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Identification and characterization of a novel splice site mutation in the SERPING1 gene in a family with hereditary angioedema. Clin Immunol 2014; 150:143-8. [DOI: 10.1016/j.clim.2013.11.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 11/20/2013] [Accepted: 11/22/2013] [Indexed: 11/21/2022]
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Abstract
The plasma coagulation system reacts quickly to limit blood loss from injury sites but also contributes to vascular thrombosis. In current models of hemostatic balance, normal coagulation and thrombosis represent two sides of the same coin, however, recent data from gene-deleted murine models have challenged this dogma. Deficiency of coagulation Factor XII (Hageman factor), a serine protease that initiates the intrinsic pathway of coagulation, severely impairs arterial thrombus formation but is not associated with excessive bleeding. These findings suggest that fibrin-generating mechanisms that operate during pathologic thrombus formation involve pathways distinct from those that are active during normal hemostasis. As Factor XII selectively contributes to thrombus formation in occlusive disease, but not to normal hemostasis, inhibition of this protease may offer a novel treatment strategy for prevention of arterial thrombosis with minimal or no risk of bleeding.
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Affiliation(s)
- Thomas Renné
- Institute for Clinical Biochemistry and Pathobiochemistry Division, Julius-Maximilians-University Würzburg, Josef-Schneider Strasse 2 Building, D-97080 Würzburg, Germany.
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Craig TJ, Bernstein JA, Farkas H, Bouillet L, Boccon-Gibod I. Diagnosis and Treatment of Bradykinin-Mediated Angioedema: Outcomes from an Angioedema Expert Consensus Meeting. Int Arch Allergy Immunol 2014; 165:119-27. [DOI: 10.1159/000368404] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 09/12/2014] [Indexed: 11/19/2022] Open
Abstract
Several types of angioedema exist beyond hereditary angioedema (HAE) types I/II; however, the diagnostic and treatment needs of these conditions are not well understood. Noticeably, there are no licensed treatments available for other forms of angioedema beyond HAE types I/II, and similarly they are unresponsive to conventional antihistamine/glucocorticoid treatment. A group of angioedema experts met in Budapest in May 2013 to discuss such issues, presenting their experience, reviewing available literature and identifying unmet diagnostic and treatment needs in three different angioedema types: HAE with normal C1-inhibitor (C1-INH; previously referred to as type III HAE); nonallergic angiotensin-converting enzyme inhibitor (ACEI)-induced angioedema (ACEI-AAE), and acquired angioedema due to C1-INH deficiency (C1-INH-AAE). The group identified unmet diagnostic and treatment needs in HAE-nC1-INH, C1-INH-AAE and ACEI-AAE, explored remedies and made recommendations on how to diagnose and treat these forms of angioedema. The group discussed the difficulties associated with using diagnostic markers, such as the level and function of C1-INH, C1q and C4 to reliably diagnose the angioedema type, and considered the use of genetic testing to identify mutations in <i>FXII</i> or <i>XPNPEP2 </i>that have been associated with HAE-nC1-INH and ACEI-AAE, respectively. Due to the lack of approved treatments for HAE-nC1-INH, ACEI-AAE and C1-INH-AAE, the group presented several case studies in which therapies approved for treatment of HAE types I/II, such as icatibant, ecallantide and pasteurized, nanofiltered C1-INH, were successful. It was uniformly agreed that further studies are needed to improve the diagnosis and treatment of angioedema other than HAE types I/II. i 2014 S. Karger AG, Basel
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Bernstein JA. Managing Hereditary Angioedema Patients Undergoing Otolaryngeal Procedures. Am J Rhinol Allergy 2013; 27:522-7. [DOI: 10.2500/ajra.2013.27.3964] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Hereditary angioedema (HAE), a rare autosomal dominant disorder, is characterized by repeated attacks of swelling of the skin, gastrointestinal tract, face, larynx, and other organs. In most cases it is caused by low levels of functional C1 esterase inhibitor (C1-INH), a serine protease inhibitor that plays important regulatory roles in the complement, contact, and fibrinolytic pathways. Methods Lack of functional C1-INH results in excessive release of bradykinin, which triggers vasodilation, vascular permeability, and edema. Most attacks are mild and self-limiting, but untreated laryngeal attacks may cause rapid asphyxiation and death. Potential triggers of laryngeal attacks include trauma to or manipulation of the face, mouth, or upper airway. Therefore, before performing such a procedure in a patient with HAE, the otolaryngologist should consult with the patient, the physician managing the HAE, and the anesthesiologist and make appropriate preparations for prevention and/or treatment of an attack. Results Current World Allergy Organization and European guidelines recommend the use of i.v. plasma-derived C1-INH replacement for short-term prophylaxis of angioedema attacks. Other effective options include danazol given for several days before and after the procedure and fresh-frozen plasma, but these may not be as effective as C1-INH and may be associated with a high rate of adverse events. Conclusion Acute attacks, which may occur many hours after a procedure, may be treated with C1-INH; icatibant, a bradykinin B2-receptor antagonist; or ecallantide, a kallikrein inhibitor, all of which have been shown to reduce the duration and severity of HAE attacks.
