Original article 621
Induction therapy alters plasm
a fibrin clot properties inmultiple myeloma patients: association withthromboembolic complicationsAnetta Undasa, Lidia Zubkiewicz-Usnarskab, Grzegorz Helbigc,Dariusz Woszczykd, Justyna Kozinskae, Anna Dmoszynskae, Jakub Debskib,Maria Podolak-Dawidziakb and Kazimierz KuliczkowskibInduction therapy in patients with multiple myeloma
increases the risk of thromboembolism. We have recently
shown that multiple myeloma patients tend to form denser
fibrin clots displaying poor lysability. We investigated the
effect of induction therapy on fibrin clot properties in
multiple myeloma patients. Ex-vivo plasma fibrin clot
permeability, turbidity, susceptibility to lysis, thrombin
generation, factor VIII and fibrinolytic proteins were
compared in 48 multiple myeloma patients prior to and
following 3 months of induction therapy, mainly with
cyclophosphamide-thalidomide-dexamethasone regimen.
Patients on thromboprophylaxis with aspirin or heparins
were eligible. A 3-month induction therapy resulted in
improved clot properties, that is higher clot permeability,
compaction, shorter lag phase and higher final turbidity,
along with shorter clot lysis time and higher rate of D-dimer
release from fibrin clots than the baseline values. The
therapy also resulted in lower thrombin generation,
antiplasmin and thrombin-activatable fibrinolysis inhibitor
(TAFI), but elevated factor VIII. Progressive disease was
associated with lower posttreatment clot permeability and
lysability. Despite thromboprophylaxis, two patients
developed ischemic stroke and 10 had venous
thromboembolism. They were characterized by
pretreatment lower clot permeability, prolonged clot lysis
Copyright © 2015 Wolters Kluwer
0957-5235 Copyright � 2015 Wolters Kluwer Health, Inc. All rights reserved.
time, longer lag phase, higher peak thrombin generation,
TAFI and plasminogen activator inhibitor -1. Formation of
denser plasma fibrin clots with reduced lysability and
increased thrombin generation at baseline could
predispose to thrombotic complications during induction
treatment in multiple myeloma patients. We observed
improved fibrin clot properties and thrombin generation in
multiple myeloma patients except those with progressive
disease. Blood Coagul Fibrinolysis 26:621–627 Copyright �2015 Wolters Kluwer Health, Inc. All rights reserved.
Blood Coagulation and Fibrinolysis 2015, 26:621–627
Keywords: fibrin clot, fibrinolysis, induction treatment, multiple myeloma,thromboembolism
aInstitute of Cardiology, Jagiellonian University Medical College, and John Paul IIHospital, Krakow, bDepartment of Hematology, Blood Neoplasms and BoneMarrow Transplantation, Wrocław Medical University, Wroclaw, cDepartment ofHematology and Bone Marrow Transplantation, Silesian Medical University,Katowice, d1st Department of Hematology, City Hospital, Opole andeDepartment of Hematology, Medical University of Lublin, Lublin, Poland
Correspondence to Anetta Undas, MD, PhD, Institute of Cardiology JagiellonianUniversity Medical College, 80 Pradnicka St., 31202 Cracow, PolandTel: +48 12 6143004; fax: +48 12 4233900; e-mail: [email protected]
Received 30 July 2014 Revised 16 March 2015Accepted 25 March 2015
IntroductionMultiple myeloma is associated with an increased throm-
boembolic risk, particularly venous thromboembolism
(VTE) during therapy based on thalidomide combined
with chemotherapy [1,2]. Cerebrovascular ischemic
events and myocardial infarction (MI) also occur more
frequently in multiple myeloma patients [3]. Throm-
boembolism in multiple myeloma patients has been
demonstrated to be associated with a three-fold higher
risk of death during follow-up [4].
The mechanism underlying increased thromboembolic
risk in multiple myeloma patients is poorly understood.
Paraproteins have been shown to enhance platelet
adhesion and aggregation, increase blood viscosity, lead
to acquired activated protein C resistance and endothelial
damage, together with increased circulating factor (F)VIII
[5,6]. The immunomodulatory drugs have been shown to
enhance expression of tissue factor (TF) and vascular
endothelial growth factor, downregulate thrombospondin,
cause activated protein C resistance and increase FVIII
[7]. Genes and pathways associated with drug transport/
metabolism, DNA repair and cytokine balance may also
be involved in thalidomide-associated VTE [8]. Thalido-
mide given in combination with other chemotherapies or
dexamethasone, endothelial cell and monocyte-associated
procoagulant activity may be induced through phospha-
tidylserine exposure, or TF expression [9].
