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Severe high-molecular-weight kininogen deficiency: clinical characteristics, deficiency-causing KNG1 variants, and estimated prevalence. JOURNAL OF THROMBOSIS AND HAEMOSTASIS : JTH 2023; 21:237-254. [PMID: 36700498 DOI: 10.1016/j.jtha.2022.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/27/2022] [Accepted: 10/27/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Severe high-molecular-weight kininogen (HK) deficiency is a poorly studied autosomal recessive contact system defect caused by pathogenic, biallelic KNG1 variants. AIM We performed the first comprehensive analysis of diagnostic, clinical, genetic, and epidemiological aspects of HK deficiency. METHODS We collected clinical information and blood samples from a newly detected HK-deficient individual and from published cases identified by a systematic literature review. Activity and antigen levels of coagulation factors were determined. Genetic analyses of KNG1 and KLKB1 were performed by Sanger sequencing. The frequency of HK deficiency was estimated considering truncating KNG1 variants from GnomAD. RESULTS We identified 48 cases of severe HK deficiency (41 families), of these 47 have been previously published (n = 19 from gray literature). We genotyped 3 cases and critically appraised 10 studies with genetic data. Ten HK deficiency-causing variants (one new) were identified. All of them were truncating mutations, whereas the only known HK amino acid substitution with a relevant phenotype instead causes hereditary angioedema. Conservative estimates suggest an overall prevalence of severe HK deficiency of approximately one case per 8 million population, slightly higher in Africans. Individuals with HK deficiency appeared asymptomatic and had decreased levels of prekallikrein and factor XI, which could lead to misdiagnosis. CONCLUSION HK deficiency is a rare condition with only few known pathogenic variants. It has an apparently good prognosis but is prone to misdiagnosis. Our understanding of its clinical implications is still limited, and an international prekallikrein and HK deficiency registry is being established to fill this knowledge gap.
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2
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Adenaeuer A, Barco S, Trinchero A, Lackner KJ, Lämmle B, Rossmann H. Definite diagnosis of plasma prekallikrein deficiency should not be based exclusively on shortening of the aPTT upon prolonged pre-incubation. Int J Lab Hematol 2022; 44:e179-e180. [PMID: 35377536 DOI: 10.1111/ijlh.13841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/04/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Anke Adenaeuer
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany.,Institute for Clinical Chemistry and Laboratory Medicine, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany.,Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Alice Trinchero
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | - Karl J Lackner
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany.,Institute for Clinical Chemistry and Laboratory Medicine, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Bernhard Lämmle
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany.,Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Haemostasis Research Unit, University College London, London, UK
| | - Heidi Rossmann
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany.,Institute for Clinical Chemistry and Laboratory Medicine, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
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3
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Abraham R, Viswanathan GK, Dass J, Dhawan R, Aggarwal M, Kumar P, Seth T, Mahapatra M. Prekallikrein deficiency: Challenges in laboratory testing. Int J Lab Hematol 2022; 44:e185-e186. [PMID: 35377535 DOI: 10.1111/ijlh.13843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/02/2022] [Accepted: 03/14/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Reema Abraham
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | | | - Jasmita Dass
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Rishi Dhawan
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Mukul Aggarwal
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Pradeep Kumar
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Tulika Seth
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Manoranjan Mahapatra
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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4
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Abraham RM, Viswanathan GK, Dass J, Dhawan R, Aggarwal M, Kumar P, Seth T, Mahapatra M. Prekallikrein deficiency due to homozygous KLKB1(+) mutation c.444_445insT (p.Ser151PhefsTer34). Int J Lab Hematol 2021; 44:e132-e134. [PMID: 34847617 DOI: 10.1111/ijlh.13773] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/06/2021] [Accepted: 11/13/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Reema Miria Abraham
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | | | - Jasmita Dass
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Rishi Dhawan
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Mukul Aggarwal
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Pradeep Kumar
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Tulika Seth
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Manoranjan Mahapatra
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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5
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A novel murine in vivo model for acute hereditary angioedema attacks. Sci Rep 2021; 11:15924. [PMID: 34354123 PMCID: PMC8342443 DOI: 10.1038/s41598-021-95125-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 06/15/2021] [Indexed: 12/03/2022] Open
Abstract
Hereditary Angioedema (HAE) is a rare genetic disease generally caused by deficiency or mutations in the C1-inhibitor gene, SERPING1, a member of the Serpin family. HAE results in acute attacks of edema, vasodilation, GI pain and hypotension. C1INH is a key inhibitor of enzymes controlling complement activation, fibrinolysis and the contact system. In HAE patients, contact system activation leads to uncontrolled production of bradykinin, the vasodilator responsible for the characteristic symptoms of HAE. In this study, we present the first physiological in vivo model to mimic acute HAE attacks. We evaluate hypotension, one of the many hallmark symptoms of acute HAE attacks using Serping1 deficient mice (serping1−/−) and implanted telemetry. Attacks were induced by IV injection of a silica nanoparticle (SiNP) suspension. Blood pressure was measured in real time, in conscious and untethered mice using implanted telemetry. SiNP injection induced a rapid, reversible decrease in blood pressure, in the presence of angiotensin converting enzyme (ACE) inhibition. We also demonstrate that an HAE therapeutic, ecallantide, can prevent HAE attacks in this model. The in vivo murine model described here can facilitate the understanding of acute HAE attacks, support drug development and ultimately contribute to improved patient care.
