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Raina R, Sethi S, Khooblall A, Kher V, Deshpande S, Yerigeri K, Pandya A, Nair N, Datla N, McCulloch M, Bunchman T, Davenport A. Non-anticoagulation pediatric continuous renal replacement therapy methods to increase circuit life. Hemodial Int 2022; 26:147-159. [PMID: 34989465 DOI: 10.1111/hdi.13003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Acute kidney injury (AKI) is a clinical condition characterized by an abrupt increase in serum creatinine levels due to functional changes in the kidneys from a newfound insult or injury. For supportive treatment, continuous renal replacement therapy (CRRT) is one of the most widely used modalities due to its precise control of fluid balance over extended periods of time. However, its complications include circuit clotting, the most frequent cause for CRRT interruption. Vascular access and circuit management were found to be major determinants of performance efficiency. Anticoagulation required to prevent clotting has the downside of increasing the risk of bleeding, especially in the setting of overdosage. Hence, a delicate balance needs to be maintained consistently. METHODS This study explores the adequacy of non-anticoagulation measures in the prevention of circuit clotting. A comprehensive literature search was conducted using PubMed/Medline and Embase databases to include all relevant studies. FINDINGS The most-effective CRRT catheter would be made of nonthrombogenic material, noncuffed and nontunneled with separate lumens for arterial and venous blood. Further, studies show that blood flow during the process is optimized at 200 ml/min, which can be lowered in the pediatric population due to more narrow catheters. Platelet count and hematocrit need to be closely monitored as levels above 450,000 × 106 /L and 0.40, respectively, increase risk of clotting. Predilution is a non-anticoagulation technique to reduce the risk of clotting by returning replacement solution to the blood before it reaches the filter. Also, biocompatible membranes such as polyacrylonitrile or polysulfone activate the coagulation cascade significantly less than the conventional cellulose-based membranes, thereby reducing clotting chances. DISCUSSIONS With the advent of such techniques and maneuvers, anticoagulation can be efficiently maintained in patients undergoing CRRT without increasing the risk of bleeding.
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Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Sidharth Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | - Amrit Khooblall
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Vijay Kher
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | - Shweta Deshpande
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Keval Yerigeri
- Department of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Aadi Pandya
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Nikhil Nair
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Nithin Datla
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Mignon McCulloch
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Timothy Bunchman
- Pediatric Nephrology & Transplantation, Children's Hospital of Richmond at VCU, Richmond, Virginia, USA
| | - Andrew Davenport
- University College London Centre for Nephrology, Division of Medicine, University College London Medical School, Royal Free Hospital, London, UK
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Berkestedt I, Andersson P, Herwald H, Valik JK, Sörensen O, Bodelsson M. Early depletion of contact system in patients with sepsis: a prospective matched control observational study. APMIS 2018; 126:892-898. [PMID: 30397964 DOI: 10.1111/apm.12898] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 09/25/2018] [Indexed: 01/24/2023]
Abstract
Activation of the contact system generates bradykinin from high-molecular-weight kininogen and has been suggested to participate in the pathophysiology of sepsis. To test this, we prospectively measured bradykinin and high-molecular-weight kininogen levels in a cohort of sepsis patients requiring intensive care. From 29 patients meeting criteria for sepsis or septic shock according to Sepsis-3, blood was sampled within 24 h and on the fourth day following admittance to intensive care. Patients planned for neurosurgery served as matched controls. Sequential organ failure assessment score and 90-day mortality was registered. Bradykinin levels (median [interquartile range]) were lower in sepsis patients (79 [62-172] pg/ml) compared to controls (130 [86-255] pg/ml, p < 0.025) and did not correlate with mortality or severity of circulatory derangement. High-molecular-weight kininogen levels were lower in sepsis patients (1.6 [0.8-4.8] densitometry units) compared to controls (4.4 [2.9-7.7] densitometry units, p < 0.001), suggesting previous contact system activation. High-molecular-weight kininogen levels were lower in non-survivors than survivors (p = 0.003) and negatively correlated to severity of circulatory derangement. We conclude that a role for bradykinin in later stages of severe sepsis must be challenged. Low high-molecular-weight kininogen concentrations suggest that the decrease in bradykinin is due to substrate depletion.