The final step of the blood coagulation is the formation of
clots relatively resistant to lysis [10]. Such clot phenotype
has been demonstrated in patients with MI [11,12],
cryptogenic ischemic stroke [13] and VTE [14], along
with advanced atherosclerotic vascular disease [15].
Recently, we have reported that unfavourable clot prop-
erties can be detected in multiple myeloma patients at
the time of diagnosis compared with the matched control
individuals [16].
Health, Inc. All rights reserved.
DOI:10.1097/MBC.0000000000000315
622 Blood Coagulation and Fibrinolysis 2015, Vol 26 No 6
The current study was designed to evaluate the effect
of induction therapy on fibrin characteristics in associ-
ation with thromboembolic episodes in multiple myel-
oma patients.
Patients and methodsWe studied 48 adult patients with newly diagnosed
multiple myeloma out of the 106 patients recruited in
four Polish hematologic centres, in Wroclaw from
November 2010 to June 2012 and in Lublin, Katowice,
Opole, all three from November 2011 to July 2012. The
inclusion and exclusion criteria were described pre-
viously [16].
The International Staging System (ISS) for multiple
myeloma was used to stratify patients into three stages
[17]. The exclusion criteria were a recent (<6 months)
thrombotic event, liver cirrhosis, end-stage renal failure,
current anticoagulant therapy, severe thrombocytopenia
and hypofibrinogenemia (<1 g/l). Control individuals
recruited from outpatients and hospital staff were fre-
quency matched for age, sex, arterial hypertension, dia-
betes and previous thromboembolic events. The
University Ethical Committee approved the study, and
patients provided written, informed consent.
The patients received induction treatment, predominantly
using a cyclophosphamide-thalidomide-dexamethasone
regimen (CTD), cyclophosphamide 500 mg/m2 per day
intravenously (i.v.) on day 1, thalidomide 100 mg/d orally
(p.o.) each day, dexamethasone 20 mg/d p.o. on days 1–4
and 9–12. Individuals receiving thalidomide-dexametha-
sone regimen were also eligible. None of the patients
received lenalidomide-based regimens or erythropoietin.
Other therapies considered necessary by the physician for
the supportive care were allowed.
Response to therapy was categorized into four groups,
that is partial remission, very good partial response
(VGPR), complete remission (including stringent com-
plete response, CR) and progressive disease based on
the current criteria.
All patients received thromboprophylaxis either with
aspirin 75–150 mg/day or enoxaparin 40 mg/day during
induction treatment as recommended in 2008 [18].
Patients were assessed before the onset of immunomo-
dulatory therapy and after the first 90� 10 days since
enrolment. We analysed documented VTE episodes, MI,
ischemic stroke and death within the first 3 months of
therapy on the basis of medical records. The diagnosis of
deep-vein thrombosis (DVT) was established by a
positive finding of colour duplex sonography. The diag-
nosis of pulmonary embolism was based on the presence
of typical symptoms and positive results of high-resol-
ution spiral computed tomography. Ischemic stroke and
MI were diagnosed according to the WHO criteria.
Patients who developed a thromboembolic event and
Copyright © 2015 Wolters Kluwer
required administration of vitamin K antagonists (VKAs)
or therapeutic doses of low-molecular-weight heparins
(LMWHs) were excluded from the final analysis.
Laboratory investigationsBlood was drawn from an antecubital vein between 0800
and 1000 h. Patients receiving LMWH as thrombopro-
hylaxis were drawn at least 12 h since the last injection.
Blood cell count, glucose, total cholesterol, triglycerides,
activated partial thromboplastin time (aPTT), prothrom-
bin time, D-dimer, lactate dehydrogenase (LDH),
calcium, albumin, IgG, IgA, creatinine and b2-microglo-
bulin were assayed by routine laboratory techniques.
Fibrinogen was determined using the Clauss method.
Blood and urine immunofixation was performed to
confirm the diagnosis. The kappa and lambda free light
chain (FLC) concentrations were measured and the
kappa/lambda FLC ratios were calculated.
Plasminogen and antiplasmin were measured by chromo-
genic assays (STA Stachrom; Diagnostica Stago, Asnieres,
France). Plasma PAI-1 activity was determined using a
biofunctional immunosorbent assay (Chromolize PAI-1,
Biopool, Sweden). Plasma thrombin-activatable fibrinoly-
sis inhibitor (TAFI) activity was measured by
a chromogenic assay using the ACTICHROME Plasma
TAFI Activity Kit (American Diagnostica, Stamford, Con-
necticut, USA). Plasma factor VIII activity was determined
by the coagulometric assay (Siemens, Marburg, Germany).