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6
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Kallikrein directly interacts with and activates Factor IX, resulting in thrombin generation and fibrin formation independent of Factor XI. Proc Natl Acad Sci U S A 2021; 118:2014810118. [PMID: 33397811 PMCID: PMC7826336 DOI: 10.1073/pnas.2014810118] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Prekallikrein (PK) is a zymogen that is converted to kallikrein (PKa) by factor (F)XIIa. PK and FXII reciprocally activate each other; the resulting FXIIa initiates activation of the coagulation system via the cleavage of FXI to FXIa, which then activates FIX. This manuscript describes a novel high-affinity binding interaction between FIX(a) and PK(a) and reports that PKa can dose- and time-dependently activate FIX to generate FIXa, resulting in thrombin generation and clot formation independent of FXIa. Characterization of the kinetics of FIX activation reveal that PKa is a more significant activator of FIX than previously considered. This work highlights a new amendment to the coagulation cascade where PKa can directly activate FIX. Kallikrein (PKa), generated by activation of its precursor prekallikrein (PK), plays a role in the contact activation phase of coagulation and functions in the kallikrein-kinin system to generate bradykinin. The general dogma has been that the contribution of PKa to the coagulation cascade is dependent on its action on FXII. Recently this dogma has been challenged by studies in human plasma showing thrombin generation due to PKa activity on FIX and also by murine studies showing formation of FIXa-antithrombin complexes in FXI deficient mice. In this study, we demonstrate high-affinity binding interactions between PK(a) and FIX(a) using surface plasmon resonance and show that these interactions are likely to occur under physiological conditions. Furthermore, we directly demonstrate dose- and time-dependent cleavage of FIX by PKa in a purified system by sodium dodecyl sulfate-polyacrylamide gel electrophoresis analysis and chromogenic assays. By using normal pooled plasma and a range of coagulation factor-deficient plasmas, we show that this action of PKa on FIX not only results in thrombin generation, but also promotes fibrin formation in the absence of FXII or FXI. Comparison of the kinetics of either FXIa- or PKa-induced activation of FIX suggest that PKa could be a significant physiological activator of FIX. Our data indicate that the coagulation cascade needs to be redefined to indicate that PKa can directly activate FIX. The circumstances that drive PKa substrate specificity remain to be determined.
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7
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Riano I, Prasongdee K. A Rare Cause of Isolated Prolonged Activated Partial Thromboplastin Time: An Overview of Prekallikrein Deficiency and the Contact System. J Investig Med High Impact Case Rep 2021; 9:23247096211012187. [PMID: 33940978 PMCID: PMC8114252 DOI: 10.1177/23247096211012187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Prekallikrein (PK) deficiency, also known as Fletcher factor deficiency, is a very rare disorder inherited as an autosomal recessive trait. It is usually identified incidentally in asymptomatic patients with a prolonged activated partial thromboplastin time (aPTT). In this article, we present the case of a 52-year-old woman, with no prior personal or family history of thrombotic or hemorrhagic disorders, who was noted to have substantial protracted aPTT through the routine coagulation assessment before a kidney biopsy. The patient had an uneventful biopsy course after receiving fresh frozen plasma (FFP). Laboratory investigations performed before the biopsy indicated normal activity for factors VIII, IX, XI, XII, and von Willebrand factor (vWF) as well as negative lupus anticoagulant (LA) screen. The plasma PK assay revealed low activity at 15% consistent with mild PK deficiency. The deficit of PK is characterized by a severely prolonged aPTT and normal prothrombin time (PT) in the absence of bleeding tendency. PK plays a role in the contact-activated coagulation pathway and the inflammatory response. Thus, other differential diagnoses of isolated prolonged aPTT include intrinsic pathway factor deficiencies and nonspecific inhibitors such as LA. We concluded that the initial evaluation of a prolonged aPTT with normal PT should appraise the measurement of contact activation factors and factor inhibitors. PK deficiency should be considered in asymptomatic patients with isolated aPTT prolongation, which corrects on incubation, with normal levels of the contact activation factors and factor inhibitors.
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Affiliation(s)
- Ivy Riano
- MetroWest Medical Center, Framingham, MA, USA.,Tufts University, Boston, MA, USA
| | - Klaorat Prasongdee
- MetroWest Medical Center, Framingham, MA, USA.,Tufts University, Boston, MA, USA
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8
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Adenaeuer A, Ezigbo ED, Fawzy Nazir H, Barco S, Trinchero A, Laubert-Reh D, Strauch K, Wild PS, Lackner KJ, Lämmle B, Rossmann H. c.451dupT in KLKB1 is common in Nigerians, confirming a higher prevalence of severe prekallikrein deficiency in Africans compared to Europeans. J Thromb Haemost 2021; 19:147-152. [PMID: 33073460 DOI: 10.1111/jth.15137] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/01/2020] [Accepted: 10/12/2020] [Indexed: 12/18/2022]
Abstract
Essentials Prekallikrein (PK) deficiency is a recessive trait with isolated aPTT prolongation. KLKB1 c.451dupT is common in Nigerians (7/600 alleles) and absent in a European group (0/600). To date, all genotyped PK-deficient patients of African ancestry were homozygous for 451dupT. Diagnostics of isolated aPTT prolongation in African descendants should include PK testing. ABSTRACT: Background Severe prekallikrein deficiency (PK deficiency) is an autosomal-recessive condition thought to be very rare. Recently we reported that the previously unnoticed variant c.451dupT, p.Ser151Phefs*34 in KLKB1, which is listed in databases aggregating genome data, causes PK deficiency and is common in Africans according to gnomAD (allele frequency 1.43%). Patients/Methods The most common African (c.451dupT) and European (c.1643G>A, p.Cys548Tyr) PK deficiency causing KLKB1 variants were analyzed in two population-based collectives of 300 Nigerian and 300 German subjects. Genome databases were evaluated for variant frequencies and ethnicity of the subjects. The geographic origin of PK-deficient cases due to 451dupT was assessed. Results Two of five patients with PK deficiency caused by homozygous 451dupT were African, one African American, one from Oman, and one of unknown origin. The frequency of 451dupT was 1.17% in the Nigerian collective (7/600 alleles); none had Cys548Tyr. Subjects with 451dupT were found among different Nigerian ethnicities. Both variants were absent in the European collective. Database research was compatible with these findings, even though mainly data of African Americans (451dupT: 1.12%-1.78%) was accessible. A relevant number of non-American Africans are included only in the 1000Genomes collective: 451dupT frequency was 1.29% in native Africans and 1.56% in African Caribbeans. Conclusions This study underlines the higher prevalence of PK deficiency among people with African descent compared to Europeans. In order to avoid delay of necessary surgical procedures in patients of African origin, diagnostic algorithms for isolated, unexplained, activated partial thromboplastin time prolongation in these subjects should include PK deficiency screening.
