1
|
Haupeltshofer S, Mencl S, Szepanowski RD, Hansmann C, Casas AI, Abberger H, Hansen W, Blusch A, Deuschl C, Forsting M, Hermann DM, Langhauser F, Kleinschnitz C. Delayed plasma kallikrein inhibition fosters post-stroke recovery by reducing thrombo-inflammation. J Neuroinflammation 2024; 21:155. [PMID: 38872149 PMCID: PMC11177352 DOI: 10.1186/s12974-024-03149-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 06/06/2024] [Indexed: 06/15/2024] Open
Abstract
Activation of the kallikrein-kinin system promotes vascular leakage, inflammation, and neurodegeneration in ischemic stroke. Inhibition of plasma kallikrein (PK) - a key component of the KKS - in the acute phase of ischemic stroke has been reported to reduce thrombosis, inflammation, and damage to the blood-brain barrier. However, the role of PK during the recovery phase after cerebral ischemia is unknown. To this end, we evaluated the effect of subacute PK inhibition starting from day 3 on the recovery process after transient middle artery occlusion (tMCAO). Our study demonstrated a protective effect of PK inhibition by reducing infarct volume and improving functional outcome at day 7 after tMCAO. In addition, we observed reduced thrombus formation in cerebral microvessels, fewer infiltrated immune cells, and an improvement in blood-brain barrier integrity. This protective effect was facilitated by promoting tight junction reintegration, reducing detrimental matrix metalloproteinases, and upregulating regenerative angiogenic markers. Our findings suggest that PK inhibition in the subacute phase might be a promising approach to accelerate the post-stroke recovery process.
Collapse
Affiliation(s)
- Steffen Haupeltshofer
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Hufelandstr. 55, D-45147, Essen, Germany.
| | - Stine Mencl
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Hufelandstr. 55, D-45147, Essen, Germany
| | - Rebecca D Szepanowski
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Hufelandstr. 55, D-45147, Essen, Germany
| | - Christina Hansmann
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Hufelandstr. 55, D-45147, Essen, Germany
| | - Ana I Casas
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Hufelandstr. 55, D-45147, Essen, Germany
- Department of Pharmacology & Personalized Medicine, MeHNS, Faculty of Health, Medicine & Life Science, Maastricht University, Maastricht, The Netherlands
| | - Hanna Abberger
- Institute of Medical Microbiology, University Hospital Essen, Virchowstr. 179, D-45147, Essen, Germany
- Division of Immunology, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, 3052, Australia
- Department of Medical Biology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Wiebke Hansen
- Institute of Medical Microbiology, University Hospital Essen, Virchowstr. 179, D-45147, Essen, Germany
| | - Alina Blusch
- Department of Neurology, Center for Huntington's Disease NRW, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstr. 56, D-44791, Bochum, Germany
| | - Cornelius Deuschl
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstr. 55, D-45147, Essen, Germany
| | - Michael Forsting
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstr. 55, D-45147, Essen, Germany
| | - Dirk M Hermann
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Hufelandstr. 55, D-45147, Essen, Germany
- Chair of Vascular Neurology, Dementia and Ageing, Department of Neurology, Medical Research Centre, University Hospital Essen, Hufelandstr. 55, D-45147, Essen, Germany
| | - Friederike Langhauser
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Hufelandstr. 55, D-45147, Essen, Germany
| | - Christoph Kleinschnitz
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Hufelandstr. 55, D-45147, Essen, Germany
| |
Collapse
|
2
|
Farkas H, Balla Z. Kallikrein inhibitors for angioedema: the progress of preclinical and early phase studies. Expert Opin Investig Drugs 2024; 33:191-200. [PMID: 38366937 DOI: 10.1080/13543784.2024.2320700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 02/15/2024] [Indexed: 02/19/2024]
Abstract
INTRODUCTION Hereditary angioedema (HAE) is a rare genetic disorder characterized by recurrent edema and predominantly caused by the dysregulation of the kinin-kallikrein system. AREAS COVERED This manuscript presents the results of preclinical and early clinical trials of newer drugs targeting the dysregulated kinin-kallikrein system. ATN-249 is an oral drug that has shown promising results in preclinical and Phase I studies, and good tolerability in the prophylactic treatment of attacks. KVD900 is also an oral agent developed for the on-demand treatment of HAE attacks. It has shown positive results in Phase I/II studies, with rapid absorption. The third drug, IONIS-PKKRx, is an antisense oligonucleotide targeting plasma prekallikrein mRNA. It has shown a dose-dependent reduction of plasma prekallikrein levels and proenzyme activation in Phase I/II studies, and has shown promising results. STAR-0215 is a long acting anti-activated kallikrein monoclonal antibody. A Phase 1a single ascending dose trial evaluated its safety, pharmacokinetics, and pharmacodynamics. Lastly, NTLA-2002 is an investigational gene-editing therapy. EXPERT OPINION The targeted treatment of the dysregulated kinin-kallikrein system with specific inhibitors is promising for the prevention of angioedema attacks. Ongoing phase III studies will provide further insight into the efficacy and long-term safety of these novel therapies, potentially expanding treatment options for HAE treatment.
Collapse
Affiliation(s)
- Henriette Farkas
- Hungarian Angioedema Center of Reference and Excellence, Department of Internal, Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Zsuzsanna Balla
- Hungarian Angioedema Center of Reference and Excellence, Department of Internal, Medicine and Haematology, Semmelweis University, Budapest, Hungary
- HNO-Praxis Schaffhausen, Schaffhausen, Switzerland
| |
Collapse
|
3
|
Parente R, Sartorio S, Brussino L, De Pasquale T, Zoli A, Agolini S, Di Agosta E, Quattrocchi P, Borrelli P, Bignardi D, Petraroli A, Senter R, Popescu Janu V, Cogliati C, Guarino MD, Rossi O, Firinu D, Pucci S, Spadaro G, Triggiani M, Cancian M, Zanichelli A. Multicentric Observational Study on Safety and Tolerability of COVID-19 Vaccines in Patients with Angioedema with C1 Inhibitor Deficiency: Data from Italian Network on Hereditary and Acquired Angioedema (ITACA). Vaccines (Basel) 2023; 11:vaccines11040852. [PMID: 37112764 PMCID: PMC10145557 DOI: 10.3390/vaccines11040852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/11/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
Angioedema due to C1 inhibitor deficiency (AE-C1-INH) is a rare disease characterized by recurrent and unpredictable attacks of angioedema. Multiple trigger factors, including trauma, emotional stress, infectious diseases, and drugs, could elicit angioedema attacks. The aim of this study was to collect data on the safety and tolerability of COVID-19 vaccines in a population of patients affected by AE-C1-INH. Adult patients with AE-C1-INH, followed by Reference Centers belonging to the Italian Network for Hereditary and Acquired Angioedema (ITACA), were enrolled in this study. Patients received nucleoside-modified mRNA vaccines and vaccines with adenovirus vectors. Data on acute attacks developed in the 72 h following COVID-19 vaccinations were collected. The frequency of attacks in the 6 months after the COVID-19 vaccination was compared with the rate of attacks registered in the 6 months before the first vaccination. Between December 2020 and June 2022, 208 patients (118 females) with AE-C1-INH received COVID-19 vaccines. A total of 529 doses of the COVID-19 vaccine were administered, and the majority of patients received mRNA vaccines. Forty-eight attacks of angioedema (9%) occurred within 72 h following COVID-19 vaccinations. About half of the attacks were abdominal. Attacks were successfully treated with on-demand therapy. No hospitalizations were registered. There was no increase in the monthly attack rate following the vaccination. The most common adverse reactions were pain at the site of injection and fever. Our results show that adult patients with angioedema due to C1 inhibitor deficiency can be safely vaccinated against SARS-CoV-2 in a controlled medical setting and should always have available on-demand therapies.
Collapse
Affiliation(s)
- Roberta Parente
- Division of Allergy and Clinical Immunology, University of Salerno, 84131 Salerno, Italy
| | - Silvio Sartorio
- Referral Centre for Systemic Autoimmune Diseases, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico di Milano, 20122 Milan, Italy
| | - Luisa Brussino
- Allergy and Clinical Immunology Unit, Department of Medical Sciences, University of Torino & Mauriziano Hospital, 10128 Torino, Italy
| | | | - Alessandra Zoli
- SOD Immunologia Clinica, Azienda Ospedaliera Universitaria Ospedali Riuniti di Ancona, 60126 Ancona, Italy
| | - Stefano Agolini
- SOD Immunologia Clinica, Azienda Ospedaliera Universitaria Ospedali Riuniti di Ancona, 60126 Ancona, Italy
| | - Ester Di Agosta
- Immunoallergology Unit, University Hospital of Careggi, 50141 Florence, Italy
| | - Paolina Quattrocchi
- Department of Clinical and Experimental Medicine, School and Operative Unit of Allergy and Clinical Immunology, University of Messina, 98125 Messina, Italy
| | - Paolo Borrelli
- SSD Dermatologia e Allergologia-Ospedale Beauregard, 11100 Aosta, Italy
| | - Donatella Bignardi
- Department of Medicine Integrated with the Territory, Ospedale Policlinico San Martino, IRCCS Ospedale Policlinico, Genova UO Allergologia, 16142 Genova, Italy
| | - Angelica Petraroli
- Department of Internal Medicine, Clinical Immunology, Clinical Pathology and Infectious Disease, Azienda Ospedaliera Universitaria Federico II, 80131 Napoli, Italy
| | - Riccardo Senter
- Department of Systems Medicine, University Hospital of Padua, 35126 Padua, Italy
| | | | - Chiara Cogliati
- Internal Medicine, L Sacco Hospital, ASST Fatebenfratelli-Sacco, 20157 Milan, Italy
- Department of Biomedical and Clinical Sciences, University of Milan, 20157 Milan, Italy
| | | | - Oliviero Rossi
- Immunoallergology Unit, University Hospital of Careggi, 50141 Florence, Italy
| | - Davide Firinu
- Division of Allergy and Clinical Immunology, University of Cagliari, 09124 Cagliari, Italy
| | | | - Giuseppe Spadaro
- Department of Internal Medicine, Clinical Immunology, Clinical Pathology and Infectious Disease, Azienda Ospedaliera Universitaria Federico II, 80131 Napoli, Italy
| | - Massimo Triggiani
- Division of Allergy and Clinical Immunology, University of Salerno, 84131 Salerno, Italy
| | - Mauro Cancian
- Department of Systems Medicine, University Hospital of Padua, 35126 Padua, Italy
| | - Andrea Zanichelli
- Operative Unit of Medicine, Angioedema Center, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, 20097 Milan, Italy
| |
Collapse
|
4
|
Dyga W, Obtulowicz A, Mikolajczyk T, Bogdali A, Dubiela P, Obtulowicz K. The Role of Bradykinin Receptors in Hereditary Angioedema Due to C1-Inhibitor Deficiency. Int J Mol Sci 2022; 23:ijms231810332. [PMID: 36142237 PMCID: PMC9499460 DOI: 10.3390/ijms231810332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/31/2022] [Accepted: 09/04/2022] [Indexed: 12/03/2022] Open
Abstract
Background: Hereditary angioedema (HAE) is a rare, genetic disease caused by the decreased level or function of the C1 inhibitor. The primary mediator of symptoms in HAE is bradykinin acting through its two receptors, namely receptors 1 (BR1) and 2 (BR2). Although BR2 is well characterized, the role of BR1 remains unclear. Objective: To study the role of bradykinin receptors 1 (BR1) in the etiopathogenesis of HAE. Methods: A total of 70 individuals, 40 patients with HAE, and 30 healthy subjects were recruited to the study. HAE was diagnosed in accordance with the international guideline. The level of bradykinin receptors was determined in populations of CD3+, CD4+, CD8+, and CD14++CD16−, CD14++CD16+ monocytes. In addition, the level of disease activity-specific markers was measured. Results: There were statistically significant differences in the subpopulation of lymphocytes and monocytes between patients with HAE compared to healthy subjects. The level of BR1 and BR2 on PBMCs was comparable in healthy subjects and HAE patients during remission with significant overexpression of both receptors, triggered by HAE attack. Moreover, a significant increase in TNF-alpha and IL-1 plasma levels was observed among HAE patients. Conclusions: BR1 expression may play an important role in the pathomechanism of HAE.
