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Petersen RS, Fijen LM, Levi M, Cohn DM. Hereditary Angioedema: The Clinical Picture of Excessive Contact Activation. Semin Thromb Hemost 2024; 50:978-988. [PMID: 36417927 PMCID: PMC11407848 DOI: 10.1055/s-0042-1758820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hereditary angioedema is a rare, genetic disorder characterized by painful, debilitating and potentially life-threatening angioedema attacks in subcutaneous and submucosal tissue. While usually unpredictable, attacks can be provoked by a variety of triggers including physical injury and certain medication and are often preceded by prodromal symptoms. Hereditary angioedema has a profound influence on the patients' lives. The fundamental cause of hereditary angioedema in almost all patients is a mutation in the SERPING1 gene leading to a deficiency in C1-inhibitor. Subsequently, the contact activation cascade and kallikrein-kinin pathway are insufficiently inhibited, resulting in excessive bradykinin production triggering vascular leakage. While C1-inhibitor is an important regulator of the intrinsic coagulation pathway, fibrinolytic system and complement cascade, patients do not have an increased risk of coagulopathy, autoimmune conditions or immunodeficiency disorders. Hereditary angioedema is diagnosed based on C1-inhibitor level and function. Genetic analysis is only required in rare cases where hereditary angioedema with normal C1-inhibitor is found. In recent years, new, highly specific therapies have greatly improved disease control and angioedema-related quality of life. This article reviews the clinical picture of hereditary angioedema, the underlying pathophysiology, diagnostic process and currently available as well as investigational therapeutic options.
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Affiliation(s)
- Remy S Petersen
- Department of Vascular Medicine, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, the Netherlands
| | - Lauré M Fijen
- Department of Vascular Medicine, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, the Netherlands
| | - Marcel Levi
- Department of Vascular Medicine, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, the Netherlands
| | - Danny M Cohn
- Department of Vascular Medicine, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, the Netherlands
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2
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Tarandovskiy ID, Surov SS, Parunov LA, Liang Y, Jankowski W, Sauna ZE, Ovanesov MV. Investigation of thrombin concentration at the time of clot formation in simultaneous thrombin and fibrin generation assays. Sci Rep 2024; 14:9225. [PMID: 38649717 PMCID: PMC11035586 DOI: 10.1038/s41598-023-47694-5] [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: 07/18/2023] [Accepted: 11/16/2023] [Indexed: 04/25/2024] Open
Abstract
Thrombin generation (TG) and fibrin clot formation represent the central process of blood coagulation. Up to 95% of thrombin is considered to be generated after the clot is formed. However, this was not investigated in depth. In this study, we conducted a quantitative analysis of the Thrombin at Clot Time (TCT) parameter in 5758 simultaneously recorded TG and clot formation assays using frozen plasma samples from commercial sources under various conditions of activation. These samples were supplemented with clotting factor concentrates, procoagulant lipid vesicles and a fluorogenic substrate and triggered with tissue factor (TF). We found that TCT is often close to a 10% of thrombin peak height (TPH) yet it can be larger or smaller depending on whether the sample has low or high TPH value. In general, the samples with high TPH are associated with elevated TCT. TCT appeared more sensitive to some procoagulant phenotypes than other commonly used parameters such as clotting time, TPH or Thrombin Production Rate (TPR). In a minority of cases, TCT were not predicted from TG parameters. For example, elevated TCT (above 15% of TPH) was associated with either very low or very high TPR values. We conclude that clotting and TG assays may provide complementary information about the plasma sample, and that the TCT parameter may serve as an additional marker for the procoagulant potential in plasma sample.
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Affiliation(s)
- Ivan D Tarandovskiy
- U.S. Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, MD, 20993, USA
| | - Stepan S Surov
- U.S. Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, MD, 20993, USA
| | - Leonid A Parunov
- U.S. Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, MD, 20993, USA
| | - Yideng Liang
- U.S. Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, MD, 20993, USA
| | - Wojciech Jankowski
- U.S. Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, MD, 20993, USA
| | - Zuben E Sauna
- U.S. Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, MD, 20993, USA
| | - Mikhail V Ovanesov
- U.S. Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, MD, 20993, USA.
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Lima H, Zheng J, Wong D, Waserman S, Sussman GL. Pathophysiology of bradykinin and histamine mediated angioedema. FRONTIERS IN ALLERGY 2023; 4:1263432. [PMID: 37920409 PMCID: PMC10619149 DOI: 10.3389/falgy.2023.1263432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/26/2023] [Indexed: 11/04/2023] Open
Abstract
Angioedema is characterized by swelling localized to the subcutaneous and submucosal tissues. This review provides an overview of angioedema, including the different types, triggers, and underlying pathophysiologic mechanisms. Hereditary and acquired angioedema are caused by dysregulation of the complement and kinin pathways. In contrast, drug-induced and allergic angioedema involve the activation of the immune system and release of vasoactive mediators. Recent advances in the understanding of the pathophysiology of angioedema have led to the development of targeted therapies, such as monoclonal antibodies, bradykinin receptor antagonists, and complement inhibitors, which promise to improve clinical outcomes in patients with this challenging condition. To accurately diagnose and manage angioedema, an understanding of this condition's complex and varied pathophysiology is both necessary and critical.
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Affiliation(s)
- Hermenio Lima
- LEADER Research Inc., Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Dennis Wong
- Division of Clinical Immunology and Allergy, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Susan Waserman
- Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Gordon L. Sussman
- Department of Medicine and Division of Clinical Immunology & Allergy, University of Toronto, Toronto, ON, Canada
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Hvas CL, Larsen JB. The Fibrinolytic System and Its Measurement: History, Current Uses and Future Directions for Diagnosis and Treatment. Int J Mol Sci 2023; 24:14179. [PMID: 37762481 PMCID: PMC10532028 DOI: 10.3390/ijms241814179] [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: 08/25/2023] [Revised: 09/13/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
The fibrinolytic system is a key player in keeping the haemostatic balance, and changes in fibrinolytic capacity can lead to both bleeding-related and thrombosis-related disorders. Our knowledge of the fibrinolytic system has expanded immensely during the last 75 years. From the first successful use of thrombolysis in myocardial infarction in the 1960s, thrombolytic therapy is now widely implemented and has reformed treatment in vascular medicine, especially ischemic stroke, while antifibrinolytic agents are used routinely in the prevention and treatment of major bleeding worldwide. Despite this, this research field still holds unanswered questions. Accurate and timely laboratory diagnosis of disturbed fibrinolysis in the clinical setting remains a challenge. Furthermore, despite growing evidence that hypofibrinolysis plays a central role in, e.g., sepsis-related coagulopathy, coronary artery disease, and venous thromboembolism, there is currently no approved treatment of hypofibrinolysis in these settings. The present review provides an overview of the fibrinolytic system and history of its discovery; measurement methods; clinical relevance of the fibrinolytic system in diagnosis and treatment; and points to future directions for research.
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Affiliation(s)
- Christine Lodberg Hvas
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, 8200 Aarhus N, Denmark;
- Department of Clinical Medicine, Faculty of Health Sciences, Aarhus University, 8200 Aarhus N, Denmark
| | - Julie Brogaard Larsen
- Department of Clinical Medicine, Faculty of Health Sciences, Aarhus University, 8200 Aarhus N, Denmark
- Department of Clinical Biochemistry, Regional Hospital Horsens, 8700 Horsens, Denmark
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5
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Grover SP, Kawano T, Wan J, Tanratana P, Polai Z, Shim YJ, Snir O, Brækkan S, Dhrolia S, Kasthuri RR, Bendapudi PK, McCrae KR, Wolberg AS, Hansen JB, Farkas H, Mackman N. C1 inhibitor deficiency enhances contact pathway-mediated activation of coagulation and venous thrombosis. Blood 2023; 141:2390-2401. [PMID: 36701760 PMCID: PMC10273165 DOI: 10.1182/blood.2022018849] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/04/2023] [Accepted: 01/20/2023] [Indexed: 01/27/2023] Open
Abstract
C1 inhibitor (C1INH) is a multifunctional serine protease inhibitor that functions as a major negative regulator of several biological pathways, including the contact pathway of blood coagulation. In humans, congenital C1INH deficiency results in a rare episodic bradykinin-mediated swelling disorder called hereditary angioedema (HAE). Patients with C1INH deficiency-associated HAE (C1INH-HAE) have increased circulating markers of activation of coagulation. Furthermore, we recently reported that patients with C1INH-HAE had a moderate but significant increased risk of venous thromboembolism. To further investigate the impact of C1INH deficiency on activation of coagulation and thrombosis, we conducted studies using patient samples and mouse models. Plasmas from patients with C1INH-HAE had significantly increased contact pathway-mediated thrombin generation. C1INH-deficient mice, which have been used as a model of C1INH-HAE, had significantly increased baseline circulating levels of prothrombin fragment 1+2 and thrombin-antithrombin complexes. In addition, whole blood from C1INH-deficient mice supported significantly increased contact pathway-mediated thrombin generation. Importantly, C1INH-deficient mice exhibited significantly enhanced venous, but not arterial, thrombus formation. Furthermore, purified human C1INH normalized contact pathway-mediated thrombin generation and venous thrombosis in C1INH-deficient mice. These findings highlight a key role for endogenous C1INH as a negative regulator of contact pathway-mediated coagulation in humans and mice. Further, this work identifies endogenous C1INH as an important negative regulator of venous thrombus formation in mice, complementing the phenotype associated with C1INH-HAE.