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Affiliation(s)
- Jonathan A. Bernstein
- Division of Immunology/Allergy Section, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
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156
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Ghannam A, Defendi F, Charignon D, Csopaki F, Favier B, Habib M, Cichon S, Drouet C. Contact System Activation in Patients with HAE and Normal C1 Inhibitor Function. Immunol Allergy Clin North Am 2013; 33:513-33. [PMID: 24176216 DOI: 10.1016/j.iac.2013.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Hereditary angioedema caused by the p.Thr309Lys mutation in the F12 gene: A multifactorial disease. J Allergy Clin Immunol 2013; 132:986-9.e1-5. [DOI: 10.1016/j.jaci.2013.04.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 04/18/2013] [Accepted: 04/23/2013] [Indexed: 11/19/2022]
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Kiss N, Barabás E, Várnai K, Halász A, Varga LÁ, Prohászka Z, Farkas H, Szilágyi Á. Novel duplication in the F12 gene in a patient with recurrent angioedema. Clin Immunol 2013; 149:142-5. [DOI: 10.1016/j.clim.2013.08.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Revised: 07/29/2013] [Accepted: 08/01/2013] [Indexed: 10/26/2022]
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Abstract
Until recently it was assumed that hereditary angioedema was a disease that results exclusively from a genetic deficiency of the C1 inhibitor. In 2000, families with hereditary angioedema, normal C1 inhibitor activity, and protein in plasma were described. Since then, numerous patients and families with that condition have been reported. Most of the patients were women. In many of the affected women, oral contraceptives, hormone replacement therapy containing estrogens, and pregnancies triggered the clinical symptoms. In some families mutations in the coagulation factor XII (Hageman factor) gene were detected.
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Affiliation(s)
- Konrad Bork
- Department of Dermatology, Johannes Gutenberg University, Langenbeckstr. 1, 55131 Mainz, Germany.
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160
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Javaud N, Fain O, Martin L. Angioedèmes bradykiniques. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0696-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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161
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Riedl MA. Hereditary Angioedema with Normal C1-INH (HAE Type III). THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2013; 1:427-32. [DOI: 10.1016/j.jaip.2013.06.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 06/14/2013] [Indexed: 10/26/2022]
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Abstract
Angioedema usually occurs within the setting of allergic diseases or urticaria, but situations occur in which angioedema itself represents a disease, such as in hereditary angioedema. Evaluation of patients for recurrent angioedema without wheals must take into account both specific clinical signs and symptoms and specialized laboratory testing.
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Affiliation(s)
- Marco Cicardi
- Department of Biological and Clinical Sciences Luigi Sacco, Ospedale Luigi Sacco, University of Milan, Milano, Italy.
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163
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Defendi F, Charignon D, Ghannam A, Baroso R, Csopaki F, Allegret-Cadet M, Ponard D, Favier B, Cichon S, Nicolie B, Fain O, Martin L, Drouet C. Enzymatic assays for the diagnosis of bradykinin-dependent angioedema. PLoS One 2013; 8:e70140. [PMID: 23940538 PMCID: PMC3734293 DOI: 10.1371/journal.pone.0070140] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 06/20/2013] [Indexed: 01/11/2023] Open
Abstract
Background The kinins (primarily bradykinin, BK) represent the mediators responsible for local increase of vascular permeability in hereditary angioedema (HAE), HAE I-II associated with alterations of the SERPING1 gene and HAE with normal C1-Inhibitor function (HAE-nC1INH). Besides C1-Inhibitor function and concentration, no biological assay of kinin metabolism is actually available to help physicians for the diagnosis of angioedema (AE). We describe enzymatic tests on the plasma for diagnosis of BK-dependent AE. Methods The plasma amidase assays are performed using the Pro-Phe-Arg-p-nitroanilide peptide substrate to evaluate the spontaneous amidase activity and the proenzyme activation. We analyzed data of 872 patients presenting with BK-dependent AE or BK-unrelated diseases, compared to 303 controls. Anti-high MW kininogen (HK) immunoblot was achieved to confirm HK cleavage in exemplary samples. Reproducibility, repeatability, limit of blank, limit of detection, precision, linearity and receiver operating characteristics (ROC) were used to calculate the diagnostic performance of the assays. Results Spontaneous amidase activity was significantly increased in all BK-dependent AE, associated with the acute phase of disease in HAE-nC1INH, but preserved in BK-unrelated disorders. The increase of the amidase activity was associated to HK proteolysis, indicating its relevance to identify kininogenase activity. The oestrogens, known for precipitating AE episodes, were found as triggers of enzymatic activity. Calculations from ROC curves gave the optimum diagnostic cut-off for women (9.3 nmol⋅min−1⋅mL−1, area under curve [AUC] 92.1%, sensitivity 80.0%, and specificity 90.1%) and for men (6.6 nmol·min−1⋅mL−1, AUC 91.0%, sensitivity 87.0% and specificity 81.2%). Conclusion The amidase assay represents a diagnostic tool to help physicians in the decision to distinguish between BK-related and –unrelated AE.
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Affiliation(s)
- Federica Defendi
- Centre de Référence des Angioedèmes à Kinines, CREAK, Grenoble, France.
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164
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Björkqvist J, Jämsä A, Renné T. Plasma kallikrein: the bradykinin-producing enzyme. Thromb Haemost 2013; 110:399-407. [PMID: 23846131 DOI: 10.1160/th13-03-0258] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 06/04/2013] [Indexed: 12/21/2022]
Abstract
Plasma prekallikrein is the liver-derived precursor of the trypsin-like serine protease plasma kallikrein (PK) and circulates in plasma bound to high molecular weight kininogen. The zymogen is converted to PK by activated factor XII. PK drives multiple proteolytic reaction cascades in the cardiovascular system such as the intrinsic pathway of coagulation, the kallikrein-kinin system, the fibrinolytic system, the renin-angiotensin system and the alternative complement pathway. Here, we review the biochemistry and cell biology of PK and focus on recent in vivo studies that have established important functions of the protease in procoagulant and proinflammatory disease states. Targeting PK offers novel strategies not previously appreciated to interfere with thrombosis and vascular inflammation in a broad variety of diseases.