Collapse
Affiliation(s)
- Wojciech Dyga
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Botaniczna 3, 31-503 Krakow, Poland
| | - Aleksander Obtulowicz
- Department of Dermatology, Jagiellonian University Medical College, Kopernika 50, 31-501 Krakow, Poland
| | - Tomasz Mikolajczyk
- Department of Internal and Agricultural Medicine, Jagiellonian University Medical College, Skarbowa 1, 31-121 Krakow, Poland
| | - Anna Bogdali
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Botaniczna 3, 31-503 Krakow, Poland
| | - Pawel Dubiela
- Department of Pathophysiology and Allergy Research, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
- Department of Regenerative Medicine and Immune Regulation, Medical University of Bialystok, Waszyngtona 13, 15-269 Bialystok, Poland
- Correspondence:
| | - Krystyna Obtulowicz
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Botaniczna 3, 31-503 Krakow, Poland
| |
Collapse
|
5
|
Balla Z, Andrási N, Pólai Z, Visy B, Czaller I, Temesszentandrási G, Csuka D, Varga L, Farkas H. The characteristics of upper airway edema in hereditary and acquired angioedema with C1-inhibitor deficiency. Clin Transl Allergy 2021; 11:e12083. [PMID: 34962723 PMCID: PMC8805691 DOI: 10.1002/clt2.12083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/02/2021] [Accepted: 11/14/2021] [Indexed: 11/24/2022] Open
Abstract
Background Angioedemas localized in the upper airway are potentially life threatening, and without proper treatment, they may lead to death by suffocation. Upper airway edemas (UAE) in bradykinin‐mediated angioedemas can even be the first symptoms of the disease. Methods Our survey was performed with a retrospective long‐term follow‐up method from the medical history of 197 hereditary (C1‐INH‐HAE) and 20 acquired C1‐inhibitor deficiency (C1‐INH‐AAE), 3 factor XII and 3 plasminogen gene mutation (FXII‐HAE, PLG‐HAE) patients treated at our center between 1990 and 2020. The UAE group included edemas localized to the mesopharynx, hypopharynx, and larynx, as narrowing of these anatomical regions can lead to suffocation. Results 98/197 C1‐INH‐HAE (47 families) and 13/20 C1‐INH‐AAE, 1/3 PLG‐HAE, 1/3 FXII‐HAE patients had experienced UAE at least once according to their medical history. In case of C1‐INH‐HAE patients, in 6/47 families who had undiagnosed ancestors had 13 members who died of suffocation. After the diagnosis, 1‐1 member of two families died of UAE. 44/64 C1‐INH‐HAE patients did not smoke, 20/64 did. The occurrence of UAE was significantly higher in smoker patients. We analyzed 7607 HAE attacks of 56/98 patients. Out of all attacks, the incidence of UAE in the C1‐INH‐HAE group was 4%, and 9.5% in the C1‐INH‐AAE group, respectively. Conclusion Early diagnosis is key in bradykinin‐mediated angioedemas cases, since the patient must be provided with adequate treatment; and also it is essential to inform patients about the importance of avoiding the trigger factors and the early symptoms of UAE, as these measures could significantly decrease the incidence of lethal UAEs.
Collapse
Affiliation(s)
- Zsuzsanna Balla
- Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Budapest, Hungary.,School of PhD Studies, Semmelweis University, Budapest, Hungary
| | - Noémi Andrási
- Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Budapest, Hungary.,School of PhD Studies, Semmelweis University, Budapest, Hungary.,2nd Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Zsófia Pólai
- Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Budapest, Hungary.,School of PhD Studies, Semmelweis University, Budapest, Hungary
| | - Beáta Visy
- Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Budapest, Hungary.,Heim Pál Children's Hospital, Budapest, Hungary
| | - Ibolya Czaller
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | | | - Dorottya Csuka
- Research Laboratory, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary.,MTA-SE Research Group of Immunology and Hematology, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Lilian Varga
- Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Budapest, Hungary
| | - Henriette Farkas
- Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Budapest, Hungary
| |
Collapse
|
6
|
Grumach AS, Staubach-Renz P, Villa RC, Diez-Zuluaga S, Reese I, Lumry WR. Triggers of Exacerbation in Chronic Urticaria and Recurrent Angioedema-Prevalence and Relevance. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2160-2168. [PMID: 34112472 DOI: 10.1016/j.jaip.2021.04.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/09/2021] [Accepted: 04/15/2021] [Indexed: 02/06/2023]
Abstract
Patients with urticaria and angioedema often have triggers that cause an outbreak or a swelling episode or worsen their chronic condition. Exploring these factors with each patient may result in better understanding and control of their disease. Patients should be advised to avoid known triggers, if feasible, or prepare to prevent or control an exacerbation with appropriate pretreatment if avoidance is not possible. In this review, we describe and discuss a variety of factors for which there is evidence that they cause or exacerbate chronic spontaneous urticaria and angioedema. These potentially exacerbating factors include drugs, food additives, and naturally occurring pseudoallergens, mental stress, and trauma.
Collapse
Affiliation(s)
| | | | - Ricardo Cardona Villa
- Facultad de Medicina-Universidad de Antioquia, Grupo de Alergología Clínica y Experimental, Medellín, Colombia
| | - Susana Diez-Zuluaga
- Facultad de Medicina-Universidad de Antioquia, Grupo de Alergología Clínica y Experimental, Medellín, Colombia
| | - Imke Reese
- Dietary Counseling and Nutrition Therapy Centre, Munich, Germany
| | - William R Lumry
- Clinical Faculty, University of Texas Southwestern Medical School, Allergy and Asthma Specialists, Dallas, Texas.
| |
Collapse
|
7
|
Advances in Hereditary Angioedema: The Prevention of Angioedema Attacks With Subcutaneous C1-Inhibitor Replacement Therapy. JOURNAL OF INFUSION NURSING 2021; 43:134-145. [PMID: 32287168 PMCID: PMC7328861 DOI: 10.1097/nan.0000000000000365] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is Available in the Text. Hereditary angioedema (HAE) is a debilitating condition caused by a functional C1-inhibitor (C1-INH) deficiency and characterized clinically by episodes of subcutaneous or submucosal swelling. C1-INH replacement is highly effective for preventing HAE attacks and can improve health-related quality of life. Once available only for intravenous use, C1-INH is now available as a subcutaneous formulation for self-administration, shown to provide sustained plasma levels of C1-INH and reducing the monthly median HAE attack rate by 95% versus placebo in the phase 3 COMPACT study. Subcutaneously administered C1-INH satisfies multiple unmet needs in the management of patients with HAE.
Collapse
|
8
|
Willems E, Lorés-Motta L, Zanichelli A, Suffritti C, van der Flier M, van der Molen RG, Langereis JD, van Drongelen J, van den Heuvel LP, Volokhina E, van de Kar NC, Keizer-Garritsen J, Levin M, Herberg JA, Martinon-Torres F, Wessels HJ, de Breuk A, Fauser S, Hoyng CB, den Hollander AI, de Groot R, van Gool AJ, Gloerich J, de Jonge MI. Quantitative multiplex profiling of the complement system to diagnose complement-mediated diseases. Clin Transl Immunology 2020; 9:e1225. [PMID: 33318796 PMCID: PMC7724921 DOI: 10.1002/cti2.1225] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/16/2020] [Accepted: 11/16/2020] [Indexed: 02/06/2023] Open
Abstract
Objectives Complement deficiencies are difficult to diagnose because of the variability of symptoms and the complexity of the diagnostic process. Here, we applied a novel ‘complementomics’ approach to study the impact of various complement deficiencies on circulating complement levels. Methods Using a quantitative multiplex mass spectrometry assay, we analysed 44 peptides to profile 34 complement proteins simultaneously in 40 healthy controls and 83 individuals with a diagnosed deficiency or a potential pathogenic variant in 14 different complement proteins. Results Apart from confirming near or total absence of the respective protein in plasma of complement‐deficient patients, this mass spectrometry‐based profiling method led to the identification of additional deficiencies. In many cases, partial depletion of the pathway up‐ and/or downstream of the absent protein was measured. This was especially found in patients deficient for complement inhibitors, such as angioedema patients with a C1‐inhibitor deficiency. The added value of complementomics was shown in three patients with poorly defined complement deficiencies. Conclusion Our study shows the potential clinical utility of profiling circulating complement proteins as a comprehensive read‐out of various complement deficiencies. Particularly, our approach provides insight into the intricate interplay between complement proteins due to functional coupling, which contributes to the better understanding of the various disease phenotypes and improvement of care for patients with complement‐mediated diseases.