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Affiliation(s)
- Steven P. Grover
- UNC Blood Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC
- Division of Hematology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Tomohiro Kawano
- UNC Blood Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC
- Division of Hematology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jun Wan
- UNC Blood Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC
- Division of Hematology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Pansakorn Tanratana
- UNC Blood Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC
- Division of Hematology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Pharmacology, Faculty of Science, Mahidol University, Bangkok, Thailand
| | - Zsofia Polai
- Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Budapest, Hungary
| | - Young J. Shim
- Taussig Cancer Institute and Department of Cellular and Molecular Medicine, Cleveland Clinic, Cleveland, OH
| | - Omri Snir
- Department of Clinical Medicine, Thrombosis Research Center, UiT – The Arctic University of Norway, Tromsø, Norway
| | - Sigrid Brækkan
- Department of Clinical Medicine, Thrombosis Research Center, UiT – The Arctic University of Norway, Tromsø, Norway
- Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Sophia Dhrolia
- UNC Blood Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC
- Division of Hematology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Rohan R. Kasthuri
- UNC Blood Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC
- Division of Hematology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Pavan K. Bendapudi
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA
- Division of Hematology and Blood Transfusion Service, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Keith R. McCrae
- Taussig Cancer Institute and Department of Cellular and Molecular Medicine, Cleveland Clinic, Cleveland, OH
| | - Alisa S. Wolberg
- UNC Blood Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Pathology and Laboratory Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - John-Bjarne Hansen
- Department of Clinical Medicine, Thrombosis Research Center, UiT – The Arctic University of Norway, Tromsø, Norway
- Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Henriette Farkas
- Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Budapest, Hungary
| | - Nigel Mackman
- UNC Blood Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC
- Division of Hematology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
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6
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Humphreys SJ, Whyte CS, Mutch NJ. "Super" SERPINs-A stabilizing force against fibrinolysis in thromboinflammatory conditions. Front Cardiovasc Med 2023; 10:1146833. [PMID: 37153474 PMCID: PMC10155837 DOI: 10.3389/fcvm.2023.1146833] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/31/2023] [Indexed: 05/09/2023] Open
Abstract
The superfamily of serine protease inhibitors (SERPINs) are a class of inhibitors that utilise a dynamic conformational change to trap and inhibit their target enzymes. Their powerful nature lends itself well to regulation of complex physiological enzymatic cascades, such as the haemostatic, inflammatory and complement pathways. The SERPINs α2-antiplasmin, plasminogen-activator inhibitor-1, plasminogen-activator inhibitor-2, protease nexin-1, and C1-inhibitor play crucial inhibitory roles in regulation of the fibrinolytic system and inflammation. Elevated levels of these SERPINs are associated with increased risk of thrombotic complications, obesity, type 2 diabetes, and hypertension. Conversely, deficiencies of these SERPINs have been linked to hyperfibrinolysis with bleeding and angioedema. In recent years SERPINs have been implicated in the modulation of the immune response and various thromboinflammatory conditions, such as sepsis and COVID-19. Here, we highlight the current understanding of the physiological role of SERPINs in haemostasis and inflammatory disease progression, with emphasis on the fibrinolytic pathway, and how this becomes dysregulated during disease. Finally, we consider the role of these SERPINs as potential biomarkers of disease progression and therapeutic targets for thromboinflammatory diseases.
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7
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Tarandovskiy ID, Buehler PW, Karnaukhova E. Sex-dependent balance between thrombin and plasmin generation in the presence of thrombomodulin. J Thromb Thrombolysis 2022; 55:566-570. [PMID: 36508084 DOI: 10.1007/s11239-022-02742-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Assessing simultaneous generation of thrombin (TG) and plasmin (PG) is an approach to evaluate the balance between coagulation and fibrinolysis with sensitivity to predict endogenous thrombin and plasmin generation. The addition of thrombomodulin (TM), provides the essential component for thrombin activation of protein C and thrombin-activatable fibrinolysis inhibitor. However, the influence of sex on the balance between TG and PG with and without TM addition has not been investigated to date. OBJECTIVES To investigate the possible sex-based differences in TG and PG in the presence and absence of TM. METHODS Simultaneous TG and PG were measured in plasma samples obtained from 17 males and 17 females upon tissue factor and tissue plasminogen activator addition. Thrombin- and plasmin-specific fluorogenic substrates Z-Gly-Gly-Arg-AMC and Boc-Glu-Lys-Lys-AMC were used in the study. Thrombin and plasmin peak height (TPH and PPH) and production rate (TPR and PPR) values were determined. To evaluate the balance between TG and PG, the ratios between TPH and PPH (TPH/PPH) and TPR and PPR (TPR/PPR) were calculated. RESULTS AND CONCLUSIONS TPH between males and females demonstrated significant difference regardless of TM addition. TPR demonstrated differences between males and females only upon TM addition, while PG parameters was not dependent on the sex of the donor. TM significantly lowered TPH/PPH in males, and enhanced TPR/PPR in females. Thus, TPH/PPH and TPR/PPR significantly differed between men and women. Our results indicate that TM may act differently in males and females by shifting the underlying TG/PG balance to fibrinolysis in males and to coagulation in females.
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Affiliation(s)
- Ivan D Tarandovskiy
- Hemostasis Branch, Center for Biologics Evaluation and Research, Food and Drug Administration, 10903 New Hampshire Avenue, 20993, Silver Spring, MD, USA.
| | - Paul W Buehler
- Department of Pathology, The Center for Blood Oxygen Transport and Hemostasis, Department of Pediatrics, University of Maryland, Baltimore, MD, USA
| | - Elena Karnaukhova
- Laboratory of Biochemistry and Vascular Biology, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
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8
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Grover SP, Mackman N. Anticoagulant SERPINs: Endogenous Regulators of Hemostasis and Thrombosis. Front Cardiovasc Med 2022; 9:878199. [PMID: 35592395 PMCID: PMC9110684 DOI: 10.3389/fcvm.2022.878199] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 03/29/2022] [Indexed: 12/17/2022] Open
Abstract
Appropriate activation of coagulation requires a balance between procoagulant and anticoagulant proteins in blood. Loss in this balance leads to hemorrhage and thrombosis. A number of endogenous anticoagulant proteins, such as antithrombin and heparin cofactor II, are members of the serine protease inhibitor (SERPIN) family. These SERPIN anticoagulants function by forming irreversible inhibitory complexes with target coagulation proteases. Mutations in SERPIN family members, such as antithrombin, can cause hereditary thrombophilias. In addition, low plasma levels of SERPINs have been associated with an increased risk of thrombosis. Here, we review the biological activities of the different anticoagulant SERPINs. We further consider the clinical consequences of SERPIN deficiencies and insights gained from preclinical disease models. Finally, we discuss the potential utility of engineered SERPINs as novel therapies for the treatment of thrombotic pathologies.
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Sundler Björkman L, Persson B, Aronsson D, Skattum L, Nordenfelt P, Egesten A. Comorbidities in hereditary angioedema-A population-based cohort study. Clin Transl Allergy 2022; 12:e12135. [PMID: 35344299 PMCID: PMC8967273 DOI: 10.1002/clt2.12135] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 02/08/2022] [Accepted: 03/10/2022] [Indexed: 11/25/2022] Open
Abstract
Background In hereditary angioedema (HAE), low levels (type 1) or defect in function (type 2) of the serine‐protease inhibitor C1 Inhibitor protein results in activation of the classical pathway of the complement system as well as the contact system. Here, we investigated the risk of comorbidities in HAE. Methods Individuals with HAE (n = 239; identified through a physician made diagnosis) and a control cohort from the general population (n = 2383; matched for age, gender, and county of residence) were compared with the Swedish inpatient, cause of death, cancer, and prescription registers. Conditional logistic regression was used to analyze the data. Results Increased risk of cardiovascular disease (odds ratio [OR] 1.83; 95% confidence interval [CI] 1.32–2.54), including arterial (OR 6.74; 95% CI 1.89–24.06) and venous thromboembolic disease (OR 4.20; 95% CI 2.42–7.23) as well as hypertension (OR 1.64; 95% CI 1.12–2.39) was seen in HAE. There was also an increased number of individuals diagnosed with hyperlipidemia (OR 2.01; 95% CI 1.16–3.50) among HAE patients. Furthermore, the risk of autoimmune disease was increased (OR 1.65; 95% CI 1.15–2.35) being particularly pronounced for systemic lupus erythematosus (OR 71.87; 95% CI 8.80–586.7). The risk of having two or more autoimmune diseases was also higher among HAE patients (p = 0.017). In contrast, the risk of cancer was not increased. Data from the prescription register revealed higher prescription rates of drugs against hypertension, hypothyroidism, and hyperlipidemia among HAE patients. Conclusions The results warrant for awareness and prevention of comorbid conditions, in particular, thromboembolic and autoimmune diseases in HAE. Future prophylactic interventions may modify these risks.
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Affiliation(s)
- Linda Sundler Björkman
- Respiratory Medicine & Allergology, Department of Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
| | - Barbro Persson
- Department of Immunology, Genetics and Pathology, The Rudbeck Laboratory, Uppsala University, Uppsala, Sweden
| | - David Aronsson
- Respiratory Medicine & Allergology, Department of Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
| | - Lillemor Skattum
- Department of Laboratory Medicine, Section of Microbiology, Immunology and Glycobiology, Lund University and Clinical Immunology and Transfusion Medicine, Lund, Sweden
| | - Patrik Nordenfelt
- Respiratory Medicine & Allergology, Department of Internal Medicine, County Hospital of Ryhov, Jönköping, Sweden
| | - Arne Egesten
- Respiratory Medicine & Allergology, Department of Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
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Plasminogen Activators in Neurovascular and Neurodegenerative Disorders. Int J Mol Sci 2021; 22:ijms22094380. [PMID: 33922229 PMCID: PMC8122722 DOI: 10.3390/ijms22094380] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/14/2021] [Accepted: 04/20/2021] [Indexed: 12/14/2022] Open
Abstract
The neurovascular unit (NVU) is a dynamic structure assembled by endothelial cells surrounded by a basement membrane, pericytes, astrocytes, microglia and neurons. A carefully coordinated interplay between these cellular and non-cellular components is required to maintain normal neuronal function, and in line with these observations, a growing body of evidence has linked NVU dysfunction to neurodegeneration. Plasminogen activators catalyze the conversion of the zymogen plasminogen into the two-chain protease plasmin, which in turn triggers a plethora of physiological events including wound healing, angiogenesis, cell migration and inflammation. The last four decades of research have revealed that the two mammalian plasminogen activators, tissue-type plasminogen activator (tPA) and urokinase-type plasminogen activator (uPA), are pivotal regulators of NVU function during physiological and pathological conditions. Here, we will review the most relevant data on their expression and function in the NVU and their role in neurovascular and neurodegenerative disorders.
