Module 1.

3 FIBRINOLYSIS

FIBRINOLYSIS - process of breaking down fibrin clot to hydrolysis of fibrin. It starts few hours
after fibrin polymerization cross linkage.
- Another name: THROMBOLYSIS

*FDP and D-dimer, these are the degradation product.

*Nganung naay fibrinolysis? What’s the purpose? – If you leave the (thrombolysis) clot,
magkadako ang fibrin clot.
*What will happen?
- it will press on the local structures there.
- mu occlude dayon ang vessel. Wala nay proper blood flow. Naay occlusion sa vessel pwede
ang patient maka heart attack.
*Which enzyme breakdown the clot?- PLASMIN
*Kung ma break na ni plasmin, then what? – the clot is broken down into fragments
*Kung ma break down na ang clot then naay fragments, unsay sunod? – kanang mga fragments
gina cleared na siya sa sewage system sa body.
*Unsa nga mga organ ang naa sa sewage system? – LIVER and KIDNEY

COMPONENTS
 Plasminogen – stored and transported in eosinophils.
*normally present in plasma. It also sensitize in the liver.
- Zymogen for plasmin
*Zymogen – precursor
 *Plasminogen is increase in inflammation
*Incorporated in blood clot during its formation. Si TPA (TISSUE PLASMINOGEN
ACTIVATOR) and muadd ana niya. Si TPA normally present in our endothelial cells. Kung
ma add si TPA niya, mahimo siyang PLASMIN.

 Plasmin
- Active enzyme for fibrinolysis
- Degrades proteins susceptible to degradation
- Relevant hemostatic target: FIBRIN, FIBRINOGEN, FACTOR V, and FACTOR
VIII
*It also digests FACTOR II and FACTOR XII.
*Nganung daghan ma na degrade si plasmin? – si plasmin iyang idigest si fibrinogen (for what
reason), becuz ug iya rapod biyaan tung uban (fibrinogen), mahimo tung fibrin kay gina convert
man to ni thrombin, naa may thrombin nabilin didto, iyaha rapod ipolymerize together para
mahimong fibrin. Then anf fibrin mag cross link napod. Naa napod siya didto, maghimo napod
siyag STABILIZE CLOT didto. Iyaha napod idigest si fibrinogen.
*Nganung idigest man niya si FACTOR V and FACTOR VIII? – Plasmin will digest your
coagulation factors to prevent new clot formation.

 Tissue Plasminogen Activator (TPA)

- Other name: STREPTOKINASE
*Group B (Beta Hemolytic Streptococci) – the name itself streptokinase, naay ingani nga
enzyme and inyoang beta hemolytic streptococci.
- Produced by endothelial cells
- Activates plasminogen

 Urokinase Plasminogen Activator

- Secreted by EPITHELIAL CELLS, MONOCYTES, and MACROPHAGES
- Circulates with little activity
- Digest extracellular matrix.

 Streptokinase
- Causes conformational change to plasminogen when bound.
*Mubound man si TPA ni plasminogen. So siya ang mahimong conformational change para
mahimong plasmin.
- Not localized to fibrin
*Becuz streptokinase is from your GROUP B STREPTOCOCCI. Dili siya localized ni fibrin.

 Staphylokinase
- Fibrin required for activation of plasminogen
*Staphylokinase from the name itself comes from staphylococci

OUTCOMES (MAO NI ANG RESULTS SA FIBRINOLYSIS)

 Fibrin Degradation Products (FDP)
- Fragment X
- Fragment Y, D, E

 D-dimers
- Indicative of clot formation
*Usa siya sa product after your fibrinolysis, and it will indicate if naay clot formation nahitabo sa
patient. Dili siya and mudigest sa clot.

*Thrombomodulin + thrombin, mubound si thrombin ni thrombomodulin maactivate si protein

