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Factor XIII

Factor XIII (FXIII), also known as fibrin-stabilizing factor, is a transglutaminase zymogen that serves as the terminal enzyme in the blood coagulation cascade, where it cross-links fibrin molecules to stabilize clots and enhance their resistance to mechanical stress and fibrinolysis.^[1] In plasma, FXIII primarily exists as a heterotetramer composed of two catalytic A subunits (encoded by the F13A1 gene) and two carrier B subunits (encoded by F13B), forming the A₂B₂ complex, while a homodimeric form of A subunits (A₂) is found intracellularly in platelets, monocytes, and macrophages.^[1]^[2] Activation occurs during the final stages of coagulation when thrombin cleaves an activation peptide from the A subunit in the presence of calcium ions, releasing active FXIIIa (A₂*), which detaches from the B subunits and catalyzes ε-(γ-glutamyl)lysine isopeptide bonds between fibrin chains and other substrates like α₂-antiplasmin.^[1]^[2] Beyond its essential role in hemostasis, FXIII supports wound healing by cross-linking extracellular matrix proteins to maintain fibrin scaffold integrity and reduce vascular permeability at injury sites.^[2] It also promotes angiogenesis by facilitating the cross-linking of vascular endothelial growth factor receptor 2 (VEGFR-2) and suppressing anti-angiogenic factors such as thrombospondin-1, thereby aiding tissue repair and remodeling.^[2] Congenital FXIII deficiency, a rare autosomal recessive disorder with an incidence of approximately 1 in 2 million individuals, results primarily from mutations in the F13A1 gene and manifests as severe bleeding tendencies, including umbilical stump hemorrhage, intracranial bleeds, and poor wound healing, often presenting in infancy.^[1]^[2] Acquired deficiencies, which are more common, arise from autoantibodies, liver disease, or consumptive coagulopathies in trauma and sepsis, leading to delayed bleeding and increased mortality risk if untreated.^[1] Therapeutic management typically involves replacement with plasma-derived or recombinant FXIII concentrates to maintain trough levels above 5-10%, with a half-life of 11-14 days.^[1]^[2]

Molecular Structure and Genetics

Protein Structure

Factor XIII circulates in plasma as a heterotetramer composed of two identical catalytic A subunits and two non-catalytic B subunits, denoted as FXIII-A₂B₂.^[3] Each A subunit has a molecular mass of approximately 83 kDa, while each B subunit is a glycoprotein with a molecular mass of about 80 kDa, containing roughly 8.5% carbohydrate.^[4] The B subunits serve as carrier proteins that protect the A subunits from premature activation and enhance the solubility of the complex in circulation.^[5] The A subunit exhibits a modular architecture divided into four distinct domains: an N-terminal activation peptide (residues 1-37), a β-sandwich domain (residues 38-184), a central catalytic core domain (residues 185-515), and two C-terminal β-barrel domains (barrel 1: residues 516-628; barrel 2: residues 629-731).^[6] The catalytic core houses the active site, featuring a cysteine residue (Cys314) essential for transglutaminase activity, along with the supporting residues of the catalytic triad: His373 and Asp396.^[7] These domains fold into a compact structure in the zymogen form, with the activation peptide and β-barrel domains partially occluding the active site to maintain inactivity.^[8] In contrast, the B subunit comprises ten tandem sushi domains (also known as short consensus repeats), each stabilized by two internal disulfide bonds, forming an elongated chain that wraps around and shields the A subunits.^[9] These sushi domains contribute to the overall stability and solubility of the heterotetramer by interacting with the catalytic core and β-barrel 1 of the A subunits, preventing aggregation and oxidative damage.^[10] The zymogen FXIII-A₂B₂ represents the inactive plasma form, whereas the activated FXIIIa consists of the A₂ dimer following cleavage of the activation peptide and dissociation of the B subunits, resulting in an extended conformation that exposes the catalytic triad for transglutaminase function.^[11] Crystal structures, such as that of the recombinant human cellular FXIII zymogen A₂ dimer (PDB ID: 1F13), reveal the head-to-tail dimerization of A subunits and the buried active site, providing insights into how structural rearrangements enable cross-linking of fibrin and other substrates upon activation.^[12] More recent cryo-EM structures of the full native plasma heterotetramer further elucidate the flexible arrangement of B subunit sushi domains around the A₂ core, underscoring their role in modulating access to the catalytic site.^[13]