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11
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Molecular Dambusters: What Is Behind Hyperpermeability in Bradykinin-Mediated Angioedema? Clin Rev Allergy Immunol 2021; 60:318-347. [PMID: 33725263 PMCID: PMC7962090 DOI: 10.1007/s12016-021-08851-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2021] [Indexed: 02/08/2023]
Abstract
In the last few decades, a substantial body of evidence underlined the pivotal role of bradykinin in certain types of angioedema. The formation and breakdown of bradykinin has been studied thoroughly; however, numerous questions remained open regarding the triggering, course, and termination of angioedema attacks. Recently, it became clear that vascular endothelial cells have an integrative role in the regulation of vessel permeability. Apart from bradykinin, a great number of factors of different origin, structure, and mechanism of action are capable of modifying the integrity of vascular endothelium, and thus, may participate in the regulation of angioedema formation. Our aim in this review is to describe the most important permeability factors and the molecular mechanisms how they act on endothelial cells. Based on endothelial cell function, we also attempt to explain some of the challenging findings regarding bradykinin-mediated angioedema, where the function of bradykinin itself cannot account for the pathophysiology. By deciphering the complex scenario of vascular permeability regulation and edema formation, we may gain better scientific tools to be able to predict and treat not only bradykinin-mediated but other types of angioedema as well.
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12
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Assessing Plasmin Generation in Health and Disease. Int J Mol Sci 2021; 22:ijms22052758. [PMID: 33803235 PMCID: PMC7963172 DOI: 10.3390/ijms22052758] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/20/2021] [Accepted: 03/05/2021] [Indexed: 12/13/2022] Open
Abstract
Fibrinolysis is an important process in hemostasis responsible for dissolving the clot during wound healing. Plasmin is a central enzyme in this process via its capacity to cleave fibrin. The kinetics of plasmin generation (PG) and inhibition during fibrinolysis have been poorly understood until the recent development of assays to quantify these metrics. The assessment of plasmin kinetics allows for the identification of fibrinolytic dysfunction and better understanding of the relationships between abnormal fibrin dissolution and disease pathogenesis. Additionally, direct measurement of the inhibition of PG by antifibrinolytic medications, such as tranexamic acid, can be a useful tool to assess the risks and effectiveness of antifibrinolytic therapy in hemorrhagic diseases. This review provides an overview of available PG assays to directly measure the kinetics of plasmin formation and inhibition in human and mouse plasmas and focuses on their applications in defining the role of plasmin in diseases, including angioedema, hemophilia, rare bleeding disorders, COVID-19, or diet-induced obesity. Moreover, this review introduces the PG assay as a promising clinical and research method to monitor antifibrinolytic medications and screen for genetic or acquired fibrinolytic disorders.
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Porebski G, Kwitniewski M, Reshef A. Biomarkers in Hereditary Angioedema. Clin Rev Allergy Immunol 2021; 60:404-415. [PMID: 33560480 PMCID: PMC8272698 DOI: 10.1007/s12016-021-08845-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2021] [Indexed: 12/20/2022]
Abstract
A biomarker is a defined characteristic measured as an indicator of normal, biologic, pathogenic processes, or biological responses to an exposure or intervention. Diagnostic biomarkers are used to detect a disease or a subtype of a disease; monitoring biomarkers are measured serially to assess a medical condition; response biomarkers are used to check biologic response following a medical intervention; predictive biomarkers are used to identify patients who are more likely to respond to a medical intervention; and prognostic biomarkers are used to assess the future likelihood of a clinical event. Although biomarkers have been extensively investigated and validated in many diseases and pathologies, very few are currently useful for the diagnosis, evaluation of disease activity, and treatment of hereditary angioedema (HAE). Pathophysiologic pathways involved in HAE reveal a plethora of molecules from the complement, coagulation, and fibrinolysis systems or from the vascular endothelium, which may serve as biomarkers. The most promising candidates, together with their laboratory readout systems, should be evaluated with regard to their analytical and clinical validity and utility. To be highly specific, such biomarkers should be linked to the pathomechanisms of HAE, particularly the bradykinin-generating cascade. Additionally, major advances in high-throughput omics-based technologies may facilitate the discovery of new candidate biomarkers in the future. This review will cover the existing as well as future potential biomarkers that will support the diagnosis, monitor disease activity, and can be used to assess the efficacy of new avenues of therapy of HAE and other forms of angioedema.
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Affiliation(s)
- Grzegorz Porebski
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Krakow, Poland.
| | - Mateusz Kwitniewski
- Department of Immunology, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland
| | - Avner Reshef
- Barzilai University Medical Centre, Ashkelon, Israel
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Reshef A, Levy D, Longhurst H, Cicardi M, Craig T, Keith PK, Feussner A, Feuersenger H, Machnig T, Prusty S, Pragst I. Effects of Continuous Plasma-Derived Subcutaneous C1-Esterase Inhibitor on Coagulation and Fibrinolytic Parameters. Thromb Haemost 2020; 121:690-693. [PMID: 33202446 DOI: 10.1055/s-0040-1721147] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Avner Reshef
- Division of Allergy, Immunology, and Angioedema, Barzilai Medical Center, Ashkelon, Israel
| | - Donald Levy
- Division of Basic and Clinical Immunology, Department of Medicine, University of California at Irvine, Orange, California, United States
| | - Hilary Longhurst
- Department of Immunology, Addenbrooke's Hospital, Cambridge and UCLH, London, United Kingdom
| | - Marco Cicardi
- Ospedale Luigi Sacco/U.O. Medicina Generale, Milano, Italy
| | - Timothy Craig
- Allergy, Immunology and Respiratory Research, Department of Medicine and Pediatrics, Penn State University, Hershey, Pennsylvania, United States
| | - Paul K Keith
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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15
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Firinu D, Arba M, Vincenzoni F, Iavarone F, Costanzo G, Cabras T, Castagnola M, Messana I, Del Giacco SR, Sanna MT. Proteomic Analysis of the Acid-Insoluble Fraction of Whole Saliva from Patients Affected by Different Forms of Non-histaminergic Angioedema. J Clin Immunol 2020; 40:840-850. [PMID: 32519288 DOI: 10.1007/s10875-020-00802-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 06/01/2020] [Indexed: 01/17/2023]
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16
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Burnham K, Reinert JP. Thromboembolic Risk of C1 Esterase Inhibitors: A Systematic Review on Current Evidence. Expert Rev Clin Pharmacol 2020; 13:779-786. [PMID: 32476505 DOI: 10.1080/17512433.2020.1776110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The exact risk of developing a thromboembolic event (TEE) while using complement 1 esterase inhibitors (C1-INHs) is currently undetermined for patients with hereditary angioedema (HAE). This systematic review aimed to define the potential risk of TEEs from these agents. AREAS COVERED This evaluation covers publications examining or mentioning the risk of TEEs in association with C1-INHs. A systematic literature search was conducted utilizing PubMed, Scopus, and ProQuest. This review utilized search results through January 2020 and followed the PRISMA recommendations for a systematic review. Articles not available in English and animal or in-vitro studies were excluded. For inclusion, studies had to be open-label, randomized-controlled, cross-sectional, or clinical observational studies. A total of 13 studies met inclusion criteria and yielded 1716 patients receiving at least one dose of C1-INH, though only 41 incidences of thrombosis were documented. EXPERT OPINION Significant heterogeneity exists in the available literature concerning both study design and the reporting of data; therefore, interpretation of thrombotic risk is difficult. TEEs are rarely reported in the literature, and they seem unlikely to occur in patients without underlying risk factors. Important risk factors include those found in the prescribing information of C1-INHs.
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Affiliation(s)
- Kevin Burnham
- Ben and Maytee Fisch College of Pharmacy, The University of Texas , Tyler, TX, USA
| | - Justin P Reinert
- Ben and Maytee Fisch College of Pharmacy, The University of Texas , Tyler, TX, USA
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17
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Interspecies comparison of simultaneous thrombin and plasmin generation. Sci Rep 2020; 10:3885. [PMID: 32127577 PMCID: PMC7054422 DOI: 10.1038/s41598-020-60436-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 01/27/2020] [Indexed: 01/08/2023] Open
Abstract
Animal models of hemostasis are often extrapolated to humans; however, only a few studies have compared coagulation and fibrinolysis across species. Simultaneous thrombin (TG) and plasmin (PG) generation is useful to assessing coagulation and fibrinolysis within the same sample. In this study, we performed simultaneous TG and PG analysis in blood plasma samples from humans and 6 species commonly evaluated in pre-clinical research. TG and PG were investigated in male and female donor platelet-poor plasmas (PPP) obtained from 28 healthy humans, 10 baboons, 12 rhesus monkeys, 20 Yorkshire pigs, 20 Sprague-Dawley rats, 10 New Zealand White rabbits and 14 Hartley guinea pigs. The continuous generation of the 7-amino-4-methylcoumarin (AMC) from substrates specific to thrombin or plasmin was monitored. The thrombin and plasmin concentration peak heights (PH) and production rates (PR) were calculated. TG and PG parameters from baboon and rhesus macaque plasma approximated that of humans. The other species differed significantly from both human and non-human primates. For example, swine and rat plasmas demonstrated similar TG, but swine plasmas did not generate plasmin. TG and PG parameters from Guinea pig samples were extremely low, while rabbit plasmas showed variable PG curves demonstrating one or two peaks with low and high PR values, respectively. Correlations between PH and PR values were significant with the exceptions of human PG, baboon TG, rat TG and Guinea pig PG. These findings are informative to pre-clinical animal species selection and optimization of coagulation and fibrinolysis translational research.