C. Pag activate ni protein C w/ the help of protein S. kinza gani tung gina depende ni protein C,
we have the FACTOR 5 and FACTOR 8. Ma inactivate pod and TPA inhibitor. Kani si TPA naa
pod ga inhibit ani niya. Maactivate si protein C, ang iyang role dili lang and pag inactivate sa F5
and F8, iyaha pod ge inactivate ang inhibitor ni TPA. And result, active naman si TPA, muadto
na siya ni plasminogen, dayon pag magbound na si plasminogen ug ang TPA, mahimo ng
plasmin. Pag naa na si plasmin, ma digest na ang clot. Plasmin dayon lyses of clot (fibrin).
*W/ yout TPA, naa mana siyay mga inhibitor, naay gapugong ana niya nga inhibitor, we have
PLASMINOGEN ACTIVATOR INHIBITOR 1 and 2 (PAI-1 and PAI-2). Plasminogen to
plasmin w/ the help of TPA. Also not only TPA, we have FACTOR IIa, FACTOR XIIa,
KALLIKREIN, it will help the plasminogen to be converted into plasmin. (kanang mga red
arrow) that will be your inhibitor. Naay mga inhibitor si plasmin we have, a2-ANTIPLASMIN
and a2-MACROGLOBULIN. The a2-antiplasmin is the major inhibitor of fibrinolysis. This will
be the first one that will bind to plasmin. The a2-macroglobulin will be the second one. The a1-
antitrypsin is the last major naturally occurring defense against plasmin. Plasmin will lyse the
clot / dissolved, naa tay mga fibrin degradation products.

*The process of fibrin degradation products, we have fibrin polymer strand, it will clean at the
alpha chain, cross links. Mahimong YY/DXD complex, mao ni ilang ge deeper (?) view sa ilang
degradation products geunsa iyang porma. The first product, we have YY/DXD complex mao
nay ma form sa una tapos ma cleave napod na siya. Naa napod tay DED complex plus your
DY/YD complex mufragment napod na siya.
INHIBITORS
 Plasminogen Activator Inhibitors (PAI)
a.) PAI-1: inhibits TPA, scUPA, and uPA
b.) PAI-2: located in placenta and macrophages, inhibits TPA and uPA(urokinase
plasminogen activator)

 Thrombin-activatable Fibrinolysis Inhibitor (TFPI)

- Inhibits binding and activation of plasminogen
*harangan niyas plasmin nga makaabot sa plasminogen para di maka bind.

 A2-Antiplasmin
- Major inhibitor. First will bind to plasmin
- Inhibitors of circulating plasmin
- Inhibitors the clot-promoting activities pf plasma kallikrein
- Inhibits the serine proteases XIIa, XIa, IIa, and Xa.

 A2-Macroglobulin
- Second to bind to plasmin
- Inhibits component in both the fibrinolysis and coagulation systems
- Inhibits plasmin after 2 anti-plasmindepletion
*Nganung second siya? – usahay raman gud siya muinhibit if mahurot na si a2-antiplasmin, na
deplet na siya. After sa depletion, ayha pa pod muinhibit si a2-marcoglobulin.

 A1-Antitrypsin
- Last major / last weapon
- Inhibits Xia and inactivates plasmin

EXTRINSIC ACTIVATION
- Organ tissues
a. Myocardium
b. Prostate
c. Uterus
INTRINSIC ACTIVATION
- HMW Kininogen
- Kallikrein
- Factor XIIa
- Plasma proactivator

SECRETIONS
- Urine (Urokinase)
- Tears
- Saliva
- Semen
- Milk

Plasminogen – plasma serine protease, plasmin digests fibrin/fibrinogen

Tissue Plasminogen Activator – serine protease secreted by activated endothelium, activates
plasminogen
Urokinase – serine protease secreted by kidney, activates plasminogen
Plasminogen Activator Inhibitor-I – secreted by endothelium, inhibits tissue plasminogen
activator
A2-antiplasmin – inhibits plasmin
Thrombin-activatable Fibrinolysis Inhibitor – suppresses fibrinolysis by removing fibrin C-
terminal lysine binding site.

LABORATORY DIAGNOSIS
 Whole Blood Clot Lysis Time (WBCLT)
- Clot should remain intact for approximately 48hrs at 37 degree C.

 Protamine Sulfate Dilution Test

- Detects the presence of fibrin monomers in the plasma.
*If protamine sulfate is added to the plasma, it displace (?) secondary degradation products from
fibrin monomers and primary FDP which will then polymerize spontaneously.
  Ethanol Gelation Time Test
- Determination of the lysis products in the fibrinolysis
- Less sensitive compared to protamine sulfate dilution test but more specific
*In a presence of 50% solution of ethanol, any soluble fibrin monomer complexes present will
dissolve resulting inploymerization of the monomers and subsequently gel formation. So likely,
and inproduct of ethyl gelation time test from name itself gelation is gel formation.

 Latex D-dimer Assay

- Latex: mouse anti-human D-dimer
- Normal value: 200 ng/L
*The latex particle gina coated ni siyag antibody against FDP D and E/ human fibrinogen are
mixed with patient’s serum. And result ani, macroscopic agglutination of latex particles. If naay
macroscopic agglutination sa latex particles, it will indicate the presence of FDP.