Collapse
Affiliation(s)
- Esther Willems
- Laboratory of Medical Immunology Department of Laboratory Medicine Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen The Netherlands.,Radboud Center for Infectious Diseases Radboud University Medical Center Nijmegen The Netherlands.,Translational Metabolic Laboratory Department of Laboratory Medicine Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen The Netherlands
| | - Laura Lorés-Motta
- Department of Ophthalmology Donders Institute for Brain Cognition and Behaviour Radboud University Medical Center Nijmegen The Netherlands
| | - Andrea Zanichelli
- Department of Biomedical and Clinical Sciences Luigi Sacco ASST Fatebenefratelli Sacco University of Milan Milan Italy
| | - Chiara Suffritti
- Department of Biomedical and Clinical Sciences Luigi Sacco ASST Fatebenefratelli Sacco University of Milan Milan Italy
| | - Michiel van der Flier
- Laboratory of Medical Immunology Department of Laboratory Medicine Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen The Netherlands.,Radboud Center for Infectious Diseases Radboud University Medical Center Nijmegen The Netherlands.,Department of Pediatrics University Medical Center Utrecht Utrecht The Netherlands.,Amalia Children's Hospital Radboud University Medical Center Nijmegen The Netherlands
| | - Renate G van der Molen
- Laboratory of Medical Immunology Department of Laboratory Medicine Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen The Netherlands
| | - Jeroen D Langereis
- Laboratory of Medical Immunology Department of Laboratory Medicine Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen The Netherlands
| | - Joris van Drongelen
- Department of Obstetrics and Gynecology Radboud University Medical Center Nijmegen The Netherlands
| | - Lambert P van den Heuvel
- Translational Metabolic Laboratory Department of Laboratory Medicine Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen The Netherlands.,Amalia Children's Hospital Radboud University Medical Center Nijmegen The Netherlands
| | - Elena Volokhina
- Translational Metabolic Laboratory Department of Laboratory Medicine Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen The Netherlands.,Amalia Children's Hospital Radboud University Medical Center Nijmegen The Netherlands
| | - Nicole Caj van de Kar
- Amalia Children's Hospital Radboud University Medical Center Nijmegen The Netherlands
| | - Jenneke Keizer-Garritsen
- Translational Metabolic Laboratory Department of Laboratory Medicine Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen The Netherlands
| | - Michael Levin
- Department of Medicine Section for Paediatrics Imperial College London London UK
| | - Jethro A Herberg
- Department of Medicine Section for Paediatrics Imperial College London London UK
| | - Federico Martinon-Torres
- Translational Pediatrics and Infectious Diseases Instituto de Investigación Sanitaria de Santiago Hospital Clínico Universitario de Santiago Santiago de Compostela Spain
| | - Hans Jtc Wessels
- Translational Metabolic Laboratory Department of Laboratory Medicine Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen The Netherlands
| | - Anita de Breuk
- Department of Ophthalmology Donders Institute for Brain Cognition and Behaviour Radboud University Medical Center Nijmegen The Netherlands
| | - Sascha Fauser
- Department of Ophthalmology University Hospital Cologne Koln Germany.,F. Hoffmann - La Roche AG Basel Switzerland
| | - Carel B Hoyng
- Department of Ophthalmology Donders Institute for Brain Cognition and Behaviour Radboud University Medical Center Nijmegen The Netherlands
| | - Anneke I den Hollander
- Department of Ophthalmology Donders Institute for Brain Cognition and Behaviour Radboud University Medical Center Nijmegen The Netherlands
| | - Ronald de Groot
- Laboratory of Medical Immunology Department of Laboratory Medicine Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen The Netherlands.,Radboud Center for Infectious Diseases Radboud University Medical Center Nijmegen The Netherlands
| | - Alain J van Gool
- Translational Metabolic Laboratory Department of Laboratory Medicine Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen The Netherlands
| | - Jolein Gloerich
- Translational Metabolic Laboratory Department of Laboratory Medicine Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen The Netherlands
| | - Marien I de Jonge
- Laboratory of Medical Immunology Department of Laboratory Medicine Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen The Netherlands.,Radboud Center for Infectious Diseases Radboud University Medical Center Nijmegen The Netherlands
| |
Collapse
|
9
|
Genetic variants of SERPING1 gene in Polish patients with hereditary angioedema due to C1 inhibitor deficiency. Cent Eur J Immunol 2020; 45:301-309. [PMID: 33437182 PMCID: PMC7790005 DOI: 10.5114/ceji.2020.101252] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 09/11/2019] [Indexed: 11/29/2022] Open
Abstract
Hereditary angioedema due to C1-inhibitor deficiency (C1-INH-HAE) type I and II is a rare and life-threatening disease caused by SERPING1 gene mutations. Previous genetic studies indicated a wide spectrum of disease-associated variants in the SERPING1 gene and often lack of correlation with patient’s phenotypes. The aim of this study was to evaluate the presence, type, and localization of mutations in the SERPING1 gene in 41 Polish patients with C1-INH-HAE and their relation with case/family history, type of C1-INH-HAE, fC1-INH, age of onset, and disease severity. Sanger sequencing and MLPA method were used for detection of disease-associated variants. In 34 (82.9%) patients, mutations located in various regions of SERPING1 gene were revealed. The detected alterations in patients with C1-INH-HAE type I differed and were positioned in various exons/introns of the SERPING1 gene. The most frequent disease-associated variants appeared in exon 3 (especially in type I) and in exon 8 (type I and II). Out of 20 different disease-causing variants, 9 were not previously described. We did not find any relation between the type and location of the mutations and no type of features included in phenotype evaluation of the patients, such as case and family history, type of C1-INH-HAE, age of onset, biochemical parameters, or severity of disease.
Collapse
|
10
|
Gambardella J, Sorriento D, Bova M, Rusciano M, Loffredo S, Wang X, Petraroli A, Carucci L, Mormile I, Oliveti M, Bruno Morelli M, Fiordelisi A, Spadaro G, Campiglia P, Sala M, Trimarco B, Iaccarino G, Santulli G, Ciccarelli M. Role of Endothelial G Protein-Coupled Receptor Kinase 2 in Angioedema. Hypertension 2020; 76:1625-1636. [PMID: 32895019 DOI: 10.1161/hypertensionaha.120.15130] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Excessive BK (bradykinin) stimulation is responsible for the exaggerated permeabilization of the endothelium in angioedema. However, the molecular mechanisms underlying these responses have not been investigated. BK receptors are Gq-protein-coupled receptors phosphorylated by GRK2 (G protein-coupled receptor kinase 2) with a hitherto unknown biological and pathophysiological significance. In the present study, we sought to identify the functional role of GRK2 in angioedema through the regulation of BK signaling. We found that the accumulation of cytosolic Ca2+ in endothelial cells induced by BK was sensitive to GRK2 activity, as it was significantly augmented by inhibiting the kinase. Accordingly, permeabilization and NO production induced by BK were enhanced, as well. In vivo, mice with reduced GRK2 levels in the endothelium (Tie2-CRE/GRK2fl+/fl-) exhibited an increased response to BK in terms of vascular permeability and extravasation. Finally, patients with reduced GRK2 levels displayed a severe phenotype of angioedema. Taken together, these findings establish GRK2 as a novel pivotal regulator of BK signaling with an essential role in the pathophysiology of vascular permeability and angioedema.
Collapse
Affiliation(s)
- Jessica Gambardella
- From the Department of Advanced Biomedical Science (J.G., D.S., A.F., B.T., G.I., G. Santulli), University of Naples Federico II, NA, Italy.,Division of Cardiology, Department of Medicine, Wilf Family Cardiovascular Research Institute (J.G., X.W., M.B.M., G. Santulli), Albert Einstein College of Medicine, Montefiore University Hospital, NY.,Department of Molecular Pharmacology, Fleischer Institute for Diabetes and Metabolism (FIDAM) (J.G., X.W., M.B.M., G. Santulli), Albert Einstein College of Medicine, Montefiore University Hospital, NY.,International Translational Research and Medical Education Consortium (ITME), NA, Italy (J.G., B.T., G. Santulli)
| | - Daniela Sorriento
- Department of Translational Medical Sciences and Interdepartmental Center for Research in Basic and Clinical Immunology Sciences (M.B., S.L., A.P., L.C., I.M., G. Spadaro), University of Naples Federico II, NA, Italy
| | - Maria Bova
- Department of Translational Medical Sciences and Interdepartmental Center for Research in Basic and Clinical Immunology Sciences (M.B., S.L., A.P., L.C., I.M., G. Spadaro), University of Naples Federico II, NA, Italy
| | - Mariarosaria Rusciano
- Montevergine Hospital, Mercogliano, Italy (M.R.).,Department of Medicine and Surgery (M.R., M.O., M.C.), University of Salerno, Italy
| | - Stefania Loffredo
- Department of Translational Medical Sciences and Interdepartmental Center for Research in Basic and Clinical Immunology Sciences (M.B., S.L., A.P., L.C., I.M., G. Spadaro), University of Naples Federico II, NA, Italy
| | - Xujun Wang
- Division of Cardiology, Department of Medicine, Wilf Family Cardiovascular Research Institute (J.G., X.W., M.B.M., G. Santulli), Albert Einstein College of Medicine, Montefiore University Hospital, NY.,Department of Molecular Pharmacology, Fleischer Institute for Diabetes and Metabolism (FIDAM) (J.G., X.W., M.B.M., G. Santulli), Albert Einstein College of Medicine, Montefiore University Hospital, NY
| | - Angelica Petraroli
- Department of Translational Medical Sciences and Interdepartmental Center for Research in Basic and Clinical Immunology Sciences (M.B., S.L., A.P., L.C., I.M., G. Spadaro), University of Naples Federico II, NA, Italy
| | - Laura Carucci
- Department of Translational Medical Sciences and Interdepartmental Center for Research in Basic and Clinical Immunology Sciences (M.B., S.L., A.P., L.C., I.M., G. Spadaro), University of Naples Federico II, NA, Italy
| | - Ilaria Mormile
- Department of Translational Medical Sciences and Interdepartmental Center for Research in Basic and Clinical Immunology Sciences (M.B., S.L., A.P., L.C., I.M., G. Spadaro), University of Naples Federico II, NA, Italy
| | - Marco Oliveti
- Department of Medicine and Surgery (M.R., M.O., M.C.), University of Salerno, Italy
| | - Marco Bruno Morelli
- Division of Cardiology, Department of Medicine, Wilf Family Cardiovascular Research Institute (J.G., X.W., M.B.M., G. Santulli), Albert Einstein College of Medicine, Montefiore University Hospital, NY.,Department of Molecular Pharmacology, Fleischer Institute for Diabetes and Metabolism (FIDAM) (J.G., X.W., M.B.M., G. Santulli), Albert Einstein College of Medicine, Montefiore University Hospital, NY
| | - Antonella Fiordelisi
- From the Department of Advanced Biomedical Science (J.G., D.S., A.F., B.T., G.I., G. Santulli), University of Naples Federico II, NA, Italy
| | - Giuseppe Spadaro
- Department of Translational Medical Sciences and Interdepartmental Center for Research in Basic and Clinical Immunology Sciences (M.B., S.L., A.P., L.C., I.M., G. Spadaro), University of Naples Federico II, NA, Italy
| | - Pietro Campiglia
- Division of Biomedicine, Department of Pharmaceutical Science (P.C., M.S.), University of Salerno, Italy
| | - Marina Sala
- Division of Biomedicine, Department of Pharmaceutical Science (P.C., M.S.), University of Salerno, Italy
| | - Bruno Trimarco
- International Translational Research and Medical Education Consortium (ITME), NA, Italy (J.G., B.T., G. Santulli)
| | - Guido Iaccarino
- From the Department of Advanced Biomedical Science (J.G., D.S., A.F., B.T., G.I., G. Santulli), University of Naples Federico II, NA, Italy
| | - Gaetano Santulli
- From the Department of Advanced Biomedical Science (J.G., D.S., A.F., B.T., G.I., G. Santulli), University of Naples Federico II, NA, Italy.,Division of Cardiology, Department of Medicine, Wilf Family Cardiovascular Research Institute (J.G., X.W., M.B.M., G. Santulli), Albert Einstein College of Medicine, Montefiore University Hospital, NY.,Department of Molecular Pharmacology, Fleischer Institute for Diabetes and Metabolism (FIDAM) (J.G., X.W., M.B.M., G. Santulli), Albert Einstein College of Medicine, Montefiore University Hospital, NY.,International Translational Research and Medical Education Consortium (ITME), NA, Italy (J.G., B.T., G. Santulli)
| | - Michele Ciccarelli
- Department of Medicine and Surgery (M.R., M.O., M.C.), University of Salerno, Italy
| |
Collapse
|
11
|
Lang GE, Tadayoni R, Tang W, Barth C, Weiss-Haljiti C, Chong V. Bradykinin 1 Receptor Antagonist BI1026706 Does Not Reduce Central Retinal Thickness in Center-Involved Diabetic Macular Edema. Transl Vis Sci Technol 2020; 9:25. [PMID: 32818112 PMCID: PMC7396196 DOI: 10.1167/tvst.9.4.25] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 12/09/2019] [Indexed: 12/02/2022] Open
Abstract
Purpose The bradykinin 1 receptor may be important in inflammatory retinal vascular leakage in diabetic macular edema. BI 1026706 is an antagonist of bradykinin 1 receptor that has demonstrated efficacy in preclinical studies. Boehringer Ingelheim trial 1320.22 (NCT02732951) was a randomized, double-blind, placebo-controlled study. The pharmacodynamics, safety, and tolerability of oral BI 1026706 for 12 weeks were evaluated in patients with type 1 or type 2 diabetes mellitus and mild visual impairment owing to center-involved diabetic macular edema. Methods Patients (n = 105) were randomized to receive either oral BI 1026706 100 mg twice daily (morning and evening) or placebo for 12 weeks. The primary end point of the study was week 12 change from baseline in central subfield foveal thickness (CSFT) by spectral domain optical coherence tomography. Additional end points included absolute CSFT values, safety, and pharmacokinetics. Results After 12 weeks of treatment, there was no meaningful change from baseline in the adjusted mean CSFT in either treatment group (BI 1026706, 10.3 µm; placebo, –6.2 µm; adjusted mean treatment difference, 16.5 µm [95% confidence interval, –16.2 to 49.1]). There were also no differences in best-corrected visual acuity outcomes between treatment groups. Most reported adverse events were of mild or moderate intensity, and were balanced between treatment groups. Conclusions BI 1026706 was not superior to placebo in CSFT week-12 change from baseline. Therefore, BI 1026706 does not reduce CSFT, a morphologic sign of diabetic macular edema. Translational Relevance Kinin-kallikrein inhibition effects may not be apparent over 12 weeks for bradykinin 1 receptor inhibition alone.