Plasma thrombogenic potential was assessed using cali-
brated automated thrombography (CAT; Thrombino-
scope BV, Maastricht, Netherlands) at 378C according to
the manufacturer’s instructions. Eighty microlitres of pla-
telet poor plasma were diluted with 20 ml of a TF-based
activator (Diagnostica Stago, Asnieres, France) containing
5 pmol/l recombinant TF, 4 micromolar phosphatidylser-
ine/phosphatidylcholine/phosphatidylethanolamine
vesicles and 20 ml of FluCa solution (Hepes, pH 7.35,
100 nmol/l CaCl2, 60 mg/ml bovine albumin and
2.5 mmol/l Z-Gly-Gly-Arg-amidomethylcoumarin). The
peak thrombin level was analysed.
Plasma fibrin clot analysisPlasma fibrin clot variables were determined in duplicate
by technicians blinded to the origin of the samples
(intraassay and interassay coefficients of variation, 5–
8%, for all variables), as described [11,13,14].
(1) F
He
ibrin clot permeation using a pressure-driven
system, with calculation of a permeation coefficient
(Ks), which indicates the pore size. Lower Ks values
indicate reduced permeability.
(2) T
he lag phase of the turbidity curve, which reflectsthe time required for initial protofibril formation and
maximum absorbance at 405 nm at the plateau phase
(DAbmax), indicating the number of protofibrils
per fibre.
alth, Inc. All rights reserved.
Thromboembolism in multiple myeloma Undas et al. 623
(3) F
Table
AgeMalePreviDiabeHypePreviHaemRBCWBCPlateIgG (IgA (LDHCalciAlbumb2 mCreaProthFibrinAPTTD-dimGlucTotalTrigly
Valuenons
ibrinolysis induced by 1 mg/ml recombinant tPA (rt-
PA; Boerhinger Ingelheim, Ingelheim, Germany)
added simultaneously with human thrombin to
citrated plasma. Clot lysis time was defined as the
time required for a 50% decrease in clot turbidity at
405 nm (t50%).
(4) F
ibrinolysis of the clots formed as described aboveand perfused with the same buffer containing
0.2 mmol/l rtPA. The lysis rate was determined by
measuring D-dimer every 20 min in the effluent.
Maximum rates of increase in D-dimer levels (D-
Drate), and their maximum values (D-Dmax) detected
at 80 or 100 min were analysed.
(5) C
ompaction of a plasma fibrin clot formed in thepresence of 0.7 IU/ml thrombin and 20 mmol/l
calcium in tubes and then centrifuged at 6000g for
60 s. Compaction was expressed as the volume of the
supernatant evacuated from the tubes divided by the
initial plasma volume used to form the clot.
Scanning electron microscopyClots from patients and controls were fixed using 2.5% of
glutaraldehyde PBS solution for 2 h. Fixed clots were
gently removed and washed with distilled water, and
then dehydrated in graded water-ethanol solutions, dried
by the critical point procedure and sputter coated with
gold. Samples were scanned in six different areas (micro-
scope HITACHI S-4700).
Statistical analysisContinuous variables were expressed as mean�SD for
normally distributed variables and as median and inter-
quartile range for nonnormally distributed variables.
Copyright © 2015 Wolters Kluwe
1 Comparison of multiple myeloma patients at baseline and aft
MM patients at baseline (n¼48)
(years) 62 (56–71), n (%) 18 (37.5)ous VTE, n (%) 2 (4.2)tes, n (%) 9 (18.8)rtension, n (%) 14 (29.2)ous stroke, n (%) 1 (2.1)oglobin (g/dl) 10.2 [8.9–12.5](106/ml) 3.4 [2.9–4.1](103/ml) 6.2 [4.8–8.4]
lets (103/ml) 236 [176–282]g/l) 26.5 [6.8–54.0]g/l) 1.1 [0.3–31.1](IU/l) 195 [138–329]um (mmol/l) 3.3 [2.3–4.6]in (g/l) 34 [29–37]
icroglobulin (mg/l) 4.3 [2.5–6.6]tinine (mmol/l) 89.6 [67.2–167.1]rombin time (s) 13.4 [12.8–14.3]ogen (g/l) 3.4 [2.6–4.3](s) 31 [28–34]er (ng/ml) 1111 [584–2755]
ose (mmol/l) 5.5 [5–6.6]cholesterol (mmol/l) 4.7 [3.7–5.2]cerides (mmol/l) 1.2 [0.8–1.9]
s are given as number (percentage) or median (IQR). APTT, activated partial tignificant; RBC, red blood cells; VTE, venous thromboembolism; WBC, white bl
Continuous variables were checked for normal distri-
bution by the Shapiro–Wilk statistic. To analyse two
independent groups, we used the Kruskal–Wallis test.
