and 7.45.
 
18
Most cells interact with the environment thanks to receptors able to recognize molecules carrying signals and inducing specific stimuli (cytokines).
 
19
Gp recalls that these receptors are glycoproteins receptors denoted as GPIb (i.e. containing sugar chains).
 
20
A protein with elongated molecule (fibril) which comes in many different types and is abundant in many tissues, including blood vessels. It makes 1/4–1/3 of the protein content in the body.
 
21
Commonly known as Adrenaline, it was the first hormone to be discovered (1900) though the term hormone was introduced in 1905 by Ernest Starling (see the next chapter), after the Greek word ormè (impetus), for the hormone he discovered (secretin).
 
22
In 1998 the Nobel Prize in Medicine was awarded to R.F. Furchgott, L.J. Ignarro, and F. Murad for their work on the signalling role of NO.
 
23
For instance Thrombospondin 1, a multifunctional protein (e.g. antiangiogenic), and Nexin II, whose role will be discussed later. Platelets also release Growth Factors which help repairing the damaged tissue.
 
24
Through the same property it exerts the anti-inflammatory and analgesic action. For more information on the transformation of arachidonic acid in platelets and the possible consequences of COX deficiency see [148].
 
25
Drugs containing citrates have the effects of lowering Calcium concentration, inducing some anticoagulant effect. Therefore their use must be avoided in while assuming potent anticoagulants.
 
26
Mast Cells are another group of granulocytes, affine to basophils, which reside in connective and mucosal tissues (as different species) and may live for weeks or months. They are part of the immune system, which includes WBCs along with dendritic cells (present in blood in the immature stage and residing in various tissues: see the book [206]).
 
27
B-cells types: Plasmocytes, memory B-cells, B1- and B2-cells, marginal zone B-cells, Follicular B-cells, regulatory B-cells. The “B” comes from the name of the organ in which they mature in birds, Bursa of Fabricius, where B-cells were first discovered. It was then found that in humans B-cells mature in the Gut Associated Lymphoid Tissue (GALT), mainly located in the intestine.
 
28
T-cells types: helper, cytotoxic, memory, regulatory, natural killer (not the same as the ones already listed), mucosal associated invariant, gamma-delta.
 
29
From which the “T” derives.
 
30
Each RBC contains 270 million hemoglobin molecules.
 
31
RBCs smaller than 80 fL are typical of microcytic anemia. When their volume exceeds 100 fL we have macrocytic anemia.
 
32
AMP, ADP, ATP contain 1 (Mono-), 2 (Di-), 3 (Tri-) atoms of phosphorus and they are obtained in that sequence by addition of a P atom (a process called phosphorylation). ATP has a vital importance in cells metabolism.
 
33
This condition can be produced by arterial stenosis, possibly as a consequence of clotting itself, or because of the mechanical action of implanted devices (rigid artificial heart valves).
 
34
Platelet Factors 1–3 actually regulate interactions with the Coagulation Factors IIa (thrombin), V, X.
 
35
Prostaglandins make a large family. The first prostaglandin was isolated in seminal liquid (1935) by the Swedish physiologist Ulf von Euler (1905–1983) and believed to be produced only in the prostate gland. Actually several other tissues are able to secrete prostaglandins. See the section on anticoagulants.
 
36
Ecto-enzymes act at the exterior of cells. For more details about this enzyme see [85].
 
37
Though there is some disagreement on the exact meaning of this name, it is sometimes attributed to TF.
 
38
Serine proteases are a large class of enzymes. The list of serine proteases is impressively long. See http://​biochem.​wustl.​edu/​~protease/​ser_​pro_​help.​html.
 
39
A distinguished physiologist born in today Estonia, Schmidt had the idea that fibrin had to come from fibrinogen as the result of an enzymatic reaction, whose agent he called thrombin, which in turn had a precursor, which he called prothrombin [220, 221].
 