Collapse
Affiliation(s)
| | - Ramin Tadayoni
- Ophthalmology Department, AP-HP, Hôpital Lariboisière, Université de Paris, F-75010, Paris, France
| | - Wenbo Tang
- Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA
| | - Claudia Barth
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | | - Victor Chong
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | |
Collapse
|
12
|
Brodszki N, Frazer-Abel A, Grumach AS, Kirschfink M, Litzman J, Perez E, Seppänen MRJ, Sullivan KE, Jolles S. European Society for Immunodeficiencies (ESID) and European Reference Network on Rare Primary Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN RITA) Complement Guideline: Deficiencies, Diagnosis, and Management. J Clin Immunol 2020; 40:576-591. [PMID: 32064578 PMCID: PMC7253377 DOI: 10.1007/s10875-020-00754-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 01/20/2020] [Indexed: 12/14/2022]
Abstract
This guideline aims to describe the complement system and the functions of the constituent pathways, with particular focus on primary immunodeficiencies (PIDs) and their diagnosis and management. The complement system is a crucial part of the innate immune system, with multiple membrane-bound and soluble components. There are three distinct enzymatic cascade pathways within the complement system, the classical, alternative and lectin pathways, which converge with the cleavage of central C3. Complement deficiencies account for ~5% of PIDs. The clinical consequences of inherited defects in the complement system are protean and include increased susceptibility to infection, autoimmune diseases (e.g., systemic lupus erythematosus), age-related macular degeneration, renal disorders (e.g., atypical hemolytic uremic syndrome) and angioedema. Modern complement analysis allows an in-depth insight into the functional and molecular basis of nearly all complement deficiencies. However, therapeutic options remain relatively limited for the majority of complement deficiencies with the exception of hereditary angioedema and inhibition of an overactivated complement system in regulation defects. Current management strategies for complement disorders associated with infection include education, family testing, vaccinations, antibiotics and emergency planning.
Collapse
Affiliation(s)
- Nicholas Brodszki
- Department of Pediatrics, Children's Hospital, Skåne University Hospital, Lund, Sweden
| | - Ashley Frazer-Abel
- Division of Rheumatology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Anete S Grumach
- Clinical Immunology, Reference Center on Rare Diseases, University Center Health ABC, Santo Andre, SP, Brazil
| | | | - Jiri Litzman
- Department of Clinical Immunology and Allergology, St Anne's University Hospital, and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Elena Perez
- Allergy Associates of the Palm Beaches, North Palm Beach, FL, USA
| | - Mikko R J Seppänen
- Rare Disease Center, Children's Hospital, and Adult Primary Immunodeficiency Outpatient Clinic, Inflammation Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kathleen E Sullivan
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, Cardiff University & University Hospital of Wales, Cardiff, UK.
| |
Collapse
|
13
|
Lepelley M, Bernardeau C, Defendi F, Crochet J, Mallaret M, Bouillet L. Update on bradykinin-mediated angioedema in 2020. Therapie 2020; 75:195-205. [DOI: 10.1016/j.therap.2020.02.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 11/15/2019] [Indexed: 12/11/2022]
|
14
|
Cancian M, Perego F, Senter R, Arcoleo F, De Pasquale T, Zoli A, Cicardi M, Zanichelli A. Pediatric angioedema: Essential features and preliminary results from the Hereditary Angioedema Global Registry in Italy. Pediatr Allergy Immunol 2020; 31 Suppl 24:22-24. [PMID: 32017221 DOI: 10.1111/pai.13170] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2019] [Indexed: 11/27/2022]
Abstract
Isolated angioedema, which is a localized, non-pitting, and transient swelling of the subcutaneous or submucosal tissue not associated with pruritus, urticaria, or anaphylaxis, may be classified, based on genetic pattern and mediators, respectively, as acquired or hereditary and histamine- or non-histamine-induced. The pediatric population with C1-INH-HAE (Hereditary angioedema due to C1-inhibitor deficiency) is mostly symptomatic. The frequency of symptoms in such a population compared to adults seems to be lower, but we need more prospective data to conclude on this point. The HGR (Hereditary angioedema global registry), which collects symptoms in real time, will probably provide such information. In terms of treatments, pediatric patients are significantly disadvantaged due to the few studies aimed at registering treatment for this population.
Collapse
Affiliation(s)
- Mauro Cancian
- Department of Medicine, University of Padova, Padova, Italy
| | | | | | - Francesco Arcoleo
- Ospedali Riuniti Villa Sofia-Cervello, Unità Operativa Complessa di Patologia Clinica, Palermo, Italy
| | | | - Alessandra Zoli
- Servizio di Immunologia Clinica e Tipizzazione Tessutale-Ospedali Riuniti di Ancona, Ancona, Italy
| | - Marco Cicardi
- IRCCS Istituti Clinici Scientifici Maugeri, Milano, Italy.,Department of Biomedical and Clinical Sciences Luigi Sacco, University of Milan, Milano, Italy
| | | |
Collapse
|
15
|
Contradictory to its effects on thrombin, C1-inhibitor reduces plasmin generation in the presence of thrombomodulin. J Thromb Thrombolysis 2019; 48:81-87. [PMID: 31030323 DOI: 10.1007/s11239-019-01869-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
C1-inhibitor (C1INH) was shown to enhance thrombin generation (TG) in the presence of thrombomodulin (TM) by reducing production of activated protein C. Because C1INH is known to inhibit fibrinolytic system proteases, the objective of this study was to evaluate the effect of moderate (3 IU/ml) and high (16 IU/ml) C1INH concentrations on TG and plasmin generation (PG) in the presence of TM. These concentrations were evaluated based on expected maximum plasma levels following C1INH replacement therapy and recently suggested supraphysiologic dosing. TG and PG were investigated in platelet poor plasmas obtained from 21 healthy donors. An assay designed to monitor the continuous generation of the 7-amino-4-methylcoumarin fluorescence from substrates specific to thrombin or plasmin was used to evaluate the impact of C1INH activity. To characterize the C1INH effects on TG and PG, the thrombin and plasmin concentration peaks and production rates were calculated. TM addition to donor plasma shifted the concentration dependence of C1INH on TG parameters from reduction to enhancement. Conversely, PG parameters were significantly reduced by 16 IU/ml in both the presence and absence of TM. Moderate C1INH concentration (3 IU/ml) reduced TG and PG in the absence of TM but did not significantly affect these parameters in the presence of TM. Finally, 3 IU/ml of C1INH reduced PG more so than TG in the absence of TM. The presented results suggest a mechanism by which C1INH could potentiate thrombosis by inhibition of fibrinolysis.
Collapse
|
16
|
Schröder-Braunstein J, Kirschfink M. Complement deficiencies and dysregulation: Pathophysiological consequences, modern analysis, and clinical management. Mol Immunol 2019; 114:299-311. [PMID: 31421540 DOI: 10.1016/j.molimm.2019.08.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 07/31/2019] [Accepted: 08/03/2019] [Indexed: 02/07/2023]
Abstract
Complement defects are associated with an enhanced risk of a broad spectrum of infectious as well as systemic or local inflammatory and thrombotic disorders. Inherited complement deficiencies have been described for virtually all complement components but can be mimicked by autoantibodies, interfering with the activity of specific complement components, convertases or regulators. While being rare, diseases related to complement deficiencies are often severe with a frequent but not exclusive manifestation during childhood. Whereas defects of early components of the classical pathway significantly increase the risk of autoimmune disorders, lack of components of the terminal pathway as well as of properdin are associated with an enhanced susceptibility to meningococcal infections. The impaired synthesis or function of C1 inhibitor results in the development of hereditary angioedema (HAE). Furthermore, complement dysregulation causes renal disorders such as atypical hemolytic uremic syndrome (aHUS) or C3 glomerulopathy (C3G) but also age-related macular degeneration (AMD). While paroxysmal nocturnal hemoglobinuria (PNH) results from the combined deficiency of the regulatory complement proteins CD55 and CD59, which is caused by somatic mutation of a common membrane anchor, isolated CD55 or CD59 deficiency is associated with the CHAPLE syndrome and polyneuropathy, respectively. Here, we provide an overview on clinical disorders related to complement deficiencies or dysregulation and describe diagnostic strategies required for their comprehensive molecular characterization - a prerequisite for informed decisions on the therapeutic management of these disorders.
Collapse
Affiliation(s)
- Jutta Schröder-Braunstein
- University of Heidelberg, Institute of Immunology, Im Neuenheimer Feld 305, 69120 Heidelberg, Germany
| | - Michael Kirschfink
- University of Heidelberg, Institute of Immunology, Im Neuenheimer Feld 305, 69120 Heidelberg, Germany.
| |
Collapse
|
17
|
Longhurst HJ, Bork K. Hereditary angioedema: an update on causes, manifestations and treatment. Br J Hosp Med (Lond) 2019; 80:391-398. [DOI: 10.12968/hmed.2019.80.7.391] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Hereditary angioedema is a rare genetic disorder caused by deficiency of C1 esterase inhibitor (C1-INH) and characterized by recurrent episodes of severe swelling that affect the limbs, face, intestinal tract and airway. Since laryngeal oedema can be life-threatening as a result of asphyxiation, correct diagnosis and management of hereditary angioedema is vital. Hereditary angioedema attacks are mediated by bradykinin, the production of which is regulated by C1-INH. Hereditary angioedema therapy relies on treatment of acute attacks, and short- and long-term prophylaxis. Acute treatment options include C1-INH concentrate, icatibant and ecallantide. Self-administration of treatment is recommended and is associated with increased quality of life of patients with hereditary angioedema. Advances in diagnosis and management have improved the outcomes and quality of life of patients with hereditary angioedema.