To compare the patients before and after treatment,
Wilcoxon signed ranks test was used. Categorical vari-
ables were compared by x2 test or Fisher’s exact test as
appropriate. The Spearman rank correlation coefficients
were calculated to test the association between two
variables. Multivariate linear regression models was used
to choose variables that influence the fibrin indicators.
Only those with P values less than 0.1 in univariate
regression models were included in multivariable models.
Models were built in order to optimally explain the
variation in fibrin variables and checked for collinearity
between independent ones. All models were additionally
adjusted to age and fibrinogen. Logistic regression
analysis was used to show odds ratios (ORs) of throm-
boembolic events in the extreme quartiles of fibrin clot
variables at baseline. A two-sided P value less than 0.05
was considered statistically significant. All analyses were
performed using STATISTICA version 10.0 (StatSoft,
Inc., Tulsa, Oklahoma, USA).
ResultsPatient characteristics and therapy outcomeForty-eight multiple myeloma patients, including 24
(50%) with IgG multiple myeloma, 13 (27.1%) with IgA
multiple myeloma and 11 (22.9%) with light chain disease
(LCD) were studied (Table 1). The stage III ISS was
observed in 29 patients (60.4%), stage II in 10 patients
(20.8%) and stage I in nine patients (18.8%). Forty (83.3%)
patients received CTD treatment. Six (12.5%) patients
r Health, Inc. All rights reserved.
er 3 months’ induction therapy
MM patients after 3 months (n¼34) P
63 (57–70) NS12 (35.3) NS
1 (2.9) NS5 (14.7) NS
13 (38.2) NS0 –
11.7 [10.8–12.9] <0.0013.9 [3.7–4.0] <0.0015.2 [4.5–6.9] 0.003
251 [204–311] NS7.7 [4.9–20.2] <0.0011.2 [0.4–12.9] NS169 [124–301] 0.042.6 [2.2–4.3] 0.0139 [35–43] <0.001
2.7 [2.3–3.7] <0.00182.8 [63.3–120.1] 0.0213.1 [12.5–14.4] NS
3.3 [2.7–4.1] NS30 [27–33] NS
692 [450–1153] 0.025.4 [5.1–6.5] NS4.6 [3.7–5.6] NS1.5 [1.1–2] 0.05
hromboplastin time; LDH, lactate dehydrogenase; MI, myocardial infarction; NS,ood cells.
624 Blood Coagulation and Fibrinolysis 2015, Vol 26 No 6
Fig. 1
(a)
(b)
Representative scanning electron microscopy images of plasmafibrin clots obtained for a male patient with IgG multiple myelomaprior to (a) and after the induction therapy with thalidomide-basedregimen (b) resulting in a complete remission associated with thereduction of serum IgG from 56 to 15 g/l. Magnification 5000x.A bar denotes 2 mm.
were treated with melphalan-prednisone-thalidomide
(MPT) and the remaining three patients with thalido-
mide-dexamethasone. Forty-two patients declared taking
aspirin 75–150 mg/day, and six patients (12.5%) received
LMWH.
After 3 months of therapy, we observed partial remission
in 23 (48.0%) patients, VGPR in six (12.5%), CR in nine
(18.8%) and progressive disease in the remaining seven
individuals (14.6%). Three patients (8.3%) died.
There were posttreatment increases in haemoglobin, red
blood cells, white blood cells, albumin and LDH, while
beta2-microglobulin, calcium, creatinine and D-dimer
decreased (Table 1). Fibrinogen remained unaltered.
During induction therapy, 10 VTE episodes, including
nine DVT and one pulmonary embolism, and two
ischemic strokes were recorded in 12 multiple myeloma
patients (25%), including 10 individuals in stage III ISS.