Normal value of Fibrinogen: 200-400 mg/dL

 Euglobulin Lysis Time

- Screening procedure for the measurement of fibrinolytic activity.
Procedure:
- Plasma + water > acidified = euglobulin (thrombin)
- Time for complete lysis: >2hrs
- Normal Value: Lysis should be observed greater than 2 hrs
*If wala kaabot ug 2hrs then na lysed na siya, meaning walay fibrinolytic activity. Although
naay fibrinolytic activity di lang jud siya increased.
*If increased fibrinolytic activity, naay problem ang patient.
* This is not detects FDPs
*Your euglobulin are proteins
*When plasma is diluted/added w/ water and acidified. Your euglobulin will formed when
plasma diluted w/ water then gina acidified.
*The time need for complete lysis at 37 degree C is your euglobulin lysis time.
*Lysis less than 2hrs, increased fibrinolytic activity meaning naay problem.
ADDITIONAL INFORMATION:
Fibrin Degradation Products (FDP)
- Water soluble
- It can be excreted by the kidney
*Unsay role sa FDP? – FDP is the substance that remain in our bloodstream after the body
dissolves the clot. This is commonly used to detect the DIC (Disseminated Intravascular
Coagulation).
*Your NORMAL VALUE should not be more than 10 mg/L.
*Clot is degraded by plasmin, plasmin converts fibrinogen into initially X component (your
FDP) mag una si X component. Kaning si X component cleave into Y and B. Ang component Y
cleave into D and E component. Your component B is also called D-dimer.
*X and Y is the EARLY DEGRADATION PRODUCT
*D and E is the LATE DEGRADATION PRODUCT
*Pathologic effect(?):
- X and Y it has ANTICOAGULANT ACTIVITY
- Y and B inhibit FIBRIN POLYMERIZATION
- E is the POWERFUL INHIBITOR of thrombin
*Para wala nay mahimong fibrin clot (fibrinogen to fibrin)

ADDITIONAL NOTES:
Fibrinolysis (2 types)
- Primary Fibrinolysis
- Secondary Fibrinolysis
PRIMARY FIBRINOLYSIS
What will happen:
- Degradation of fibrinogen
- NO FORMATION of fibrin monomer, fibrin polymer, and D-dimer.
- NEGATIVE protamine sulfate test (test of fibrinolysis)
- EXCESSIVE AMOUNT of plasminogen activators from damaged cells
- Converts PLASMINOGEN TO PLASMIN in the absence of fibrin formation.
SECONDARY FIBRINOLYSIS
What will happen:
- Degradation of fibrin
- WITH fibrin monomer, fibrin polymer, and D-dimer
- POSITIVE protamine sulfate test
- DIC (Disseminated Intravascular Coagulation)
*Uncontrolled inappropriate formation of fibrin within the blood vessels, there is
a mass of consumption of platelets. (ubos iyang platelets ani nga sakit)

- There is infection
- Neoplasm
- Can have snake bite
- Hemolytic Transfusion Reaction

Fibrinolysis
- It is normal body process
- Prevents blood clots that occur naturally from growing and causing problems.
*We do not want our platelet play grow and grow cuz that will disturb all the local sites of our
body. Eventually, it will lead to occlusion. Sometimes it will lead to heart attack.

Primary Fibrinolysis
- Refers to the NORMAL BREAKDOWN OF CLOTS.
*That is why, you don’t have D-dimer in the P.F., it is negative in protamine
sulfate test.

Secondary Fibrinolysis
- Refers to the BREAKDOWN OF BLOOD CLOTS due to the medical disorder,
medicine, or other causes.
*This may cause SEVERE BLEEDING
 MODULE 1.4 LABORATORY DIAGNOSIS
Secondary Hemostasis
*Clotting time- most oldest test in the lab.
- we cannot determine a particular clotting factor deficiency.
- it measures the time only.

PROTHROMBIN TIME (PT)

- Assess EXTRINSIC and COMMON pathway.
- Specimen requirement: CITRATED PLATELET POOR PLASMA for 15 mins at
2,500x and process with 24 hrs.
- Reagent: SIMPLASTIN = THROMBOPLASTIN + CACL
- Uses: to monitor patients in WARFARIN THERAPHY and to detect coagulation
factor deficiency.
- Reference range: 10-13 secs *pwede pod 10-12 secs
*There are lots of variations, for ex. You have this in your PT, it said the citrated for plasma for
15mins at 2,500x. Other books, it stated that 2,000x for 10mins lang.
- Epoxide reductase (VKORC1)
- International Normalized Ratio (INR)
*Preferred reporting sa PT
*It is developed to help standardized the difference in sensitivity individual thromboplastin
reagent and the effect of your PT assays.
Formula:
INR=¿) ^ISI