Genetic Basis

Factor XIII is encoded by two distinct genes: the F13A1 gene, located on chromosome 6p25.1, spans approximately 160 kb and consists of 15 exons that encode the A subunit, the catalytically active component of the enzyme.^[14] The F13B gene, situated on chromosome 1q31.3, covers about 28 kb with 12 exons and encodes the B subunit, which stabilizes the A subunit in circulation.^[15]^[16]

Activation and Function

Activation Mechanism

Factor XIII, circulating primarily as a heterotetramer (A₂B₂) in plasma, is activated through a multi-step process involving proteolytic cleavage and ion-dependent conformational changes to form the active transglutaminase XIIIa (A₂*).^[11] The initial step in activation is thrombin-mediated proteolysis of the A subunits at the Arg³⁷-Gly³⁸ bond within the N-terminal activation peptide, a 37-residue segment that inhibits the catalytic site in the zymogen form.^[2] This cleavage is greatly accelerated by fibrin, which acts as a cofactor by forming a ternary complex with thrombin and Factor XIII, enhancing the reaction rate by up to 100-fold compared to fibrin-free conditions.^[17] Without fibrin, the cleavage occurs inefficiently, underscoring its essential role in physiological activation during hemostasis.^[18] Following cleavage, calcium ions (Ca²⁺) bind to the A subunits at concentrations of 5-10 mM, inducing a conformational rearrangement that exposes the active site catalytic triad (Cys³¹⁴, His³⁷³, Asp³⁹⁶).^[2] This binding, particularly at sites Cab2 and Cab3, destabilizes the zymogen structure and promotes the release of the cleaved activation peptide, transitioning the A₂ subunits to an intermediate form (A₂').^[11] Concurrently, Ca²⁺ facilitates the dissociation of the non-catalytic B subunits from the A₂B₂ complex, yielding the active A₂* homodimer fully capable of transglutaminase activity.^[2] The overall activation kinetics are rapid under clot-forming conditions, ensuring timely stabilization of the fibrin network.^[11] In contrast, platelet-derived Factor XIII, which exists as an A₂ homodimer lacking B subunits, undergoes activation independent of fibrin, relying primarily on thrombin cleavage and Ca²⁺-induced changes for efficiency in localized thrombus reinforcement.^[19]

Biochemical Function

Activated Factor XIII (FXIIIa) functions primarily as a transglutaminase enzyme, catalyzing the formation of covalent ε-(γ-glutamyl)lysine isopeptide bonds between the glutamine and lysine residues of substrate proteins, which releases ammonia as a byproduct. This activity stabilizes the fibrin clot by initially cross-linking adjacent γ-chains of fibrin molecules, followed by cross-linking of α-chains, thereby enhancing the mechanical strength and resistance to deformation of the fibrin network.^[20] The enzymatic reaction involves the deamidation of a glutamine residue to form a glutamyl intermediate, which then reacts with a nearby lysine amine group on another protein chain, resulting in an irreversible isopeptide linkage that reinforces clot architecture.^[21] A critical aspect of FXIIIa's biochemical role is the cross-linking of α2-antiplasmin to the α-chains of fibrin, which incorporates this potent plasmin inhibitor into the clot structure and thereby confers resistance to fibrinolysis. This modification significantly prolongs clot survival by limiting plasmin-mediated degradation, ensuring hemostatic efficacy during the early phases of wound repair.^[20] Beyond fibrin and α2-antiplasmin, FXIIIa cross-links additional extracellular matrix proteins such as collagen and fibronectin, which supports cell adhesion, migration, and matrix remodeling essential for tissue regeneration. Similarly, cross-linking of von Willebrand factor (vWF) to fibrin and other substrates contributes to platelet adhesion and thrombus stability at sites of vascular injury.^[21]^[22] These cross-linking activities extend to processes beyond acute hemostasis, including wound healing and angiogenesis, where FXIIIa-mediated stabilization of the provisional matrix facilitates fibroblast proliferation, keratinocyte migration, and endothelial cell sprouting. In wound healing, cross-linked fibronectin and collagen provide a scaffold for granulation tissue formation, while in angiogenesis, interactions with vWF and other substrates promote vascular network assembly.^[20] FXIIIa's activity is regulated by proteolytic inactivation, notably by plasmin, which cleaves FXIIIa at specific sites (e.g., between Lys468 and Gln469), thereby terminating its transglutaminase function during fibrinolysis and preventing excessive clot stabilization.^[23]