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Affiliation(s)
- J Björkqvist
- Thomas Renné, MD, PhD, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital Solna (L1:00), SE-171 76 Stockholm, Sweden, Tel.: +46 8 517 73390, Fax: +46 310376, E-mail:
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165
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Zuraw BL, Bernstein JA, Lang DM, Craig T, Dreyfus D, Hsieh F, Khan D, Sheikh J, Weldon D, Bernstein DI, Blessing-Moore J, Cox L, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CR, Schuller DE, Spector SL, Tilles SA, Wallace D. A focused parameter update: Hereditary angioedema, acquired C1 inhibitor deficiency, and angiotensin-converting enzyme inhibitor–associated angioedema. J Allergy Clin Immunol 2013; 131:1491-3. [DOI: 10.1016/j.jaci.2013.03.034] [Citation(s) in RCA: 127] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 03/11/2013] [Accepted: 03/14/2013] [Indexed: 11/26/2022]
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Barbara DW, Ronan KP, Maddox DE, Warner MA. Perioperative angioedema: background, diagnosis, and management. J Clin Anesth 2013; 25:335-43. [DOI: 10.1016/j.jclinane.2012.07.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Revised: 07/11/2012] [Accepted: 07/21/2012] [Indexed: 11/26/2022]
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167
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López-Lera A, Cabo FS, Garrido S, Dopazo A, López-Trascasa M. Disease-modifying factors in hereditary angioedema: an RNA expression-based screening. Orphanet J Rare Dis 2013; 8:77. [PMID: 23688356 PMCID: PMC3671971 DOI: 10.1186/1750-1172-8-77] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 05/09/2013] [Indexed: 11/10/2022] Open
Abstract
Background Hereditary Angioedema due to C1-Inhibitor deficiency (HAE types I and II) is a monogenic disease characterized by sudden, self-limited episodes of cutaneous and mucosal swelling due to local deregulation of vascular permeability. Despite its monogenic pattern of inheritance, HAE exhibits great clinical variability and low genotype/phenotype correlation among those affected, which ultimately hinders therapeutic approach and probably underlies yet unknown genetic and environmental factors. Methods We studied whole-genome RNA expression of PBMCs in three HAE type-I families (accounting for 40 individuals), 24 of which carry the same R472X mutation in the C1-Inhibitor gene and show large variability in terms of disease expression. Those included in this study were analyzed according to the presence of mutation and/or clinical symptoms. Results Instead of a single, common disease-associated expression pattern, we found different transcriptome signatures in two of the families studied. In one of them (referred to as DR family), symptoms correlate with the upregulation of 35 genes associated to the biological response to viral infections (including RSADs, OAS, MX and ISG pathway members) and immune response. In another pedigree (Q family), disease manifestation is linked to the upregulation of 43 genes with diverse functions, including transcription and protein folding. Moreover, symptoms-free members of the Q pedigree display relatively higher expression of 394 genes with a wide diversity of functions. Conclusion We found no evidence for a common altered PBMC expression pattern linked to HAE symptoms in the three families analyzed. All the data considered, differential gene expression in PBMCs do not seem to play a significant role in the predisposition or protection against HAE in the basal -between crises- conditions analyzed. Although the RNA expression pattern associated to the response to viral infections observed in the DR family supports the idea of infectious diseases as a modifying factor for HAE severity, large-scale studies would be needed to statistically associate such expression pattern to the development of this rare disease.
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Affiliation(s)
- Alberto López-Lera
- Immunology Unit, Hospital Universitario La Paz and Hospital La Paz Research Institute (IdiPAZ), Madrid, Spain.
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168
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Lang DM, Aberer W, Bernstein JA, Chng HH, Grumach AS, Hide M, Maurer M, Weber R, Zuraw B. International consensus on hereditary and acquired angioedema. Ann Allergy Asthma Immunol 2013. [PMID: 23176876 DOI: 10.1016/j.anai.2012.10.008] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- David M Lang
- Allergy/Immunology, Respiratory Institute, Cleveland Clinic, Ohio, USA.