40
Publication was delayed because of II World War.
 
41
Fibrinogen was described as the precursor of Fibrin by R. Virchow in 1847 [252]. It has also other specific functions, illustrated in this chapter. It is also known to intervene in RBC’s aggregation (forming the so-called rouleaux), a phenomenon of great importance in blood rheology.
 
42
Found by B. Alexander in 1949 [7] and isolated a few years later [131].
 
43
Isolated in 1937 by A.J. Patek and F.H.L. Taylor [185], following the experiments made a year earlier by Patek and R.H. Stetson [184].
 
44
Stephen Christmas was the first patient diagnosed with FIX deficiency (hemophilia B) (Oxford, 1952) at the age of five. He was a patient of R. Biggs and R.G. Mcfarlane [32]. He died in 1993 by AIDS. Many of transfusion dependent patients were infected by the HIV virus before blood screening became obligatory. A case which became emblematic was the one of Ryan Wayne White, affected by hemophilia A, who became discriminated when he was diagnosed with AIDS. He died still a teenager in 1990.
 
45
Named after the patients Rufus Stuart and Audrey Prower and described in 1957 by C. Hougie ad coworkers [109].
 
46
Identified in 1953 by R.L. Rosenthal and coworkers [212].
 
47
Named after Ratnoff’s patient John Hageman (1955) [200, 201]. Oscar David Ratnoff (1916–2008) was one of the leading American scientists in hematology. See more in the section on anticoagulants.
 
48
K. Laki and L. Lorand suggested its existence in 1948 [136].
 
49
Discovered in 1960 by Walter H. Seegers.
 
50
A very important function of Protein S in the organism is to facilitate phagocytosis of apoptotic cells by macrophages. Discovered in 1979 (by E.W. Davie) in Seattle, takes its name after that city.
 
51
Denominated after the German name Koagulationvitamin. Discovered in the 1930s, a Nobel prize was attributed in 1943 to H.K.P. Dam and to E.A. Doisy for their studies on it, though its real action in the coagulation process became clear only in the 1970s.
 
52
See the section on Anticoagulants for some historical news on Warfarin.
 
53
Already in the 1950s it was known that deficiency of vWF was accompanied by a deficiency of FVIII.
 
54
The symbol X-ase is sometimes used.
 
55
It was first described in 1965 by W.E. Hathaway [101] who investigated treats of abnormal coagulation in members of Fletcher family (Kentuky), not exhibiting bleeding disorders. Prekallikrein as a precursor of kallilkrein was isolated in 1972 by K.D. Wuepper [280] who identified it with Fletcher factor one year later [279].
 
56
Kininogens are proteins which are precursors of kinins (see next footnote), such as bradikinin and kallidin, which are vasodilator. HMWK is also known as Williams Factor or Flaujeac Factor. The Flaujeac trait was described by J.M. Lacombe in 1975 [135]. The cause was soon identified with HMWK deficiency [281].
 
57
Here we refer to Plasma Kallikrein, distinct from the numerous group of Tissue Kallikreins which are enzymes performing various actions. It was named after the Greek words kalli (sweet, in this context) and krein (flesh) referring to pancreatic tissue. Plasma Kallikrein (like some of its tissue analogs) liberates kinins from the kininogens. The so-called kinin-kallikrein system has a role in regulating blood pressure, owing to its vasodilation action (see e.g. the book [69]). In 1909 J.E. Abelous and E. Bardier [1] observed that human urine injected in dogs caused a drop in blood pressure and conjectured that a substance produced in some organ and eliminated through urine had to be responsible. The (Kallikrein) substance was identified and named in 1930 [132], then extensively studied by E.K. Frey, E. Werle and others.
 
58
Also Kallikrein and FXIIa can activate plasminogen.
 
59
So-called because it is secreted by some bacteria in the streptococci family. Since it is not produced in the body it may trigger immune response and must be used with care.
 