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Tanaka KA, Mondal S, Morita Y, Williams B, Strauss ER, Cicardi M. Perioperative Management of Patients With Hereditary Angioedema With Special Considerations for Cardiopulmonary Bypass. Anesth Analg 2020; 131:155-169. [DOI: 10.1213/ane.0000000000004710] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Hofman ZL, den Elzen MT, Kuijpers J, Maat S, Hack CE, Knulst AC, Röckmann H, Maas C. Evidence for bradykinin release in chronic spontaneous urticaria. Clin Exp Allergy 2020; 50:343-351. [DOI: 10.1111/cea.13558] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 12/12/2019] [Accepted: 12/24/2019] [Indexed: 01/10/2023]
Affiliation(s)
- Zonne L.M. Hofman
- Laboratory of Clinical Chemistry and Haematology University Medical Center Utrecht Utrecht University Utrecht The Netherlands
- Laboratory for Translational Immunology University Medical Center Utrecht Utrecht University Utrecht The Netherlands
| | - Mignon T. den Elzen
- Laboratory for Translational Immunology University Medical Center Utrecht Utrecht University Utrecht The Netherlands
- Department of Dermatology/Allergology University Medical Center Utrecht Utrecht University Utrecht The Netherlands
| | - Jeffrey Kuijpers
- Laboratory of Clinical Chemistry and Haematology University Medical Center Utrecht Utrecht University Utrecht The Netherlands
| | - Steven Maat
- Laboratory of Clinical Chemistry and Haematology University Medical Center Utrecht Utrecht University Utrecht The Netherlands
| | - C. Erik Hack
- Laboratory for Translational Immunology University Medical Center Utrecht Utrecht University Utrecht The Netherlands
| | - André C. Knulst
- Laboratory for Translational Immunology University Medical Center Utrecht Utrecht University Utrecht The Netherlands
- Department of Dermatology/Allergology University Medical Center Utrecht Utrecht University Utrecht The Netherlands
| | - Heike Röckmann
- Laboratory for Translational Immunology University Medical Center Utrecht Utrecht University Utrecht The Netherlands
- Department of Dermatology/Allergology University Medical Center Utrecht Utrecht University Utrecht The Netherlands
| | - Coen Maas
- Laboratory of Clinical Chemistry and Haematology University Medical Center Utrecht Utrecht University Utrecht The Netherlands
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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.
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21
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Uzun T. Management of patients with hereditary angio-oedema in dental, oral, and maxillofacial surgery: a review. Br J Oral Maxillofac Surg 2019; 57:992-997. [PMID: 31591028 DOI: 10.1016/j.bjoms.2019.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 09/11/2019] [Indexed: 01/13/2023]
Abstract
Hereditary angio-oedema (HEA) is an autosomal dominant, life-threatening genetic disorder that is caused by insufficiency or dysfunction of the C1 esterase inhibitor that develops coincidentally with recurrent oedema in the skin, internal organs, and upper respiratory tract. Increased production of bradykinin secondary to increased plasma kallikrein activity is the primary cause of attacks. Dental procedures cause emotional stress and mechanical trauma and may also initiate attacks. The most feared complication is asphyxiation as a result of laryngeal oedema. Cases that resulted in death after tooth extraction have been reported, so dentists and oral and maxillofacial surgeons should take maximum care in the treatment of patients with HAO, consult with the patient's doctor, and ensure that prophylaxis is given before the procedure. They should work as atraumatically as possible and use procedures to minimise stress. In the event of an attack of HAO, despite all the correct measures having been taken, the procedure should be terminated immediately and treatment of the attack started as soon as possible. The first drugs for the treatment of acute attacks are C1-INH (C1 inhibitor), ecallantide, or icatibant.
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Affiliation(s)
- T Uzun
- Trabzon Oral and Dental Health Hospital, Department of Oral and Maxillofacial Surgery, DDS, Trabzon, Turkey. tugce--
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22
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Levi M, Cohn DM. The Role of Complement in Hereditary Angioedema. Transfus Med Rev 2019; 33:243-247. [DOI: 10.1016/j.tmrv.2019.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 08/15/2019] [Accepted: 08/16/2019] [Indexed: 11/28/2022]
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23
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Maas C. Plasminflammation-An Emerging Pathway to Bradykinin Production. Front Immunol 2019; 10:2046. [PMID: 31507620 PMCID: PMC6719523 DOI: 10.3389/fimmu.2019.02046] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/13/2019] [Indexed: 11/16/2022] Open
Abstract
Plasminogen activation is essential for fibrinolysis—the breakdown of fibrin polymers in blood clots. Besides this important function, plasminogen activation participates in a wide variety of inflammatory conditions. One of these conditions is hereditary angioedema (HAE), a rare disease with characteristic attacks of aggressive tissue swelling due to unregulated production and activity of the inflammatory mediator bradykinin. Plasmin was already implicated in this disease decades ago, but a series of recent discoveries have made it clear that plasmin actively contributes to this pathology. Collective evidence points toward an axis in which the plasminogen activation system and the contact system (which produces bradykinin) are mechanistically coupled. This is amongst others supported by findings in subtypes of HAE that are caused by gain-of-function mutations in the genes that respectively encode factor XII or plasminogen, as well as clinical experience with the antifibrinolytic agents in HAE. The concept of a link between plasminogen activation and the contact system helps us to explain the inflammatory side effects of fibrinolytic therapy, presenting as angioedema or tissue edema. Furthermore, these observations motivate the development and characterization of therapeutic agents that disconnect plasminogen activation from bradykinin production.
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Affiliation(s)
- Coen Maas
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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24
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Márkus B, Veszeli N, Temesszentandrási G, Farkas H, Kalabay L. Serum fetuin-A, tumor necrosis factor alpha and C-reactive protein concentrations in patients with hereditary angioedema with C1-inhibitor deficiency. Orphanet J Rare Dis 2019; 14:67. [PMID: 30885236 PMCID: PMC6423823 DOI: 10.1186/s13023-019-0995-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 01/07/2019] [Indexed: 12/16/2022] Open
Abstract
Background and aims Hereditary angioedema with C1-inhibitor deficiency (C1-INH-HAE) is characterized by localized, non-pitting, and transient swelling of submucosal or subcutaneous region. Human fetuin-A is a multifunctional glycoprotein that belongs to the proteinase inhibitor cystatin superfamily and has structural similarities to the high molecular weight kininogen. Fetuin-A is also known a negative acute phase reactant with anti-inflammatory characteristics. In this study we aimed to determine serum fetuin-A, C-reactive protein (CRP) and tumor necrosis factor alpha (TNFα) concentrations in patients with C1-INH-HAE during symptom-free period and during attacks and compare them to those of healthy controls. Further we analyzed possible relationship among these parameters as well as D-dimer levels which was known as marker of HAE attacks. Patients and methods Serum samples of 25 C1-INH-HAE patients (8 men, 17 women, age: 33.1 ± 6.9 years, mean ± SD) were compared to 25 healthy controls (15 men, 10 women, age: 32.5 ± 7.8 years). Serum fetuin-A and TNFα concentrations were determined by ELISA, CRP and D-dimer by turbidimetry. Results Compared to healthy controls patients with C1-INH-HAE in the symptom-free period had significantly decreased serum fetuin-A 258 μg/ml (224–285) vs. 293 μg/ml (263–329), (median (25–75% percentiles, p = 0.035) and TNFα 2.53 ng/ml (1.70–2.83) vs. 3.47 ng/ml (2.92–4.18, p = 0.0008) concentrations. During HAE attacks fetuin-A levels increased from 258 (224–285) μg/ml to 287 (261–317) μg/ml (p = 0.021). TNFα and CRP levels did not change significantly. We found no significant correlation among fetuin-A CRP, TNFα and D-dimer levels in any of these three groups. Conclusions Patients with C1-INH-HAE have decreased serum fetuin-A concentrations during the symptom-free period. Given the anti-inflammatory properties of fetuin-A, the increase of its levels may contribute to the counter-regulation of edema formation during C1-INH-HAE attacks.
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Affiliation(s)
- Bernadett Márkus
- Department of Family Medicine, Semmelweis University, Budapest POB 2, Kútvölgyi str. 4, Budapest, H-1125, Hungary
| | - Nóra Veszeli
- Hungarian Angioedema Reference Center, 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - György Temesszentandrási
- Hungarian Angioedema Reference Center, 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Henriette Farkas
- Hungarian Angioedema Reference Center, 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - László Kalabay
- Department of Family Medicine, Semmelweis University, Budapest POB 2, Kútvölgyi str. 4, Budapest, H-1125, Hungary. .,Semmelweis University, POB 2, Budapest, H-1428, Hungary.
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25
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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.
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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
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Del Giacco SR, Firinu D, Minciullo PL, Barca MP, Manconi PE, Tartarisco G, Cristani M, Saija A, Gangemi S. Oxidative stress markers in patients with hereditary angioedema. Arch Med Sci 2019; 15:92-98. [PMID: 30697258 PMCID: PMC6348350 DOI: 10.5114/aoms.2017.66160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 01/18/2017] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Hereditary angioedema due to C1-INH deficiency (C1-INH-HAE) or with normal C1-INH is characterized by recurrent swellings due to uncontrolled production of vasoactive mediators, among which bradykinin (BK) is crucial. Through the binding and activation of the two human BK-receptors, kinins may have dual beneficial and deleterious effects in vascular and inflammation physiopathology by inducing oxidative stress. We aimed to assess the serum concentrations of advanced glycation end products (AGEs) and advanced oxidation protein products (AOPPs) in patients affected by HAE. MATERIAL AND METHODS Blood samples were collected to measure the serum concentrations of AGEs and AOPPs by spectrofluorimetric and spectrophotometric methods in patients affected by C1-INH-HAE and FXII-HAE during the remission state. RESULTS We showed that the circulating levels of AOPPs observed on control group (0.94 (0.36) nmol/mg) were significantly lower than those observed on the C1-INH-HAE group (1.68 (0.47) nmol/mg; p = 0.002) and FXII-HAE (1.50 (0.27) nmol/mg; p = 0.001). Moreover, the circulating levels of AGEs were significantly higher in C1-INH-HAE group (211.58 (151.05) AU/g; p = 0.02) than the FXII group (141.48 (89.59) AU/g), thus demonstrating a state of heightened oxidative stress. CONCLUSIONS Our observations show additional underlying events involved in HAE and are of central importance for further investigations of differences in bradykinin receptors signaling among the two disease subgroups.
