Leiderman, K. | bioRxiv Science

bioRxiv2022

Low normal factor V enhances thrombin generation in hemophilia A through a substrate competition mechanism with factor Xa

Bleeding patterns in people with hemophilia A cannot be predicted solely by factor VIII (FVIII) levels. Some of the variance in bleeding may be attributed to differences in plasma protein composition, and specifically other coagulation factors where the normal ranges span 50-150% of the population mean. We recently used a mathematical model of thrombus formation that identified factor V (FV) levels as a strong modifier of thrombin generation in FVIII deficiencies. Counterintuitively, the model predicted low normal FV levels enhanced thrombin generation. Here, we tested this prediction and investigated its mechanism. Thrombin generation in plasma from people with FVIII deficiencies (<5%) were negatively correlated with FV levels. A substrate competition mechanism wherein FV and FVIII compete for activation by FXa during the initiation of coagulation was tested in three models: In a purified system containing only FV, FVIII, and FXa, reducing FV enhanced FVIII activation. In synthetic plasma containing the essential proteins of the extrinsic coagulation pathway, low normal FV levels resulted in enhanced thrombin generation both in the presence or absence of TFPI. In mixture studies using FVIII-deficient human plasma immunodepleted of FV, thrombin generation was enhanced at lower levels of FV. In all models the trend was nonlinear as the effect size was significant at low, but not high, FV levels. Our data show that low normal plasma levels of FV enhance thrombin generation in hemophilia A by reducing FXa substrate competition for FVIII activation and implicate FV levels as a strong modifier of bleeding in hemophilia A. Key PointsO_LILow normal levels of FV enhance thrombin generation in hemophilia A by reducing substate competition for FVIII activation. C_LIO_LIPlasma FV levels are a strong modifier of bleeding in hemophilia A. C_LI

biochemistry↗

bioRxiv2018

A mathematical model of flow-mediated coagulation identifies factor V as a modifier of thrombin generation in hemophilia A

Hemophilia A is a bleeding disorder categorized as severe, mild, and moderate deficiencies in factor VIII (FVIII). Within these categories the variance in bleeding severity is significant and the origins unknown. The number of parameters that could modify bleeding are so numerous that experimental approaches are not feasible for considering all possible combinations. Consequently, we turn to a mathematical model of coagulation under flow to act as a screening tool to identify parameters that are most likely to enhance thrombin generation. We performed global sensitivity analysis on 110,000 simulations that varied coagulation factor levels by 50-150% of their normal values in humans while holding FVIII levels at 1%. These simulations identified low factor V (FV) levels as the strongest candidate, with additional enhancement when combined with high prothrombin levels. This prediction was confirmed in two experimental models: Partial FV inhibition boosted fibrin deposition in flow assays performed at 100 1/s on collagen-tissue factor surfaces using whole blood from individuals with mild and moderate FVIII deficiencies. Low FV (~50%) or partial FV inhibition also augmented thrombin generation in FVIII-inhibited or FVIII-deficient plasma in calibrated automated thrombography. These effects were amplified by high prothrombin levels in both experimental models. Our mathematical model suggests a mechanism in which FV and FVIII compete to bind to factor Xa to initiate thrombin generation in low FV, FVIII-deficient blood. This unexpected result was made possible by a mechanistic mathematical model, providing an example of the potential of such models in making predictions in complex biological networks.

systems biology↗