60
Proteases are enzymes attacking proteins (proteolysis).
 
61
AT I-IV are also found in the literature, with specific targets.
 
62
Discovered in 1918 [110], though isolated in 1916 in canine liver tissue [158]. See more in the section on Anticoagulants. Heparin can be secreted by basophils.
 
63
Its deficiency leads to degradation of tissues, particularly in the lungs, causing emphysema. Smoke is believed to inactivate this serpin, thus causing additional damage to lungs.
 
64
The main function of C1-inhibitor is to contrast some of the molecules in the C1-complement group part of the so called complement system having an adjuvant role in the immune system.
 
65
PAI-2 is detectable only in pregnant women, a fact that may justify the increased risk of thrombosis during pregnancy.
 
66
Some FVIIa can reach TF in nonvascular tissues even in the absence of a lesion [289], thus making FIXa and FXa accidentally available. However, coagulation does not start because it requires for instance the intervention of platelets, which are not available out of the bloodstream.
 
67
FXa itself is an extremely mild activator of prothrombin. The rate of thrombin generation by prothrombinase is 300,000 times larger the one by FXa alone [149]. The prothrombin to thrombin transition is a quite complicated process. Details can be found in the review paper [133].
 
68
The proteins responsible for this regulatory action have a fundamental role in eventually halting the clot growth. They are inevitably produced at this initial stage too, but it is known that free FVa inhibition by APC is far less efficient than on the surface of endothelial cells. One can wonder whether, besides the clotting confining action, the simultaneous slowing down of the initial process may have a precise aim, for instance letting the platelet plug become thicker.
 
69
FVa on platelets membrane is inactivated faster than the same factor complexed with FXa (see e.g. [173, 238]). Likewise FVIIIa is partially protected when it is complexed with FIXa. For more details and for the role of Protein S is these processes see [174].
 
70
The book [154] collects and comments a number of historical papers on bleeding disorders and other blood diseases.
 
71
The Latin word for purple. Purpura denotes spots in the range 3–10 mm, smaller spots are called petechiae, and those more extended are called ecchymoses.
 
72
The Latin equivalent of the Greek derived word idiopathic is sui generis. In this context it means “of no specific origin”.
 
73
Congenital deficiency accounts for a small fraction of TTP cases and is known as Upshaw-Schülman syndrome.
 
74
In 1944 an Argentinean doctor (Alfredo Pavlosky) had the idea of mixing two blood samples from hemophilic patients and observed that the mixture had acquired the ability to clot. He concluded that there must have been different types of the illness.
 
75
More common among Ashkenazi Jews.
 
76
Mr. John Hageman died in 1968, quite unexpectedly, by pulmonary embolism following a hip fracture, a fact that was puzzling for Ratnoff himself [203]. It was conjectured that FXII may actually protect against thrombosis. Such a behavior has been explained considering that FXII is a plasminogen activator (see Sect. 2.3, ref. [94]). Correlations of FXII deficiency with miscarriage, coronary infarct, etc. have been reported, but the interpretation of such findings is not unanimous (see [236]). An interesting review paper on FXII is [48].
 
77
As we said, the kallikrein-kinin system is particularly important in the regulation of blood pressure. Therefore any dysfunction of it can cause hypertension (see [194]).
 
78
Since immobilization is a frequent cause, DVT is also called the economy class syndrome, because many cases have been reported in passengers after long flights.
 
79
As in the Paget-Schrötter disease. We also recall the tumor related Trusseau syndrome (see the historical section).
 
80
Not with fibrinolytic proteins (like tPA or urokinase), because they could fragment rather than gradually dissolve the clot. Fibrinolytic therapies are instead used to attack arterial thrombosis in the heart or the brain.
 
81
Major veins are provided with valves preventing flux inversion, thus helping circulation in the presence of reduced pressure gradients (see more on valves in Chap. 1).
 
82
Some hemophilia therapies actually bypass the intervention of FVIII and FIX. We will return to this question in Sect. 2.7.
 