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Affiliation(s)
- Anke Adenaeuer
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Eyiuche D Ezigbo
- Thrombosis & Haemostasis unit, Department of Medical Laboratory Sciences, Faculty of Health Sciences & Technology, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria
| | - Hanan Fawzy Nazir
- Child Health Department, Sultan Qaboos University Hospital, Muscat, Oman
- Department of Pediatrics, Alexandria Faculty of Medicine, Alexandria, Egypt
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Alice Trinchero
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | - Dagmar Laubert-Reh
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Preventive Cardiology and Preventive Medicine Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Konstantin Strauch
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Philipp S Wild
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Preventive Cardiology and Preventive Medicine Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Karl J Lackner
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Bernhard Lämmle
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Haemostasis Research Unit, University College London, London, UK
| | - Heidi Rossmann
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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9
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Baker P, Platton S, Gibson C, Gray E, Jennings I, Murphy P, Laffan M. Guidelines on the laboratory aspects of assays used in haemostasis and thrombosis. Br J Haematol 2020; 191:347-362. [PMID: 32537743 DOI: 10.1111/bjh.16776] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Peter Baker
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sean Platton
- Haemophilia Centre, Barts Health NHS Trust, London, UK
| | - Claire Gibson
- Specialist Haemostasis, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Elaine Gray
- Haemostasis Section, Biotherapeutics Group, National Institute for Biological Standards and Controls, Hertfordshire, UK
| | | | - Paul Murphy
- Department of Haematology, the Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Mike Laffan
- Centre for Haematology, Imperial College and Hammersmith Hospital, London, UK
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10
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Girolami A, Ferrari S. An acquired prekallikrein deficiency can be diagnosed only after a sure exclusion of a congenital condition. Blood Coagul Fibrinolysis 2020; 31:419. [PMID: 32852325 DOI: 10.1097/mbc.0000000000000940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Antonio Girolami
- Department of Medicine, University of Padua Medical School, Padua, Italy
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11
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Barco S, Sollfrank S, Trinchero A, Adenaeuer A, Abolghasemi H, Conti L, Häuser F, Kremer Hovinga JA, Lackner KJ, Loewecke F, Miloni E, Vazifeh Shiran N, Tomao L, Wuillemin WA, Zieger B, Lämmle B, Rossmann H. Severe plasma prekallikrein deficiency: Clinical characteristics, novel KLKB1 mutations, and estimated prevalence. J Thromb Haemost 2020; 18:1598-1617. [PMID: 32202057 DOI: 10.1111/jth.14805] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/03/2020] [Accepted: 03/18/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Severe plasma prekallikrein (PK) deficiency is an autosomal-recessive defect characterized by isolated activated partial thromboplastin time prolongation. To date, no comprehensive methodologically firm analysis has investigated the diagnostic, clinical, and genetic characteristics of PK deficiency, and its prevalence remains unknown. PATIENTS/METHODS We described new families with PK deficiency, retrieved clinical and laboratory information of cases systematically searched in the (gray) literature, and collected blood of these cases for complementary analyses. The Genome Aggregation Database (gnomAD) and the population-based Gutenberg Health Study served to study the prevalence of mutations and relevant genetic variants. RESULTS We assembled a cohort of 111 cases from 89 families and performed new genetic analyses in eight families (three unpublished). We identified new KLKB1 mutations, excluded the pathogenicity of some of the previously described ones, and estimated a prevalence of severe PK deficiency of 1/155 668 overall and 1/4725 among Africans. One individual reported with PK deficiency had, in fact, congenital kininogen deficiency associated with decreased PK activity. One quarter of individuals had factor XII clotting activity below the reference range. Four major bleeding events were described in 96 individuals, of which 3 were provoked, for a prevalence of 4% and an annualized rate of 0.1%. The prevalence of cardiovascular events was 15% (6% <40 years; 21% 40-65 years; 33% >65 years) for an annualized rate of 0.4%. CONCLUSIONS We characterized the genetic background of severe PK deficiency, critically appraised mutations, and provided prevalence estimates. Our data on laboratory characteristics and clinical course of severe PK deficiency may have clinical implications.
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Affiliation(s)
- Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- Clinic of Angiology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Stefanie Sollfrank
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Alice Trinchero
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- Department of Medical Oncology and Hematology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Anke Adenaeuer
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Hassan Abolghasemi
- Pediatric Congenital Hematologic Disorders Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Pediatrics, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Laura Conti
- Clinical Pathology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Friederike Häuser
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Johanna A Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Karl J Lackner
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Felicia Loewecke
- Zentrum für Kinder- und Jugendmedizin, Klinik IV, Universitätsklinikum Freiburg, Freiburg, Germany
| | | | - Nader Vazifeh Shiran
- Department of Hematology and Blood Banking, Paramedical Faculty, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Luigi Tomao
- Clinical Pathology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
- Department of Pediatric Hematology-Oncology, IRCCS Bambino Gesù Children's Hospital, Roma, Italy
| | - Walter A Wuillemin
- Division of Hematology and Central Hematology Laboratory, Department of Internal Medicine, Kantonsspital Lucerne, Lucerne, Switzerland
| | - Barbara Zieger
- Zentrum für Kinder- und Jugendmedizin, Klinik IV, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Bernhard Lämmle
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Haemostasis Research Unit, University College London, London, UK
| | - Heidi Rossmann
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
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12
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Yasin H, Jamil MO, Williams Iii LA. Diagnostic Pearls and Clinical Implications of Prekallikrein Deficiency. Cureus 2020; 12:e8349. [PMID: 32617222 PMCID: PMC7325379 DOI: 10.7759/cureus.8349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Prekallikrein (PK) deficiency is extremely rare, and manifestations are not well characterized due to a small number of cases reported and the lack of scientific clarity about its role in clot formation in vivo. Here, we report a case of a 64-year-old male, with no known history of abnormal bleeding, who scheduled to undergo deep brain stimulator placement for control of his Parkinson's disease. During pre-procedure testing, activated partial thromboplastin time (PTT) was found to be prolonged at 146 seconds. Mixing studies were suggestive of a coagulation factor deficiency. His PTT characteristically became shorter with prolonged incubation, providing a clue at testing for PK levels, which were found to be severely low. He, subsequently, underwent surgery without any complications. Our case further highlights the clinical pearls for diagnosis and further endorses that these patients can safely undergo surgical procedures without the need for plasma transfusions or factor concentrate usage.
