Cryoprecipitate transfusion in trauma patients attenuates hyperfibrinolysis and restores normal clot structure and stability: Results from a laboratory sub-study of the FEISTY trial

Gael B Morrow, Timea Feller, Zoe McQuilten, Elizabeth Wake, Robert A S Ariëns, James Winearls, Nicola J Mutch, Mike A Laffan, Nicola Curry, Gael B Morrow, Timea Feller, Zoe McQuilten, Elizabeth Wake, Robert A S Ariëns, James Winearls, Nicola J Mutch, Mike A Laffan, Nicola Curry

Abstract

Background: Fibrinogen is the first coagulation protein to reach critical levels during traumatic haemorrhage. This laboratory study compares paired plasma samples pre- and post-fibrinogen replacement from the Fibrinogen Early In Severe Trauma studY (FEISTY; NCT02745041). FEISTY is the first randomised controlled trial to compare the time to administration of cryoprecipitate (cryo) and fibrinogen concentrate (Fg-C; Riastap) in trauma patients. This study will determine differences in clot strength and fibrinolytic stability within individuals and between treatment arms.

Methods: Clot lysis, plasmin generation, atomic force microscopy and confocal microscopy were utilised to investigate clot strength and structure in FEISTY patient plasma.

Results: Fibrinogen concentration was significantly increased post-transfusion in both groups. The rate of plasmin generation was reduced 1.5-fold post-transfusion of cryo but remained unchanged with Fg-C transfusion. Plasminogen activator inhibitor 1 activity and antigen levels and Factor XIII antigen were increased post-treatment with cryo, but not Fg-C. Confocal microscopy analysis of fibrin clots revealed that cryo transfusion restored fibrin structure similar to those observed in control clots. In contrast, clots remained porous with stunted fibres after infusion with Fg-C. Cryo but not Fg-C treatment increased individual fibre toughness and stiffness.

Conclusions: In summary, our data indicate that cryo transfusion restores key fibrinolytic regulators and limits plasmin generation to form stronger clots in an ex vivo laboratory study. This is the first study to investigate differences in clot stability and structure between cryo and Fg-C and demonstrates that the additional factors in cryo allow formation of a stronger and more stable clot.

Keywords: Clot structure; Cryoprecipitate; Fibrinogen; Fibrinolysis; Trauma coagulopathy.

Conflict of interest statement

N.C has received funding from CSL Behring for investigator led studies. N.J.M has received funding from LFB for investigator led studies. G.B.M, T.F, Z.M, E.W, J.W, R.A.S.A and M.L have no conflict of interest to disclose.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Cryoprecipitate transfusion attenuates fibrinolysis. A PAI-1, B FXIII and C plasmin activity levels were measured using chromogenic assays in plasma samples pre- and post-cryoprecipitate (cryo) and fibrinogen concentrate (Fg-C) transfusion. Grey dotted lines indicate the mean value for 16 healthy volunteers. **p < 0.01
Fig. 2
Fig. 2
Clots formed post cryoprecipitate have increased fibre density. A Plasma clots were formed from pooled normal plasma (PNP) or patient plasma pre- and post-cryoprecipitate (cryo) or fibrinogen concentrate (Fg-C) transfusion. Alexa Fluor 488 labelled fibrinogen was incorporated to visualise the fibrin network by confocal microscopy. Representative images of n = 3 per cohort. Clots were formed in duplicate. B number of fibres and C fibre length were calculated using Diameter J software. Three areas were analysed per clot. **p < 0.01, ***p < 0.001, ****p < 0.0001
Fig. 3
Fig. 3
Factor XIII cross-linking is attenuated in trauma patients. A Plasma clots were formed from pooled normal plasma (PNP) or patient plasma pre- and post-cryoprecipitate (cryo) or fibrinogen concentrate (Fg-C) transfusion. Alexa Fluor 488 labelled fibrinogen (red) and Alexa Fluor 555 DDXLink monoclonal antibody (blue) specific for fibrin cross-links was incorporated to visualise the fibrin network by confocal microscopy. Representative images of n = 3 per cohort. B The intensity of DDXLink monoclonal antibody staining was determined using Image J software. Three areas were analysed per clot. **p < 0.01
Fig. 4
Fig. 4
Cryoprecipitate transfusion augments fibrin fibres strength. The mechanical response of individual fibrin fibres in plasma clots formed pre- and post-cryoprecipitate (cryo) and fibrinogen concentrate (Fg-C) were analysed using atomic force microscopy and A toughness and B Modulus 1 calculated