83
Nevertheless, in the paper [50] experiments were performed emphasizing the importance of the Hageman Factor FXII in resting blood.
 
84
Reduced oxygen concentration is more marked in valves, since, differently from veins and other blood vessel, they do not possess their own vessels (vasa vasorum).
 
85
This paper is an extensive study on the role of TF and of thrombin in promoting angiogenesis and contains a large bibliography. Excessive TF production may be accompanied by upregulated expression of VEGF (the angiogenic factor) and downregulated expression of thrombospondin 1 (see Sect.2.3).
 
86
Clots are mostly originated in the left atrium and more precisely in an area called left atrial appendage.
 
87
For this reason patients receiving artificial mechanical heart valves are permanently treated with anticoagulants. Valves taken from pigs do not have this inconvenience, but have a limited duration ( ∼ 15 years).
 
88
It was the American chemist Linus Carl Pauling (1901–1994), Nobel laureate (1954), to describe the causes of the disease in 1949 [187]. This was an early success of molecular biology, of which Pauling was one of the founders.
 
89
Veterinarians know that some mammals, like whales and dolphins, do not even possess FXII.
 
90
For the sake of brevity we omit to list hemostatic drugs. Some of them act on platelets stimulating their adhesion (microfibrillar collagen hemostat, chitosan), some force strong vasoconstriction (anhydrous aluminum phosphate). Batroxobin (or reptilase) acts in a way similar to thrombin. It is contained in the venom of a group of Southern American vipers. Venoms of many snakes exert a strong coagulant action in various ways (including direct activation of Factor X).
 
91
The history of Aspirin is controversial. The synthesis of pure ASA (1897) has been credited to the young Bayer chemist Felix Hoffmann (impure ASA had been previously produced by the French chemist Charles Frédéric Gerhardt in 1857). Many years later Arthur Eichengrün, another German chemist employed at Bayer at the time of Aspirin discovery, claimed that Hoffmann had just followed his plans. Though recent studies have confirmed that Eichengrün’s thesis was credible, Bayer officially dismissed his claims. The analgesic and anti-inflammatory properties of the willow (latin salix) leaf have been known since antiquity. It has been documented in a Sumer tablet and in the Ebers Papyrus. Hippocrates mentioned it and its effects were well known in western and also Arab civilizations well before ASA chemical synthesis.
 
92
Farming, and especially milk production, was the backbone of Wisconsin economy (“the Dairy State”). The disease, described in 1924 by the veterinarian Frank Shofield, was brought to Link’s attention by a Wisconsin farmer in 1933.
 
93
This theory may have some ground, since Stalin was going to launch another purge and Beria would have been one of the first victims. The symptoms produced by warfarin poisoning would have been compatible with the brain hemorrhage that actually killed Stalin and with his clinical picture. Others claim that Stalin ‘s murder was ordered by Tito.
 
94
Equation (13) (as well as (14) and (15)) shows the phenomenon of dissociation of FVIIa in subunits. This factor has a very complicated structure. For an illustration see e.g. [73].
 
95
An intermediate step in prothrombin activation.
 
96
It consists in a term proportional to the product of viscosity and velocity, typical of the equation describing the flow of a Newtonian fluid through coarse porous media.
 
97
Named after the Australian mathematician Renfrey Potts [197].
 
98
See e.g. [84].
 
99
See e.g. [5, 66].
 
100
The case in which a finite bound is imposed to particles volume requires a different setting, with the introduction of a volume scattering term (see [70]).
 
101
See the experimental literature quoted therein.
 
102
Actually applicable to spheres, it practically coincides with (2.9).
 
103
From that paper it can be concluded that slip up to 20% of blood maximal velocity in the vessel is possible.
 
104
If Ω is a circle of radius R, then H = πR∕2.
 
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Metadaten
Titel
Blood Coagulation
verfasst von
Antonio Fasano
Adélia Sequeira
Copyright-Jahr
2017
DOI
https://doi.org/10.1007/978-3-319-60513-5_2

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