Blood coagulation

Blood Coagulation

Hemostasis

Blood Coagulation

Blood clotting
The ability of the body to control (stop) the flow of

blood (bleeding) following vascular injury

Is a complex process by which blood forms clots

Blood Coagulation

Hemostasis:
Hemostasis is defined as a property of circulation

whereby blood is maintained within a vessel and the ability of the system to prevent excessive blood loss

when injured.
Hemostasis is composed of 3 major stages that occur

in a set order following the loss of vascular integrity.

Blood Coagulation

Hemostasis (cont.):
DAMAGE TO BLOOD VESSEL leads to:
1.

Vasoconstriction.

2. 3.

The formation of platelet plug. The production of a web of fibrin proteins that penetrates and surrounds the platelet plug.

Blood Coagulation

Steps in Hemostasis
1.

Vascular Constriction: Immediate constriction of blood vessel

Vessel walls pressed together become sticky/adherent to each other

Minimize blood loss

Blood Coagulation

Steps in Hemostasis(Cont.):
2. Platelet Plug formation: PLATELETS attach to exposed collagen with the presence of von Willebrand factor (vWF) and Glycoprotein IbIX Aggregation of platelets causes release of chemical mediators (ADP, Thromboxane A2) ADP attracts more platelets Thromboxane A2 (powerful vasoconstrictor) * promotes aggregation & more ADP Leads to formation of platelet plug!
7 Blood Coagulation

Platelet
In adults, platelets originate in the red bone marrow by

fragmentation

of

the

cytoplasm

of

mature

megakaryocytes(Gr. Megas, big, + karyon, nucleus, + kytos),

which, in turn, arise by differentiation of megakaryoblasts.
Megakaryoblasts.

Megakaryocytes

Platelets.

Platelets are repelled from each in absence of blood vessel

damage.
8 Blood Coagulation

Role of platelets in blood clotting:

Platelets (Thrombocytes) have several functions in blood

clotting:
Form platelet plug at the site of injury Sites of activation of some clotting factors (II, X) Provide the surface on which certain clotting factors bind (Va, Xa, II, Ca2+) Sources of some clotting factors (XIII, PL)
9 Blood Coagulation

Role of platelets in blood clotting (cont....):

If platelets are not lysed, blood does not clot
Individuals with thrombocytopenia (low platelets), bleeding

for a long time

Platelets deficiency can be due to many agents

(drugs, some infections, ionizing radiation)

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Blood Coagulation

Simplified diagram to illustrate platelet production from Megalocytes.

11 Blood Coagulation

Hemostasis: Vasoconstriction & Plug Formation

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Blood Coagulation

Platelets adhesion

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Blood Coagulation

Steps in Hemostasis (cont)

3- Blood Coagulation (clot formation):
Final Step in Hemostasis:
Transformation of blood from liquid to solid Clot reinforces the plug Multiple cascade steps in clot formation Fibrinogen
Thrombin

Fibrin

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Blood Coagulation

Clotting Cascade
A cascade is a mechanism in which enzymes activate other

enzymes sequentially usually leading to an amplification of an initial signal.

Participation of 14 different clotting factors (except for

calcium and thromboplastin, clotting factors are proteins)

These factors circulate as inactive zymogens

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Blood Coagulation

Clotting Cascade (cont)

Factors are designated by a Roman numeral (I, II, III, IV,

V, VI, VII, VIII, X, IX, XI, XII, XIII).

Active forms are usually designated by the letter a after

the Roman numeral and may also have a different name for example: Ia/ Fibrin).
Cofactors are needed for many reactions in the cascade

example: Calcium, platelet factor 3 (PF3).

16 Blood Coagulation

Coagulation Factors (Cont.)

The intrinsic and extrinsic coagulation pathways are a series

of reactions involve coagulation factors known as

1.

Enzyme precursors (zymogens)

2. 3.
4.

Non-enzymatic (cofactors) Calcium (Ca ++) Phospholipids (PL).

All coagulation factors normally are present in the plasma, with

PL being provided by platelets.

17 Blood Coagulation

 Zymogens:
Factors II, VII, IX, X, XI, XII, and prekallikrein NO biologic activity until converted by enzymes to active

enzymes called serine proteases

Cofactors
Factors V, VIII, tissue factor, and HMWK
18 Blood Coagulation

Clotting Cascade (cont)

The last step of the cascade leads to insoluble fibrin as the

end product.
The reactions leading to fibrin formation can be divided into

the extrinsic, intrinsic and common pathways.

Both pathways are initially independent, then they converge

on common pathway leading to the formation of a fibrin

clot !
19 Blood Coagulation

Clotting Cascade

Ca2+
Ca2+ PL

Inactive Active

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Blood Coagulation

CLOT !