Physiological Role

Synthesis and Distribution

Factor XIII, also known as fibrin-stabilizing factor, is synthesized in distinct cellular compartments depending on its subunits. The A subunits (FXIII-A) are primarily produced by cells of hematopoietic origin, including monocytes, macrophages, and megakaryocytes in the bone marrow.^[24] These cells incorporate FXIII-A into intracellular stores, with megakaryocytes transferring the protein to platelets during thrombopoiesis.^[25] In contrast, the B subunits (FXIII-B) are synthesized and secreted by hepatocytes in the liver, which possess the necessary machinery for their production and release into circulation.^[26] This tissue-specific expression ensures the availability of both subunits for functional assembly. Upon release, FXIII-A and FXIII-B subunits associate in plasma to form the mature heterotetrameric complex FXIII-A₂B₂, where the B subunits act as carriers that stabilize and protect the catalytic A subunits.^[27] The assembly occurs extracellularly in the bloodstream, facilitated by non-covalent interactions primarily involving the sushi domains of FXIII-B.^[28] In platelets, however, FXIII exists as an A₂ homodimer stored in the cytoplasm, lacking B subunits and representing the intracellular form that can be mobilized upon platelet activation.^[29] Approximately 50% of total circulating FXIII-A is sequestered within platelets, highlighting the dual plasma and cellular distribution of the protein.^[30] In healthy individuals, plasma FXIII-A₂B₂ concentrations range from 14 to 28 mg/L (approximately 45-90 nM), reflecting steady-state levels maintained by ongoing synthesis.^[31] The protein exhibits a prolonged half-life of 9-14 days, which supports its role in sustained hemostatic function.^[32] Turnover of FXIII is closely tied to liver function, as impaired hepatocyte activity in conditions like chronic liver disease reduces FXIII-B production and overall plasma levels.^[33] This distribution ensures FXIII is readily available both in circulation and at sites of vascular injury.

Role in Hemostasis

Factor XIII plays a pivotal role in the final stages of hemostasis by stabilizing the fibrin clot formed during the coagulation cascade. Once activated, it functions as a transglutaminase that introduces covalent cross-links between adjacent fibrin molecules, specifically forming γ-chain dimers and extensive α-chain polymers, which enhance the mechanical strength of the clot against shear stress and physical disruption. This stabilization is crucial for effective primary hemostasis, as cross-linked fibrin provides a robust scaffold that withstands vascular pressures, thereby reducing bleeding time and preventing hemorrhage.^[34]^[35] In addition to mechanical reinforcement, Factor XIII confers resistance to premature fibrinolysis by cross-linking α₂-antiplasmin to the fibrin network, which inhibits plasmin-mediated degradation and prolongs clot integrity under physiological conditions. This antifibrinolytic protection requires approximately 50% of normal plasma activity to maintain adequate stability. Factor XIII also interacts with other coagulation components in the post-thrombin phase, binding to fibrinogen and factors Va and VIII to localize within the platelet-fibrin complex, further optimizing clot architecture. Through these enzymatic cross-links, Factor XIII regulates platelet adhesion by interacting with and downregulating integrin αIIbβ3 activity, thereby limiting excessive thrombus expansion. It also promotes clot retraction by facilitating red blood cell retention within the fibrin mesh, ensuring a compact and functional thrombus.^[34]^[35]^[36] Deficiency in Factor XIII impairs these hemostatic functions, resulting in clots that are more porous, permeable, and susceptible to mechanical breakdown and lysis, which compromises overall clot mechanics and increases bleeding risk. Such unstable clots exhibit reduced rigidity and faster dissolution, highlighting Factor XIII's indispensable contribution to durable hemostasis.^[34]^[35] Beyond coagulation, Factor XIII supports non-hemostatic processes integral to tissue homeostasis. In wound healing and tissue repair, it cross-links extracellular matrix components like fibronectin and collagen, promoting fibroblast migration, matrix remodeling, and angiogenesis to facilitate scar formation and regeneration. During pregnancy, Factor XIII maintains placental stability by stabilizing the fibrin deposits in the intervillous space, with levels below 10% associated with recurrent miscarriage due to impaired implantation and fetal development. In vascular biology, Factor XIII contributes to atherosclerosis prevention by enhancing endothelial repair and modulating plaque stability; for instance, the V34L polymorphism in the F13A1 gene accelerates Factor XIII activation, altering fibrin cross-linking and clot properties, which has been associated with lower risk of myocardial infarction in some populations.^[34]^[35]^[37]