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Affiliation(s)
- Ingrid Berkestedt
- Department of Clinical Sciences Lund, Anaesthesiology and Intensive Care, Lund University, Skane University Hospital, Lund, Sweden
| | - Pia Andersson
- Department ofInfection Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Heiko Herwald
- Department ofInfection Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - John Karlsson Valik
- Infectious Diseases Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Ola Sörensen
- Department of Clinical Sciences Lund, Anaesthesiology and Intensive Care, Lund University, Skane University Hospital, Lund, Sweden
| | - Mikael Bodelsson
- Department of Clinical Sciences Lund, Anaesthesiology and Intensive Care, Lund University, Skane University Hospital, Lund, Sweden
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Abstract
INTRODUCTION Kinins are peptide mediators exerting their pro-inflammatory actions by the selective stimulation of two distinct G-protein coupled receptors, termed BKB1R and BKB2R. While BKB2R is constitutively expressed in a multitude of tissues, BKB1R is hardly expressed at baseline but highly inducible by inflammatory mediators. In particular, BKB1R was shown to be involved in the pathogenesis of numerous inflammatory diseases. Areas covered: This review intends to evaluate the therapeutic potential of substances interacting with the BKB1R. To this purpose we summarize the published literature on animal studies with antagonists and knockout mice for this receptor. Expert Opinion: In most cases the pharmacological inhibition of BKB1R or its genetic deletion was beneficial for the outcome of the disease in animal models. Therefore, several companies have developed BKB1R antagonists and tested them in phase I and II clinical trials. However, none of the developed BKB1R antagonists was further developed for clinical use. We discuss possible reasons for this failure of translation of preclinical findings on BKB1R antagonists into the clinic.
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Affiliation(s)
- Fatimunnisa Qadri
- a Max-Delbrück Center for Molecular Medicine (MDC) , Berlin , Germany
| | - Michael Bader
- a Max-Delbrück Center for Molecular Medicine (MDC) , Berlin , Germany.,b Berlin Institute of Health (BIH) , Berlin , Germany.,c Charité University Medicine Berlin , Germany.,d German Center for Cardiovascular Research (DZHK) site Berlin , Berlin , Germany.,e Institute for Biology , University of Lübeck , Lübeck , Germany
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4
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Yang A, Xie Z, Wang B, Colman RW, Dai J, Wu Y. An essential role of high-molecular-weight kininogen in endotoxemia. J Exp Med 2017; 214:2649-2670. [PMID: 28794132 PMCID: PMC5584120 DOI: 10.1084/jem.20161900] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 05/25/2017] [Accepted: 07/07/2017] [Indexed: 01/08/2023] Open
Abstract
High-molecular-weight kininogen (HK) is a plasma protein. Yang et al. show that HK binds LPS and supports endotoxemia. Blockade of their binding attenuates circulating LPS level. Therefore, HK is essential for endotoxemia and is a new target for LPS clearance and sepsis treatment. In this study, we show that mice lacking high-molecular-weight kininogen (HK) were resistant to lipopolysaccharide (LPS)-induced mortality and had significantly reduced circulating LPS levels. Replenishment of HK-deficient mice with human HK recovered the LPS levels and rendered the mice susceptible to LPS-induced mortality. Binding of HK to LPS occurred through the O-polysaccharide/core oligosaccharide, consistent with the ability to bind LPS from K. pneumoniae, P. aeruginosa, S. minnesota, and different E. coli strains. Binding of LPS induced plasma HK cleavage to the two-chain form (HKa, containing a heavy chain [HC] and a light chain [LC]) and bradykinin. Both HKa and the LC, but not the HC, could disaggregate LPS. The light chain bound LPS with high affinity (Kd = 1.52 × 10−9 M) through a binding site in domain 5 (DHG15). A monoclonal antibody against D5 significantly reduced LPS-induced mortality and circulating LPS levels in wild-type mice. Thus, HK, as a major LPS carrier in circulation, plays an essential role in endotoxemia.
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Affiliation(s)
- Aizhen Yang
- Cyrus Tang Hematology Center, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Zhanli Xie
- Cyrus Tang Hematology Center, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Bo Wang
- Cyrus Tang Hematology Center, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Robert W Colman
- Sol Sherry Thrombosis Research Center, Temple University School of Medicine, Philadelphia, PA
| | - Jihong Dai
- Sol Sherry Thrombosis Research Center, Temple University School of Medicine, Philadelphia, PA.,Department of Pathology and Laboratory Medicine, Rutgers-New Jersey Medical School, Newark, NJ
| | - Yi Wu
- Cyrus Tang Hematology Center, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China .,Sol Sherry Thrombosis Research Center, Temple University School of Medicine, Philadelphia, PA
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5
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Zhou ZH, Chen T, Arora K, Hyams K, Kozlowski S. Complement C1 esterase inhibitor levels linked to infections and contaminated heparin-associated adverse events. PLoS One 2012; 7:e34978. [PMID: 22514695 PMCID: PMC3325920 DOI: 10.1371/journal.pone.0034978] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Accepted: 03/08/2012] [Indexed: 11/18/2022] Open
Abstract
Activation of kinin-kallikrein and complement pathways by oversulfated-chondroitin-sulfate (OSCS) has been linked with recent heparin-associated adverse clinical events. Given the fact that the majority of patients who received contaminated heparin did not experience an adverse event, it is of particular importance to determine the circumstances that increase the risk of a clinical reaction. In this study, we demonstrated by both the addition and affinity depletion of C1inh from normal human plasma, that the level of C1inh in the plasma has a great impact on the OSCS-induced kallikrein activity and its kinetics. OSCS-induced kallikrein activity was dramatically increased after C1inh was depleted, while the addition of C1inh completely attenuated kallikrein activity. In addition, actual clinical infection can lead to increased C1inh levels. Plasma from patients with sepsis had higher average levels of functional C1inh and decreased OSCS-induced kallikrein activity. Lastly, descriptive data on adverse event reports suggest cases likely to be associated with contaminated heparin are inversely correlated with infection. Our data suggest that low C1inh levels can be a risk factor and high levels can be protective. The identification of risk factors for contact system-mediated adverse events may allow for patient screening and clinical development of prophylaxis and treatments.
