Thrombin Generation Assays: What are the Current Clinical Applications?

Abstract

The thrombin generation assay (TGA), originally developed by McFarlane and Biggs in 1956, was modified in the 2000s by Hemker and coworkers. TGA aims to monitor the continuous generation of thrombin upon activation of coagulation in plasma by the addition of such triggers as small amounts of tissue factor, synthetic phospholipids, and calcium chloride. TGA is sensitive to hypo- and hypercoagulability and is affected by prohemostatic as well as antithrombotic drugs. The review of the current literature shows that TGA is mainly used to investigate conditions characterized by hypo- as well as hypercoagulability and as a laboratory tool to elucidate coagulation mechanisms that are not yet completely understood. This article aims to overview the value and limits of current procedures for TGA for the investigation of hemostasis.

Keywords

hypocoagulability - hypercoagulability - hemorrhage - thrombosis - cirrhosis - hemophilia

Publication History

Article published online:
07 April 2025

• References

• 1 MacFarlane RG, Biggs R. A thrombin generation test; the application in haemophilia and thrombocytopenia. J Clin Pathol 1953; 6 (01) 3-8
• 2 Hemker HC, Willems GM, Béguin S. A computer assisted method to obtain the prothrombin activation velocity in whole plasma independent of thrombin decay processes. Thromb Haemost 1986; 56 (01) 9-17
• 3 Hemker HC, Wielders S, Kessels H, Béguin S. Continuous registration of thrombin generation in plasma, its use for the determination of the thrombin potential. Thromb Haemost 1993; 70 (04) 617-624
• 4 Hemker HC, Giesen PL, Ramjee M, Wagenvoord R, Béguin S. The thrombogram: monitoring thrombin generation in platelet-rich plasma. Thromb Haemost 2000; 83 (04) 589-591
• 5 Chantarangkul V, Clerici M, Bressi C, Giesen PL, Tripodi A. Thrombin generation assessed as endogenous thrombin potential in patients with hyper- or hypo-coagulability. Haematologica 2003; 88 (05) 547-554
• 6 Ninivaggi M, de Laat-Kremers R, Tripodi A. et al. Recommendations for the measurement of thrombin generation: Communication from the ISTH SSC Subcommittee on Lupus Anticoagulant/Antiphospholipid Antibodies. J Thromb Haemost 2021; 19 (05) 1372-1378
• 7 van Paridon PCS, Panova-Noeva M, van Oerle R. et al. Thrombin generation in cardiovascular disease and mortality - results from the Gutenberg Health Study. Haematologica 2020; 105 (09) 2327-2334
• 8 Tripodi A, Primignani M, Chantarangkul V. et al. Thrombin generation in patients with cirrhosis: the role of platelets. Hepatology 2006; 44 (02) 440-445
• 9 Tripodi A. Detection of procoagulant imbalance. Modified endogenous thrombin potential with results expressed as ratio of values with-to-without thrombomodulin. Thromb Haemost 2017; 117 (05) 830-836
• 10 Antovic JP, Mikovic D, Elezovic I. et al. Two global haemostatic assays as additional tools to monitor treatment in cases of haemophilia A. Thromb Haemost 2012; 108 (01) 21-31
• 11 Tran HTT, Sørensen B, Bjørnsen S, Pripp AH, Tjønnfjord GE, Andre Holme P. Monitoring bypassing agent therapy - a prospective crossover study comparing thromboelastometry and thrombin generation assay. Haemophilia 2015; 21 (02) 275-283
• 12 Dargaud Y, Lienhart A, Negrier C. Prospective assessment of thrombin generation test for dose monitoring of bypassing therapy in hemophilia patients with inhibitors undergoing elective surgery. Blood 2010; 116 (25) 5734-5737
• 13 Mancuso ME, Chantarangkul V, Clerici M. et al. Low thrombin generation during major orthopaedic surgery fails to predict the bleeding risk in inhibitor patients treated with bypassing agents. Haemophilia 2016; 22 (04) e292-e300
• 14 Santagostino E, Mancuso ME, Tripodi A. et al. Severe hemophilia with mild bleeding phenotype: molecular characterization and global coagulation profile. J Thromb Haemost 2010; 8 (04) 737-743