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Saule C, Boccon-Gibod I, Fain O, Kanny G, Plu-Bureau G, Martin L, Launay D, Bouillet L, Gompel A. Benefits of progestin contraception in non-allergic angioedema. Clin Exp Allergy 2013; 43:475-82. [DOI: 10.1111/cea.12055] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 10/20/2012] [Accepted: 10/24/2012] [Indexed: 11/30/2022]
Affiliation(s)
- C. Saule
- Gynaecological Endocrinology Unit; Paris Descartes University; Port Royal Cochin; APHP; Paris; France
| | | | | | | | - G. Plu-Bureau
- Gynaecological Endocrinology Unit; Paris Descartes University; Port Royal Cochin; APHP; Paris; France
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Pathak M, Wong SS, Dreveny I, Emsley J. Structure of plasma and tissue kallikreins. Thromb Haemost 2013; 110:423-33. [PMID: 23494059 DOI: 10.1160/th12-11-0840] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 02/27/2013] [Indexed: 12/14/2022]
Abstract
The kallikrein kinin system (KKS) consists of serine proteases involved in the production of peptides called kinins, principally bradykinin and Lys-bradykinin (kallidin). The KKS contributes to a variety of physiological processes including inflammation, blood pressure control and coagulation. Here we review the protein structural data available for these serine proteases and examine the molecular mechanisms of zymogen activation and substrate recognition focusing on plasma kallikrein (PK) and tissue kallikrein (KLK1) cleavage of kininogens. PK circulates as a zymogen bound to high-molecular-weight kininogen (HK). PK is activated by coagulation factor XIIa and then cleaves HK to generate bradykinin and factor XII to generate further XIIa.A structure has been described for the activated PK protease domain in complex with the inhibitor benzamidine. Kallikrein-related peptidases (KLKs) have a distinct domain structure and exist as a family of 15 genes which are differentially expressed in many tissues and the central nervous system.They cleave a wide variety of substrates including low-molecular-weight kininogen (LK) and matrix proteins. Crystal structures are available for KLK1, 3, 4, 5, 6 and 7 activated protease domains typically in complex with S1 pocket inhibitors. A substrate mimetic complex is described for KLK3 which provides insight into substrate recognition. A zymogen crystal structure determined for KLK6 reveals a closed S1 pocket and a novel mechanism of zymogen activation. Overall these structures have proved highly informative in understanding the molecular mechanisms of the KKS and provide templates to design inhibitors for treatment of a variety of diseases.
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Affiliation(s)
- M Pathak
- Dr. Jonas Emsley, Centre for Biomolecular Sciences, School of Pharmacy, University of Nottingham, University Park, Nottingham, NG72RD, UK, Tel.: +44 1158467092, Fax: +44 1158468002, E-mail:
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172
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Abstract
Some skin conditions may require treatment in intensive care units. The early diagnosis of life-threatening dermatoses is a considerable challenge. We review skin diseases which may require intensive care. In addition to Stevens-Johnson syndrome and toxic epidermal necrolysis, representing adverse skin reactions, we discuss staphylococcal scalded skin syndrome and necrotizing fasciitis as infection-associated dermatoses, as well as angioedema. We focus on the course of disease describing clinical presentations, diagnostics and therapeutic strategies with respect to critical medical conditions.
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Affiliation(s)
- C Marks
- Abt. für Hämatologie/Onkologie, Medizinische Universitätsklinik Freiburg, Hugstetter Str. 55, 79106, Freiburg, Deutschland.
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174
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del Río-Espínola A, Fernández-Cadenas I, Giralt D, Quiroga A, Gutiérrez-Agulló M, Quintana M, Fernández-Álvarez P, Domingues-Montanari S, Mendióroz M, Delgado P, Turck N, Ruíz A, Ribó M, Castellanos M, Obach V, Martínez S, Freijo MM, Jiménez-Conde J, Cuadrado-Godia E, Roquer J, Chacón P, Martí-Fábregas J, Sánchez JC, Montaner J. A predictive clinical-genetic model of tissue plasminogen activator response in acute ischemic stroke. Ann Neurol 2012; 72:716-29. [DOI: 10.1002/ana.23664] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2011] [Revised: 05/29/2012] [Accepted: 06/01/2012] [Indexed: 11/07/2022]
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175
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Horiuchi T, Ohi H, Ohsawa I, Fujita T, Matsushita M, Okada N, Seya T, Yamamoto T, Endo Y, Hatanaka M, Wakamiya N, Mizuno M, Nakao M, Okada H, Tsukamoto H, Matsumoto M, Inoue N, Nonaka M, Kinoshita T. Guideline for hereditary angioedema (HAE) 2010 by the Japanese Association for Complement Research - secondary publication. Allergol Int 2012; 61:559-62. [PMID: 23093794 DOI: 10.2332/allergolint.12-rai-0471] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Indexed: 11/20/2022] Open
Abstract
This guideline was provided by the Japanese Association for Complement Research targeting clinicians for making an accurate diagnosis of hereditary angioedema (HAE), and for prompt treatment of the HAE patient in Japan. This is a 2010 year version and will be updated according to any pertinent medical advancements.
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Affiliation(s)
- Takahiko Horiuchi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan. −u.ac.jp
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[Diagnostics and exclusion of hereditary angioedema : a standarized approach for the practice]. Hautarzt 2012; 63:567-72. [PMID: 22751857 DOI: 10.1007/s00105-012-2388-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The differentiation between mast cell mediator-mediated and bradykinin-mediated forms of angioedema can be difficult. Bradykinin-mediated hereditary angioedema is a rare autosomal dominant hereditary disease which is characterized by recurrent edema attacks of varying magnitude. The edema occurs in the skin and mucous membranes and can be temporarily disfiguring, very painful and life-threatening by attacks in the laryngeal region. Because of the multitude of differential diagnoses, a final diagnosis is only achieved after an average duration of more than 10 years. The anamnestic and laboratory diagnostic algorithm presented here is designed to assist a simpler differentiation of the various forms of angioedema and to reach the correct diagnosis more quickly.