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Affiliation(s)
- Zhao-Hua Zhou
- Division of Monoclonal Antibodies, Office of Pharmaceutical Sciences, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, United States of America
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6
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Ngo ML, Mahdi F, Kolte D, Shariat-Madar Z. Upregulation of prolylcarboxypeptidase (PRCP) in lipopolysaccharide (LPS) treated endothelium promotes inflammation. JOURNAL OF INFLAMMATION-LONDON 2009; 6:3. [PMID: 19171072 PMCID: PMC2639534 DOI: 10.1186/1476-9255-6-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Accepted: 01/27/2009] [Indexed: 02/06/2023]
Abstract
BACKGROUND Prolylcarboxypeptidase (Prcp) gene, along with altered PRCP and kallikrein levels, have been implicated in inflammation pathogenesis. PRCP regulates angiotensin 1-7 (Ang 1-7) - and bradykinin (BK) - stimulated nitric oxide production in endothelial cells. The mechanism through which kallikrein expression is altered during infection is not fully understood. Investigations were performed to determine the association between PRCP and kallikrein levels as a function of the upregulation of PRCP expression and the link between PRCP and inflammation risk in lipopolysaccharide (LPS)-induced endothelium activation. METHODS The Prcp transcript expression in LPS-induced human umbilical vein endothelial cells (HUVEC) activation was determined by RT-PCR for mRNA. PRCP-dependent kallikrein pathway was determined either by Enzyme Linked ImmunoSorbent Assay (ELISA) or by biochemical assay. RESULTS We report that PRCP is critical to the maintenance of the endothelial cells, and its upregulation contributes to the risk of developing inflammation. Significant elevation in kallikrein was seen on LPS-treated HUVECs. The conversion of PK to kallikrein was blocked by the inhibitor of PRCP, suggesting that PRCP might be a risk factor for inflammation. CONCLUSION The increased PRCP lead to a sustained production of bradykinin in endothelium following LPS treatment. This amplification may be an additional mechanism whereby PRCP promotes a sustained inflammatory response. A better appreciation of the role of PRCP in endothelium may contribute to a better understanding of inflammatory vascular disorders and to the development of a novel treatment.
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Affiliation(s)
- My-Linh Ngo
- School of Pharmacy, Department of Pharmacology, University of Mississippi, Oxford, MS, USA.
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7
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Miyoshi S, Oh EG, Hirata K, Shinoda S. Exocellulr Toxic Factors Prowced byVibrio Vulnificus. ACTA ACUST UNITED AC 2008. [DOI: 10.3109/15569549309014409] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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8
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Schaefer U, Brücker B, Elbers A, Neugebauer E. THE CAPACITY OF α2-MACROGLOBULIN TO INHIBIT AN EXOGENOUS PROTEASE IS SIGNIFICANTLY INCREASED IN CRITICALLY ILL AND SEPTIC PATIENTS. Shock 2004; 22:16-22. [PMID: 15201696 DOI: 10.1097/01.shk.0000130586.63862.27] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The image of alpha2-macroglobulin is based on a paradigm evolved in the 1970s. During this decade alpha2-macroglobulin was shown to irreversibly entrap and thereby inhibit a maximum of two proteases. Additional binding of nonproteolytic proteins, i.e., inflammatory mediators and growth factors, is dependent on the conformational status of alpha2-macroglobulin. It was our aim to clarify whether the interaction of nonproteolytic proteins with alpha2-macroglobulin during inflammatory conditions might also modulate the capacity of alpha2-macroglobulin to inhibit proteases. To explore this possibility, bromelain, an exogenous protease, was titrated against plasma of critically ill or septic patients, whose pathophysiological conditions are defined by a massive release of inflammatory mediators. The stoichiometry of bromelain inhibition by alpha2-macroglobulin was quantified by caseolytic activity assays. The maximal alpha2-macroglobulin/bromelain inhibition ratios were significantly increased (1:6 and 1:8 in the two patient groups, P < 0.01) as compared with control groups (1:2 with purified alpha2-macroglobulin and 1:4 in healthy volunteers). The increase of alpha2-macroglobulin inhibition capacity in patients was paralleled by the appearance of a large signal on Western blots, suggesting the formation of additional complexes. Our results demonstrate alpha2-macroglobulin to have more flexibility than had been thought, and it may thereby contribute to a shift in a 30-year-old paradigm.