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Affiliation(s)
| | - Davide Firinu
- Department of Medical Sciences “M. Aresu”, University of Cagliari, Cagliari, Italy
| | - Paola Lucia Minciullo
- School and Operative Unit of Allergy and Clinical Immunology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Maria Pina Barca
- Department of Medical Sciences “M. Aresu”, University of Cagliari, Cagliari, Italy
| | - Paolo Emilio Manconi
- Department of Medical Sciences “M. Aresu”, University of Cagliari, Cagliari, Italy
| | - Gennaro Tartarisco
- National Research Council of Italy (CNR) – Institute of Applied Science and Intelligent System (ISASI), Messina Unit, Messina, Italy
| | - Mariateresa Cristani
- Department of Drug Sciences and Health Products, University of Messina, Messina, Italy
| | - Antonella Saija
- Department of Drug Sciences and Health Products, University of Messina, Messina, Italy
| | - Sebastiano Gangemi
- School and Operative Unit of Allergy and Clinical Immunology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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27
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Levi M, Cohn DM, Zeerleder S. Hereditary angioedema: Linking complement regulation to the coagulation system. Res Pract Thromb Haemost 2019; 3:38-43. [PMID: 30656274 PMCID: PMC6332742 DOI: 10.1002/rth2.12175] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 11/12/2018] [Indexed: 12/20/2022] Open
Abstract
Congenital deficiency of C1 inhibitor, the main inhibitor of the classic complement system pathway, leads to paroxysmal angioedema (hereditary angioedema) that can be debilitating or life-threatening for affected patients. In the past few years many new insights on the pathogenesis of angioedema formation in the presence of low levels of C1 inhibitor has been accumulated. There is a central role for bradykinin that is released upon activation of the kallikrein-kinin system that is insufficiently controlled by adequate levels of C1 inhibitor. As C1 inhibitor also possesses a central regulatory role of other plasma systems, including the contact activation system of coagulation and the plasminogen-plasmin system that governs endogenous fibrinolysis, it is interesting to observe the effects of C1 inhibitor deficiency on activation of these systems and relevance for hemostasis in vivo and thrombo-embolic disease. Interestingly, and despite significant activation of these pathways, C1 inhibitor deficiency is not at all associated with a hemorrhagic tendency or prothrombotic state. New therapeutic options for treatment of C1 inhibitor efficiency have become available in recent years, including various forms of C1 inhibitor concentrate. Restoration of C1 inhibitor levels in patients with hereditary angioedema has not resulted in thrombotic complications or any other relevant disorder associated with the hemostatic system.
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Affiliation(s)
- Marcel Levi
- Department of MedicineUniversity College London HospitalsNHS Foundation TrustLondonUK
- Cardiometabolic ProgrammeUniversity College London HospitalsNHS Foundation TrustLondonUK
- Department of Vascular MedicineAmsterdam Universities Medical CenterAmsterdamThe Netherlands
| | - Danny M. Cohn
- Department of Vascular MedicineAmsterdam Universities Medical CenterAmsterdamThe Netherlands
| | - Sacha Zeerleder
- Department of Molecular Cell BiologySanquin Research & Landsteiner LaboratoryAmsterdamThe Netherlands
- Department of Hematology and Central Hematology LaboratoryInselspitalBern University HospitalBernSwitzerland
- Department for BioMedical ResearchBern University HospitalBernSwitzerland
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Saini SS, Kaplan AP. Chronic Spontaneous Urticaria: The Devil's Itch. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2018; 6:1097-1106. [PMID: 30033911 PMCID: PMC6061968 DOI: 10.1016/j.jaip.2018.04.013] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/15/2018] [Accepted: 04/23/2018] [Indexed: 11/20/2022]
Abstract
Chronic urticaria is defined as the presence of urticaria for a period exceeding 6 weeks, assuming symptoms for most days of the week. It is divided into chronic inducible urticarias and chronic spontaneous urticaria, previously termed chronic idiopathic urticaria. The latter designation emphasizes that patients can experience urticaria independent of any exogenous stimulus even if one can define circumstances that may worsen symptoms. A search for such an external "cause" is fruitless because the underlying abnormality is "intrinsic," whether it is autoimmune, or some unknown process. Approximately 40% of patients with chronic spontaneous urticaria report accompanying episodes of angioedema, whereas 10% have angioedema as their primary manifestation. In most cases, it is a self-limiting disorder, persisting for 2 to 5 years in most cases, although 20% of patients suffer for more than 5 years. The treatment that has evolved is largely empiric, based on double-blind, placebo-controlled studies whenever possible, but is not yet targeted to any particular pathogenic mechanism. In this article, we review the current status regarding pathogenesis, discuss the diagnostic workup, and update the approach to treatment including consideration of published guidelines, our own experience, and guideline updates that are being prepared.
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Affiliation(s)
- Sarbjit S Saini
- Department of Medicine, Division of Allergy and Clinical Immunology, Johns Hopkins Asthma and Allergy Center, Baltimore, Md.
| | - Allen P Kaplan
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Allergy and Clinical Immunology, Medical University of South Carolina, Charleston, SC
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29
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Takahashi T, Minami S, Teramura K, Tanaka T, Fujimoto N. Four cases of acute infectious urticaria showing significant elevation of plasma D-dimer level. J Dermatol 2018; 45:1013-1016. [PMID: 29797525 DOI: 10.1111/1346-8138.14481] [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: 01/19/2018] [Accepted: 04/18/2018] [Indexed: 11/29/2022]
Abstract
D-dimer, a fibrinolytic end-product, has been regarded as a biomarker indicating the severity of urticaria, especially in chronic urticaria. Regarding acute urticaria, D-dimer level is also suggested to be elevated, which may be significant in comparison with chronic urticaria. However, the clinical features of acute urticaria with concomitant significant elevation of D-dimer level have not been investigated in detail so far. We present four cases of acute urticaria fulfilling the proposed diagnostic criterion of acute infectious urticaria, in which significant elevation of D-dimer level and rapid spontaneous normalization in parallel with the resolution of fever and urticaria occurs. No cases had deep vein thrombosis, disseminated intravascular coagulation and malignancy. All cases responded well to antihistaminic treatment in combination with antibiotics, and their fever and urticaria resolved within 10 days. All cases showed severe wheals persistent for several days resolving with hyperpigmentation. Histologically, infiltration into blood vessel walls and interstitial infiltration of lymphocytes and polymorphonuclear cells were marked in the dermis. In our cases, clinical features accorded with acute infectious urticaria, and their histological features were similar to those of neutrophilic urticaria as described previously. In conclusion, there is a certain group of acute urticaria associated with significant elevation of D-dimer level. These common features of our cases may be characteristic in acute urticaria showing the coagulative and fibrinolytic abnormalities.
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Affiliation(s)
| | - Shino Minami
- Department of Dermatology, Shiga University of Medical Science, Otsu, Japan
| | - Kazuya Teramura
- Department of Dermatology, Shiga University of Medical Science, Otsu, Japan
| | - Toshihiro Tanaka
- Department of Dermatology, Shiga University of Medical Science, Otsu, Japan
| | - Noriki Fujimoto
- Department of Dermatology, Shiga University of Medical Science, Otsu, Japan
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Firinu D, Bassareo PP, Zedda AM, Barca MP, Crisafulli A, Mercuro G, Del Giacco S. Impaired Endothelial Function in Hereditary Angioedema During the Symptom-Free Period. Front Physiol 2018; 9:523. [PMID: 29867566 PMCID: PMC5964294 DOI: 10.3389/fphys.2018.00523] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 04/24/2018] [Indexed: 12/13/2022] Open
Abstract
Introduction: The presence of coronary endothelial dysfunction was previously shown in Hereditary Angioedema (HAE) patients. The aim of our study was to evaluate the effect of HAE on systemic endothelial function and whether there was a relationship among endothelial function, asymmetric dimethylarginine (ADMA) -which is a strong inhibitor of nitric oxide synthesis-, and disease severity scores. Methods: Twenty-four HAE patients (18 females, aged 47.9 ± 2 years) without factors known to interfere with endothelial function were studied and compared with 24 healthy peers age- and gender-matched. Endothelial function was assessed by means of non-invasive finger plethysmography (reactive hyperaemia index: RHI) and ADMA levels by high-performance liquid chromatography. HAE severity scores have been calculated according to published literature. Results: In HAE patients RHI was lower (2.03 ± 0.46 vs. 2.82 ± 0.34, p < 0.0001) and ADMA higher (0.636 ± 7 vs. 585 ± 5 micromol/L, p < 0.01) than in controls. A statistically significant inverse correlation was revealed between RHI and patients' ADMA levels (r = −0.516, p = 0.009) as well as between RHI and patients' chronological age (r = −0.49, p = 0.015). A statistically significant correlation between RHI and ADMA was confirmed even when excluding the possible influence of cholesterol (r = −0.408, p = 0.048). No other significant correlations were found with the examined laboratory and clinical parameters (chronological age, age at disease onset, disease duration, severity scores, and gender). Conclusion: The dysfunction previously shown in HAE patients at the coronary arteries seems to involve the peripheral vessels as well, without a correlation with disease severity.