Clinical Aspects

Inherited Factor XIII Deficiency

Inherited Factor XIII deficiency is a rare autosomal recessive bleeding disorder caused by mutations in the genes encoding the A (F13A1) or B (F13B) subunits of Factor XIII, leading to impaired fibrin cross-linking and clot stabilization. It manifests primarily in homozygotes or compound heterozygotes, with heterozygous carriers typically remaining asymptomatic.^[38]^[39] Inherited Factor XIII deficiency is primarily caused by mutations in the F13A1 gene (A-subunit deficiency, accounting for over 95% of cases and leading to severe bleeding due to catalytic defects) or, more rarely, in the F13B gene (B-subunit deficiency, resulting in milder bleeding as the A subunit is unstable without B for protection in plasma). Combined deficiencies are exceedingly rare and associated with severe outcomes.^[39]^[40] Worldwide prevalence is estimated at 1 in 2 to 5 million individuals, though underdiagnosis likely inflates the true incidence. In Iran, the prevalence is markedly higher, estimated at approximately 1 in 200,000 due to widespread consanguineous marriages, with around 500 cases reported (likely underdiagnosed).^[38]^[41]^[42]^[43] Clinical presentations often emerge in infancy or early childhood, with umbilical stump bleeding occurring in about 80% of affected neonates, frequently accompanied by delayed separation beyond 2 weeks. Intracranial hemorrhage affects up to 30% of neonates with severe deficiency, carrying a 30% mortality rate and significant risk of neurological sequelae in survivors. Other manifestations include delayed wound healing in 25% of cases, recurrent miscarriages in up to 66% of affected pregnancies, menorrhagia, bruising, and joint bleeds, though spontaneous bleeding is less common than in other severe coagulopathies.^[39]^[38]^[44] Prenatal diagnosis is feasible through genetic testing of chorionic villus sampling or amniocentesis, targeting known mutations in F13A1 or F13B, particularly in high-risk families from consanguineous backgrounds.

Acquired Factor XIII Deficiency

Acquired factor XIII (FXIII) deficiency arises from non-genetic mechanisms that impair FXIII activity or levels, leading to unstable fibrin clots and bleeding tendencies in adults. The primary causes include immune-mediated processes, such as autoantibodies that develop idiopathically or secondary to drugs like isoniazid, phenytoin, or penicillin, which neutralize FXIII function. Non-immune causes encompass hyperconsumption during procedures like extracorporeal membrane oxygenation (ECMO) or surgery, disseminated intravascular coagulation (DIC), and increased turnover in myeloid neoplasms such as acute leukemia. Additionally, hyposynthesis occurs in liver disease due to reduced hepatic production of FXIII. Mechanisms involve either direct inhibition by autoantibodies binding to FXIII-A or FXIII-B subunits, preventing activation and cross-linking, or accelerated clearance and consumption exceeding synthesis rates in consumptive states.^[45]^[46]^[47]^[48] This condition is rare overall, with fewer than 10 reported cases annually excluding pandemic-related surges like COVID-19, and it is frequently underdiagnosed due to the lack of routine FXIII screening in standard coagulation panels. In specific high-risk settings, prevalence is notably higher; for instance, up to 93% of adult ECMO patients develop acquired FXIII deficiency (activity <70%), often starting pre-initiation in 39% of cases. Recent studies from 2024-2025 also associate low FXIII levels with postpartum hemorrhage (PPH), where activity below 50% correlates with increased blood loss exceeding 500 mL. Symptoms typically manifest as adult-onset bleeding diatheses, including delayed wound healing, soft tissue hematomas, and postoperative hemorrhage, affecting approximately 80% of cases with major bleeding events; intracranial hemorrhage occurs in about 10%, particularly in ECMO contexts, sometimes leading to hydrocephalus. Paradoxical thrombosis has been observed in select cases, possibly due to uneven fibrin stabilization.^[48]^[49]^[50] Recent findings underscore evolving clinical insights, including the 2025 International Society on Thrombosis and Haemostasis (ISTH) Scientific and Standardization Committee project on updated classification and diagnostic recommendations for FXIII deficiencies, emphasizing refined assays for immune versus consumptive etiologies. Case studies from 2024-2025 highlight severe outcomes in ECMO patients, with FXIII deficiency linked to major bleeding in 75% and intracranial events contributing to morbidity, as seen in a 2025 prospective study of 44 adults where low activity modestly correlated with transfusion needs. A 2025 prospective study of adult ECMO patients confirmed acquired FXIII deficiency in a majority, with activity levels correlating modestly with transfusion needs and major bleeding (75%). Ongoing trials, such as the SWIFT study (NCT06481995), are evaluating early FXIII replacement to reduce postpartum blood loss. In myeloid neoplasms, acquired deficiency exacerbates bleeding in up to 20% of acute leukemia cases at diagnosis, often resolving with disease control. These developments stress the need for targeted FXIII monitoring in at-risk populations to mitigate underdiagnosis.^[51]^[49]^[52]^[53]^[47]

