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Overview of Hemostasis
Hemostasis is a dynamic process whereby blood
coagulation is initiated and terminated in a rapid and
tightly regulated fashion (Nathan, Orkin, Ginsburg, &
Look, 2003). Blood coagulation (the cessation of blood
loss from a damaged vessel) is part of an important host
defense mechanism. Upon vessel injury, platelets adhere
to macromolecules in subendothelial tissues at the site
of injury and then aggregate to form the primary hemostatic plug. Platelets stimulate the local activation of
plasma coagulation factors, which leads to the generation of a fibrin clot that reinforces the platelet aggregate.
Later, as wound healing occurs, the platelet aggregate
and fibrin clot are broken down and removed.
Hemostasis is regulated by 3 basic components
namely, the vascular wall, platelets, and the coagulation
James P. Riddel Jr, MS, RN, CPNP, is a pediatric nurse practitioner and
doctoral student in the Division of Hematology at Childrens Hospital and
Research Center Oakland, Oakland, California. Bradley E. Aouizerat,
PhD, is a basic scientist and professor of genetics in the Department of
Physiological Nursing & Institute for Human Genetics at the University of
California, San Francisco. Christine Miaskowski, PhD, RN, is a nurse scientist and professor of nursing in the Department of Physiological Nursing
at the University of California, San Francisco. David P. Lillicrap, MD,
FRCPC, is a hematologist and professor in the Department of Pathology &
Molecular Medicine at Queens University, Kingston, Ontario, Canada.
Address for correspondence: James P. Riddel Jr, MS, RN, CPNP, Division
of Hematology, Childrens Hospital and Research Center Oakland, 747
52nd Street, Oakland, CA 94609-1809; e-mail: jriddel@mail.cho.org.
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Riddel et al
Thrombokinase*
Calcium
Prothrombin
Thrombin
Fibrinogen
Fibrin
Historical Sketch
Hippocrates, Aristotle, Celsius, and Galen were fully
aware of the fact that freshly drawn blood usually clots
within minutes. They described in detail various internal and superficial bleeding tendencies. A common
observation was that blood congealed on cooling. It was
thought that by leaving a wound in contact with air, the
blood cooled, stopping the hemorrhage. However, they
did not associate blood coagulability with a concept of
hemostasis (Nichols & Bowie, 2001).
Two thousand years later in the early 1720s, French
surgeon Jean-Louis Petit noted that hemostasis after
amputation of a limb was caused by clots forming in
the blood vessels. This observation was the first time
blood clotting was related to hemostasis. In 1828,
Swiss physician Friedrich Hopff (Nichols & Bowie,
2001) noted that the well-known familial bleeding tendency in males was associated with pronounced
hypocoagulability, now recognized as hemophilia, an
X chromosomelinked disorder. Therefore, coagulability was essential to prevent bleeding. This recognition of abnormal coagulation and its association with
bleeding led to a rapid increase in research into the
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Intrinsic Pathway
The intrinsic pathway consists of a cascade of protease reactions initiated by factors that are present
within the blood. When in contact with a negatively
charged surface such as glass or the membrane of
an activated platelet, a plasma protein called FXII
(Hageman factor) becomes FXIIa (the suffix a indicates that this is the activated form of FXII). A
molecule called high molecular weight kininogen
(HMWK), a product of platelets that may in fact be
attached to the platelet membrane, helps anchor FXII
to the charged surface and thus serves as a cofactor.
However, this HMWK-assisted conversion of FXII to
FXIIa is limited in speed.
Once a small amount of FXIIa accumulates, this
protease converts prekallikrein to kallikrein, with
HMWK as an anchor. In turn, the newly produced
kallikrein accelerates the conversion of FXII to
FXIIa, an example of positive feedback. In addition
to amplifying its own generation by forming
kallikrein, FXIIa (together with HMWK) proteolytically cleaves FXI, forming FXIa. In turn, FXIa (also
bound to the charged surface by HMWK) proteolytically cleaves FIX to FIXa, which is also a protease.
The extrinsic pathway also includes protein cofactors and enzymes. This pathway is initiated by the formation of a complex between TF on cell surfaces and
FVIIa that is located outside the vascular system.
Nonvascular cells constitutively express the integral
membrane protein TF (variably known as FIII or tissue
thromboplastin), which is a receptor for the plasma
protein FVII (Kumar et al., 2005).
When an injury to the endothelium allows FVII to
come into contact with TF, the TF nonproteolytically
activates FVII to FVIIa. The mechanism of the initial
conversion of the zymogen FVII to FVIIa is still
debated but is most likely due to autocatalytic activation
and not a TF effect (M. Hoffman & Monroe, 2005).
This binding of FVIIa to TF forms an enzyme complex
that activates FX to FXa. The FVIIa/TF complex, similar in function to the tenase complex, converts FX to its
active form (FXa), which binds to the cofactor FV and
is bound on membrane surfaces in the presence of calcium ions to generate the prothrombinase complex. The
prothrombinase complex converts prothrombin to
thrombin, which converts fibrinogen to fibrin to generate the fibrin clot. During laboratory analysis of blood
clotting, the extrinsic pathway of blood coagulation is
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Common Pathway
The common pathway begins with the activation of
FX within the intrinsic pathway, the extrinsic pathway,
or both. FXa from either the intrinsic or extrinsic pathway is the first protease of the common pathway. FXa,
in the presence of FV, Ca2+, and phospholipids,
converts prothrombin to its active form, thrombin
(Harmening, 2002). The main action of thrombin is to
catalyze the proteolysis of the soluble plasma protein
fibrinogen to form fibrin monomers that remain soluble. Fibrin monomers then polymerize to form a gel of
fibrin polymers that trap blood cells. Thrombin also
activates FXIII, which is converted to FXIIIa and
mediates the covalent cross-linking of the fibrin polymers to form a mesh termed stable fibrin, which is less
soluble than fibrin polymers (Boron & Boulpaep,
2005). Thrombin can catalyze the formation of new
thrombin from prothrombin and can catalyze the formation of the cofactors FVa and FVIIIa, resulting in
efficient amplification of coagulation. Because the
common pathway contains the factors FX, FV, and FII
(any deficiency in which may lead to a hemorrhagic
disorder), these factors may be monitored by both the
PT and the PTT (Harmening, 2002).