• 15 Oldenburg J, Mahlangu JN, Kim B. et al. Emicizumab prophylaxis in hemophilia A with inhibitors. N Engl J Med 2017; 377 (09) 809-818
• 16 Mahlangu J, Oldenburg J, Paz-Priel I. et al. Emicizumab prophylaxis in patients who have hemophilia A without inhibitors. N Engl J Med 2018; 379 (09) 811-822
• 17 Tripodi A, Chantarangkul V, Novembrino C, Peyvandi F. Advances in the treatment of hemophilia: Implications for laboratory testing. Clin Chem 2019; 65 (02) 254-262
• 18 Tripodi A, Chantarangkul V, Novembrino C. et al. Emicizumab, the factor VIII mimetic bi-specific monoclonal antibody and its measurement in plasma. Clin Chem Lab Med 2020; 59 (02) 365-371
• 19 Arcudi S, Gualtierotti R, Scalambrino E. et al. Predictive parameters for spontaneous joint bleeding during emicizumab prophylaxis. Blood Adv 2024; 8 (11) 2901-2907
• 20 Matsushita T, Shapiro A, Abraham A. et al.; explorer7 Investigators. Phase 3 trial of concizumab in hemophilia with inhibitors. N Engl J Med 2023; 389 (09) 783-794
• 21 Young G, Srivastava A, Kavakli K. et al. Efficacy and safety of fitusiran prophylaxis in people with haemophilia A or haemophilia B with inhibitors (ATLAS-INH): a multicentre, open-label, randomised phase 3 trial. Lancet 2023; 401 (10386): 1427-1437
• 22 Srivastava A, Rangarajan S, Kavakli K. et al. Fitusiran prophylaxis in people with severe haemophilia A or haemophilia B without inhibitors (ATLAS-A/B): a multicentre, open-label, randomised, phase 3 trial. Lancet Haematol 2023; 10 (05) e322-e332
• 23 Tripodi A, Legnani C, Chantarangkul V, Cosmi B, Palareti G, Mannucci PM. High thrombin generation measured in the presence of thrombomodulin is associated with an increased risk of recurrent venous thromboembolism. J Thromb Haemost 2008; 6 (08) 1327-1333
• 24 van Hylckama Vlieg A, Baglin CA, Luddington R, MacDonald S, Rosendaal FR, Baglin TP. The risk of a first and a recurrent venous thrombosis associated with an elevated D-dimer level and an elevated thrombin potential: results of the THE-VTE study. J Thromb Haemost 2015; 13 (09) 1642-1652
• 25 Tripodi A, Primignani M, Badiali S. et al. Body mass index reduction improves the baseline procoagulant imbalance of obese subjects. J Thromb Thrombolysis 2019; 48 (01) 52-60
• 26 Saibeni S, Saladino V, Chantarangkul V. et al. Increased thrombin generation in inflammatory bowel diseases. Thromb Res 2010; 125 (03) 278-282
• 27 Tripodi A, Spina L, Pisani LF. et al. Anti-TNF-α treatment reduces the baseline procoagulant imbalance of patients with inflammatory bowel diseases. Inflamm Bowel Dis 2021; 27 (12) 1901-1908
• 28 Tripodi A, Branchi A, Chantarangkul V. et al. Hypercoagulability in patients with type 2 diabetes mellitus detected by a thrombin generation assay. J Thromb Thrombolysis 2011; 31 (02) 165-172
• 29 Tripodi A, Ammollo CT, Semeraro F. et al. Hypercoagulability in patients with Cushing disease detected by thrombin generation assay is associated with increased levels of neutrophil extracellular trap-related factors. Endocrine 2017; 56 (02) 298-307
• 30 Fuchs TA, Brill A, Duerschmied D. et al. Extracellular DNA traps promote thrombosis. Proc Natl Acad Sci U S A 2010; 107 (36) 15880-15885
• 31 Tripodi A, Rossi SC, Clerici M. et al. Pro-coagulant imbalance in patients with community acquired pneumonia assessed on admission and one month after hospital discharge. Clin Chem Lab Med 2021; 59 (10) 1699-1708
• 32 Curvers J, Thomassen MC, Nicolaes GA. et al. Acquired APC resistance and oral contraceptives: differences between two functional tests. Br J Haematol 1999; 105 (01) 88-94
• 33 Jick H, Jick SS, Gurewich V, Myers MW, Vasilakis C. Risk of idiopathic cardiovascular death and nonfatal venous thromboembolism in women using oral contraceptives with differing progestagen components. Lancet 1995; 346 (8990): 1589-1593
• 34 van Hylckama Vlieg A, Helmerhorst FM, Vandenbroucke JP, Doggen CJ, Rosendaal FR. The venous thrombotic risk of oral contraceptives, effects of oestrogen dose and progestogen type: results of the MEGA case-control study. BMJ 2009; 339: b2921