References

    1. World Health Organization. Global health estimates 2016: deaths by cause, age, sex, by country and by region, 2000–2016. Geneva: World Health Organization. 2018.
    1. Norton R, Kobusingye O. Injuries. N Engl J Med. 2013;368(18):1723–1730. doi: 10.1056/NEJMra1109343.
    1. Sobrino J, Shafi S. Timing and causes of death after injuries. Proc (Bayl Univ Med Cent) 2013;26(2):120–123.
    1. Sauaia A, Moore FA, Moore EE, Moser KS, Brennan R, Read RA, et al. Epidemiology of trauma deaths: a reassessment. J Trauma. 1995;38(2):185–193. doi: 10.1097/00005373-199502000-00006.
    1. Kahl JE, Calvo RY, Sise MJ, Sise CB, Thorndike JF, Shackford SR. The changing nature of death on the trauma service. J Trauma Acute Care Surg. 2013;75(2):195–201. doi: 10.1097/TA.0b013e3182997865.
    1. Shackford SR, Mackersie RC, Holbrook TL, Davis JW, Hollingsworth-Fridlund P, Hoyt DB, et al. The epidemiology of traumatic death. A population-based analysis. Arch Surg. 1993;128(5):571–575. doi: 10.1001/archsurg.1993.01420170107016.
    1. Callcut RA, Kornblith LZ, Conroy AS, Robles AJ, Meizoso JP, Namias N, et al. The why and how our trauma patients die: a prospective multicenter western trauma association study. J Trauma Acute Care Surg. 2019;86(5):864–870. doi: 10.1097/TA.0000000000002205.
    1. Evans JA, van Wessem KJ, McDougall D, Lee KA, Lyons T, Balogh ZJ. Epidemiology of traumatic deaths: comprehensive population-based assessment. World J Surg. 2010;34(1):158–163. doi: 10.1007/s00268-009-0266-1.
    1. Soreide K, Kruger AJ, Vardal AL, Ellingsen CL, Soreide E, Lossius HM. Epidemiology and contemporary patterns of trauma deaths: changing place, similar pace, older face. World J Surg. 2007;31(11):2092–2103. doi: 10.1007/s00268-007-9226-9.
    1. Oyeniyi BT, Fox EE, Scerbo M, Tomasek JS, Wade CE, Holcomb JB. Trends in 1029 trauma deaths at a level 1 trauma center: Impact of a bleeding control bundle of care. Injury. 2017;48(1):5–12. doi: 10.1016/j.injury.2016.10.037.
    1. Teixeira PG, Inaba K, Hadjizacharia P, Brown C, Salim A, Rhee P, et al. Preventable or potentially preventable mortality at a mature trauma center. J Trauma. 2007;63(6):1338–46.
    1. Holcomb JB, del Junco DJ, Fox EE, Wade CE, Cohen MJ, Schreiber MA, et al. The prospective, observational, multicenter, major trauma transfusion (PROMMTT) study: comparative effectiveness of a time-varying treatment with competing risks. JAMA Surg. 2013;148(2):127–136. doi: 10.1001/2013.jamasurg.387.
    1. Cohen MJ, Christie SA. New understandings of post injury coagulation and resuscitation. Int J Surg. 2016;33(Pt B):242–245. doi: 10.1016/j.ijsu.2016.05.037.
    1. Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J Trauma. 2003;54(6):1127–1130. doi: 10.1097/01.TA.0000069184.82147.06.
    1. MacLeod JB, Lynn M, McKenney MG, Cohn SM, Murtha M. Early coagulopathy predicts mortality in trauma. J Trauma. 2003;55(1):39–44. doi: 10.1097/01.TA.0000075338.21177.EF.
    1. Maegele M, Lefering R, Yucel N, Tjardes T, Rixen D, Paffrath T, et al. Early coagulopathy in multiple injury: an analysis from the German Trauma Registry on 8724 patients. Injury. 2007;38(3):298–304. doi: 10.1016/j.injury.2006.10.003.