IgG multiple myeloma, IgA multiple myeloma and LCD
were equally represented (four individuals from each
group). Seven patients received CTD regimen. Of the
12 patients with thromboembolic complications, pro-
gression was observed in five patients, partial remission
in four, CR in two and one patient died during the 3
months’ follow-up. All episodes developed despite
thromboprophylaxis, that is nine patients were on low-
dose aspirin and three were on prophylactic enoxaparin at
the time of the event. The multiple myeloma patients
with thromboembolism (n¼ 12) did not differ from the
remainder with regard to demographic variables or rou-
tine laboratory parameters (data not shown).
Posttreatment changes in coagulation and fibrinvariablesAfter induction treatment, a slight, but significant,
improvement in all the variables describing fibrin clot
structure and function was observed in 34 available
multiple myeloma patients (70.8%). The analysis
excluded 14 individuals who died or developed throm-
boembolic episodes. Clot permeability and compaction
increased, indicating looser fibrin meshwork structure.
Fibrinolysis was accelerated in both assays used. The
DAbmax increased and the lag phase became slightly
shorter (all P< 0.05) after 3 months of therapy. In seven
patients with progressive disease, in whom none of the
fibrin parameters altered after therapy, as compared with
the individuals with CR, we observed lower posttreat-
ment Ks, longer lysis time and lower DAbmax.
Representative SEM images of a multiple myeloma
patient free of thromboembolic events were shown in
Fig. 1. Posttreatment images for the patients without
those with progressive disease were similar to those
typical of normal individuals [11,13,16].
Induction therapy was associated with the reduction in
peak thrombin generation, TAFI activity, and slightly,
Copyright © 2015 Wolters Kluwer
antiplasmin (Table 2). Importantly, FVIII rose at the
same time. In seven patients with progressive disease
versus the remaining 29 individuals, we observed higher
posttreatment peak thrombin generation (þ15%) and
TAFI activity (þ12%; both P< 0.05). Plasma levels of
PAI-1, antiplasmin, plasminogen and FVIII were similar
in the two subgroups (data not shown).
Health, Inc. All rights reserved.
Thromboembolism in multiple myeloma Undas et al. 625
Table 2 Comparison of fibrin clot variables and associated proteins in multiple myeloma patients
VariableMM patients at
baseline (n¼48)MM patients after3 months (n¼34) P
MM patients withthromboembolism
(n¼12)
MM patients withoutthromboembolism
(n¼36) P
Ks (10–9 cm2) 6 [5.7–6.6] 6.6 [5.9–7.2] 0.003 5.5 [5.1–5.9] 6.1 [5.6–6.8] 0.03t50% (min) 11 [10.4–11.9] 10.1 [9.6–11.3] <0.001 11.6 [11.2–11.9] 11.3 [10.3–11.8] NSD-Dmax (mg/l) 4.52 [4.4–5.1] 4.48 [4.3–4.8] NS 5.1 [4.9–5.2] 4.8 [4.6–5.1] NSD-Drate (mg/l/min) 0.067 [0.064–0.07] 0.072 [0.067–0.077] <0.001 0.061 [0.059–0.062] 0.067 [0.063–0.071] <0.001DAbmax (405 nm) 0.61 [0.52–0.7] 0.73 [0.63–0.75] <0.001 0.61 [0.5–0.67] 0.6 [0.51–0.71] NSLag phase (s) 51 [47–55] 48 [43–52] 0.02 60 [52–60.5] 50 [47–55] 0.01Compaction (%) 42 [37–44] 49 [40–51] 0.004 38.5 [36.5–49] 44 [40–47] NSPeak trombin (nmol/l) 344 [275–398] 284 [248–389] <0.001 503.5 [418–550] 344.8 [269–411] <0.001TAFI act (mg/ml) 36.4 [30.7–40.8] 30.9 [25.2–37.9] 0.005 45.3 [44.6–47.4] 38.9 [33.5–42.3] <0.001Antiplasmin (%) 102.2 [87.4–116.4] 96.3 [84.2–106.9] 0.04 101.5 [86.3–111.8] 104.1 [90.2–110.5] NSPlasminogen (%) 104.6 [93.2–111.8] 103.2 [93.5–110.8] NS 97.5 [87–103.8] 105.8 [97.4–113.1] 0.03PAI-1 act (IU/ml) 7.8 [6.2–10.0] 7.6 [6–10.8] NS 11 [9.9–12.8] 8.3 [6.4–10.5] 0.004Factor VIII (%) 196 [156–235] 219 [195–269] 0.002 192.5 [183.5–266.5] 188 [166.5–223] NS
n values are given as median [IQR]. DAbmax, maximum absorbance of fibrin gel determined by using turbidimetry; act, activity; D-Dmax, maximum D-dimer levels in the lysisassay; D-Drate, maximum rate of increase in D-dimer levels in the lysis assay; Ks, permeability coefficient; NS, nonsignificant; PAI-1, plasminogen activator inhibitor; t50%, half-lysis time; TAFI, thrombin-activatable fibrinolysis inhibitor.