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Affiliation(s)
- Ute Schaefer
- Department of Surgery, University of Cologne, Cologne, Germany.
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9
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Stoves J, Goode NP, Visvanathan R, Jones CH, Shires M, Will EJ, Davison AM. The bradykinin response and early hypotension at the introduction of continuous renal replacement therapy in the intensive care unit. Artif Organs 2001; 25:1009-13. [PMID: 11843770 DOI: 10.1046/j.1525-1594.2001.06703.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We assessed the relationship of certain clinical variables (including bradykinin [BK] release and dialysis membrane) to initial mean arterial pressure (MAP) reduction in 47 patients requiring continuous renal replacement therapy (CRRT) in an intensive care unit. The pretreatment MAP was 84 +/- 14 mm Hg for the group as a whole. The initial MAP reduction was 11.5 (7-20) mm Hg, occurring 4 to 8 min after connection. MAP reduction was 9 (6-15) mm Hg with polyacryonitrile (PAN) membranes versus 14 (5-19) mm Hg with polysulfone (PS) (not significant). There were positive correlations between MAP reduction and BK concentration at 3 (BK3; r = 0.58, p < 0.01) and 6 (BK6; r = 0.67, p < 0.001) min with PAN but not with PS. A greater reduction in MAP was seen in patients who were not receiving inotropic support (Mann-Whitney test, p < 0.01). BK3 and BK6 values for the PAN and PS groups were not significantly different. However, BK concentrations greater than 1,000 pg/ml were only seen with PAN (6 patients, MAP reduction 27 [17-31] mm Hg). There were positive (albumin) and negative (age; acute physiology, age, and chronic health evaluation score; C-reactive protein [CRP]; calcium) correlations with BK3/BK6 in the PAN and PS groups, some of which (albumin, CRP) reached statistical significance. In summary, MAP reduction at the start of CRRT correlates with BK concentration. The similarity of response with PAN and PS suggests an importance for other clinical factors. In this study, hemodynamic instability was more likely in patients with evidence of a less severe inflammatory or septic illness.
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Affiliation(s)
- J Stoves
- Department of Renal Medicine, St. James's University Hospital, Leeds, United Kingdom
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10
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Cyr M, Lepage Y, Blais C, Gervais N, Cugno M, Rouleau JL, Adam A. Bradykinin and des-Arg(9)-bradykinin metabolic pathways and kinetics of activation of human plasma. Am J Physiol Heart Circ Physiol 2001; 281:H275-83. [PMID: 11406494 DOI: 10.1152/ajpheart.2001.281.1.h275] [Citation(s) in RCA: 119] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In the serum of 116 healthy individuals, exogenous bradykinin (BK) half-life (27 +/- 10 s) was lower than that of des-Arg(9)-BK (643 +/- 436 s) and was statistically different in men compared with women. The potentiating effect of an angiotensin-converting enzyme (ACE) inhibitor was, however, more extensive for BK (9.0-fold) than for des-Arg(9)-BK (2.2- fold). The activities of ACE, aminopeptidase P (APP), and kininase I were respectively 44 +/- 12, 22 +/- 9, and 62 +/- 10 nmol x min(-1) x ml(-1). A mathematical model (y = kt(alpha)e(-beta t), t > 0), applied to the BK kinetically released from endogenous high-molecular-weight kininogen (HK) during plasma activation in the presence of an ACE inhibitor, revealed a significant difference in the rate of formation of BK between men and women. For des-Arg(9)-BK, the active metabolite of BK, the rate of degradation was higher in women compared with men, correlating significantly with serum APP activity (r(2) = 0.6485, P < 0.001). In conclusion, these results constitute a basis for future pathophysiological studies of inflammatory processes where activation of the contact system of plasma and the kinins is involved.
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Affiliation(s)
- M Cyr
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada H3C 3J7
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11
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Schmidt W, Stenzel K, Gebhard MM, Martin E, Schmidt H. C1-esterase inhibitor and its effects on endotoxin-induced leukocyte adherence and plasma extravasation in postcapillary venules. Surgery 1999. [DOI: 10.1016/s0039-6060(99)70238-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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12
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Colman RW, Sartor RB, Adam AA, DeLa Cadena RA, Stadnicki A. The plasma kallikrein-kinin system in sepsis, inflammatory arthritis, and enterocolitis. Clin Rev Allergy Immunol 1998; 16:365-84. [PMID: 9926286 DOI: 10.1007/bf02737657] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- R W Colman
- Sol Sherry Thrombosis Research Center, Temple University School of Medicine, Philadelphia, PA 19140, USA.