Collapse
Affiliation(s)
- Hilary J Longhurst
- Consultant, Department of Immunology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ
| | - Konrad Bork
- Univ.-Prof. Dr, Department of Dermatology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| |
Collapse
|
18
|
Shen Y, Oda T, Tamura N, Kohmura-Kobayashi Y, Furuta-Isomura N, Yaguchi C, Uchida T, Suzuki K, Itoh H, Kanayama N. Elevated bradykinin receptor type 1 expression in postpartum acute myometritis: Possible involvement in augmented interstitial edema of the atonic gravid uterus. J Obstet Gynaecol Res 2019; 45:1553-1561. [PMID: 31179603 DOI: 10.1111/jog.14012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 05/13/2019] [Indexed: 11/29/2022]
Abstract
AIM Uterine atony is a major cause of postpartum hemorrhage. We recently proposed a new concept for the histopathophysiology of refractory uterine atony, postpartum acute myometritis (PAM), characterized by acute inflammatory changes with massive stromal edema, increased numbers of complement C5a receptors and diffuse mast cell activation in the myometrium. We herein focused on the possible involvement of the kinin-kallikrein system in the rapid development of interstitial edema in PAM, particularly bradykinin receptor type 1 (B1R), which is up-regulated under inflammatory conditions. The present study investigated B1R expression with uterine interstitial edema in PAM. METHODS Our institution plays an important role in a Japanese amniotic fluid embolism registry project. We selected PAM cases from uterine samples delivered to us for further analyses between 2012 and 2017. Control tissues were collected during cesarean section and planned hysterectomy. B1R expression was semi-quantitatively measured by immunohistochemistry, while uterine interstitial edema was estimated by semi-quantitative measurements of the alpha smooth muscle actin-negative area using immunohistochemistry. RESULTS There were 36 and 8 cases in the PAM and control groups, respectively. The alpha smooth muscle actin-negative area was increased in the PAM group, concomitant with the significant up-regulation of B1R expression in uterine smooth muscle cells, vascular endothelial cells, and neutrophils. A positive correlation was observed between these two factors. CONCLUSION We demonstrated the up-regulated expression of B1R in the myometrium and its positive correlation with histologically estimated interstitial edema, suggesting the contribution of the kinin-kallikrein-B1R system to the development of interstitial edema in PAM cases.
Collapse
Affiliation(s)
- Yi Shen
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tomoaki Oda
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Naoaki Tamura
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yukiko Kohmura-Kobayashi
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Naomi Furuta-Isomura
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Chizuko Yaguchi
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Toshiyuki Uchida
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Kazunao Suzuki
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hiroaki Itoh
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Naohiro Kanayama
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| |
Collapse
|
19
|
Partridge JR, Choy RM, Silva-Garcia A, Yu C, Li Z, Sham H, Metcalf B. Structures of full-length plasma kallikrein bound to highly specific inhibitors describe a new mode of targeted inhibition. J Struct Biol 2019; 206:170-182. [PMID: 30876891 DOI: 10.1016/j.jsb.2019.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 02/28/2019] [Accepted: 03/01/2019] [Indexed: 10/27/2022]
Abstract
Plasma kallikrein (pKal) is a serine protease responsible for cleaving high-molecular-weight kininogen to produce the pro-inflammatory peptide, bradykinin. Unregulated pKal activity can lead to hereditary angioedema (HAE) following excess bradykinin release. HAE attacks can lead to a compromised airway that can be life threatening. As there are limited agents for prophylaxis of HAE attacks, there is a high unmet need for a therapeutic agent for regulating pKal with a high degree of specificity. Here we present crystal structures of both full-length and the protease domain of pKal, bound to two very distinct classes of small-molecule inhibitors: compound 1, and BCX4161. Both inhibitors demonstrate low nM inhibitory potency for pKal and varying specificity for related serine proteases. Compound 1 utilizes a surprising mode of interaction and upon binding results in a rearrangement of the binding pocket. Co-crystal structures of pKal describes why this class of small-molecule inhibitor is potent. Lack of conservation in surrounding residues explains the ∼10,000-fold specificity over structurally similar proteases, as shown by in vitro protease inhibition data. Structural information, combined with biochemical and enzymatic analyses, provides a novel scaffold for the design of targeted oral small molecule inhibitors of pKal for treatment of HAE and other diseases resulting from unregulated plasma kallikrein activity.
Collapse
Affiliation(s)
- James R Partridge
- Global Blood Therapeutics, South San Francisco, CA 94080, United States.
| | - Rebeca M Choy
- Global Blood Therapeutics, South San Francisco, CA 94080, United States
| | - Abel Silva-Garcia
- Global Blood Therapeutics, South San Francisco, CA 94080, United States
| | - Chul Yu
- Global Blood Therapeutics, South San Francisco, CA 94080, United States
| | - Zhe Li
- Global Blood Therapeutics, South San Francisco, CA 94080, United States
| | - Hing Sham
- Global Blood Therapeutics, South San Francisco, CA 94080, United States
| | - Brian Metcalf
- Global Blood Therapeutics, South San Francisco, CA 94080, United States
| |
Collapse
|
20
|
Tarandovskiy ID, Buehler PW, Ataullakhanov FI, Karnaukhova E. C1-esterase inhibitor enhances thrombin generation and spatial fibrin clot propagation in the presence of thrombomodulin. Thromb Res 2019; 176:54-60. [PMID: 30784776 DOI: 10.1016/j.thromres.2019.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 01/29/2019] [Accepted: 02/11/2019] [Indexed: 10/27/2022]
Abstract
Package inserts for C1-esterase inhibitor (C1INH) products include warnings for an elevated risk of possible thrombosis in certain individuals, referring to thromboembolic events (TEEs) that were reported to occur after C1INH infusions. However, the mechanism(s) that could explain possible development of TEEs due to C1INH remains unknown. In this work, we evaluated plausible impact of C1INH on the protein C (PC) anticoagulant system. We performed thrombin generation (TG) assays (TGA) and analyzed spatial fibrin clot propagation using thrombodynamics in plasma of individual donors after the addition of thrombomodulin (TM) and C1INH. The addition of C1INH was consistent with the plasma concentrations resulting from doses currently approved for the HAE treatment up to ones consistent with off-label use in patients with risk of inflammation. 16 IU/ml of C1INH significantly enhanced thrombin peak (TP) generation in the presence of 12 and 15 nM TM. TG enhancement was observed by the addition of C1INH to make concentrations equal to 2 and 4 IU/ml in some donor plasmas. C1INH addition in the presence of TM enhanced the stop time of spatial clot growth in Thrombodynamics assay. A chromogenic activity assay demonstrated that C1INH inhibited PC activation by thrombin in the presence of TM. Substitution of TM with APC in TGA attenuated the TP enhancing effect of C1INH. The collective results of the present study suggest a concentration dependent C1INH interaction with the PC system. This study introduces a plausible TM-dependent mechanism, that may explain reported TEEs via suppressed production of APC in the presence of C1INH.
Collapse
Affiliation(s)
- Ivan D Tarandovskiy
- Laboratory of Biochemistry and Vascular Biology, Center for Biologics Evaluation Research, US Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, MD, United States.
| | - Paul W Buehler
- Laboratory of Biochemistry and Vascular Biology, Center for Biologics Evaluation Research, US Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, MD, United States
| | - Fazoil I Ataullakhanov
- Center for Theoretical Problems of Physicochemical Pharmacology, Russian Academy of Sciences, Kosygina str., 4, Moscow 119334, Russia
| | - Elena Karnaukhova
- Laboratory of Biochemistry and Vascular Biology, Center for Biologics Evaluation Research, US Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, MD, United States
| |
Collapse
|
21
|
Valerieva A, Cicardi M, Baraniuk J, Staevska M. The physician and hereditary angioedema friend or foe: 62-year diagnostic delay and iatrogenic procedures. Allergy Asthma Clin Immunol 2018; 14:75. [PMID: 30386388 PMCID: PMC6201585 DOI: 10.1186/s13223-018-0275-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 07/10/2018] [Indexed: 12/15/2022] Open
Abstract
Background Hereditary angioedema due to C1 inhibitor deficiency (C1-INH-HAE) is a rare autosomal dominant disease characterized by episodes of acute subcutaneous swelling, and/or recurrent severe abdominal pain. The disease is potentially fatal if the upper-airway is involved. Iatrogenic harm can occur if HAE is not considered in the differential diagnosis, the specialists are not aware of the natural history, diagnosis and treatment of HAE, or as a result of unnecessary surgical and other iatrogenic interventions. Case presentation We present the case of a 72-year-old man who began suffering recurrent abdominal pain at the age of 8 years. The pain led to frequent emergency department visits, three emergency surgical interventions, and 5 endoscopies before C1-INH-HAE was diagnosed at the age of 70. Infrequent subcutaneous swellings were attributed to unknown allergic reactions that were not related to the primary diagnosis of abdominal pain. Family history was positive for recurrent abdominal pain and angioedema but was ignored until the propositus’ grandson developed recurrent severe oro-facial edema attacks. The boy’s mother searched the worldwide web and found educational materials on a patient association website. She suggested complement C4 and C1-INH testing that led to the appropriate diagnosis of C1-INH-HAE type 1 in her son and his grandfather. Conclusion This report emphasizes the importance of accurately evaluating personal and family history in patients with a long history of recurrent, acute, severe but medically unexplained abdominal pain and cutaneous swellings. Here, the diagnosis of HAE was overlooked for 62 years and the focus on abdominal complaints led to numerous surgical interventions without consideration of the full differential diagnosis. Screening family members from all generations for unrecognized angioedema, abdominal pain, and measurement of C1-INH and C4 are essential for accurate and timely diagnosis of HAE.
Collapse
Affiliation(s)
- Anna Valerieva
- 1Clinical Center of Allergology, Clinic of Allergy and Asthma, University Hospital "Alexandrovska", Medical University of Sofia, 1, Georgi Sofiiski Str., 1431 Sofia, Bulgaria
| | - Marco Cicardi
- 2Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital-Polo Ospedaliero, University of Milan, Milan, Italy
| | - James Baraniuk
- 3Division of Rheumatology, Immunology and Allergy, Department of Medicine, Georgetown University, Washington, DC USA
| | - Maria Staevska
- 1Clinical Center of Allergology, Clinic of Allergy and Asthma, University Hospital "Alexandrovska", Medical University of Sofia, 1, Georgi Sofiiski Str., 1431 Sofia, Bulgaria
| |
Collapse
|
22
|
Moldovan D, Bara N, Nădășan V, Gábos G, Mihály E. Consequences of Misdiagnosed and Mismanaged Hereditary Angioedema Laryngeal Attacks: An Overview of Cases from the Romanian Registry. Case Rep Emerg Med 2018; 2018:6363787. [PMID: 30425862 PMCID: PMC6217881 DOI: 10.1155/2018/6363787] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 10/09/2018] [Indexed: 11/18/2022] Open
Abstract
Emergency department (ED) physicians frequently encounter patients presenting with angioedema. Most of these involve histamine-mediated angioedema; however, less common forms of angioedema (bradykinin-mediated) also occur. It is vital physicians correctly recognize and treat this; particularly since bradykinin-mediated angioedema does not respond to antihistamines, corticosteroids or epinephrine and hereditary angioedema (HAE) laryngeal attacks can be fatal. Here we present four case reports illustrating how failures in recognizing, managing, and treating laryngeal edema due to HAE led to asphyxiation and death of the patient. Recognition of the specific type of angioedema is critical for rapid and effective treatment of HAE attacks. Bradykinin-mediated angioedema should be efficiently differentiated from the most common histamine-mediated form. Improved awareness of HAE and the associated risk of life-threatening laryngeal edema among emergency physicians, patients, and relatives and clear ED treatment protocols are warranted. Moreover, appropriate treatments should be readily available to reduce fatalities associated with laryngeal edema.