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Kaplan A. Type III hereditary angioedema: defined, but not understood. Ann Allergy Asthma Immunol 2012; 109:153-4. [PMID: 22920066 DOI: 10.1016/j.anai.2012.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Revised: 07/03/2012] [Accepted: 07/07/2012] [Indexed: 11/29/2022]
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Castelli R, Zanichelli A, Cugno M. Therapeutic options for patients with angioedema due to C1-inhibitor deficiencies: from pathophysiology to the clinic. Immunopharmacol Immunotoxicol 2012; 35:181-90. [DOI: 10.3109/08923973.2012.726627] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
Coagulation factor XII (FXII, Hageman factor, EC = 3.4.21.38) is the zymogen of the serine protease, factor XIIa (FXIIa). FXII is converted to FXIIa through autoactivation induced by "contact" to charged surfaces. FXIIa is of crucial importance for fibrin formation in vitro, but deficiency in the protease is not associated with excessive bleeding. For decades, FXII was considered to have no function for coagulation in vivo. Our laboratory developed the first murine knockout model of FXII. Consistent with their human counterparts, FXII(-/-) mice have a normal hemostatic capacity. However, thrombus formation in FXII(-/-) mice is largely defective, and the animals are protected from experimental cerebral ischemia and pulmonary embolism. This murine model has created new interest in FXII because it raises the possibility for safe anticoagulation, which targets thrombosis without influence on hemostasis. We recently have identified platelet polyphosphate (an inorganic polymer) and mast cell heparin as in vivo FXII activators with implications on the initiation of thrombosis and edema during hypersensitivity reactions. Independent of its protease activity, FXII exerts mitogenic activity with implications for angiogenesis. The goal of this review is to summarize the in vivo functions of FXII, with special focus to its functions in thrombosis and vascular biology.
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Charignon D, Späth P, Martin L, Drouet C. Icatibant , the bradykinin B2 receptor antagonist with target to the interconnected kinin systems. Expert Opin Pharmacother 2012; 13:2233-47. [PMID: 22970904 DOI: 10.1517/14656566.2012.723692] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
INTRODUCTION HOE-140/ Icatibant is a selective, competitive antagonist to bradykinin (BK) against its binding to the kinin B2 receptor. Substitution of five non-proteogeneic amino acid analogues makes icatibant resistant to degradation by metalloproteases of kinin catabolism. Icatibant has clinical applications in inflammatory and vascular leakage conditions caused by an acute (non-controlled) production of kinins and their accumulation at the endothelium B2 receptor. The clinical manifestation of vascular leakage, called angioedema (AE), is characterized by edematous attacks of subcutaneous and submucosal tissues, which can cause painful intestinal consequences, and life-threatening complications if affecting the larynx. Icatibant is registered for the treatment of acute attacks of the hereditary BK-mediated AE, i.e., AE due to C1 inhibitor deficiency. AREAS COVERED This review discusses emerging knowledge on the kinin system: kinin pharmacological properties, biochemical characteristics of the contact phase and kinin catabolism proteases. It underlines the responsibility of the kinins in AE initiation and the potency of icatibant to inhibit AE formation by kinin-receptor interactions. EXPERT OPINION Icatibant antagonist properties protect BK-mediated AE patients against severe attacks, and could be developed for use in inflammatory conditions. More studies are required to confirm whether or not prolonged and frequent applications of icatibant could result in the impairment of the cardioprotective effect of BK.
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Affiliation(s)
- Delphine Charignon
- Université Joseph Fourier Grenoble 1, GREPI/AGIM CNRS-UJF FRE 3405 and Centre de Référence des Angioedèmes CREAK, CHU Grenoble POBox 217, F-38043 Grenoble, France
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Giard C, Nicolie B, Drouet M, Lefebvre-Lacoeuille C, Le Sellin J, Bonneau JC, Maillard H, Rénier G, Cichon S, Ponard D, Drouet C, Martin L. Angio-oedema induced by oestrogen contraceptives is mediated by bradykinin and is frequently associated with urticaria. Dermatology 2012; 225:62-9. [PMID: 22922353 DOI: 10.1159/000340029] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Accepted: 06/04/2012] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Hereditary C1-inhibitor (C1-Inh) deficiency is associated with 'bradykinin-mediated angio-oedema' (BK-AO) and is believed not to be associated with urticaria. Acquired AO has been related to oestrogen contraceptives. OBJECTIVE To demonstrate that AO precipitated by oestrogens and characterized by nonfunctional C1-Inh is mediated by BK and to evaluate the occurrence of urticaria in these patients. METHODS A retrospective evaluation of patients referred for AO related to oestrogen was undertaken. Circulating C1-Inh, high molecular weight kininogen (HK) and enzymes involved in the metabolism of bradykinin were investigated. RESULTS Fifteen patients were included. HK cleavage concurrent to oestrogen intake was demonstrated in 10 patients with available plasma. Eight patients reported recurrent or chronic urticaria. Discontinuation of the contraceptive resulted in a return to native C1-Inh and HK in all cases studied and to normal kininogenase activity in all but one. The clinical manifestations completely disappeared in 6 patients and improved in 7 after the withdrawal of oestrogen. CONCLUSION Patients display extensive cleavage of HK in the plasma, which supports that AO precipitated by oestrogen contraception is BK-mediated. Recurrent urticaria may have been underestimated in this context. The presence of recurrent urticaria should not systematically rule out the diagnosis of BK-AO when the history is suggestive.