Clotting Cascade

A cascade is a mechanism in which enzymes activate other enzymes sequentially usually leading to an amplification of an initial signal.
Each of these pathways leads to the conversion of factor X (inactive) to factor Xa (active)

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Blood Coagulation

Hemostasis: Coagulation & Clot Stabilization

Prothrombin Ca++

Fibrinogen
Fibrin Polymerization

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Blood Coagulation

Intrinsic Pathway:
The formation of clot in response to abnormal vessel wall in

absence of tissue injury is the result of intrinsic pathway

Begins with the activation of factor XII

(Hageman factor)

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Blood Coagulation

Extrinsic Pathway
Fibrin clot formation in response to tissue injury is the

result of extrinsic pathway

Requires tissue factors external to blood: Factor III

(Tissue Thromboplastin) Each of these pathways leads to the conversion of factor X (inactive) to factor Xa (active)

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Blood Coagulation

Intrinsic Clotting Pathway

Under

normal physiological conditions, it is less

significant to hemostasis than extrinsic pathway

Under

abnormal physiology (hyperlipidemic states;

bacterial infiltration) activation of thrombosis via intrinsic clotting cascade

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Blood Coagulation

Intrinsic Clotting Pathway (cont)

The intrinsic pathway requires:
1. 2.

3.
4.

The factors VIII, IX, X, XI, and XII The proteins: Prokallikrein (PK), High MW Kininogen (HK) Calcium ions PLs from platelets

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Blood Coagulation

Intrinsic Clotting Pathway (cont)

Initiation of the intrinsic pathway occurs when Prokallikrein

(PK), high MW Kininogen (HK), factor XI, and factor XII are exposed to a negatively charged surface Contact phase.

Contact phase occurred as result of interaction with: o PLs,

o Circulating lipoprotein particles (VLDL, Chylomicrons) o On the surface of bacteria

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Blood Coagulation

Clotting Cascade

Ca2+
Ca2+ PL

Inactive Active

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Blood Coagulation

CLOT !

Factor III common pathway of blood clottinginjury by trauma The extrinsicapathwayatin the factorthe site and extrinsic final is the site is triggered at VIIa which catalyzed Xa is cofactor which the intrinsic of involves (serious injury or shock to the body), activation ofcascade converge to factor activates factor VII activation of prothrombin into which coagulation factor X (inactive) thrombinXa (active)
and releases a lipoprotein, called tissue factor (Factor III) , from blood vessels

Inactive Active

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Blood Coagulation

CLOT !

Coagulation cascade

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Blood Coagulation

Activation of prothrombin into thrombin

Prothrombin is soluble single chain glycoprotein (72kDa) synthesized

in liver Thrombin is produced by the enzymatic cleavage of two sites on prothrombin by activated Factor X (Xa) and generate active 2 chain thrombin molecule which is then released from platelet surface The A and B chains of thrombin are held together by a dissulfide bond
S S S S

2
Xa

A
Xa

Fragment 2 -1

Active thrombin
(34 kDa)

Fragment 2 -1
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Prethrombin

Prothrombin (72kDa)

Blood Coagulation

Converts fibrinogen to fibrin

Factor Xa

Thrombin in Hemostasis
32 Blood Coagulation

Factor Xa produced by either intrinsic or extrinsic pathway activates prothrombin (factor II) to thrombin (factor IIa) which converts fibrinogen to fibrin

The activation of prothrombin occurs on the surface of activated platelets and requires assembly of prothrombinase complex consisting of platelet anionic PLs, Ca2+, factor Xa and prothrombin

This complex is termed factor Va which is activated by traces of thrombin

Factor Va is subsequently inactivated by further action of thrombin to limit activation of prothrombin to thrombin
Blood Coagulation

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Fibrinogen (Factor I):

Fibrinogen is soluble plasma glycoprotein that consists

of 3 non identical pairs of polypeptides chains (A, B, )2 covalently linked by disulfide bonds.
It has a molecular weight of 340kDa .

Represent the first coagulation factor.

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Blood Coagulation

Conversion of Fibrinogen to Fibrin

The A and B portions of the

A and B chains, termed

Fibrinopeptide A (FPA) and

Fibrinopeptide B (FPB)

Thrombin
Release of FBs by thrombin generate fibrin monomer (weak)

Aggregate spontaneously forming

insoluble fibrin polymer (fibrin clot)
35 Blood Coagulation

(hard, insoluble)

Control of thrombin level:

There are 2 principal mechanisms by which thrombin activity is

regulated:
1. The predominant form of thrombin in circulation is the

inactive prothrombin, whose activation requires the pathways

of proenzyme activation (coagulation cascade) At each step

in the cascade, feed back mechanism regulate the balance between active and inactive enzymes
2. Activation of thrombin is also regulated by 4 specific thrombin

inhibitors (natural inhibitors of blood clotting):