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13
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Karlsrud TS, Buø L, Aasen AO, Johansen HT. Cleavage of plasma high molecular weight kininogen in surgical ICU patients. Intensive Care Med 1996; 22:760-5. [PMID: 8880244 DOI: 10.1007/bf01709518] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To characterize kininogens in plasma from surgical patients in the intensive care unit (ICU). DESIGN Prospective study. SETTING Surgical ICU. PATIENTS 35 patients aged 19-79 years, divided into two groups: sepsis (defined by standard criteria) and nonsepsis. MEASUREMENTS AND RESULTS Studies of proteolytic degradation of H-kininogen showed degradation in both patient groups compared to healthy controls. Functional quantification of prekallikrein showed a reduction of prekallikrein in plasma from both patients groups. Functional quantification of kininogens by a cysteine proteinase inhibitor assay showed no significant differences between the patients and the controls. Immunological levels of H-kininogen and total kininogen were not significantly different from normal plasma. No differences could be detected between the two patient groups in any of the parameters studied. CONCLUSIONS This study showed that contact activation took place in surgical ICU patients: partial kinin release and consumption of prekallikrein took place in vivo.
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Affiliation(s)
- T S Karlsrud
- Department of Pharmacology, School of Pharmacy, University of Oslo, Norway
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14
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Miyoshi S, Narukawa H, Tomochika K, Shinoda S. Actions of Vibrio vulnificus metalloprotease on human plasma proteinase-proteinase inhibitor systems: a comparative study of native protease with its derivative modified by polyethylene glycol. Microbiol Immunol 1995; 39:959-66. [PMID: 8789055 DOI: 10.1111/j.1348-0421.1995.tb03299.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Vibrio vulnificus, an opportunistic human pathogen causing wound infection and septicemia, produces a metalloprotease (VVP) which is suspected to be a virulent determinant. The interactions of VVP, as well as its derivative (PEG1-VVP) modified with polyethylene glycol, with a variety of human plasma proteins were investigated. We found that native VVP and its derivative were able to act directly on many biologically important human plasma proteins even in the presence of alpha-macroglobulin, the sole plasma inhibitor of native VVP. The activities of both classical and alternative pathways of the complement cascade system were drastically abolished by incubation with either VVP. Furthermore, these proteases rapidly digested the A alpha-chain of human fibrinogen into fragment(s) with no clotting ability. Therefore both VVPs are thought to function as a fibrinogenolytic enzyme, causing delay of the coagulation reaction. VVP and PEG1-VVP were also shown to destroy plasma proteinase inhibitors including alpha 1-proteinase inhibitor, a major inhibitor in human plasma. Because endogenous proteolytic enzymes and their inhibitors are indispensable in maintaining physiological homeostasis, these findings suggest that VVP (and PEG1-VVP) may cause an imbalance of human plasma proteinase-proteinase inhibitor systems, thus eliciting an immunocompromised state in the host and facilitating the development of a systemic V. vulnificus infection such as septicemia.
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Affiliation(s)
- S Miyoshi
- Faculty of Pharmaceutical Sciences, Okayama University, Japan
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15
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Ridings PC, Blocher CR, Fisher BJ, Fowler AA, Sugerman HJ. Beneficial effects of a bradykinin antagonist in a model of gram-negative sepsis. THE JOURNAL OF TRAUMA 1995; 39:81-8; discussion 88-9. [PMID: 7636914 DOI: 10.1097/00005373-199507000-00011] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
UNLABELLED Activation of the kallikrein-kinin system in sepsis has long been recognized, but its role, beneficial or pathologic, has not been determined. Recently, however, specific bradykinin (BK) antagonists have become available and we sought to determine the effects of a BK antagonist, NPC17731, in a model of sepsis-induced acute lung injury (ALI). METHODS Anesthetized swine were studied for 5 hours, receiving a 1-hour infusion of saline (Controls) or live Pseudomonas aeruginosa (Septic untreated). Treatment groups received a 5 mg/kg bolus of NPC17731 followed by a 1 mg/kg bolus hourly commencing either just before sepsis (Pretreatment) or 30 minutes following the onset of sepsis (Posttreatment). RESULTS Septic untreated animals showed a rapid, progressive decline in arterial PaO2 compared to controls, and this was significantly improved in both treatment groups. Bronchoalveolar lavage at 5 hours in both treatment groups also showed significant decreases in neutrophil (PMN) counts and protein content compared to untreated septic animals, indicating decreased PMN migration and alveolar-capillary membrane damage. Both treatment groups also showed reduced PMN sequestration in the lung compared to untreated animals, although PMNs did exhibit significant upregulation of PMN CD18 receptor expression and superoxide generation. CONCLUSIONS These data imply a significant role for BK in the pathogenesis of sepsis-induced ALI. Use of a competitive BK antagonist significantly attenuated the development of ALI without inhibiting PMN activation. BK antagonists may be a useful adjunct in the armamentarium against sepsis-induced ALI.