Collapse
Affiliation(s)
- Dumitru Moldovan
- Romanian Network for Hereditary Angioedema, 11a Sântana St, 540256 Tîrgu-Mureş, Romania
- University of Medicine and Pharmacy, Mureş County Hospital, 1 Marinescu St, 540139 Tîrgu-Mureş, Romania
- Mureş County Hospital, 1 Marinescu St, 540103 Tîrgu-Mureş, Romania
- MediQuest Medical Center, Sângeorgiu de Mureș, Romania
| | - Noémi Bara
- Romanian Network for Hereditary Angioedema, 11a Sântana St, 540256 Tîrgu-Mureş, Romania
- MediQuest Medical Center, Sângeorgiu de Mureș, Romania
| | - Valentin Nădășan
- Romanian Network for Hereditary Angioedema, 11a Sântana St, 540256 Tîrgu-Mureş, Romania
- University of Medicine and Pharmacy, Mureş County Hospital, 1 Marinescu St, 540139 Tîrgu-Mureş, Romania
- MediQuest Medical Center, Sângeorgiu de Mureș, Romania
| | - Gabriella Gábos
- Romanian Network for Hereditary Angioedema, 11a Sântana St, 540256 Tîrgu-Mureş, Romania
- Mureş County Hospital, 1 Marinescu St, 540103 Tîrgu-Mureş, Romania
| | - Enikő Mihály
- Romanian Network for Hereditary Angioedema, 11a Sântana St, 540256 Tîrgu-Mureş, Romania
- Mureş County Hospital, 1 Marinescu St, 540103 Tîrgu-Mureş, Romania
- MediQuest Medical Center, Sângeorgiu de Mureș, Romania
| |
Collapse
|
23
|
Antia C, Baquerizo K, Korman A, Bernstein JA, Alikhan A. Urticaria: A comprehensive review. J Am Acad Dermatol 2018; 79:599-614. [DOI: 10.1016/j.jaad.2018.01.020] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
24
|
Valerieva A, Caccia S, Cicardi M. Recombinant human C1 esterase inhibitor (Conestat alfa) for prophylaxis to prevent attacks in adult and adolescent patients with hereditary angioedema. Expert Rev Clin Immunol 2018; 14:707-718. [DOI: 10.1080/1744666x.2018.1503055] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Anna Valerieva
- Medical University of Sofia, Clinical Center of Allergology, University Hospital “Alexandrovska”, Sofia, Bulgaria
| | - Sonia Caccia
- Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Marco Cicardi
- Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| |
Collapse
|
25
|
Castellano G, Divella C, Sallustio F, Montinaro V, Curci C, Zanichelli A, Bonanni E, Suffritti C, Caccia S, Bossi F, Gallone A, Schena FP, Gesualdo L, Cicardi M. A transcriptomics study of hereditary angioedema attacks. J Allergy Clin Immunol 2018; 142:883-891. [DOI: 10.1016/j.jaci.2018.03.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 02/20/2018] [Accepted: 03/28/2018] [Indexed: 01/21/2023]
|
26
|
Federici C, Perego F, Borsoi L, Crosta V, Zanichelli A, Gidaro A, Tarricone R, Cicardi M. Costs and effects of on-demand treatment of hereditary angioedema in Italy: a prospective cohort study of 167 patients. BMJ Open 2018; 8:e022291. [PMID: 30061443 PMCID: PMC6067408 DOI: 10.1136/bmjopen-2018-022291] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES To explore treatment behaviours in a cohort of Italian patients with hereditary angioedema due to complement C1-inhibitor deficiency (C1-INH-HAE), and to estimate how effects and costs of treating attacks in routine practice differed across available on-demand treatments. DESIGN Cost analyses and survival analyses using attack-level data collected prospectively for 1 year. SETTING National reference centre for C1-INH-HAE. PARTICIPANTS 167 patients with proved diagnosis of C1-INH-HAE, who reported data on angioedema attacks, including severity, localisation and duration, treatment received, and use of other healthcare services. INTERVENTIONS Attacks were treated with either icatibant, plasma-derived C1-INH (pdC1-INH) or just supportive care. MAIN OUTCOME MEASURES Treatment efficacy in reducing attack duration and the direct costs of acute attacks. RESULTS Overall, 133 of 167 patients (79.6%) reported 1508 attacks during the study period, with mean incidence of 11 attacks per patient per year. Only 78.9% of attacks were treated in contrast to current guidelines. Both icatibant and pdC1-INH significantly reduced attack duration compared with no treatment (median times from onset 7, 10 and 47 hours, respectively), but remission rates with icatibant were 31% faster compared with pdC1-INH (HR 1.31, 95% CI 1.14 to 1.51). However, observed treatment behaviours suggest patterns of suboptimal dosing for pdC1-INH. The average cost per attack was €1183 (SD €789) resulting in €1.58 million healthcare costs during the observation period (€11 912 per patient per year). Icatibant was 54% more expensive than pdC1-INH, whereas age, sex and prophylactic treatment were not associated to higher or lower costs. CONCLUSIONS Both icatibant and pdC1-INH significantly reduced attack duration compared with no treatment, however, icatibant was more effective but also more expensive. Treatment behaviours and suboptimal dosing of pdC1-INH may account for the differences, but further research is needed to define their role.
Collapse
Affiliation(s)
- Carlo Federici
- Centre for Research on Health and Social Care Management (CeRGAS), SDA Bocconi University, Milan, Italy
| | - Francesca Perego
- Department of Biomedical and Clinical Sciences, “Luigi Sacco” University Hospital, University of Milan, Milan, Italy
| | - Ludovica Borsoi
- Centre for Research on Health and Social Care Management (CeRGAS), SDA Bocconi University, Milan, Italy
| | - Valentina Crosta
- Department of Biomedical and Clinical Sciences, “Luigi Sacco” University Hospital, University of Milan, Milan, Italy
| | - Andrea Zanichelli
- Department of Biomedical and Clinical Sciences, “Luigi Sacco” University Hospital, University of Milan, Milan, Italy
| | - Antonio Gidaro
- Department of Biomedical and Clinical Sciences, “Luigi Sacco” University Hospital, University of Milan, Milan, Italy
| | - Rosanna Tarricone
- Government, Health and Non Profit Division, SDA Bocconi University, Milan, Italy
| | - Marco Cicardi
- Department of Biomedical and Clinical Sciences, “Luigi Sacco” University Hospital, University of Milan, Milan, Italy
| |
Collapse
|
27
|
The Complex Interaction Between Polycystic Ovary Syndrome and Hereditary Angioedema: Case Reports and Review of the Literature. Obstet Gynecol Surv 2018; 72:417-424. [PMID: 28715060 DOI: 10.1097/ogx.0000000000000457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Importance Hereditary angioedema (HAE) is a rare but severe disease, with high risk of death, and attacks have been associated to high estrogen levels. Polycystic ovary syndrome (PCOS) is a common hyperandrogenic condition, which is frequently treated with combined oral contraceptives. Objective The aim of this study was to describe 2 clinical cases of young women diagnosed as having PCOS who developed HAE attacks after the introduction of combined estrogen-progestin pills to treat PCOS symptoms. Evidence Acquisition Literature review of sex hormones' role in genesis of HAE attacks and possible mechanisms involved. Results In the cases reported, after initiation of combined contraceptives, patients presented with facial swelling with airway involvement (laryngeal edema) and abdominal pain. They had a familial history of angioedema and normal C1 inhibitor (C1-INH) levels, leading to the diagnosis of HAE with normal C1-INH (HAEnC1-INH) or HAE type III. After suspension of exogenous estrogen, patients remained asymptomatic from HAE. Conclusions and Relevance HAEnC1-INH is an estrogen-dependent form of HAE. It is well established that exogenous estrogen triggers attacks of all types of HAE. However, this is the first description of the association between PCOS and HAE, in which PCOS could be masking HAE symptoms. We propose that PCOS might have a protective role regarding HAE attacks, because of its particular hormonal features, that is, hyperandrogenism and relative stable levels of estradiol. The use of combined estrogen-progestin compounds in women with PCOS and HAE must be avoided, and treatment must be individualized.
Collapse
|
28
|
Honda D, Ohsawa I, Sato N, Inoshita H, Mano S, Tomino Y, Suzuki Y. Diminished capacity of opsonization and immune complex solubilization, and detection of anti-C1q antibodies in sera from patients with hereditary angioedema. Allergol Int 2017; 66:603-609. [PMID: 28433622 DOI: 10.1016/j.alit.2017.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 03/01/2017] [Accepted: 03/14/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Hereditary angioedema (HAE) is an autosomal dominant disease caused by deficiency of C1 esterase inhibitor. Symptoms of HAE include edema, which can potentially cause suffocation. Some patients with HAE exhibit immunological abnormalities, which could prevent an accurate diagnosis. Low levels of complement components are characteristic of HAE and in other settings are thought to reduce elimination of apoptotic cells and immune complex (IC). Thus, we aimed to experimentally clarify the mechanism of immunological abnormalities using sera from HAE patients. METHODS Serum samples from 18 patients with HAE were collected when free from angioedema attack and compared with normal human pooled sera (NHPS) from 20 healthy volunteers. Opsonization was measured as the rate of phagocytosis of apoptotic Jurkat cells by macrophages differentiated from THP-1 cells incubated with serum. IC solubilization in serum was analyzed by quantifying peroxidase released from a synthetic IC composed of peroxidase and anti-peroxidase antibodies. Anti-C1q antibody levels were detected using an enzyme-linked immunosorbent assay. RESULTS Serological immunological abnormalities were detected in 12 patients. Opsonization in serum samples from each patient with HAE was lower than that in NHPS (∼20% versus 70%, respectively). The rate of IC solubilization was lower in serum from HAE patients than NHPS. Some patients had high serum anti-C1q antibody levels with increased serum IC levels. CONCLUSIONS Sera from patients with HAE exhibit anti-C1q antibodies, with a lower capacity for opsonization and IC solubilization. This may be associated with immunological abnormalities and should be investigated further to facilitate accurate diagnosis of HAE.