Diagnosis

Diagnosis of Factor XIII deficiency typically begins with clinical suspicion based on unexplained bleeding tendencies or family history, as routine coagulation tests such as prothrombin time and activated partial thromboplastin time remain normal.^[39] Specialized laboratory assays are essential to confirm the diagnosis by measuring Factor XIII activity, antigen levels, or the presence of inhibitors.^[54] Screening is recommended in cases of delayed umbilical stump bleeding, recurrent miscarriages, or intracranial hemorrhage in neonates.^[39] Activity assays are the cornerstone for detecting functional Factor XIII deficiency. The urea clot solubility test serves as a qualitative screening method, where fibrin clots formed in the presence of thrombin and calcium are incubated in 5 M urea; dissolution within 24 hours indicates severe deficiency (activity <1%), though it lacks sensitivity for milder cases and can yield false positives due to other factors like increased fibrinolysis.^[39] For quantitative assessment, the ammonia release assay measures transglutaminase activity by detecting ammonia liberation from a synthetic substrate using photometric methods at 340 nm, providing precise activity levels with a reference range of 70-140%.^[39] Antigen assays quantify the A and B subunits to distinguish between type I (reduced quantity) and type II (dysfunctional) deficiencies. Enzyme-linked immunosorbent assay (ELISA) is widely used to detect Factor XIII-A and -B antigens, with high sensitivity down to 0.001 IU/mL, though it may not correlate with activity in type II cases.^[39] More recently, liquid chromatography-tandem mass spectrometry (LC-MS/MS) has emerged as a precise method for quantifying plasma Factor XIII-A and -B subunits, offering low coefficients of variation (<10%) and strong correlation with functional assays, enhancing diagnostic accuracy in clinical samples.^[55] Detection of inhibitors, which cause acquired deficiency, involves mixing studies followed by quantitative assays. Patient plasma is mixed 1:1 with normal plasma; failure to correct activity suggests an inhibitor, confirmed using a Bethesda-Nijmegen-like method where inhibitor titers are expressed in Bethesda units (BU), with 1 BU defined as the amount reducing Factor XIII activity to 50% of normal.^[56] Titers are calculated from serial dilutions, typically ranging from 1-60 BU in affected patients.^[56] Severe deficiency is defined by Factor XIII activity below 1%, associated with life-threatening bleeding, while levels between 1-5% may cause milder symptoms; prophylactic screening targets individuals with activity <30% in high-risk scenarios.^[57] Challenges in diagnosis include the insensitivity of routine and screening tests, leading to underdiagnosis, particularly in developing regions where quantitative assays are unavailable.^[54] Specialized laboratories are required for accurate testing, and standardization remains inconsistent across methods.^[54]