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Affiliation(s)
- P C Ridings
- Department of Surgery, Medical College of Virginia, Richmond 23298, USA
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16
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Ridings PC, Sugerman HJ, Blocher CR, Fisher BJ, Fowler AA. Hemodynamic effects of bradykinin antagonism in porcine gram-negative sepsis. J INVEST SURG 1995; 8:115-22. [PMID: 7619781 DOI: 10.3109/08941939509016514] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Activation of the kallikrein-kinin system in sepsis has long been recognized, but its role, beneficial or pathologic, has not been defined. Recently, however, specific bradykinin (BK) antagonists have become available and this study investigated the effects of a BK antagonist, NPC17731 (Scios-Nova) on systemic and pulmonary hemodynamics in a model of gram-negative sepsis. Anesthetized swine were studied for 5 h receiving a 1-h infusion of saline (controls, group 1, N = 8) or live Pseudomonas aeruginosa (septic, group 2, N = 8). Group 3 (treatment, N = 6) received NPC17731 (5 mg/kg initial bolus followed by 1 mg/kg hourly) just prior to the onset of sepsis. Group 2 animals showed a rapid decrease in systemic arterial pressure (SAP) from 30 min onward, and sustained significant hypotension from 2 h onward. In group 3, SAP fell similarly until 2 h then progressively rose, returning to baseline levels by 5 h. In contrast, cardiac index fell progressively from 3 h onward in groups 2 and 3. Systemic vascular resistance index (SVRI) fell significantly by 2 h in group 2 animals, recovering to baseline by 5 h. Group 3 showed a similar initial fall followed by a rebound increase in SVRI, which, at 5 h was significantly raised above the other groups. Group 2 developed significant, persistent pulmonary artery hypertension which was not reduced by NPC17731. The data imply a significant role for bradykinin in the pathogenesis of hypotension in septic shock in this model. Septic shock was reversed by a BK antagonist which increased peripheral resistance without affecting cardiac output.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- P C Ridings
- Department of Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, USA
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17
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Pixley RA, Zellis S, Bankes P, DeLa Cadena RA, Page JD, Scott CF, Kappelmayer J, Wyshock EG, Kelly JJ, Colman RW. Prognostic value of assessing contact system activation and factor V in systemic inflammatory response syndrome. Crit Care Med 1995; 23:41-51. [PMID: 7528118 DOI: 10.1097/00003246-199501000-00010] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To test if serially sampled determinations of the contact system proteins and factor V have prognostic value for death in patients who develop the systemic inflammatory response syndrome. DESIGN Prospective, observational study with sequential measurements in an inception cohort. SETTING Medical intensive care unit (ICU) in a community hospital. PATIENTS Over a 1-yr period, a population base sample of 23 patients was selected from all ICU admissions who met established criteria for the systemic inflammatory response syndrome. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Components of the contact system, factor XII, prekallikrein, high-molecular-weight kininogen, factor XI, alpha 2-macroglobulin-kallikrein complexes and factor V values were measured in plasma samples collected serially (day of admission, and at 2, 12, 24, 48 and/or 72 hrs or at discharge). Data were analyzed to determine if admission values or serially obtained values within 48 hrs were useful in predicting outcome. Fourteen patients survived and nine died. At admission, in all patients, assay values indicated that prekallikrein, high-molecular-weight kininogen, and factor V were significantly lower than normal (as observed in a range of 20 to 23 healthy adults), alpha 2-macroglobulin-kallikrein complexes were higher than normal, while concentrations of factor XII and factor XI were in the normal range. No differences were detected in the admission values between survivors and nonsurvivors, nor between patients with positive or negative blood cultures. However, subsequent values demonstrated a difference in values between survivors and nonsurvivors. Survivors showed improvement in high molecular weight kininogen values and higher than normal factor V values, as compared with nonsurvivors. CONCLUSIONS Low or persistently low serial factor XII, high-molecular-weight kininogen and factor V values are associated with a poor prognosis, whereas high or increasing values of factor XII, high-molecular-weight kininogen, prekallikrein, and factor V all correlate with a favorable outcome.