Collapse
|
29
|
Aberer W, Maurer M, Bouillet L, Zanichelli A, Caballero T, Longhurst HJ, Perrin A, Andresen I. Breakthrough attacks in patients with hereditary angioedema receiving long-term prophylaxis are responsive to icatibant: findings from the Icatibant Outcome Survey. Allergy Asthma Clin Immunol 2017; 13:31. [PMID: 28690642 PMCID: PMC5497380 DOI: 10.1186/s13223-017-0203-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 06/20/2017] [Indexed: 12/30/2022] Open
Abstract
Background Patients with hereditary angioedema (HAE) due to C1-inhibitor deficiency (C1-INH-HAE) experience recurrent attacks of cutaneous or submucosal edema that may be frequent and severe; prophylactic treatments can be prescribed to prevent attacks. However, despite the use of long-term prophylaxis (LTP), breakthrough attacks are known to occur. We used data from the Icatibant Outcome Survey (IOS) to evaluate the characteristics of breakthrough attacks and the effectiveness of icatibant as a treatment option. Methods Data on LTP use, attacks, and treatments were recorded. Attack characteristics, treatment characteristics, and outcomes (time to treatment, time to resolution, and duration of attack) were compared for attacks that occurred with versus without LTP. Results Data on 3228 icatibant-treated attacks from 448 patients with C1-INH-HAE were analyzed; 30.1% of attacks occurred while patients were using LTP. Attack rate, attack severity, and the distribution of attack sites were similar across all types of LTP used, and were comparable to the results found in patients who did not receive LTP. Attacks were successfully treated with icatibant; 82.5% of all breakthrough attacks were treated with a single icatibant injection without C1-INH rescue medication. Treatment outcomes were comparable for breakthrough attacks across all LTP types, and for attacks without LTP. Conclusions Patients who use LTP should be aware that breakthrough attacks can occur, and such attacks can be severe. Thus, patients with C1-INH-HAE using LTP should have emergency treatment readily available. Data from IOS show that icatibant is effective for the treatment of breakthrough attacks. Trial Registration NCT01034969
Collapse
Affiliation(s)
- Werner Aberer
- Department of Dermatology and Venerology, Medical University of Graz, Auenbruggerplatz 8, A-8036 Graz, Austria
| | - Marcus Maurer
- Department of Dermatology and Allergy, Allergie-Centrum-Charité, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Laurence Bouillet
- National Reference Centre for Angioedema, Internal Medicine Department, Grenoble University Hospital, Boulevard de la Chantourne-CS10217, 38043 Grenoble, France
| | - Andrea Zanichelli
- Department of Biomedical and Clinical Sciences Luigi Sacco, ASST Fatebenefratelli Sacco, University of Milan, Via G.B. Grassi 74, 20157 Milan, Italy
| | - Teresa Caballero
- Allergy Department, Hospital La Paz Institute for Health Research (IdiPaz), Biomedical Research Network on Rare Diseases (CIBERER, U754), Paseo de la Castellana 261, 28046 Madrid, Spain
| | - Hilary J Longhurst
- Department of Immunology, Barts Health NHS Trust, 80 Newark Street, London, E1 2ES UK
| | | | | | | |
Collapse
|
30
|
Venditto C, Jager Z, LoGiudice J, Matloub H. Pediatric Hereditary Angioedema as a Cause of Acute Compartment Syndrome of the Hand and Forearm: A Case Report. Hand (N Y) 2017; 12:NP46-NP50. [PMID: 28453344 PMCID: PMC5480669 DOI: 10.1177/1558944716668830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Compartment syndrome of the upper extremity is a surgical emergency that, when left untreated, can have dire consequences. Its causes are numerous, one of which is the uncommon entity hereditary angioedema, an autosomal dominant disease resulting in edema in a variety of potential locations, including the extremities. This is only the second time hereditary angioedema has been mentioned in the literature as a cause of compartment syndrome. METHODS We present a case of hereditary angioedema leading to hand and forearm compartment syndrome in a 13-year-old pediatric patient. Diagnosis of hereditary angioedema was made by our Rheumatology colleagues with physical exam and a thorough history, and confirmed by laboratory studies. RESULTS Our patient presented with compartment syndrome of the hand and forearm and underwent hand and volar forearm fasciotomies. She was subsequently worked up for hereditary angioedema with laboratory results confirming the diagnosis. She was discharged after a 5-day hospitalization with prophylactic C1-inhibitor therapy. CONCLUSIONS Hereditary angioedema is a rare but known cause of compartment syndrome of the upper extremity, and must be considered when patients present with compartment syndrome of unknown etiology. This disease can be diagnosed by laboratory studies and symptoms can be controlled with medical therapy.
Collapse
Affiliation(s)
| | | | | | - Hani Matloub
- Medical College of Wisconsin, Milwaukee, USA,Zablocki VA Medical Center, Milwaukee, WI, USA,Hani Matloub, Department of Plastic Surgery, Medical College of Wisconsin, 8700 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
| |
Collapse
|
31
|
Abstract
The genomic revolution in the past decade fuelled by breathtaking advances in sequencing technologies has defined several new genetic diseases of the immune system. Many of these newly characterized diseases are a result of defects in genes involved in immune regulation. The discovery of these diseases has opened a vista of new therapeutic possibilities. Immunomodulatory agents, a hitherto unexplored therapeutic option in primary immunodeficiency diseases have been tried in a host of these newly described maladies. These agents have been shown conclusively to favorably modulate immune responses, resulting in abatement of clinical manifestations both in experimental models and patients. While some of the treatment options have been approved for therapeutic use or have been shown to be of merit in open-label trials, others have been shown to be efficacious in a handful of clinical cases, animal models, and cell lines. Interferon γ is approved for use in chronic granulomatous disease (CGD) to reduce the burden of infection and and has a good long-term efficacy. Recombinant human IL7 therapy has been shown increase the peripheral CD4 and CD8 T cell counts in patients with idiopathic CD4. Anti-IL1 agents are approved for the management of cryopyrin-related autoinflammatory syndrome, and their therapeutic efficacy is being increasingly recognized in other autoinflammatory syndromes and CGD. Mammalian target of rapamycin (mTOR) inhibitors have been proven useful in autoimmune lymphoproliferative syndrome (ALPS) and in IPEX syndrome. Therapies reported to be potential use in case reports include abatacept in CTLA4 haploinsufficiency and LRBA deficiency, ruxolitinib in gain-of-function STAT1, tocilizumab in gain-of-function STAT3 defect, mTOR inhibitors in PIK3CD activation, magnesium in XMEN syndrome, and pioglitazone in CGD. Treatment options of merit in human cell lines include interferon α and interferon β in TLR3 and UNC-93B deficiencies, anti-interferon therapy in SAVI, and Rho-kinase inhibitors in TTC7A deficiency. Anti-IL17 agents have show efficacy in animal models of leukocyte adhesion defect (LAD) and ALPS. This topical review explores the use of various immunomodulators and other biological agents in the context of primary immunodeficiency and autoinflammatory diseases.
Collapse
|
32
|
Schoenfeld AK, Lahrsen E, Alban S. Regulation of Complement and Contact System Activation via C1 Inhibitor Potentiation and Factor XIIa Activity Modulation by Sulfated Glycans - Structure-Activity Relationships. PLoS One 2016; 11:e0165493. [PMID: 27783665 PMCID: PMC5082678 DOI: 10.1371/journal.pone.0165493] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 10/12/2016] [Indexed: 01/27/2023] Open
Abstract
The serpin C1 inhibitor (C1-INH) is the only regulator of classical complement activation as well as the major regulator of the contact system. Its importance is demonstrated by hereditary angioedema (HAE), a severe disease with potentially life-threatening attacks due to deficiency or dysfunction of C1-INH. C1-INH replacement is the therapy of choice in HAE. In addition, C1-INH showed to have beneficial effects in other diseases characterized by inappropriate complement and contact system activation. Due to some limitations of its clinical application, there is a need for improving the efficacy of therapeutically applied C1-INH or to enhance the activity of endogenous C1-INH. Given the known potentiating effect of heparin on C1-INH, sulfated glycans (SG) may be such candidates. The aim of this study was to characterize suitable SG by evaluating structure-activity relationships. For this, more than 40 structurally distinct SG were examined for their effects on C1-INH, C1s and FXIIa. The SG turned out to potentiate the C1s inhibition by C1-INH without any direct influence on C1s. Their potentiating activity proved to depend on their degree of sulfation, molecular mass as well as glycan structure. In contrast, the SG had no effect on the FXIIa inhibition by C1-INH, but structure-dependently modulated the activity of FXIIa. Among the tested SG, β-1,3-glucan sulfates with a Mr ≤ 10 000 were identified as most promising lead candidates for the development of a glycan-based C1-INH amplifier. In conclusion, the obtained information on structural characteristics of SG favoring C1-INH potentiation represent an useful elementary basis for the development of compounds improving the potency of C1-INH in diseases and clinical situations characterized by inappropriate activation of complement and contact system.
Collapse
Affiliation(s)
- Ann-Kathrin Schoenfeld
- Department of Pharmaceutical Biology, Pharmaceutical Institute, Christian-Albrechts-University of Kiel, Kiel, Schleswig-Holstein, Germany
| | - Eric Lahrsen
- Department of Pharmaceutical Biology, Pharmaceutical Institute, Christian-Albrechts-University of Kiel, Kiel, Schleswig-Holstein, Germany
| | - Susanne Alban
- Department of Pharmaceutical Biology, Pharmaceutical Institute, Christian-Albrechts-University of Kiel, Kiel, Schleswig-Holstein, Germany
| |
Collapse
|
33
|
Bork K, Witzke G. Shortened Activated Partial Thromboplastin Time May Help in Diagnosing Hereditary and Acquired Angioedema. Int Arch Allergy Immunol 2016; 170:101-7. [DOI: 10.1159/000447695] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 06/15/2016] [Indexed: 11/19/2022] Open
|
34
|
Prohászka Z, Nilsson B, Frazer-Abel A, Kirschfink M. Complement analysis 2016: Clinical indications, laboratory diagnostics and quality control. Immunobiology 2016; 221:1247-58. [PMID: 27475991 DOI: 10.1016/j.imbio.2016.06.008] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 06/10/2016] [Accepted: 06/10/2016] [Indexed: 10/21/2022]
Abstract
In recent years, complement analysis of body fluids and biopsies, going far beyond C3 and C4, has significantly enhanced our understanding of the disease process. Such expanded complement analysis allows for a more precise differential diagnosis and for critical monitoring of complement-targeted therapy. These changes are a result of the growing understanding of the involvement of complement in a diverse set of disorders. To appreciate the importance of proper complement analysis, it is important to understand the role it plays in disease. Historically, it was the absence of complement as manifested in severe infection that was noted. Since then complement has been connected to a variety of inflammatory disorders, such as autoimmune diseases and hereditary angioedema. While the role of complement in the rejection of renal grafts has been known longer, the significant impact of complement. In certain nephropathies has now led to the reclassification of some rare kidney diseases and an increased role for complement analysis in diagnosis. Even more unexpected is that complement has also been implicated in neural, ophtalmological and dermatological disorders. With this level of involvement in some varied and impactful health issues proper complement testing is clearly important; however, analysis of the complement system varies widely among laboratories. Except for a few proteins, such as C3 and C4, there are neither well-characterized standard preparations nor calibrated assays available. This is especially true for the inter-laboratory variation of tests which assess classical, alternative, or lectin pathway function. In addition, there is a need for the standardization of the measurement of complement activation products that are so critical in determining whether clinically relevant complement activation has occurred in vivo. Finally, autoantibodies to complement proteins (e.g. anti-C1q), C3 and C4 convertases (C3 and C4 nephritic factor) or to regulatory proteins (e.g. anti-C1inhibitor, anti-factor H) are important in defining autoimmune processes and diseases based on complement dysregulation. To improve the quality of complement laboratory analysis a standardization commmittee of the International Complement Society (ICS) and the International Union of Immunological Societies (IUIS) was formed to provide guidelines for modern complement analysis and standards for the development of international testing programs.
