FIBRINOLYSIS - Because: it stops the activation of plasminogen

to plasmin
Fibrinolysis
 Plasminogen is activated to become the clot-
 Digestion of fibrin clot lysing enzyme PLASMIN
 Keeps the vascular system free of deposited
fibrin/fibrin clot  Plasminogen activators:
 Begins with activation of Plasminogen to  tPA tissue plasminogen activator
PLASMIN
▪ PRINCIPAL PLASMINOGEN
ACTIVATOR

 ScuPA single-chain urokinase

plasminogen activator

 TcuPA – two-chain urokinase

plasminogen activator

*These activators are found in the

Plasminogen endothelium as well as in granulocytes
and monocytes
 A zymogen which is normally present in the
plasma Inhibitors of Fibrinolysis
 Synthesized in the liver - α2 antiplasmin
 Stored and transported in eosinophils o Major inhibitor of fibrinolysis
- α2 macroglobulin
Plasminogen Activators
o Inhibits plasmin and kallikrein
Intrinsic Activators - Thrombospondin
- Plasminogen Inhibitors 1 and 2
- In blood
- Factor XIIa, Kallikrein (binds to HMWK), HMWK Other Inhibitors of Fibrinolysis
Tissue type Plasminogen Activators - α1-antitrypsin
o Inhibits plasmin
- Urokinase –like PA
- Antithrombin (formerly Antithrombin III)
Therapeutic PA o Inhibits plasmin and kallikrein
- C’1-inactivator
- Streptokinase
o Inhibits plasmin
- Urokinase
- Tissue-like PA - manufactured in-vitro by Fibrin(ogen) Degradation by Plasmin
recombinant DNA techniques
 Fragment X and Y are referred to as early
Therapeutic Plasminogen Activators degradation products
 Fragment D and E are late degradation products
1. Urokinase
 Fragment X is the first and the largest fragment
- A protease present in the urine and produced
formed
by the kidney
 Fragment X is the results of Plasmin (P) cleavage
- Advantage over streptokinase - it lacks
of the terminal portion of the alpha (α) chains
antigenicity
from a fibrin polymer
2. Epsilon-aminocaproic acid (EACA)
- Useful in the treatment of primary fibrinolysis

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DISORDERS OF FIBRINOLYSIS intermittently exposed to small
amounts of TF.
Disorders of Primary Fibrinolysis
 Acute/Uncompensated
 Excessive amount of plasminogen activators  Acute DIC develops when
released from malignant or damaged cells sudden exposure of blood to
 Converts plasminogen to plasmin in the procoagulants generates
absence of fibrin formation intravascular coagulation
 Example: Prostatic Carcinoma
DIC | Lab Test
 NO: fibrin polymer, fibrin monomer, D-dimer
CHRONIC/ COMPENSATED
Disorders of Secondary Fibrinolysis
 Decrease liver production of regulatory
 Seen in DIC  inappropriate formation of fibrin
antithrombin, protein C or protein S
within the blood vessels
 Also seen in: Infections, Neoplasms, Snake bite  Only elevated test may be the D-dimer
and HTR assay value
 With: fibrin monomer, fibrin polymer, D-dimer
ACUTE / UNCOMPENSATED
(demonstration of this is the most specific test
for DIC)  PT, PTT, thrombin time: prolonged

DISSEMINATED INTRAVASCULAR  Fibrinogen level : <100 mg/dL

COAGULATION  Fibrin degradation products including D-dimers
are significantly increased
 Defibrination syndrome
 Consumption coagulopathy Laboratory diagnosis

 Presence of schistocytes
- Disorder due to systemic activation of blood
coagulation  Thrombocytopenia
Clinical Manifestations of DIC  Prolonged clotting times (PT, APTT)
DIC | CAUSE  Presence/ prolonged of Fibrin degradation
products and D-dimer
 Sepsis
 Low levels of coagulation inhibitors
 Blood transfusion reaction
 Low levels of coagulation factors
 Cancer, especially acute promyelocytic
leukemia  Fibrinogen levels not useful diagnostically but
low
 Pregnancy complications ( retained placenta )
DIC | TREATMENT & MEDICATION
 Recent surgery or anesthesia
o Anticoagulant agents
 Severe liver disease
o unfractionated heparin therapy,
 Severe tissue injury (as in burns and head
antithrombin III
injury)
o Recombinant human activated protein C
Chronic/Compensated
o Drotrecogin alfa-activated
 A compensated state that develops
when blood is continuously or
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TESTS FOR FIBRINOLYSIS PRINCIPLE:

Tests of Fibrinolysis - Streptokinase-plasminogen complex

- Color intensity is proportional to the
1. Fibrin Degradation Product Immunoassay plasminogen concentration
2. Plasminogen Chromogenic Substrate Assay - **yellow color