Treatment and Management

The primary therapeutic approach for Factor XIII (FXIII) deficiency involves replacement therapy to restore hemostatic function. Plasma-derived FXIII concentrates, such as Fibrogammin P (Corifact), are administered prophylactically at doses of 10-25 IU/kg every 4 weeks to maintain adequate FXIII activity levels and prevent bleeding episodes.^[39] Recombinant FXIII A-subunit products, including catridecacog alfa (Tretten), provide an alternative with a standard monthly dose of 35 IU/kg, offering similar efficacy while minimizing risks associated with plasma-derived sources.^[58] Prophylactic replacement therapy is the cornerstone of management for patients with severe congenital FXIII deficiency (activity <5%), significantly reducing the risk of spontaneous and trauma-induced bleeds. Regular infusions targeting FXIII activity levels above 5-15% can prevent up to 90% of bleeding events, with studies showing a reduction from approximately 2.5 spontaneous bleeds per year to 0.2 on prophylaxis.^[59] For severe cases requiring higher hemostatic support, such as during surgery or pregnancy, target levels of 30% or more may be aimed for to ensure robust clot stabilization.^[60] In mild deficiency (activity 5-30%), prophylaxis is typically reserved for those with a history of bleeding.^[39] For acute bleeding episodes, immediate replacement with a bolus dose of 10-20 IU/kg of FXIII concentrate is recommended to rapidly achieve activity levels exceeding 5%, often sufficient for resolution without repeated dosing due to the protein's long half-life.^[6] In patients with inhibitors, which can develop against FXIII and complicate therapy, high-dose regimens (up to 50 IU/kg) or switching to recombinant products may bypass the issue and restore efficacy.^[39] Supportive measures complement replacement therapy, including antifibrinolytic agents like tranexamic acid (1-1.5 g IV every 6-8 hours) for minor bleeds or perioperative use to enhance clot stability, though these should be avoided in certain acquired deficiencies associated with disseminated intravascular coagulation.^[58] Genetic counseling is essential for individuals with inherited FXIII deficiency to assess recurrence risks and inform family planning.^[38] Recent advances in FXIII management include the widespread adoption of recombinant catridecacog alfa since its 2013 approval, which has demonstrated annualized bleeding rates as low as 0.04 per patient-year in prophylactic use, improving safety and immunogenicity profiles over plasma-derived options.^[61]

History and Research

Discovery

Factor XIII, initially identified as a fibrin-stabilizing factor, was discovered in 1948 by Hungarian-American biochemists Kálmán Laki and László Loránd while studying bovine plasma. Their research revealed that this serum component was essential for rendering fibrin clots insoluble in urea or monochloroacetic acid, distinguishing it from earlier observations of clot formation. They termed it "fibrinoligase" due to its apparent role in preventing fibrinolysis, marking the first recognition of a transglutaminase-like activity in hemostasis. In the 1950s, further investigations linked the factor to the insolubility of clots in urea solutions, building on Loránd's 1950 study that demonstrated how the absence or inhibition of this factor led to readily dissolvable fibrin networks. This property became a cornerstone for early functional assessments. By 1963, the International Committee on Blood Clotting Factors formally designated it as Factor XIII within the Roman numeral nomenclature system for coagulation proteins, resolving prior inconsistencies in naming such as "fibrin-stabilizing factor" or "Laki-Loránd factor."^[62] Early diagnostic assays for Factor XIII emerged in the mid-20th century, with clot solubility tests—initially qualitative evaluations in 5 M urea or 1% monochloroacetic acid—gaining prominence by the 1960s and refined through the 1970s for better sensitivity in detecting severe deficiencies. The first reported human case of inherited Factor XIII deficiency occurred in 1960, described by Duckert et al. as a congenital hemorrhagic diathesis in a Swiss boy, where umbilical cord bleeding and poor wound healing were attributed to absent fibrin stabilization via the urea solubility test. Nomenclature evolved over time, with the International Society on Thrombosis and Haemostasis (ISTH) standardizing terms in 2005 to distinguish plasma (FXIII) from cellular forms and subunits (A and B), promoting consistency in research and clinical reporting.^[63]