Collapse
Affiliation(s)
- Zoltán Prohászka
- 3rd Department of Internal Medicine, Research Laboratory and Füst György Complement Diagnostic Laboratory, Semmelweis University, Budapest, Hungary
| | - Bo Nilsson
- Clinical Immunology, Rudbeck Laboratory (C5), University Hospital, Uppsala, Sweden
| | | | | |
Collapse
|
35
|
Chen WL, Gallagher J, Zafra H, Gedeit R. Hereditary angioedema presenting as compartment syndrome in a white girl. Ann Allergy Asthma Immunol 2016; 117:321-2. [PMID: 27397069 DOI: 10.1016/j.anai.2016.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 06/14/2016] [Accepted: 06/19/2016] [Indexed: 01/10/2023]
Affiliation(s)
- Wei-Liang Chen
- Medical College of Wisconsin, Milwaukee, Wisconsin; Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Joel Gallagher
- Medical College of Wisconsin, Milwaukee, Wisconsin; Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Heidi Zafra
- Medical College of Wisconsin, Milwaukee, Wisconsin; Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Rainer Gedeit
- Medical College of Wisconsin, Milwaukee, Wisconsin; Children's Hospital of Wisconsin, Milwaukee, Wisconsin.
| |
Collapse
|
36
|
Landsem A, Fure H, Mollnes T, Nielsen E, Brekke O. C1-inhibitor efficiently delays clot development in normal human whole blood and inhibits Escherichia coli-induced coagulation measured by thromboelastometry. Thromb Res 2016; 143:63-70. [DOI: 10.1016/j.thromres.2016.04.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 04/27/2016] [Accepted: 04/27/2016] [Indexed: 11/15/2022]
|
37
|
Polyphosphate is a novel cofactor for regulation of complement by a serpin, C1 inhibitor. Blood 2016; 128:1766-76. [PMID: 27338096 DOI: 10.1182/blood-2016-02-699561] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 06/20/2016] [Indexed: 01/11/2023] Open
Abstract
The complement system plays a key role in innate immunity, inflammation, and coagulation. The system is delicately balanced by negative regulatory mechanisms that modulate the host response to pathogen invasion and injury. The serpin, C1-esterase inhibitor (C1-INH), is the only known plasma inhibitor of C1s, the initiating serine protease of the classical pathway of complement. Like other serpin-protease partners, C1-INH interaction with C1s is accelerated by polyanions such as heparin. Polyphosphate (polyP) is a naturally occurring polyanion with effects on coagulation and complement. We recently found that polyP binds to C1-INH, prompting us to consider whether polyP acts as a cofactor for C1-INH interactions with its target proteases. We show that polyP dampens C1s-mediated activation of the classical pathway in a polymer length- and concentration-dependent manner by accelerating C1-INH neutralization of C1s cleavage of C4 and C2. PolyP significantly increases the rate of interaction between C1s and C1-INH, to an extent comparable to heparin, with an exosite on the serine protease domain of the enzyme playing a major role in this interaction. In a serum-based cell culture system, polyP significantly suppressed C4d deposition on endothelial cells, generated via the classical and lectin pathways. Moreover, polyP and C1-INH colocalize in activated platelets, suggesting that their interactions are physiologically relevant. In summary, like heparin, polyP is a naturally occurring cofactor for the C1s:C1-INH interaction and thus an important regulator of complement activation. The findings may provide novel insights into mechanisms underlying inflammatory diseases and the development of new therapies.
Collapse
|
38
|
Abstract
Hereditary angioedema (HAE) is a rare disease caused by deficiency of C1 esterase inhibitor (C1-INH). It is an autosomal dominant disease caused by a variety of mutations in the C1-INH gene. C1-INH is an important regulator of several pathways. One pathway it affects is the kallikrein–kinin pathway, which results in the generation of bradykinin. Bradykinin is an important mediator of edema. Diagnosis is based on low levels of C1-INH. HAE with normal C1-INH is also recognized in the literature and the pathophysiology is due to another aspect of the pathway being affected leading to increased bradykinin level. Bradykinin results in intermittent swelling of the cutaneous and mucosal surfaces. The swelling usually evolves over several hours and lasts a few days. Location of the swelling can involve any part of the body including fatal laryngeal edema. Newer treatments exist to treat acute attacks and reduce the frequency of future attacks. Earlier diagnosis and treatment of hereditary angioedema can prevent HAE-associated mortality. Statement of novelty: New treatments are used to treat these attacks. These treatments are aimed at patients having a more normal life with hereditary angioedema.
Collapse
|
39
|
Diagnostic and therapeutic management of hereditary angioedema due to C1-inhibitor deficiency: the Italian experience. Curr Opin Allergy Clin Immunol 2016; 15:383-91. [PMID: 26106828 DOI: 10.1097/aci.0000000000000186] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Hereditary angioedema (HAE) due to C1-inhibitor (C1-INH) deficiency (C1-INH-HAE) is a rare disease, with a reported prevalence of about 1 : 50 000. C1-INH-HAE causes disabling symptoms, which may be life-threatening if swelling affects upper airways. Diagnostic procedures are now well established and the role of bradykinin as the main mediator of plasma outflow eliciting angioedema formation has been clearly elucidated. RECENT FINDINGS Increased understanding of the pathogenesis of C1-INH-HAE allowed in recent years the development of new drugs targeted to inhibit bradykinin synthesis (Ecallantide) or activity (Icatibant). At the same time, a recombinant C1-INH concentrate (Ruconest) was produced from the milk of transgenic rabbits and two plasma-derived C1-INHs (Berinert, Cinryze) underwent controlled trials to obtain marketing authorization. In 2012, an Italian network for C1-INH-HAE (ITACA) was established by physicians of 17 HAE reference centres to collect data from Italian patients and to homogenize and improve the diagnostic and therapeutic approach to the disease. SUMMARY Although there is a widespread agreement on therapeutic goals and treatment of C1-INH-HAE acute attacks, different approaches to prophylaxis are still present among HAE experts. The clinical experience of ITACA on a large population of C1-INH-HAE patients followed for several years may help in identifying the most effective strategies for the management of the disease.
Collapse
|
40
|
Hereditary angioedema in a Jordanian family with a novel missense mutation in the C1-inhibitor N-terminal domain. Mol Immunol 2016; 71:123-130. [DOI: 10.1016/j.molimm.2016.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Revised: 02/01/2016] [Accepted: 02/05/2016] [Indexed: 01/20/2023]
|
41
|
Schmaier AH. The contact activation and kallikrein/kinin systems: pathophysiologic and physiologic activities. J Thromb Haemost 2016; 14:28-39. [PMID: 26565070 DOI: 10.1111/jth.13194] [Citation(s) in RCA: 252] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 10/29/2015] [Indexed: 12/31/2022]
Abstract
The contact activation system (CAS) and kallikrein/kinin system (KKS) are older recognized biochemical pathways that include several proteins that skirt the fringes of the blood coagulation, fibrinolytic, complement and renin-angiotensin fields. These proteins initially were proposed as part of the hemostatic pathways because their deficiencies are associated with prolonged clinical assays. However, the absence of bleeding states with deficiencies of factor XII (FXII), prekallikrein (PK) and high-molecular-weight kininogen indicates that the CAS and KKS do not contribute to hemostasis. Since the discovery of the Hageman factor 60 years ago much has been learned about the biochemistry, cell biology and animal physiology of these proteins. The CAS is a pathophysiologic surface defense mechanism against foreign proteins, organisms and artificial materials. The KKS is an inflammatory response mechanism. Targeting their activation through FXIIa or plasma kallikrein inhibition when blood interacts with the artificial surfaces of modern interventional medicine or in acute attacks of hereditary angioedema restores vascular homeostasis. FXII/FXIIa and products that arise with PK deficiency also offer novel ways to reduce arterial and venous thrombosis without an effect on hemostasis. In summary, there is revived interest in the CAS and KKS due to better understanding of their activities. The new appreciation of these systems will lead to several new therapies for a variety of medical disorders.
Collapse
Affiliation(s)
- A H Schmaier
- Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
- University Hospitals Case Medical Center, Cleveland, OH, USA
| |
Collapse
|
42
|
Applying complement therapeutics to rare diseases. Clin Immunol 2015; 161:225-40. [PMID: 26341313 DOI: 10.1016/j.clim.2015.08.009] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 08/20/2015] [Indexed: 02/06/2023]
Abstract
Around 350 million people worldwide suffer from rare diseases. These may have a genetic, infectious, or autoimmune basis, and several include an inflammatory component. Launching of effective treatments can be very challenging when there is a low disease prevalence and limited scientific insights into the disease mechanisms. As a key trigger of inflammatory processes, complement has been associated with a variety of diseases and has become an attractive therapeutic target for conditions involving inflammation. In view of the clinical experience acquired with drugs licensed for the treatment of rare diseases such as hereditary angioedema and paroxysmal nocturnal hemoglobinuria, growing evidence supports the safety and efficacy of complement therapeutics in restoring immune balance and preventing aggravation of clinical outcomes. This review provides an overview of the candidates currently in the pharmaceutical pipeline with potential to treat orphan diseases and discusses the molecular mechanisms triggered by complement involved with the disease pathogenesis.
Collapse
|
43
|
Moldovan D, Bernstein JA, Cicardi M. Recombinant replacement therapy for hereditary angioedema due to C1 inhibitor deficiency. Immunotherapy 2015; 7:739-52. [DOI: 10.2217/imt.15.44] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Hereditary angioedema is a rare genetic condition transmitted as an autosomal dominant trait and characterized most commonly by the production of either inadequate or nonfunctioning C1 esterase inhibitor (C1-INH), a blood protein that regulates proteases in the complement, fibrinolytic and contact systems. Patients with hereditary angioedema suffer from episodic, unpredictable manifestations of edema affecting multiple anatomical locations, including the GI tract, facial tissue, the upper airway, oropharynx, urogenital region and/or the arms and legs. A rational approach to treatment is replacement of C1-INH protein, to normalize the levels of C1-INH activity and halt the progression of the biochemical activation processes underlying the edema formation. Ruconest is a highly purified recombinant human C1-INH. This article will focus on the results of ten clinical studies demonstrating the efficacy and safety of Ruconest® (Pharming Group NV, Leiden, the Netherlands), which is now approved for use in Europe, Israel and the USA.
Collapse
Affiliation(s)
- Dumitru Moldovan
- University of Medicine & Pharmacy, Mures County Hospital, 1 Marinescu St, 540103 Tîrgu Mures, Romania
| | - Jonathan A Bernstein
- Allergy Section, Division of Immunology, Department of Internal Medicine, College of Medicine, University of Cincinnati, 231 Albert Sabin Way ML#563 Room 7413, Cincinnati, OH 45267-0563, USA
| | - Marco Cicardi
- Department of Biomedical & Clinical Sciences Luigi Sacco, University of Milan, Luigi Sacco Hospital, Via G.B. Grassi 74, 20157 Milan, Italy
| |
Collapse
|