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Affiliation(s)
- Hassaan Yasin
- Hematology/Oncology, Joan C. Edwards School of Medicine, Marshall University, Huntington, USA
| | - Muhammad Omer Jamil
- Hematology/Oncology, Joan C. Edwards School of Medicine, Marshall University, Huntington, USA
| | - Lance A Williams Iii
- Transfusion Medicine/Pathology, University of Alabama at Birmingham, Birmingham, USA
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13
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Yang S, Ge M, Li X, Pan C. The spatial distribution of the normal reference values of the activated partial thromboplastin time based on ArcGIS and GeoDA. INTERNATIONAL JOURNAL OF BIOMETEOROLOGY 2020; 64:779-790. [PMID: 32337616 DOI: 10.1007/s00484-020-01868-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 11/23/2019] [Accepted: 01/20/2020] [Indexed: 06/11/2023]
Abstract
We explored the variation and spatial distribution of the activated partial thromboplastin time (APTT) reference values of healthy people at different altitudes in China in order to develop a scientific basis for a unified standard. The APTT reference values of 49,020 healthy males (41-75 years old) and 32,447 healthy females (41-75 years old) were collected from 601 work units and 546 work units in China, respectively. The relationship between the APTT reference values and altitude was tested by correlation analysis. Linear regression analysis and curve analysis were employed to predict the APTT reference values in the whole country. Trend surface analysis, the variation function, kriging interpolation, and Getis-Ord Gi* statistic were utilized to reveal the spatial characteristics of the values. The result showed a significant positive correlation between the APTT reference values and altitude. The APTT values for females were prolonged for a greater amount of time than the males in several same areas in China. The spatial contact forms of the APTT reference values of healthy Chinese were mainly "high-high" and "low-low," which was in accord with the first law of geography. The APTT reference values still showed spatial autocorrelation and regional variation. The values were higher in the western and northern areas than in the eastern and southern areas of China. The APTT reference values of people aged 41-75 in China showed regional differences. The APTT reference values in one area can be estimated by using the best prediction model or can be obtained by the geographical distribution.
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Affiliation(s)
- Shaofang Yang
- Institute of Healthy Geography, School of Geography and Tourism, Shaanxi Normal University, Xi'an, 710119, China.
| | - Miao Ge
- Institute of Healthy Geography, School of Geography and Tourism, Shaanxi Normal University, Xi'an, 710119, China
| | - Xiaoping Li
- Institute of Healthy Geography, School of Geography and Tourism, Shaanxi Normal University, Xi'an, 710119, China
| | - Chiqin Pan
- Forest Inventory and Planning Institute in Guizhou, Guiyang, 550003, China
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Jeong D, Goo JY, Kim HK, Chong SY, Kang MS. The First Korean Case of High-Molecular-Weight Kininogen Deficiency, With a Novel Variant, c.488delG, in the KNG1 Gene. Ann Lab Med 2019; 40:264-266. [PMID: 31858768 PMCID: PMC6933067 DOI: 10.3343/alm.2020.40.3.264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 08/18/2019] [Accepted: 11/26/2019] [Indexed: 11/19/2022] Open
Affiliation(s)
- Dajeong Jeong
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ja Yoon Goo
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hyun Kyung Kim
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Korea.
| | - So Young Chong
- Department of Internal Medicine, CHA Bundang Medical Center, Seongnam, Korea
| | - Myung Seo Kang
- Department of Laboratory Medicine, CHA Bundang Medical Center, Seongnam, Korea
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15
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Hereditary Angioedema: Insights into inflammation and allergy. Mol Immunol 2019; 112:378-386. [PMID: 31279849 DOI: 10.1016/j.molimm.2019.06.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 06/24/2019] [Accepted: 06/24/2019] [Indexed: 11/21/2022]
Abstract
Hereditary Angioedema (HAE) is a rare autosomal recessive bradykinin (BK)-mediated disease characterized by local episodes of non-pitting swelling. Initially considered a complement-mediated disease, novel pathogenic mechanisms uncovered in the last decade have revealed new HAE-associated genes and tight physiological relationships among complement, contact, coagulation, fibrinolysis and inflammation. Uncontrolled production of BK due to inefficient regulation of the plasma contact system, increased activity of contact and coagulation factors or a deficient regulation of BK receptor-triggered intracellular signalling are on the basis of HAE pathology. In this new scenario, HAE can result from different mechanisms that may generate distinct clinical phenotypes of the disease. This review focuses in the recent advances and unsolved challenges in our comprehension of this ever increasingly complex pathology.
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Ryu S, Gu JY, Hong KT, Han DH, Kim HK. The First Case of Congenital Prekallikrein Deficiency in Korea With a Novel Pathogenic Variant (c.1198G>T). Ann Lab Med 2019; 39:229-231. [PMID: 30430790 PMCID: PMC6240513 DOI: 10.3343/alm.2019.39.2.229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 06/11/2018] [Accepted: 09/20/2018] [Indexed: 11/19/2022] Open
Affiliation(s)
- Sohee Ryu
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ja Yoon Gu
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung Taek Hong
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Doo Hee Han
- Department of Otorhinolaryngology, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Kyung Kim
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea.,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea.
