CC BY 4.0 · Thromb Haemost 2023; 123(11): 1034-1041
DOI: 10.1055/a-2101-7961
Coagulation and Fibrinolysis

Sensitive Measurement of Clinically Relevant Factor VIII Levels in Thrombin Generation Assays Requires Presence of Factor XIa

1   Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), University Maastricht, Maastricht, The Netherlands
2   Department of Hematology, Division of Internal Medicine, Maastricht UMC + , Maastricht, The Netherlands
Erik A. M. Beckers
2   Department of Hematology, Division of Internal Medicine, Maastricht UMC + , Maastricht, The Netherlands
Floor C. J. I. Heubel-Moenen
2   Department of Hematology, Division of Internal Medicine, Maastricht UMC + , Maastricht, The Netherlands
Yvonne M. C. Henskens
3   Central Diagnostics Laboratory, Maastricht UMC + , Maastricht, The Netherlands
M. Christella L. G. D. Thomassen
1   Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), University Maastricht, Maastricht, The Netherlands
Tilman M. Hackeng
1   Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), University Maastricht, Maastricht, The Netherlands
› Author Affiliations


Background Hemophilia A (HA) is characterized by decreased or absent factor VIII (FVIII) activity. Current FVIII assays are based on clotting time and thus only provide information about the initiation of coagulation. In contrast, thrombin generation assays (TGAs) can be used to measure the full coagulation spectrum of initiation, propagation, and termination that provide information on the whole course of thrombin generation and inhibition. However, the commercially available TG kits lack sensitivity for measurements of hemophilia plasma within lower FVIII ranges, which is essential for explaining differences in bleeding phenotypes in hemophiliacs at clinically low levels of FVIII.

Aims Optimization of the TGA for measurements of low FVIII levels in severe HA patients.

Methods TGA measurements were performed in severe HA pooled plasma (n = 10). Investigations of several preanalytical and analytical variables of the assay were performed in a stepwise process and adjusted based on sensitivity toward intrinsic coagulation activation.

Results TGA initiated by tissue factor (TF) alone at varying concentrations was unable to significantly differentiate between FVIII levels below 20%. In contrast, TGA activation with low concentrations of TF in presence of FXIa appeared to be highly sensitive for FVIII changes both in high and low ranges. In addition, a representative TGA curve at trough levels could only be produced using the dual TF/FXIa TGA.

Conclusion We propose a critical optimization for the setup of the TGA for measurements in severe HA plasma. The dual TF/FXIa TGA shows increased sensitivity, especially in lower FVIII ranges, which allows for better individual characterization at baseline, prediction of interventions, and follow-up.

Supplementary Material

Publication History

Received: 28 June 2022

Accepted: 08 May 2023

Accepted Manuscript online:
26 May 2023

Article published online:
10 July 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (

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