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18
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Abstract
Knowledge concerning the pathophysiologic mechanisms of traumatic optic neuropathy is limited. The optic nerve is a tract of the brain. Therefore, the cellular and biochemical pathophysiology of brain and spinal cord trauma and ischemia provide insight into mechanisms that may operate in traumatic optic neuropathy. The dosage of methylprednisolone (30 mg/kg/6 hours) which was successful in the National Acute Spinal Cord Injury Study 2 (NASCIS 2) evolved from the unique pharmacology of corticosteroids as antioxidants. The management of traumatic optic neuropathy rests on an accurate diagnosis which begins with a comprehensive clinical assessment and appropriate neuroimaging. The results of medical and surgical strategies for treating this injury have not been demonstrated to be better than those achieved without treatment. The spinal cord is a mixed grey and white matter tract of the brain in contrast to the optic nerve which is a pure white matter tract. The treatment success seen with methylprednisolone in the NASCIS 2 study may not generalize to the treatment of traumatic optic neuropathy. Conversely, if the treatment does generalize to the optic nerve, NASCIS 2 data suggests that treatment must be started within eight hours of injury, making traumatic optic neuropathy one of the true ophthalmic emergencies. Given the uncertainties in the treatment, ophthalmologists involved in the management of traumatic optic neuropathy are encouraged to participate in the collaborative study of traumatic optic neuropathy.
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Affiliation(s)
- K D Steinsapir
- Orbital and Ophthalmic Plastic Surgery Division, Jules Stein Eye Institute, UCLA School of Medicine
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Singer M, McNally T, Screaton G, Mackie I, Machin S, Cohen SL. Heparin clearance during continuous veno-venous haemofiltration. Intensive Care Med 1994; 20:212-5. [PMID: 8014289 DOI: 10.1007/bf01704703] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To determine whether premature clotting of haemofiltration circuits could be related to heparin removal across the filter membrane into the ultrafiltrate. DESIGN Randomised study using either unfractionated (n = 8) or low molecular weight (n = 7) heparin for anticoagulation of the haemofiltration circuit at 1000 and 600 U/h respectively. Samples were drawn at 1 and 2 h from arterial and venous limbs of the haemofilter circuit for measurement of plasma heparin (as anti-Factor Xa activity), antithrombin III and haematocrit. Ultrafiltrate samples were collected at the same time for measurement of anti-Xa activity. SETTING Intensive care unit. PATIENTS Patients in acute renal failure requiring haemofiltration. RESULTS Both unfractionated and low molecular weight heparin plasma levels were within the range required for therapeutic anticoagulation in all but one patient at 2 h. Ultrafiltrate anti-Xa levels were insignificant. Antithrombin III levels in these critically ill patients were subnormal in 11 of the 15 studies. CONCLUSIONS Despite their small sizes, neither unfractionated nor low molecular weight heparins cross the haemofilter membrane into the ultrafiltrate in any measurable quantity. Both heparins were present in plasma at a level suitable for therapeutic anticoagulation. Subnormal levels of antithrombin III may be an important factor in determining filter longevity.
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Affiliation(s)
- M Singer
- Bloomsbury Institute of Intensive Care Medicine, Department of Medicine, UCL Medical School, London, UK
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20
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From Localized Angioedema to Generalized Capillary Leak Syndrome: Evidence for a Pivotal Role of C1-Inhibitor in Septic Shock-like Syndromes. ACTA ACUST UNITED AC 1994. [DOI: 10.1007/978-3-642-85036-3_39] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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21
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Lorente JA, García-Frade LJ, Landín L, de Pablo R, Torrado C, Renes E, García-Avello A. Time course of hemostatic abnormalities in sepsis and its relation to outcome. Chest 1993; 103:1536-42. [PMID: 8486040 DOI: 10.1378/chest.103.5.1536] [Citation(s) in RCA: 230] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES To investigate the time course and the relation to prognosis of coagulation and fibrinolytic abnormalities in patients with septic shock. PATIENTS AND METHODS Forty-eight consecutive patients admitted to the medical ICU with the diagnosis of septic shock (diagnosed by defined criteria) were studied. Mortality was 25 of 48. Mean age was 57 +/- 7.3 years. Blood samples were obtained on days 1, 4, and 7 after hospital admission to measure tissue-type plasminogen activator antigen (t-PA), urokinase-type plasminogen activator (u-PA), plasminogen activator inhibitor antigen (PAI-1), plasminogen, alpha 2-antiplasmin, fibrinogen, antithrombin III, protein C, protein S, thrombin-antithrombin complexes (TAT), D-dimer, and von Willebrand factor-related antigen (vWF:Ag). RESULTS All patients showed marked abnormalities in both the coagulation and fibrinolytic systems. There were signs of coagulation activation and elevation of both activators and inhibitors of fibrinolysis. Nonsurvivors showed lower levels of protein C and antithrombin III and higher concentration of TAT than survivors. While both t-PA and PAI-1 concentrations were high in survivors and nonsurvivors, only survivors showed a progressive normalization of both parameters during the study period. Low plasminogen levels and plasminogen/alpha 2-antiplasmin ratio were found in both groups, presenting a trend toward normalization only in survivors. The differences reported were not apparent at the time of hospital admission. CONCLUSIONS Septic shock is characterized by coagulation activation and fibrinolysis activation and inhibition. Nonsurvivors present a particular hemostatic profile characterized by a more marked activation of coagulation and a more intense inhibition of fibrinolysis. None of the abnormalities studied was significantly different between survivors and nonsurvivors at the time of hospital admission. In the presence of fibrin formation, nonsurvivors present a maintained imbalance in the fibrinolytic response determined by higher PAI-1 plasma concentration, probably contributing to their poor outcome.