Recent Developments

Since 2020, recombinant Factor XIII (FXIII) therapies have seen expanded applications, particularly with catridecacog (NovoThirteen), which received regulatory nods for further studies in regions like India in 2023 to broaden access for congenital FXIII deficiency treatment.^[64] Ongoing clinical trials, such as the SWIFT trial initiated in 2024, are evaluating early FXIII replacement with recombinant forms to reduce blood loss in postpartum hemorrhage. These developments build on established prophylactic uses, enhancing safety profiles for long-term administration in pediatric and adult patients.^[65] Recent studies from 2024-2025 have highlighted acquired FXIII deficiency in critical care settings, with a prospective observational study reporting high prevalence (up to 70%) in adults on extracorporeal membrane oxygenation (ECMO), correlating with increased bleeding risks and transfusion requirements.^[66] Similarly, case series published in 2025 linked acquired FXIII deficiency to myeloid neoplasms, emphasizing its role in malignancy-associated coagulopathy and the need for routine screening in such patients to mitigate hemorrhagic complications.^[67] Diagnostic advancements include the introduction of targeted liquid chromatography-tandem mass spectrometry (LC-MS/MS) assays in 2025, which offer superior sensitivity for quantifying FXIII A/B subunits compared to traditional functional tests, improving early detection of deficiencies with reduced false negatives.^[55] The International Society on Thrombosis and Haemostasis (ISTH) released updated guidelines in 2025 for FXIII deficiency classification, incorporating these assays and recommending activity thresholds below 30% for diagnosis, standardizing global approaches to inherited and acquired forms.^[51] The therapeutic market for FXIII deficiency treatments is projected to grow at a compound annual growth rate (CAGR) of 5.8% from $210.3 million in 2023 to $400.7 million by 2034, fueled by demand for long-acting concentrates and explorations into gene therapy for rare coagulopathies.^[68] Emerging research has also elucidated FXIII's role in COVID-19-associated coagulopathy, with a 2023 retrospective analysis showing elevated FXIII levels in milder cases and declines predicting severe outcomes, informing potential adjunctive therapies in post-pandemic coagulopathic states.^[69]