ISI (INTERNATIONAL SENSITIVITY INDEX)

- This is assay manufacturers after comparing each batch of reagent to a working
reference.
- Found in PT reagent bottle assigned by the manufacturers
*Unsay may gamit sa ISI? – more sensitive the thromboplastin reagent, the longer the PT.
*This manufacturer give this ISI, so they have this reagent. Ang ilang gebasihan ani nga
effectiveness of your reagent. THE MORE SENSITIVE THE REAGENT, THE LONGER PT
RESULTS and THE LESS SENSITIVE THE RESGENT, THE SHORTER PT RESULTS.
- Range: 2.0-3.0
- More sensitive thromboplastin has <1.0 and less sensitive reagents have an index of >1.0.

ACTIVATED PARTIAL THROMBOPLASTIN TIME (APTT)

- Asses the INTRINSIC and COMMON pathway.
- Specimen requirement: CITRATED PLATELET POOR PLASMA for 15mins at
2,500xg and process within 4hrs.
- Reagent: PHOSPOLIPID (platelet substitute) and CACL
- Activators: SILICA, KAOLIN, CELITE, BENTONITE, ELLAGIC ACID
- Uses: to monitor patient in HEPARIN THERAPHY and to detect coagulation
factor deficiency.
- Reference range: 35-45 sec (book: 25-35 sec)

Therapeutic Anticoagulants
 Oral Anticoagulant (Coumarin drug)
- WARFARIN = inhibit synthesis of clotting factors II, VII, IX, X (Vit. K
dependent coagulation factor)
*ginatumar through mouth

 Intravenous Anticoagulant
- Heparin = most commonly used
*ge inject ra

STYPVEN TIME (RUSSEL VIPER VENOM TIME)

- Other name: BR VVT dilute Russel Viper Venom Test
- Determines the problem in COMMON pathway.
- Used snake venom (Vipera Russeli)
- Reagent: PLATELIN + CHLORIDE
- Specimen: Platelet poor plasma
- Normal value: 6-10 sec
*Snake is the instrument of medicine
 >> worm not snake

Dracunculus Medinensis- fiery serpent of the Israelites

*Venom – comes from the snake DABOIRA RUSSELI / EAST INDIAN VIPER / VIPERA
RUSSELI
*Stypven time (Russeli Viper)- it is to detect your lupus(?) anticoagulant and used to detect
ANTI-B2-GLYCOPROTEIN.

THROMBIN TIME (TT)

*(?) fibrinogen to fibrin monomer subsequent polymerization to form insoluble clot.
Normal Value of Fibrinogen: 200-400 mg/dL
- PROLONGED IN FIBRINOGEN DEFICIENCY, when function of fibrinogen is
impaired, and in the PRESENCE OF FDPs and THROMBOLYTIC AGENTS
such as streptokinase and heparin.
*High concentration of immunoglobulin, ex. Multiple Myeloma
*Important is HEPARIN THERAPHY – prolonged in TT
*It measures the final step of coagulation

- Normal Value: 15-18sec / 10-14 sec *Basta less than 20 sec lang dapat
- Spx: Platelet poor plasma
- Reagent: THROMBIN + CACL
- End point: Clot formation

REPTILASE TIME
- NOT affected by HEPARIN
- Use enzyme found in the venom of BOTHROPS ATROX snake
Bothrops atrox
- It is a snake and thrombin like in nature
*The difference between Thrombin time and Reptilase time is that Reptilase is not affected by
heparin. But Reptilase has the same function with Thrombin time.

- Normal Value: 10-15sec

- Spx: Platelet poor plasma
- Reagent: ATROXIN
- End point: Clot formation

DUCKERT’S TEST (5M UREA SOLUBILITY TEST)

- Test only for FACTOR XIII (FIBRIN STABILIZING FACTOR)
- Reagent: 5M UREA (1% MONOCHLOROACETIC ACID / 2% ACETIC
ACID)
- Normal Value: Insoluble to urea when incubated for 24hrs.
*Dapat di ma dissolved

ADDITIONAL NOTE:
*If a person is taking a heparin, your reptilase time is NORMAL. But in thrombin time, it is
PROLONGED.
*Your coagulation time cannot tell whether the problem is primary hemostasis or secondary
hemostasis unlike PT/APTT
*Unsay another factor to consider? – BLOOD TRANSFUSION