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De Maat S, Hofman ZLM, Maas C. Hereditary angioedema: the plasma contact system out of control. J Thromb Haemost 2018; 16:1674-1685. [PMID: 29920929 DOI: 10.1111/jth.14209] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 06/11/2018] [Indexed: 01/06/2023]
Abstract
The plasma contact system contributes to thrombosis in experimental models. Even though our standard blood coagulation tests are prolonged when plasma lacks contact factors, this enzyme system appears to have a minor (if any) role in hemostasis. In this review, we explore the clinical phenotype of C1 esterase inhibitor (C1-INH) deficiency. C1-INH is the key plasma inhibitor of the contact system enzymes, and its deficiency causes hereditary angioedema (HAE). This inflammatory disorder is characterized by recurrent aggressive attacks of tissue swelling that occur at unpredictable locations throughout the body. Bradykinin, which is considered to be a byproduct of the plasma contact system during in vitro coagulation, is the main disease mediator in HAE. Surprisingly, there is little evidence for thrombotic events in HAE patients, suggesting mechanistic uncoupling from the intrinsic pathway of coagulation. In addition, it is questionable whether a surface is responsible for contact system activation in HAE. In this review, we discuss the clinical phenotype, disease modifiers and diagnostic challenges of HAE. We subsequently describe the underlying biochemical mechanisms and contributing disease mediators. Furthermore, we review three types of HAE that are not caused by C1-INH inhibitor deficiency. Finally, we propose a central enzymatic axis that we hypothesize to be responsible for bradykinin production in health and disease.
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Affiliation(s)
- S De Maat
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Z L M Hofman
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - C Maas
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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18
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Simão F, Feener EP. The Effects of the Contact Activation System on Hemorrhage. Front Med (Lausanne) 2017; 4:121. [PMID: 28824910 PMCID: PMC5534673 DOI: 10.3389/fmed.2017.00121] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 07/12/2017] [Indexed: 01/12/2023] Open
Abstract
The contact activation system (CAS) exerts effects on coagulation via multiple mechanisms, which modulate both the intrinsic and extrinsic coagulation cascades as well as fibrinolysis and platelet activation. While the effects of the CAS on blood coagulation measured as activated partial thromboplastin time shortening are well documented, genetic mutations that result in deficiencies in the expression of either plasma prekallikrein (PPK) or factor XII (FXII) are not associated with spontaneous bleeding or increased bleeding risk during surgery. Deficiencies in these proteins are often undiagnosed for decades and detected later in life during routine coagulation assays without an apparent clinical phenotype. Increased interest in the CAS as a potentially safe target for antithrombotic therapies has emerged, in large part, from studies on animal models with provoked thrombosis, which have shown that deficiencies in PPK or FXII can reduce thrombus formation without increasing bleeding. Gene targeting and pharmacological studies in healthy animals have confirmed that PPK and FXII blockade does not cause coagulopathies. These findings support the conclusion that CAS is not required for hemostasis. However, while deficiencies in FXII and PPK do not significantly affect bleeding associated with peripheral wounds, recent reports have demonstrated that these proteins can promote hemorrhage in the retina and brain. Intravitreal injection of plasma kallikrein (PKal) induces retinal hemorrhage and intracerebral injection of PKal increases intracranial bleeding. PPK deficiency and PKal inhibition ameliorates hematoma formation following cerebrovascular injury in diabetic animals. Moreover, both PPK and FXII deficiency are protective against intracerebral hemorrhage caused by tissue plasminogen activator-mediated thrombolytic therapy in mice with thrombotic middle cerebral artery occlusion. Thus, while the CAS is not required for hemostasis, its inhibition may provide an opportunity to reduce hemorrhage in the retina and brain. Characterization of the mechanisms and potential clinical implications associated with the effects of the CAS on hemorrhage requires further consideration of the effects of PPK and FXII on hemorrhage beyond their putative effects on coagulation cascades. Here, we review the experimental and clinical evidence on the effects of the CAS on bleeding and hemostatic mechanisms.
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Affiliation(s)
- Fabrício Simão
- Research Division, Vascular Cell Biology, Joslin Diabetes Center, Harvard Medical School, Boston, MA, United States
| | - Edward P Feener
- Research Division, Vascular Cell Biology, Joslin Diabetes Center, Harvard Medical School, Boston, MA, United States
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20
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de Maat S, Björkqvist J, Suffritti C, Wiesenekker CP, Nagtegaal W, Koekman A, van Dooremalen S, Pasterkamp G, de Groot PG, Cicardi M, Renné T, Maas C. Plasmin is a natural trigger for bradykinin production in patients with hereditary angioedema with factor XII mutations. J Allergy Clin Immunol 2016; 138:1414-1423.e9. [DOI: 10.1016/j.jaci.2016.02.021] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 02/11/2016] [Accepted: 02/26/2016] [Indexed: 10/22/2022]
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21
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Zheng S, Just S, Brighton T. Prekallikrein deficiency. Pathology 2016; 48:634-7. [DOI: 10.1016/j.pathol.2016.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 07/01/2016] [Accepted: 07/13/2016] [Indexed: 11/30/2022]
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22
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Abstract
Factor XII is a mysterious plasma protein without a clear physiologic function. It was identified as a clotting factor, but has no clear role in hemostasis. However, FXII also contributes to the production of bradykinin, a short-lived inflammatory peptide. A growing body of mechanistic research from animal models indicates that FXII contributes to thrombotic disease by triggering excessive coagulation. FXII is evolutionarily conserved, suggesting that this molecule does have a physiologic function. This leads to intriguing questions: What does FXII really do? Is it even a real clotting factor at all? Before the groundbreaking discovery of a role for FXII in thrombotic disease, many studies investigated the biochemical properties of FXII and its activators. In this review, we highlight several biochemical studies that reveal much about the natural behavior of FXII. On the basis of these findings, it is possible to draft a conceptual model to explain how FXII reacts to surface materials. We then discuss how this model applies to the activities of FXII in its natural environment. There are two tentative physiologic functions of FXII that can operate exclusively: (i) maintenance of thrombus stability; (ii) local regulation of vascular permeability. Either, or both, of these natural functions may explain the evolutionary development and maintenance of FXII.
