Kaolin, used to trigger coagulation in thrombin generation test, increases sensitivity of the method in hemophilia patients

Thrombin generation test (TGT) is well established tool to research blood coagulation in plasma of hemophilia patients. Traditionally coagulation in this test is triggered by a tissue factor (TF), an extrinsic coagulation pathway activator. However, it is known that disorders of the intrinsic pathway are most important for coagulation in hemophilia. In this study, we hypothesized that triggering coagulation via the intrinsic pathway could increase a sensitivity of the TGT to monitor hemophilia treatment. The aim of this study was to compare thrombin generation in hemophilia A patients with inhibitors to factor VIII before and after infusion of bypassing agent [recombinant-activated factor VIIa (rVIIa)] using standard activation of coagulation by TF or by kaolin, an activator of coagulation by intrinsic pathway. Endogenous thrombin potential (ETP) in nine patients was measured. ETP before (ETP0) and 60 min after rVIIa infusion (ETP60) were compared. It was shown that ETP(0)and ETP(60)were significantly different when using any coagulation activator (paired Student'sttest,P = 0.017 and 3.7 x 10(-5)for clotting activation by TF and kaolin, respectively). The ratios of ETP60/ETP(0)were 1.2 +/- 0.2 or 30.0 +/- 22.4 (mean +/- SD,n = 9) for coagulation activated by TF or kaolin, respectively, and were significantly different (paired Student'sttest,P < 0.005). The TGT clearly distinguished between ETP(0)and ETP(60)in the case of any coagulation activator, but ETP increasing after rVIIa infusion was significantly higher when activated with kaolin. This provided increased sensitivity of this method for monitoring hemophilia therapy.