Although these concepts represented a significant
advance in the understanding of coagulation and
served for many years as a useful model, more recent
clinical and experimental observations demonstrate
that the cascade/waterfall hypothesis does not fully
and completely reflect the events of hemostasis in
vivo (M. Hoffman & Monroe, 2001). In recent years,
deficiencies of this scheme have become apparent.
First, no explanation existed for the absence of a clinical bleeding tendency in deficiencies of FXII,
prekallikrein, or high molecular weight kininogen,
even though deficiencies in any one of these factors
markedly prolong surface-activated coagulation
assays for hemostasis in vitro. Second, no explanation
existed for why FVIII or FIX deficiency caused clinically severe bleeding, even though the extrinsic pathway would be expected to bypass the need for FVIII
and FIX (Hoffbrand et al., 2005).
These key observations led to a revision of earlier
models of coagulation. A vital observation was that a
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Riddel et al
Table 1.
Summary of the 4 Phases of Coagulation, as Proposed by the Current Cell-Based Theory of Coagulation
Process Stages in Hemostasis
Initiation
Vascular endothelium and
circulating blood cells are
perturbed; interaction of
plasma-derived FVIIa with
tissue factor
Amplification
Propagation
Termination
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Amplification Phase
A small amount of thrombin generated on the TFbearing cell has several important functions. A major
function is the activation of platelets, exposing
receptors and binding sites for activated clotting factors. As a result of this activation, the platelets
release partially activated forms of FV onto their surfaces. Another function of the thrombin formed during the initiation phase is the activation of the
cofactors FV and FVIII on the activated platelet surface. In this process, the FVIII/VWF complex is dissociated, permitting VWF to mediate additional
platelet adhesion and aggregation at the site of
injury. In addition, small amounts of thrombin activate FXI and FXIa on the platelet surface during this
phase (Loscalzo, 2003; Oliver, Monroe, Roberts, &
Hoffman, 1999).
Propagation Phase
As large numbers of platelets are recruited to the
site of injury, the propagation phase of clot formation occurs on the surface of activated platelets.
First, FIXa activated during the initiation phase
can now bind to FVIIIa on the platelet surface.
Second, additional FIXa can be supplied by
platelet-bound FXIa. Third, because FXa cannot
move effectively from the TF-bearing cell to the
activated platelet, FXa must be provided directly
on the platelet surface by the FIXa/FVIIIa complex. Fourth, the FXa rapidly associates with FVa
bound to the platelet during the amplification
phase. Finally, the completion of this platelet
prothrombinase assembly leads to a burst of thrombin generation of sufficient magnitude to clot fibrinogen (Dahback, 2005; M. Hoffman, 2004;
Loscalzo, 2003).
Termination Phase
Once a fibrin platelet clot is formed over an area
of injury, the clotting process must be limited to
avoid thrombotic occlusion in surrounding normal
areas of the vasculature. Unless controlled, clotting
could propagate throughout the entire vascular tree
(M. Hoffman, 2004).
Three types of natural anticoagulants regulate clotting: antithrombin (ATIII) inhibits the activity of thrombin and other serine proteases, such as FIXa, FXa,
FXIa, and FXIIa. Binding to heparin-like molecules on
endothelial cells activates antithrombin. Proteins C and
S are characterized by their ability to inactivate the procoagulant cofactors FVa and FVIIIa. Protein C is a vitamin Kdependent plasma glycoprotein that, when
activated, functions as an anticoagulant by inactivating
FVa and FVIIIa. Protein C activity is enhanced by
another vitamin Kdependent inhibitory cofactor, protein S. Protein S functions as a cofactor to protein C by
enhancing its activity against FVa and FVIIIa (Hoppe &
Matsunaga, 2002). In addition, TF pathway inhibitor
(TFPI), a protein secreted by endothelium, complexes
to FXa and to TF/FVIIa, inactivating them to rapidly
limit coagulation (Kumar et al., 2005). Protein C is activated by thrombin that is bound to the transmembrane
protein thrombomodulin (TM) on the surface of intact
endothelial cells. In human plasma, about 30% of protein S circulates as free protein; the remainder is bound
to the complement regulatory protein C4b-binding protein. Only the free form of protein S functions as a
cofactor to activated protein C (Dahback, 2005).
Platelet-Protein Interactions
As previously discussed, primary hemostasis is triggered in response to the damage of the vascular wall
and the exposure of blood to subendothelial tissue.
Several coordinated interactions among tissue components, plasma proteins, and receptors on platelets lead
to the initial sealing of the damaged vessel wall.
Platelets are specialized blood cells that play a central role in the physiologic processes of hemostasis.
The formation of the primary platelet plug is temporally and spatially coordinated with the activation of
the blood coagulation system. Through the process of
adhesion and aggregation, mediated by VWF and fibrinogen, the platelets form an occlusive plug or clot.
Upon damage to the vascular wall, platelets undergo
a series of events such as adhesion, aggregation, release
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