    1. Hiippala ST, Myllyla GJ, Vahtera EM. Hemostatic factors and replacement of major blood loss with plasma-poor red cell concentrates. Anesth Analg. 1995;81(2):360–365.
    1. Floccard B, Rugeri L, Faure A, Saint Denis M, Boyle EM, Peguet O, et al. Early coagulopathy in trauma patients: an on-scene and hospital admission study. Injury. 2012;43(1):26–32. doi: 10.1016/j.injury.2010.11.003.
    1. Hagemo JS, Stanworth S, Juffermans NP, Brohi K, Cohen M, Johansson PI, et al. Prevalence, predictors and outcome of hypofibrinogenaemia in trauma: a multicentre observational study. Crit Care. 2014;18(2):R52. doi: 10.1186/cc13798.
    1. Bale MD, Ferry JD. Strain enhancement of elastic modulus in fine fibrin clots. Thromb Res. 1988;52(6):565–572. doi: 10.1016/0049-3848(88)90129-6.
    1. Mockros LF, Roberts WW, Lorand L. Viscoelastic properties of ligation-inhibited fibrin clots. Biophys Chem. 1974;2(2):164–169. doi: 10.1016/0301-4622(74)80037-2.
    1. Shen L, Lorand L. Contribution of fibrin stabilization to clot strength. Supplementation of factor XIII-deficient plasma with the purified zymogen. J Clin Invest. 1983;71(5):1336–1341. doi: 10.1172/JCI110885.
    1. Sakata Y, Aoki N. Cross-linking of alpha 2-plasmin inhibitor to fibrin by fibrin-stabilizing factor. J Clin Invest. 1980;65(2):290–297. doi: 10.1172/JCI109671.
    1. Fraser SR, Booth NA, Mutch NJ. The antifibrinolytic function of factor XIII is exclusively expressed through alpha(2)-antiplasmin cross-linking. Blood. 2011;117(23):6371–6374. doi: 10.1182/blood-2011-02-333203.
    1. Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Critical Care. 2019 doi: 10.1186/s13054-019-2347-3.
    1. Inaba K, Karamanos E, Lustenberger T, Schochl H, Shulman I, Nelson J, et al. Impact of fibrinogen levels on outcomes after acute injury in patients requiring a massive transfusion. J Am Coll Surg. 2013;216(2):290–297. doi: 10.1016/j.jamcollsurg.2012.10.017.
    1. Rourke C, Curry N, Khan S, Taylor R, Raza I, Davenport R, et al. Fibrinogen levels during trauma hemorrhage, response to replacement therapy, and association with patient outcomes. J Thromb Haemost. 2012;10(7):1342–1351. doi: 10.1111/j.1538-7836.2012.04752.x.
    1. Morrison JJ, Ross JD, Dubose JJ, Jansen JO, Midwinter MJ, Rasmussen TE. Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury: findings from the MATTERs II Study. JAMA Surg. 2013;148(3):218–225. doi: 10.1001/jamasurg.2013.764.
    1. Innerhofer P, Westermann I, Tauber H, Breitkopf R, Fries D, Kastenberger T, et al. The exclusive use of coagulation factor concentrates enables reversal of coagulopathy and decreases transfusion rates in patients with major blunt trauma. Injury. 2013;44(2):209–216. doi: 10.1016/j.injury.2012.08.047.
    1. Marsden M, Benger J, Brohi K, Curry N, Foley C, Green L, et al. Coagulopathy, cryoprecipitate and cryostat-2: realising the potential of a nationwide trauma system for a national clinical trial. Br J Anaesth. 2019;122(2):164–169. doi: 10.1016/j.bja.2018.10.055.
    1. Novak A, Stanworth SJ, Curry N. Do we still need cryoprecipitate? Cryoprecipitate and fibrinogen concentrate as treatments for major hemorrhage - how do they compare? Expert Rev Hematol. 2018;11(5):351–360. doi: 10.1080/17474086.2018.1458610.
    1. Nicola Curry CR, Ross Davenport, Simon Stanworth, Karim Brohi. Fibrinogen replacement in trauma haemorrhage. London Trauma Conference 2013. 2013.