References

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Nov 21, 2019 · Plasma FXIII circulates as a pro-transglutaminase with two catalytic A subunits and two carrier-protective B subunits in a heterotetramer (FXIII-A 2 B 2 ).
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https://pdfs.semanticscholar.org/7da5/2ed1b66d8b78dc3bf2f601ee1a14cb0911cf.pdf
[34]
Interactions of factor XIII with fibrin as substrate and cofactor - PubMed
Factor XIIIa (a2') is a homodimeric transglutaminase that is formed via limited alpha-thrombin-catalyzed proteolysis of the platelet (a2) or plasma (a2b2) ...
[35]
Activated platelets retain and protect most of their factor XIII-A cargo ...
Oct 8, 2024 · Platelet factor XIII-A (FXIII-A) is a major cytoplasmic protein (∼3% of total), representing ∼50% of total circulating FXIII.
[36]
A simple, quick one-step ELISA assay for the ... - PubMed
A new highly sensitive sandwich ELISA assay was developed for the determination of plasma factor XIII (FXIII) ... A reference interval of 14-28 mg/L (67-133%) was ...
[37]
The half life of factor XIII in the management of inherited deficiency
The half life was found to be about 9--10 days. This is longer than most previous reports suggest. An explantation for this finding is offered.
[38]
[PDF] An Indispensable “Factor” in Haemostasis and Wound Healing
Mar 17, 2021 · Abstract: Factor XIII (FXIII) is a transglutaminase enzyme that catalyses the formation of ε-(γ- glutamyl)lysyl isopeptide bonds into ...
[39]
https://www.ncbi.nlm.nih.gov/books/NBK557467/
[40]
https://pubmed.ncbi.nlm.nih.gov/21738029/
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https://pubmed.ncbi.nlm.nih.gov/25615432/
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https://academic.oup.com/labmed/article/47/3/220/2453834
[43]
Factor XIII Deficiency - Symptoms, Causes, Treatment | NORD
Cases of factor XIII deficiency due to mutations of the F13A1 gene are sometimes referred to as factor XIIIA deficiency or factor XIII deficiency type 2.
[44]
Novel aspects of factor XIII deficiency - PubMed
Here we review recent developments concerning the diagnosis, classification and treatment of factor XIII (FXIII) deficiency and new findings related to the ...<|control11|><|separator|>
[45]
Factor XIII Deficiency - Medscape Reference
Mar 18, 2024 · Congenital FXIII deficiency is due principally to defects in the catalytic A subunit of FXIII, with more than 100 mutations throughout the ...<|separator|>
[46]
New developments in the management of congenital Factor XIII ...
FXIII concentrate has the longest plasma half-life (11–14 days) of all clotting factors. Primary prophylaxis is practical and feasible in cases of FXIII ...
[47]
Acquired factor XIII deficiency: A review - PubMed
Oct 30, 2018 · Causes of acquired deficiency include immune-mediated inhibition, as well as non-immune FXIII hyperconsumption or hyposynthesis.Missing: mechanisms | Show results with:mechanisms
[48]
[PDF] Acquired factor XIII deficiency due to an inhibitor - Haematologica
Table 1. Causes of acquired factor XIII deficiency. Impaired synthesis. Liver disease. Increased turn-over and consumption. Acute and chronic leukemia.
[49]
Acquired factor XIII deficiency in myeloid neoplasms: case s...
In acute leukemias, acquired FXIII deficiency has been reported and replacement of FXIII helped to control significant bleeding.
[50]
Acquired factor XIII deficiency: A scoping review
Acquired deficiency is due to two aetiologies: immune causes due to the rare development of autoantibodies targeting FXIII epitopes, and nonimmune causes due to ...
[51]
Acquired factor XIII deficiency in adult patients during ECMO: a prospective observational study - Scientific Reports
### Summary of Findings on Acquired FXIII Deficiency in ECMO Patients
[52]
Factor XIII in the Acute Care Setting and Its Relevance in Obstetric ...
On the basis of acute tissue injury which leads to major bleeding, acquired FXIII deficiency is traditionally considered to be secondary to consumption. However ...
[53]
View the newest SSC projects for the end of 2025
Sep 10, 2025 · Specific objectives include: (i) refining the classification of FXIII deficiencies, (ii) identifying relevant first-line and confirmatory assays ...
[54]
Factor XIII deficiency diagnosis: Challenges and tools - PubMed
Oct 13, 2017 · This report presents an overview of FXIIID diagnosis and laboratory methods and suggests an algorithm to improve diagnostic efficiency and prevent missed or ...
[55]
A Targeted LC-MS/MS-based Quantitative Assay for Detecting ...
These results establish the clinical utility of the LC-MS/MS assay and highlight its potential to improve diagnostic accuracy for FXIII ...
[56]
https://doi.org/10.1111/jth.13982
[57]
Factor XIII Deficiency Testing | Test Fact Sheet - ARUP Consult
May 14, 2025 · Reference interval: FXIII activity, 69-143% · Severe bleeding usually does not occur until FXIII level <1-3% · Mild or moderate deficiencies may ...Missing: percent | Show results with:percent
[58]
Factor XIII Deficiency Treatment & Management
Mar 18, 2024 · Following initial therapy, subsequent replacement with an FXIII concentrate dose of 50 U/kg every 5 weeks was sufficient to prevent rebleeding ...Approach Considerations · Medical Care · Surgical Care · Complications
[59]
Prophylactic therapy with Fibrogammin P is associated ... - PubMed
The mean annual number of spontaneous bleeds was 2.5 events per year prior to Fibrogammin P prophylaxis and 0.2 events per year during Fibrogammin P prophylaxis ...
[60]
[PDF] Corifact® (Factor XIII Concentrate [human] intravenous infusion
Dec 4, 2024 · Prospective data showed that a level of 30% Factor XIII clotting activity is an adequate therapeutic target for most patients. Treatment of.
[61]
Recombinant FXIII (rFXIII-A 2 ) Prophylaxis Prevents Bleeding and ...
Recombinant factor XIII-A 2 (rFXIII-A 2 ) was developed for prophylaxis and treatment of bleeds in patients with congenital FXIII A-subunit deficiency.
[62]
Factor XIII and the clotting of fibrinogen: from basic research to ...
Apr 11, 2005 · Contrary to what was originally thought, the protein responsible for the production of a urea-insoluble clot, which I named fibrin stabilizing ...