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Affiliation(s)
- C Giard
- Department of Dermatology, L’UNAM University, Angers Hospital, Angers, France
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Marcos C, López Lera A, Varela S, Liñares T, Alvarez-Eire MG, López-Trascasa M. Clinical, biochemical, and genetic characterization of type III hereditary angioedema in 13 Northwest Spanish families. Ann Allergy Asthma Immunol 2012; 109:195-200.e2. [PMID: 22920075 DOI: 10.1016/j.anai.2012.05.022] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 05/09/2012] [Accepted: 05/16/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND A new variant of hereditary angioedema has been reported during the last decade. Three main characteristics distinguish it from classic hereditary angioedema: normal C1 inhibitor activity, predominance in women, and different genetic alterations. OBJECTIVE To assess the symptoms, laboratory findings, and treatment of a population with type III hereditary angioedema from Northwest Spain. METHODS We studied 29 patients (26 female and 3 male) from 13 different families. RESULTS The 26 female patients showed a similar clinical pattern to the classic forms of hereditary angioedema, and 22 of these patients had the estrogen-dependent phenotype. Three patients had a negative family history, and 1 of the parents was confirmed as an asymptomatic carrier in 2 of them. All had functional C1 inhibitor activity within the normal range in periods without high estrogen levels, but during attacks (in female patients) and pregnancy, activity decreased to below 50%. One male patient had normal C1 inhibitor activity during attacks, and he was initially diagnosed as having idiopathic angioedema. The C4 and antigenic C1 inhibitor levels were always normal. All studied patients had the c.1032C>A, Thr309Lys mutation in the factor XII gene. The mutation was also found in asymptomatic relatives: 5 of 6 men studied and 1 of 8 women studied. CONCLUSION Positive family history is a diagnosis criterion, but it could be lacking because there may be asymptomatic relatives, primarily males.
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Affiliation(s)
- Carmen Marcos
- Allergy Service of University Hospital Complex of Vigo, Pontevedra, Spain.
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183
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Boccon-Gibod I, Bouillet L. Safety and efficacy of icatibant self-administration for acute hereditary angioedema. Clin Exp Immunol 2012; 168:303-7. [PMID: 22519593 DOI: 10.1111/j.1365-2249.2012.04574.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
We evaluated the efficacy and safety of icatibant self-administration in 15 patients with hereditary angioedema (HAE) types I or III, for 55 acute attacks (mostly severe or very severe). Icatibant self-administration was generally effective: first symptom improvement occurred in 5 min-2 h (HAE type I; n = 17) and 8 min-1 h (HAE type III; n = 9) for abdominal attacks and 5-30 min (HAE type I; n = 4) and 10 min-12 h (HAE type III; n = 6) for laryngeal attacks. Complete symptom resolution occurred in 15 min-19 h (HAE type I; n = 8) and 15 min-48 h (HAE type III; n = 9) for abdominal attacks and 5-48 h (HAE type I; n = 3) and 8-48 h (HAE type III; n = 5) for laryngeal attacks. No patient required emergency hospitalization. The only adverse events were mild, spontaneously resolving injection site reactions. Patients reported that carrying icatibant with them gave them greater confidence in managing their condition.
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Affiliation(s)
- I Boccon-Gibod
- National Reference Center for Angioedema-CREAK, Department of Internal Medicine, Grenoble University Hospital, Grenoble, France.
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184
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Boccon-gibod I. Urticaire/angioedème histaminique ou bradykinique ? REVUE FRANCAISE D ALLERGOLOGIE 2012. [DOI: 10.1016/j.reval.2012.02.154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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185
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Senaratne KT, Cottrell AM, Prentice RL. Successful Perioperative Management of a Patient with C1 Esterase Inhibitor Deficiency with a Novel Bradykinin Receptor B2 Antagonist. Anaesth Intensive Care 2012; 40:523-6. [DOI: 10.1177/0310057x1204000320] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We present the case of a 28-year-old female with a previous diagnosis of C1 esterase inhibitor deficiency presenting for dental extractions under general anaesthesia. Following prophylaxis with a new bradykinin receptor 2 antagonist (icatibant), surgery was carried out uneventfully with an unremarkable postoperative course.
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Affiliation(s)
- K. T. Senaratne
- Department of Anaesthesia and Peioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - A. M. Cottrell
- Department of Anaesthesia and Peioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - R. L. Prentice
- Department of Anaesthesia and Peioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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Many faces of angioedema: focus on the diagnosis and management of abdominal manifestations of hereditary angioedema. Eur J Gastroenterol Hepatol 2012; 24:353-61. [PMID: 22410711 DOI: 10.1097/meg.0b013e3283517998] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Angioedema of the intestinal tract is an infrequent but well-described cause of abdominal pain that can occur because of inherited, acquired, allergic, or drug-induced causes. Hereditary angioedema (HAE) is a genetic disorder that causes recurrent attacks of severe edema of various body parts, including the intestinal tract. Moderate to severe abdominal pain occurs in 43-93% of such attacks due to intestinal edema. Laryngeal edema is a potentially life-threatening manifestation. Failure to recognize and diagnose HAE or other causes of intestinal angioedema can lead to years of delay in diagnosis, and in the case of HAE, often to unnecessary abdominal surgeries. Recognizing the typical history of recurrent attacks of abdominal pain, oropharyngeal/laryngeal angioedema or cutaneous angioedema, family history of similar symptoms, association of attacks with stress or menses, and exacerbation of attacks after administration of estrogens or angiotensin-converting enzyme inhibitors will increase diagnostic accuracy. Interdisciplinary treatment is often necessary after the diagnosis of HAE, first with acute management in the emergency room or the intensive care unit, followed by either drug prophylaxis against future attacks using a C1-esterase inhibitor concentrate or attenuated androgens and discontinuation of medications known to trigger attacks. Newer drugs approved for treatment of acute attacks may have future roles in the prevention of attacks if further studies support their efficacy. Gastroenterologists in particular should maintain a high index of suspicion for the possibility of HAE or other causes of intestinal angioedema in patients with a history of recurrent abdominal pain.