    1. Whyte CS, Rastogi A, Ferguson E, Donnarumma M, Mutch NJ. The efficacy of fibrinogen concentrates in relation to cryoprecipitate in restoring clot integrity and stability against lysis. Int J Mol Sci. 2022;23(6):2944. doi: 10.3390/ijms23062944.
    1. Neisser-Svae A, Hegener O, Gorlinger K. Differences in the biochemical composition of three plasma derived human fibrinogen concentrates. Thromb Res. 2021;205:44–46. doi: 10.1016/j.thromres.2021.06.020.
    1. Winearls J, Wullschleger M, Wake E, Hurn C, Furyk J, Ryan G, et al. Fibrinogen early in severe trauma study (FEISTY): study protocol for a randomised controlled trial. Trials. 2017;18(1):241. doi: 10.1186/s13063-017-1980-x.
    1. Winearls J, Wullschleger M, Wake E, McQuilten Z, Reade M, Hurn C, et al. Fibrinogen early in severe trauma study (FEISTY): results from an Australian multicentre randomised controlled pilot trial. Crit Care Resusc. 2021;23(1):32–46.
    1. Morrow GB, Carlier MSA, Dasgupta S, Craigen FB, Mutch NJ, Curry N. Fibrinogen replacement therapy for traumatic coagulopathy: does the fibrinogen source matter? Int J Mol Sci. 2021;22(4):2185. doi: 10.3390/ijms22042185.
    1. Longstaff C. Development of shiny app tools to simplify and standardize the analysis of hemostasis assay data communication from the SSC of the ISTH. J Thromb Haemost. 2017;15(5):1044–6. doi: 10.1111/jth.13656.
    1. Coppinger J, Fitzgerald DJ, Maguire PB. Isolation of the platelet releasate. Methods Mol Biol. 2007;357:307–311.
    1. Booth NA, Simpson AJ, Croll A, Bennett B, MacGregor IR. Plasminogen activator inhibitor (PAI-1) in plasma and platelets. Br J Haematol. 1988;70(3):327–333. doi: 10.1111/j.1365-2141.1988.tb02490.x.
    1. Duval C, Baranauskas A, Feller T, Ali M, Cheah LT, Yuldasheva NY, et al. Elimination of fibrin gamma-chain cross-linking by FXIIIa increases pulmonary embolism arising from murine inferior vena cava thrombi. Proc Natl Acad Sci USA. 2021 doi: 10.1073/pnas.2103226118.
    1. Blomback B, Hogg DH, Gardlund B, Hessel B, Kudryk B. Fibrinogen and fibrin formation. Thromb Res. 1976;8(2 suppl):329–346. doi: 10.1016/0049-3848(76)90075-X.
    1. Rahe-Meyer N, Sorensen B. For: Fibrinogen concentrate for management of bleeding. J Thromb Haemost. 2011;9(1):1–5. doi: 10.1111/j.1538-7836.2010.04099.x.
    1. Martini WZ, Holcomb JB. Acidosis and coagulopathy: the differential effects on fibrinogen synthesis and breakdown in pigs. Ann Surg. 2007;246(5):831–835. doi: 10.1097/SLA.0b013e3180cc2e94.
    1. Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernandez-Mondejar E, et al. Management of bleeding following major trauma: an updated European guideline. Crit Care. 2010;14(2):R52. doi: 10.1186/cc8943.
    1. Chowdary P, Saayman AG, Paulus U, Findlay GP, Collins PW. Efficacy of standard dose and 30 ml/kg fresh frozen plasma in correcting laboratory parameters of haemostasis in critically ill patients. Br J Haematol. 2004;125(1):69–73. doi: 10.1111/j.1365-2141.2004.04868.x.
    1. Khan S, Davenport R, Raza I, Glasgow S, De'Ath HD, Johansson PI, et al. Damage control resuscitation using blood component therapy in standard doses has a limited effect on coagulopathy during trauma hemorrhage. Intensive Care Med. 2015;41(2):239–247. doi: 10.1007/s00134-014-3584-1.