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Affiliation(s)
- Davide Firinu
- Unit of Internal Medicine, Department of Medical Sciences and Public Health, Allergy and Clinical Immunology, University of Cagliari, Cagliari, Italy
| | - Pier P Bassareo
- Unit of Cardiology and Angiology, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Angela M Zedda
- Unit of Cardiology and Angiology, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Maria P Barca
- Unit of Internal Medicine, Department of Medical Sciences and Public Health, Allergy and Clinical Immunology, University of Cagliari, Cagliari, Italy
| | - Antonio Crisafulli
- Sports Physiology Lab., Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Giuseppe Mercuro
- Unit of Cardiology and Angiology, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Stefano Del Giacco
- Unit of Internal Medicine, Department of Medical Sciences and Public Health, Allergy and Clinical Immunology, University of Cagliari, Cagliari, Italy
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Farkas H, Debreczeni ML, Kőhalmi KV. Investigational drugs in phase I and phase II clinical trials for hereditary angioedema. Expert Opin Investig Drugs 2017; 27:87-103. [PMID: 29226721 DOI: 10.1080/13543784.2018.1415325] [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] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Hereditary angioedema (HAE) with C1-inhibitor deficiency (C1-INH-HAE) is a rare bradykinin-mediated disease characterized by recurrent subcutaneous and/or submucosal angioedematous attacks (HAE attacks), which occur unpredictably. The recurrent HAE attacks do not respond to conventional treatments, and may evolve into a life-threatening condition; therefore, special therapy is required. AREAS COVERED The agents used so far for the acute management of HAE attacks act by blocking the release of bradykinin, or its binding to its receptor. By contrast, the investigational medicinal products under evaluation in Phase I and II clinical trials are targeted at the prevention of HAE attacks. Chemically, these new drugs are small synthetic molecules, oligonucleotides, or antibodies, which inhibit either kallikrein, or Factor XII. EXPERT OPINION The key considerations for the development of new medicinal products include more straightforward dosing, self-administration, longer duration of action, and keeping the patient attack-free. This review summarizes the status and the findings of the currently ongoing Phase I and Phase II clinical trials of C1-INH-HAE.
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Affiliation(s)
- Henriette Farkas
- a Hungarian Angioedema Center, 3rd Department of Internal Medicine , Semmelweis University , Budapest , Hungary
| | - Márta Lídia Debreczeni
- a Hungarian Angioedema Center, 3rd Department of Internal Medicine , Semmelweis University , Budapest , Hungary
| | - Kinga Viktória Kőhalmi
- a Hungarian Angioedema Center, 3rd Department of Internal Medicine , Semmelweis University , Budapest , Hungary
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Kaplan AP, Maas C. The Search for Biomarkers in Hereditary Angioedema. Front Med (Lausanne) 2017; 4:206. [PMID: 29214154 PMCID: PMC5702621 DOI: 10.3389/fmed.2017.00206] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 11/06/2017] [Indexed: 11/16/2022] Open
Abstract
The unpredictable nature of attacks of tissue swelling in hereditary angioedema requires the identification of reliable biomarkers to monitor disease activity as well as response to therapy. At present, one can assess a C4 level (by ELISA) to assist in diagnosis but neither C4 nor C1 inhibitor levels reflect clinical course or prognosis. We will here review a collection of plasma proteins involved in blood coagulation, fibrinolysis, and innate immunity (Figure 1). A main focus is those proteins that are key to the formation of bradykinin (BK); namely, factor XII, plasma prekallikrein/kallikrein, high-molecular weight kininogen, and BK itself since overproduction of BK is key to the disease. Considerations include new approaches to measurement of active enzymes, ELISA methods that may supersede SDS gel analysis of bond cleavages, and examples of changes outside the BK cascade that may reflect when, where, and how an attack of swelling is initiated. We will discuss their usefulness as biomarker candidates, with pros and cons, and compare the analytical methods that are being developed to measure their levels or activity.
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Affiliation(s)
- Allen P. Kaplan
- Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Coen Maas
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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Magerl M, Germenis AE, Maas C, Maurer M. Hereditary Angioedema with Normal C1 Inhibitor. Immunol Allergy Clin North Am 2017; 37:571-584. [DOI: 10.1016/j.iac.2017.04.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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34
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Simão F, Feener EP. The Effects of the Contact Activation System on Hemorrhage. Front Med (Lausanne) 2017; 4:121. [PMID: 28824910 PMCID: PMC5534673 DOI: 10.3389/fmed.2017.00121] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 07/12/2017] [Indexed: 01/12/2023] Open
Abstract
The contact activation system (CAS) exerts effects on coagulation via multiple mechanisms, which modulate both the intrinsic and extrinsic coagulation cascades as well as fibrinolysis and platelet activation. While the effects of the CAS on blood coagulation measured as activated partial thromboplastin time shortening are well documented, genetic mutations that result in deficiencies in the expression of either plasma prekallikrein (PPK) or factor XII (FXII) are not associated with spontaneous bleeding or increased bleeding risk during surgery. Deficiencies in these proteins are often undiagnosed for decades and detected later in life during routine coagulation assays without an apparent clinical phenotype. Increased interest in the CAS as a potentially safe target for antithrombotic therapies has emerged, in large part, from studies on animal models with provoked thrombosis, which have shown that deficiencies in PPK or FXII can reduce thrombus formation without increasing bleeding. Gene targeting and pharmacological studies in healthy animals have confirmed that PPK and FXII blockade does not cause coagulopathies. These findings support the conclusion that CAS is not required for hemostasis. However, while deficiencies in FXII and PPK do not significantly affect bleeding associated with peripheral wounds, recent reports have demonstrated that these proteins can promote hemorrhage in the retina and brain. Intravitreal injection of plasma kallikrein (PKal) induces retinal hemorrhage and intracerebral injection of PKal increases intracranial bleeding. PPK deficiency and PKal inhibition ameliorates hematoma formation following cerebrovascular injury in diabetic animals. Moreover, both PPK and FXII deficiency are protective against intracerebral hemorrhage caused by tissue plasminogen activator-mediated thrombolytic therapy in mice with thrombotic middle cerebral artery occlusion. Thus, while the CAS is not required for hemostasis, its inhibition may provide an opportunity to reduce hemorrhage in the retina and brain. Characterization of the mechanisms and potential clinical implications associated with the effects of the CAS on hemorrhage requires further consideration of the effects of PPK and FXII on hemorrhage beyond their putative effects on coagulation cascades. Here, we review the experimental and clinical evidence on the effects of the CAS on bleeding and hemostatic mechanisms.
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Affiliation(s)
- Fabrício Simão
- Research Division, Vascular Cell Biology, Joslin Diabetes Center, Harvard Medical School, Boston, MA, United States
| | - Edward P Feener
- Research Division, Vascular Cell Biology, Joslin Diabetes Center, Harvard Medical School, Boston, MA, United States
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35
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Csuka D, Veszeli N, Varga L, Prohászka Z, Farkas H. The role of the complement system in hereditary angioedema. Mol Immunol 2017; 89:59-68. [PMID: 28595743 DOI: 10.1016/j.molimm.2017.05.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 05/22/2017] [Accepted: 05/23/2017] [Indexed: 10/19/2022]
Abstract
Hereditary angioedema (HAE) is a rare, but potentially life-threatening disorder, characterized by acute, recurring, and self-limiting edematous episodes of the face, extremities, trunk, genitals, upper airways, or the gastrointestinal tract. HAE may be caused by the deficiency of C1-inhibitor (C1-INH-HAE) but another type of the disease, hereditary angioedema with normal C1-INH function (nC1-INH-HAE) was also described. The patient population is quite heterogeneous as regards the location, frequency, and severity of edematous attacks, presenting large intra- and inter-individual variation. Here, we review the role of the complement system in the pathomechanism of HAE and also present an overview on the complement parameters having an importance in the diagnosis or in predicting the severity of HAE.
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Affiliation(s)
- Dorottya Csuka
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary.
| | - Nóra Veszeli
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Lilian Varga
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Zoltán Prohászka
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Henriette Farkas
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
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Hofman Z, de Maat S, Hack CE, Maas C. Bradykinin: Inflammatory Product of the Coagulation System. Clin Rev Allergy Immunol 2017; 51:152-61. [PMID: 27122021 PMCID: PMC5025506 DOI: 10.1007/s12016-016-8540-0] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Episodic and recurrent local cutaneous or mucosal swelling are key features of angioedema. The vasoactive agents histamine and bradykinin are highly implicated as mediators of these swelling attacks. It is challenging to assess the contribution of bradykinin to the clinical expression of angioedema, as accurate biomarkers for the generation of this vasoactive peptide are still lacking. In this review, we will describe the mechanisms that are responsible for bradykinin production in hereditary angioedema (HAE) and the central role that the coagulation factor XII (FXII) plays in it. Evidently, several plasma parameters of coagulation change during attacks of HAE and may prove valuable biomarkers for disease activity. We propose that these changes are secondary to vascular leakage, rather than a direct consequence of FXII activation. Furthermore, biomarkers for fibrinolytic system activation (i.e. plasminogen activation) also change during attacks of HAE. These changes may reflect triggering of the bradykinin-forming mechanisms by plasmin. Finally, multiple lines of evidence suggest that neutrophil activation and mast-cell activation are functionally linked to bradykinin production. We put forward the paradigm that FXII functions as a ‘sensor molecule’ to detect conditions that require bradykinin release via crosstalk with cell-derived enzymes. Understanding the mechanisms that drive bradykinin generation may help to identify angioedema patients that have bradykinin-mediated disease and could benefit from a targeted treatment.
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Affiliation(s)
- Zonne Hofman
- Laboratory of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht, The Netherlands.,Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven de Maat
- Laboratory of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C Erik Hack
- Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Coen Maas
- Laboratory of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht, The Netherlands.
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Abstract
Angioedema, as a distinct disease entity, often becomes a clinical challenge for physicians, because it may cause a life-threatening condition, whereas prompt and accurate laboratory diagnostics may not be available. Although the bedside diagnosis needs to be established based on clinical symptoms and signs, family history, and the therapeutic response, later, laboratory tests are available. Currently, only for five out of the nine different types of angioedema can be diagnosed by laboratory testing, and these occur only in a minority of the patient population. Hereditary angioedema with C1-inhibitor (C1-INH) deficiency type I can be diagnosed by the low C1-INH function and concentration, whereas in type II, C1-INH function is low, but its concentration is normal or even elevated. C1q concentration is normal in both forms. Acquired angioedema with C1-INH deficiency type I is characterized by the low C1-INH function and concentration; however, C1q concentration is also low, and autoantibodies against C1-INH cannot be detected. Complement profile of acquired angioedema with C1-INH deficiency type II is similar to that of type I, but in this form, autoantibodies against C1-INH are present. Hereditary angioedema due to a mutation of the coagulation factor XII can be diagnosed exclusively by mutation analysis of FXII gene. Diagnostic metrics are not available for idiopathic histaminergic acquired angioedema, idiopathic non-histaminergic acquired angioedema, acquired angioedema related to angiotensin-converting enzyme inhibitor, and hereditary angioedema of unknown origin; these angioedemas can be diagnosed by medical and family history, clinical symptoms, and therapeutic response and by excluding the forms previously described. Several potential biomarkers of angioedema are used to date only in research. In the future, they could be utilized into the clinical practice to improve the differential diagnosis, therapy, as well as the prognosis of angioedema.