Predictors of thromboembolic eventsPatients who experienced venous or arterial thromboem-
bolic complications had lower Ks, and D-Drate together
with longer lag phase measured at baseline than the
remaining patients (Table 2). Other fibrin variables were
similar in these two subgroups (Table 2).
Moreover, thromboembolism in multiple myeloma
patients was associated with higher baseline peak throm-
bin concentration, activated TAFI and PAI-1 activity as
well as lower plasminogen (Table 2).
Logistic regression analysis showed that two baseline
fibrin clot parameters could predict thromboembolism in
our group. The OR of thromboembolism in multiple
myeloma patients in the lowest quartile of baseline D-
Drate was 12.1 (3.6–59.1; P< 0.0001) relative to the
remaining patients, with the highest area under the curve
(AUC) of 0.78. Similar ORs were noted for the upper
quartile of the lag phase [OR 95% confidence interval
(95% CI), 7.5 (2.1–30.8), P< 0.001] with the AUC
of 0.72.
DiscussionThe current study shows that plasma fibrin clot phe-
notype is favourably altered after 3 months of induction
therapy largely based on thalidomide in multiple myel-
oma patients. We observed that no improvement in clot
phenotype occurs in individuals with progressive dis-
ease. Importantly, the multiple myeloma patients who
experienced thromboembolism during induction treat-
ment displayed lower clot permeability and tPA-
induced lysis at baseline. This suggests that unfavour-
able altered fibrin clot characteristics prior to therapy
may contribute to thrombotic complications observed
in multiple myeloma patients and cannot be normal-
ized by aspirin or LMWH prophylaxis.
Until now, there have been no data as to whether
specific immunomodulatory drugs produce specific
Copyright © 2015 Wolters Kluwe
fibrin-altering effects in multiple myeloma patients.
Several studies have shown that thrombosis occurs
mainly when thalidomide is used in combination with
high-dose dexamethasone, anthracyclines or any che-
motherapy in multiple myeloma patients [19]. Multiple
prothrombotic mechanisms by which thalidomide-
based therapy promotes thrombosis have been postu-
lated [1,19]. Posttreatment prothrombotic alterations
in multiple myeloma patients we observed here
include elevation of FVIII activity and lower antiplas-
min activity.
We found that induction therapy, when analysed in the
whole group, slightly improved plasma fibrin clot charac-
teristics and reduced thrombin formation. Changes in
clot structure were previously demonstrated by Carr
et al. [20] with a major contribution of paraprotein levels
in multiple myeloma patients. We found a significant
impact of thrombin formation on fibrin variables in
multiple myeloma patients as suggested in other clinical
situations [21], including cancer patients [22]. Stimu-
lation of prothrombinase by paraproteins has been
suggested in vitro [23]. A role of thrombin generation
in predicting thromboembolism in various malignant
diseases, including multiple myeloma, has been shown
by Ay et al. [24]. This study indicates that this role of
thrombin could be in part mediated by unfavourable
clot properties.
In terms of unfavourable changes in coagulation during
thalidomide-based therapy, our findings show that
there is no overall activation of blood coagulation,
higher thrombin generation and fibrin formation in
individuals treated with mostly thalidomide combined
with corticosteroids. However, the described favour-
able changes in coagulation and fibrinolysis are largely
driven by the effects observed in patients with partial
or complete remission, with no alterations to coagu-
lation parameters in individuals with progressive dis-
ease. Importantly, progression of multiple myeloma
r Health, Inc. All rights reserved.
626 Blood Coagulation and Fibrinolysis 2015, Vol 26 No 6
was associated with worse posttreatment fibrin para-
meters compared with those in individuals with CR. A
beneficial modulator of on-treatment fibrin clot pheno-
type in our study could be thromboprophylaxis. It has
been shown that aspirin, which acetylates fibrinogen
and other proteins, may accelerate plasma fibrin clot
lysis and make clots more permeable [25]. Similar
effects can induce LMWH [26]. Thromboprophy-
laxis-induced changes in fibrin structure were not
potent enough to abolish pretreatment differences
between individuals with thromboembolism during induc-
tion therapy versus the remainder. Our results suggest that
there is a subgroup of multiple myeloma patients ident-
ifiable prior to therapy, based on a prothrombotic plasma
fibrin clot phenotype, in whom there is a high risk for
thromboembolism. It is likely that a markedly higher
baseline thrombin generation observed in multiple myel-
oma patients prone to thromboembolism might contribute
to unfavourable clot properties.