• 35 Tripodi A, Salerno F, Chantarangkul V. et al. Evidence of normal thrombin generation in cirrhosis despite abnormal conventional coagulation tests. Hepatology 2005; 41 (03) 553-558
• 36 Tripodi A, Caldwell SH, Hoffman M, Trotter JF, Sanyal AJ. Review article: the prothrombin time test as a measure of bleeding risk and prognosis in liver disease. Aliment Pharmacol Ther 2007; 26 (02) 141-148
• 37 Tripodi A, Chantarangkul V, Mannucci PM. Acquired coagulation disorders: revisited using global coagulation/anticoagulation testing. Br J Haematol 2009; 147 (01) 77-82
• 38 Bosch J, Thabut D, Bendtsen F. et al.; European Study Group on rFVIIa in UGI Haemorrhage. Recombinant factor VIIa for upper gastrointestinal bleeding in patients with cirrhosis: a randomized, double-blind trial. Gastroenterology 2004; 127 (04) 1123-1130
• 39 Bosch J, Thabut D, Albillos A. et al.; International Study Group on rFVIIa in UGI Hemorrhage. Recombinant factor VIIa for variceal bleeding in patients with advanced cirrhosis: A randomized, controlled trial. Hepatology 2008; 47 (05) 1604-1614
• 40 Planinsic RM, van der Meer J, Testa G. et al. Safety and efficacy of a single bolus administration of recombinant factor VIIa in liver transplantation due to chronic liver disease. Liver Transpl 2005; 11 (08) 895-900
• 41 Lodge JPA, Jonas S, Oussoultzoglou E. et al. Recombinant coagulation factor VIIa in major liver resection: a randomized, placebo-controlled, double-blind clinical trial. Anesthesiology 2005; 102 (02) 269-275
• 42 Massicotte L, Beaulieu D, Thibeault L. et al. Coagulation defects do not predict blood product requirements during liver transplantation. Transplantation 2008; 85 (07) 956-962
• 43 Lisman T, Bongers TN, Adelmeijer J. et al. Elevated levels of von Willebrand factor in cirrhosis support platelet adhesion despite reduced functional capacity. Hepatology 2006; 44 (01) 53-61
• 44 Tripodi A, Mannucci PM. The coagulopathy of chronic liver disease. N Engl J Med 2011; 365 (02) 147-156
• 45 Northup PG, Garcia-Pagan JC, Garcia-Tsao G. et al. Vascular liver disorders, portal vein thrombosis, and procedural bleeding in patients with liver disease: 2020 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2021; 73 (01) 366-413
• 46 European Association for the Study of the Liver. Electronic address: [e-mail]; Clinical Practice Guideline Panel; Chair: EASL Governing Board representative; Panel members. EASL Clinical Practice Guidelines on non-invasive tests for evaluation of liver disease severity and prognosis—2021 update. J Hepatol 2021; 75: 659-689
• 47 Lisman T, Bakhtiari K, Pereboom IT, Hendriks HG, Meijers JC, Porte RJ. Normal to increased thrombin generation in patients undergoing liver transplantation despite prolonged conventional coagulation tests. J Hepatol 2010; 52 (03) 355-361
• 48 Tripodi A, Primignani M, Chantarangkul V. et al. An imbalance of pro- vs anti-coagulation factors in plasma from patients with cirrhosis. Gastroenterology 2009; 137 (06) 2105-2111
• 49 Zanetto A, Campello E, Bulato C. et al. Whole blood thrombin generation shows a significant hypocoagulable state in patients with decompensated cirrhosis. J Thromb Haemost 2024; 22 (02) 480-492
• 50 Tripodi A, Padovan L, Veena C, Scalambrino E, Testa S, Peyvandi F. How the direct oral anticoagulant apixaban affects thrombin generation parameters. Thromb Res 2015; 135 (06) 1186-1190
• 51 Shaw JR, Castellucci LA, Siegal D, Carrier M. DOAC-associated bleeding, hemostatic strategies, and thrombin generation assays - a review of the literature. J Thromb Haemost 2023; 21 (03) 433-452
• 52 Ninivaggi M, de Laat-Kremers RMW, Carlo A, de Laat B. ST Genesia reference values of 117 healthy donors measured with STG-BleedScreen, STG-DrugScreen and STG-ThromboScreen reagents. Res Pract Thromb Haemost 2020; 5 (01) 187-196