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MacBeth LS, Volcheck GW, Sprung J, Weingarten TN. Perioperative course in patients with hereditary or acquired angioedema. J Clin Anesth 2016; 34:385-91. [DOI: 10.1016/j.jclinane.2016.05.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 04/27/2016] [Accepted: 05/02/2016] [Indexed: 11/30/2022]
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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
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41
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Farkas H. Icatibant as acute treatment for hereditary angioedema in adults. Expert Rev Clin Pharmacol 2016; 9:779-88. [DOI: 10.1080/17512433.2016.1182425] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Henriette Farkas
- Hungarian Angioedema Center, 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
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42
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Farkas H. Conestat alfa: an orphan drug for the treatment of hereditary angioedema. Expert Opin Orphan Drugs 2016. [DOI: 10.1517/21678707.2016.1153965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Veszeli N, Csuka D, Zotter Z, Imreh É, Józsi M, Benedek S, Varga L, Farkas H. Neutrophil activation during attacks in patients with hereditary angioedema due to C1-inhibitor deficiency. Orphanet J Rare Dis 2015; 10:156. [PMID: 26654922 PMCID: PMC4674948 DOI: 10.1186/s13023-015-0374-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 12/02/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Earlier studies have shown that the absolute number of neutrophil granulocytes (NGs) may increase during attack of hereditary angioedema due to C1-inhibitor deficiency (C1-INH-HAE). Whether NGs undergo activation during attack has not yet been investigated. However, as neutrophil elastase (NE) can cleave and inactivate C1-INH which may contribute to the dysregulation of the kallikrein-kinin system and hence, to edema formation. Our aim was to investigate the possible activation of NGs during attacks. METHODS We studied blood samples obtained from 26 patients with C1-INH-HAE during symptom-free periods and during attacks, along with samples from 26 healthy volunteers. NG count (NGC), NE, myeloperoxidase (MPO), pentraxin 3 (PTX3), CRP, C5a, factor H, IL-8, and TNF-α levels were measured. RESULTS NGC was higher during attacks than during symptom-free periods (p = 0.0132), and the same was observed for NE (p = 0.0026), MPO (p = 0.0008), and PTX3 levels (p = 0.0409). There was a strong positive correlation between NE and MPO levels during attacks (p < 0.0001, R = 0.709). Furthermore, IL-8 (p = 0.0061) and TNF-α (p = 0.0186) levels were also elevated during attacks, compared with symptom-free periods. By contrast, C5a and factor H levels were similar in samples obtained during attacks or in symptom-free periods. CONCLUSION Increased NGC was associated with elevated NE and MPO levels - this suggests neutrophil activation during attacks. The strong positive correlation between NE and MPO levels, together with the elevated PTX3 concentration, may indicate the expression of neutrophil extracellular traps. All these processes may contribute to the activation of kallikrein-kinin system, which leads to the onset of an edematous episode.
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Affiliation(s)
- Nóra Veszeli
- Hungarian Angioedema Center, 3rd Department of Internal Medicine, Semmelweis University, Kútvölgyi út 4, H-1125, Budapest, Hungary.
| | - Dorottya Csuka
- Hungarian Angioedema Center, 3rd Department of Internal Medicine, Semmelweis University, Kútvölgyi út 4, H-1125, Budapest, Hungary.
| | - Zsuzsanna Zotter
- Hungarian Angioedema Center, 3rd Department of Internal Medicine, Semmelweis University, Kútvölgyi út 4, H-1125, Budapest, Hungary. .,Urology Department, Medical Center, Hungarian Defence Forces, Budapest, Hungary.
| | - Éva Imreh
- Central Laboratory, Kútvölgyi Clinical Block, Budapest, Hungary.
| | - Mihály Józsi
- MTA-ELTE "Lendület" Complement Research Group, Department of Immunology, Eötvös Loránd University, Budapest, Hungary.
| | - Szabolcs Benedek
- Haematology Unit, 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary.
| | - Lilian Varga
- Hungarian Angioedema Center, 3rd Department of Internal Medicine, Semmelweis University, Kútvölgyi út 4, H-1125, Budapest, Hungary.
| | - Henriette Farkas
- Hungarian Angioedema Center, 3rd Department of Internal Medicine, Semmelweis University, Kútvölgyi út 4, H-1125, Budapest, Hungary.
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Csuka D, Veszeli N, Imreh É, Zotter Z, Skopál J, Prohászka Z, Varga L, Farkas H. Comprehensive study into the activation of the plasma enzyme systems during attacks of hereditary angioedema due to C1-inhibitor deficiency. Orphanet J Rare Dis 2015; 10:132. [PMID: 26452350 PMCID: PMC4600308 DOI: 10.1186/s13023-015-0351-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 10/01/2015] [Indexed: 11/20/2022] Open
Abstract
Background The activation of plasma enzyme systems contributes to hereditary angioedema attacks. We aimed to study the activation markers of the fibrinolytic, coagulation, and contact systems in a larger number of paired samples obtained from the same C1-INH-HAE patients in symptom-free periods and during attacks. Methods Eleven parameters (Factors XI, XII, and C1-inhibitor activity; the concentrations of the D-dimer, prothrombin fragments 1 + 2, plasminogen, plasminogen activator inhibitor-1 [PAI-1], thrombin-anti-thrombin III [TAT] complex, fibrinogen) were measured along with prothrombin time and activated partial thromboplastin time (aPTT), using commercial kits. We compared these markers in samples obtained from the same 39 patients during attack-free periods and during 62 edematous episodes. Forty healthy subjects of matching sex and age served as controls. Results Compared with the healthy controls, significantly higher FXI and FXII activity (p = 0.0007, p = 0.005), as well as D-dimer (p < 0.0001), prothrombin fragments 1 + 2 (p < 0.0001), and TAT (p = 0.0303) levels were ascertained in the patients during symptom-free periods. The evaluation of samples from symptom-free periods or obtained during attacks revealed the increase of FXII activity, as well as of the concentration of D-dimer, prothrombin fragments 1 + 2, and TAT during edematous episodes. PAI-1 level, prothrombin time, and aPTT decreased significantly during attacks, compared with symptom-free periods. D-dimer level was significantly higher during multiple- vs. single-site attacks. Conclusions Comparing a large number of paired samples from symptom-free periods or from edematous episodes allowed accurate appraisal of the changes occurring during attacks. Moreover, our study pointed out that individual episodes may be characterized by different marker patterns.
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Affiliation(s)
- Dorottya Csuka
- 3rd Department of Internal Medicine, Semmelweis University, Faculty of Medicine, Kútvölgyi út 4, H-1125, Budapest, Hungary.
| | - Nóra Veszeli
- 3rd Department of Internal Medicine, Semmelweis University, Faculty of Medicine, Kútvölgyi út 4, H-1125, Budapest, Hungary.
| | - Éva Imreh
- 3rd Department of Internal Medicine, Semmelweis University, Faculty of Medicine, Kútvölgyi út 4, H-1125, Budapest, Hungary.
| | - Zsuzsanna Zotter
- 3rd Department of Internal Medicine, Semmelweis University, Faculty of Medicine, Kútvölgyi út 4, H-1125, Budapest, Hungary.
| | - Judit Skopál
- Department of Cardiology, Heart & Vascular Center, Semmelweis University, Budapest, Hungary.
| | - Zoltán Prohászka
- 3rd Department of Internal Medicine, Semmelweis University, Faculty of Medicine, Kútvölgyi út 4, H-1125, Budapest, Hungary.
| | - Lilian Varga
- 3rd Department of Internal Medicine, Semmelweis University, Faculty of Medicine, Kútvölgyi út 4, H-1125, Budapest, Hungary.
| | - Henriette Farkas
- 3rd Department of Internal Medicine, Semmelweis University, Faculty of Medicine, Kútvölgyi út 4, H-1125, Budapest, Hungary.
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Joseph K, Tholanikunnel BG, Wolf B, Bork K, Kaplan AP. Deficiency of plasminogen activator inhibitor 2 in plasma of patients with hereditary angioedema with normal C1 inhibitor levels. J Allergy Clin Immunol 2015; 137:1822-1829.e1. [PMID: 26395818 DOI: 10.1016/j.jaci.2015.07.041] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 07/20/2015] [Accepted: 07/29/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hereditary angioedema with normal C1 inhibitor levels (HAE-N) is associated with a Factor XII mutation in 30% of subjects; however, the role of this mutation in the pathogenesis of angioedema is unclear. OBJECTIVE We sought evidence of abnormalities in the pathways of bradykinin formation and bradykinin degradation in the plasma of patients with HAE-N both with and without the mutation. METHODS Bradykinin was added to plasma, and its rate of degradation was measured by using ELISA. Plasma autoactivation was assessed by using a chromogenic assay of kallikrein formation. Plasminogen activator inhibitors (PAIs) 1 and 2 were also measured by means of ELISA. RESULTS PAI-1 levels varied from 0.1 to 4.5 ng/mL (mean, 2.4 ng/mL) in 23 control subjects, from 0.0 to 2 ng/mL (mean, 0.54 ng/mL) in patients with HAE-N with a Factor XII mutation (12 samples), and from 0.0 to 3.7 ng/mL (mean, 1.03 ng/mL) in patients with HAE-N without a Factor XII mutation (11 samples). PAI-2 levels varied from 25 to 87 ng/mL (mean, 53.8 ng/mL) in control subjects and were 0 to 25 ng/mL (mean, 4.3 ng/mL) in patients with HAE-N with or without the Factor XII mutation. Autoactivation at a 1:2 dilution was abnormally high in 8 of 17 patients with HAE-N (4 in each subcategory) and could be corrected by supplemental C1 inhibitor in 4 of them. Bradykinin degradation was markedly abnormal in 1 of 23 patients with HAE-N and normal in the remaining 22 patients. CONCLUSIONS Bradykinin degradation was normal in all but 1 of 23 patients with HAE-N studied. By contrast, there was a marked abnormality in PAI-2 levels in patients with HAE-N that is not seen in patients with C1 inhibitor deficiency. PAI-1 levels varied considerably, but a statistically significant difference was not seen. A link between excessive fibrinolysis and bradykinin generation that is estrogen dependent is suggested.