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Affiliation(s)
- S de Maat
- Department of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - C Maas
- Department of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht, the Netherlands
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de Maat S, Tersteeg C, Herczenik E, Maas C. Tracking down contact activation - from coagulationin vitroto inflammationin vivo. Int J Lab Hematol 2014; 36:374-81. [DOI: 10.1111/ijlh.12222] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 02/28/2014] [Indexed: 02/07/2023]
Affiliation(s)
- S. de Maat
- Department of Clinical Chemistry and Haematology; University Medical Center Utrecht; Utrecht the Netherlands
| | - C. Tersteeg
- Department of Clinical Chemistry and Haematology; University Medical Center Utrecht; Utrecht the Netherlands
| | - E. Herczenik
- Department of Clinical Chemistry and Haematology; University Medical Center Utrecht; Utrecht the Netherlands
| | - C. Maas
- Department of Clinical Chemistry and Haematology; University Medical Center Utrecht; Utrecht the Netherlands
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de Maat S, van Dooremalen S, de Groot PG, Maas C. A nanobody-based method for tracking factor XII activation in plasma. Thromb Haemost 2013; 110:458-68. [PMID: 23349032 DOI: 10.1160/th12-11-0792] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 12/15/2012] [Indexed: 11/05/2022]
Abstract
The physiological role of the plasma protein factor XII (FXII), as well as its involvement in human pathology, is poorly understood. While FXII is implicated in thrombotic pathology as a coagulation factor, it can contribute to inflammatory conditions without triggering coagulation. We recently generated nanobodies against the catalytic domain of activated FXII (FXIIa). Here, we describe two of these nanobodies, A10 and B7, both of which do not recognise FXII. Nanobody A10 recognises the catalytic domain of purified α-FXIIa (80 kDa), but not that of purified β-FXIIa (28 kDa), whereas nanobody B7 recognises both. This suggests minute differences in the catalytic domain between these isoforms of FXIIa. The detection of FXIIa by these nanobodies in plasma can become compromised through inactivation by serine protease inhibitors. This effect can be efficiently countered through the addition of the small-molecular protease inhibitor PPACK. Finally, we show that our nanobody-based assays in vitro distinguish various activation products of FXII that differ with the type of activator present: whereas procoagulant activators solely trigger the formation of a species that is captured by B7, proinflammatory activators first generate a species that is recognised by B7, which is later converted into a species that is recognised by A10. These findings suggest that a progressive proteolysis of FXIIa results in the generation a non-procoagulant form of FXIIa, whereas retention of intermediate forms triggers coagulation. Moreover, our findings indicate the development of nanobodies against activated enzymes offers improved opportunities to investigate their contribution to health and disease.
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Affiliation(s)
- S de Maat
- Dr. C. Maas, University Medical Center Utrecht, Department of Clinical Chemistry and Hematology, Room G.03.550, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands, Tel.: +31 88 755 6513, Fax: +31 88 755 5418, E-mail:
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Prekallikrein deficiency presenting as recurrent cerebrovascular accident: case report and review of the literature. Case Rep Hematol 2012; 2012:723204. [PMID: 22953077 PMCID: PMC3431062 DOI: 10.1155/2012/723204] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 07/24/2012] [Indexed: 11/17/2022] Open
Abstract
We report the case of a woman with history of hypertension and hyperlipidemia presenting with recurrent episodes consistent clinically with cerebrovascular accidents (CVA), and MRI changes suggestive of ischemia versus vasculitis as their cause. No anatomical neurological, rheumatic, cardioembolic, or arteriosclerotic etiologies could be determined by extensive workup. Incidentally, the patient was found to have prolonged activated Partial Thromboplastin Time (aPTT) and a normal Prothrombin Time (PT); further testing revealed a prekallikrein deficiency. Since no other cause for the CVAs was established, and other prothrombotic states were ruled out, it is proposed that they are clinical manifestations derived from the prekallikrein deficiency, which in a patient with known cardiovascular risk factors could lead to thrombotic complications such as stroke.
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27
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He Q, Gong K, Ao Q, Ma T, Yan Y, Gong Y, Zhang X. Positive charge of chitosan retards blood coagulation on chitosan films. J Biomater Appl 2011; 27:1032-45. [PMID: 22207609 DOI: 10.1177/0885328211432487] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In this study, a series of chitosan films with different protonation degrees were prepared by deacidification with NaOH aqueous or ethanol solutions. The films were then used as a model to investigate the effects of the positive charge of chitosan on blood coagulation. The results showed that the positive charge of chitosan acted as a double-edged sword, in that it promoted erythrocyte adhesion, fibrinogen adsorption, and platelet adhesion and activation, but inhibited activation of the contact system. In contrast to prevailing views, we found that the positive charge of chitosan retarded thrombin generation and blood coagulation on these films. At least two reasons were responsible for this phenomenon. First, the positive charge inhibited the contact activation, and second, the positive charge could not significantly promote the activation of non-adherent platelets in the bulk phase during the early stage of coagulation. The present findings improve our understanding of the events leading to blood coagulation on chitosan films, which will be useful for the future development of novel chitosan-based hemostatic devices.