    1. Callum J, Farkouh ME, Scales DC, Heddle NM, Crowther M, Rao V, et al. Effect of fibrinogen concentrate vs cryoprecipitate on blood component transfusion after cardiac surgery: the fibres randomized clinical trial. JAMA. 2019;322(20):1966–1976. doi: 10.1001/jama.2019.17312.
    1. Collet JP, Park D, Lesty C, Soria J, Soria C, Montalescot G, et al. Influence of fibrin network conformation and fibrin fiber diameter on fibrinolysis speed: dynamic and structural approaches by confocal microscopy. Arterioscler Thromb Vasc Biol. 2000;20(5):1354–1361. doi: 10.1161/01.ATV.20.5.1354.
    1. Weisel JW. The mechanical properties of fibrin for basic scientists and clinicians. Biophys Chem. 2004;112(2–3):267–276. doi: 10.1016/j.bpc.2004.07.029.
    1. Carr ME, Jr, Alving BM. Effect of fibrin structure on plasmin-mediated dissolution of plasma clots. Blood Coagul Fibrinolysis. 1995;6(6):567–573. doi: 10.1097/00001721-199509000-00011.
    1. Longstaff C, Thelwell C, Williams SC, Silva MM, Szabo L, Kolev K. The interplay between tissue plasminogen activator domains and fibrin structures in the regulation of fibrinolysis: kinetic and microscopic studies. Blood. 2011;117(2):661–668. doi: 10.1182/blood-2010-06-290338.
    1. Gabriel DA, Muga K, Boothroyd EM. The effect of fibrin structure on fibrinolysis. J Biol Chem. 1992;267(34):24259–24263. doi: 10.1016/S0021-9258(18)35759-4.
    1. Colle JP, Mishal Z, Lesty C, Mirshahi M, Peyne J, Baumelou A, et al. Abnormal fibrin clot architecture in nephrotic patients is related to hypofibrinolysis: influence of plasma biochemical modifications: a possible mechanism for the high thrombotic tendency? Thromb Haemost. 1999;82(5):1482–1489.
    1. Liu W, Carlisle CR, Sparks EA, Guthold M. The mechanical properties of single fibrin fibers. J Thromb Haemost. 2010;8(5):1030–1036.
    1. Helms CC, Ariëns RA, De Willige SU, Standeven KF, Guthold M. α− α Cross-links increase fibrin fiber elasticity and stiffness. Biophys J. 2012;102(1):168–75. doi: 10.1016/j.bpj.2011.11.4016.
    1. Collet JP, Shuman H, Ledger RE, Lee S, Weisel JW. The elasticity of an individual fibrin fiber in a clot. Proc Natl Acad Sci USA. 2005;102(26):9133–9137. doi: 10.1073/pnas.0504120102.
    1. Schlimp CJ, Cadamuro J, Solomon C, Redl H, Schochl H. The effect of fibrinogen concentrate and factor XIII on thromboelastometry in 33% diluted blood with albumin, gelatine, hydroxyethyl starch or saline in vitro. Blood Transf. 2013;11(4):510–517.
    1. Winstedt D, Thomas OD, Nilsson F, Olanders K, Schott U. Correction of hypothermic and dilutional coagulopathy with concentrates of fibrinogen and factor XIII: an in vitro study with ROTEM. Scand J Trauma Resusc Emerg Med. 2014;22:73. doi: 10.1186/s13049-014-0073-z.
    1. Keeling D, Tait C, Makris M. Guideline on the selection and use of therapeutic products to treat haemophilia and other hereditary bleeding disorders. A United Kingdom haemophilia center doctors' organisation (UKHCDO) guideline approved by the British committee for standards in haematology. Haemophilia. 2008;14(4):671–84. doi: 10.1111/j.1365-2516.2008.01695.x.

Source: PubMed

Sponsoren und Mitarbeiter

Krankheiten

Drogeninterventionen

3
Abonnieren