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Affiliation(s)
- J A Lorente
- Unidad de Cuidados Intensivos, Hospital Ramón y Cajal, Madrid, Spain
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22
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Narukawa H, Miyoshi S, Shinoda S. Chemical modification of Vibrio vulnificus metalloprotease with activated polyethylene glycol. FEMS Microbiol Lett 1993; 108:43-6. [PMID: 7682528 DOI: 10.1111/j.1574-6968.1993.tb06071.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Vibrio vulnificus, an opportunistic human pathogen causing septicemia, produces a metalloprotease which is suspected to be a virulence determinant, but which is labile in vivo due to inactivation by alpha-macroglobulin. To obtain a derivative which is stable in vivo, the metalloprotease was modified with activated monomethoxy polyethylene glycol. The modified protease retained full activity to a peptide substrate and 10-20% activity to protein substrates, and was resistant to entrapment by alpha-macroglobulin because of the increased molecular size (approx. 90 kDa). These findings suggest that the modified protease is stable in vivo and may be used to investigate the pathological actions of the protease in the bloodstream.
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Affiliation(s)
- H Narukawa
- Faculty of Pharmaceutical Sciences, Okayama University, Japan
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23
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Brunet F, Mira JP, Belghith M, Lanore JJ, Schlumberger S, Toulon P, Dhainaut JF. Effects of aprotinin on hemorrhagic complications in ARDS patients during prolonged extracorporeal CO2 removal. Intensive Care Med 1992; 18:364-7. [PMID: 1281849 DOI: 10.1007/bf01694366] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The effects of aprotinin, a broad-based proteinase inhibitor, in the management of hemorrhagic complications during prolonged venovenous extracorporeal CO2 removal in patients with adult respiratory distress syndrome are not evaluated. In two patients, aprotinin infusion was added to heparin to treat bleeding, occurring after few days of bypass and responsible for respiratory and hemodynamic deterioration. After aprotinin infusion (loading dose of 2 x 10(6) kIU followed by a continuous infusion of 5 x 10(5) kIU/h) combined with heparin, bleeding vanished until the end of bypass.
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Affiliation(s)
- F Brunet
- Medical Intensive Care Unit, Cochin-Port Royal University, Paris, France
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24
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Stief TW, Heimburger N. Inactivation of serine proteinase inhibitors (serpins) in human plasma by reactive oxidants. BIOLOGICAL CHEMISTRY HOPPE-SEYLER 1988; 369:1337-42. [PMID: 3266555 DOI: 10.1515/bchm3.1988.369.2.1337] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Activated polymorphonuclear neutrophils (PMN) and macrophages generate oxidizing agents similar to or identical with N-chloroamines. Mimicking this oxidation in normal human plasma by usage of chloramine T (CT), we observed an oxidant concentration-dependent inactivating effect on plasma alpha 2-plasmin inhibitor (alpha 2-PI), antithrombin III (AT III), and alpha 1-proteinase inhibitor (alpha 1-PI). 20-50 mumol CT/ml plasma are necessary for almost complete inactivation of alpha 2-PI and AT III-activity, i.e. about 2-5 times the dose necessary for inactivation of alpha 1-PI which has already been classified as "oxidant sensitive". The inactivation of alpha 1-PI, alpha 2-PI and AT III in plasma by oxidants is the result of a specific oxidative damage since C1-inhibitor, serine proteinases and complexes of plasmin and alpha 2-PI were chloramine resistant under the conditions used. According to our results, the amount of chloramines released by 1 x 10(6) activated PMN, namely ca. 10 nmol (see Weiss et al. Science 222 625-628, 1983) would be sufficient to destroy alpha 1-PI and alpha 2-PI activity of 1.5 and 0.4 microliter of human plasma, respectively. Consequently, activated leukocytes may be able to create a microenvironment in which elastase as well as plasmin and thrombin can display their proteolytic activity unchecked by their regulator proteins. Oxidation may provide a general basis for altering enzyme/inhibitor balances.
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Affiliation(s)
- T W Stief
- Forschungslaboratorien, Behringwerke AG, Marburg
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