Recently, we have reported hypofibrinolysis in
multiple myeloma patients [16], which is in line with
a study by Yagci et al. [27]. We found that thalidomide-
based therapy is associated with slightly faster clot lysis
using two assays with different final rtPA concen-
trations. Von Marion et al. [28] observed impaired
efficiency of lysis during induction therapy. Different
patient characteristics and methodology used could
explain in part this discrepancy. Moreover, our study
suggests that pretreatment higher TAFI and PAI-1
activity with lower plasminogen can distinguish the
multiple myeloma patients who suffered from throm-
boembolic events during induction therapy from those
free of these complications.
Several limitations of this study should be acknowledged.
A sample size was small but sufficiently powered to show
posttreatment differences. Thromboembolic episodes
that were asymptomatic or not clinically recognized
would not have been detected. Posttreatment fibrin clot
analysis was not performed in all the individuals studied
due to anticoagulant therapy initiated after the diagnosis
of VTE, which suppresses thrombin formation and alters
clot structure [10]. We cannot exclude an influence of
undetected confounding factors, for example cigarette
smoking adversely affecting clot properties [10,29].
Finally, effects of novel agents used in multiple myel-
oma, for example lenalidomide, on clot phenotype were
beyond the scope of this study.
In conclusion, we have shown that induction treatment
based on thalidomide was associated with improved fibrin
clot phenotype, lower thrombin generation and faster
fibrinolysis. Our findings suggest that more compact
fibrin clots with reduced lysability, as assessed prior to
therapy, characterize individuals who experienced
thrombotic complications during induction treatment
for multiple myeloma.
Copyright © 2015 Wolters Kluwer
AcknowledgementsThe study was funded by Jagiellonian University
Medical College (grant K/ZDS/002936 to A.U.).
Conflicts of interestThe authors declare no competing financial interests.
References1 Zangari M, Berno T, Zhan F, Tricot G, Fink L. Mechanisms of thrombosis in
paraproteinemias: the effects of immunomodulatory drugs. Semin ThrombHemost 2012; 38:768–779.
2 Boyle EM, Fougquet G, Manier S, Gauthier J, Noel MP, Borie C, et al.Immunomodulator-based therapy in myeloma and the occurrence ofthrombosis. Expert Rev Hematol 2012; 5:617–627.
3 Libourel EJ, Sonneveld P, van der Holt B, de Maat MP, Leebeek FW. Highincidence of arterial thrombosis in young patients treated for multiplemyeloma: results of a prospective cohort study. Blood 2010; 116:22–26.
4 Kristinsson SY, Pfeiffer RM, Bjorkholm M, Schulman S, Landgren O.Thrombosis is associated with inferior survival in multiple myeloma.Haematologica 2012; 97:1603–1607.
5 Uaprasert N, Voorhees PM, Mackman N, Key NS. Venousthromboembolism in multiple myeloma: current perspectives inpathogenesis. Eur J Cancer 2010; 46:1790–1799.
6 Kristinsson SY, Bjorkholm M, Schulman S, Landgren O.Hypercoagulability in multiple myeloma and its precursor state,monoclonal gammopathy of undetermined significance. Semin Hematol2011; 48:46–54.
7 Cesarman-Maus G, Braggio E, Fonseca R. Thrombosis in multiple myeloma(MM). Hematology 2012; 17 (Suppl 1):S177–S180.
8 Johnson DC, Corthals S, Ramos C, Hoering A, Cocks K, Dickens NJ, et al.Genetic associations with thalidomide mediated venous thrombotic eventsin myeloma identified using targeted genotyping. Blood 2008; 112:4924–4934.
9 Hoshi A, Matsumoto A, Chung J, Isozumi Y, Koyama T. Activation ofcoagulation by a thalidomide-based regimen. Blood Coagul Fibrinolysis2011; 22:532–540.
10 Undas A. Fibrin clot properties and their modulation in thromboticdisorders. Thromb Haemost 2014; 112:32–42.
11 Undas A, Szułdrzynski K, Stepien E, Zalewski J, Godlewski J, Tracz W, et al.Reduced clot permeability and susceptibility to lysis in patients with acutecoronary syndrome: effects of inflammation and oxidative stress.Atherosclerosis 2007; 196:551–558.