36 Blood Coagulation

Natural inhibitors of blood clotting

1- Antithrombin III
Is the most important one: contributes 75% of antithrombin

activity in plasma

It is a plasma protein that inactivates thrombin by forming an

irreversible complex with it

It resembles 1-antitrypsin except that it inhibits thrombin

much more strongly than it inhibits elastase

namely, factors XIIa, XIa, IXa, and Xa
Blood Coagulation

Also, it blocks other serine proteases in the clotting cascade

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Natural inhibitors of blood clotting (cont)

2.Heparin
The inhibitory action of antithrombin III is enhanced by

heparin
It is a negatively charged polysaccharide found in mast cells

near the walls of blood vessels and on the surfaces of

endothelial cells
Heparin acts as an anticoagulant by increasing the rate of

formation of irreversible complexes between antithrombin III and the serine protease clotting factors
38 Blood Coagulation

Natural inhibitors of blood clotting (cont)

3. Alpha 2-macroglobulins:
Contributes most of the remaining (25%) of antithrombin

activity in plasma 4. Alpha 1-antitrypsin:

Acts as a minor inhibitor under physiological conditions, which

normally inhibits elastase

Alpha 1-Antitrypsin activity normally increases markedly after

injury to counteract excess elastase arising from stimulated

neutrophils
39 Blood Coagulation

Dissolution of fibrin clot : fibrinolysis

(The removal of fibrin from the blood)

Clot is slowly dissolved by the fibrin splitting called Plasmin

Plasmin gets trapped in clot and slowly dissolves it by breaking down the fibrin meshwork at various places,

leading to the production of circulating fragments that are cleaved by other proteases or by the kidney and liver.

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Blood Coagulation

Dissolution of fibrin clot : fibrinolysis (cont)

Plasminogen is the inactive pre-cursor that is activated by

activators in plasma:
1.

Tissue plasminogen activator (t-PA)

2.

Urokinase (to lesser extend)

Is produced as a precursor prourokinase by epithelial cells

Its main action is probably in the degradation of

extracellular matrix
41 Blood Coagulation

Dissolution of fibrin clot : fibrinolysis (cont)

Inactive t-PA is released from vascular endothelial cells following

injury
It binds to fibrin and is consequently activated

Active t-PA converts plasminogen into plasmin

Dissolves the clot

42 Blood Coagulation

Coagulation factor disorders

Inherited bleeding

Acquired bleeding

disorders
Hemophilia A and B Von Willebrand disease

disorders
Liver disease

Other factor deficiencies

Vitamin K deficiency

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Blood Coagulation

Coagulation factor disorders (cont)

1- Hemophilia A and B
Are the best-known coagulation factor disorders
Hemophilia A Coagulation factor deficiency Inheritance Factor VIII X-linked recessive
1/10,000 males

Hemophilia B Factor IX X-linked recessive

1/50,000 males

Incidence

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Blood Coagulation

Coagulation factor disorders (cont)

2- von Willebrand Disease
It is the most common hereditary bleeding disorder and is

characterized as being inherited autosomal recessive or dominant

In this disease there is a defect in von Willebrand factor

(vWF) which:
1.
2.

acts as a carrier for factor VIII mediates the binding of glycoprotein Ib (GPIb) to collagen

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Blood Coagulation

Coagulation factor disorders (cont)

2- von Willebrand Disease
This binding helps the activation of platelets and formation of primary hemostasis

vWD is characterized by excessive bleeding in infants because platelets fail to form hemostatic plug

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Blood Coagulation

3- Deficiency of Vitamin K
Source of vitamin K
Green vegetables Synthesized by intestinal flora

Required for synthesis Causes of deficiency

Factors II, VII, IX ,X contribute to bleeding disorders Malnutrition Biliary obstruction Malabsorption Antibiotic therapy

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Blood Coagulation

Function of Vitamin K
1. Formation of carboxyglutamate
Vitamin K is essential for the functioning of several proteins

involved in blood clotting (II, VII, IX and X)

These proteins contain a unique modified glutamate residue,

called carboxyglutamate (Gla).

These proteins are synthesized as inactive precursors that are

activated by the vitamin K-dependent carboxylase which converts glutamate in these proteins to carboxyglutamate forming mature clotting factors.
48 Blood Coagulation

Function of Vitamin K (cont)

1. Formation of carboxyglutamate (cont)

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Blood Coagulation

Function of Vitamin K (cont)

1. Formation of carboxyglutamate (cont)

(mature)

Dicumarol, Warfarin

(Gla residue)

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Blood Coagulation

Function of Vitamin K (cont)

2. Interaction of prothombin with platelets
The Gla residue of prothrombin is a natural high affinity binder

(chelator) of positively calcium ions, hence the designation of calcium as a co-factor (factor IV) in the schematic.
The prothrombin-calcium complex is then able to bind to PLs

essential for blood clotting on the surface of platelets.

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Blood Coagulation