3. Tissue Plasminogen Activator Assay Reference interval: 5-13.5 mg/dl

4. Plasminogen Activator Inhibitor 1 Assay DECREASED:

5. Whole Blood Clot Lysis Time  Thrombolytic therapy

 DIC
6. Euglobin Clot Lysis Time Test
 Hepatitis
7. Protamine Sulfate Test  Cancer
 Hereditary deficiencies
8. Ethanol Gelation Test
INCREASED:
9. D-Dimer Immunoassay

1. FIBRIN DEGRADATION PRODUCT IMMUNOASSAY  Inflammation

 Pregnancy
 FDP assay  Hemorrhage
 FDPs may be detected using as semiquantitative  Systemic fibrinolysis
visible agglutination immunoassay

METHOD: 3. TISSUE PLASMINOGEN ACTIVATOR ASSAY

2 Human Plasminogen Activators:
- Thrombo-Wellcotest 1. TPA
o Polysterene latex particles in buffered - In vascular endothelial cells
saline coated with polyclonal Ab specific - 3 minutes half-life
for D and E fragments - Averages 5 ng/ml
o At a concentration of 2 mcg/ml or 2. Urokinase
greater - In kidney and vascular endothelial cells
SPECIMEN - 7 minutes half-life
- 2-4 ng/ml
- Special tubes that promote clotting and prevent
in vitro fibrinolysis PRINCIPLE:
- Plasma based-assays are also available - Enzyme immunoassay
- Plasminogen reagent is added to patient plasma
2. PLASMINOGEN CHROMOGENIC SUBSTRATE ASSAY = plasmin activity is measured using a
 Plasminogen – when bound to fibrin, is chromogenic substrate
converted to plasmin
 Congenital plasminogen deficiency are REFERENCE INTERVAL:
associated with thrombosis - Upper Limit for TPA activity = 1.1 units/ml
 Acquired plasminogen deficiency – seen in DIC - Upper Limit for TPA antigen = 14 ng/ml
and acute promyelocytic leukemia - ** DECREASED TPA level may indicate increased
- Thrombolytic therapy is ineffective when risk of AMI, stroke or deep vein thrombosis
plasminogen activity is low
TPA activity – exhibits diurnal variation
SPECIMEN: PPP
- Unstable in vitro
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SPECIMEN COLLECTION 8. LATEX AGGLUTINATION TEST FOR D-DIMER
- Most specific for DIC
- Patients should be at rest
- Coat on the latex  Anti-D-dimer antibodies
- Tourniquet application should be minimal
- + result: turbidity
- Immediate acidification of the specimen in
o Measured through turbidometric or
acetate buffer is necessary
nephelometric means
- Acidification may be accomplished using a
- Most methods detect at least 10ng/mL of D-
STABILYTE acidified citrate tube
dimer
- Supernatant PPP may be frozen at -70C until
assay is performed
9. D-DIMER TEST
- PAI-1 – produced by vascular endothelial cell
- Thrombin activates the Fibrinolytic system with
and hepatocytes
the production of plasmin at the site of the clot.
 Circulates in plasma bound to vitronectin - Plasmin lyses the fibrin and produces FDP that
contain the portion called D-dimer.
 Average concentration of 10 mcg/L with - Plasmin will also lyse fibrinogen, but will NOT
diurnal variation produce the D-dimer.
- The presence of D-dimer indicates that a stable
 Inactive form are in high concentration
fibrin clot has been lysed.
in platelet
- Found in:
 It inactivates free TPA o Pulmonary embolism-
o Deep vein thrombosis
SPECIMEN: PPP from citrated tube o DIC
4. WHOLE BLOOD CLOT LYSIS TIME o Arterial thromboembolism
 Normal: NO clot lysis w/in 48 hours o Sickle cell disease
- FSP/FDP (+) = DIC or pathological fibrinolysis
 Increased fibrinolysis: clot lysis < 48 hours
- FDP(+), D-dimer (-) = Pathological fibrinolysis
- FDP(+), D-dimer (+) = DIC
5. EUGLOBULIN CLOT LYSIS TIME
 Euglobulin  portion of plasma w/c consist of
plasminogen, plasminogen activators and
fibrinogen
 Procedure:
o Plasma + acetic acid  prec. Euglobulin
o Euglobulin dissolved in buffer +
thrombin  clot euglobulin
 Normal: NO clot lysis after 2 hours
 Increased fibrinolysis: clot lysis in less than 2
hours

6. PROTAMINE SULFATE TEST

- Determines fibrin monomers (Secondary
Fibrinolysis)
- Plasma + protamine sulfate  + gel-like clot

7. ETHANOL GELATION TEST

- Determines fibrin monomers (Secondary
Fibrinolysis)
- Plasma + NaOH + EtOH  + precipitation
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