12 Collet JP, Allali Y, Lesty C, Tanguy ML, Silvain J, Ankri A, et al. Alteredfibrin architecture is associated with hypofibrinolysis and prematurecoronary atherothrombosis. Arterioscler Thromb Vasc Biol 2006;26:2567–2573.
13 Undas A, Podolec P, Zawilska K, Pieculewicz M, Jedlinski I, Stepien E, et al.Altered fibrin clot structure/function as a novel risk factor for cryptogenicischemic stroke. Stroke 2009; 40:1499–1501.
14 Undas A, Zawilska K, Ciesla-Dul M, Lehmann-Kopydlowska A, Skubiszak A,Ciepluch K, Tracz W. Altered fibrin clot structure/function in patients withidiopathic venous thromboembolism and in their relatives. Blood 2009;114:4272–4278.
15 Okraska-Bylica A, Wilkosz T, Słowik L, Bazanek M, Konieczynska M, UndasA. Altered fibrin clot properties in patients with premature peripheral arterydisease. Pol Arch Med Wewn 2012; 122:608–615.
16 Undas A, Zubkiewicz-Usnarska L, Helbig G, Woszczyk D, Kozinska J,Dmoszynska A, et al. Altered plasma fibrin clot properties and fibrinolysisin patients with multiple myeloma. Eur J Clin Invest 2014; 44:557–566.
17 Durie BG, Harousseau JL, Miguel JS, Blade J, Barlogie B, Anderson K, et al.International Myeloma Working Group. International uniform responsecriteria for multiple myeloma. Leukemia 2006; 20:1467–1473.
18 Palumbo A, Rajkumar SV, Dimopoulos MA, Richardson PG, San Miguel J,Barlogie B, et al. Prevention of thalidomide- and lenalidomide-associatedthrombosis in myeloma. Leukemia 2008; 22:414–423.
19 Colombo R, Gallipoli P, Castelli R. Thrombosis and hematologicalabnormalities in hematological malignancies. Clin Lymphoma MyelomaLeuk 2014; 14:441–450.
20 Carr ME Jr, Dent RM, Carr SL. Abnormal fibrin structure and inhibition offibrinolysis in patients with multiple myeloma. J Lab Clin Med 1996;128:83–88.
21 Wolberg AS. Thrombin generation and fibrin clot structure. Blood Rev2007; 21:131–142.
Health, Inc. All rights reserved.
Thromboembolism in multiple myeloma Undas et al. 627
22 Gronostaj K, Richter P, Nowak W, Undas A. Altered plasma fibrin clotproperties in patients with digestive tract cancers: links with the increasedthrombin generation. Thromb Res 2013; 131:262–267.
23 Thiagarajan P, Dannenbring R, Matsuura K, Tramontano A, Gololobov G,Paul S. Monoclonal antibody light chain with prothrombinase activity.Biochemistry 2000; 39:6459–6465.
24 Ay C, Dunkler D, Simanek R, Thaler J, Koder S, Marosi C, et al. Prediction ofvenous thromboembolism in patients with cancer by measuring thrombingeneration: results from the Vienna Cancer and Thrombosis Study. J ClinOncol 2011; 29:2099–2103.
25 Ajjan RA, Standeven KF, Khanbhai M, Phoenix F, Gersh KC, Weisel JW,et al. Effects of aspirin on clot structure and fibrinolysis using a novel in vitrocellular system. Arterioscler Thromb Vasc Biol 2009; 29:712–717.
Copyright © 2015 Wolters Kluwe
26 Yeromonahos C, Marlu R, Polack B, Caton F. Antithrombin-independenteffects of heparins on fibrin clot nanostructure. Arterioscler Thromb VascBiol 2012; 32:1320–1324.
27 Yagci M, Sucak GT, Haznedar R. Fibrinolytic activity in multiple myeloma.Am J Hematol 2003; 74:231–237.
28 van Marion AM, Auwerda JJ, Minnema MC, van Oosterom R, Adelmeijer J,de Groot PG, et al. Hypofibrinolysis during induction treatment of multiplemyeloma may increase the risk of venous thrombosis. Thromb Haemost2005; 94:1341–1343.
29 Szpak D, Grochowalski A, Chrzaszcz R, Florek E, Jawien W, Undas A.Tobacco smoke exposure and endothelial dysfunction in patients withadvanced coronary artery disease. Pol Arch Med Wewn 2013; 123:474–481.
r Health, Inc. All rights reserved.
Top Related