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Affiliation(s)
- Qing He
- State Key Laboratory of Biomembrane and Membrane Biotechnology, School of Life Sciences, Tsinghua University, Beijing 100084, China
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28
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Girolami A, Scarparo P, Candeo N, Lombardi AM. Congenital prekallikrein deficiency. Expert Rev Hematol 2011; 3:685-95. [PMID: 21091145 DOI: 10.1586/ehm.10.69] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The congenital deficiency of prekallikrein (PK) is a rare condition in which there is a peculiar discrepancy between a severe in vitro defect and absence of bleeding. The gene controlling PK synthesis is located on chromosome 4 and consists of 14 exons and 15 introns. Only approximately 80 cases of PK deficiency have been described in the literature. Owing to the lack of bleeding, most cases go undetected or, if detected, go unreported. Occasional bleeding or thrombosis have been reported in a few patients but this was only due to the presence of associated risk factors. It is certain that the defect does not protect from thrombosis. Diagnosis is based on the presence of a great prolongation of partial thromboplastin time and normal prothrombin time and thrombin time. The long partial thromboplastin time is fully corrected by the addition of normal plasma or normal serum and presents the unusual feature of shortening on long incubation times. Platelet and vascular tests are normal. Immunological studies allow differentiation into two types, namely cases of true deficiency, which are approximately 70% of the total, and cases with abnormal forms. PK is a glycoprotein synthesized in the liver as a single-chain peptide of 88000 Da. It mostly circulates (∼75%) as a complex with high-molecular-weight kininogen. It is cleaved by FXIIa into a heavy chain and a light chain (catalytic domain), held together by disulfide bonds. Molecular biology techniques have so far only been applied to eleven families, and these studies do not yet allow definite phenotype/genotype conclusions. The exons involved are 5, 8, 11, 14 and 15. The noncoagulative effects of PK, mainly based on the effect of kallikrein, have been studied less, since they appear to be the result of the involvement of other components of the contact phase. Kallikrein can mainly affect the formation of bradykinin from high-molecular-weight kininogen and the activation of pro-urokinase to urokinase. Bradykinin causes inflammation, vasodilatation and an increase in vessel permeability. The activation of pro-urokinase results in enhanced fibrinolysis. However, fibrinolysis has been reported to be normal or defective in these patients.
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Affiliation(s)
- Antonio Girolami
- Department of Medical and Surgical Sciences, Padua University, Via Ospedale, Padua, Italy.
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29
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Hyperglycemia-induced cerebral hematoma expansion is mediated by plasma kallikrein. Nat Med 2011; 17:206-10. [PMID: 21258336 PMCID: PMC3038677 DOI: 10.1038/nm.2295] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Accepted: 12/16/2010] [Indexed: 01/20/2023]
Abstract
Hyperglycemia is associated with increased hematoma expansion and worse clinical outcomes following intracerebral hemorrhage. We demonstrate that cerebral hematoma expansion triggered by intracerebral infusion of autologous blood is increased in diabetic rats and mice, and this response is ameliorated by plasma kallikrein (PK) inhibition and deficiency, respectively. Both diabetes and hyperglycemia induced in nondiabetic rats increase hematoma expansion following intracerebral injection of purified PK, a response not observed with bradykinin, plasmin, or tissue plasminogen activator. This response is rapid, prevented by co-injection of the glycoprotein VI (GPVI) agonist convulxin, and mimicked by GPVI inhibition or deficiency. We show that PK binding to collagen and PK-mediated inhibition of collagen-induced platelet aggregation is enhanced by hyperglycemia. Hyperosmotic mannitol also increases hematoma expansion induced by blood and PK, and increases PK-mediated inhibition of platelet aggregation. These findings suggest that hyperglycemia increases cerebral hematoma expansion by PK-mediated osmotic-sensitive inhibition of hemostasis.
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30
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Yi Qian, Jing Pan, Xiaodong Zhou, Hourcade DE, Liszewski MK, Atkinson JP, Hong Lu, Lijuan Zhang. Oversulfated Heparin By-Products Induce Thrombin Generation in Human Plasmas Through Contact System Activation. Clin Appl Thromb Hemost 2010; 16:244-50. [DOI: 10.1177/1076029610362071] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Thrombin generation is thought to be mediated predominantly by the tissue factor or ‘‘extrinsic’’ coagulation pathway. An alternate pathway to thrombin generation (the ‘‘intrinsic’’ pathway or contact system) has been observed when blood or plasma comes in contact with artificial surfaces. Here we present evidence for a new route to thrombin formation that begins with the activation of the contact system protein prekallikrein by oversulfated heparin (OS-HB). Kallikrein, instead of activated factor X, cleaves prothrombin to form thrombin. Thrombin then cleaves fibrinogen to form fibrin clots. Moreover, we show that OS-HB by-products induce kallikrein- and thrombin-like activities in normal human plasma and in human plasma devoid of coagulation factor X or downstream contact system components factor IX or factor XI. Oversulfated heparin by-product-induced thrombin generation may have had a role in the adverse reactions associated with the recent clinical use of contaminated heparin.