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188
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Hack CE, Relan A, van Amersfoort ES, Cicardi M. Target levels of functional C1-inhibitor in hereditary angioedema. Allergy 2012; 67:123-30. [PMID: 21923668 DOI: 10.1111/j.1398-9995.2011.02716.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hereditary angioedema (HAE) is a heterozygous deficiency of first component of complement-inhibitor (C1INH). Insufficient C1INH activity leads to uncontrolled activation of plasma cascade systems, which results in acute angioedema attacks in patients with HAE. Plasma-derived or recombinant C1INH products are approved for the treatment of such angioedema attacks. The target level of C1INH activity needed to achieve optimal efficacy, however, remains unknown. We determined the plasma level of C1INH associated with optimal clinical efficacy in the treatment of angioedema attacks. METHODS Efficacy and pharmacokinetic data were reviewed from recently published placebo-controlled randomized trials in the treatment of HAE with either plasma-derived or recombinant C1INH products, tested at various doses. RESULTS A dose-dependent effect was observed on time to the beginning of relief of symptoms, on time to resolution of symptoms, and on the response rate within 4 h. Optimal efficacy of C1INH therapy is achieved at doses ≥50 U/kg. This dose increases plasma C1INH activity in almost all patients to values ≥0.7 U/ml (70% of normal), the lower limit of the normal range. The differences in half-lives of the various C1INH products do not have an obvious effect on clinical efficacy. CONCLUSION A review of the efficacy and pharmacokinetic data from recently published controlled studies in the treatment of HAE attacks suggests that efficacy of C1INH therapy is optimal when C1INH activity levels are restored to the normal range.
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Affiliation(s)
- C E Hack
- Department of Dermatology/Allergology, Rheumatology and Immunology, University Medical Center Utrecht, Utrecht, the Netherlands.
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189
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Abstract
Background Laryngeal angioedema may be associated with significant morbidity and even mortality. Because of the potential severity of attacks, both allergists and otolaryngologists must be knowledgeable about the recognition and treatment of laryngeal angioedema. This study describes the clinical characteristics and pathophysiology of bradykinin-mediated angioedema. Methods A literature review was conducted concerning the clinical characteristics and pathophysiology of types I and II hereditary angioedema (HAE), type III HAE, acquired C1 inhibitor (C1INH) deficiency, and angiotensin-converting enzyme (ACE) inhibitor–associated angioedema. Results The diagnosis of type I/II HAE is relatively straightforward as long as the clinician maintains a high index of suspicion. Mutations in the SERPING1 gene result in decreased secretion of functional C1INH and episodic activation of plasma kallikrein and Hageman factor (FXII) of the plasma contact system with cleavage of high molecular weight kininogen and generation of bradykinin. In contrast, there are no unequivocal criteria for making a diagnosis of type III HAE, although a minority of these patients may have a mutation in the factor XII gene. Angioedema attacks and mediator of swelling in acquired C1INH deficiency are similar to those in type I or II HAE; however, it occurs on a sporadic basis because of excessive consumption of C1INH in patients who are middle aged or older. ACE inhibitor–associated angioedema should always be considered in any patient taking an ACE inhibitor who experiences angioedema. ACE is a kininase, which when inhibited is thought to result in increased bradykinin levels. Bradykinin acts on vascular endothelial cells to enhance vascular permeability. Conclusion Laryngeal swelling is not infrequently encountered in bradykinin-mediated angioedema. Novel therapies are becoming available that for the first time provide effective treatment for bradykinin-mediated angioedema. Because the characteristics and treatment of these angioedemas are quite distinct from each other and from histamine-mediated angioedema, it is crucial that the physician be able to recognize and distinguish these swelling disorders.
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Affiliation(s)
- Bruce L. Zuraw
- Department of Medicine, University of California, San Diego, and San Diego Veteran's Affairs Medical Center, La Jolla, California
| | - Sandra C. Christiansen
- Department of Allergy, Kaiser Permanente and University of California, San Diego, California
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Bork K, Wulff K, Meinke P, Wagner N, Hardt J, Witzke G. A novel mutation in the coagulation factor 12 gene in subjects with hereditary angioedema and normal C1-inhibitor. Clin Immunol 2011; 141:31-5. [DOI: 10.1016/j.clim.2011.07.002] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2011] [Revised: 07/15/2011] [Accepted: 07/19/2011] [Indexed: 10/17/2022]
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191
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The procoagulant and proinflammatory plasma contact system. Semin Immunopathol 2011; 34:31-41. [DOI: 10.1007/s00281-011-0288-2] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Accepted: 07/20/2011] [Indexed: 10/17/2022]
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Bouillet L, Mannic T, Arboleas M, Subileau M, Massot C, Drouet C, Huber P, Vilgrain I. Hereditary angioedema: Key role for kallikrein and bradykinin in vascular endothelial-cadherin cleavage and edema formation. J Allergy Clin Immunol 2011; 128:232-4. [DOI: 10.1016/j.jaci.2011.02.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Revised: 02/10/2011] [Accepted: 02/17/2011] [Indexed: 11/16/2022]
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Baeza ML, Rodríguez-Marco A, Prieto A, Rodríguez-Sainz C, Zubeldia JM, Rubio M. Factor XII gene missense mutation Thr328Lys in an Arab family with hereditary angioedema type III. Allergy 2011; 66:981-2. [PMID: 21631522 DOI: 10.1111/j.1398-9995.2011.02562.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- M L Baeza
- Hospital General Universitario Gregorio, Madrid, Spain.