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Affiliation(s)
- Kusumam Joseph
- Department of Biochemistry and Molecular Biology, Medical University of South Carolina, Charleston, SC.
| | - Baby G Tholanikunnel
- Department of Biochemistry and Molecular Biology, Medical University of South Carolina, Charleston, SC
| | - Bethany Wolf
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Konrad Bork
- Department of Dermatology, Johannes Gutenberg University, Mainz, Germany
| | - Allen P Kaplan
- Department of Medicine, Medical University of South Carolina, Charleston, SC
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Reshef A, Zanichelli A, Longhurst H, Relan A, Hack CE. Elevated D-dimers in attacks of hereditary angioedema are not associated with increased thrombotic risk. Allergy 2015; 70:506-13. [PMID: 25640891 PMCID: PMC4409094 DOI: 10.1111/all.12587] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2015] [Indexed: 12/23/2022]
Abstract
Background Recommended management of attacks of hereditary angioedema (HAE) due to C1 esterase inhibitor (C1-INH) deficiency (C1-INH-HAE) includes therapy with exogenous C1INH. Thrombotic/thromboembolic events (TEE) have been reported with plasma-derived C1INH, but so far none with recombinant human C1INH (rhC1INH). This phase III, randomized, placebo (saline)-controlled study evaluated the safety of rhC1INH 50 IU/kg for the treatment of acute attacks in 74 patients with C1-INH-HAE. Methods Monitoring for TEE and assessment of risk of deep vein thrombosis (DVT) by the Wells prediction rule were performed, and levels of fibrin degradation products (plasma D-dimers) were assessed before study drug administration (baseline), 2 h, and 7 days posttreatment. Results Plasma D-dimer levels were elevated in 80% of the patients (median [25th–75th percentiles]: 2149 [480–5105] μg/l; normal ≤250 μg/l) and were higher in patients with submucosal (abdominal, oropharyngeal–laryngeal) attacks (3095 [890–10000] μg/l; n = 29) compared with subcutaneous (peripheral, facial) attacks (960 [450–4060] μg/l; n = 35). Median plasma D-dimer levels were comparable across treatment groups at baseline (1874 [475–4568] μg/l rhC1INH; 2259 [586–7533] μg/l saline) and 2 h postinfusion (2389 [760–4974] μg/l rhC1INH; 2550 [310–8410] μg/l saline); median plasma D-dimer levels were decreased by Day 7 in both groups (425 [232–3240] μg/l rhC1INH; 418 [246–2318] μg/l saline). No increased risk of DVT was identified, nor any TEE reported in rhC1INH treated or controls. Conclusion Elevated plasma D-dimer levels were associated with acute C1-INH-HAE attacks, particularly with submucosal involvement. However, rhC1INH therapy was not associated with thrombotic events.
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Affiliation(s)
- A. Reshef
- Sheba Medical Center University of Tel Aviv Tel‐Hashomer Israel
| | - A. Zanichelli
- Department of Biomedical & Clinical Sciences Ospedale Luigi Sacco University of Milan Milan Italy
| | | | - A. Relan
- Pharming Technologies BV Leiden The Netherlands
| | - C. E. Hack
- Laboratory for Translational Immunology University Medical Center Utrecht Utrecht The Netherlands
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Busse P, Bygum A, Edelman J, Lumry W, Machnig T, Martinez-Saguer I, Rojavin M. Safety of C1-Esterase Inhibitor in Acute and Prophylactic Therapy of Hereditary Angioedema: Findings from the Ongoing International Berinert Patient Registry. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:213-9. [DOI: 10.1016/j.jaip.2014.08.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 07/25/2014] [Accepted: 08/21/2014] [Indexed: 10/24/2022]
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Roeen Z, Toda M, D'Alessandro-Gabazza CN, Onishi M, Kobayashi T, Yasuma T, Urawa M, Taguchi O, Gabazza EC. Thrombomodulin inhibits the activation of eosinophils and mast cells. Cell Immunol 2014; 293:34-40. [PMID: 25497974 DOI: 10.1016/j.cellimm.2014.11.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 11/10/2014] [Accepted: 11/13/2014] [Indexed: 01/21/2023]
Abstract
Eosinophils and mast cells play critical roles in the pathogenesis of bronchial asthma. Activation of both cells leads to the release of pro-inflammatory mediators in the airway of asthmatic patients. Recently, we have shown that inhaled thrombomodulin inhibits allergic bronchial asthma in a mouse model. In the present study, we hypothesize that thrombomodulin can inhibit the activation of eosinophils and mast cells. The effect of thrombomodulin on the activation and release of inflammatory mediators from eosinophils and mast cells was evaluated. Thrombomodulin inhibited the eotaxin-induced chemotaxis, upregulation of CD11b and degranulation of eosinophils. Treatment with thrombomodulin also significantly suppressed the degranulation and synthesis of inflammatory cytokines and chemokines in eosinophils and mast cells. Mice treated with a low-dose of inhaled thrombomodulin have decreased number of eosinophils and activated mast cells and Th2 cytokines in the lungs compared to untreated mice. The results of this study suggest that thrombomodulin may modulate allergic responses by inhibiting the activation of both eosinophils and mast cells.
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Affiliation(s)
- Ziaurahman Roeen
- Department of Immunology, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu City, Mie Prefecture 514-8507, Japan
| | - Masaaki Toda
- Department of Immunology, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu City, Mie Prefecture 514-8507, Japan
| | - Corina N D'Alessandro-Gabazza
- Department of Immunology, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu City, Mie Prefecture 514-8507, Japan
| | - Masahiro Onishi
- Department of Pulmonary and Critical Care Medicine, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu City, Mie Prefecture 514-8507, Japan
| | - Tetsu Kobayashi
- Department of Pulmonary and Critical Care Medicine, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu City, Mie Prefecture 514-8507, Japan
| | - Taro Yasuma
- Department of Endocrinology, Diabetes and Metabolism, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu City, Mie Prefecture 514-8507, Japan
| | - Masahito Urawa
- Department of Immunology, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu City, Mie Prefecture 514-8507, Japan; Department of Pulmonary and Critical Care Medicine, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu City, Mie Prefecture 514-8507, Japan
| | - Osamu Taguchi
- Department of Pulmonary and Critical Care Medicine, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu City, Mie Prefecture 514-8507, Japan
| | - Esteban C Gabazza
- Department of Immunology, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu City, Mie Prefecture 514-8507, Japan.
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Suffritti C, Zanichelli A, Maggioni L, Bonanni E, Cugno M, Cicardi M. High-molecular-weight kininogen cleavage correlates with disease states in the bradykinin-mediated angioedema due to hereditary C1-inhibitor deficiency. Clin Exp Allergy 2014; 44:1503-14. [DOI: 10.1111/cea.12293] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 01/31/2014] [Accepted: 02/10/2014] [Indexed: 11/29/2022]
Affiliation(s)
- C. Suffritti
- Department of Biomedical and Clinical Sciences Luigi Sacco; University of Milan, Ospedale Luigi Sacco; Milan Italy
| | - A. Zanichelli
- Department of Biomedical and Clinical Sciences Luigi Sacco; University of Milan, Ospedale Luigi Sacco; Milan Italy
| | - L. Maggioni
- Department of Biomedical and Clinical Sciences Luigi Sacco; University of Milan, Ospedale Luigi Sacco; Milan Italy
| | - E. Bonanni
- Department of Biomedical and Clinical Sciences Luigi Sacco; University of Milan, Ospedale Luigi Sacco; Milan Italy
| | - M. Cugno
- Department of Internal Medicine; IRCCS Fondazione Ospedale Maggiore Policlinico Mangiagalli Regina Elena; University of Milan; Milan Italy
| | - M. Cicardi
- Department of Biomedical and Clinical Sciences Luigi Sacco; University of Milan, Ospedale Luigi Sacco; Milan Italy
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Abstract
BACKGROUND Angioedema is a serious medical condition characterized by recurrent non-pitting tissue edema. Hereditary (HAE) forms of this disorder are potentially fatal. METHODS PubMED, Up to Date and Cochrane Library databases were used to identify scholarly peer reviewed original research or review articles on angioedema. Search terms used were: angioedema, HAE, ACE inhibitor induced angioedema, acquired angioedema, type III HAE (now termed HAE with normal C1-INH), diagnosis of HAE, and treatment of HAE. Inclusive dates of the search were 1946 through 2013. Articles on urticaria were excluded. RESULTS The pathophysiology, clinical manifestations, differential diagnosis and treatments of angioedema are presented. Three variants of HAE are discussed and differentiated from acquired, ACE induced and allergic types of angioedema. Emphasis is placed on understanding that HAE is mediated by bradykinin, not histamine, and is therefore unresponsive to antihistamines, corticosteroids and epinephrine. In contrast, newer therapies that replace C1-INH or block bradykinin production or action are the appropriate treatments for prophylaxis and acute treatment of HAE. CONCLUSION Recognition of HAE by primary care providers and distinguishing it from allergic histamine mediated angioedema is essential in preventing recurrent attacks and avoiding inappropriate therapy, and may be life-saving.
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