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Affiliation(s)
- Yi Qian
- Departments of Pathology and Immunology, and Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Jing Pan
- Departments of Pathology and Immunology, and Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Xiaodong Zhou
- Departments of Pathology and Immunology, and Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Dennis E. Hourcade
- Departments of Pathology and Immunology, and Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - M. Kathryn Liszewski
- Departments of Pathology and Immunology, and Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - John P. Atkinson
- Departments of Pathology and Immunology, and Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Hong Lu
- Departments of Pathology and Immunology, and Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Lijuan Zhang
- Departments of Pathology and Immunology, and Medicine, Washington University School of Medicine, St. Louis, MO, USA,
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Girolami A, Marun S, Vettore S, Scaliter G, Molina A, Scarparo P, Tabares A, Lombardi AM. A large family from Argentina with prekallikrein deficiency due to a compound heterozygosis (T insertion in intron 7 and Asp558Glu in exon 15): prekallikrein Cordoba. Am J Hematol 2010; 85:363-6. [PMID: 20301226 DOI: 10.1002/ajh.21654] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Corno AR, Campolo J, Redaelli R, Caimi TM, Mostarda G, Morra E, Nichelatti M. Automated APTT cycle for the rapid identification of plasma prekallikrein deficiency. Thromb Res 2010; 126:e152-3. [PMID: 20207395 DOI: 10.1016/j.thromres.2010.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Revised: 02/02/2010] [Accepted: 02/03/2010] [Indexed: 11/16/2022]
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Qian Y, Pan J, Zhou X, Weiser P, Lu H, Zhang L. Molecular Mechanism Underlines Heparin-Induced Thrombocytopenia and Thrombosis. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2010; 93:395-421. [DOI: 10.1016/s1877-1173(10)93017-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
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Odumosu MC, Yoong WC, Fakokunde AF. Fletcher factor deficiency in a woman requiring emergency caesarean section. J OBSTET GYNAECOL 2009; 29:442. [DOI: 10.1080/01443610902952554] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Bryant J, Shariat-Madar Z. Human plasma kallikrein-kinin system: physiological and biochemical parameters. Cardiovasc Hematol Agents Med Chem 2009; 7:234-50. [PMID: 19689262 PMCID: PMC4905712 DOI: 10.2174/187152509789105444] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The plasma kallikrein-kinin system (KKS) plays a critical role in human physiology. The KKS encompasses coagulation factor XII (FXII), the complex of prekallikrein (PK) and high molecular weight kininogen (HK). The conversion of plasma prekallikrein to kallikrein by the activated FXII and in response to numerous different stimuli leads to the generation of bradykinin (BK) and activated HK (HKa, an antiangiogenic peptide). BK is a proinflammatory peptide, a pain mediator and potent vasodilator, leading to robust accumulation of fluid in the interstitium. Systemic production of BK, HKa with the interplay between BK bound-BK receptors and the soluble form of HKa are key to angiogenesis and hemodynamics. KKS has been implicated in the pathogenesis of inflammation, hypertension, endotoxemia, and coagulopathy. In all these cases increased BK levels is the hallmark. In some cases, the persistent production of BK due to the deficiency of the blood protein C1-inhibitor, which controls FXII, is detrimental to the survival of the patients with hereditary angioedema (HAE). In others, the inability of angiotensin converting enzyme (ACE) to degrade BK leads to elevated BK levels and edema in patients on ACE inhibitors. Thus, the mechanisms that interfere with BK liberation or degradation would lead to blood pressure dysfunction. In contrast, anti-kallikrein treatment could have adverse effects in hemodynamic changes induced by vasoconstrictor agents. Genetic models of kallikrein deficiency are needed to evaluate the quantitative role of kallikrein and to validate whether strategies designed to activate or inhibit kallikrein may be important for regulating whole-body BK sensitivity.
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Affiliation(s)
- J.W. Bryant
- Pfizer Global Research and Development, CVMED Exploratory, Groton, CT 06340
| | - z Shariat-Madar
- School of Pharmacy, Department of Pharmacology, University of Mississippi, University, MS 38677-1848
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36
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Zhuo R, Vogler EA. Practical application of a chromogenic FXIIa assay. Biomaterials 2006; 27:4840-5. [PMID: 16765435 DOI: 10.1016/j.biomaterials.2006.05.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2006] [Accepted: 05/10/2006] [Indexed: 11/17/2022]
Abstract
Autohydrolysis of blood factor XII (FXII+FXIIa-->2FXIIa) is found to be a facile reaction in neat-buffer buffer solutions of FXII but an insignificant reaction in the presence of plasma proteins. Autohydrolysis causes a chromogenic assay for FXIIa in buffer solution to strongly deviate from the traditional plasma-coagulation assay. Autohydrolysis can be accommodated by performing chromogenic detection of FXIIa as a rate assay in swamping concentrations of FXII. Rate-assay results performed in this way are shown to be in analytical agreement with the plasma-coagulation assay. Autohydrolysis can be used as a means of amplifying FXIIa produced by contacting neat-buffer solutions of FXII with biomaterials, suggesting a route to highly sensitive measurement of biomaterial hemocompatibility.
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Affiliation(s)
- Rui Zhuo
- Department of Bioengineering, University Park, PA 16802, USA
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37
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Acar K, Yağci M, Sucak GT, Haznedar R. Isolated prolonged activated partial thromboplastin time in an asymptomatic patient: Fletcher factor deficiency. Thromb Res 2006; 118:765-6. [PMID: 16414101 DOI: 10.1016/j.thromres.2005.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2005] [Revised: 11/30/2005] [Accepted: 12/05/2005] [Indexed: 10/25/2022]
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Abstract
AbstractThe differential diagnosis of a long APTT with a normal prothrombin time can be due to either a clotting factor deficiency or the presence of an inhibitor, which can be distinguished by using a plasma-mixing study. The various clotting factor deficiency states are reviewed. Clinical bleeding following cardiac bypass surgery due to acquired factor V and thrombin antibodies is also reviewed.
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Affiliation(s)
- Lawrence L K Leung
- VA Palo Alto HCS, Medical Service, B2-125, 3801 Miranda Ave., Palo Alto, CA 94304, USA.
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Wynne Jones D, Russell G, Allford SL, Burdon K, Hawkins GA, Bowden DW, Minaee S, Mumford AD. Severe prekallikrein deficiency associated with homozygosity for an Arg94Stop nonsense mutation. Br J Haematol 2004; 127:220-3. [PMID: 15461630 DOI: 10.1111/j.1365-2141.2004.05180.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
An elderly patient with no abnormal bleeding presented with prolongation of the activated partial thromboplastin time (aPTT). Preincubation of plasma with aPTT reagent caused shortening of the abnormal clotting time. Plasma prekallikrein (PK) activity and antigen were <5 u/dL. Molecular analysis showed a homozygous Arg94Stop substitution in the PK gene, predicted to prevent expression of the mutant allele. The five heterozygous offspring of the proband each showed a normal aPTT but reduced PK activity and antigen. This is the first description of a kindred in which absence of expression of one or both PK alleles has been confirmed by genotype.
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Affiliation(s)
- D Wynne Jones
- Department of Biosciences, University of Kent and Kent Haemophilia Centre, Kent & Canterbury Hospital, Canterbury, Kent, UK
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