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Oschatz C, Maas C, Lecher B, Jansen T, Björkqvist J, Tradler T, Sedlmeier R, Burfeind P, Cichon S, Hammerschmidt S, Müller-Esterl W, Wuillemin WA, Nilsson G, Renné T. Mast cells increase vascular permeability by heparin-initiated bradykinin formation in vivo. Immunity 2011; 34:258-68. [PMID: 21349432 DOI: 10.1016/j.immuni.2011.02.008] [Citation(s) in RCA: 192] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2008] [Revised: 08/16/2010] [Accepted: 12/10/2010] [Indexed: 10/18/2022]
Abstract
Activated mast cells trigger edema in allergic and inflammatory disease. We report a paracrine mechanism by which mast cell-released heparin increases vascular permeability in vivo. Heparin activated the protease factor XII, which initiates bradykinin formation in plasma. Targeting factor XII or kinin B2 receptors abolished heparin-triggered leukocyte-endothelium adhesion and interfered with a mast cell-driven drop in blood pressure in rodents. Intravital laser scanning microscopy and tracer measurements showed heparin-driven fluid extravasation in mouse skin microvessels. Ablation of factor XII or kinin B2 receptors abolished heparin-induced skin edema and protected mice from allergen-activated mast cell-driven leakage. In contrast, heparin and activated mast cells induced excessive edema in mice deficient in the major inhibitor of factor XII, C1 esterase inhibitor. Allergen exposure triggered edema attacks in hereditary angioedema patients, lacking C1 esterase inhibitor. The data indicate that heparin-initiated bradykinin formation plays a fundamental role in mast cell-mediated diseases.
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Affiliation(s)
- Chris Oschatz
- Clinical Chemistry, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Guichon C, Floccard B, Coppéré B, Hautin E, Bagès-Limoges F, Rouvière O, Monnier N, Drouet C, Allaouchiche B. One hypovolaemic shock…two kinin pathway abnormalities. Intensive Care Med 2011; 37:1227-8. [PMID: 21484080 DOI: 10.1007/s00134-011-2225-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2011] [Indexed: 11/28/2022]
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197
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Les angioedèmes à bradykinine. Ann Dermatol Venereol 2011; 138:328-35; quiz 327, 336. [DOI: 10.1016/j.annder.2010.12.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Revised: 11/26/2010] [Accepted: 12/20/2010] [Indexed: 11/20/2022]
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Giavina-Bianchi P, França AT, Grumach AS, Motta AA, Fernandes FR, Campos RA, Valle SO, Rosário NA, Sole D. Brazilian guidelines for the diagnosis and treatment of hereditary angioedema. Clinics (Sao Paulo) 2011; 66:1627-36. [PMID: 22179171 PMCID: PMC3164416 DOI: 10.1590/s1807-59322011000900021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Accepted: 05/01/2011] [Indexed: 01/16/2023] Open
Abstract
Hereditary angioedema is an autosomal dominant disease characterized by edema attacks with multiple organ involvement. It is caused by a quantitative or functional deficiency of the C1 inhibitor, which is a member of the serine protease inhibitor family. Hereditary angioedema is unknown to many health professionals and is therefore an underdiagnosed disease. The causes of death from hereditary angioedema include laryngeal edema with asphyxia. The estimated mortality rate in patients in whom the disease goes undetected and who are therefore incorrectly treated is 25-40%. In addition to edema of the glottis, hereditary angioedema often results in edema of the gastrointestinal tract, which can be incapacitating. Patients with hereditary angioedema may undergo unnecessary surgical interventions because the digestive tract can be the primary or only organ system involved, thus mimicking acute surgical abdomen. It is estimated that patients with hereditary angioedema experience some degree of disability 20-100 days per year. The Experts in Clinical Immunology and Allergy of the "Associação Brasileira de Alergia e Imunopatologia -ASBAI" developed these guidelines for the diagnosis, therapy, and management of hereditary angioedema.
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Abstract
Hereditary angioedema is an episodic swelling disorder with autosomal dominant inheritance. Attacks are characterized by nonpitting edema of external or mucosal body surfaces. Patients often present with swelling of the extremities, abdominal pain, and swelling of the mouth and throat, which can at times lead to asphyxiation. The disease is caused by a mutation in the gene encoding the complement C1-inhibitor protein, which leads to unregulated production of bradykinin. Long-term therapy has depended on the use of attenuated androgens or plasmin inhibitors but in the US there was, until recently, no specific therapy for acute attacks. As well, many patients with hereditary angioedema in the US were either not adequately controlled on previously available therapies or required doses of medications that exposed them to the risk of serious adverse effects. Five companies have completed or are currently conducting phase III clinical trials in the development of specific therapies to terminate acute attacks or to be used as prophylaxis. These products are based on either replacement therapy with purified plasma-derived or recombinant C1-inhibitor, or inhibition of the kinin-generating pathways with a recombinant plasma kallikrein inhibitor or bradykinin type 2 receptor antagonist. Published studies thus far suggest that all of these products are likely to be effective. These new therapies will likely lead to a totally new approach in treating hereditary angioedema.
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Affiliation(s)
- Rafael Firszt
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina 27710, USA
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Kaplan AP. Enzymatic pathways in the pathogenesis of hereditary angioedema: The role of C1 inhibitor therapy. J Allergy Clin Immunol 2010; 126:918-25. [DOI: 10.1016/j.jaci.2010.08.012] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Revised: 06/24/2010] [Accepted: 08/05/2010] [Indexed: 11/24/2022]
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